CLASSROOM

PRESENTATION ON
PHYSIOLOGICAL
CHANGES DURING
PREGNANCY

By,
Aditi Biswas
Roll No 28
Bsc.(N) 4th year
IINR, Kalyani
 Introduction

• During pregnancy there is progressive

anatomical, physiological and
biochemical changes not only confined to
the genital organs but also to all systems
of the body. This is principally a
phenomenon of maternal adaptation to
the increasing demands of the growing
fetus.
Genital Organs
• Vulva
• Vagina
• Uterus
• Fallopian Tube
• Ovary
• Breasts
Vulva
• Vulva become Edematous and more vascular
• Superficial varicositis may appear specially in multi-
parae
• Labia minora are pigmented and hypertrophied.
Vagina
• Vaginal walls become hypertrophied, edematous and
more vascular.
• Jacquemier’s sign appears.
• Osiander’s sign appears.
• Secretion : The secretion becomes copious thin and
cardy white and the pH become acidic(3.5-6)
• Cytology: there is preponderence of navicular cells in
cluster.
Uterus

• There is a enormous growth of the

uterus during pregnancy. The uterus
which is in non-pregnant state weights
about 60 g with a cavity of 5-10 ml
and measures about 7.5 cn in length,
at term weights 900-1000 g and
measures 35 cm in length.
Body of the
uterus
There is a increase in growth and enlargement of the body of the
uterus.
• Changes in the muscles
1. Hypertrophy and hyperplasia
2. Stretching
• Arrangement of the muscle fibres
1. Outer longitudinal
2. Inner circular
3. Intermediate
• There is simultaneous increase in number and size of the supporting fibres
and elastic tissues –
1. Vascular system
• Where is in the non pregnant state, the blood supply to the uterus is mainly
through the uterine and least through the ovarian but in pregnant state the letter
carries as much as the blood as the former.
• Doppler velocimetry has shown uterine artery diameter becomes double and blood
flow increases by 8-4 at 20 weeks of pregnancy.
• The uterine enlargement is not a symmetrical one, the fundus in large more than
the body.
2. Weight
The increase in weight is due to the increased growth of the uterine muscles
connective tissues and vascular channels.
3. Relation
Shape- non pregnant pyriform shape is maintained in early months. It becomes
globular at 12 weeks as the uterus enlarge. The shape once more becomes
pyriform or ovoid by 28 weeks and changes to spherical beyond 36th week.
4. Position
• normal antibioted position is exaggerated up to 8 weeks.
• Afterwards, it becomes erect, the long axis of the uterus conforms more or less
to the axis of the inlet.
5. Lateral Obliquity
• As the uterus enlarge to occupy the abdominal cavity it usually rotates on its long
Axis to the right (dextrorotation)
• The cervix, as a result, is deviated to the lift side labour rotation bringing it closer
to the ureter.
6. Uterine peritonium
• the peritoneum maintain the relation proportionately with the growing uterus.
• The euro sacrile ligaments and the basis of the broad ligament rises up to the
level of the pelvic bream
• This results in deepening of the pouch of Douglas.
7. Contractions (Braxton-Hicks)
• From the very early weeks of pregnancy, the uterus undergoes spontaneous
contraction which can be felt during by manual patient in early weeks or during
abdominal Pal patient when the uterus feels firmer at one moment and softer
at another.
• The contractions are irregular. Infrequent, spasmodic and painless without any
effect on dilatation of the cervix.
• Near term the contractions become frequent with increase in intensity so as to
produce some discount for to the patient. It merges with the painful uterine
contractions of labor.
8. Endometrium
• the endometrium of the pregnant uterus is called the decidua.
• The increased structural and secretary activity of the endometrium that is
brought about in response to progesterone following implantation is known as
decidual reaction.
• The fibrous connectivity shoes of the stroma become changed into epithelial
cells called decidual cells.
• The well developed decidua differentiate into 3 layers-
1. Superficial compact layer
2. Intermediate spongy layer
3. Thin basal layer
• After the interstitial implantation of the
blastocyst into the compact layer of the
decidua, the different portions of the
decidu are renamed as-
1. Decidua basalis or serotina
2. Decidua capsularis or reflexa
3. Decidua Vera or parietalis
• It’s thickness progressively increases to
maximum of 5 to 10 mm at the end of the
second month and their after regression
occurs with advancing pregnancy so that
beyond 20th week, it measures not more
than 1 mm.
Isthmus of the
uterus
• During the first trimester, isthmus hypertrophies
and elongates to about three times its original
length and become softer.
• With advancing pregnancy beyond 12 weeks, it
progressively unfolds from above, downward
until it is incorporated into the uterine cavity.
• The circularly arranged muscle fibers in the
region, function as a sphincter in early pregnancy
& thus help to retain the fetus within the uterus.
Cervix of the
uterus
1. Stroma:
• There are hypertrophy and hyperplasia of the
elastic and connective tissues. Fluids
