(SEMINAR)

A MATERIAL ON
PHYSIOLOGICAL CHANGES
IN PREGNANCY

SUBMITTED TO SUMBITTED BY
MADAM MRS CIMIL BABU MS. ANURADHA
PROFESSOR MSc. NURSING 1ST YEAR
HFCON HFCON
 (SEMINAR)

A LESSON PLAN ON
PHYSIOLOGICAL CHANGES
IN PREGNANCY

SUBMITTED TO SUMBITTED BY
MADAM MRS CIMIL BABU MS. ANURADHA
PROFESSOR MSc. NURSING 1ST YEAR
HFCON HFCON
 IDENTIFICATION DATA

NAME OF THE STUDENT TEACHER: Ms. Anuradha

ADVISOR NAME: Madam Mrs Cimil Babu
SUBJECT: Obstetrical and Gynaecological Nursing
TOPIC: Physiological Changes in pregnancy.
UNIT NAME: Pregnancy
DATE OF TEACHING: 1 November 2019
TIME OF TECAHING: 2:00 pm to 3:00 pm
DURATION OF TEACHING: 1 hour
PLACE OF TEACHING: M Sc. Nursing 1st year classroom
METHOD OF TEACHING: Seminar
GROUP: Msc 1st year students (Obs and Gynae Speciality)
GROUP SIZE: 4 Students
AV AIDS: Power point presentation, chart, flannel, pocket chart, flash card
PREVIOUS KNOWLEDGE: Student have some Basic knowledge regarding physiological
changes in pregnancy as studied earlier in under graduation programme
GENERAL OBJECTIVES: At the end of this topic student will be having knowledge
regarding physiological changes in pregnancy so that they will be able to utilize it in their
clinical practice and can enhance their knowledge
SPECIFIC OBJECTIVES:
AS PER STUDENT POINT OF VIEW
 Student will be able to enhance their knowledge regarding physiological changes in
pregnancy
 Students will be able to apply their knowledge in learning skills.
 Students will be able to enhance their learning experience.
 Student will be able to establish a solid framework of understanding that can better
support new knowledge
AS PER TEACHER POINT OF VIEW
After teaching, student teacher will be able to:
 Gain confidence in teaching skills.
 Use of effective audio-visual aids in teaching.
 Facing the group confidently.
 Enhance her knowledge.
 PHYSIOLOGICAL CHANGES DURING PREGNANCY
INTRODUCTION
Pregnancy usually occurs during the reproductive period (15-44 years) of a woman. The mean
duration of pregnancy based on the date of last menstrual period(LMP) is 280 days or 40 weeks
(9 calendar months and 7 days). Pregnancy is traditionally divided into three unequal
trimesters, with the second trimester being the longest. Physiological alteration does occur in
the mother during pregnancy to enable her to provide and maintain a healthy environment for
satisfactory fetal growth, without compromise her own health.
There are profound anatomical, physiological, endocrinological and biochemical changes
during pregnancy in various systems of the body.
REPRODUCTIVE SYSTEM (GENITAL ORGANS)
VULVA AND VAGINA
 Increased vascularity, varicosities, hyperemia and edema can develop on the vulva,
vagina and perineum.
 Increased blood supply of the venous plexus surrounding the wall gives bluish or
violet discoloration of vagina (jacquemier’s or chadwick’s sign) along with
hobnailed appreance of vagina due to hyperthrophy of papillae of the vagina
mucosa.
 Labia minora are pigmented and hypertrophied.
 The length of the anterior vaginal wall is increased.
Vaginal secretion:
 Secretion becomes excessive thick white due to marked increased of exfoliated cells,
bacteria and increased cervical secretion.
 PH is acidic (varying from 3.5-6) due to more conversion of glycogen into lactic acid
by the lactobacillus acidophilus in the vaginal epithelium as a result of high estrogen
level level.
 Highly acidic ph reduces growth of pathological bacteria but favours the growth of
yeast and candida albicans.
Vaginal cytology:
There is excess of navicular cells which are ovoid cells with elongated nuclei due to high
progesterone levels.
UTERUS
There is enormous growth of the uterus during pregnancy. The uterus which is non-pregnant
state weighs about 50gm and measures about 7.5cm in length, at term weighs 900-1000gm and
measures 35cm in length. Changes occurs in all the parts of the uterus-body, isthmus and
cervix.
Body of the uterus
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 muscle:
i. Hypertrophy and hyperplasia: individual muscle fibre increases in length and
breadth but there is limited addition of new muscle fibres. This occur under the
influence of the hormones-estrogen and progesterone limited to the first half of the
pregnancy but profound upto 12 weeks.
ii. Stretching: the muscle fibre 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 nongravid uterus.
