RUFAIDA COLLEGE OF NURSING,

JAMIA HAMDARD

ASSIGNMENT
ON
PHYSIOLOGICAL
CHANGES
DURING PREGNANCY

SUBMITTED TO: SUBMITTED BY:

Mrs. Mikki Khan Mrs. Shabnam Nesha
Assistant Professor M.Sc. Nursing 1st year
IDENTIFICATION DATA
Name : Mrs. Shabnam Nesha
Class : M.Sc Nursing 1st year
Subject : Obstetrics and Gynaecology
Unit : III
Topic : Physiological changes during pregnancy
Target Group : M.Sc Nursing students
Size of the group : 06 students
Venue : M.Sc Nursing 1st year classroom
Duration : 1 hour
Method of teaching : Lecture cum discussion
Date : 23rd January, 2024.
Time : 9-10 am
Name of the supervisor : Mrs. Mikki Khan
Previous knowledge : The students have some knowledge about the
Physiological changes during pregnancy
PHYSIOLOGICAL CHANGES IN PREGNANCY
 Haematological
 Cardiovascular
 Respiratory
 Renal
 Endocrine
 Gastrointestinal
 Dermatological
 Genital tract
Haematological
 Plasma volume increases 50-70%
-Beginning by the 6th wk
 RBC mass increases 20-35%
-Beginning by the 12th wk
 Hemodilution- the practice of intentionally removing red blood cells to lower the
haematocrit.
Blood and its components
In the course of a pregnancy, there is an increase in the total blood volume, the plasma
volume and red cell mass (Table 4.1). The total blood volume increases by 30-40% by about
34 weeks. This is largely due to an increase in plasma volume (45%), while the red cell mass
increases by 18%. This results in haemodilution, often incorrectly called a physiological
anaemia.
The white cell count increases from approximately 7000/mm³ before pregnancy to 10000-
15000/mm³. This is due to an increase in neutrophils the other cells do not increase. Plate-
lets rise considerably from 180000/mm³ to over 300 000/mm³, and this rise is doubled again
in the puerperium.
The erythrocyte sedimentation rate (ESR) rises due to increased fibrinogen and globulin
levels. Normal (10mm/hr) & in pregnancy (40mm/hr increase).
The plasma protein changes are shown in Table 4.1. All lipid fractions increase, while there is
a fall in the levels of all electrolytes associated with haemodilution.

Table 4.1 Plasma protein alterations during pregnancy

Protein Non pregnancy pregnancy
Total protein 180 gm 280 gm (inc.)
Serum protein 7 gm 6 gm (dec.)
due to heamodilution
Serum albumin 4.3 gm 3 gm (dec.)
Serum globulin 2.7 gm 3 gm (inc.)
Serum albumin:globulin 1.7:1 1:1

Cardiovascular system
The main changes relate to increased cardiac output, which is produced by an increase in both
heart rate and stroke volume. Peripheral resistance falls and as a result blood pressure usually
remains steady throughout pregnancy, or frequently it may fall below prepregnancy during
midpregnancy.
Apical pulse-5th intercostal space->4th intercostal space.
The cardiac output increases by 30-60% during pregnancy. Most of this increase occurs by
the end of the first trimester, then slowly rising to 28 weeks, and is maintained to term.
Further increases in cardiac output occur during labour (Table 4.2). During the first stage, a
30% increase occurs, while in the second stage an even greater output can be measured
during bearing down.
Table 4.2 Cardiac blood output
Condition Output (l/min)
Non-pregnant 4.5
Pregnant 6.7
1st stage of labour 8.0
2nd stage of labour 9.0

