Changes During Pregnancy

PHYSIOLOGICAL CHANGES
DURING PREGNANCY
Mohan C. Regmi
Changes in reproductive system:
• VAGINA & PERINEUM
Increased vasularity/softening of connective
tissue of perineum & vulva
Increased vascularity of vagina- chadwick
sign
Increase thickness of mucosa,hypertrophy of
smooth muscle,loosening of connective
tissue of vagina
Increased volume of cervical secretions
Ph of vagina(acidic) -3.5-6
Preponderance of navicular cells.
CERVIX:
• Increased vascularity & edema of cervix-
softening &cyanosis- goodell’s sign
• Rearrangement of collagen rich connective
tissue
• Hypertrophy & hyperplasia of cervical glands
• Mucus plug formation
• Marked endocervical mucosa proliferation-
appears as cervical erosion
• Squamous cells -hyperactive-stimulating
carcinoma insitu
UTERUS
Thin walled muscular structure- 5liter, wt-1100gm
dextrorotated
Stretching,hypertrophy of muscles
Accumulation of fibrous tissue/increase in elastic
tissues
Muscle cells arranged-3 layers
-outer hood like
-middle layer- interlacing network of muscles
-inner layer- sphincter like fibers
Palmars sign
Braxton Hicks contractions
• Uteroplacental flow
-placental perfusion-uterine blood flow
-blood flow increases- 450-650 ml/min near

term
-uterine artery diameter doubles by 20 weeks &

concomittent mean doppler velocimetry
increased by 8 fold.
-vasodilatation is mainly mediated by estrogen

and progesteron,other factors icludes
resistance to pressor effect of angiotensinII.
FALLOPIAN TUBES & OVARIES :
• Masculature of tubes –little hypertrophy
• Single corpus luteum of pregnacy found in the
ovaries maxm functioning up to 7wks of
pregnancy
• Pregnancy luteoma - solid ovarian tmr
-composed of large acidophilic luteinized cells
-size ranges from microscopic ~20cms
-regress after delivery,may recur
-may result in maternal virilization
• Theca-lutein cysts-exaggerated physiological
follicle stimulation- hyperreactio luteinalis
-b/l cystic ovaries
CHANGES IN SKIN:
• Striae gravidarum
-SYN:Stretch marks
• Linea nigra
• Chloasma or melasma gravidarum-
mask of pregnancy
• Estrogen & progesteron –melanocyte
stimulating effect
• Vascular Spider & palmer erythema
CHANGES IN BREASTS:
• Tenderness and tingling
• Enlargement of breast
• Nipples deeply pigmented,larger and erectile
• Areola deeply pigmented/broader,formation of
secondary areola in 2nd trimester
• Glands of montgomery- hypertrophied
sebaceous glands
• Secretion of thick yellowish fluid- colostrum,
12th weeks onwards
• gigantomastia
HEMATOLOGICAL CHANGES
1. Blood volume
• Near term increase 40-45%
• Includes (a)plasma vol (b)RBC vol
• Begins to increase during 1st
trimester, by 12th weeks plasma
volume expands by 15%,peaks at30-32
week then plateaus
Non pregnant Pregnancy (term) percentage
Plasma volume 2600ml 1250ml 50%
RBC volume 1400ml 240ml 18%(without fe )
400ml 30%(with fe)
haematocrit 38% 32%

Advantages of hemodilution
• Decrease blood viscosity ensures optimal

gaseous exchange between maternal and fetal
circulation
• Protection against adverse effect of blood

loss during delivery
• Decrease viscosity – decrease resistance to

flow of blood increase in cardiac output
without much increase in cardiac work load.
2)immunological &leukocyte functions
• Decrease in humoral and cell-mediated

immunity to accommodate foreign
semiallogeneic fetus
• Neutrophilic chemotaxis/adherence
decrease from 2nd trimester
• Cervical mucus IgG, IgA higher ~10fold
• Leucocyte count 5000-12000/microlit
• ESR elevated
• Complement C3 and C4 elevated during
2nd and 3rd trimester
3)COAGULATION
• Coagulation cascade is in activated state
• Increase in all clotting factor except XI and

XIII
increase level of fibrinogen - by 50%~450mg/dl
• Fibrinolytic activity is reduced
• Slight decrease in platelet counts,

