Physiological Changes

during Pregnancy
CHANGES IN THE GENITAL
ORGANS
1.Vulva &Vagina
2. Uterus
3. lsthmus
4.Cervix
5. Fallopian Tube
6. O v ar y
 Vulva
• Oedematous
• More Vascular
• Superficial varicosities may appear
specially in multiparae.
• Labia minora are pigmented and
hypertrophied
 Vagina
• Vaginalwalls become
hypertrophied, oedematous
and more vascular.
• Increased blood supply of the
venous plexus
surrounding the walls gives
bluish discoloration of the
mucosa (Jacquemier’s sign)
• The length of the anteriorvaginal wall
is increased.
 Secretion becomes copious,
Cont…
thin and curdy white due to
marked exfoliated cells and
bacteria.
• pH becomes acidic (3.5-6) due
to more conversion of glycogen
into lactic acid by the lacto
bacillus acidophilus consequent
in high estrogen level.
 Uterus
• Non-pregnant state weighs about
50gm, with a cavity of 5-10 ml and
measures about 7.5 cm in length, at
term, weighs 900-1000 gm and
measures 35cm in length
• Changes occur in all the parts of uterus
body,
isthmus and cervix.
•Increase in growth and enlargement of
the body of the uterus.
Enlargement- It is affected by the
following factors;
 Changes in the muscles
(1)Hypertrophy and hyperplasia-occur
under the influence of the hormones-
oestrogen and progesterone
(2)Stretching: The muscle fibres
further elongate beyond 20
weeks due to distension by
the growing foetus. The wall
becomes thinner and at term,
measures about 1.5cm or less.
The uterus feels soft and elastic in
contrast to firm feel of the non
gravid uterus.
 Arrangement of the muscle fibres
1)Outer longitudinal — follows a hood like
arrangement over the fundus; some fibres
are continuous with the round ligaments
(2)Inner circular — It is scanty and have
sphincter like arrangement around the tubal
orifices and internal os
(3) Intermediate - It is the thickest and
strongest layer arranged in criss-cross
fashion through whichblood vessels run.
Simultaneous increase in number and size
of the supporting fibrous and elastic
tissues.
*
Cont…
Apposition of two
double curve muscle
fibres give the figure of
‘8’ form, when the
muscle contract , they
occlude the blood
vessels running
through the fibers and
hence it called as
living ligature.
 Vascular system
• Uterine artery diameter becomes double
• Blood flow increases by eight fold at 20
weeks of pregnancy.
• Vasodilatation is mainly due to estradiol
and
progesterone.
• Veins become dilated and are
valveless. Numerous lymphatic
channels open up.
Vascular changes are most
pronounced at the
placental site
 Weight

Weight is due to the increased

growth of the uterine muscles,
connective tissues and vascular
channels
 Relation:Shape
• Non pregnant pyriform shape is
maintained in early months.
• Becomes globular at 12 weeks.
• As the uterus enlarge, the shape
once more becomes pyriform or
ovoid by 28 weeks
• Changes to spherical beyond
36th week
 Position
• Normal anteverted positions exaggerated
up to 8 weeks
• The enlarged uterus may lie on the
bladder rendering it incapable of filling,
clinically evident by frequency of
micturation.
• Afterwards, it becomes erect, the long axis
of the uterus conforms more is a tendency
of ante version in case of multiparae at term
.
Primi'gravidae with good tone of the
abdominal muscles, it is held firmly against the
maternal spine.
Contractions (Braxton-Hicks) : Uterine
contraction in pregnancy has been
named after braxton hicks who first
described its entity during pregnancy.
From the very early weeks of
pregnancy the uterus undergoes
spontaneous contraction. This can be
felt during bimanual palpation in early
weeks .Irregular, infrequent, spasmodic
and painless without any effect on
dilatation of the cervix.
Endometrium : structural and
secretory activity of the endometrium
Isthmus-
•Structural and functional changes in
the isthmus during pregnancy.
During the first trimester, isthmus
hypertrophies and elongates to
about 3 times its original
length.
