1.

ANATOMICAL CHANGES
2. PHYSIOLOGICAL CHANGES
3. BIOCHEMICAL CHANGES
ANATOMICAL CHANGES
GENITAL
BREAST
SKIN
SKELETO
N
EYES
 GENITAL CHANGES
UTERUS
Outer Longitudinal layer
Musles of Uterus Intermediate Layer

Inner Circular Layer

PronouncedUpto:

In pregnancy muscles undergo both 12

HYPERTROPHY and HYPERPLASIA. WEEKS
Fundus > Body
NON PREGNANT UTERUS PREGNANT UTERUS
900-1000 grams
60 grams
Cavity: 1000 ml
Cavity: 5-10 ml
Length: 35 cm
Length: 7.5 cm Capacity: 500-1000 times
Arterial supply: Uterine Arterial supply: Uterine Artery
Artery and Ovarian Artery
Shape of Uterus:

NON
PREGNANT 12 Weeks: 28 Weeks: 36 Weeks:
:
GLOBULAR PYRIFORM GLOBULAR
PYRIFO
RM
 Genital changes
- Uterine ligaments: Hypertrophy

Dextro-rotation of Uterus:
the uterus is tilted and twisted to the right in 80%
of cases

Levorotation of Cervix
- Uterine Peritonium: Deepening of the pouch of
Doughlas

- Lower uterine segment (LUS)

the LUS is formed from the isthmus
formed from the 4th month to reach 10 cm at full
term
Lower uterine segment
BRAXTON HICKS CONTRACTION:
 Irregular
 Infrequent

 Spasmodic

 Painless

 Without any effect on dilation of cervix

 Intra uterine pressure < 8 mmHg

 Detected bimanually by 2nd trimester.

 Intensity- 5-25 mmHg

Not Seen in ABDOMINAL PREGNANCY.

Uterine Vessels
At 20 weeks diameter became twice thus
causing increase blood flow.
Spiral artery loose contractibility
Estrogen stimulation
17β estradiol cause:
Increase uterine
artery vasodilation
 Decrease uterine

vascular resistance
Genital changes
• The cervix
• Changes seen after 1 month of pregnancy.
- edema and congestion, and becomes soft
- Hypertrophy and hyperplasia of cervical gland
- mucus plug (operculum): cervical mucus closing the
cervical
canal
-act as immunoglobulin barrier to protect uterine content
against infection
- increased secretion from its glands
• The vulva
shows increased vascularity and
varicosities
Labia minora: pigmented &
hypertrophied.

Fallopian tube:
Hypertrophy.
Flattened epithelium.
Torsion
Genital changes
• The vagina
- shows increased vascularity soft, moist and bluish
- distention of JACQUEMIER’S SIGN
vagina at birth pH- 3.5-6
• The ovary
shows increased vascularity and size
one ovary contains the corpus luteum
Extrauterine decidual reaction
beneath the surface.

• Pelvic ligaments
- relaxation of the ligaments
- relaxation of the pelvic joints
- the pelvis become more mobile and increases in
Breast changes
Breasts: increase in circulation
Engorgement and venous prominence
Mastodynia (breast ternderness): tingling to frank
pain caused by hormonal responses of the
mammary ducts and alveolar system
Montgomery’s tubercles: enlargement of
circumlacteal sebaceous glands of the areola
Colostrum secretion: can be sqweezed out at
about 12 weeks.
By 16 weeks become thick and YELLOWISH.
 Montgomery
tubercles
non pigmented nodules
(12-20) around the areola
in 2nd month (enlarged
sebaceous glands or
rudimentary lactiferous
ducts).
Skin
•
changes
Pigmentation
due to increased melanocyte stimulating hormone:
-linea nigra: pigmentation of the linea alba, more marked below
the umbilicus
-chloasma gravidarum: Butterfly pigmentation of the face (mask
of pregnancy)

• Striae gravidarum
- stretch of the abdominal wall
rupture of the subcutaneous elastic
fibers pink lines in flanks
- become white after labor
 Skeletal changes

• Increased lumbar
lordosis

• Relaxation of pelvic
joints and
ligaments due to
progesterone and
relaxin
EYES
Increased vitreous Decrease in Intraocular
outflow pressure
Corneal sensitivity is decreased
Increase in corneal thickness thus may have difficulty
with previously comfortable contact lenses.
Brownish-red opacities on the posterior surface of the
cornea—Krukenberg spindles—have also been observed
Increased pigmentation
Transient loss of accommodation
Visual function is unaffected
 Weight increase
1st Trimester 2nd Trimester 3rd Trimester
1 kg 5 kg 5 kg

•There is an increase
weight of approximately
12.5 Kg at term.

