Occur in response to physiological stimuli provided

by the fetus and placenta.

Physiological adaptations of normal pregnancy can be

misinterpreted as pathological

Unmask or worsen preexisting disease.

virtually every organ system undergoes anatomical

and functional changes

This can alter appreciably criteria for diagnosis and

treatment of diseases.
Changes
VAGINA &in reproductive system:
PERINEUM
Increased vasularity/softening of connective
tissue of perineum & vulva
Increased vascularity of vagina-chadwick sign
Increase thickness of mucosa,hypertrophy of
smooth muscle,loosening of connective tissue of
vagina
Increased volume of cervical secretions
Ph of vagina(acidic) -3.5-6
CERVIX:
Increased vascularity & edema of cervix-
softening &cyanosis-goodell’s sign
Rearrangement of collagen rich connective tissue
Hypertrophy & hyperplasia of cervical glands
Mucus plug formation rich in IGs
Marked endocervical mucosa proliferation-
appears as cervical erosion
Squamous cells -hyperactive-stimulating
carcinoma insitu
UTERUS
Thin walled muscular structure-5liter,wt-1100gm
dextrorotated
Stretching,hypertrophy of muscles, minimal
hyperplasia.
Accumulation of fibrous tissue/increase in elastic
tissues
Muscle cells arranged-3 layers
-outer hood like
-middle layer-interlacing network of muscles
-inner layer-sphincter like fibers
Uterine shape size and position;
Palmars sign
Braxton Hicks contractions
Uteroplacental flow
-placental perfusion-uterine blood flow

-blood flow increases-450-650 ml/min near term

-uterine artery diameter doubles by 20 weeks &

concomittent mean doppler velocimetry increased
by 8 fold.
Marked spiralling – max 20 weeks

-vasodilatation is mainly mediated by estrogen and

progesteron,other factors icludes resistance to
pressor effect of angiotensinII.
FALLOPIAN TUBES & OVARIES :
Masculature of tubes –little hypertrophy

Single corpus luteum of pregnacy found in the

ovaries maxm functioning up to 7wks of pregnancy

Ovarian and uterine cycle suspended

CHANGES IN SKIN:
Increased cutaneous blood flow -dissipate excess
heat generated by increased metabolism
Striae gravidarum
-SYN:Stretch marks
diastasis recti of varying extent
Linea nigra
Chloasma or melasma gravidarum-mask of
pregnancy
Estrogen & progesteron –melanocyte
stimulating effect
Vascular Spider & palmer erythema
CHANGES IN BREASTS:
Tenderness and tingling
Enlargement of breast
Nipples deeply pigmented,larger and erectile
Areola deeply pigmented/broader,formation of
secondary areola in 2nd trimester
Glands of montgomery-hypertrophied sebaceous
glands
Secretion of thick yellowish fluid-colostrum,12th
weeks onwards
gigantomastia
HEMATOLOGICAL CHANGES
1. Blood volume
 Near term increase 40-45%
 Includes (a)plasma vol (b)RBC vol
 Begins to increase during 1st trimester,by 12th
weeks plasma volume expands by 15%,peaks
at30-32 week then plateaus
Non Pregnancy (term) percentage
pregnant
Plasma volume 2600ml 1250ml 50%

RBC volume 1400ml 240ml 18%(without fe )

400ml 30%(with fe)

haematocrit 38% 32%

Advantages of hemodilution
Decrease blood viscosity ensures optimal gaseous
exchange between maternal and fetal circulation

Protection against adverse effect of blood loss

during delivery

Decrease viscosity –decrease resistance to flow

of blood increase in cardiac output without
much increase in cardiac work load.
2)immunological &leukocyte functions
 Decrease in humoral and cell-mediated immunity
to accommodate foreign semiallogeneic fetus
 suppression of T-helper (Th) 1 and T-cytotoxic (Tc) 1
cells, - decreases secretion of interleukin-2,
interferon-, and tumor necrosis factor.
 Neutrophilic chemotaxis/adherence decrease
from 2nd trimester
 Cervical mucus IgG,IgA higher ~10fold
 Leucocyte count 5000-12000/microlit
 ESR elevated
 Complement C3 and C4elevated during 2nd and
3rd trimester
3)COAGULATION
Coagulation cascade is in activated state
both coagulation and fibrinolysis are augmented but
remain balanced to maintain hemostasis