• Becomes softer.
• With advancing pregnancy
beyond 12 weeks, it becomes
unfolds from above ,downward
until it is incorporated into the
uterine cavity. The circular
arranged muscle fibers in the
region function as a sphincter in
early pregnancy and helps to
retain fetus within the uterus.
 Cervix
• Stroma- Hypertrophy and
hyperplasia of the elastic and
connective tissues. Fluid
accumulate inside and in
between the fibers.
• Vascularity is increased beneath
the sqamous epithelium of the
portio vaginalis which is
responsible for its bluish
discolouration.
• Softening of the cervix (Goodell's
• Squamous cells also become
Cont..
hyperactive
• Mucosal changes simulate basal
cell hyperplasia or cervical
intraepithelial neoplasia
(CIN)
Secretion is copious and,
tenacious — physiological
leucorrhoea of pregnancy.
This is due to the effect of
progesterone.
The length of the cervix
Cont….
The cervix is directed posteriorly but
after the engagement of the head,
directed in line of vagina. There is no
alteration in the relation of the cervix.
There is unfolding of the isthmus ,
beginning 12 weeks onwards and takes
part in the formation of the lower
uterine segment. Variable amount of
effacement is noticed near term in
primigravidae. In multiparae, the canal
is slightly dilated.
 Fallopian Tube
• Total length is increased
• Tube becomes congested
• Muscles undergo
hypertrophy
 Ovar
• Growth andyfunction of the corpus
luteum reaches its maximum at 8 th
week when it measures about 2.5 cm
and becomes cystic. It looks bright
orange, later on becomes yellow and
finally pale. Regression occurs
following decline in the secretion of
HCG from the placenta. Colloid
degeneration occurs at 12th week
which later becomes calcified at term.
Cont..
• Hormones-estrogen and
progesterone secreted by the
corpus luteum maintain the
environment for the growing ovum
before the action is taken over by
the placenta.
• Control the formation and maintenance
of decidua of pregnancy but also
inhibit ripening of the follicles. Both
the ovarian and uterine cycles of the
normal menstruation remain
suspended.
 BREAST CHANGES
• Increased size of the breasts
• Marked hypertrophy and proliferation of
the
ducts (oestrogen and progesterone)
• Vascularity is increased
• The nipples become larger, erectile and
deeply
pigmented
• Sebaceous glands (5-15) become
hypertrophied and are called
Montgomery's tubercles
• Outer zone of less marked and irregular
pigmented area appears in the second
trimester and is called secondary
areola
• Secretion (colostrum) can be squeezed
out of
the breast at about 12th week which at
first becomes sticky. Later on by 16 th
week ,it becomes thick and yellowish.
 CUTANEOUS CHANGES
Face (cholasma gravidarum or
pregnancy mask)
It is an extreme form of pigmentation
around the cheek, forehead and around
the eyes. It may be patchy or diffuse,
disappear spontaneously after delivery.
Breast
changes
Abdome
•n Linea nigra : a brownish black
pigmented area in the midline
stretching from the xiphisternum to
the symphysis pubis
• Straie qraviderum :sIightIy
depressed linear
marks with varying len th
and
breadth found in pregnancy
 Cont…
They are predominately found in the
abdominal wall below the umblicus ,
sometimes over the thighs and breasts. These
represent the scar tissues in the deeper layer
of the cutis. Initially these are pinkish but after
delivery , the scar tissues contract and
obliterate the capillaries and they become
glistening white in appearance and are called
striae albicans. But in multiparae both pinkish
and white striae are visible. Apart from the
mechanical stretching of the skin, increase in
aldosterone production during pregnancy are
responsible factors.
Cont…
Other cutaneous changes;
These include vascular spider and
palmar erythema which are due
to high oestrogen level. There
may be tendency of falling hairs
or increased brittleness of the
nails.
 HEMATOLOGICAL
CHANGES
Blood volume
• Due to increased vascularity of the
enlarging uterus, Blood volume is
markedly raised during
pregnancy
• The blood volume starts to increase
from about 6th week, expends rapidly
thereafter to maximum 40-50% above
the nonpregnant level at 30-32 weeks.
