PHYSIOLOGICAL ADAPTATION IN PREGNANCY

INTRO

During pregnancy, the body goes through various anatomical and physiological changes to
provide suitable environment for fetal development, to cater to the increased metabolic
demands and to prepare for the childbirth.

GENITAL ORGANS

VULVA

Vulva becomes oedematous and more vascular. Superficial varicosities may appear especially in
multiparous women. Labia minora becomes 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 colour of the mucosa. This is known as
Jacquemier’s sign. The length of the anterior vaginal wall is increased. Vaginal secretions
become copious, thin and curdy white, due to marked exfoliated cells and bacteria. The pH
becomes acidic due to conversion of glycogen into lactic acid by the Lactobacillus acidophilus
consequent on high estrogen level. The acidic pH prevents multiplication of pathogenic
organisms.

UTERUS

....The non pregnant uterus weighs about 60 gms, with a cavity of 5-10 ml and measures
about 7.5 cm in length. At term, weighs about 900- 1000 gm and measures 35 cm in length. The
capacity is increased by 500 to 1000 times. Changes occur in all the parts of the uterus- body,
isthmus and cervix.

BODY OF UTERUS

There is increase in growth and enlargement of the body of the uterus as a result of
hypertrophy and hyperplasia of muscles. The individual muscle fibres increases in length and
breadth. These occur under the influence of the hormones estrogen and progesterone up to 12
weeks. The muscle fibres further elongates beyond 20 weeks due to distension by the growing
fetus. This is known as stretching. The uterus feels soft and elastic in contrast to firm feel of the
non gravid uterus.
 Three distinct layers of muscle fibres are evident: (1) Outer longitudinal-it 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 which the blood vessels run. Apposition of two double curve muscle fibres
gives the figure of eight form. Thus, when the muscles contract, they occlude the blood vessels
running through the fibres and hence called living ligature.

Vascular system

There is marked spiralling of the arteries, reaching the maximum at 20 weeks, thereafter they
straighten out. The uterine artery diameter becomes doubles and blood flow increases by eight
fold at 20 weeks of pregnancy. This vasodilatation is mainly due to estradiol and progesterone.
Veins become dilated and are valveless. Numerous lymphatic channels open up. The vascular
changes are most pronounced at the placental site.

The uterine enlargement is not symmetrical. The fundus enlarges more than the
body. It is evident by the low down attatchment of the round ligaments or insertion of the
uterine end of the fallopian tubes at term.

Weight

The increase in weight is due to the increased growth of the uterine muscles, connective tissue
and vascular changes.

Shape

Non pregnant pyriform shape is maintained in early months. It becomes globular at 12 weeks.
As the uterus enlarges, the shape once more becomes pyriform or ovoid by 28 weeks and
changes to spherical beyond 36th week.

Position

Normal anteverted position is exaggerated upto 8 weeks. The enlarged uterus lies on the
bladder rendering it incapable of filling, which clinically evident by frequency of micturition.
Afterwards it become erect. At term, there is a tendency of anteversion especially in
multiparae. In primi with good tone of the abdominal muscles it is held firmly against the
maternal spine.

Lateral obliquity

As the uterus enlarges to occupy the abdominal cavity, it usually rotates on its long axis to the
right. This is known as dextro- rotation. This is due to the occupation of the recto sigmoid in the
left posterior quadrant. This makes the anterior surface of the uterus to turn to the right and
brings the left cornu closer to the abdominal wall. As a result of this the cervix is deviated to the
left side. This is known as levo rotation.

Contraction

The uterus undergoes spontaneous contraction from the very early weeks of pregnancy. This
can be felt during bimanual palpation in early weeks or during abdominal palpation. The
contractions are irregular, infrequent, spasmodic and painless without any effect on dilatation
of the cervix.

ISTHMUS

The isthmus undergoes structural and functional changes in the isthmus during pregnancy.
During first trimester, isthmus hypertrophied and length increases 3 times from it’s original
length. With advancing pregnancy beyond 12 weeks it progressively unfolds from above,
downwards until it is incorporated into the uterine cavity. The circularly arranged muscle fibres
in the region function as a sphincter that helps to retain the fetus within the uterus.
Incompetency in the sphincter may cause miscarriage.

CERVIX

Hypertrophy and hyperplasia of the elastic and connective tissue occurs. Vascularity is
increased. There is marked hypertrophy and hyperplasia of the glands occurs. All these lead to
marked softening of the cervix, known as Goodell’s sign which is elicited by 6 weeks. The
secretions become copious due to the effect of progesterone.

