Physiologic Changes of Pregnancy (Normal)

 It occurs during pregnancy are the basis for the signs and symptoms used to confirm a
pregnancy.

Categories:

1. Local (i.e., confined to the reproductive organs)

2. Systemic (i.e., affecting the entire body)

REPRODUCTIVE SYSTEM CHANGES

1. Reproductive tract changes are those involving the uterus, ovaries, vagina, and breasts.

Uterine changes

1. The most obvious alterations in woman's body during pregnancy.

2. Increase in size to accommodate the growing fetus.

1. Over 10 lunar months of pregnancy, the uterus increases in:

1. Length- grows from approximately 6.5cm to 32cm.

2. Depth- increases from 2.5cm to 22cm.
3. Width- expands from 4cm to 24cm.
4. Weight- increases from 50g to 1000g.
5. Wall Thickness- early in pregnancy uterine wall thickens from about 1cm to about 2cm; toward
the end of pregnancy, the wall thins to become supple and only about 0.5cm thick.
6. Volume- increases from about 2ml to more than 1000ml. This make it possible for a uterus to
hold a 7-lb (3,175-g) fetus plus 1000 ml of amniotic fluid for a total of about 4,000g.

1. By the end of the 12th week of pregnancy, the uterus is large enough that it can be palpated as
a firm globe under the abdominal wall, just above the symphysis pubis.
2. By the 20th or 22nd week of pregnancy, it typically reaches the level of the umbilicus.
3. By the 36th week, it usually touches the xiphoid process and can make breathing difficult.
4. About 2 weeks before term (the 38th week) for a primigravida, a woman in her first pregnancy,
the fetal head settles into the pelvis and the uterus returns to the height it was at 36 weeks.
5. The exact shape of the uterus is influenced by the position of a growing fetus inside.
6. As the uterus grows larger, it pushes the intestines to the side of the abdomen, elevates the
diaphragm and liver, compresses the stomach, and puts pressure on the bladder.
7. Uterine blood flow increases during pregnancy as the placenta requires more and more blood
for perfusion.

1. Uterine blood flow:

1. Before pregnancy- 15 to 20 ml/min.

2. End of pregnancy- expands to as much as 500 to 750 ml/min, with 75% of that volume going to
the placenta.

1. Bimanual examination- (one finger of an examiner is placed in the vagina, the other hand on the
abdomen) can de monstrate that, with pregnancy, the uterus feels more anteflexed larger, and
softer to the touch than usual.

Amenorrhea

1. Means absence of menstrual flow.

2.
3. occurs with pregnancy because of the suppression of follicle-stimulating hormone (FSH) by rising
estrogen levels.
4.
5. In a healthy woman who has menstruated previously, the absence of a menstrual flow strongly
suggests impregnation has occurred.
6.
7. Amenorrhea, however, also heralds the onset of menopause or could result from unrelated
reasons such as uterine infection, anxiety (perhaps over becoming pregnant), a chronic illness
such as severe anemia, hormonal imbalance, or undue stress.
8.
9. It also is seen in athletes who train strenuously, especially in long-distance runners and ballet
dancers if their body fat percent-age drops belowa critical point.
10.
11. Amenorrhea is, therefore, only a presumptive symptom of pregnancy.

Cervical changes

1. The cervix of the uterus becomes more vascular and edematous because of the increased level
of circulating estrogen from the placenta during pregnancy.
2. Operculum- A mucous plug, forms to seal out bacteria during pregnancy and helps prevent
infection in the fetus and membranes.
3. Goodell's sign- softening in cosistency and increased vascularity of the cervix of pregnant causes
it to darken from pale pink to violet hue.
4. The consistency of a nonpregnant cervix can be compared with that of the nose; the consistency
of a pregnant cervix closely resembles an earlobe.
5. Just before labor, the cervix becomes so soft it takes on the consistency of butter or is said to be
"ripe" for birth.

Vaginal Changes

1. Under the influence of estrogen, the vaginal epithelium and underlying tissues increase in size as
they become enriched with glycogen.
2. As preparation for great distention at birth, muscle fibers loosen from their connective tissue.
3. This increase in the activity of the epithelial cells it results in a slight white vaginal discharge
throughout pregnancy.
4. Chadwick's sign- Due to increase in circulation it changes the color of the vaginal walls from their
normal light pink to a deep violet.
5. Vaginal secretions before pregnancy have a pH value greater than 7 (an alkaline pH). During
pregnancy, the pH level falls to 4 or 5 (an acid pH), which helps make the vagina resistant to
bacterial invasion for the length of the pregnancy. This occurs because of the action of
Lactobacillus acidophilus, a bacteria that grows freely in the increased glycogen environment,
which increases the lactic acid content of secretions.

