Unit VIII

Physiology of Pregnancy (Changes and Adaptation)

Changes in Endocrine System during Pregnancy
Pregnancy alters the function of most endocrine glands, partly because the placenta produces
hormones and partly because most hormones circulate in protein bound form and protein
binding increases during pregnancy.

Changes in Endocrine Glands during Pregnancy

Parathyroid Gland

 Slightly increase in size of the gland.

 Meets the increased requirement for calcium needed for fetal growth (25 to 30 gm) by the
second half of pregnancy.
 Parathyroid hormones controls calcium and magnesium metabolism.
 During pregnancy fetal demands for calcium and phosphorus increase and maternal
parathyroid gland respond by producing additional parathyroid hormone.
 Parathyroid hormone generally acts to improve absorption of calcium from the intestine
to decrease renal losses.
 The concentration of parathyroid hormone gradually rises from 20- 24 weeks of gestation
and reaches a peak level at term.
Pituitary Gland

 Most hormones from the pituitary glands are suppressed during pregnancy.
 The only hormone from the anterior pituitary that increases is prolactin, which prepares
the breast to produce milk.
 The posterior pituitary secrets oxytocin, a second hormone that is involved in lactation.
 Oxytocin stimulates the milk ejection reflex after child birth.
 Oxytocin also stimulates contraction of the uterus but during pregnancy, this action is
inhibited by progesterone, which relaxes smooth muscle fibres.
 After childbirth progesterone levels decline, and oxytocin play an important role in
keeping the uterus contracted and thus in preventing excessive bleeding.
Thyroid Gland

 Hyperplasia of the thyroid gland occurs during pregnancy and causes slight generalized
enlargement of the gland which can frequently be seen and palpated.
 The lower level of free thyroxin stimulate the thyroid stimulating hormone, which in turn
causes the thyroid to enlarge.
 The basal metabolic rate increased by as much as 20- 25% in pregnancy probably due to
oxygen conjuction by the fetus, causing greater cardiac output, pulse rate and heat
intolerance.
Adrenal Gland

 The adrenal glands enlarge slightly during pregnancy but they produce a significant
increase in two adrenal hormones; Cortisol & Aldosterone.
 Cortisol regulates carbohydrate and protein metabolism.
 It stimulate gluconeogenesis (formation of glycogen from noncarbohydrate source such as
amino or fatty acids), whenever the supply of glucose is inadequate to meet the body's
needs for energy.
 Aldosterone regulates the absorption of sodium from the distal tubules of kidney.
 Aldosterone thereby maintains the necessary level of sodium in the greatly expanded
blood volume.
Pancreas

 Significant changes in the pancreas during pregnancy are due to alterations in maternal
blood glucose and consequent fluctuations in insulin production.
 The increased maternal and fetal metabolic needs create a demand for fuel, causing a state
of accelerated starvation.
 Exaggerated fasting hypoglycemia and starvation ketosis are common.
 Insulin resistance increases with advancing pregnancy mainly due to insulin antagonism
by human placental lactogen.
 To overcome symptomatic hypoglycemia, the pregnant women is advised to consume
small frequent meals.

Hormones of Placenta
 The placenta acts as temporary endocrine gland during pregnancy.
 It produces large amount of estrogen and progesterone by 10- 12 weeks of pregnancy.
 It serves to maintain the growth of the uterus, helps to control uterine activity and is
responsible for many of the maternal changes in the body.
 Placenta produce a variety of hormones of which Steroids and Protein hormones are
significantly important.
Steroid Hormones
 Oestrogens: Oestriol, Oestradial and Oestrone
 Progesterone
Protein Hormones
 Human Chorionic Gonadotrophin (HCG)
 Human Placental Lactogen (HPL)
 Human Chorionic thyrotrophin (HCT)

 Human Chorionic Corticotrophin (HCC)

 Pregnancy Specific B-1 Glycoprotein (PSBG)
 Pregnancy Associated Plasma Proteins (PAPP)
Steroid Hormones

 Estrogen
 It is secreted by ovaries in early pregnancy but by 7 weeks gestation over half of the
estrogen is secreted by the placenta.
 It stimulates uterine growth and increase blood supply to uterine vessels.
 Maintenance of breast growth and its ductal structures.
 Enlargement of external genitalia.
 Increased activity of the salivary glands and hyperemia of the gums and nasal mucous
membrane.
 Hyper pigmentation, vascular changes in the skin, causing vasodilation.
 Estrogen may decrease secretion of HCL acid and pepsin which may be responsible for
digestive upsets such as nausea.