accumulates inside and in between the fibres.
• Vascularity is increased specially beneath The
squamous epithelium of the partio vaginalis which
is responsible for its Lewis coloration.
• All these leads to marked softening of the cervix
(Goodel’s sign) which is evident as early as 6
weeks, It begins at the margin of the external OS
and then spreads upward. The changes in the
service facilitates its dilatation during labor.
2. Epithelium:
• There are marked proliferation of the endocervical mucosa with downward extension beyond the
squamocolumnar junction.
• Sometimes, the squamous cells also become hyperactive and the mucosal changes stimulates basal cell
hyperplasia or cervical intra-epithelial neoplasia (CIN). These changes are hormone induced oestrogen
and regress spontaneously after delivery.
3. Secretion:
• The secretion is copious and tenacious - physiological secretion of pregnancy. This is due to the effect of
progesterone.
• The mucus not only feels up the glands but also forms a thick plug effectively sealing the cervical canal.
4. Anatomical:
• The length of the service remains and altered but become balky.
• The cervix is directed posteriorly but after the engagement of the head, directed in line of vagina.
• There is unfolding of the isthmas; beginning 12 weeks onwards and takes part in the formation of the
lower uterine segment.
Fallopian
Tube
• As the uterine end rises up and the fimbrial end is
held up by the infundibulopelvic ligament, it is
placed almost vertical by the side of the uterus.
• The total length is sum what increased.
• The tube become congested.
• Muscles undergo hypertrophy.
• Epithelium becomes flat end and patches of
decidual reaction are observed.
Ovary
• The growth and function of the Corpus luteum
reaches its maximum at 8th week when it
measures about 2.5 cm and becomes cystic.
• Regression occurs following decline in the
secretion of hCG from the placenta.
• Hormones secreted by the Corpus luteum maintain
the environment for the growing ovum before the
action is taken over by the placenta.
• Decidual reaction appears.
Breasts
• Size: Increased size of the breast is due to marked
hypertrophy and proliferation of the ducts (estrogen)
and the alveoli (estrogen and progesterone) which
are marked in the peripheral lobules.
• Nipples & Areola: The nipple become larger
erectile and deeply pigmented.
• Montgomery’s tubercles are seen.
• Secondary areola is appears in second trimester.
• Secretion: Secretion can be squeezed out of the
breast at about 12 weeks which at first becomes
sticky. Letter on, by 16th week it becomes thick and
yellowish.
Cutaneous
changes
1. Face: chloasma gravidarum or
pregnancy mask
2. Abdomen:
1.Linea nigra,
2. Striae gravidarum
3. Other cuteneous changes
Weight Gain
On Pregnancy
• The total weight gain during the
course of a singleton pregnancy for a
healthy women average 11 to 12 Kg.
• Fetus – 3.3 kg
• Liquor – 0.8 kg
• Maternal store (fat & protein) – 3.5 kg
• Blood volume – 1.2 kg
• Placenta – 0.6 kg
• Uterus – 0.9 kg
• Breast – 0.4 kg
• Extra-cellular fluid – 1.3 kg
Total weight gain – 12 kg
This has been distributed to 1 kg in 1st trimester and 5 kg each in 2nd and 3rd
trimester.
Body Water
Metabolism
• Pregnancy is a state of hypervolemia.
During pregnancy the amount of
water retained at term is about 6.5 L.
• Dead is active retention of sodium
(900mEq) potassium (300mEq) and
water.
• The important causes of sodium retention and volume overload are-
1. Changes in maternal osmoregulation.
2. Increased estrogen and progesterone.
3. Increase in RAAS activity.
4. Increased aldosterone deoxycorticosterone.
5. Control by Arjun vassarpressin from posterior pituitary.
• There is resetting of the osmotic threshold for thirst and AVP secretion.
Hematologic
al System
1. Blood volume:
• blood volume is markedly raised during
pregnancy.
• 2. Plasma volume:
• It starts to increase by 6 weeks and it plateaus
30 weeks of gestation.
• Total plasma volume increases to the extent of
1.25 L.
3. RBC & Hemoglobin
• The RBC mass is increased to the extent of 20-30%.. The total increase in volume is
about 350 ml.
• The disproportionate increase in plasma and RBC volume produces a state of
hemodilution during pregnancy.
• Thus even though the total Hb mass increases during pregnancy to the extent of 18-
20%, there is apparent fall in hemoglobin concentration. At term the fall is about 2g%
from the non pregnant value (physiological anemia).
4. Leukocytes & immune system
• Neutrophilic leukocytosis occurs to the extent of 8000/mm^3 and even to
20,000/mm^3 in labor.
• The major changes in the immune system is the modulation away from cell mediated
cytotoxic immune response toward increased humoral and innate immune responses.
5. Blood coagulation factors:
• pregnancy is hypercoglable state.
• Dead is increase in plasma levels and activities of plotting factors like VII, VIII, IX,
X, I
• The level of factor II, V, XII are either and changed or mindly increased.
• the level of factors XI & XIII are slightly decreased.
• The clotting time does not show any significant change.
Principal blood changes during pregnancy:-

