CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY
DIAGNOSIS OF PREGNANCY
PRESUMPTIVE SIGNS AND SYMPTOMS OF PREGNANCY
• Those signs and symptoms that are usually noted by the
patient, which impel her to make an appointment with a
physician.
• These signs and symptoms are not proof of pregnancy, but
they will make the physician and woman suspicious of
pregnancy.
• They could easily indicate other conditions.
1. AMENORRHEA (CESSATION OF MENSTRUATION)
• One of the earliest clues of pregnancy.
2. NAUSEA AND VOMITING (MORNING SICKNESS)
• Usually occurs in the early morning during the first 2 weeks of
pregnancy.
• Usually spontaneous and subsides in 6 to 8 weeks or by the
12th to 16th week of pregnancy.
• Hyperemesis gravidarum
o This is referred to as nausea and vomiting that is severe
and lasts beyond the 4th month of pregnancy.
o It causes weight loss and upsets fluid and electrolyte
balance of the patient.
3. FREQUENT URINATION
• It is caused by pressure of the expanding uterus on the
bladder.
• It subsides as pregnancy progresses and the uterus rises out of
the pelvic cavity.
• The uterus returns during the last weeks of pregnancy as the
head of the fetus presses against the bladder.
4. BREAST CHANGES
• In early pregnancy, changes start with a slight, temporary
enlargement of the breasts, causing a sensation of weight,
fullness, and mild tingling.
• As pregnancy continues the patient may notice:
a) Darkening of the areola -- the brown part around the
nipple.
b) Enlargement of Montgomery glands –the tiny nodules or
sebaceous glands within the areola.
c) Increased firmness or tenderness of the breasts.
d) More prominent and visible veins due to the increased
blood supply.
e) Presence of colostrum (thin yellowish fluid that is the
precursor of breast milk).
- This can be expressed during the second trimester
and may even leak out in the latter part of the
pregnancy.
5. VAGINAL CHANGES
• Leukorrhea
o This is an increase in the white or slightly gray mucoid
discharge that has a faint musty odor.
o It is due to hyperplasia of vaginal epithelial cells of the
cervix because of increased hormone level from the
pregnancy.
o Leukorrhea is also present in vaginal infections.
6. QUICKENING (FEELING OF LIFE)
• This is the first perception of fetal movement within the
uterus.
o It usually occurs toward the 18th week.
o A multigravida can feel quickening as early as 16 weeks.
o A primigravida usually cannot feel quickening until after
18 weeks.
7. SKIN CHANGES
• Striae gravidarum (stretch marks)
o These are marks noted on the abdomen and/or buttocks.
o These marks are caused by increased production or
sensitivity to adrenocortical hormones during pregnancy,
not just weight gain.
• Linea nigra
o This is a black line in the midline of the abdomen that may
run from the sternum or umbilicus to the symphysis
pubis.
o This appears on the primigravida by the 3rd month and
keeps pace with the rising height of the fundus.
o The entire line may appear on the multigravida before the
third month.
• Chloasma (Melasma)
o This is called the "Mask of Pregnancy."
o It is a bronze type of facial coloration seen more on dark-
haired women.
o It is seen after the 16th wk of pregnancy.
8. FATIGUE
• This is a common complaint by most patients during the first
trimester.
• Fatigue may also be a result of anemia, infection, emotional
stress, or malignant disease.
PROBABLE SIGNS OF PREGNANCY
• Those signs that are commonly noted by the physician upon
examination of the patient.
• These signs include uterine changes, abdominal changes,
cervical changes, basal body temperature, positive pregnancy
test by physician, and fetal palpation.
1. UTERINE CHANGES
• Position
o By the 12th week, the uterus rises above the symphysis
pubis, and it should reach the xiphoid process by the 36th
week of pregnancy.
• Size
o The uterine increases in width and length approximately 5
times its normal size. Its weight increases from 50 grams
to 1,000 grams.
• Hegar’s Sign
o Softening of the lower uterine segment just above the
cervix.
o When the uterine is compressed between examining
fingers, the wall feels tissue paper thin.
o The Hegar's sign is noted by the 6th to 8th week of
pregnancy.
