Seminar on Physiologic

changes of pregnancy
Presenters;
1.Elias Getu
2.Ezra Workneh
3.Matiyas Solomon
4.Mesenbet Buta
5.Michael Yohannes Moderator;
6.Nardos Teshome Dr.Mequanent ( OBGYN specialist)
7.Tigist Tamiru Dr.Balemlay ( OBGYN Resident)
Outline
 Objectives
 Introduction
 Physiologic changes of pregnancy in each system
Objectives
 At the end of this seminar students are expected to know
 Definition of physiologic changes of pregnancy
 The importance of knowing this changes
 what are this changes and the possible mechanism
 Introduction…
 Pregnancyplaces considerable stress on a woman’s
body and requires adjustments in nearly all the organ
systems.
Physiologic changes of pregnancy is a phenomenon of
progressive maternal adaptation( anatomic, physiologic
and biochemical) to the increasing demands of the
growing fetus .
Cont……
What is the importance of knowing these changes?
 modify criteria for disease diagnosis and
treatment( to prevent misinterpretation)
 unmask or worsen preexisting disease.
understanding normal laboratory
measurements,
knowing the drugs likely to require dose
adjustments
These changes are regulated through hormones
produced by the placenta and the fetal adrenals.
Hormone Physiological action in pregnancy

Estrogen Uterine growth; Breast growth; liver enzyme changes; increased peripheral
insulin resistance; increased proliferation of blood vessels in uterus;
hematopoiesis

Progesterone Uterine smooth muscle relaxation; peripheral arteriolar and other blood
vessels relaxation; Increased peripheral blood flow due to vascular
relaxation; increased respiratory rate due to effect on respiratory center

Human Increased peripheral insulin resistance; Increased lipolysis and ketone body
placental production
lactogen

Growth Increased peripheral insulin resistance

hormone

Cortisol Fluid and electrolyte retention leading to increased total body water and
electrolytes; Increased insulin resistance

Mellanocyte Dark coloration of the breast, areola, linea nigra

stimulating
hormone
 Cont…….
 A FEW OF THE MAJOR ADJUSTMENTS AND
EFFECTS OF PREGNANCY ARE DESCRIBED
HERE.

 Local changes General changes

In the uterus: • Weight
• Corpus • Abdominal wall
• Skin and mucous
• Lower uterine segment
membranes
• Uteroplacental blood flow
• Breasts
• Cervix • Hematologic changes
Other genital organs: • Circulatory system
• Ovaries • Respiratory system
• Fallopian tubes and round • Urinary system
ligaments • Alimentary system
• Vagina • Endocrine system
• Outlet • Musculoskeletal system
• Central nervous system
• Immune system
REPRODUCTIVE TRACT CHANGES
Uterus
• Capacity
• Size:
It  5-6 times: from 7x5x3cm35x25x22cm
•Weight:
Undergoes a 20-fold : from 50-70 g1-1.1kg
• Position:
• It changes as pregnancy advances
• Early, an exaggerated anteflexion is usual; by the end of the 12 th week it
rises from the pelvis and contacts the anterior abdominal wall It usually
rotates somewhat to the right as result in large measure from the presence of
the rectosigmoid in the left side of the pelvis
• Uterine growth is caused :
• almost entirely by hypertrophy of the muscle cells( most
common)
• there is an increase in the amount of elastic connective tissue
• there is a remarkable increase in the size and number of blood
vessels and lymphatics
• also, hypertrophy of the nerve supply of the uterus takes place
 Cont……
Uterine contractility
◦ Braxton Hick contractions
Myocyte arrangement
This arrangement is crucial and permits myocytes to contract after
delivery and constrict penetrating blood vessels to halt bleeding
Lower uterine segment
◦ From the beginning of the 2nd trimester until the last few weeks of
pregnancy the isthmic portion hypertrophies and becomes indistinguishable
from the rest of the uterine muscle

◦ But, late in pregnancy and most particularly during labor the lower uterine
segment becomes thinned out
 Uteroplacental blood flow

The delivery of most substances essential for the growth and

metabolism of the fetus and placenta, as well as removal of
most metabolic wastes, is dependant upon adequate perfusion
of the placenta by maternal blood, which depends upon blood
flow to the uterus through uterine and ovarian arteries