Parameters Non- Pregnancy Total Change

pregnant near term increment

Blood volume 4000 5500 1500 + 30-40%

(ml)
Plasma volume 2500 3750 1250 + 40-50%
(ml)
Red cell 1400 1750 350 + 20-30%
volume (ml)
Total Hb (g) 475 560 85 + 18-20%

Hematocrit 38% 32% Diminished

Total protein:-

Parameters Non-pregnant Pregnancy near Changes

term
Total protein 180 230 Increased

Plasma protein 7 6 Decreased

concentration
(g/100ml)
Albumin (g/100ml) 4.3 3 Decreased (30%)

Globulin (g/100ml) 2.7 3 Slightly increased

Albumin:Globulin 1.7:1 1:1 Decreased

Cardiovascular
System
1. Anatomical changes:
Due to elevation of the diaphragm consequent to the enlarged
uterus, the heart is pushed upward and outward with slight
rotation to left.
2. Cardiac output:
• the cardiac output starts to increase from 5th week of pregnancy
and reach its pic 40-50% at about 30-34 weeks.
• Cardiac output increases further during labor (+50%) and
immediately following delivery (+70%) over the prelabor values.
3. Blood pressure:
• Inspite of the large increase in cardiac output the maternal BP (BP=CO×SVR) is
decreases due to decrease in SVR.
• There is overall decrease in diastolic BP & mean arterial pressure (MAP) by 5-10
mmHg in mid pregnancy.
4. Venous pressure:
• Femoral Venous pressure is markedly raised especially in the later months due to
pressure exerted by the gravity uterus on the common area veins more on the
right side due to dextro-rotation of the uterus.
• Distensibility of the veins and stagnation of blood in the venous system explain
the development of edema, varicose vein, piles and deep vein thrombosis.
5. Central hemodynamics:
• There is no significant change in CVP, MAP and PCWP though there is increase in BV, CO and HR.
As, bed ease significant fall in SVR, PVR and colloidal osmotic pressure.
6. Supine hypotension syndrome (Postural hypotension):
• During late pregnancy, the gravid uterus produces a compression effect on the IVC when the
patient is in supine position. This, however, results in opening up of the collateral circulation by
means of para-vertebral azygos vein. 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 BP is quickly restored by turning the patient to
lateral position.
7. Regional distribution of blood flow:
• Uterine blood flow is increased about 750 ml near term.
• By Term pregnant uterus receives about 15% of CO.
• Pulmonary blood flow is increased by 2,500 ml/min.
• blood blood flow increases by 400 ml/min at 16 th week.
Metabolic
Changes
• General metabolic changes:
Total metabolism is increased due to
the needs of the growing foetus 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:
• there is a positive nitrogenous balance throughout pregnancy.
• As The breakdown of amino acid to urea is suppressed the blood urea level talls to 15 to
20 mg%.
• Carbohydrate metabolism:
• Insulin secretion is increased in response to glucose and amino acids.
• Sensitivity of insulin receptors is reduced 44% specially during later months of pregnancy.
• Plasma insulin level is increased due to a number of Contra insulin factors.
• There is increased tissue resistance to insulin this mechanism insurance continuous
supply of glucose to the foetus.
• Overall effect is maternal fasting hypoglycemia (due to fetal consumption) and
postprandial hyperglycemia and hyper insulinemia (due to anti insulin factors).
• Fat metabolism:
• And average of 3 to 4 kg of fat is stored during pregnancy mostly in the
abdominal wall, breasts, hips and thighs.
• Plasma lipids and lipoproteins increased appreciably during the letter half of
pregnancy due to increase oestrogen, progesteron, HPL and leptin levels.
• Lipid metabolism:
• HDL level increases by 15%.
• LDL is utilised for placental steroid synthesis.
• This hyperlipidemia of normal pregnancy is not atherogenic.
• Iron metabolism:
• Iron is transported actively across the placenta to the foetus.
• Total iron requirement during pregnancy is estimated approximately 1000 mg.
• This iron need is not surely distributed throughout the pregnancy but mostly limited
to the third trimester.
• Thus. in the second half, the daily requirement actually becomes very much
increased to the extent of about 6 to 7 mg.
• In the absence of iron supplementation, there is drop in hemoglobin serum iron and
serum ferritin concentration at term pregnancy. Thus. Pregnancy is an invitable iron
deficiency state.
Systemic
Changes
1. Respiratory system
2. Urinary system
3. Alimentary system
4. Liver and gallbladder
5. Nervous system
6. Calcium metabolism and skeletal system.
Respiratory
System
• With the enlargement of the uterus, there is elevation of the
diaphragm by 4 cm.
• Total land capacity is reduced by 5% due to this elevation.
• The sub coastal angle increases from 68°-103° the
transverse diameter of the chest expense by 2 m and the
chest circumference increased by 5 to 7 cm.
• A state of hyperventilation occurs during pregnancy leading
to increase in tidal volume and their for respiratory minute
volume by 40%. It occurs due to the action of progesterone.
• Acid base balance: the arterial PaCO2 falls 38 - 32 mmHg and PaO2 rises 95 -
105 mmHg.
• The pH rises: in order to 0.02 unit and there is a base excess of 2 mEq/L. Thus,
pregnancy is in a state of respiratory alkalosis.
• Parameters
Changes in respiratory system:
Non-pregnant Pregnancy near Change
term
Respiration rate/min 15 15 Unaffected

