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PHYSIOLOGIC CHANGES OF PREGNANCY

 Can be categorized as LOCAL (confined to the reproductive organs) or SYSTEMIC (affecting the entire body)
 Both symptoms (subjective findings) and signs (objective findings) of the physiologic changes are used to
diagnose and mark the progress of pregnancy

LOCAL CHANGES: REPRODUCTIVE SYSTEM CHANGES

1. UTERINE CHANGES
 Uterus increases in size to make room for the growing fetus
 Length grows from approx. 6.5 – 32 cm
 Depth increases from 2.5 – 22 cm
 Width expands from 4 – 24 cm
 Weight increases from 50 – 1000 g
 Uterine wall thickens (early in pregnancy) from 1 – about 2 cm; toward the end of pregnancy, thins to
become supple and only about 0.5 cm thick

UTERINE CHANGES
 Volume increases from 2 mL to more than 1000 mL; can hold a 7lb (3.175 g) fetus plus 1000 mL of
amniotic fluid (total of about 4000 g)
 Great uterine growth is due partly to formation of a few muscle fibers in the uterine myometrium but
principally due to the stretching of existing muscle fibers
 End of 12th week of pregnancy – large enough to be palpated as a firm globe under the abdominal wall,
just above the symphysis pubis
 Uterine growth is constant, steady and predictable increase in size
 20th – 22nd week = level of the umbilicus
 36th week = touch the xiphoid process
 2 weeks before term (38th week) – primigravida, woman in her 1st pregnancy – fetal head
settles into pelvis to prepare for birth, uterus returns to the height it was @ 36 weeks =
termed lightening, because woman’s breathing is so much easier it seems to lighten the
woman’s load
• Lightening not predictable in multipara (woman who has had one or more children)

FUNDIC HEIGHT
MEASURING UTERINE HEIGHT
 Uterine height is measured from the top of the symphysis pubis over the top of the uterine fundus

 Uterine blood flow increases during pregnancy as placenta grows and requires more and more blood for
perfusion
• Doppler ultrasonography – from 15 – 20 mL/min (before pregnancy) to 500 – 750 mL (end of pregnancy)
• 75% of that volume goes to the placenta;
• Toward end of pregnancy – 1/6 of the total body blood supply is circulating through the uterus
 Uterine bleeding is always potentially dangerous – vaginal blood loss (suggesting uterine
bleeding), shd be reported to health care practitioners
 Bimanual examination – (one finger of the examiner is placed in the vagina, the other hand on the
abdomen) – shows that uterus is more anteflexed (bent forward), larger and softer to the touch than
usual; HEGAR SIGN
• 16th – 20th week  fetus is small in relation to the amount of amniotic fluid = ballottement (French
word balloter, meaning to toss about)
 Braxton Hicks contractions- at least 12th week; “practice” contractions – serve as warm-up exercises for
labor and also increase placental perfusion; become so strong and noticeable in the last month; may be
mistaken from labor contractions (false labor) – no cervical dilatation

2. AMENORRHEA
 Occurs with pregnancy due to suppression of follicle stimulating hormone (FSH) by rising estrogen levels
 Healthy woman – amenorrhea strongly suggests impregnation ha occurred
 May also indicate onset of menopause, uterine infection, worry over becoming pregnant, chronic illness
(severe anemia, stress); athletes who train strenuously, %age of body fat drops below critical point –
making amenorrhea only a presumptive sign
3. CERVICAL CHANGES
 Cervix of the uterus becomes more vascular and edematous – response to the increased level of
circulating estrogen from the placenta during pregnancy
 Softening of the consistency of the cervix (Goodell’s sign) – due to increased fluid between cells
 Nonpregnant cervix – tip of nose
 Pregnant cervix - earlobe
 Just before labor – consistency is like butter or is said to be “ripe” for birth

 Darkening of the cervix from a pale pink to violet – due to increased vascularity
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 Gland of the endocervix undergo both hypertrophy and hyperplasia and distend w/ mucus
 Tenacious coating of mucus fills cervical canal – mucus plug, called operculum – acts to seal
out bacteria and helps prevent infection in the fetus and membranes