The uterine blood flow in normal term pregnancy averages

500 ml/min
( 50 ml/min in the nonpregnant state)
 Cont…….
 Cervix
 softening and cyanosis of the cervix occurs
 hypertrophy and hyperplasia of the cervical glands
 Vagina and perineum
 Softening of underlying connective tissue
 Hypervascularity causing hyperemia
Chadwick sign ( violet color of cervix and vagina due to
hypervascularity)
In preparation for the distension that occurs in labor:
• the mucosa thickens
• the connective tissue becomes less dense
• the muscular coat hypertrophies
Breast
In early pregnancy, women often experience breast
tenderness and paresthesias.
After the second month, the breasts grow in size, and
delicate veins are visible just beneath the skin. The nipples
become considerably larger, more deeply pigmented, and
more erectile.
Areolae become broader and more deeply pigmented
Glands of Montgomery, which are hypertrophic sebaceous
glands
Colostrum
 Metabolic changes
 By 3rd trimester basal metabolic rate increased to 20% or higher
compared to non pregnant state. This rate grows by an
additional 10 percent in women with a twin gestation
Weight
 Most of the normal weight gain in pregnancy is attributable to the
 uterus and its contents,
 the breasts, and
 expanded blood and extravascular extracellular fluid volumes
Cont….
Water metabolism
◦Increased water retention
◦Osmolality decrease 10 mOsm/kg
◦Extra water gain: 6.5 L
partially mediated by a change in maternal osmoregulation through altered
secretion of arginine vasopressin and
Renin-Angiotensin-Aldosterone System activation
Protein metabolism
◦Positive nitrogen balance throughout pregnancy
◦Anabolism
Carbohydrate Metabolism
◦Fasting glucose -> hypoglycemia => rapid conversion to fat metabolism -> Ketonemia
◦Postprandial hyperglycemia,
◦Insulin production increased
◦Insulin resistance increased
Cont…….
Lipid metabolism
◦ Hyperlipidemia
Minerals and electrolyte
Skin changes
Skin changes are common. Fernandes and Amaral (2015), found at least one
physiological cutaneous change in 89 percent of the women examined.

Abdominal wall
◦ striae gravidarum or stretch marks
◦ Occasionally, the muscles of the abdominal walls do not
withstand the tension of the expanding pregnancy. As a result,
rectus muscles separate in the midline, creating diastasis recti .
Cont……
Hyperpigmentation ( MSH)
Ocure in 90% of pregnant women and more pronounced in black
complexion
◦ Linea nigra
◦ chloasma or melasma gravidarum—the mask of pregnancy
◦ Areola and genital skin
cutaneous vascular changes (estrogen):
◦ Spider angioma (common on the face, neck, upper chest, and arms)
◦ are minute, red skin papules with radicles branching out from a central lesion
◦ palmar erythema
Hair changes
◦ Anagen phase lengthns
Cont…….
HEMATOLOGIC CHANGES
Change in fluid balance

•Retention of sodium and water has important

hemodynamic consequences:
• Total body water  steadily: 6-8 l accumulate in a normal
pregnancy, most being located in the extracellular space
• Excess sodium retention reaches 500-900 mEq by the
time of delivery
•Maternal blood volume  40–50% above nonpregnant
levels (the main contribution to this expansion is plasma
volume)
Total red cell volume
and Fe metabolism

•Total red cell volume begins to rise at 10wks rises until

term,average 450ml(increase by 33%). Compared with total
red cell volume plasma volume
Increase greater  hemodilution with a Hct termed “the
physiologic anemia of pregnancy
The increase in blood volume
 Protects the mother from the possibility of hge during
pregnancy.
 Helps fill the expanded vascular system created by
vasodilatation and large low -resistance vascular pool with
in the uteroplacental unit
• Protect the mother and fetus against the deleterious
effects of impaired VR in the supine and erect positions.
• Iron requirements: In normal pregnancy 1 g (200
mg is excreted + 300 mg is transferred to fetus +
500 mg is needed for the mother). Daily average
requer. is 6-7 mg/day
 So:
if Fe is not supplemented

maternal plasma Fe concentration often 
during pregnancy because
the amounts of Fe absorbed from diet
+
that mobilized from stores
¹ to meet the demands
Coagulation and fibrinolysis