• clotting time uneffected
• Level of coagulation normalizes 2 wks
postpartum
CARDIOVASCULAR SYSTEM
• Cardiac output starts to rise from 10wk of
pregnancy reaches its peak 40% (6lit/min)
at ~24-30wk , almost1/2 of total increase
occurs by 8wks
• Systemic and pulmonary vascular

resistance decreases, mid pregnancy drop
of blood pressure
• left ventricular function normal, no change

in intrinsic left ventricular contractility
• Blood flow in legs retarded...enlarged uterus
compressing IVC,
-responsible for pedal edema
-development of varicose veins in legs and vulva
-predispose to DVT
• SUPINE HYPOTENSION:
Enlarged uterus compression venous system
impairs blood return from lower
extrimity...decreased cardiac filling...decrease
cardiac output..supine hypotension syndrome
RESPIRATORY SYSTEM
• Transverse diameter thoracic cage - increase
2cm
• 0xygen consumption increases 45ml/min
• R.R is changed a little
• Tidal volume increases from 500 to 700ml,
minute ventillatory vol increases by 40%,
minute O2 intake increases
• FRC (ERV+RV) decreses by 500ml
• RV decreases
• Lung compliance uneffected
• Total pulmonary resistance uneffected
ter
• physiological dyspnoea occurs- due to increase
in tidal volume that lowers blood PCO2
• Increase respiratory effort – mediated by
progesteron
• To compensate resulting respiratory alkalosis
plasma HCO3 level decreases (26-20mmol)
• Minimal increase in blood Ph- shifts O2

dissociation curve to left thus increasing
affinity of maternal blood to O2 - bohr effect
• But increase in Ph also stimulate increase in

2,3- DPG in maternal RBC, counteracts Bohr
effect
RENAL CHANGES
• KIDNEY
-increase in length by 1cm
-GFR increases by 50%
-renal blood flow increases by 25-50%
-Increase excretion of various nutrients
-GFR increase without alternation of production
of urea & creatinine, thus their levels
decreases
-creatinine clearance in pregnancy 30% higher
than 100-115ml/min measured normally
-glycosuria
-proteinuria/hematuria
-
• URETER
- dilatation of ureter above pelvic brim occurs due
to enlargement of uterus compressing them at
pelvic brim & due to effect of progesteron
- Right > left
- elongation, kinking and outward displacement of
ureter
• BLADDER
-marked congestion with hypertrophy of muscles
-increase frequency of micturition 6-8 wks
subsides after 12 wks, in late pregnancy again
frequency due to pressure on bladder as
presenting part descends
- stress urinary incontinence occurs- weak sphincter
ALTERNATION CLINICAL RELEVANCE
Increased renal size Renal length approx 1 cm Postpartum decreases in size

greater on radiographs should not be mistaken for
parenchymal loss
Dilation of pelves, Resembles hydronephrosis Not to be mistaken for obstructive

calyces and ureters on ultrasound or IVP (more uropathy, collection errors, upper
marked on right) urinary tract infections, elective
pyelography should be deferred
to at least 12 wks postpartum
Increased renal Glomerular filtration rate Serum creatinine and urea
hemodynamics and renal plasma flow nitrogen values decreases during
increases approx 50% normal gestation
Renal water handling Osmoregulation altered , Serum osmolarity decreases

osmotic thresholds for AVP 10mOsm/l, during normal
release and thirst gestation, increased metabolism of
decrease,hormonal disposal AVP may cause transient diabetes
rates increase insipidus in pregnancy
CHANGES IN GIT SYSTEM:
• Gums become soft,congested
• Pyrosis (heart burn)- decrease in tone of lower
esophageal sphincter
• Muscle tone and motility of entire GIT
diminished
• Gastric emptying time unchanged
• LIVER- alkaline phosphotase - activity doubles-
increase is due to heat stable placental alkaline
phosphatase isoenzymes
• AST/ALT/gamma GT/bilirubin level DECREASES
• Gall bladder contractility reduced- increase serum
cholesterol –increase stone formation
ENDOCRINE SYSTEM
PITUITARY GLAND
• growth hormone - 1st timester by
maternal pituitary, by 17wks placenta is
principle source. 10wks 3.5ng/ml, 28 wks
14ng/ml there after plateaus.
• Prolactin-increase by 10 fold ~150

