PHYSIOLOGICAL

CHANGES IN
PREGNANCY
 GENITAL ORGANS

VULVA: Vulva becomes edematous and more vascular; superficial varicosities may appear especially
in multiparae. Labia minora are pigmented and hypertrophied.
VAGINA: Vaginal walls become hypertrophied, edematous and more vascular. Increased blood supply
of the venous plexus surrounding the walls gives the bluish coloration of the mucosa (Jacquemier’s
sign). The length of the anterior vaginal wall is increased .

Secretion: The secretion becomes copious, thin and curdy white due to marked exfoliated cells
and bacteria. The pH becomes acidic (3.5–6) due to more conversion of glycogen into lactic acid
by the Lactobacillus acidophilus consequent on high estrogen level. The acidic pH prevents
multiplication of pathogenic organisms.
Cytology: There is preponderance of navicular cells in cluster (small intermediate cells with
elongated nuclei) and plenty of lactobacillus

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in pregnancy
The uterus which in nonpregnant state weighs about 60 g, with a cavity of 5–10 mL and measures about 7.5
cm in length, at term, weighs 900–1,000 g and measures 35 cm in length. The capacity is increased by
500–1,000 times. Changes occur in all the parts of the uterus—body, isthmus and cervix.
BODY OF THE UTERUS: There is increase in growth and enlargement of the body of the uterus.
Enlargement: The enlargement of the uterus is affected by the following factors:
 Changes in the muscles—(1) Hypertrophy and hyperplasia. These occur under the influence of the
hormones—estrogen and progesterone.
 (2) Stretching: Th e muscle fibers further elongate beyond 20 weeks due to distension by the growing
fetus. The wall becomes thinner and, at term, measures about 1.5 cm or less. Th e uterus feels soft and
elastic.

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 Arrangement of the muscle fibers: Three distinct layers of
muscle fibers are evident:

1) Outer longitudinal—It follows a hood-like

arrangement over the fundus.
2) (2) Inner circular—It is scanty and sphincter like
arrangement around the tubal orifices and internal os.
(3) Intermediate—It is the thickest and strongest layer
arranged in crisscross fashion through which the blood
vessels run. n There is simultaneous increase in number
and size of the supporting fibrous and elastic tissues.
The uterine enlargement is not a symmetrical one. The
fundus enlarges more than the body.

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 CERVIX
.
Uterine contraction in pregnancy has been named after
BraxtonHicks who first described its entity during pregnancy
softening of the cervix (Goodell’s sign)
The contractions are irregular, infrequent, spasmodic and
painless without any effect on dilatation of the cervix.

ISTHMUS A B C

There are important structural and functional changes in the

isthmus during pregnancy.
During the first trimester, isthmus hypertrophies and elongates to
about 3 times its original length. It becomes softer. With advancing
pregnancy beyond 12 weeks, it progressively unfolds from above,
downward until it is incorporated into the uterine cavity.

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 BREAST
SIZE: Increased size of the breasts becomes evident even in early
weeks. This is due to marked hypertrophy and proliferation of
the ducts (estrogen) and the alveoli (estrogen and progesterone)
which are marked in the peripheral lobules. The “axillary tail”
(prolongation of the breast tissue under cover of the pectoralis
major) becomes enlarged and painful.
NIPPLES AND AREOLA: The nipples become larger, erectile and
deeply pigmented, the areola, become hypertrophied and are
called Montgomery’s tubercles. Those are placed surrounding
the nipples. Their secretion keeps the nipple and the areola
moist and healthy.
SECRETION: Secretion (colostrum) can be squeezed out of the breast at about
12th week which at first becomes sticky. Later on, by 16th week, it becomes
thick and yellowish. The demonstration of secretion from the breast of a
woman who has never lactated is an important sign of pregnancy..

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 CUTANEOUS CHANGES

CUTANEOUS CHANGES

PIGMENTATION: The distribution of pigmentary changes is selective.

•Face
• (chloasma 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; disappears spontaneously after delivery.
•Abdomen:
1.Linea nigra: It is a brownish black pigmented area in the midline
stretching from the xiphisternum to the symphysis pubis The pigmentary
changes are probably due to melanocyte stimulating hormone from the
anterior pituitary.
2.Striae gravidarum. These stretch marks represent the scar tissues in the
deeper layer of the cutis. Initially, these are pinkish but after the delivery, the
scar tissues contract and obliterate the capillaries and they become
glistening white in appearance and are called striae albicans.

OTHER CUTANEOUS CHANGES: These include vascular spider and palmar

erythema which are due to high estrogen level. Mild degrees of hirsutism may be
observed and in puerperium the excess hair is lost.

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 WEIGHT GAIN

• REPRODUCTIVE WEIGHT GAIN : 6Kg

• Uterus—0.9 kg and breasts—0.4 kg

• Accumulation of fat (mainly) and protein—3.5 kg

• Increase in blood volume—1.3 kg

• Increase in extracellular fluid—1.2 kg

• The amount of water retained during pregnancy at term is estimated to be 6.5 litres.
• Weight gain for a woman with normal BMI (20–26) is 11–16 kg.