Normal pregnancy is accompanied by major changes

in the coagulation system:  in the level of all
except Factors xi and xiii .particularly marked  of
plasma fibrinogen(inc.50%).average 450mg late in
pregnancy
fibrinolytic activity is  during pregnancy
Net effect –to produce hypercoagulable state
 The alterations in the coagulation and fibrinolytic
systems
+
­ blood volume
+
myometrial contraction

help to combat the hazard of hemorrhage during and
after
placental separation
CIRCULATORY SYSTEM
Heart
•Position and size: It is a little  and pushed by the elevation
of the diaphragm and rotated forwards, so that the apex beat
is moved upwards and laterally
•Heart rate: Its average  about 10-15 beats/min to  the
cardiac output
•Heart sounds: The 1st and 3rd sounds become louder. The 2nd
sound is not notably affected
•Murmurs: Systolic ejection murmurs develop in most of the
women; . In some women a diastolic murmur may occur
•EKG: Its changes may be attributed to the changed position
of the heart: slight deviation of the electrical axis of the left
Cardiac output

It’s the most significant hemodynamic change

during pregnancy
Begins to  5th week and  40% 20-24 weeks (the
highest levels). The cardiac output fluctuates
markedly with changes in body position
-lowest in sitting or supine position –enlarged utrus
Compresses the IVC –decrease VR from lower
extremities
-highest in Rt and Lt lateral and knee chest position
Blood pressure
• Arterial BP:  during 2nd trimester &  thereafter 
• Venous pressure in the femoral venous: there is a tendency
toward stagnation in the lower extremities
Sytemic vascular resistance
decreases
• Exact mechanism??
-smooth muscle relaxing effect of progesterone
-presence of circulating substances exerting a vasodilatory
effect on arterial and venous vasculature (NO,PG,ANP).
RESPIRATORY SYSTEM
 The major influence in the phenomenon of overbreathing is a
change in central respiratory control
but
alterations in the subdivision of lung volume are largely due
to anatomical changes:
• the level of the diaphragm rises about 4 cm
• the subcostal angle widens
• the transverse diameter of the thoracic cage increases
about 2 cm
• the circumference of the thoracic cage increases about 6
cm
•respiratory functions:
•vital capacity, unchanged.
•FRC,RV,ERV decreased –due to elevated
diaphragm

•tidal volume: inceased ( 40%)

•respiratory rate: no changes
SO:
minute ventilation  from 7ml/min to 10,5 ml/min in
late pregnancy
Alimentary
• As pregnancy progresses, the stomach and intestines
are displaced by the enlarging uterus.
• The appendix, is usually displaced upward and
somewhat laterally as the uterus enlarges. it may
reach the right flank..
• Progesterone causes relaxation of the lower
esophageal sphincter and increased reflux, making
many women prone to heartburn.
• Appetite is usually increased, sometimes with specific
cravings
• GI motility is reduced and transit time is
consequently longer. This allows increased nutrient
absorption and leads to constipation
• Hemorrhoids are common during pregnancy They are
caused in large measure by constipation and elevated
pressure in veins below the level of the enlarged
uterus.
Gall bladder
• Progesterone impairs gallbladder contraction by
inhibiting cholecystokinin-mediated smooth muscle
stimulation, Impaired emptying, subsequent stasis,
and an increased bile cholesterol saturation of
pregnancy contribute to the increased prevalence of
cholesterol gallstones and pruritus gravidarum .
• Intrahepatic cholestasis has been linked to high
circulating levels of estrogen, which inhibit
intraductal bile acid transport .
Liver
• there is no increase in liver size during human pregnancy .
• Hepatic arterial and portal venous blood flow, however,
increase substantively.
• The serum albumin concentration decreases.
• By late pregnancy, albumin concentrations may be near
3.0 g/dL compared with 4.3 g/dL in non pregnant women
MSS
• Increased ligamental laxity caused by increased levels of
relaxin contribute to back pain and pubic symphysis
dysfunction.
• Shift in posture with exaggerated lumbar lordosis leading
to the typical gait of late pregnancy
Urinary system
• Glomerular filtration rate (GFR) increases by 50% early in
pregnancy, that’s why frequency of micturition is often
present
• The frequency of micturition in late pregnancy is due to
the pressure of the uterus upon the bladder
• kidneys: size increased because of increased vasculature
& Interstitial volume, urinary dead space.

• ureters: dilatation of the calyces, renal pelvis and

ureters, they are prominent on the right side & can be
seen as early as the 1st trimester and are present in
90% of women by the 3rd trimester
 causes
hormonal effect–smooth muscle relaxation by progesterone
Hydronephrosis and hydro-ureter exist:
 loss of smooth muscle tone by progesterone
 mechanical pressure by uterus at pelvic brim

 Vesico-ureteric reflux
 Increased UTI to kidney
 Improves in the latter part of pregnancy as
the uterus grows above the pelvic brim and
rising oestrogen levels cause hypertrophy of
the ureteric muscle.
Bladder
◦ As the uterus enlarges, the urinary bladder is displaced
upward and flattened in the anteroposterior diameter.
◦ Bladder vascularity increases and muscle tone decreases,
which increases bladder capacity up to 1500 mL.
Central nervous system
Changes in the central nervous center are relatively few and mostly subtle.

