Physiological Changes in Pregnancy

Most of the changes are ready by the first trimester, so we could

say that this period is a transitional stage between pregnant and
non-pregnant states.
Why these Changes?
1-Increased availability of precursors for hormonal production,
fetal-placental metabolism. Through increased Dietary intake and
endocrinological changes.
2-Increased transport capacity. Through increased CO.
3-Maternal-fetal exchange. Placenta starts to control the
exchange at 10-12 weeks but who feeds the fetus before that?
Progestrone causes swelling in the endometrial stromal cells
filling it with glycogen, lipids, proteins, these cells are called
decidual cells and it is called the decidua.
4-Removal of Additional waste products. Through increased
ventilation, renal filtration, and peripheral vasodilatation.
Volume Homeostasis and Cardiovascular System:
Increased Blood Volume : It starts at week 6 and plateus at week
32 to 34 weeks, increased TBW from 6.5 L to 8.5 L , how this
could happen, and what are the consequences?
Cardiovascular Dynamics:
Could mimic a heart disease how?
Breathlessness (diaphragmatic elevation, increase in minute
elevation).
Oedema (Increase in plasma volume, compression on pelvic
veins)
Lightheadness and syncope due to compression on IVC.
Palpitations( Sinus Tachycardia, premature ventricular or atrial
beats)
Increase in the force of apical beat.
Increase in the volume of the peripheral pulse.
Heart Sounds Changes:
Increased intensity of 1st heart sound and split sometimes.
3rd hear sound is audible.
Ejection Systolic murmur.

At the labour the CO increases more to around 7L as with each

uterine contraction it sqeezes blood into the circulation, at
deleivery auto transfusion transfers more blood causing increase
in about 10-20%.
SV, CO , HR remains high during the first 2 dats postpartum.
CO needs 24 weeks to get back to normal.
Blood Changes:
Why there is anemia ?
1- Due to decreased Hb concentration ( falling from 13.3 to 10.9
g/dL).
2-Decrease in Iron due to transfer of iron from mother to fetus
although there is changes to adapt this such as increase in iron
absorption so pregnant women still need Iron.
3-Increase of renal clearance of folic acid.
Pregnancy is a hypercoagulable State (Return to normal after 4
weeks of delivery).
These Changes are important for hemostasis in delivery, as the
myometrium contracts occluding the blood vessels supplying the
placenta, then fibrin deposits used to occlude this site, any
abnormality of placental separation or uterine contractions could
affect this process, and could deplete fibrinogen.
Decreased Protein levels:
1- Decrease oncotic pressure.
2- Decrease in the peak plasma concentration of drugs that are
highly protein bound.
Respiratory System:
Because of the increased basal metabolic rate of a pregnant
woman and because of her greater size, the total amount of
oxygen used by the mother shortly before birth of the baby is
about 20 percent above normal and a commensurate amount
of carbon dioxide is formed. These effects cause the mother’s
minute ventilation to increase. It is also believed that the high
levels of progesterone during pregnancy increase the minute
ventilation even more, because progesterone increases the
respiratory center’s sensitivity to carbon dioxide. The net
result is an increase in minute ventilation of about 50 percent
and a decrease in arterial Pco2 to several millimeters of
mercury below that in a nonpregnant woman. Simultaneously,
the growing uterus presses upward against the abdominal
contents, which press upward against the diaphragm, so the
total excursion of the diaphragm is decreased. Consequently,
the respiratory rate is increased to maintain the extra
ventilation.