• Ballottement
o This is demonstrated during the bimanual exam at the
16th to 20th week.
o Ballottement is when the lower uterine segment or the
cervix is tapped by the examiner's finger and left there,
the fetus floats upward, then sinks back and a gentle tap
is felt on the finger.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY
2. UTERINE CHANGES
• Goodell's sign
o The cervix is normally firm like the cartilage at the end of
the nose.
o The Goodell's sign is when there is marked softening of
the cervix.
o This is present at 6 weeks of pregnancy.
• Formation of a mucous plug (Operculum)
o This is due to hyperplasia of the cervical glands as a result
of increased hormones.
o It serves to seal the cervix of the pregnant uterus and to
protect it from contamination by bacteria in the vagina.
3. BRAXTON-HICK'S CONTRACTIONS
• This involves painless uterine contractions occurring
throughout pregnancy.
• It usually begins about the 12th week of pregnancy and
becomes progressively stronger.
• These contractions will, generally, cease with walking.
• Do not cause the cervix to dilate.
4. POSITIVE PREGNANCY TEST BY THE PHYSICIAN
• Even if the test is positive, it could be the result of ectopic
pregnancy or a hydatidiform mole (an abnormal growth of a
fertilized ovum).
5. FETAL OUTLINE PALPATION
• This is a probable sign of early pregnancy.
• The physician can palpate the abdomen and identify fetal
parts.
• It is not always accurate.
POSITIVE SIGNS OF PREGNANCY
• Those signs that are definitely confirmed as a pregnancy.
• They include fetal heart sounds, ultrasound scanning of the
fetus, palpation of the entire fetus, palpation of fetal
movements, x-ray, and actual delivery of an infant.
1. FETAL HEART SOUNDS
• 5 weeks
o Echocardiography can demonstrate a heartbeat.
• 6th to 7th week
o An ultrasound can reveal a beating fetal heart.
• 10th to 12th week of gestation
o Able to detect fetal heart sounds through Doppler.
• 18 to 20 weeks of pregnancy
o Fetal heartbeat can be heard through an ordinary
stethoscope as early as
o The normal fetal heart rate is 120 to 160 beats.
2. ULTRASOUND SCANNING OF THE FETUS
• The gestation sac can be seen and photographed.
• An embryo as early as the 4th week after conception can be
identified.
• The fetal parts begin to appear by the 10th week of gestation.
3. PALPATION OF THE ENTIRE FETUS
• Palpation must include the fetus head, back, and upper and
lower body parts.
• This is a positive sign after the 24th week of pregnancy if the
woman is not obese.
4. PALPATION OF FETAL MOVEMENT
• This is done by a trained examiner.
• It is easily elicited at 20th – 24th week of pregnancy.
PHYSIOLOGIC CHANGES DURING PREGNANCY
• Physiologic changes that occur during pregnancy are the basis
for the signs and symptoms used to confirm pregnancy.
• They can be categorized as:
1. Local (i.e., confined to the reproductive organs)
2. Systemic (i.e., affecting the entire body).
LOCAL CHANGES
UTERINE CHANGES
• Length grows from approx. 6.5 to 32 cm.
• Depth increases from 2.5 to 22 cm.
• Width expands from 4 to 24 cm.
• Weight increases from 50 to 1,000 gms.
• Early pregnancy – uterine wall thickens from 1 cm to 2 cm.
• End of pregnancy – the wall thins to become supple and only
about 0.5 cm thick.
• Due partly to formation of new muscle fibers in the uterine
myometrium. (Progesterone)
• Principally due to stretching of existing muscle fibers.
(Estrogen)
• Uterus is able to withstand the stretching of its muscle fibers
due to formation of fibroelastic tissue between fibers that
binds them together.
• Volume of uterus increases from about 2 ml to more than
1,000 ml.
• Uterus can hold a 7 lb fetus and 1,000 ml of amniotic fluid for a
total of about 4,000 gms.
• Hegar’s sign
o Softening of the lower uterine segment.
• Ballotement
o “To toss about”
o Fetus can be felt to bounce and rise in the amniotic fluid.
• Braxton Hick Contractions
o “Practice contractions”
o Also plays a role in ensuring the placenta receives
adequate blood.
