Physiolosical changes during pregnancy

PHYSIOLOGICAL CHANGES DURING PREGNANCY

1. PREPARED BY : JAYDIP NINAMA PHYSIOLOSICAL CHANGES DURING PREGNANCY

2. REPRODUCTIVE SYSTEM a) Vulva : becomes vascular and hypertrophied, pigmented and varicose veins appear in some.

3. b) Vagina It becomes vascular and hypertrophied, looks bluish, felt soft. Increased blood supply of the venous plexus surrounding the walls gives the bluish colouration of the mucosa( Jacquemier’s sign ) Vaginal secretion, increases in amount and is acidic (3.5-6) due to the production of lactic acid.

4. c) Cervix : remains 2.5 cm long throughout pregnancy, but the hygroscopic properties of oestrogen cause it to increase in width. Oestrogen increases cervical vascularity and if viewed through a speculum the cervix looks purple

5. Softening of the cervix ( Goodell’s sign Cervical mucosa undergo hypertrophy and hyperplasia and occupies inner half of cervix. A mucus plug called “ operculum ” is formed between the maternal and external os .

6. INTERNAL OS VASCULARITY INCREASES MUCUS PLUG HYPERTROPHY OF ENDOCERVIX CERVIX EXTERNAL OS

7. d) Uterus: Gravid uterus gradually enlarges from 50 gm muscular organ to 900 gm at term pregnancy. Non-pregnant state measures about 7.5 cm in length, 5 cm in breadth and 2.5 cm in thickness. Length becomes 30 cm; breadth 22.5 cm and thickness 20 cm. Uterine wall forms a sac containing amniotic fluid and foetus

8. The perimetrium is the outermost layer of the uterus. It does not totally cover the uterus. The myometrium or muscle coat surrounds the lower uterine segment and cervix during labour . The muscle layer is involved in the contraction necessary to expel the foetus at the end of the pregnancy

9. Arrangement of the muscle fibres 1)Outer longitudinal – follows a hood like arrangement over the fundus . 2) Inner circular – It is scanty and have sphincter like arrangement around the tubal orifices and internal os 3) Intermediate – It is the thickest and strongest layer arranged in criss-cross fashion through which the blood vessels run. Apposition of two double curve muscle fibres give the figure of ‘8’ form, it called as living ligature.

10. The outer longitudinal layer of muscle fibres contract and retract during labour causing upper segment to thicken. The thickened upper segment acts as a piston to force the foetus into the receptive, passive lower segment.

11. Changes in Uterine Shape Non pregnant - pyriform shape is maintained in early months. Becomes globular at 12 weeks. As the uterus enlarge, the shape once more becomes pyriform or ovoid by 28 weeks Changes to spherical beyond 36 th week

12. Position Normal anteverted positions exaggerated up to 8 weeks The enlarged uterus may lie on the bladder Afterwards, it becomes erect, the long axis of the uterus conforms more is a tendency of ante version Primigravidae with good tone of the abdominal muscles, it is held firmly against the maternal spine.

13. Cont.. Contractions (Braxton-Hicks) : Irregular, infrequent, spasmodic and painless without any effect on dilatation of the cervix. Endometrium : structural and secretory activity of the endometrium

14. e) Isthmus: During the first trimester isthmus hypertrophies and elongates to about 3 times its original length Becomes softer

15. ISTHMUS CERVIX 8 WEEKS INTERNAL OS 12 WEEKS EXTERNAL OS LOWER UTERINE SEGMENT 16 WEEKS

16. f) Fallopian tube: Total length is increased Tube becomes congested Muscles undergo hypertrophy

17. f) Ovaries : Ovulation ceases throughout pregnancy. Corpus luteum of usual menstrual cycle persists and enlarges to 2.5 cm till 8th week due to the changes in the fertilized ovum ( trophoblast ) and helps in producing hormones.

