Pregnancy and

Physiologic Maternal
Adaptation

Dr. Tigor PS, SpOG., M. KES

OBSTETRIC AND GYNECOLOGY DEPARTMENT

MEDICAL FACULTY OF UKI
JAKARTA
 Learning Objective

1.The students know the sign and

symptoms of pregnancy, and able to make
diagnostic.

2.The students understand and can explain

about physiologic changes or maternal
adaptation to pregnancy.
 1. Pregnancy
Diagnosis of Pregnancy:

I. Presumptive Evidence Of Pregnancy:

A. Subjective Symptoms:
B. Presumptive sign

II. Probable Evidence Of Pregnancy

III. Positive Sign Of Pregnancy

 1. Pregnancy
Diagnosis of Pregnancy:

I. Presumptive Evidence Of Pregnancy:

A. Subjective Symptoms:
1. Nausea with or without vomiting
2. Disturbances in urination
3. Fatigue
4. the perception of fetal movement
 1. Pregnancy
Diagnosis of Pregnancy:

I. Presumptive Evidence Of Pregnancy:

B. Presumptive sign :
1. Cessation of menses
2. Changes in the breasts
3. Discoloration of the vaginal mucosa
4. Increased skin pigmentation and
development of abdominal strie
 1. Pregnancy
Diagnosis of Pregnancy:

II. Probable Evidence Of Pregnancy:

1. Enlargement of the abdoment
2. Changes in the shape, size, and
consistency of the uterus
3. Anatomical changes in the serviks
4. Braxton Hicks contraction
5. Ballotement
6. Physical outlining of the fetus
7. Chorionic gonadotropin in urine or serum
 1. Pregnancy
Diagnosis of Pregnancy:

III. Positive Sign Of Pregnancy:

1. Identification of fetal heart action

2. Perception of active fetal movements

3. Recognition of the embryo and fetus any time

 2. PHYSIOLOGIC
MATERNAL ADAPTATION OF
PREGNANCY
Physiologic changes/ Maternal adaptation to
pregnancy, such as:
1. Genital Tract
2. Skin
3. Breats
4. Metabolic changes
5. Hematologic changes
6. Cardivascular system
7. Respiratoric Tract
8. Urinary system
9. Gastro intestinal Tract
10. Endocrin system
11. 11 Musculo sceletal system
 INTRODUCTION
 THE ANATOMICAL, PHYSIOLOGICAL, AND BIOCHEMICAL
ADAPTATIONS OF PREGNANCY ARE PROFOUND

 CHANGES  BEGIN SOON AFTER FERTILIZATION AND

CONTINUE THROUGHOUT GESTATION

 MOST OF THESE REMARKABLE ADAPTATION  RESPONSE

TO PHYSIOLOGICAL STIMULI PROVIDE BY THE FETUS

 RETURNED ALMOST COMPLETELY TO HER PRE-

PREGNANCY STATE AFTER DELIVERY AND LACTATION

 PHYSIOLOGICAL ADAPTATIONS  MISINTERPRETED AS

DISEASE.
 1. GENITAL TRACT
 UTERUS

 CERVIX

 OVARIES

 VAGINA AND
PERINEUM
 UTERUS CHANGES
 TRANSFORMED INTO A RELATIVELY
THIN-WALLED MUSCULAR ORGAN
 ACCOMMODATE THE FETUS,
PLACENTA, AND AMNIOTIC FLUID

 THE END OF 12TH WEEK  TOO

LARGE TO REMAIN TOTALLY
WITHIN THE PELVIS

 DEXTROROTATION

 TOTAL VOLUME OF THE CONTENT

AT TERM AVERAGE ABOUT 5-20 L
 UTERUS CHANGES (2)
 FROM 1ST TRIMESTER ONWARD
 UNDERGOES IRREGULAR
CONTRACTIONS  PAINLESS 
BRAXTON HICKS
CONTRACTIONS

 LAST WEEK OR TWO OF

GESTATION  CONTRACTION
MAY DEVELOP AS OFTEN AS 10-
20 MINUTES, RHYMICITY,
DISCOMFORT  FALSE LABOR

 BLOOD FLOW  450-650

ML/MIN IN LATE PREGNANCY
UTERUS CHANGES
 CERVIX
 SOFTENING AND CYANOSIS OF
THE CERVIX

 CERVICAL GLANDS UNDERGO

MARKED PROLIFERATION

 SOON AFTER CONCEPTION  A

CLOT OF VERY THICK MUCUS
OBSTRUCT IN THE CERVICAL
CANAL

 AT THE ONSET OF LABOR 

MUCUS PLUG IS EXPELLED 
BLOODY SHOW
 OVARIES
 ORDINALY ONLY ONE
SINGLE CORPUS LUTEUM
OF PREGNANCY CAN BE
FOUND IN THE OVARIES
OF PREGNANT WOMAN

 FUNCTION MAXIMALLY 
DURING FIRST 6-7
WEEKS OF PREGNANCY
(4-5 WEEKS
POSTOVULATIONS)
 VAGINA AND PERINEUM

 INCREASED VASCULARITY
HYPREMIA DEVELOP IN THE
SKIN AND MUSCLES OF THE
PERINEUM AND VULVA

 SOFTENING OF THE
NORMALLY ABUNDANT
CONECTIVE TISSUE

 THE COPIOUS SECRETIONS

AND THE CHARACTERISTIC
VIOLET COLOR OF THE
VAGINA (CHADWICK SIGN)
RESULT FROM HYPREMIA
 2. SKIN
 LATER MONTHS OF
PREGNANCY  REDDISH,
SLIGHTLY DEPRESSED
STREAKS  STRIA
GRAVIDARUM