The fundus enlarges more than the body. The uterine enlargement is inconsistent specially
during the second half of pregnancy when the stretching factors starts to operate.
Arrangement of the muscle fibres: three distinct layers of muscle fibres are evident:
1. Outer longitudinal: follows the hood like arrangement over the fundus; some fibres
are continuous with the round ligament.
2. Inner circular: it is scanty and have sphincter like arrangement around the tubal
orifices and internal os.
3. Intermediate: thickest and strongest layer arranged in criss-cross fashion through
which the blood vessels run. Apposition of two double curve muscle fibres give the
figure of ‘8’ form. When muscle contract, they occlude the blood vessels running
through the fibres and hence called living ligature.
There is simultaneous increase in number and size of the supporting fibrous and elastic.
Vascular system:
 In non-pregnant state, the blood supply to the uterus is mainly through the uterine and
least through the ovarian but in the pregnant state, the latter carries as much the blood
as the former.
 Marked spiralling of the arteries, reaching the maximum at 20 weeks; thereafter they
become straighten out and become dilated.
 Veins are much dilated which have got no valves
 Numerous lymphatic channels are opened up.
 Vascular changes are more pronounced at the placental site.
Weight: increased in weight is due to the increased growth of the uterine muscles, connective
tissues and vascular channels.
NON PREGNANT UTERUS
 Weight - 60 gm; Cavity – 5 to10 cm; Length – 7.5 cm
PREGNANT UTERUS
 Weight - 900- 1000 gm; Cavity – 1000 gm; Length – 35 cm
Shape: non-pregnant pyriform shape is maintained in early moths. It becomes globular at 12
weeks. As uterus enlarges, the shape once more becomes pyriform or oval by 28 weeks and
changes to spherical beyond 36 weeks.
Position: normal anteverted position is exaggerated upto 8 weeks. The enlarge uterus may lie
on the bladder rendering it incapable of filling, clinically evident by the frequency of
micturition.
Afterwards it becomes erect, long axis of the uterus conforms more or less to the axis of the
inlet. At term, in multipara with lax abdominal wall, there is tendency of anteversion, but in
primigravida with good tone of the abdominal muscle. It is held firmly against the maternal
spine.
Lateral obliquity:
 As uterus enlarges to occupy the abdominal cavity, it usually roattes on its long axis to
the right (dextro rotation).
 This is due to the recto-sigmoid in the left posterior quadrant of the pelvis.
 It makes to turn uterus to the right and brings the left cornu closer to the abdominal
wall.
 Hence, the cervix is deviated to the left side(levo-rotation) bringing it closer to the
uterus.
Uterine peritoneum:
 Peritoneum maintains the relation proportionately with the growing uterus.
 The uterosacral ligaments and the bases of the broad ligament rise upto the level of the
pelvic brim. This results in deepening of the pouch of Douglas.
 Large areas of the lower lateral wall of the uterus remains uncovered by peritoneum.
 These places are filled up by loose and vascular connective tissue.
Contraction(Braxton-Hicks):
 it is named after the Braxton-Hicks who first described its entity during pregnancy.
 From the early weeks of pregnancy, the uterus undergoes spontaneous contraction
which can be felt during bimanual palpation in early weeks or during abdominal
palpation when the uterus feels shimmer at one momenta and soft at another.
 Contraction can be excited by rubbing the uterus.
 The contraction are regular, infrequent, spasmodic and painless without any effect on
dilation of the cervix.
 The patient is not conscious about the contraction but near term it becomes frequent
with increase in intensity so as it produces discomfort to the patient and ultimately get
merges with the painful uterine contraction of labour.
 Intrauterine pressure remains below 8mm Hg
 In abdominal pregnancy, Braxton-hicks contraction is not felt.
 During contraction there is complete closure of the uterine veins with partial occlusion
of the arteries in relation to intervillous space resulting in stagnation of blood in the
space. This diminishes the placental perfusion, causing transient fetal hypoxia which
leads to the fetal bradycardia coinciding with the contraction.
Endometrium: the endometrium of the non-pregnant uterus changes into decidua of
pregnancy.