Increase in all clotting factor except XI and

XIII
increase level of fibrinogen-by 50%~450mg/dl

Fibrinolytic activity is reduced

Slight decrease in platelet counts,

clotting time uneffected
 CARDIOVASCULAR SYSTEM
Cardiac output starts to rise from 10wk of
pregnancy reaches its peak 40%(6lit/min)at ~24-
30wk ,almost1/2 of total increase occurs by 8wks
Increase in heart rate- 10 b/min

Systemic and pulmonary vascular resistance

decreases,mid pregnancy drop of blood pressure

left ventricular function normal,no change in

intrinsic left ventricular contractility
Blood flow in legs retarded...enlarged uterus
compressing IVC,
-responsible for pedal edema
-development of varicose veins in legs and vulva
-predispose to DVT

SUPINE HYPOTENSION:
Enlarged uterus compression venous system
impairs blood return from lower
extrimity...decreased cardiac filling...decrease
cardiac output..supine hypotension syndrome
Heart

displaced to the left and upward and rotated

somewhat on its long axis.
As a result, the apex is moved somewhat laterally
from its usual position, causing a larger cardiac
silhouette on chest radiograph
 benign pericardial effusion
no characteristic electrocardiographic changes other
than slight left-axis deviation as a result of the altered
heart position.
Heart sounds
an exaggerated splitting of the first heart sound with
increased loudness of both components;
no definite changes in the aortic and pulmonary
elements of the second sound;
 a loud, easily heard third sound .
 systolic murmur – 90%
Heart rate (beats/min)+17%
Cardiac output (L/min)+43%
Systemic vascular resistance (dyne/sec/cm–5)–21%
Pulmonary vascular resistance (dyne/sec/cm–5)–34%
Serum colloid osmotic pressure (mm Hg)–14%
Mean arterial pressure , Pulmonary capillary wedge
pressure , Central venous pressure - unchanged
RESPIRATORY SYSTEM
diaphragm rises about 4 cm during pregnancy
Transverse diameter thoracic cage-increase2cm
0xygen consumption increases 45ml/min
R.R is changed a little
Tidal volume increases from 500 to700ml,minute
ventillatory vol increases by 40%,minute o2 intake
increases
FRC(ERV+RV)decreses by 500ml
RV decreases
Lung compliance uneffected
Total pulmonary resistance uneffected
ter
physiological dyspnoea occurs- due to increase in
tidal volume that lowers blood Pco2- paradox
Increase respiratory effort –mediated by
progesteron
To compensate resulting respiratory alkalosis
plasma HCO3 level decreases(26-20mmol)

Minimal increase in blood Ph-shifts O2

dissociation curve to left thus increasing affinity
of maternal blood to O2-bohr effect

But increase in Ph also stimulate increase

in23DPG in maternal RBC,counteracts Bohr effect
RENAL CHANGES
KIDNEY
-increase in length by 1cm
-GFR increases by 50%
-renal blood flow increases by 25-50%
-Increase excretion ofvarious nutrients
-GFR increase without alternation of production of
urea & creatinine,thus their levels decreases
-creatinine clearance in pregnancy 30%higher than
100-115ml/min measured normally
-glycosuria
-proteinuria/hematuria
 -
URETER
-dilatation of ureter above pelvic brim occurs due
to enlargement of uterus compressing them at
pelvic brim & due to effect of progesteron
-Right>left
-elongation,kinking and outward displacement of
ureter
BLADDER
-marked congestion with hypertrophy of muscles
-increase frequency of micturition 6-8 wks subsides
after 12 wks,in late pregnancy again frequency
due to pressure on bladder as presenting part
descends
-stress urinary incontinence occurs-weak sphincter
CHANGES IN GASTROINTESTINAL
SYSTEM:
Gums become soft,congested
Pyrosis (heart burn)-decrease in tone of lower
esophageal sphincter
Muscle tone and motility of entire GIT diminished
Gastric emptying time unchanged
LIVER-alkaline phosphotase-activity doubles-
increase is due to heat stable placental alkaline
phosphatase isoenzymes
AST/ALT/gamma GT/bilirubin level DECREASES
Gall bladder contractility reduced- increase
serum cholesterol –increase stone formation
 ENDOCRINE SYSTEM
PITUITARY GLAND
growth hormone-1st timester by maternal
pituitary,by 17wks placenta is principle
source.10wks3.5ng/ml,28 wks 14ng/ml there after
plateaus.