18. f) Ovaries : Ovulation ceases throughout pregnancy. Corpus luteum of usual menstrual cycle persists and enlarges to 2.5 cm till 8th week due to the changes in the fertilized ovum ( trophoblast ) Hormones-oestrogen and progesterone secreted by the corpus luteum maintain the environment for the growing ovum Control the formation and maintenance of decidua of pregnancy Inhibit ripening of the follicles

19. g) Breasts : under the stimulation of estrogen and progesterone the breasts increase in size, nodularity and sensitivity throughout pregnancy with increased vascularitis . Total weight becomes 0.4 kg volume. Enlargement is due to alveolar proliferation and deposition of fat. Sebaceous glands (5-15) become hypertrophied and are called Montgomery’s tubercles

20. Areola becomes dark pigmented, which is primary areola, and a second zone of pigmentation appears around the primary areola in second trimester, which is secondary areola. Secretion ( colostrum ) can be squeezed out of the breast at about 12 th week

21. CUTANEOUS CHANGES Face ( chloasma gravidarum or pregnancy mask) an extreme form of pigmentation around the cheek, forehead and around the eyes

22. ABDOMEN Linea nigra : a brownish black pigmented area in the midline stretching from the xiphisternum to the symphysis pubis Straie graviderum :slightly depressed linear marks with varying length and breadth found in pregnancy

23. CHANGES IN OTHER SYSTEMS OF THE BODY

24. CARDIOVASCULAR SYSTEM Heart works more during pregnancy. increase in the cardiac volume by 10% no change in E.C.G. WHAT IS RELATION BETWEEN CARDIAC OUTPUT AND HEART RATE ?

25. Cardiac output increases by 15-30% due to increased heart rate and increase stroke volume. Pulse rate near term increases by 10 per minute. Platelet count shows slight decrease due to increased concentration .

26. Blood Pressure and Blood volume Blood pressure remains within normal limits due to pressure of gravid uterus on pelvic veins Venous pressure– Femoral venous pressure rises from 10 cm water to 30 cm water. Blood volume increases from 3 rd month and reaches a peak of 25% rise at 32 weeks. The red cell volume increases by 200 ml, plasma volume increases to 1000 ml .

27. RESPIRATORY SYSTEM increased inspiration so the increased oxygen intake results in improved oxygen supply to the foetus . increased expiration , more carbondioxide is expelled, there is low maternal carbondioxide leading to easy transfer of CO2 from foetus to mother’s blood. breathing difficulty which is relieved after lightening.

28. DIGESTIVE SYSTEM WHICH IS COMMON GI PROBLEM / COMPLAINT OF WOMAN DURING PREGNANCY ?

29. regurgitation of stomach juice and heart burn slow emptying of stomach constipation. Gums become spongy and vascular and may bleed during brushing in many women.

30. NERVOUS SYSTEM Slumpliness is common and mood changes occur in many. Pregnancy is one of the periods in a woman’s life when there seems to be lowering of the ability to cope with emotional experiences in life. Even the cases where the coming of the baby is welcome a mild degree of depression or irritability may be evident during the early months.

31. URINARY SYSTEM Frequency of micturition Stress incontinence Due to dilatation of uterus and renal pelvis during early pregnancy which continues till mid-pregnancy there is a tendency for urinary stasis and these favours infection . Glomerular filtration rate ( GFR ) increases by 50% early in pregnancy, increasing creatinine clearance. Serum creatinine and urea will fall by about 25%.

32. Increased GFR also increases filtered sodium. Aldosterone levels rise by 2-3 times to reabsorb the filtered sodium. Increased GFR and impaired tubular reabsorption of glucose produce glucosuria in approximately 15% of normal pregnancies. Proteinuria is abnormal in pregnancy.

33. LOCOMOTOR SYSTEM Due to Lordisis of pregnancy and relaxation of joints under the influences of relaxin hormone backache is common. Leg cramps occur due to pressure on sacral and lumbar plexus. Gait becomes waddling .

34. ENDOCRINE SYSTEM Gonadotrophine : FSH, LH are inhibited by placental steroids. Prolactin rises throughout pregnancy. Protein hormones, HCG appears in blood and urine from 8th day of fertilisation , and reaches a peak at 9th-10th week, thereafter drops rapidly and remains at a plateau for the rest of pregnancy.

35. HCG values are increased in presence of multiple pregnancies . Oestrogen and progesterone levels increase and continue to be secreted from the placenta during the last 6 months of pregnancy. Progesterone is produced by all steroid-forming glands including ovaries, testes and adrenal. It acts as an immediate or precursor for other hormones.