4. VAGINAL CHANGES
 Vaginal epithelium and underlying tissue become hypertrophic and enriched w/ glycogen – due to
influence of estrogen
 Structures loosen from connective tissue attachments – in preparation for great distention @ birth =
resulting in a white vaginal discharge throughout pregnancy
 Change in the color of the vagina from normal light pink to a deep violet (Chadwick’s sign) – due to
increase in the vascularity of the vagina, increase in circulation
 Vaginal secretions fall from a pH of greater than 7 (alkaline) to 4 or 5 (acid pH) – due to the action of
Lactobacillus acidophilus, bacteria that grow freely in the glycogen enriched environment, increasing lactic
acid content of secretions
 Helps make vagina resistant to bacterial invasion for the length of pregnancy
 Change in pH favors growth of Candida albicans – a specie of yeast-like fungi; candidal infection is
manifested by itching, burning sensation, cream cheese-like discharge;
 Candidal infection in the newborn – thrush or oral monilia

5. OVARIAN CHANGES
 Ovulation stops w/ pregnancy – due to the active feedback mechanism of estrogen and progesterone
produced by the corpus luteum (early in pregnancy) and placenta (later)
 Feedback causes the pituitary gland to halt production of FSH and LH

6. BREAST CHANGES
 One of the 1st physiologic changes in pregnancy (@ about 6 weeks) – feeling of fullness, tingling, or
tenderness in her breast – due to increased stimulation of breast tissue by the high estrogen level
 Breast size increases as pregnancy progresses – due to hyperplasia of the mammary alveoli and fat
deposits
 Areola of the nipple darkens, diameter es from about 3.5 cm (1.5 in) to 5 or 7 cm (2 – 3 in)
 Darkening of skin surrounding the areola in some women – forming secondary areola
 Blue veins may become prominent over surface of the breasts – due to increased vascularity of the breasts
 Montgomery’s tubercles – sebaceous glands of the areola – enlarge and become protruberant
 Secretions from these glands keep the nipple from cracking and drying during lactation
 16th week – colostrum, the thin, watery, high-protein fluid that is the precursor of breastmilk – can be
expelled from the nipples

SYSTEMIC CHANGES

1. INTEGUMENTARY SYSTEM
 As uterus increases in size, abdominal wall must stretch to accommodate it
 Stretching (plus possibly adrenal cortex activity) – can cause rupture and atrophy of small segments of
connective layer of the skin in the abdomen = pink or reddish streaks (striae gravidarum) appearing
on the sides of the abdominal wall and sometimes on thighs and breasts
 Weeks after birth – lighten to silvery – white color (striae albicantes or atrophicae); tho’
permanent, become barely noticeable
 Occasionally, abdominal wall has difficulty stretching enough to accommodate growing fetus causing rectus
muscles to actually separate = known as diastasis
 Umbilicus is stretched – by 28th week depression becomes obliterated and smooth because it has been
pushed so far outward
 Most women – may appear as if it has turned inside out, protruding as a round bump @ the center of
the abdominal wall
 Linea nigra, melasma – caused by melanocyte-stimulating hormone (secreted by the pituitary)
 Vascular spiders – small, fiery-red branching spots, sometimes seen on the skin of pregnant woman,
particularly on the thighs = increased level of estrogen; may fade out but not completely disappear after
childbirth
 Increased activity of sweat glands – increase in perspiration
 Palmar erythema – redness and itching on the hands; increased estrogen level
 Increased Scalp hair growth= overall increased metabolism

2. Respiratory system
 Marked congestion, or “stuffiness” of the nasopharynx – response to increased estrogen levels
 Pressure from growing uterus – diaphragm may be displaced
 Crowding of chest cavity – causes SOB late in pregnancy until lightening relieves the pressure
 To keep mother’s pH level from becoming acid due to the load of carbon dioxide being shifted to her
by the fetus – increased ventilation (mild hyperventilation) to blow off excess CO 2 begins early in
pregnancy
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3. TEMPERATURE
 Early in pregnancy – body temperature increases slightly = due to secretion of progesterone from the
corpus luteum
 As the placenta takes over the fxn of the corpus luteum @ about 16 weeks – temperature usually
decreases to normal