Women often report problems with attention,

concentration, and memory throughout pregnancy and the early
puerperium.

Beginning as early as approximately 12 weeks’ gestation and extending

through the first 2 months postpartum, women have difficulty with going
to sleep, frequent awakenings, fewer hours of night sleep, and reduced
sleep efficiency.
 Endocrine
Pitutary
• Enlarges by 135% -proliferation of prolactin producing cells
in the anterior pituitary.
• Pituitary enlargement is primarily caused by estrogen-
stimulated hypertrophy and hyperplasia of the lactotrophs.
Prolactin
• Maternal plasma prolactin levels increase markedly during
normal pregnancy, and concentrations are usually tenfold
greater at term—about 150 ng/mL—compared with those
of non pregnant women.
 Growth hormone

• During the first trimester, growth hormone is secreted

predominantly from the maternal pituitary gland.
• As early as 8 weeks’ gestation, growth hormone secreted from
the placenta becomes detectable .
• Maternal serum values increase slowly from approximately
3.5 ng/mL at 10 weeks to plateau after 28 week approximately
14 ng/mL
 Thyroid gland
• Physiological changes of pregnancy cause the thyroid gland to increase
production of thyroid hormones by 40 to 100 percent to meet maternal and
fetal needs.
• To accomplish this the thyroid gland undergoes moderate enlargement
during pregnancy caused by glandular hyperplasia and increased
vascularity.
• Early in the first trimester, levels of the principal carrier protein—
thyroxine-binding globulin (TBG)—increase- elevated TBG levels increase
total serum thyroxine (T4) and triiodothyronine (T3) concentrations but do
not affect the physiologically important serum free T4 and T3 levels.
Parathyroid Hormone

• The production of active vitamin D will increased during pregnancy due to placental
production of either PTH or a PTH-related protein.
• During pregnancy, the amount of calcium
absorbed rises gradually and reaches approximately 400 mg/day in the third trimester.

• Calcitonin
• Pregnancy and lactation cause profound calcium stress, and during
these times.
• calcitonin levels are appreciably higher than those in non pregnant
women
 Immunology
• The total white cell count increases during pregnancy due to an increase
in neutrophil,which peaks at 30 weeks’ gestation before plateauing.
• This increase in neutrophils is initiated at the time of the estrogen peak
in a normal menstrual cycle and then continues if conception occurs a
further fourfold increase in the number of polymorphs occurs during
labor and immediately following delivery.
• the WBC count should not be used clinically in determining the presence
of infection.
• Eosinophil, basophil, and monocyte levels remain relatively constant
during pregnancy until a significant reduction in eosinophils occurs at the
time of labor and delivery.
• The lymphocyte count does not alter significantly during pregnancy and
there is no change in the number of circulating T and B cells .
• Platelets can decrease in number throughout a normal
pregnancy and the platelet volume increases from 28 weeks’
gestation due to an increase in large and immature platelets.
• About 8% of gravidas develop gestational thrombocytopenia
with platelet counts between 70,000 and 150,000/mm3. This
is not associated with an increase in pregnancy complications
• There are dramatic changes to the coagulation system in
pregnancy with a mild coagulopathy throughout normal
pregnancy.
• Pregnancy places women at a fivefold to sixfold increased risk
for thromboembolic disease
• Factors VII, VIII, VIII:C, X, and IX are all increased in pregnancy .
• factors II and V remain constant.
• Factor XI and XIII both decrease in pregnancy by 60– 70% and 50%
respectively.
• Protein S, a cofactor of protein C which inactivates factors V and
VIII, is reduced in the first two trimesters of pregnancy.
• Plasma fibrinogen levels approximately double in pregnancy from
2.5– 4 g/ L to 6.0 g/ L in late pregnancy, this increase in fibrinogen
contributes to a rise in the erythrocyte sedimentation rate.
• plasma fibrinolytic activity is decreased in pregnancy and labour
but quickly returns to non- pregnant values after delivery.
 References
 Williams obstetrics 25th Edition
 Gabbe obstetrics normal and problem pregnancies
THANK YOU!!