 Progesterone
 In the very early stage of pregnancy, corpus luteum secretes 17 hydroxyl progesterone.
 Progesterone stimulates the development of thick vascular decidua, ready for the
imbedding of the ovum and it normally maintains the healthy decidua throughout
pregnancy.
 Progesterone decreases the contractility of the pregnant uterus, thus preventing uterine
contractions from causing spontaneous abortion.
 It relaxes plain muscles in the body. The ureters are affected and becoming kinking and
dilated, with a consequent stasis of urine plain muscle of the bowel is relax, constipation
is common. Relax of the plain muscles in the walls of vein may lead to development of
vericose vein of legs, rectum and vulva.
Other Hormones in Pregnancy
1) Relaxin Hormone
 Secreted by corpus luteum of the ovary and by placental tissues.
 Its secretion is increased by a stimulating effect of human chorionic gonadotrophin.
 Present by the time of first missed menstrual period.
 Relaxin inhibits uterine activity, softens connective tissue in the cervix relaxes pelvic
joints and stimulates growth of breast.

2) Human Chorionic Gonatotrophin (HCG) Hormone

 In early pregnancy, HCG is produced by the trophoblastic cell (Syncytiotrophoblasts) that
surrounds the developing embryo.
 The primary function of the HCG in early pregnancy is to stimulate the corpus luteum to
produce progesterone and estrogen until the placenta is sufficiently developed.
 The hormone is responsible for positive test because HCG excreted via kidney appears in
urine especially in early pregnancy (60- 70 day of pregnancy).
 By the 12th and 13th week, placenta is fully form and take over the production of estrogen
and progesterone, therefore the production of HCG begins to fall at about 10th weeks and
the corpus luteum gradually declines.
3) Human Placental Lactogen (HPL)
 Also known as human chorionic somatomammotrophin (HCS).
 Synthesized by the syncytiotrophoblast of the placenta.
 In early pregnancy it can be detectable in maternal blood.
 Primary function of the HPL is to increase the availability of glucose for the fetus, who
needs constant supply for growth and development.

4) Pregnancy specific B- 1 glycoprotein (PSBG)

 It is produced by trophoblast.
 It reaches into the maternal blood stream and amniotic fluid.
 It can be detected in maternal serum as early as 7 days after ovulation.

5) Other protein Hormones

HCC, HCT is produced by placenta and involved in accelerating the activity of thyroid,
adrenal cortex and pancreas to meet the additional needs of pregnancy.

Diagnosis of Pregnancy
The diagnosis of pregnancy is based on three groups of findings;

 Symptoms experienced by the women

 Physical signs found on examination
 Special investigations including laboratory tests

Symptoms Experienced by the women

Subjective (Presumptive) Signs and Symptoms of Pregnancy
 Presumptive signs and symptoms are those signs and symptoms of pregnancy that are
usually noted (two or more are experienced together) by the patient, which impel her to
make an appointment with a physician.
 Each of these presumptive signs and symptoms is subjective and non- specific and could
easily be caused by conditions unrelated to pregnancy.
 These signs and symptoms are not a concussive diagnosis of pregnancy but they will
make the physician and woman suspicious of pregnancy.

1)Amenorrhea
 Amenorrhea is one of the earliest clues of pregnancy.
 The majority of young women have no periodic bleeding after the onset of pregnancy.
 However, amenorrhea may also occur in times of emotional stress and change in some
endocrine disorder and in anemia.
 There is tendency for slight bleeding during the 1st three months, which is called
implantation bleeding.
 So, the length and amount of loss must be associated.
2)Morning Sickness (Nausea & Vomiting)
 It is associated with amenorrhea.
 More than 50% of pregnant women experience nausea and vomiting.
 It appears soon following the missed period and rarely lasts beyond 16 weeks.
 This usually occurs on rising in the morning, but may continue throughout the day. But it
usually does not affect the health status of mother.
 The cause is thought to be due to high blood levels of HCG and estrogen.
 Nausea and Vomiting could be due to non- pregnant causes such as gastritis, hepatitis etc.

3) Bladder Irritability
 Frequency of micturition without any signs of infection such as burning or pain often
occurs in early pregnancy.
 Particularly occurs between 8- 12 weeks.
 It occurs due to;
Resting of the bulky uterus on the fundus of the bladder because of exaggerated
anteverted position of the uterus.
Changes in maternal osmoregulation (increased renal blood flow & GFR).
Congestion of bladder mucosa.
 As the uterus straighten up after 12th week, the symptoms disappear.

4) Breast Changes
 Breast discomfort as feeling of fullness and prickling sensation.
 6- 8th week of pregnancy in primigravida.
 As pregnancy continues;
Darkening of areola
Enlargement of Montgomery gland
Prominent & visible vein.
Thin yellowish secretion (Colostrum) can be expressed as early as 12th week.

5) Quickening
 Perception of active fetal movement by the women.
 Recognized earlier in pregnancy by woman who has previously been pregnant, and
therefore felt quickening before.
 In primigravida, occurs at 18th week- 20th week of pregnancy.