•The main increase

occurs in the 2nd half of
the pregnancy,
0.5 Kg/week
PHYSIOLOGICAL CHANGES
CARDIOVASCULAR
HEMATOLOGICAL
RESPIRATORY
RENAL
NERVOUS
GASTROINTESTINA
L
 Position and size of heart:
 Due to elevation of diaphragm heart moves to left and upward,
apex shifted laterally.
 Chest X-ray changes:
 Larger cardiac silhouette with horizontal positioning.
 Staightening of left upper cardiac border.
 Small benign pericardial effusion
 ECG changes
 Increased heart rate (+15%) i.e Sinus
tachycardia
 15-degree left axis deviation i.e
QRS deviation.
 Lead III: small Q wave & inverted
P wave.
 V1 and V2: Increase R/S ratio
ECHOCARDIOGRAM CHANGES:
 Slightly increased End diastolic and
End systolic volume.
 Slightly improved LV function.
 Slightly increased venticular
dimension with
Spherical left ventricular
remodelling.
 Small pericardial effusion.
 Increased tricuspid annulus
diameter.
 Physiological tricuspid
regurgitation.
 No change in septal thickness or
ejection fraction
 HEART SOUNDS:
Apex beat shifted to 4th intercostal space, 2.5 cm lateral to
midclavicular line.
SYSTOLIC MURMER: Apical or pulmonary area: Due
to decreased blood viscosity & torsion of great vessels.
MAMMARY MURMER:
Continous hissing murmer at tricuspid area i.e left 2nd & 3rd
ICS due to increased blood flow
through internal mammary vessels.

S3 or THIRD HEART SOUND:

due to rapid diastolic filling.
Cardiovascular changes (cont)
Stroke volume +30%
Heart rate +15%
Cardiac output +40%
Oxygen +20%
consumption
SVR (systemic vascular resistance) -
5%
Systolic BP -10mmHg
Diastolic -15mmHg
BP -15mmHg
Mean BP
  SUPINE HYPOTENSION SYNDROME:
During pregnancy, cardiac output is
very sensitive to positional
alterations. In the supine position,
the inferior vena cava is
compressed by the enlarged uterus,
resulting in decreased cardiac
output.
Although most women do not
become overtly hypotensive when
lying supine due to opening of
collateral circulation
In some cases (10%) may have
symptoms that include dizziness,
light-headedness, tachycardia and
syncope.

Cardiac output increases

1.2L/min
i.E 20% when woman moves from
Venous pressure: Venous blood flow

 Unchanged in the upper body

 Significantly increases in the lower extremities,

esp. during supine, sitting or standing position,
returns to near normal in lateral recumbent position
HEMATOLOGICAL CHANGES
HEMATOLOGICAL CHANGES
Blood volume +30%
Plasma volume +40%
Red blood cell +20%
volume

Dilusional anemia
Increase cardiac output
 Decrease blood viscosity
 Vasodilatation

 Haematological changes
• Circulating red cell mass increases by
20- 30%
( rises more in multiple pregnancies and
iron supplement)

• Serum iron concentration falls

absorption from gut and iron-binding
capacity rise

• Plasma folate concentration halves by

term ( due to increased renal clearance)
red cell folate concentration falls less

• Mild maternal anaemia associated with

increased placental/birthweight ratio
decreased birthweight
Haematological changes
• Erythropoietin rises especially if iron supplement not taken

• Human placental lactogen may stimulate haematopoiesis

• Fall in packed cell volume from 36% in early pregnancy to 32% in the 3rd
trimester ( normal plasma volume expansion)

• WBC count rises ( increase in polymorphonuclear leucocytes)

• Neutrophil number rises with oestrogen

peak at 33 weeks
stabilizing after that
until labour and the puerperium, when
they rise sharply

Platelet count and platelet volume are

 Iron metabolism
Only 10% of ingested iron is absorbed.
Total iron requirement in pregnancy is 1000 mg.
Fetus & placenta Expanded RBC mass Obligatory loss
300 mg 400 mg 200 mg

Iron loss in menstrual bleeding is 30mg/ cycle.