 The fibrous connective tissues of stroma become changed into epitheloid cells called
decidual cells.
The well-developed decidua differentiates into three layers:
 Superficial compact layer consists of compact mass of decidual cells, gland dogs
and dilated capillaries. The greater part of the surface epithelium is either thinned out
all lost.
 Intermediate spongy layer (cavernous layer) contains dilated uterine glands,
decidual cells and blood vessels. It is through this layer that the cleavage of placental
separation occurs.
 Thin basal layer containing the basal portion of the glands and is apposed to the
uterine muscle. Regeneration of the mucus occurs from this layer following
parturition.
After the interstitial implantation of the blastocyst into the compact layer of the decidua, the
different portions of the decidua are renamed as-
 Decidua basalis or serotine- the portion of the decidua in contact with the base of
blastocyst;

 Decidua capsularis or reflexa- the thin superficial compact layer covering the
blastocyst and

 Decidua vera or parietalis- the rest of the decidua lining the uterine cavity outside the
site of implantation. It’s thickness progressively increases to maximum of 5 to 10 MM
at the end of second month and thereafter regression occurs with advancing pregnancy
so that beyond 20th week, it measures not more than 1mm.

Isthmus:
 It undergoes important structural and functional changes during pregnancy.
 It is soft and compressible between 10-12week (hegar’s sign)
 It opens out after 12th week and its canal is incorporated into the uterine cavity to form
lower uterine segment.
 The circularly arranged muscle fibres in the region function as a spincture in early
pregnancy and thus helps to retain the fetus within the uterus.
 Its incompetency of the spincteric action leads to mild trimester abortion and the
encircle operation done to rectify the defects is based on the principle of restoration of
the retentive function of the isthmus.
CERVIX
 There is hypertrophy and hyperplasia of the elastic and connective tissues.
 Marked softening of the cervix(goodell’s sign) which facilitates its dilation during labor
is seen.
 It begins at the margin of the external os and then spreads upwards
  There is marked proliferation of the endocervical mucosa with downward extension
beyond the squamo-columnar junction.
 Under estrogen influence there is excessive proliferation and downward extension of
the endocervical mucosa beyond the squamo-columnar junction causing cervical
erosion or eversion of pregnancy which may bleed on touch and Pap smear.
 Secretion is copious and tenacious-physiological leucorrhoea of pregnancy. This is due
to the effects of progesterone. The mucous not only fills up the glands but forms a thick
plug effectively sealing the cervical canal.
 Anatomically the length of cervix remains unaltered but becomes bulky. The cervix
directly posteriorly but after the engagement of the head. Directed in the line of vagina.
FALLOPIAN TUBE
 Fallopian tube becomes elongated and more congested due to marked increase in
vascularity.
 As the uterine end rises up and the fimbrial end is held up by the infundibulo-pelvic
ligament, it is placed almost vertical by the side of the uterus.
 At term, its attachment to the uterus is placed at the lower end of the upper 1/3rd ,
because of the marked growth of the fundus.
 The tube becomes congested.
OVARY
 There is persistence growth of the corpus luteum which reaches its maximum at 8th
week when its measures about 2.5cm and becomes cystic.
 Both ovaries are enlarged due to increased vascularity and edema, particularly the ovary
which contains corpus luteum.
 The corpus luteum (2.5cm in size) reaches its maximum, both in function and structure
at 8 weeks of gestation, which is solely responsible for the hormonal maintenance of
pregnancy upto 8 weeks. It looks bright orange, later becomes yellow and finally pale.
And thereafter the placenta takes over.
 The corpus luteum then starts degeneration at 12 weeks, becomes yellow and eventually
white and atretic due to decline in secretion of HCG from the placenta.
BREASTS
The changes in the breast are best evident in a primigravida.
Size: increased size of the breast becomes evident even in early weeks. This is due to marked
hypertrophy and proliferation of the ducts (oestrogen) and the alveoli (oestrogen and
progesterone) which are marked in the peripheral lobules and deposition of fat delicate veins
become visible just beneath the skin
 The connective tissue stroma is also hypertrophied while the epithelial cells becomes
more prominent.
 The weight of east breast at term is 400-800gm.
 The axillary tail of Spence (prolongation of the breast tissue in axilla) may be swollen,
painful and tender.
 There may be stria formation due to stretching of skin like on abdomen.
Nipples and areola:
 The nipples become larger, erectile and deeply pigmented.
 Variable number of sebaceous glands (5-15) which remain invisible in the non-pregnant
state in the aerola, become hypertrophied and are called Montgomery’s tubercles.
 These secretion keeps the nipples and the areola moist and healthy.
Secretion:
 Secretion can be squeezed out of the breast at about 12 weeks which at first becomes
sticky.
 Later at 16th weeks becomes yellow and thick.
CUTANEOUS CHANGES
The distribution of pigmentary changes are:
1) Face (chloasma gravidarum or pregnancy mask): it is an extreme forth of pigmentation
around the cheek, forehead and around the eyes. It may be patchy or diffuse; disappears
spontaneously after delivery
2) Abdomen:
1. Linea nigra: brownish black pigmented area in the midline stretching from the
xiphisternum to the sysmphysis pubis.
This changes is due to melanocytes stimulating hormone from the anterior
pituitary.
2. Striae gravidarum: theses are slightly depressed linear marks with varying
length and breadth found in pregnancy.
They are predominantly found in the abdominal wall below the umbilicus,
sometimes over the thighs and breast.
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.
WEIGHT GAIN
 In normal pregnancy, variable amount of weight gains in a constant phenomenon.
 In early weeks, the patient the patient may lose weight because of nausea and vomiting.
 During subsequent months, the weight gains in progressive until the last one or two
weeks, when the weight remains static.
 The total weight gains during pregnancy the course of a singleton pregnancy for a
healthy woman average is 11kg which has been distributed as 1 kg in first trimester and
5 kg in each second and third trimester.
 Rapid weight gain of more than 0.5kg a week or more than 2 kg in a month in later
months of pregnancy may be the early manifestation of pre-eclampsia.
 Stationary or falling weight may suggest intrauterine death of the fetus.
BODY WATER METABOLISM
 The amount of water retained at term is about 6.5 L.
 The water content of the fetus, placenta and amniotic fluid is about 3.5L. pregnancy is
state of hypervolemia
  During pregnancy there is increased retention of electrolytes mainly sodium (900m
mol) and potassium(350m.mol)
 Increased sodium retention during pregnancy are:
i. increased oestrogen and progesterone
ii. increased in renin-angiotensin activity
iii. increased antidiuretic hormone.
iv. Changes in osmoregulation
v. Increased aldosterone, deoxycorticosterone
vi. Control by argineine vasopression(AVP) from posterior pituitary
vii. Arterial natriuretic peptide
 There is resetting of the osmotic thresholds for thirst and AVP (ADH) secretion.
Increased in water retention due to lowered osmotic threshold for thirst causes polyuria
in early pregnancy until the threshold for AVP secretion has been reset after 8 weeks.
HAEMATOLOGICAL CHANGES
Blood volume: there is increased vascularity of the enlarging uterus with the interposition of
utero-placental circulation. Blood volume is markedly raised during pregnancy.
The blood volume starts to increase from about 6th week expands rapidly thereafter to
maximum 40-50% above the non-pregnant level at 30-32 weeks.
Plasma volume: it increases during pregnancy. The rate of increase almost parallel to that of
blood volume but the maximum is reached to the extent of 50%.
Total plasma volume increases to the extent of 1.25L. The increase is greater in multigravida,
in multiple pregnancy and large baby.
RBC and haemoglobulin:
 RBC volume increased to the extent of 20-30%. The total increases in volume is about
350ml, the amount to be regulated by the increased demand of oxygen transport during
pregnancy.
 Reticulocyte count increases by 2%.
 Erythropoietin level is raised.
 The disproportion increase in plasma and RBC volume produces aa state of
haemodilution during pregnancy.
 At term there is about 2gm% fall in haemoglobulin level, red cells by 15-20% and the
haematocrit level also.
The advantages of haemodilution are:
1. Diminished blood viscosity ensures optimum gaseous exchange between the maternal
and fetal circulation this is facilitated by lowered oxygen affinity of maternal red cells
observed in later half of pregnancy.
2. Protection of mother against the adverse effects of blood loss during delivery.
Leucocytes
 It rises upto 10-15.000/cu.mm and even to 20,000/cu.mm in labour. The increase in due
to rise in level of oestrogen and cortisol.
Total Protein
 It increases from 180gm in non-pregnant state to 230 gm at term.
 But due to haemodilution, the plasma protein concentration falls from 7gm% to 6 gm%.
This result in diminished viscosity of the blood and reduced colloid osmotic tension.
 There is marked fall in albumin level from 4.3gm% to 3 gm% - a fall of about 30% and
only slight rise in globulin(mainly alpha globulin).
 The normal albumin:globulin ratio of 1:7 is diminished to 1:1.
Blood Coagulation Factors
 Fibrinogen level is raised by 50% from 200-400 in non-pregnant state to 300-600% in
pregnancy as pregnancy is a hypercoagulable state.
 ESR get raised.
 Gestational thrombocytopenia may be due to increased platelet consumption.
 Fibrinogen activity is diminished at term.
 Clotting time remain unaffected.
HEART AND CIRCULATORY CHANGES
Anatomical changes
 due to elevation of the diaphragm consequent to the enlarged uterus, the heart is pushed
upwards and outwards with the slight rotation.
Abnormal clinical findings
 apex beat is shifted to the 4th intercostal space about 2.5cm outside the midclavicular
line.