6) Fatigue
 A frequent symptom which may occur early in pregnancy.
Objective (Probable) Signs of Pregnancy
 Probable signs are those signs commonly noted by the physician or Midwife upon
examination of the woman.
 These signs include skin changes, breast changes, uterine change, abdominal changes,
cervical changes, positive pregnancy test etc.
 Although these signs are more reliable than the presumptive signs and symptoms.

1) Skin Change
 Pigmentation of the skin
 Chlosma is usually noticeable from 16th week of pregnancy.

2) Breast Change
 Subcutaneous veins become noticeable from 6-8 weeks.
 Montgomery's tubercle are prominent and extend to the secondary areola.
 Increase in the size and pigmentation of the nipple and areola.
 Colostrum becomes thick and yellowish by 16th week.

3) Per Abdominal Change

 Uterus remains as pelvic organ until 12th week, it may be just felt per abdomen as a
suprapubic bulge.
 From 12th week, as the uterus grows, the height of fundus rises.

4) Changes in the Pelvic Organs

The various signs can be demonstrated during vaginal examination.
 Jacqueminer's Sign
Dark purplish coloration of the mucous membrane of the wall of vagina.
Discoloration is due to increased blood supply of the venous plexus surrounding the wall.
Occurs from 8th week.

 Chadwick's Sign
Dark bluish purple coloration of cervix that extends to include vagina.
One of the earliest sign of pregnancy.
Discoloration is due to increased vascularity especially beneath squamous epithelium.
Occurs at 8th week of pregnancy.

 Osiander's Sign
Pulsation of the uterine arteries feels through the lateral fornices of the vagina.
Occurs at 8th week of pregnancy.
Occurs due to increase in vascularity.

 Cervical Signs (Goodle's Sign)

Cervix becomes soft as early as 6th week, a little earlier in multiparae called Goodle's
sign.
 The pregnant cervix feels like the lips of the mouth, while in the non- pregnant state, like
that of tip of the nose.

5) Uterine Changes
 Uterus changes in shape, size and consistency.
Uterus enlarge to;
Size of hen's egg at 6th week
Size of cricket ball at 8th week
From 12th week, fundus can be palpated abdominally just above symphysis pubis.
From 16th week, uterus becomes more ovoid shape.

 Hagar's Sign
 It is present in two- third of cases.
 Can be demonstrated between 6 and 10 weeks, a little earlier in multiparae.
This sign is due to;
Upper part of the uterus is enlarged by growing fetus.
Lower part of the body is empty and extremely soft.
The cervix is comparatively firm.
 On bimanual examination with two finger in one hand in the vagina and the fingers of the
one hand pressing downward and backward on the anterior abdominal wall, the finger of
two hands seems to oppose below the body of the uterus.

Fig: Hagar's Sign

 Palmer Sign's
 Regular and rhythmic uterine contraction can be elicited during bimanual examination as
early as 4- 8 weeks.

 Uterine Souffle
 A soft blowing sound that synchronizes with the pregnant woman's pulse.
 Head from 16th week on auscultation.
 It is sound of the maternal blood causing through the enlarged vessels.
 It must not be confused with the sound of the fetal heart.
 Braxton- Hick's Contraction
 Small waves of painless contraction of the uterus are called Braxton- Hick's
Contraction.
 It is felt as the pregnancy progress.
 Felt after 20th week.

 Ballotment
 External Ballotment
Usually elicited as early as 20th week, when fetus is relatively smaller than the volume
of amniotic fluid.
Difficult to elicit in obese patient and increase with scanty liquor amnii.
The test is elicited when the patient is in dorsal position. One hand taps the uterus on
the side to displace the fetus, the other hand which is placed on the other side to
steady the uterus can perceive the impulse.

Fig: External & Internal Ballotment

 Internal Ballotment
It can be elicited between 16- 28th week.
Not elicited incase with scanty liquor amnii or fetus is transversely placed.
Perform with patient in dorsal position.
Two fingers are introduced into the vagina and fundus of the uterus steadied by other
hand. With the tips of the vaginal fingers, the head or the breech is gently pushed up
through the fornix placing the fingers against the fornix to displace upward but
quickly rebound to its original position and the fingers feel the tap.
References
Subedi,D.,& Gautam, S. (Jan, 2016). Midwifery Nursing Part- I. In Antenatal Examination
and Care (3rd edition ed., pp. 184- 187, 189- 193). Medhabi Publication, Jamal,
Kantipath, Kathmandu.
Tuitui, R. (2018). Manual of Midwifery - I (Antepartum Care and Gynecological Nursing). In
Antenatal Examination (pp. 193- 195). Vidyarthi Pustak Bhandar, Bhotahiti,
Kathmandu.
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