The uterus becomes bulky, the length may be unaffected. The cervix directs posteriorly until the
engagement of the fetal head. Effacement is noticed near term in primi and the canal is slightly
dilated in multiparae.

FALLOPIAN TUBE

The total length of the fallopian tube is increased and becomes congested. The muscles
undergoes hypertrophy.

OVARY

The growth and function of the corpus luteum reaches its maximum at 8 th week. It looks bright
orange, later on becomes yellow and finally pale. The estrogen and progesterone secreted by
the corpus luteum maintain the environment for the growing ovum. It inhibit the ripening of
follicles. Thus both the ovarian cycle and uterine cycles of the normal menstruation remain
suspended.
BREASTS

The breast changes are more evident in primigravida.

SIZE

The size is enlarged due to marked hypertrophy and proliferation of the ducts and alveoli which
are marked in the peripheral lobules. Myoepithelial cells become prominent. Vascularity is
increased which results in appearance of bluish veins running under the skin.

NIPPLES AND AREOLA

The nipples become larger, erectile and deeply pigmented. The sebaceous gland become
hypertrophied and are called Montgomery’s tubercles. And secondary areola appears in second
trimester.

SECRETION

Colostrum can be expressed at about 12th week. By 16th week, it becomes thick and yellowish.

CUTANEOUS CHANGES

The cutaneous changes are more evident in face, breast and abdomen.

Face

Chloasma gravidarum: It is an extreme form of pigmentation around the cheek, forehead and
around the eyes. It disappears spontaneously after delivery.

Abdomen

Linea nigra: It is a brownish black pigmented area in the midline stretching from xiphisternum
to the symphysis pubis. This may due to the melanocyte stimulating hormones produced by the
anterior pituitary. Itdisappears after delivery.

Striae gravidarum: Slightly depressed linear marks with varying length and breadth are seen in
tha abdominal wall below tha umbilicus, over the thighs and breasts. This is usually pink in
colour. After delivery, the scar tissue contract and obliterate the capillaries and they become
glistening white white in appearance and known as Striae albicans.

Vascular spider and palmar erythema may present due to high estrogen level. Hirsutism may
present.
WEIGHT GAIN

In early week of pregnancy there is chance for weight loss due to the nausea and vomiting.
During subsequent months the weight gain is progressive. The average weight gain in a
singleton pregnancy is 11 – 12 kg which is distributed as 1 kg in first trimester, 5 kg in second
trimester and 5 kg in last trimester.

Fetus 3.3kg

Placenta 0.6 kg

Liquor 0.8 kg

Uterus 0.9kg

Breasts 0.4kg

Accumulation of fat and protein 3.5kg

Increase in blood volume 1.3kg

Increase in extracellular fluid 1.2 kg

BODY WATER METABOLISM

The amount of water retained in the body at term is about 6.5 litres. The water content of the
fetus, placenta and amniotic fluid is about 3.5 litres. Pregnancy is a state of hypovolemia. There
is active retention of sodium, potassium and water. The important cause of sodium retention
and volume overload are: changes in osmoregulation, increased level of estrogen and
progesterone, increase in renin angiotensin activity, increased aldosterone,
deoxycorticosterone, control by arginine vasopressine from posterior pituitary and atrial
natriuretic peptide. Serum sodium level and plasma osmolality decreases. There is resetting of
the osmotic threshold for thirst and AVP secretion. Plasma levels of AVP remains unchanged.
This is due to increased metabolic clearance of AVP by the enzyme vasopressinase from the
placenta. Increase in water intake due to lowered osmotic threshold for thirst causes polyuria in
early pregnancy. Atrial and brain natriuretic peptide secreted by atrial myocytes and by the
brain ventricles act as diuretic, a natriuretic peptide,.

HEMATOLOGICAL CHANGES
BLOOD VOLUME

PLASMA VOLUME

RBC AND HEMOGLOBIN

LEUCOCYTES AND IMMUNE SYSTEM

TOTAL PROTEIN

BLOOD COAGULATION FACTORS

CARDIOVASCULAR SYSTEM

ANATOMICAL CHANGES

CARDIAC OUTPUT

CENTRAL HEMODYNAMICS

SUPINE HYPOTENSION SYNDROME

METABOLIC CHANGES

GENERAL METABOLIC CHANGES

PROTEIN METABOLISM

CARBOHYDRATE METABOLISM

FAT METABOLISM

LIPID METABOLISM

IRON METABOLISM

SYSTEMIC CHANGES

RESPIRATORY SYSTEM

URINARY SYSTEM

ALIMENTARY SYSTEM

LIVER AND GALL BLADDER

NERVOUS SYSTEM
LOCOMOTOR SYSTEM