Supine hypotension
During late pregnancy, a fall in blood pressure and a feeling of faintness occurs in some 10%
of women who lie supine. This is due to vena cava compression by the enlarging uterus in the
presence of a poor paravertebral collateral circulation. The resultant fall in venous return
reduces the cardiac output, and thus also a fall in blood pressure. Women in late pregnancy
and labour should never be flat on their backs.
Regional blood flow changes
The regional blood flow to the liver and brain does not significantly alter during pregnancy,
but the uterine blood flow increases ten-fold: from 50ml/min in early pregnancy to 500
ml/min at term. The renal blood flow increases by 30% renal plasma flow by 45% and
glomerular filtration rate by up However, because tubular reabsorption is unaltered the
clearance of many solutes (for example, urea, uric acid and glucose) is increased.
Metabolic changes
Metabolic changes in pregnancy are complex, and currently under much investigation. There
is a general increase in the metabolic rate, largely due to fetal demands. Oxygen consumption
rises by 20%, and the thyroid gland hypertrophies in perhaps 70% of patients.
Carbohydrate metabolism is affected by human placental lactogen during pregnancy. This
hormone antagonizes the action of insulin, breaks down body fat, and thus acts towards the
elevation of blood glucose levels. As a result, insulin rises to even higher levels, so increasing
glucose utilization but restricting any abnormal blood levels. The increased demand on the
pancreas may at this stage uncover a latent diabetic.
Protein metabolism shows an overall positive nitrogen balance, and about 500g of protein are
retained by term. Thus a high protein diet is required during pregnancy.
Fat is the main form of maternal energy store during pregnancy, mostly in the form of depot
fat. Blood lipid also increases significantly. It is important to note that because glycogen
stores are low, any major stress will draw quickly on fat for energy and so ketosis may occur.
The average total body weight gain should be about 12.5kg (28 lb), the main increase being
in the second half of the pregnancy.
THE URINARY TRACT AND RENAL FUNCTION
RENAL CHANGES
 Blood flow increases (60-70%)
 Glomerular filtration increases (50%)
 Clearance of most substance is enhanced
 Plasma, creatinine, urea and urate are reduced
 Glycosuria is normal
 Bladder capacity increase and bladder tone decrease due to progesterone hormone.

RESPIRATORY SYSTEM
Mechanical –diaphragm
Consumption-increase in needed oxygen
 Oxygen consumption increases 15-20%
 50% of this increase is required by the uterus
Stimulation-progesteron stimulation
PULMONARY CHANGES
 Mucosal hyperaemia
 Subcostal angle
 Chest circumference and diameter
 Diaphragmatic excursion
 Tidal volume: Plus 30-40%
 Po2 is increased, pco2 is decreased
 Total lung capacity decrease by 15%
 Minute ventilation: Plus 30-40%
 Mild respiratory alkalosis
ENDOCRINE SYSTEM
1. Pituitary gland
FSH and LH↓ ACTH, Thyrotrophin, melanocyte hormone and prolactin ↑
Prolactin level ↑ until the 30th week of pregnancy then more slowly to term.
2. Adrenal gland
Total corticosteroids ↑ progressively to term. This will ↑ the tendency of pregnant women to
develop abdominal strine, glycosuria and hypertension.
Pregnancy is a hyperinsulinoma condition.
3. Thyroid gland
-Enlarges during pregnancy, occasionally to twice its normal size. This is mainly due to
colloid deposition caused by a lower plasma level of iodine, consequent on the increased
ability of the kidneys to excrete during pregnancy.
-Oestrogen stimulates or increased secretion of thyroxin in binding globulin.
-Both T3 and T4 levels rise. This rise will not indicate hyperthyroidism.
GASTROINTESTINAL
 Slowed Gl motility
-Constipation, early satiety
 Relaxation of LES
-GERD
 Nausea / vomiting
-Often proportional to HCG level
 Liver/gallbladder
-Biliary stasis, cholesterol saturation
-More stones
-Coagulation factors
-Increased binding proteins (thyroid, steroid,
PHYSIOLOGIC CHANGES -
GASTROINTESTINAL
 Digestive system slow due to progesterone-Digestive system slow due to
progesterone.May be due to increased HCG and estrogen.
Many theories about cause of nausea.Gi changes are a result of the hormonal changes
and increase fundal size puts pressure on internal organs.
 Nausea and vomiting
 Ptyalism: Increase salivation
 Heartburn
 Hemorrhoids
 Prolonged gallbladder emptying time may lead to gall stones.
 Bile salt buildup may lead to itching.
 Displacement of the stomach and intestines.
 Appendix can be displaced to reach the right flank.
 Gastric emptying and intestinal transit times are delayed secondary to hormonal and
mechanical factors.
 Pyrosis is common due to the reflux of secretions.
 Vascular swelling of the gums.
 Hemorrhoids due to elevated pressure in rectum or anal area.
DERMATOLOGICAL CHANGES
 Chloasma or melasma gravidarum-also called as pregnancy mask or butterfly
sign.
Dark pigmented spot on face, neck and sometime on chest. Appear at 24 weeks. Due to
Melanocyte Stimulating Hormone (MSH).
 Straie Gravidarum
-Stretch mark on abdomen, thigh and back. Due to overstretching of muscles.
-Appear at 20 weeks of gestation.
-Color of straie Gravidarum is pink. After delivery pink stretch mark convert into white
marks and that time known as straie albicans.
 LINEA NIGRA
-A dark line appear on skin between xiphoid process to symphysis pubis.
-Appear at 20 weeks of gestation.
-Appear due to MSH(Melanocyte Stimulating Hormone) from Intermediate lobe of pituitary
gland.
MSK CHANGES
Musculoskeletal consequences that ensure as a result of hormonal changes and weight gain
(28lbs ave) include:
-Force across a joint is increased up to two-fold.
-Joint laxity (Relaxin) in the anterior and posterior longitudinal ligaments of the lumbar spine
put strain on the lumbar spine ( inc. lumber curvature due to relaxin hormone).
-There is widening and increased mobility of the sacroiliac joints and pubic symphysis to
facilitate the baby's passage through the birth canal.
-A significant increase in the anterior tilt of the pelvis occurs, with increased use of hip
extensor, abductor, and ankle plantar flexor muscles.
WEIGHT CHANGES
 Maternal store of nutrients and muscles development - 3 kg
 Increase body fluid- 2 kg
 Increased blood- 1.5-2 kg
 Breast growth -600gram
 Enlarged uterus- 1 kg
 Amniotic fluid – 1 kg
 Placenta – 600gm
 Baby – 3.4-4 kg
WEIGHT INCREASE
 There is an increase weight of approximately 12.5 kg at term.
 The maximum weight gain in the 2ndtrimester, 0.5 kg/week(5 kg in 2nd trimester)
 The maximum fetal weight gain in 3rd trimester, (5 kg in 3rd trimester)
HEALTHY WEIGHT GAIN DURING PREGNANCY
Prepregnancy Weight gain in kilograms Weight gain in pounds
BMI
Underweight 12.5-18 28-40
(under 18.5 BMI)
Normal weight 11.5-16 25-35
(18.5-25 BMI)
Overweight 7-11.5 15-25
(25-30 BMI)
Obese 5-9 11-20