Ovarian changes

1. Ovulation stops with pregnancy because of the active feedback mechanism of estrogen and
progesterone produced early in pregnancy by the corpus luteum and late in pregnancy by the
placenta.
2. This feedback causes the pituitary gland to halt production of FSH and luteinizing hormone (LH);
without stimulation from FSH and LH, ovulation does not occur.
3. The corpus luteum that was created after ovulation continues to increase in size on the surface
of the ovary until about the 16th week of pregnancy, by which time the placenta takes over as
the chief provider of progesterone and estrogen.

Changes in the Breasts

1. Subtle changes in the breasts may be one of the first physiologic changes of pregnancy a woman
notices (at about 6 weeks).
2. Typical changes tingling, feeling of fullness, or tenderness that occurs because of the increased
stimulation of breast tissue by the high estrogen level in her body.
3. As the pregnancy progresses, breast size increases because of growth in the mammary alveoli
and in fat deposits.
4. The areola of the nipple darkens, and its diameter increases from about 3.5 cm (1.5 in.) to 5 cm
or 7.5 cm (2 or 3 in.). There is additional darkening of the skin surrounding the areola in some
women, forming a secondary areola.
5. Early in pregnancy, the breasts begin readying themselves for the secretion of milk.
6. By the 16th week, colostrum, the thin, watery, high-protein fluid that is the precursor of breast
milk, can be expelled from the nipples.
7. As vascularity of the breasts increases, blue veins may become prominent over the surface of
the breasts.
8. The sebaceous glands of the areola (Montgomery's tubercles) enlarge and become protuberant.
9. Montgomery's tubercles- keeps the nipple supple and help to prevent nipples from cracking and
drying during lactation.
10. Talking to women during pregnancy about breast changes and how these changes are devised
to aid breastfeeding can be the trigger that alerts women to the importance of breastfeeding for
their baby.

SYSTEMIC CHANGES

1. changes also occur in almost all body systems.

Endocrine System

1. Almost all aspects of the endocrine system increase during pregnancy in order to support fetal
growth.
2. Placenta- Produces estrogen and progesterone (which help maintain the pregnancy), hCG
(which allows detection of early pregnancy), and other hormones during pregnancy that impact
growth of the baby and uterus and timing and onset of labor.
3. Pituitary gland- Late in pregnancy produces increased levels of prolactin (milk production);
produces oxytocin which is necessary for labor contractions.
4. Thyroid- Increases levels of hormones that increase the basal metabolic rate by 20% and can
lead to increased emotional lability, perspiration, tachycardia, and palpitations.
5. Adrenal glands- Increases levels of corticosteroids and aldosterone inhibit immune response,
thereby preventing rejection of fetus.
6. Pancreas- Increases insulin production but insulin is less effective due to estrogen,
progesterone, and other hormones that are antagonists to insulin. This allows for glucose to be
circulating in the maternal blood stream to be available to the fetus.

Immune system

1. Immunologic competency during pregnancy decreases, probably to prevent a woman's body

from rejecting the fetus as if it were a transplanted organ.
2. Immunoglobulin G (IgG) production is particularly decreased, which can make a woman more
prone to infection during pregnancy. A simultaneous increase in the white blood cell count may
help to counteract this decrease in the IgG response.
Integumentary system