CERVICAL CHANGES
• Goodell’s Sign
o Softening of the cervix.
o The cervix of the uterus becomes more vascular and
edematous than usual causing it to soften in consistency
(due to estrogen).
• Operculum
o A mucus plug forms to seal out bacteria and help prevent
infection in the fetus and membranes.
VAGINAL CHANGES
• Chadwicks Sign
o The resulting increase in circulation (due to estrogen)
changes the color of the vaginal walls from their normal
light pink to a deep violet.
• Leukorrhea
o Increase in the activity of the epithelial cells.
• Change of vaginal ph
o Fall from ph of greater than 7 (an alkaline ph) to 4 or 5
(acid ph)
o Under the influence of estrogen, the vaginal epithelium
and underlying tissues increase in size as they become
enriched with glycogen where Lactobacillus acidophilus
(Doderlein bacillus) grow freely and produce lactic acid.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY

OVARIAN CHANGES C. CARDIOVASCULAR SYSTEM

• Cessation of ovulation.
CHANGES IN THE BREASTS
• Feeling of tingling, fullness or tenderness in her breast (due to
high estrogen).
• Increase of the breast size.
• Areola of the nipple darkens and its diameter increase from
about 3.5 cm to 5 or 7.5 cm.
• Montgomery’s tubercles
o The sebaceous glands of the areola become enlarged and
protuberant, which keeps the nipple supple and helps to
prevent nipples from cracking and drying during lactation.

• Increase in blood volume

o To provide for an adequate exchange of nutrients in the
placenta.
• Pseudoanemia
o Plasma volume increases faster than RBC, concentration
of hemoglobin and erythrocytes may decline.
• Iron, Folic acid, Vitamin needs
o Fetus requires 350 – 400 mg of iron to grow.
o Increase in the mother’s circulatory RBC mass requires an
additional 400 mg of iron.
o Total requirement for iron = 800 mg
o Lack of folic acid has been linked to increased risk for
neural tube disorders in fetuses.
o Foods high in folic acid:
▪ Spinach, asparagus, legumes
SYSTEMIC CHANGES • Peripheral blood flow
A. INTEGUMENTARY SYSTEM o During 3rd tri, blood flow to lower extremities is impaired
due to pressure of gravid uterus to veins and arteries.
• Striae gravidarum
o Can lead to edema and varicosities of the vulva, rectum,
• Diastasis
legs.
o Rectus muscles separate.
• Supine Hypotension Syndrome
o Abdominal wall unable to withstand the tension created
o Weight of growing uterus presses the vena cava against
by the enlarging uterus.
the vertebrae, obstructing the blood flow from the lower
• Linea nigra
extremities.
o Brown line from umbilicus to symphysis pubis.
o This causes a decrease in blood return to the heart, and
• Melasma
consequently, decreased cardiac output and hypotension
o “Mask of pregnancy“. (lightheadedness, faintness, palpitation).
o Due to melanocyte-stimulating hormone. o Can result in fetal hypoxia.
• Vascular spiders • Increased fibrinogen (necessary for clotting)
o Due to increase of estrogen. o Due to increased estrogen.
B. RESPIRATORY CHANGES o Safeguard against major bleeding.
• Congestion or “Stuffiness“ of the nasopharynx o Pre-pregnancy - 300 mg/dL
o Due to increased estrogen level o Pregnancy - 450 g/dL
• Dyspnea (end of 3rd trimester) • Increased WBC
o Enlarging uterus places pressure upward toward the lungs o Protective mechanism.
and elevates the diaphragm. o Reflection of the woman’s increased blood volume.
• Residual volume (air remaining in the lungs after expiration) • Protein level decreased
o Up to 20% by the pressure of the diaphragm. o Indicating the amount of protein used by the fetus.
• Tidal volume (volume of air inspired) D. GASTROINTESTINAL SYSTEM
o Up to 40%. • Heartburn (pyrosis)
o O2 consumption by 20%. o Due to:
• Mild hyperventilation ▪ Reflux of stomach contents into the esophagus and a
o To blow off excess CO2 being shifted to her by the fetus. relaxed cardioesophageal sphincter caused by the
• Temperature action of relaxin and progesterone.
o Slight increase due to progesterone.