 Systolic murmur is audible in the apical and pulmonary area which is due to decreased
blood viscosity and torsion of the great vessels.
 A continuous hissing murmur may be audible over the tricuspid area in the left second
and third intercostal spaces called as “mammary murmur” which is due to increased
blood flow through the internal mammary vessels.
 Doppler echocardiography shows an increase in the left ventricular end diastolic
diameters. The left and right diameter increases.
 ECG reveals normal pattern except evidences of the left axis deviation.
Cardiac output:
 Cardiac output starts to increase from 5th week of pregnancy, reaches to peak 40-50%
at about 30-34 weeks of pregnancy and till term it remain static.
 It is lowest in sitting position or supine position and highest in the right or left lateral
or knee chest position.
 During delivery increases further to +50% and immediately following delivery +70%
over the pre labour values.
 MAP also becomes high.
 Auto transfusion takes place- flow of blood from uterus to maternal circulation.
 Cardiac output return to pre-labour values by one hour following delivery and to pre-
pregnant level by another 4 weeks time.
 The increased in cardiac output is caused by:
1. Increased blood volume.
 2. To meet the additional oxygen required due to metabolic during pregnancy. The
increase in cardiac output is chiefly affected in stroke volume and increase in pulse
rate to about 15 per minute.
Blood Pressure
 Systemic vascular resistance(SVR) decreases (-21%) due to smooth muscle relaxing
effect of progesterone, NO, prostaglandins or ANP.
 In spite of increase in cardiac output the maternal BP(BP=C*SVR) is decreased which
is due to decreased in SVR.
 There is decreased in diastolic blood pressure BP and mean arterial pressure (MAP) by
5 to 10mm Hg.
 The decrease in maternal BP is parallel that of SVR.
Venous pressure
 Ante cubital venous pressure remains unaffected.
 Femoral venous pressure is markedly raised specially in the later months which is due
to pressure exerted by the gravid uterus on the common iliac veins more on the right
side due to dextro-rotation of the uterus.
 Femoral venous pressure is raised from 8-10cm of water in non-pregnant state to about
20cm of water during pregnancy in lying down position and to about 80-100 cm of
water in standing position.
 This explains the fact that the physiological oedema of pregnancy subsides by rest
alone.
 Distensibility of the vein stagnation of blood in the venous system explain the
development of oedema varicose veins, piles and deep vein thrombosis.
Central Haemodynamic
 In pregnancy there is no significant change in CVP, MAP and PCWP though there is
increased in blood volume. This is because there is significant fall in SVR, pulmonary
vascular resistance(PVR) and colloidal osmotic pressure.
Supine hypotension syndrome (postural hypotension)
During late pregnancy, the gravid uterus produces a compression effect on the inferior vena
cava when the mother lie down in supine position, thus is results in opening of the collateral
circulation by means of paravertebral and azygos veins.
In some cases, when the collateral circulation fails to open up, the venous return of the heart
may be seriously curtailed. This causes hypotension, tachycardia and syncope.
The normal blood pressure is quickly restored by turning the patient to lateral position.
Regional distribution of blood flow
 Uterine blood flow is increased from 50ml per minute in non-pregnant state to about
750ml near term. The increased is due to the combined effect of utero-placental and
feto-placental vasodilation.
 The vasodilation is due to smooth muscle relaxing effects of progesterone, oestrogen,
nitric oxide, prostaglandins and artrial natriuretic peptide.
 Pulmonary blood flow normal 6000ml/min) is increased by 2500 ml per minute.
 Renal blood flow (normal 800ml) increases by 400ml per minute at 16th week of
pregnancy and remain same till term.
  The blood flow through the skin and mucous membranes reaches a maximum of
500ml/min by 36th week.
 Heat sensation, sweating or stuffy nose complained by the pregnant women can be
explained by the increased blood flow.
ALIMENTARY SYSTEM
 The gums become congested and spongy and may bleed to touch.
 Muscle tone and motility of the entire gastrointestinal tract are diminished due to high
progesterone.
 There is increased salivation(ptyalism) and tooth decay may occur
 Cardiac sphincter is relaxed and regurgitation of acid gastric content into the
oesophagitis and heart burn(pyrosis). Heart burn more common due to esophageal
dysmotility.
 Gastric reflux is more frequent. There is slow emptying of the stomach due to higher
progesterone and lower motilin level.
 There is diminished gastric secretion and delayed emptying time of the stomach. Risk
of peptic ulcer disease is reduced.
 Atonicity of the gut leads to constipation, while diminished peristalsis facilitates more
absorption of food materials.
 appetite changes with longing or craving for certain foods or even non edible things
like blackboard chalk, coal, mud(pica) due to reduced sensitivity of the taste buds which
creates desire for markedly sweet, sour or salty foods.