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 BODY WATER METABOLISM
• During pregnancy, the amount of water retained at term is about 6.5 liters. The water content of the
fetus, placenta and amniotic fluid is about 3.5 liters.
• Pregnancy is a state of hypervolemia.. The important causes of sodium retention and volume
overload are:
• (i) changes in maternal osmoregulation, (ii) increased estrogen and progesterone, (iii) increase in
renin-angiotensin-aldosterone system (RAAS) activity, (iv) increased aldosterone, deoxycorticosterone,
(v) control by arginine vasopressin (AVP) from posterior pituitary and (vi) atrial natriuretic peptide.
Serum sodium level and plasma osmolality decreases. There is resetting of the osmotic thresholds
for thirst and AVP (ADH) secretion. Increase in water intake due to lowered osmotic threshold for
thirst causes polyuria in early pregnancy. The threshold for AVP secretion has been reset after 8
weeks for a new steady state of osmolality. Thereafter polyuria decreases.

• Atrial and brain natriuretic peptides, secreted by atrial myocytes and brain ventricles. These act as
diuretics, natriuretics and vasorelaxants. Both the peptides are antagonist to RAAS.

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 Table: Principal Blood Changes during Pregnancy

Parameters Nonpregnant Pregnancy Near Term Total

Increment Changes

Blood volume (mL) 4000 5500

1500 + 30–40%
Plasma volume (mL) 2500 3750
1250 + 40–50%
Red Cell volume (mL) 1400 1750
35 + 20–30%
Total Hb (g) 475 560 85
+ 18–20%
Hematocrit (whole body) 38% 32% No
change Diminished

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 Table 5.3: Changes in Blood Coagulation Factors
Table 5.2: Plasma Protein Changes during Pregnancy
Parameters Nonpregnant Pregnancy near term Change
Parameters Nonpregnant Pregnancy Change
Platelets 1,60,000– Confl icting observation Static or
near term
(mm3 ) 2,00,000 15% Total protein 180 230 Increased
reduction (g)
of the
Plasma 6 Decreased
count
Fibrinogen 200–400 + 50%
protein
(mg%) concentration
(g/100 mL)

Albumin 4.3 3 Decreased

(g/100 (30%)
Fibrinolytic — Depressed —
activity mL)
Clotting — Unaff ected —
Globulin 2.7 3 Slightly
time (g/100 increased
mL)

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 CARDIOVASCULAR SYSTEM

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 SUPINE HYPOTENSION SYNDROME (POSTURAL HYPOTENSION): During late pregnancy, the gravid uterus
produces a compression effect on the inferior vena cava when the patient is in supine position. This,
however, results in opening up of the collateral circulation by means of paravertebral and azygos veins. In
some cases (10%), when the collateral circulation fails to open up, the venous return of the heart may be
seriously curtailed. This results in production of hypotension, tachycardia and syncope. The normal blood
pressure is quickly restored by turning the patient to lateral position. The augmentation of the venous
return during uterine contraction prevents the manifestation from developing during labor.
REGIONAL DISTRIBUTION OF BLOOD FLOW: Uterine blood flow is increased from 50 mL/min in
nonpregnant state to about 750 mL near term. Nonpregnant uterus receives 2% of CO and breasts 1%.
Increase in blood flow going to the organs is about 50% due to overall increase in CO. The increase is due
to the combined effect of uteroplacental and fetoplacental vasodilatation The vasodilatation is due to the
smooth muscle relaxing effects of progesterone, estrogen, nitric oxide (endothelium derived factor),
prostaglandins and atrial natriuretic peptide (ANP). In a normal pregnancy, vascular system becomes
refractory to angiotensin II, endothelin I and other pressure agents .Pulmonary blood flow (normal 6,000
mL/min) is increased by 2,500 mL/min. Renal blood flow (normal 800 mL) increases by 400 mL/min at
16th week and remains at this level till term. The blood flow through the skin and mucous membranes
reaches a maximum of 500 mL/min by 36th week. Heat sensation, sweating or stuffy nose complained
by the pregnant women can be explained by the increased blood flow.

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• Pregnancy is in a state of respiratory alkalosis. Table 5.7: Acid-Base Changes
Parameters Nonpregnant Pregnancy Change
• Renal plasma flow is increased by 50–75%. near term
Arterial 95 mm Hg 106 mm Increased
• Glomerular filtration rate (GFR) is increased by 50% all PO2 Hg
Arterial 32 mm Hg Diminished
throughout pregnancy. PCO2

• Marked hypertrophy of the muscle and the sheath of the

ureter especially the pelvic part probably due to estrogen.
There is elongation, kinking and outward displacement of
the ureters.
• Daily requirement of calcium during pregnancy and pH 7.40 7.42 Slightly
increased
lactation averages 1–1.5 g. Maternal total calcium levels Plasma 26 m mol/L 22 Decreased

fall but serum ionized calcium level is unchanged. HCO–3 mmol/L

• Calcium absorption from intestine and kidneys are doubled

due to rise in the level of 1, 25 dihydroxy vitamin D3 .
• Calcitonin levels increase by 20%.

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Thank you