Thus saving of 300mg of iron due to 10 months
of amenorrhea.
Iron requirement mostly increased in 3rd
trimester.
Daily iron
Nonrequirement
menstruating woman to compensate
1 mg the avg
daily loss:
In 2nd half of pregnancy 6-7 mg
 Plasma protein changes
Parameter Nonpregnant Pregnancy near Change
term

Total proteins (g) 180ased 230 Increased

Plasma protein 7 6 Decreased

conc.
(g/100 ml)

Albumin 4.3 3 Decreased

(g/100 ml) ( 30%)

Globulin 2.7 3 Increased

(g/100 ml)

Albumin: 1.7: 1 1: 1 Decreased

Globulin
IMMUOLOGICAL FUNCTION:
 Early pregnancy: Proinflammmatory
 Mid Pregnancy: Anti inflammatory
 Parturition: Recrudencence of an inflammatory process
 Suppresion of T-helper (Th 1) and T-cytotoxic 1 cells leads to:
 Decrease secretion of interleukin-2 (IL-2), interferone γ
and TNF-β
 Pregnancy related remission of autoimmune diseases.
 Failure of Th1 supression leads to pre-eclampsia

development.
 Upgradation of Th2 cells: Increased production of IL-4, IL-
6 & IL-13
 10 times increase in interleukin 1β in cervical and vaginal
mucus
in 1st trimester.
• T and B lymphocyte counts do not change but their function
is suppressed ( women become more susceptible to viral
infections, malaria and leprosy)
RESPIRATORY CHANGES
 Pulmonary changes
 Mucosal hyperemia
 Subcostal angle
 Chest circumference and
diameter
 Diaphragmatic excursion
 Tidal volume : +30-40%
 PO2 is increased, PCO2 is
decreased.
 Total lung capacity decrease
by 15%
 Minute ventilation
+30-40%
 Mild respiratory alkalosis
Nervous system disorders
Gastrointestinal change
• Increased salivation (ptyalism)
• Taste is often altered very early in pregnancy
• Increase appetite & thirst: frequent small snacks are adviced
• Gums: Hyperemic, softens and bleeds easily.

Localised vascular swelling known as Eppulis of Pregnancy

• Heart burn (reflux oesophagitis) due to relaxation of the cardiac sphincter due to
progesterone and relaxin
• Emesis gravidarum, morning sickness in 50 %
• Decreased gastric acidity, which interfere with iron absorption
• Constipation

reduced gut motility due to progesterone

increased water and salt absorption

• Hemorrhoids due to elevated venous pressure due compression by gravid
uterus.
• Liver
- Hepatic synthesis of albumin, plasma globulin and fibrinogen increases
- Total hepatic synthesis of globulin increases stimulated by estrogen
- Hepatic arterial and portal venous flow increases.
- Total serum Alkaline phosphatase activity almost doubles:
mostly due to Heat stable placental Alkaline phosphatase
isoenzymes

• Gallbladder
Gall bladder increases in size and empties more slowly
Progesterone potentially impairs gallbladder contraction
by
inhibiting cholecystokinin-mediated smooth muscle
stimulation, which is the primary regulator of gallbladder
contraction
Relaxation of gall bladder increases the tendency of stone
formation
Cholestasis is almost
Urinary changes
• Kidneys
- 1.5 cm increase in size
- hydronephrosis
- increase in GFR
 25% by 2nd week
 50% by 2nd trimester

- 80% increase in effective renal plasma flow before the end of 1st
trimester.

Renal Function Test:

Decrease serum creatinine level (Even >0.9mg/dl considered
abnormal) 30% higher creatnine clearance.
Glucosuria.
Protenuria—
non pregnant woman- > 150
mg/dl pregnant woman-
>300 mg/dl
 Relaxin

Endothelin and NO production

•Renal vasodilation
•Renal afferent and efferent arteriolar
resistance

Renal blood flow.

GFR

Urinary
Frequenc
y
URETER:
•Dilatation of the ureters due to compression.
•Unequal dilation due to cushoning effect of sigmoid colon on left
and dextro-rotation of uterus.
•Atony of the ureteric muscles caused by progesterone and
relaxin
causing hydro-ureter
•Vesico-ureteric reflux increased due to pressure of the uterus on
the ureter
Changes in the ureter in pregnancy leads to urinary
stasis and pyelitis
BLADDER:
HYPERPLASIA of bladder muscles elevates the Trigone

Cause thickening of its posterior or intraureteric

margins

Deepening and widening of the trigone.