Liver and Gall Bladder

 No histological change in the liver cells, but the functions are depressed.
 With the exception of alkaline phosphate, other liver function test are unchanged.
 There marked atonicity of the gall bladder. This together with the high blood cholesterol
level during pregnancy, favour stone formation.

METABOLIC CHANGES
General metabolic changes:
 Total metabolism increased due to the need of the growing uterus and the fetus.
 Basal metabolic rate is increased to the extent of 30% higher than that of the average
for the non-pregnant women.
Protein metabolism:
 Pregnancy is an anabolic state.
 There is a positive nitrogenous balance throughout pregnancy.
 At term, the fetus and placenta contain 500gm of protein and the maternal gain is also
500gmchiefly distributed in the uterus, breast and the maternal body.
 There is breakdown of amino acid to urea is suppressed, so the blood urea level falls to
15-20 mg%.
 Aminoacids are actively transported across the placenta to the fetus.
Carbohydrate metabolism:
 Pregnancy ia a diabetogenic state and a woman with an inhernt tendency to develop
diabetes during pregnancy.
  There is increased amount of transfer of glucose from mother to fetus.
 Insulin secretion is increased in response to glucose and amino acids. Increased insulin
level favour lipogenesis.
 There is hyperplasia and hypertrophy of beta cells of pancreas.
 Sensitivity of insulin receptors is decreased specially during later months of pregnancy.
 Plasma insulin level is increased due to number of contra insulin factors which are
oestrogen, progesterone, human placental lactogen, cortisol, prolactin, free fatty acids
and increased tissue resistance to insulin. This mechanism insures continuous supply
of glucose to fetus.
 During maternal fasting there is hypoglycaemia, hypoinsulinemia, hyperlipidemia and
hyperketonemia.
 Lipolysis generates fatty acids for glucogenesis and fuel supply.
 Plasma glucogen level remains unchanged.
 Effect of maternal fasting(due to fetal consumption) and post prandial hyperglycaemia
and hyperinsulinemia(due to anti insulin factors).
 Oral glucose tolerance test may show an abnormal pattern. This helps to maintain
continuous supply of glucose to the fetus.
 As maternal glucose utilisation is reduced, there is glucogenesis and glycogenolysis.
 Glomular filteration of glucose is increased to exceed the tubular absorption threshold
(normal 180mg%), so glycosuria is detected in 50% of normal pregnant women.
Fat metabolism
 Total increase of fat content by almost 3-4 kg with mainly centripetal distribution in the
abdomen, breasts, hips and thighs.
 There is increase loss of glucose to the fetus and acceleration of maternal fat
mobilization which leads on to modestly increased plasma concentrations of non-
esterfied fatty acids and ketones (increased in plasma lipids with tendency to acidosis)
which is referred to as a state of accelerated starvation. So, Pregnant women should
consume frequent, small meals.
 Total body fat increases during pregnancy, but the amount varies with total weight gain.
 During the second half of pregnancy, plasma lipids, liproteins and apolipoproteins
increase due to increased estrogen, progesterone, human placental lactogen(hPL) and
leptin levels.
 Leptin is a peptide hormone secreted by adipose tissue which has a key role in
regulating body weight and energy expenditure.
 Ghrelin is another hormone secreted by adipose tissue having role in fetal growth and
cell proliferation whose maternal levels rise and peak at mid-pregnancy and then
decreases near term.
 Total lipids increases from 650 mg/dl to 1000 mg/dl in pregnancy.
 Average serum cholesterol, LDL, HDL and triglycerides increases from 180, 60 and
80mg/dl in non-pregnant state to 260, 136, 80 and 254mg/dl in pregnancy term.
Mineral metabolism
 There is increased demand for iron, calcium, phosphate and magnesium during
pregnancy.
Calcium metabolism
 Fetus at term contains about 20-30gm of calcium in skeleton, the majority of this being
acquired from maternal serum during the third trimester.
  Loss of calcium from mother during lactation,
 There is increase in calcium absorption during pregnancy due to increase in plasma 1,
25 dihydroxycholecalciferol and therefore, there is increased trans placental transfer to
the fetus.
 In pregnancy, the bound calcium is reduced, as albumin is low. But, the ionized calcium
is normal.
 The normal requirement of calcium is about 1-1.5gm. extra calcium is supplied in
dietary supplementation of calcium sources like milk and milk products and by giving
calcium tablets as supplementation.
Iron metabolism
 Iron is absorbed in ferrous form from duodenum and jejunum and is released into the
circulatory transferrin.
 Iron is transported actively across the placenta to the fetus.
 Total iron requirement during pregnancy is estimated approximately 1000mg
distributed in fetus and placenta 300mg and expanded red cell mass 400mg. total
increase on red cell volume is 350ml and 1 ml contains 1.1 mg of iron.
 Loss of iron is 200mg through normal routes. The iron in the fetus and placenta is
permanently lost and variable amount of iron in the expanded RBC volume is also lost
due to blood loss during delivery (45mg/100ml) and the rest is returned through store.
 There is saving about 300mg of iron due to amenorrhoea for 10 months as Iron loss in
menstrual bleeding per cycle is 30mg.
 The iron is not squarely 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 6-7mg.
 The amount of iron absorbed from the diet and that mobilised from the store are
inadequate to meet the demand. Serum iron and ferritin level fall if the iron
supplementation is not given during pregnancy.
 In absence of exogenous iron supplementation. The hemoglobulin concentration and
the haematocrit fall appreciably. So pregnancy is an inevitable iron deficiency state.
RESPIRATORY SYSTEM
Anatomical changes
 There is enlargement of the uterus, specially in the later months, there is elevation of
the diaphragm(4cm) with the enlargement of the uterus and the breathing becomes
diaphragmatic.
 Subcoastal angle increases from 68 degree to 103 degree, the transverse diameter of the
chest expands by 2cm and the chest circumference increases by 5-7cm.
 Mucosa of the upper respiratory tract show hyperaemia and congestion.
Functional changes
 A state of hyperventilation occurs during pregnancy leading to increase in tidal volume
and therefore respiratory minute volume by 40% which is probably due to progesterone
acting on the respiratory centre and also to increase in sensitivity of the centre to carbon
dioxide. The women feels shortness of breath.
ACID BASE BALANCE
 The hyperventilation causes changes in the acid base balance.
  The arterial partial pressure of carbon dioxide falls from 30 to 32 mm Hg and partial
pressure of oxygen rises from 95mm Hg to 105mm of Hg which facilitates transfer of
carbon dioxide from the fetus to the mother and oxygen from the mother to the fetus
 The power of hydrogen rises in order of 0.02 unit and there is a base excess of 2mEq
per litre. So pregnancy is a state of respiratory alkalosis.
 Partial renal compression occurs through increased excretion of bicarbonate. Maternal
oxygen consumption is increased by 20% - 40%- Bohr effect and thereby decreasing
the oxygen releasing capacity of maternal blood due to increased demand of the fetus,
placenta and maternal tissues.
 Fall in the plasma bicarbonate level and mild increase in blood power of hydrogen shifts
the oxygen dissociation curve to the left.
 The slight increase in the blood ph, stimulates an increase in 2,3-diaphosphoglycerate
in maternal erythrocytes which counteracts Bohr effect by shifting the curve back to
the right, facilitating oxygen release to the fetus.
 During labour, the patient may become dyspenic. Hence hyperventilation and
respiratory alkalosis may develop leading to carpopedal spasm and acid base
imbalance.
ELECTROLYTES