4. CARDIOVASCULAR SYSTEM
 Changes in the circulatory system are extremely significant to the health of the fetus – necessary for
adequate placental and fetal circulation
 Blood Volume
 Total circulatory blood volume increases by @ least 30% (as much as 50%) – to provide for adequate
exchange of nutrients in the placenta and to provide adequate blood to compensate for blood loss @
birth
 Blood loss @ normal vaginal birth: 300 – 400 mL
 From C/S: 800 – 1000 mL
 Increase in blood volume occurs gradually beginning end of 1 st trimester
 Peaks about the 28th to the 32nd week then continues @ high level throughout 3rd trimester
 Because plasma volume increases faster than RBC production does – concentration of hemoglobin and
erythrocytes decline = giving the woman a pseudoanemia, early in pregnancy
 Woman’s body compensates by producing more RBC, creating near-normal levels by the 2 nd
trimester
 Iron Needs
 Fetus requires a total of about 350 – 400 mg of iron to grow
 Increases in the mother’s circulatory RBC mass require an additional 400 mg of iron
 Total increased need of about 800 mg
 Average woman’s store of iron is less – only about 500 mg
 Additional iron is often prescribed to prevent true anemia – because iron absorption is impaired
during pregnancy as a result of decreased gastric acidity (iron is absorbed best from an acid
medium)
 Need for folic acid increases more during pregnancy
 Not enough intake of folic acid = megalohemoglobinemia (large, non-functioning RBC)
 Inadequate folic acid levels have also been linked to an increased risk for neural tube disorders
in fetus
 Eat food high in folic acid (spinach, asparagus, legumes) during pre-pregnancy and pregnancy
period
 Folic acid is also routinely prescribed as a prenatal vitamins
 Heart
 to handle the increase in blood volume in the circulatory system, a woman’s cardiac output es
significantly, by 25% - 50% - heart has more blood to pump through the aorta
 HR es by 10 beats/minute (80 – 90 beats/min)
 Because the diaphragm is pushed upward by growing uterus late in pregnancy – heart is shifted to a
more transverse position in the chest cavity (making it appear enlarged on x-ray examination)
 Palpitation are common particularly on quick motion
 In early months – due to sympathetic nervous system stimulation
 In later months – due to increased thoracic pressure caused by pressure of the uterus against
the diaphragm
 Caution women not to feel frightened
 Blood Pressure
 BP does not normally rise – because the increased heart action takes care of the greater amount of
circulating blood
 Most women, BP es slightly during the 2nd trimester – because peripheral resistance to circulation is
lowered as the placenta expands rapidly
 3rd trimester – BP rises again to 1st trimester levels
 Peripheral Blood Flow
 3rd trimester – blood flow to lower extremities is impaired by the pressure of the expanding uterus on
veins and arteries
  in blood flow in the venous system can lead to edema and varicosities of the vulva, rectum and legs
 Supine Hypotension Syndrome
 When lying supine, the weight of the growing uterus presses the vena cava against the vertebrae,
obstructing blood flow from the lower extremities
 Causes a  in blood return to the heart and, consequently ed cardiac output and
hypotension
 This maternal hypotension is potentially dangerous because it can cause fetal hypoxia
 Feeling of lightheadedness, faintness, and palpitations
 Can easily be corrected by having the woman turn unto her side (preferably the left side) so that blood
flow through the vena cava es again.
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 Blood Constitution
 Level of circulating fibrinogen, a constituent of the blood necessary for clotting - es as much as 50%
during pregnancy
 Other clotting factors (factors VII, VIII, IX, and X) and platelet count also es
 These es are a safeguard against major bleeding should the placenta be dislodged and the uterine
arteries or veins be opened
 Total WBC count rises slightly – both as a protective mechanism and as a reflection of the woman’s
total blood volume
 Total CHON level es – indicating amount CHON being used by the fetus
 Lower Total CHON load and hypervolemia = fluid readily leaves the blood vessels to equalize
osmotic and hydrostatic pressure  common ankle and foot edema of pregnancy

5. GASTROINTESTINAL SYSTEM
 Stomach and intestines are pushed toward the back and sides of the abdomen – due to growing uterus
 Midpoint of pregnancy – intestinal peristalsis and emptying time of stomach is slowed  heartburn
(burning sensation in the substernal area due to reflux of acid contents of the stomach into the
esophagus), constipation, and flatulence
 Pressure from the uterus on veins returning from the extremities can lead to hemorrhoids
 Relaxin – hormone produced by the ovary – may contribute to decreased gastric motility
 At least 50% of women experience some nausea and vomiting early in pregnancy
 Most apparent in early morning, on rising, or if woman becomes fatigued during the day; more
frequent in women who smoke cigarettes
 Usually subsides after the 1st 3 months, after w/c woman may have a voracious appetite
 Some women notice hypertrophy @ their gum line and bleeding of gingival area when they brush
their teeth
 ed saliva formation – hyperptyalism – probably as a local response to increased levels of estrogen
 Lower than normal pH of saliva  ed tooth decay if tooth brushing is not done conscientiously

6. URINARY SYSTEM
 Changes in the urinary system result from the following:
 Effects of high estrogen and progesterone levels
 Compression of the bladder and ureters by the growing uterus
 Increased blood volume
 Postural influences