1. As the uterus increases in size, the abdominal wall must stretch to accommodate it. This
stretching (plus possibly increased adrenal cortex activity) can cause rupture and atrophy of
small segments of the connective layer of the skin, leading to streaks (striae gravidarum) on the
sides of the abdominal wall and sometimes on the thighs.
2. During the months after silvery color (striae albicantes atrophicae), and, although permanent,
they become birth, striae gravidarum lighten barely noticeable.
3. Frequently, the abdominal wall has difficulty stretching enough to accommodate the growing
fetus, causing the rectus muscles underneath the skin to actually separate, a condition known
as diastasis.
4. The umbilicus is stretched by pregnancy to such an extent that by the 28th week.
5. Extra pigmentation generally appears on the abdominal wall. A narrow, brown line (linea nigra)
may form, running from the umbilicus to the symphysis pubis and separating the abdomen into
right and left halves.
6. Darkened or reddened areas may appear on the face as well, particularly on the cheeks and
across the nose. This is known as melasma (chloasma) or the "mask of pregnancy." With the
decrease in the level of melanocyte-stimulating hormone after pregnancy, these areas lighten
but do not always disappear.
7. Vascular spiders or telangiectasias (small, fiery-red branching spots) sometimes develop on the
skin, particularly on the thighs. Palmar erythema, may occur on the hands. Both of these
symptoms result from the increased level of estrogen in the body and telangiectasias may fade
but not completely disappear after pregnancy.
8. The activity of sweat glands increases throughout the body beginning early in pregnancy,
leading as a round bump at the to increased perspiration.
9. Fewer hairs on the head enter a resting phase because of overall increased metabolism, so scalp
hair growth is increased.

Respiratory System

1. A local change that often occurs in the respiratory system is marked congestion, or "stuffiness,"
of the nasopharynx, a response, again, to increased estrogen levels. Women may worry this
stuffiness indicates an allergy or a cold.
2. Because the uterus enlarges so much during pregnancy, the diaphragm, and ultimately, the
lungs, receive an increasing amount of pressure. Toward the end of pregnancy, this can actually
displace the diaphragm by as much as 4 cm upward.
3. Even with all this crowding, however, a woman's vital capacity (the maximum volume exhaled
after a maximum inspiration) does not decrease during pregnancy because, although the lungs
are crowded in the vertical dimension, they can still expand horizontally.
1. Two major changes do occur with pregnancy:

1. A more rapid than usual breathing rate (18-20 breaths/min),

2. Chronic feeling of shortness of breath.

1. Residual volume (the amount of air remaining in the lungs after expiration) is decreased up to
20% because of the pressure of the diaphragm.
2. Tidal volume (the volume of air inspired) is increased up to 40% as a woman draws in deeper
breaths trying to increase the effectiveness of her air exchange.
3. Total oxygen consumption increases by as much as 20%.
4. The increased level of progesterone appears to set a new level in the hypothalamus for
acceptable serum carbon dioxide levels (PCO2) because, during pregnancy, a woman's body
tends to maintain a PCO2 at closer to 32 mmHg than the usual 40 mmHg. This low Pco2 level
helpful as it causes a favorable CO2 gradient at the placenta (i.e., because the fetal CO2 level is
higher than that in the mother, CO2 crosses the mother).
5. At full term, a woman's total ventilation capacity may have risen by as much as 40%. This
increased ventilation may become so extreme toward the end of pregnancy that a woman
exhales more than the usual amount of CO2. To compensate, kidneys excrete plasma
bicarbonate in urine to lower this pH. This results in increased urination or polyuria, a sign of
pregnancy.
6. The total respiratory changes and the compensating mechanisms that occur in the respiratory
system can be described as a chronic respiratory alkalosis fully compensated by a chronic
metabolic acidosis.

Temperature

1. Early in pregnancy, body temperature increases slightly because of the secretion of

progesterone from the corpus luteum (the temperature, which increased at ovulation remains
elevated). As the placenta takes over the function of the corpus luteum at about 16 weeks, the
temperature usually decreases to normal.

Cardiovascular Changes

1. Changes in the circulatory system are extremely significant to the health of a fetus because they
determine whether there will be adequate placental and fetal circulation for oxygenation and
nutrition.
2. The heart adapts to the increased cardiac demand that occurs during pregnancy in many ways.

1. Cardiac output (Lit./Min.): 6.26

2. Stoke Volume (Ml.): 75
3. Heart Rate (Per min.): 85
4. Blood Pressure: Unaffected
5. Cardiac output increases throughout early pregnancy, and peaks in the third trimester, usually
to 30-50% above baseline.
6. The heart rate increases, but generally not above 100 beats/ minute.
7. Total systematic vascular resistance decreases by 20% secondary to the vasodilatory effect of
progesterone.
8. Overall, the systolic and diastolic blood pressure drops 10–15 mm Hg in the first trimester and
then returns to baseline in the second half of pregnancy.

1. All of these cardiovascular adaptations can lead to common complaints, such as palpitations,
decreased exercise tolerance, and dizziness.
2. Uterine enlargement beyond 20 weeks' size can compress the inferior vena cava, which can
markedly decrease the return of blood into the heart or preload. As a result, healthy pregnancy
patients in a supine position or prolonged standing can experience symptoms of hypotension.