Vital capacity (m^2) 3200 3300 Almost unaltered

Tidal volume (m^2) 500 700 +40%

Residual volume 965 765 -20%

(m^2)
Inspiratory 2500 2650 +10%
capacity(IC)
Minute volume 7.5 10.5 +40%
(L/min)
Total Lung Capacity 4200 4000 -5%
(ml)
Urinary System
1. Kidney
2. Ureter
3. Bladder
KIDNEY
• There is dilatation of the ureturs, renal
pelvic and the calyces . The kidney in large
in length by 1 cm.
• Renal plasma flow is increased by 50-75%,
maximum by the 16 weeks and is
maintained until 34 weeks, there after it
falls by 25%.
• Glomerular filtration rate is increased by
50% all throughout the pregnancy. It
causes reduction in maternal plasma level
of creatinine BUN and uric acid.
URETER
• Ureters become aconic due to high
progesterone level.
• Dilatation of the ureter above the pelvic
bream with stasis is marked on the right side,
specially in primI gravida. The stasis is
marked between 20 and 24 weeks.
• There is elongation, kinking and outward
displacement of the ureters.
BLADDE
R • There is marked congestion with hypertrophy
of the muscles and elastic tissues of the wall.
• In late pregnancy the bladder mucosa
becomes ademas due to Venus and
lymphatic obstruction.
• Increased frequency of maturation is noticed
at 6 to 8 weeks of pregnancy with subsides
after 12 weeks.
• It may be due to resetting of osmoregulation
causing increased water intake and polyuria.
• In late pregnancy frequency of maturation
once more reappears due to pressure on the
bladder as the presenting participles down
the pelvis.
Alimentary System

• The gums become congested and spongy and may

bleed to touch.
• Muscle tone and motility of the entire GI tract are
diminished due to high progesterone level.
• Dispepsia is common.
• Atonicity of the guts leads to constipation.
• Cardiac sphincter is relaxed and regurgitation of
acid gastric content into the oesophagus may
produce chemical esophagitis and heartburn.
Liver &
Gallbladder
• Although there is no histological
changes in the liver cells but the
functions are depressed.
• With the exception of raised alkaline
phosphatase levels other liver
function tests are unchanged.
Nervous
System
• Some sorts of temperamental changes found
during pregnancy and in the puerperium.
• Nausea, vomiting, mental irritability and
sleep disorders are probably due to some
psychological background.
• Postpartum blues, depression or psychosis
may develop in a susceptible individual.
Calcium
Metabolism &
Skeletal System
• During pregnancy there is increased in the demand
of calcium by the growing fetus to the extinct of 28
g, 80% of which is required in the last trimester for
fetal bone mineralisation.
• Daily requirement of calcium during pregnancy &
lactation averages 1-1.5 g.
• Maternal total calcium levels fall but serum ionized
calcium level is unchanged.
Summary
Evaluation
Conclusion
Bibliography
THANK YOU