 Fluid Retention
 to provide sufficient fluid volume for effective placental exchange, total body water es to 7.5L –
requires the body to increase its sodium reabsorption in the tubules to maintain osmolarity
 influence of progesterone  ed response of the angiotensin-renin system in the kidney   in
aldosterone production
• Aldosterone aids in sodium reabsorption
 Water is retained during pregnancy:
• to aid the increase in blood volume and
• to serve as a ready source of nutrients to the fetus
 Renal Function
 Woman’s kidneys must excrete not only waste products of her body but also those of the fetus
 Her kidneys must be able to excrete additional fluid and manage the demands of increased renal blood
flow
 Kidneys may  in size – changing their structure and affecting their function
 Urinary output gradually es (by about 60% - 80%)
 Specific gravity decreases
 GFR and renal plasma flow begin to increase in early pregnancy to meet the increased needs of the
circulatory system
 Renal threshold for glucose decreases and glucose and lactose is frequently seen in the urine
 Traces of albumin may be present in urine – due to congestion in renal capillaries
 Ureter and Bladder Function
 Increased urinary frequency during 1st trimester (10 – 12 times/day) – until uterus rises out of the
pelvis and relieves pressure on the bladder
 May return @ the end of pregnancy – fetal head exerts pressure on bladder
 Because of high progesterone levels = ureters  in diameter and bladder capacity es to about 1,500
mL
 Pressure of the uterus on the right ureter may lead to urinary stasis and pyelonephritis if not relieved
 Pressure on the urethra = may lead to poor bladder emptying and bladder infection – dangerous coz it:
o may ascend and become kidney infections and
o dangerous to fetus coz UTI are associated w/ preterm labor
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7. SKELETAL SYSTEM
 Calcium and phosphorus needs are increased – fetal skeleton must be built
 As pregnancy advances – gradual softening of the woman’s pelvic ligaments and joints – to create pliability
and to facilitate passage of baby through the pelvis @ birth
 Softening is caused by influence of both the ovarian hormone relaxin and placental progesterone
 Excessive mobility of the joints can cause discomfort
 Wide separation of the symphysis pubis – as much as 3 – 4 mm by 32 weeks of pregnancy = makes
women walk w/ difficulty because of pain
 To change her center of gravity and make ambulation easier – pregnant woman tends to stand straighter
and taller than usual = stance is referred to as the “pride of pregnancy”
 Standing this way – shoulders back and abdomen forward = lordosis (forward curve of the lumbar
spine) – may lead to backache

8. ENDOCRINE SYSTEM
 Most striking change is the addition of placenta as an endocrine organ
 Endocrine Gland Changes and Effects During Pregnancy

GLAND CHANGES EFFECT

Thyroid gland  Slight enlargement  Increased basal metabolism rate (20%)
 Increased thyroid hormone production  Increased O2 consumption
Parathyroid  Slight enlargement  Better utilization of calcium and vitamin
gland  ed parathyroid hormone production D
Pancreas  Early in pregnancy, ed insulin production  Additional glucose is available for fetal
because of heavy fetal demand for glucose growth
 After 1st trimester, ed insulin production
because of insulin antagonist properties of
estrogen, progesterone, and hPL
Pituitary gland  FSH and LH ed  Anovulation
 Prolactin ed  Breasts prepared for lactation
 Melanocyte-stimulating hormone ed  ed skin pigmentation
 Human growth hormone ed

Placenta  Estrogen and progesterone produced  Uterine and breast enlargement, fat
deposits
 ed blood coagulation, sodium and
water retention
 Relaxin ed  Softening of the cervix and collagen of
joints
 Human placental lactogen  es glucose available for fetus
 es utilization of CHON for energy, ing
CHON available for fetal growth

9. IMMUNE SYSTEM
 Immunologic competency during pregnancy decreases – probably to prevent the woman’s body from
rejecting fetus as if it were transplanted organ
 Immunoglobulin (IgG) production is particularly decreased = making woman more prone to infection
during pregnancy
 Increase in WBC – may help counteract the decrease in IgG response

10. Weight
 24 – 30 lbs – desirable total weight gain for pregnant woman
 Fetus : 7.5 lbs.
 Placenta : 1.5 lb.
 Amniotic Fluid : 2 lbs.
 Uterus : 2.5 lbs.
 Blood volume : 2 – 4 lb.
 Weight of breast : 3 lbs.
 Weight of additional fluid, fat, etc : 4 – 9 lbs.
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Fundic Height

Bimanual Examination – Hegar’s Sign

Cervix with OPERCULUM

SUPINE HYPOTENSION SYNDROME

LORDOSIS (“Pride of Pregnancy”)

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