Physiological changes in pregnancy

1-reproductive tract :
A-uterus :
-Non-pregnant : solid structure, 50-70g , 10ml .
-Pregnant : thin-wall structure, 1000g, 5L in capacity
How it happened?
1-hypertrophy of muscle cells(estrogen effect) and hyperplasia
(progesterone effect)
2-Stretching: pressure effects of fetus *after 12w*
Formation of lower uterine segment: After 12 weeks(due to
stretching and hyperplasia) isthmus starts to expand from 0.5cm to 10 cm
at term.
size of uterus:
At 12w uterus will be palpable just above symphysis pubis
at 16w : mid way between SP and umbilicus
20-22w will be palpable at umbilicus
36: just bellow xyphoid process
38w: above xyphoid process -> then failure to ascend till 40w
40w coming down so no calculating.
Position: dextrotation (uterus shift to abdomen -> midpostion and shift to rt
due displacement from colon)
Consistency: hegar sign: softening of isthmus at 6w to such extent that on
bimanual examination fingers meet-> cervix and uterus as 2 compartment
Utero-placental flow: Placental perfusion is dependent on uterine and
ovarian arteries.
-due to Est and PRO effect -> uterine and ovarian vessels diameter
doubled-> Decrease resistance
increase in length and tortuosity.
Utero-placental flow: 0.5L/min at term

B-
Cervix:
-edema + cyanosis(due to↑vascularity), softening
*goodell sign*
-Cervical ectropion: Columnar epithelium under effect
of estrogen -> bulge from endo-cervix inside to outside
-> Columnar ‫يولع من جوا بسبب م يتحمل االسيد‬
-Mucus plug obstructs cervical canal after conception (rich in IG) -> prevent
ascending infection to uterus.
-Crystallization(ferning)-> indicates rupture of membrane & ovulation
conception
C-Ovaries:
-Ceasing of ovulation ->due to increase BHCg-> maintain CL-> CL secrete
(Relaxin Inhibin PE)-> inhibin with others inhibit FSH , LH-> then after 10w it
will degenerates due to drop in BHCG-> placenta takes over in production of
RIPE
D-The Vagina:
- Chadwick sign: bluish discoloration discoloration of cervix, vagina
resulting from ↑ blood flow
- E-The Vulva: violet in color , Edema and varicosities may
develop.

Skin changes :
● Chloasma(melasma): brown pigmentation on face
● spiders angioma & Palmer erythema due to Estrogen.
● Striae gravidum.
● Linea nigra.
Breasts :
-↑ breast size (due to hypertrophy of mammary alveoli
and duct)
-Delicate veins becomes visible beneath skin.
-Areola & Nipples : larger, deeply pigmented
-Hypertrophy of sabaceous gland ->glands of
montgomery

1-Weight gain: 11kg avg at end of pregnancy.

6 kg is composed of (breast, blood, fat, uterine tissue)
5 kg of fetus, placenta and amniotic fluid.
If there increase of wt markedly think of preeclampsia
2-Water metabolism :
-due to VD + U.P circulation -> ↑RAAs-> salt+ h2o retention.
-6L of water is acquired-> placenta , fetus …….
-Pitting edema in dependent area (feet) is normal , Edema in non
dependandant area in face like -> pre-eclampsia
3-Electrolytes and mineral metabolism:
↑Na & K accusation with ↓ serum (dilution effect due to expand in plasma
volume->(↓ osmolality= Na , u , glucose)
-↓ Total Ca, normal Ionized Ca.
-↓Mg (total and ionized) , normal PO4
Hematological changes :
! Blood volume up to 50% (↑plasma > RBC) -> physiologic anemia):
1-Meets demands of enlarged uterus
2-Protect mother + fetus from Impaired VR & maternal blood loss.
"Hb*physiologic anemia* cutoff is 11 in 1st and 3rd , 10.5 in 2nd trimester ,
bellow that is patho.
**Iron pregnancy requirement 1000mg
500g utilized for !erythrocyte.
300g fetus and placenta
200g obligatory loss
Average daily requirement 6-7mg/day

Immunoglobulin and leukocyte :

Suppression of immune to accommodate fetal graft ->Improvement of
some autoimmune disease and susceptibility to certain infections
!: WBC , CRP, ESR.
Coagulation: Pregnancy is hypercoagulable state , risk of VTE is
2x in pregnancy and 5x postpartum.
clotting factors: ! 1978 , ! Fibrinogen-> ! D- dimer(not reliable in
VTE)
!Thromboxane A2-> ! Platelet aggregations , dec PLT No
" Protein C and Protein S ,
normal PT and PTT
Cardiovascular system : circulation contain 6.5L of blood
Earliest and most dramatic.
-Increase in myocardium of LV , LA -> ↑Inotropic
-↑H.R: 15 beats/min ( maximum at term) + ↑ SV -> ↑ Cardiac output :
Labour pain can increase CO by 40%
Immediately after delivery C.O increase by 80% *due to gush of blood
return to circulation and IVC pressure is gone*.
exam:
-Distended neck vein.
-systolic ejection murmur with loud S2 and wide split
S3 gallops (volume overload sign)
➢EKG slight left axis deviation.
➢———————————————
➢" BP form 20-32w , D:15 > S:10 and rise thereafter.
➢Supine hypotension: due to graved Uterus push on IVC—> Syncope and
bradycardia

Respiratory System:
1-Anatomical changes:
-Diaphragm elevate by 4cm.
-Wide Chest diameter with inc cardiac silhouette
Physiological response to low PCO2. :
Mucosal hyperemia, and nosebleed.
Chest X- RAY : prominent pulmonary vasculature.
Physiological dyspnea: due to displacement of diaphragm -> ↓RV ->↑TV
➔ ↓PCO2->Respiratory alkalosis and via Boher effect(shift
dissociation curve to left ) ↑ maternal Hb to bind o2 from lung.
! PH stimulate 2,3 diphosphoglycerate in maternal erythrocyte ➔
facilitate O2 release
Urinary system :
Kidneys enlarge in size by 1cm: due to
compression + hormonal effect(R>L)
GFR: increase -> " creatinine , urea
Renal glycosuria(+1) may occur in 2nd
trimester (RT 180)(2+? investigate )
Symptoms: frequency & Stress
incontinence

Gastrointestinal tract :
1. Gum hypertrophy & Ptylism (excessive
salivation)
2. Gastric emptying delayed-> Heart burn( Pyrosis) due
3. to PG relax LES
4. Decrease intestinal motility(progesterone relaxe SM)
5. Hemorrhoids
6. Liver: ! ALP, decrease in bilirubin only changes
7. Gallbladder: " contraction-> stasis + increased
cholesterol saturation ➔ stone

Insulin :
Increase insulin resistance, possibly due to human placental lactogen*human chorionic
somatotropin* , HPL*maximum level at 24-28w -> so screening to GDM at 24-28w
Musculoskeletal :
-softening of joints and ligaments-> Increase mobility of pelvic joints caused by
progesterone and relaxin.
-Symphysis pubis diastasis
-Progressive lourdosis
-Backache
-Sciatica

Notes:
C section is done at lower uterine segment , due no a lot of muscle
Upper uterine segment , there is risk to tear in next pregnancy in vaginal birth
After fertilaization ->contraction occurs from upper to lower , before fertilization
upside down.