ANATOMICAL CHANGES
 REPRODUCTIVE ORGANS
 The uterus
 The cervix
 BREAST AND LACTATION
GENETAL TRACT CHANGES
 UTERUS(40 cm length)
A. Uterine muscles grow to 15 times than pre-pregnancy length.
-Uterine weight increases from 50 g before pregnancy to 950 g at term.
-In the early weeks of pregnancy the growth is by hyperplasia and more partially by
hypertrophy of the muscle fibers.
-By 20 weeks growth ceases and the uterus expands by distension.
-The uterine blood vessels also undergo hypertrophy and become increasingly coiled in the
first half of pregnancy but no further growth after that.
The lower uterine segment is that part of the lower uterus and upper cervix lying between the
line of attachment of the peritoneum of the utero vesical pouch superiorly and the histological
internal os interiorly.
Shape( globular shape-12weeks) Weeks
Hens egg 6 weeks
Cricket ball(orange shape) 8 weeks
Fetal head 12 weeks
THE CERVIX
-Becomes softer and swollen in pregnancy, with the result that columnar epithelium lining the
cervical canal becomes exposed to the vaginal secretions.
-Prostaglandins act on the collagen fibres, especially in the last week of pregnancy. Some
time collagen is released from leucocytes, which also helps in breaking down collagen. The
cervix becomes softer and more easily dilatable the soon Called ripening of the cervix.
VAGINA
-The vaginal wall become hypertrophied, oedematous and more vascular.
-Increased blood supply of the venous plexus surrounding the walls. The length of the
anterior vaginal wall increased.
-Secretion becomes copious, thin and curdy white.
-pH becomes acidic (3.5-6)

SUMMARY
There is a significant increase in oxygen demand during normal pregnancy. This id due to
15% increase in the metabolic rate and 20% increased consumption of oxygen. There is a 40-
50% increase in minute ventilation, mostly due to increase in tidal volume, rather than in the
respiratory rate.
CONCLUSION
The physiologic changes that occur during pregnancy are the result of hormonal and
metabolic adaptations that are necessary to support the developing fetus.
BIBLIOGRAPHY
DC Dutta’s Textbook of OBSTETRICS, Hiralal Konar,JAYPEE 8TH Edition pg. No.52-64.
https://www.slideshare.net/vruticpatel/physiological-changes-during-pregnancy-33832831.