URINARY SYSTEM
Kidney
 Dilation of renal pelvis, calyces and the ureters
 Kidney is enlarged by 1 cm.
 Renal plasma flow is increased by 50-75% maximum by the 16 weeks and is maintained
until 34 weeks.
 GFR is increased by 50% all throughout pregnancy. Increased GFR causes reduction in
maternal plasma levels of creatinine, blood urea nitrogen(BUN) and uric acid.
  renal tubules fail to reabsorb glucose, uric acid, amino acids, water soluble vitamins
and other substances completely.
 The volume of urine passed each day remains normal
 Level of enzyme renin (produced in kidneys) increase in pregnancy.
Ureter
 Ureter becomes atonic due to high progesterone level.
 Dilation of the ureter above the pelvic brim with stasis is marked on the right side
specially in primigravida due to dextrorotation of the uterus pressing the right ureter
against pelvic brim and also due to pressure by the right ovarian vein which crosses the
right ureter at right angle.
 The stasis is marked between 20-24 weeks.
 There is marked hypertrophy of the muscle and the sheath of the ureter specially the
pelvic part probably due to estrogen.
 There is elongation, kinking and outward displacement of the uterus
Bladder
 There is marked congestion with the hypertrophy of the muscle and elastic tissue of the
wall.
 In late pregnancy, the bladder mucosa becomes oedematous due to venous and
lymphatic obstruction due to venous and lymphatic obstruction especially in
primigravida following early engagement.
 Increased frequency of micturition is noticed at 6-8 weeks of pregnancy which subsides
after 12 weeks. It may be due to resetting of osmo regulation causing increased water
intake and polyuria. 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 be observed in late pregnancy due to urethral sphincter
weakness.
Proteinuria
 Upto 5% pregnant women may shows orthostatic or postural proteinuria. Significant
proteinuria (more than 300mg in 24 hours) is abnormal and is usually seen in pore-
eclampsia.
Glycosuria
 Observed in 50% normal pregnant woman due to increase in glomerular filtration
(GFR) along with defective tubular reabsorption of glucose lowering its renal threshold
(normal is 180mg/dl). It may make pregnant women more susceptible to urinary tract
infection.
NERVOUS SYSTEM
 Some sorts of tempermental changes are found during pregnancy and in the puerperium.
Nausea, vomiting, mental irritability and sleeplessness are probably due to some
psychological background.
 Compression of the median nerve underneath the carpal ligament over the wrist joint
leading to pain and paraesthesia in the hands and arm (carpal tunnel syndrome) may
appear in the later months of pregnancy.
 Parathesia and sensory loss over the anterolateral aspect of the thigh may occur. It is
due to compression of the lateral cutaneous nerve of the thigh.
LOCOMOTOR SYSTEM
 There is increased mobility of the pelvic joints due to softening of the ligaments caused
mainly by relaxin.
  This along with increased lumbar lordosis during later months of pregnancy due to
enlarged uterus produces backache and waddling gait.
ENDOCRINE CHANGES
Placenta produces a variety of hormones of which protein hormone and steroid hormone are
significantly important.
Syncytiotrophoblasts are the principle site of protein and steroid hormones in pregnancy.

PROTIEN HORMONE

 HUMAN CHORIONIC GONADOTROPIN(HCG)

 Glycoprotein of molecular weight 36,000-40,000 daltons.
 Consists of non specific alpha – 92 amino acids and a hormone specific Beta – 145
amino acids
 HCG is secreted by syncytial trophoblast cells
 Secretion of HCG prevents normal menstruation
 Can be first measured in blood 8 to 9 days after ovulation
 Level of secretion reaches maximum at about 10 to 12 weeks of pregnancy
FUNCTION-
1. It acts as a stimulus for secretion of progesterone by the corpus luteum of pregnancy.
The rescue and maintenance of corpus luteum till six weeks of pregnancy is the major
biological function of hCG.
2. hCG stimulates Leydig cells of the male foetus to produce testosterone in conjunction
with fetal pituitary gonadotrophins. It is thus indirectly involved in the development
of male external genitalia.
3. It has got immune-suppressive activity which may inhibit the maternal process of
immunorejection of the fetus as a homograft.
4. Stimulates both adrenal and placental steriodogenesis.
5. Stimulates maternal thyroid because of its thyrotrophic activity

 SECRETION OF HUMAN CHORIONIC SOMATOMAMMOTROPIN or

HUMAN PLACENTAL HORMONE
 This is a protein having a molecular weight of 38000
 Synthesised by the syncytiotrophoblast of the placenta
 Secreted by placenta from the fifth week of pregnancy
 Progressively rise from 5 μg/ml to 25 μg/ml until about 36 weeks.
 FUNCTION OF HUMAN CHORIONIC SOMATOMAMMOTROPIN
 It has similar action to growth hormone.
 HPL antagonises insulin action.
 High level of maternal insulin helps protein synthesis.
 HPL causes lipolysis and proteolysis and promotes transfer of glucose and
amino acids to fetus

STEROIDAL HORMONES

SECRETION OF ESTROGEN BY PLACENTA

 Like corpus luteum placenta secretes estrogen & progesterone
  Oestrogen causes hypertrophy and hyperplasia of the uterine myometrium, thereby
increasing the accommodation capacity and blood flow of the uterus.
 Secreted by syncytial trophoblast cells of placenta
 Toward the end of pregnancy, the daily production of estrogen increases
 Secretion of estrogen by placenta is quite different form ovaries
 Placenta: formed from androgenic steroid compounds • De hydroepiandrosterone
• 16-hydroxyhydroepiandrosterone
 These weak androgens are converted into estriol,estradiol,estone.
 Oestriol is fisrt detecetable at 9 weeks (0.05 ng/ml) and increases gradually to about
30 ng/ml at term.
 FUNCTION OF ESTROGEN
 Function on most reproductive & associated organs of mother
 Extreme quantities of estrogen cause -Enlargement of mothers uterus,
Enlargement of mothers breast, Enlargement of female external genitalia,
Relaxes pelvic ligaments of mother