Prolactin-increase by 10 fold~150ng/ml,function-
ensure lactation,amniotic fluid prolactin impairs
transfer of water from fetus to maternal
compartment thus preventing fetal dehydration
THYROID GLAND
Thyroid undergoes moderate enlargement –
glandular hyperplasia/increased vascularity
Increase circulating level of thyroxin transport
protein,thyroxin binding globulin
Pregnancy accompanied by decrease availability of
iodide for maternal thyroid-increase renal
clearance
Total T3,T4 increased but free T4 level
unchanged,TSH remains Normal or sightly
increased.
BMR increases by 25%.
Parathyroid hormone
Concenttration decreases during 1st trimester then
progressively increase throughout pregnancy
-increase level due to low calcium concentration
-estrogen block action of PTH on bone resorption
-net result is physiological hyperparathyoidism
Calcitonin levels higher than in nonpregnant state
Adrenal glands
-cortisol level is increased due to decrease
metabolic clearance
-aldosterone level increased,by 3rd trimester
1mg/day.
Musculoskeletal system
Progressive lordosis
Sacroiliac,sacrococcygeal,pubic joint –increased
mobility
Relaxation of pelvic joints
CHANGES IN EYES
Decrease in intraocular pressure
Corneal senstivity decreases
Increase in corneal thickness due toedema
Transient loss of accomodation
Metabolic
Total pregnancychanges
energy demand -80,000kcal.
Weight gain:12.5 kgs
Tissues and fluids 10wks 40wks
fetus 5 3400
placenta 20 650
Amniotic fluid 30 800
uterus 140 970
breast 45 405
blood 100 1450
Extravascular fluids 0 1480
Maternal stores(fat) 310 3345
total 650 12500
WATER METABOLISM
-water retention 6.5lit

-3.5lit fetus/placenta/amniotic fluid,3 lit blood

vol,uterus and breasts

-Accumulation of fluid in lower extremities-pedal

edema-increased venous pressure below the level
of uterus/decrease in interstitial colloid osmotic
pressure
PROTEIN METABOLISM

-1000 gm protein gained-500gm in fetus,remaining

500gm added to uterus,breast,maternal blood

-total plasma protein increase180 to 230gm,

-haemodilution leads to fall 7 to 6gm%

-A:G ratio decreased to 1:1. from 1.7:1

CARBOHYDRATE METABOLISM
-Mild fasting hypoglycemia,postprandial
hyperglycemia & hyperinsulinemia
-insulin action in late pregnancy -50-70%lower
Causes of insulin resistance
1. Progesteron and estrogen
2.Human placental lactogen-growth hormone like
action
FAT METABOLISM
Lipids concentration increases
Deposition of fats occurs in central sites
Leptin peptide hormone –regulation of body fat &
energy expenditure
ELECTROLYTES &MINERALS
Iron requirement 1000gm;500mg-RBC vol
expansion,300mg-fetus,200mg obligatory loss
requirement 2.5mg/day early pregnancy,
5.5mg/day in 20-32 wks,6-8mg/day from 32 wks

1000 meq of Na+ & 300 Meq K+ retained

Calcium level decreases,ionised calcium remain
unchanged,during 3rd trimester 200mg/day ca++
deposited in fetal skeleton
Magnesium levels decline during pregnancy while
phosphate levels within normal range
THANK YOU