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY
• Flatulence, constipation
o Slow emptying time of the stomach, slow intestinal
peristalsis.
o Due to relaxin and progesterone.
• Nausea and vomiting
o Due to:
▪ Increased hCG, estrogen and progesterone levels.
▪ Decreased glucose levels (glucose being used by the
growing fetus) = FBS 95 mg/dL or lower
• Hyperptyalism
o Increase in saliva formation.
o A local response to increased levels of estrogen.
• Subclinical jaundice
o Due to decreased emptying of bile from the gallbladder
that leads to reabsorption of bilirubin into the maternal
bloodstream causing generalized itching.
o Increased tendency to stone formation due to additional
cholesterol incorporated in bile.
• Hypertrophy of gumlines and bleeding of gingival tissue when
they brush their teeth.
E. URINARY SYSTEM
• Fluid retention
o Under the influence of progesterone, there is an increased
response of the angiotensin-renin system in the kidney,
leading to increase aldosterone production.
o The renin-angiotensin-aldosterone system (RAAS) plays
an important role in regulating blood volume and
systemic vascular resistance which together influence
cardiac output and arterial pressure.
o Renin is released primarily by the kidneys, stimulates the
formation of angiotensin in blood and tissues which in
turn stimulates the release of aldosterone from the
adrenal cortex.
o Aldosterone aids in Na reabsorption.
o Water is retained to aid the increase in blood volume, and
as a ready source of fluid for the fetus.
• Renal function
o Gradual Increase in urine output by 60–80%.
o Specific gravity of urine decreases.
o Glomerular filtration rate (GFR) and renal plasma flow.
o Increased by 30 – 50% by 2nd trimester.
• Ureter and Bladder function
o Due to progesterone during pregnancy, ureters increase in
diameter, bladder capacity increases to 1,500 ml.
F. SKELETAL SYSTEM
• Gradual softening of pelvic ligaments and joints due to:
o Ovarian hormone relaxin and placental progesterone.
• Lordosis (“pride of pregnancy”)
o Forward curve of the spine.
G. ENDOCRINE SYSTEM
• Placenta
o Estrogen
▪ Causes breast & uterine enlargement.
▪ Causes palmar erythema.
o Progesterone
▪ Maintains endometrium.
▪ Inhibits uterine contractility.
▪ Aids in the development of the breasts for lactation.
o hCG
▪ Secreted by the trophoblast cells of the placenta in
early pregnancy.
o hPL
▪ Antagonist to insulin which allows more glucose to
become available for fetal growth.
o Relaxin
▪ Secreted primarily by corpus luteum.
▪ Inhibit uterine activity.
▪ Soften the cervix and collagen in joints.
o Prostaglandins
▪ Affect smooth muscle contractility.
▪ They may be the trigger that initiates labor at term.
o Pituitary Gland
▪ Production of GH & MSH.
▪ Oxytocin is produced by post. pituitary gland late in
pregnancy needed to aid in labor.
▪ Prolactin begun late in pregnancy to prepare for
lactation.
▪ Thyroid & Parathyroid
▪ Thyroid gland enlarges early in pregnancy causing
increased basal body metabolic rate by 20%.
▪ Parathyroid glands are necessary for calcium
metabolism.
o Adrenal Glands
▪ Levels of corticosteroids and aldosterone.
▪ Aids in suppressing an inflammatory reaction.
▪ Help reduce the possibility of a woman’s body
rejecting the fetus.
▪ Help regulate glucose metabolism.
▪ Aldosterone aids in promoting sodium
reabsorption and maintaining osmolarity in the
amount of fluid retained.
o Pancreas
▪ Production of insulin in response to higher levels
of glucocorticoid produced by the adrenal glands.
▪ The glucose level of fetus is 30mg/100ml.
▪ Pregnant woman should keep her diet high in
calories and should never go longer than 12 hrs.
between meals.
▪ In early pregnancy, FBS is 80–85 mg/100 ml.
H. IMMUNE SYSTEM
• Immunoglobulin G (IgG) is decreased making the woman more
prone to infection during pregnancy.
• IgG comprise 80% of the antibodies in adults (main type of
antibody).