ng/ml, function- ensure lactation, amniotic
fluid prolactin impairs transfer of water
from fetus to maternal compartment thus
preventing fetal dehydration
THYROID GLAND
• Thyroid undergoes moderate enlargement –
glandular hyperplasia/increased vascularity
• Increase circulating level of thyroxin
transport protein, thyroxin binding globulin
• Pregnancy accompanied by decrease
availability of iodide for maternal thyroid-
increase renal clearance
• Total T3,T4 increased but free T4 level
unchanged,TSH remains Normal or sightly
increased.
• BMR increases by 25%.
• Parathyroid hormone
Concenttration decreases during 1st trimester
then progressively increase throughout
pregnancy
-increase level due to low calcium concentration
-estrogen block action of PTH on bone resorption
-net result is physiological hyperparathyoidism
• Calcitonin levels higher than in nonpregnant
state
• Adrenal glands
- cortisol level is increased due to decrease
metabolic clearance
- aldosterone level increased, by 3rd trimester
1mg/day.
Musculoskeletal system
• Progressive lordosis
• Sacroiliac, sacrococcygeal, pubic joint –
increased mobility
• Relaxation of pelvic joints
CHANGES IN EYES
• Decrease in intraocular pressure
• Corneal senstivity decreases
• Increase in corneal thickness due to edema
• Transient loss of accomodation
Metabolic changes
Total pregnancy energy demand - 80,000kcal.
Weight gain: 12.5 kgs
Tissues and fluids 10wks 40wks
fetus 5 3400
placenta 20 650
Amniotic fluid 30 800
uterus 140 970
breast 45 405
blood 100 1450
Extravascular fluids 0 1480
Maternal stores(fat) 310 3345
total 650 12500
• WATER METABOLISM
-water retention 6.5lit
-3.5lit fetus/placenta/amniotic fluid, 3 lit

blood vol, uterus and breasts
-Accumulation of fluid in lower

extremities- pedal edema- increased
venous pressure below the level of
uterus/decrease in interstitial colloid
osmotic pressure
• PROTEIN METABOLISM
-1000 gm protein gained- 500gm in fetus,

remaining 500gm added to uterus,
breast, maternal blood
-total plasma protein increase 180 to

230gm,
-haemodilution leads to fall 7 to 6gm%

CARBOHYDRATE METABOLISM
-Mild fasting hypoglycemia, postprandial
hyperglycemia & hyperinsulinemia
-insulin action in late pregnancy -50-70%lower
Causes of insulin resistance
1. Progesteron and estrogen
2. Human placental lactogen-growth hormone
like action
 FAT METABOLISM
Lipids concentration increases
Deposition of fats occurs in central sites
Leptin peptide hormone – regulation of body fat
& energy expenditure
ELECTROLYTES &MINERALS
• Iron requirement 1000mg; 500mg- RBC vol
expansion, 300mg- fetus, 200mg obligatory
loss
requirement 2.5mg/day early pregnancy,
5.5mg/day in 20-32 wks, 6-8mg/day from 32
wks
• 1000 meq of Na+ & 300 Meq K+ retained

• Calcium level decreases, ionised calcium
remain unchanged, during 3rd trimester
200mg/day ca++ deposited in fetal skeleton
• Magnesium levels decline during pregnancy while
phosphate levels within normal range

Changes During Pregnancy

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PHYSIOLOGICAL CHANGES

-blood flow increases- 450-650 ml/min near

-uterine artery diameter doubles by 20 weeks &

-vasodilatation is mainly mediated by estrogen

Plasma volume 2600ml 1250ml 50%

RBC volume 1400ml 240ml 18%(without fe )

400ml 30%(with fe)

haematocrit 38% 32%

• Decrease blood viscosity ensures optimal

• Protection against adverse effect of blood

• Decrease viscosity – decrease resistance to

• Decrease in humoral and cell-mediated

• Coagulation cascade is in activated state

• Increase in all clotting factor except XI and

• Fibrinolytic activity is reduced

• Slight decrease in platelet counts,

• Systemic and pulmonary vascular

• left ventricular function normal, no change

• Minimal increase in blood Ph- shifts O2

• But increase in Ph also stimulate increase in

Increased renal size Renal length approx 1 cm Postpartum decreases in size

Dilation of pelves, Resembles hydronephrosis Not to be mistaken for obstructive

Renal water handling Osmoregulation altered , Serum osmolarity decreases

• Prolactin-increase by 10 fold ~150

Tissues and fluids 10wks 40wks

-3.5lit fetus/placenta/amniotic fluid, 3 lit

-Accumulation of fluid in lower

-1000 gm protein gained- 500gm in fetus,

-total plasma protein increase 180 to

-haemodilution leads to fall 7 to 6gm%

• 1000 meq of Na+ & 300 Meq K+ retained

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