Gastrointestinal System

1. At least 50% of women experience some nausea and vomiting early on in pregnancy. For many
women, this is the first sensation a woman experiences with pregnancy (it can be noticed even
before the first missed menstrual period). It is most apparent early in the morning, on rising, or
if a woman becomes fatigued during the day. Known as morning sickness, nausea and vomiting
begins to be noticed at the same time levels of hCG and progesterone begin to rise, so these
may contribute to its cause.
2. Another reason may be a systemic reaction to increased estrogen levels or decreased glucose
levels because glucose is being used in such great quantities by the growing fetus.
3. Nausea usually subsides after the first 3 months, after which time a woman may have a
voracious appetite.
4. Many help reduce nausea are available, such as acupuncture or wrist bands.
5. Although the acidity of stomach secretions decreases during pregnancy, heartburn can readily
result from reflux of stomach contents into the esophagus, caused by both the upward
displacement of the stomach by the uterus, and a relaxed cardioesophageal sphincter, caused
by the action of relaxin produced by the ovary.
6. As the uterus increases in size, it pushes the stomach and intestines toward the back and sides
of the abdomen. At about the midpoint of pregnancy, this pressure may be sufficient to slow
intestinal peristalsis and the emptying time of the stomach, leading to renewed heartburn,
constipation, and flatulence.
7. Pressure from the uterus on veins returning from the lower extremities can lead to
hemorrhoids.
8. The entire gastrointestinal tract may become less active from the combined actions of relaxin
and progesterone. This natural slowing of the stomach and intestine can be helpful because the
blood supply is reduced in the gastrointestinal tract as more blood is drawn to the uterus.
9. Because of the gradual slowing of the gastrointestinal tract, decreased emptying of bile from the
gallbladder may result. This can lead to reabsorption of bilirubin into the maternal bloodstream,
giving rise to a symptom o generalized itching (subclinical jaundice).
10. Some pregnant women notice hypertrophy at their gum lines and bleeding of gingival tissue
when they brush their teeth. There also may be increased saliva formation (hyperptyalism),
probably as a local response to increased levels of estrogen. This is an annoying but not a
serious problem.
11. A lower-than-normal pH of saliva may lead to increased tooth decay if tooth brushing is not
done conscientiously.

Urinary System

1. Like other systems, the urinary system undergoes specific physiologic changes during pregnancy,
including alterations in fluid retention and renal, ureter, and bladder function.
2. Renal function- Changes to excrete waste from maternal and fetal blood supplies.
3. Glomerular filtration rate- Increased by 50 %.

1. Blood urea nitrogen- Decreased by 25% , BUN of 15 mg/100 ml or higher is abnormal.

2. Creatinine- Decreased in pregnancy, creatinine clearance should be 90-180 ml/min in 24-hour
urine sample creatinine greater than 1 mg/100 ml is abnormal.
3. Renal threshold for sugar- Decreased to allow slight spillage.
4. Ureter and bladder function- Increase in urinary output but also physiologic increase in urinary
stasis (bladder infections and pyelonephritis are more likely).
5. Bladder capacity- Increased by 1,000 ml.
6. Diameter of ureters- Increased by 25%.
7. Frequency of urination- Increased slightly in first trimester, last 2 weeks of pregnancy increases
to 10-12 times per day.
8. Fluid retention- Increased aldosterone production causes increased sodium reabsorption and
fluid retention.

Musculoskeletal System

1. Calcium and phosphorus needs are increased during pregnancy because an entire fetal skeleton
must be built.
2. As pregnancy advances, a gradual softening of a woman's pelvic ligaments and joints occurs to
create pliability and to facilitate passage of the baby through the pelvis at birth. This softening is
probably caused by the influence of both the ovarian hormone relaxin and placental
progesterone.
3. This excessive mobility of joints can cause discomfort late in pregnancy especially if there is a
separation of the symphysis pubis. Separation this way causes acute pain and makes walking
difficult and painful.
4. To change her center of gravity and make ambulation easier, a pregnant woman tends to stand
straighter and taller than usual. This stance is sometimes referred to as the “pride of
pregnancy”. Standing this way, with the shoulders back and the abdomen forward, however,
creates a lordosis (forward curve of the lumbar spine), which may lead to chronic backache,
particularly in older women.