SECRETION OF PROGESTERONE BY PLACENTA

 Secreted in moderate quantities by corpus luteum at beginning & secreted in

tremendous quantities by placenta later
 Increases 10 fold during the course of pregnancy
 The average levels of plasma progesterone at 12th week, 28 week and term
approximately 25 ng/ ml, 80 ng per ML and 300 ng per ML respectively.
 Low progesterone levels are observed in ectopic pregnancy and in abortion. High
values are so observed in hydatidiform mole, RH isoimmunisation.
 After delivery, the plasma progesterone decreases rapidly and is not detectable after
24 hours.
 FUNCTION OF PROSGESTERONE
 Causes decidual cells to develop in the endometrium
 Decreases contractility of pregnant uterus
 Help the development of conceptus
 Help estrogen to prepare mothers breast for lactation

OTHER HORMONAL FACTORS

 PITUITARY SECRETION
 Anterior pituitary gland of mother enlarges to 30- 50% Of its normal size during
pregnancy, increases production of corticotrophin, thyrotropin& prolactin.
 Secretion of FSH & luteinizing hormone decreases due to inhibitory effect of estrogen
& progesterone.
 Serum prolactin level increases by 10 times
 ACTH and CRH (corticotrophin releasing hormone (CRH) and plasma vasopressin
(ADH) level unchanged.

 CORTICOSTEROID SECRETION
 Rate of adrenal cortical secretion of glucocorticoid increases
 Value of aldosterone secretion reaches a peak at end of gestation.
  SECRETION BY THYROID GLAND
 Thyroid gland enlarges up to 50% during pregnancy increases its production of
thyroxine, hyperplasia occurs.
 Iodine intake during pregnancy should be increased from 100-150 microgram/day to
200 as recommended by WHO.
 The serum protein bound iodine is increased in pregnancy, the range being 6.2 – 11.2
mg%.
 Thyroxin binding globulin (TBG) increases due to effect of oestrogen stimulation.
 Total T4 and T3 are increased and free T4 and T3 level are unchanged.
 Production of thyroxine is caused by thyrotrophic effect of HCG & HCT.

 SECRETION OF PARATHYROID GLAND

 Mothers parathyroid gland enlarges during pregnancy especially during when the
mother is on ca diet
 The main function of PTH are to regulate the renal synthesis of 1,25 dihyroxy vitamin
D3 and mobilisation of calcium from bone.
 Enlargement of these glands cause calcium absorption from mothers born
 Secretion of parathyroid hormone intensifies during lactation
 Growing baby need more calcium than fetus

 SECRETION OF ADRENAL CORTEX

 Slight enlargement of the adrenal cortex

 Significant increses in the serum level of aldosterone, deoxycorticosterone (DOC) ,
cortico steroid binding globulin (CBG), cortisol and free cortisol due to high level of
estrogen.
 The level of cortisol nearly doubles.

PSYCHOLOGICAL CHANGES
Parenthood causes psychological changes. Pregnancy is full of growth, change, excitement and
challenge. The occurrence of physiological changes along with the hormonal changes make
pregnancy a psychological and emotional event for the mother.
Hormonal level are constanty fluctuating during pregnancy, which leads to feelings of anxiety,
emotional liability, issues of self esteem and body image issue, depression, asdness,elation and
even confusion.
Psychological changes in first trimester:
She may feel anxiety about losing her baby. If the pregnancy was planned and whished for,
there is joy with the news, but if the pregnancy was unexpected, there is mixed feelings about
it.
Psychological changes in second trimester:
Stress and anxiety is less in second trimester. The mother experience a great feeling, around 20
weeks, when she starts feeling the fetal movements of the baby. The fear of miscarriage,
prevalent in first trimester, usually disappers, mother feel increased dependence on her partner.
Feeling of self-consciousness about the weight which is being put on.
Psychological changes in third trimester:
Women starts anticipating and preparing for childbirth, both physically and emotionally. While
fear of baby arrival, labor and birth occurs. Needs reassurance regarding her physical
appearance.
SUMMARY AND CONCLUSION
Physiological changes occur in pregnancy to nurture the developing foetus and prepare the
mother for labour and delivery. Some of these changes influence normal biochemical values
while others may mimic symptoms of medical disease. It is important to differentiate between
normal physiological changes and disease pathology and which can be managed earlier without
harmful effects on mother and fetus.
During pregnancy, the pregnant mother undergoes significant anatomical and physiological
changes in order to nurture and accommodate the developing foetus. These changes begin after
conception and affect every organ system in the body. For most women experiencing an
uncomplicated pregnancy, these changes resolve after pregnancy with minimal residual effects.
It is important to understand the normal physiological changes occurring in pregnancy as this
will help differentiate from adaptations that are abnormal.
BIBLIOGRAPHY
 Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition, page
no. 59-71
 Dutta D.C., Textbook of obstetrics, New Central Book agency publication 6th edition
page no: 46-63
 Daftary shirish N, Chakarvarti Sudip, Holland and Brews Manual of Obstetrics,
Elsevier India private limited, 3rd edition,page no.42-47
 Whilson Robert, Beecham Clayton M., Carrington Elise Ried, Obstetrics and
Gynecology, The C.V. Mobsy Company, 5th edition page no.64-71
 Bookmiler Mae M, Bowen George L., Textbook of obstetrics and Obstetric Nursing,
W.B. Saunders Company publication, 4th edition page no.56-64