Gastrointestinal Tract:
Oral: Pregnancy gingivitis .
Desquamation of oral Mucosa
Increased dental Caries
Increased tooth Mobility
Gut: relaxation of Lower esophageal sphincter and increased
gastric acidity.
Delayed Gastric Emptying and motility and remain so till
puerperium , so she as at increased risk of aspiration.
The intestinal musculature is relaxed, with lower motility, which
permits a greater
absorption of nutrients but may lead to constipation.
Liver: Hyperestrogenic state because the liver can’t metabolize
easily these huge quantities.
Increased in portal vein pressure and esophageal venous
pressure in late pregnancy.
Increased production of fibrinogen and clotting factors.
Increased levels of triglycerides and cholesterol.
Endocrinological Changes:
1-Pituitary:
The pituitary enlarges 50% in size, so that increasing incidence
of Sheehan Syndrome Post-partum.
Increased production of prolactin, ACTH, MCH.
Prolactin functions:
1-Lactation
2-Stress Response
3-Insulin regulation and glucose homeostasis.
Decrease production of HGH.
Thyroid Gland:
• The thyroid gland enlarges during pregnancy, occasionally to
twice its normal size. This is due mainly to colloid deposition
caused by a lower plasma level of iodine, consequent on the
increased ability of the kidneys to excrete during pregnancy.
Oestrogen stimulates an increased secretion of thyroxine-
binding globulin. In consequence both triiodothyronine (T3)
and thyroxine (T4) levels rise. These raised levels do not
indicate hyperthyroidism, as both the thyroid-stimulating
hormone (TSH) and the free thyroxine levels are in the
normal range.
• TSh in early pregnancy falls.
• Free T4 in late pregnancy falls.
Placenta and Uterus:
HCG-b is used as a sensitive test for pregnancy as it starts to
appear in the blood days after implantation in small quantities.
Its main function is to maintain the corpus luteum for the
production of progesterone till the 12th week when placenta
starts to accomplish this function.
It inhibits FSH and LH production.
Oestrogen and Progestrone starts to increase in the early
pregnancy then plateus till the end of pregnancy .
Estrogen encourages myometrium hypertrophy.
Progestrone discourages contractions.
Human Placental Lactogen Functions:
 1-Breast development was thought to induce lactation( it
doesn’t induce lactation).
2-Some weak actions like GH
3-decreased sensitivity to insulin and so making glucose higher
in the blood for exchange.
4-Release of fatty acids for energy.
Adrenal Gland:
Increased corticosteroids release so that increase in striae,
glycosuria, and hypertension.

Reproductive System:
Uterus: The uterus is composed of three layers, outer longitudinal
and inner circular and middle intercalated. The proportion of
muscle to connective tissue varies in the uterus being mostly
muscular in the fundus, while the cervix has no more than 10%
muscular tissue. Due to this variation in late pregnancy this area
is pulled or stretched with the tension in muscular tissue of the
fundus.
Till the 20th week the uterus grows through hyperplasia , and
hypertrophy of muscle fibers, but then this growth pattern ceases
and starts to grow through distension. Blood vessels as well
undergo growth through hypertrophy that causes coiling in the
first half of pregnancy but then this stops and compensate for
distension through uncoiling.
The lower uterine segment is the safest for CS incision.
Cervix : gets thinner and swollen exposing the columnar
epithelium to vaginal excretions mainly through increasing affinity
to water (hygroscopic property) done by the effect of estrogen.
Prostaglandin and collagenase in the last weeks break down
collagen making the cervix softer and dilatable preparing it for the
labour.
Vagina: Thickening in the mucosa along with muscular
hypertrophy again preparing it for the labour to stretch it,
increased secretions and desquamation of mucosal cells
predisposing to vaginitis.
Breasts and Lactation: Oestrogen increases fat around glands
and glandular ducts, while progesterone and HPL increases gland
alveoli. Prolactin induces milk secretion but in the pregnancy it is
antagonized by estrogen and by the rapid fall in estrogen in the
first 48 hours this effect disappear, producing colostrum thick
yellow secretion rich in IGs.

Kidney and Urinary Tract:

Smooth muscles of the ureters and pelvis relax and dilates, along
with relaxation of the bladder increasing the incidence of the
infections.
Relaxation of the internal Sphincter with compression of the
uterus increasing incontinence.
Increase in GFR up to 60%.

https://www.youtube.com/watch?v=2HdvKD5NnGA