36. During pregnancy, progesterone is secreted by corpus luteum up to six weeks of pregnancy. Thereafter, the placenta takes over the function of progesterone production up to term.

37. Prolactin : During pregnancy, prolactin values rise to about 100 mg/ml due to maternal pituitary activity. The decidual lining of the uterus contributes to amniotic fluid content of prolactin .

38. Oestriol : Oestriol levels reach 25-30 mg/day. Extremely low Oestrol denotes foetal death or anencephaly. High circulating oestrol values are associated with multiple pregnancies or Rh isoimmunisation . A normal oestrol level signifies foetal well being.

39. HPL (Human Placental Lactogen ) : HPL levels vary directly according to placental mass. Therefore HPL levels are higher in multiple pregnancy. Secretion of oxytocin (stimulates uterine contraction)

40. Thyroid activity is increased – In normal pregnancy thyroid gland increases in size by about 13 % due to hyperplasia and increased vascularity . There is normaly an increased uptake of iodine during pregnancy , which may be due to compensate for renal clearance of iodine leading to a reduced level of plasma iodine.

41. MUSCULOSKELETAL SYSTEM The body's posture changes as the pregnancy progresses. The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the fetus grows. These muscles are less able to contract and keep the lower back in proper alignment.

42. The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture.. The influences of increased hormones such as estrogen and relaxin initiate the remodeling of soft tissues, cartilage and ligaments.

43. 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.

44. HEMATOLOGY During pregnancy the plasma volume increases by 50% and the red blood cell volume increases only by 20-30%. Consequently, the hematocrit decreases on lab value; this is not a true decrease in hematocrit , however, but rather due to the dilution.

45. A pregnant woman will also become hypercoagulable , leading to increased risk for developing blood clots and embolisms, due to increased liver production of coagulation factors, mainly fibrinogen and factor VIII (this hypercoagulable state along with the decreased ambulation causes an increased risk of both DVT and PE ).

46. DVT

47. DVT

48. DVT

49. Women are at highest risk for developing clots during the weeks following labor. Clots usually develop in the left leg or the left iliac venous system. The left side is most afflicted because the left iliac vein is crossed by the right iliac artery. The increased flow in the right iliac artery after birth compresses the left iliac vein leading to an increased risk for thrombosis (clotting) which is exacerbated by the aforementioned lack of ambulation following delivery .

50. Edema , or swelling, of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.

51. Edema

52. Ankle odema

53. Edema

54. WEIGHT GAIN HOW MUCH WEIGHT GAIN OCCUR DURING PREGNANCY AND OF WHAT ?

55. Average weight gain during pregnancy is about 10 kilogram in the pregnant Indian woman of average built . And can be accounted for the weight of foetus , placenta, amniotic fluid, increase in weight of breasts and uterus, increase in blood value, extra cellular fluid and fat.

56. There is a wide range of normality in weight gain and many factors influence it which include maternal edema , maternal metabolic rate , dietary intake , vomiting and diarrhea etc.

57. Poor weight gain is due to nausea, vomiting, indigestion, underweight woman Inadequate food, overwork, maternal illness, intra-uterine growth retardation foetal death

58. Excessive weight gain is due to overeating, excess water intake, oedema, large foetus , multiple pregnancy and overweight of woman.

59. Reproductive weight gain Fetus – 3.3 kg , Placenta – 0.6 kg , Liquor – 0.8 kg , Uterus – 0.9 kg , Breast – 0.4 kg

60. Net maternal weight gain : Increase blood volume – 1.3 kg , Increase in extracellular fluid -1.2 kg , Accumulation of fat and protein – 3.5 kg

61. GENERAL METABOLISM The basal metabolic rate increases by 15-20%.during the later half of pregnancy in response to the demands of the growth fetus and maternal tissues and so energy requirement is higher. WHAT IS DAILY ENERGY REQUIREMENT OF PREGNANT WOMAN ?

62. In women with normal BMIs, energy requirement does not increase significantly during the first trimester, increases by about 350 Kcal/day in the second trimester and 500 Kcal/day in the third.

63. About 40% of women develop physiological ankle oedema during the last 12 weeks of pregnancy which disappears with rest and is rarely present in the morning. However, oedema in pregnancy should never be considered physiological until all pathological causes have been ruled out.

64. ANY QUESTION ??????