The level remains static till term.
,
Plasma
Volume
• Starts to increase by 6 weeks
• Rate of increase almost parallels to that
of blood volume
• Reached to the extent of 50%
• Total plasma volume increases to the
extent of
1.25 litters. The increase is greater in
multigravida, in multiple pregnancy and
with large baby.
v
n
RBC And
Haemoglobin
• The RBC mass is increased to the extent
of 20-
30%.The total increase in volume is about
350 ml, the amount to be regulated by
the Increase demand of oxygen transport
during pregnancy
• Disproportionate increase in plasma and
RBC volume produces state of
haemodilution (fail in haemocrit)
• At term , Hb faII is about 2 gm.% from
the non-pregnant
 Leucocytes And Immune System
In the second and third trimester, the action
of the polymorphoneuclear leukocytes may
be depressed, perhaps accounting for the
increased susceptibility of pregnant women
to infection
Total plasma protein increases from the
normal 180 gm. (non-pregnant) to 230 gm
at term.
Due to haemodiIution(increase plasma
volume),
the plasma protein concentration falls from 7
gm.% 6 gm.%
* BIood Coagulation Factor Pregnancy is
a hypercoagulable state. Plasma fibrinogen
 METABOLIC CHANGES
General Metabolic Changes
• Total metabolism is increased due to the
needs of the growing fetus and the uterus
• Basal metabolic rate is increased to the
extent of 30% higher than that of the average
for the non- pregnant women.
Protein Metabolism
Positive nitrogenous balance
throughout pregnancy.At term, the
fetus and the placenta contain about
500of protein and the maternal
gain is also about 500 g chiefly
distributed in the uterus, breasts
 Carbohydrate Metabolism
• Insulin secretion is increased in
response to glucose
and amino acids.
• Hyperplasia and hypertrophy of beta
cells of pancreas.
• Increased insulin level favours
lipogenesis (fat storage).This
mechanism ensures continuously
supply of glucose to the fetus
Fa t Metabolism- Average of 3-4 kg of fat is
stored during pregnancy mostly in the
abdominal wall, breasts, hips and thighs.
Plasma lipids increase during the later half of
Iron Metabolism
• Iron is absorbed in ferrous form from
duodenum and jejunum and is released
into the circulation as transferrin
• 10 percent of ingested iron is absorbed
• Total iron requirement during
pregnancy is estimated approximately
1000mg. This is distributed in fetus
and placenta 300 mg and expand red
cell volume 400 mg . There is
obligatory loss of about 200 mg
through normal routes.
• In the absence of iron supplementation,
there is drop in haemoglobin, serum iron
 Weight Gain
• In early weeks, the patient may lose
weight
because of nausea and vomiting
• During subsequent months, the weight
gain is progressive until the last one or
two weeks, when the weight
remains static
• The total weight gain during the
course of a singleton pregnancy for a
healthy woman averages 11 kg
Distributed to 1 kg in first trimester and
5 kg
* each in second and third trimester
The total weight gain at term is
distributed approximately
as :
Reproductive weight Net maternal weight
gain gatn
6 kg : 6 kg
Fetus — 3.3 kg, Increases in blood
placenta
uterus — 0.9 kg volume — 1.3 kg
0.6
andkg and •0.4
breast liquorkg,
— Increases in
0.8 kg
accumulation of the extracellular fluid —
fat and protein — 1.2 kg
3.5 kg
Cont..
The amount of water retained
during pregnancy at term is
estimated to be 6.5 liters due to
diminished colloid osmotic tension
because of hem dilution driving
the fluid out of vessels and
increased venous pressure of the
inferior extremities. Thus slight
oedema of legs is not uncommon ,
in otherwise normal pregnancy.