Endocrinal changes
PITUITARY GLAND:
Enlarge by 135 percent.
Primarily due to estrogen-stimulated hypertrophy
and hyperplasia of lactotropes.
Gonadotrophes decline in number.
Corticotrophes and thyrotropes remain constant.
Somatotrophes are suppressed.
Growth Hormon:
17 weeks: placenta is the main source of secretion.
Maternal serum values increases from 3.5 ng/ml at 10
wks to 14 ng/mi at 28 wks
Placental GH differs from pituitary GH by 13
aminoacid
–secreted by syncytiotrophoblast in nonpulsatile
fashion.
 Thyroid Gland
Hyperplasia and slight generalised enlargement
of gland.
Maternal serum iodine level fall due to increased renal
loss and transplacental shift to fetus.
Iodine intake increased from 100-150 µgm/day to 200
µg/day
Rise in BMR due to increased maternal and
fetal oxygen need.
Increased serum protein bound iodine and
thyroxine bound globulin due to estrogen stimulation.
Total T3, T4 increased but fT3, fT4 and TSH
remain same.
Contd….
Level of calcitonin increased by 20%.
Since increase in TBG is dependent on estrogen, a
failure of the PBI to rise indicate fetal compromise.
Adrenal cortex – slight enlargement of adrenal
cortex (thickness of zona fasciculata increased).
Significant increase in
aldosterone, deoxycorticosterone (DOC),
corticosteroid binding globulin, cortisol and free
cortisol.
Hypercortisolism occurs due to increased plasma
cortisol half life, delayed plasma clearance
 Changes of endocrine glands
Gland Morphological Physiological
Pituitary Increase in weight by 30- GH, Prolactin, ACTH, CRH
50%. Twice in size Normal – TSH
Gonadotrophin
Thyroid Hyperplasia BMR, TBG, Total T3,T4
Normal – fT3, fT4, TSH
Maternal Serum Iodine
Adrenal Cortex Minimal enlargement Aldosterone,
DOC(deoxycorticosterone), CBG,
Corisol, Free Cortisol

Parathyroid Hyperplasia Normal PTH – does not cross placenta

Pancreas Hyperinsulinism in 3rd Trimester. Anti
insulin factors and insulin resistance
modify action of insulin during
pregnancy
BIOCHEMICAL CHANGES
 Metabolic changes
By 3rd trimester BMR increased by 10-20%.
Additional increase of 10%in twins

Total Energy Demand: 77,000 kcal

85 kcal/day. 285 kcal/day. 475 kcal/day

Water metabolism:
• Increased water retention i.e minimum 6.5 L extra.
• Fall in plasma osmomolality by 10 mOsm/kg.
• cause pitting edema of ankles and legs.
•
Metabolic changes
• Carbohydrate metabolism
- pregnancy is hyperlipidaemic and glucosuric

- after mid-pregnancy, resistance of insulin develops

- plasma glucose concentrations rise, maintained between 4.5-5.5 mmol/L

-glucose crosses the placenta, the fetus uses glucose as primary energy
substrate, transport occurs by carrier mediated mechanism

- the insulin resistance is endocrine-driven, via increase in cortisol and

hPL

- concentrations of glucagons and the catecholamines are unaltered

Metabolic changes
• Carbohydrate metabolism
- carbohydrate deposited in the liver as glycogen
- some escapes to general circulation
- portion metabolised by the tissues:
converted to depot fat
stored as muscle glycogen

- first noticeable change occurs in blood sugar

- tested by giving a load of oral glucose (glucose tolerance
test)
-the blood sugar, after meal, remains high facilitating placental
transfer
Metabolic changes
• Carbohydrate metabolism

- with increased placental production ofsteroid, less glycogen

deposited in liver and muscles
- the effect of fasting is pronounced in
pregnancy overnight fast of 12hrs
hypoglycaemia, production ofketone
bodies
Metabolic changes
• Protein metabolism
-positive nitrogen balance
additional 1000 gm protein added
feotus and
placenta- 500 gm
Uterus and breast-
500 gm
- on average 500 g of protein
retained by the end of
pregnancy
- blood and urine urea are
reduced
• Fat metabolism
- by 30 weeks, 4Kg are stored in form of
depot fat in the abdominal wall, back and thights
modest amount in breasts
Metabolic changes
Electrolyte and mineral metabolism:
1000 mEq of Sodium and 300 mEq of
Potassium retained.
 But serum conc. Decreased due to plasma
volume.
 Excreation remain unchanged.

Total serum Calcium declined bt S. ionized calcium

remain unchanged.
Serum Magnesium level declined.
Serum Phosphate remain unchanged
Iodine requirement increased
 Increased maternal T4 production.
 Incresed demand by feotus.

 50% increased glomerular filtration rate increased.

 Acid–Base

Equilibrium
The increased respiratory effort during pregnancy, and in turn the
reduction in Pco2, is likely induced in large part by progesterone which
acts centrally and lowers the threshold and increases the sensitivity of
the chemoreflex response to CO2.
Compensating resp. alkalosis

Plasma bicarbonate level

decreases to 22

pH 2-3, DPG Shift the curve back to RIGHT.

Shift Oxygen dissociation curve to LEFT. pCO2 from maternal blood

affinity of maternal BOHR

Hb for oxygen, EFFECT CO2 transfer from fetus to mother

oxygen releasing capacity

THANK
YOU