Cont…
Importance of weight checking-
To detect abnormality. Like rapid
gain in weight of more than 0.5 kg
or 1 lb a week or more than 2 kg or
5 lb a month in later months of
pregnancy may be early
manifestations of preeclampsia and
need for careful observation. If
stationary fall in weight is the
features of IUGR or IUFD
Calcium metabolism and
locomotor
system
• Relaxation of pelvic ligaments and
muscles occurs because of the influence
of estrogen and relaxtin reaches
maximum during last weeks of the
pregnancy
• Increased lumber lordosis during later
months of the pregnancy due to
enlarged uterus backache and
wadding gait.
• Daily requirement of calcium during
pregnancy averages 1-1.5 grams.
 SYSTEMIC CHANGES
Respiratory System
• Shape of the chest and the circumference
increases in pregnancy by 6 cm
• Progressive increase in oxygen
consumption, which is caused by the
increased metabolic needs of the mother and
fetus
• The mucosa of the nasopharynx becomes
Hyperaemia and oedematous,A state of
hyperventilation occurs during pregnancy
leading to increase tidal volume The
woman feels shortness of breath because of
progesterone acting on the respiratory
 CARDIOVASCULAR CH
The Heart :
• muscle, particularly the left ventricles,
hypertrophies leading to enlargement of
the heart
• The growing uterus pushes the heart
upward and to the left
• During pregnancy the heart rate and
stroke
volume (the amount of the blood pumped
by
* “ h ea r t with each beat) increases due
to the
 Cardiac
Output
• :
increases markedly by the end
of the first trimester.
• In the third trimester, a rise, fall or no
change at all has been showed to
occur, depending on individual
variables.
• lowest in the sitting or supine
position and highest in the right or left
lateral or knee chest position.
The capacity of veins and venules
increases.
* Serial walls relax and dilate due to the
effect of progesterone. The increase
Blood Pressure
• During the mid-trimester,
changes in pressure may
occur causing fainting
• In later pregnancy, hypotension may
occur in 10% of women in
unsupported supine position. This
termed as “supine hypotensive
syndrome”
• The pressure of gravid uterus
compresses the vena cava,
reducing the venous return
Cardiac output is reduced by 25-30
percent and
Regional Distribution Of The Blood
Flow
• Uterine blood flow is increased from
50 ml per minute in non-pregnant state
about 750 ml near term
• Pulmonary blood flow (normal
6000mI/min) is increased by 2500
ml per minute
• Renal blood fl ow (normal 800 ml)
increases by 400 ml per minute at 16th
week remains at this level till term.The
blood flow through the skin and mucous
membranes reaches a maximum of
500ml/minute by 36th week.
Heat sensation, sweating or stuffy nose
Urinary
System
• kidney
• Dilatation of the ureter, renal pelvis and
calyces. The kidneys enlarge in length by 1
cm.
• Renal plasma flow is increased by 50-75% ,
maximum by the 16 weeks and is maintained
until 34 weeks. Thereafter it falls by 25%.
Renal tubules fail to reabsorb glucose, uric acid,
aminoacids , water soluble vitamins and other
substances completely due to mainly
Glomerular filtration rate (GFR) is increased by
50%all throughout the pregnancy.
• Ureter
ureters become atonic due to high
progesterone level. “Dilatation of the ureter
• Bladder
• Increased frequency of micturition is
noticed at 6-8
weeks of pregnancy which subside after
12 weeks
and In late pregnancy, frequency of
micturition once more reappears
due to pressure
on the bladder as the presenting part
descends down the pelvis.
• Stress incontinence may observe in
late
pregnancy due to urethral sphincter
weakness
 Alimentary
•System
Gums become congested and spongy
and may
bleed to touch. Muscle tone and motility
of the entire gastro intestinal tract are
diminished due to high progesterone
level. Cardiac sphincter is relaxed and
regurgitation of acid gastric contents into
the oesophagus may produce chemical
oesophagitis, and heat burn. There is
diminished gastric secretion and delayed
emptying time of the stomach.
 Atonicity of the gut leads to constipation ,
while diminished peristalsis facilitates
more absorption of food materials.
Cont…
Liver and Gall Bladder:
There is no histological changes in the
liver cells , but the functions are
depressed. Atonicity of the gall bladder
. This together with high blood
cholesterol level during pregnancy,
favors stone formation.
NERVOUS SYSTEM
• Some sorts of temperamental
changes are found during pregnancy
and in the puerperium
• Nausea, vomiting, mental
irritability and sieeplessness are
probably due to some
psychological background.
• Generalized neuritis probably due
to vitamin B1 deficiency . Rarely
cutaneous nerve involvement
may occur during pregnancy and
labour.
 Cont..
• Compression of lumbosacral trunk by
the fetal head or by the prolapsed
intervertebral disc may produce
feature of sciatica or even paralysis
of some muscles of the legs. It either
develops during late pregnancy or
labour or following delivery.
• Compression of the median nerve
underneath the carpel ligament over
the wrist joint leading to pain and
parasthesia in hand and arm i.e
carpel tunnel syndrome may appear
in the later months of pregnancy.
• Postpartum blues, depression or psychosis
CHANGES IN THE
ENDOCRINE
SYSTEM
Placental Hormones
• Placenta produces several hormones
• The high levels of estrogen and
progesterone produced by the placenta
are responsible for breast changes, skin
pigmentations and uterine enlargement
in the first trimester
Chorinonic gonadotrophin is the basis
for the ir munologic pregnancy tests
• Human placental lactogen stimulates
the growth of the breasts.
Pituitary Hormones
• The secretion of prolactin,
adrenocorticotrophic hormone,
thyrotrophic hormone and melanocyte-
stimulating hormone increases
• Follicle stimulating hormone and
luteinzing hormone secretion is
greatly inhibited by placental
progesterone and estrogen.
• The effects of prolactin secretion are
suppressed during pregnancy
Posterior pituitary gland releases oxytocin
in IN-frequency pulses throughout
pregnancy. At term the frequency of
Thyroid Function
• Gland increases in size by about 13
percent due to hyperplasia of glandular
tissue and increased vascularity
• The serum protein bound iodine is
increased during pregnancy and rise in
thought to reflect an increase in
concentration and binding capacity of
thyroxin binding globulin due to oestrogen
stimulation.
• Iodine and drugs used to treat
hyperthyroidism.
Cont..

 Pregnancy can give the

impression of
hyperthyroidism, thyroid
function is basically normal
 The basal metabolic rate is
increased mainly because
of increased oxygen
consumption by the mother
and fetus and the work of
the maternal heart and
Cont..
Adrenal cortex-
•Rise of plasma cortisol progressively
from the first trimester and attain
plateau during the second trimester. At
this level , it remains stationary until
labour begins when there is final surge
of ACTH and cortisol level.
Parathyroid gland-
It rises from 20-24 weeks of gestation
and reaches at peak level at term. It
does not cross the placenta.
The marked demand of calcium 25 to
 Cont..
by the fetus during the second half of
the pregnancy is achieved an increase
in maternal 1,25 dihydroxy vitamin D
levels and an increase in the intestinal
absorption of calcium. The absorption
and turnover of calcium occur well in
advance of fetal skeletal
mineralization . Calcium level in
pregnancy is increased.
The Pancreas –
•In pregnancy there is hyperinsulinism
and is marked particularly at third
Cont..
which coincides with the peak
concentration of placental hormones .
Despite increase in postprandial insulin
level , the fasting insulin concentration
is reduced. Several anti insulin factors
operate during pregnancy . These
include;
Increase glucagon from cells of the
longerhans of pancreas.
Increased glucocorticoid secreted by
the anterior pituitary and placenta.
Degradation of circulating insulin by
 Hormonal influences necessary for
maintenance of Lactation
The breast is modified sweat gland. It
consists of ducts ,alveoli and fibro fatty
connective tissue .During puberty,
proliferation of fibro fatty tissue , without
any change in the alveoli-ductal system.
The endocrine control of lactation can be
divided into following stages;
Preparation of breast (mammogenesis)
Synthesis and secretion of milk by breast
alveoli( lacto genesis)
Ejection of milk( Galactokinesis)
Maintenance of lactation( Galactopoiesis)