 LINEA NIGRA / LINEA

ALBA
 2. SKIN

 CHLOASMA OR MELASMA
GRAVIDARUM (MASK OF
PREGNANCY)

 ACCENTUATION OF PIGMENT
OF THE AREOLAE AND
GENITAL SKIN

 ANGIOMAS  VASCULAR
SPIDER

 PALMAR ERYTHEMA
 3. BREASTS

 EARLY WEEKS OF
PREGNANCY: TENDERNES

 AFTER THE 2ND MONTH :

INCREASE IN SIZE AND
DELICATE VEINS BECOME
VISIBLE

 AFTER THE FIRST FEW

MONTHS  COLUSTRUM
 4. METABOLIC CHANGES

 WEIGHT GAIN

 WATER METABOLISM

 CARBOHYDRAT METABOLISM

 ACID-BASE EQUILIBRIUM
 WEIGHT GAIN
 ATRIBUTE TO THE UTERUS AND ITS
CONTENTS, THE BREAST, AND INCREASE
IN BLOOD VOLUME AND EXTRAVASCULAR
EXTRACELLULAR FLUID

 MATERNAL RESERVES

 AVERAGE WEIGHT GAIN DURING

PREGNANCY IS 12,5 KG (ABOUT 25-30
POUNDS)
 WATER METABOLISM
 INCREASED WATER RETENTION

 AT TERM  THE WATER CONTENT OF THE FETUS,

PLACENTA, AND AMNIOTIC FLUID  3,5 L

 ANOTHER 3,0 L  INCREASE IN THE MATERNAL

BLOOD VOLUME, UTERUS, AND THE BREASTS

 MINIMUM AMOUNT OF EXTRA WATER THAT THE

AVERAGE WOMAN RETAINS DURING PREGNANCY
 6,5 L

 PITTING EDEMA OF THE ANKLES AND LEGS

 CARBOHYDRATE METABOLISM
 MILD FASTING HYPOGLICEMIA

 AFTER AN ORAL GLUCOSE MEAL 

PROLONGED HYPER GLICEMIA AND ,
WITH GREATER SUPRESSION OF
GLUCAGON

 THE PURPOSE OF SUCH MECHANISM  A

SUSTAINED OR MAINTAINED POST
PRANDIAL SUPPLY OF GLUCOSE TO FETUS
FIG. 1
 ACID-BASE EQUILIBRIUM

 MINUTE VENTILATION INCREASE 

RESPIRATORY ALKALOSIS BY LOWERING
THE PCO2 OF THE BLOOD

 MODERATE REDUCTION IN PLASMA

BICARBONATE FROM 26 TO ABOUT 22
MMOL/L PARTIALLY COMPENSATES FOR
THIS

 AS RESULT  MINIMAL INCREASE IN

BLOOD PH
 5. HEMATOLOGICAL CHANGES

 BLOOD VOLUME

 HEMOGLOBIN CONCENTRATION AND

HEMATOCRIT

 LEUKOCYTE COUNT

 COAGULATION
 BLOOD VOLUME
 IN NORMAL WOMAN  AT OR VERY NEAR TERM
AVERAGE 50% ABOVE THEIR NON PREGNANT
LEVEL

 STARTS TO INCREASE DURING 1ST TRIM. (SEE

FIG.2)

 EXPAND MOST RAPIDLY DURING 2ND TRIM.

 RISES AT MUCH SLOWER RATE DURING 3RD

TRIMESTER TO PLATEAU DURING THE LAST
SEVERAL WEEKS OF PREGNANCY
 BLOOD VOLUME (2)
 THIS PREGNANCY INDUCED HYPERVOLEMIA HAS
SEVERAL IMPORTANT FUNCTION :

– TO MEET THE DEMANDS OF THE ENLARGED

UTERUS WITH ITS GREATLY HYPERTROPIED
VACSULAR SYSTEM

– TO PROTECT THE MOTHER, AND IN TURN THE

FETUS, AGAINST THE DELETERIOUS EFFECT OF
IMPAIRED VENOUS RETURN IN THE SUPPINE AND
ERRECT POSSITIONS

– TO SAFEGUARD THE MOTHER AGAINST THE

ADVERSE EFFECT OF BLOOD LOSS ASSOCIATED
WITH DELIVERY
FIG. 2
 HEMOGLOBIN CONCENTRATION
AND HEMATOCRIT

 IN SPITE OF AUGMENTED
ERYTHROPOIESIS :
HEMOGLOBIN CONCENTRATION AN
HEMATOCRIT DECREASE SLIGHTLY
 LEUKOCYT COUNT
 VARIES CONSIDERABLY

 RANGES FROM 5000-12.000/µL

 DURING LABOR AND THE EARLY

PUERPERIUM  MAY BECOME MARKEDLY
ELEVATED, ATTAINING LEVELS OF 25.000
OR EVEN MORE  AVERAGES 14.000 –
16.000 /µL
 COAGULATION

 INCREASED CONCENTRATIONS OF ALL

CLOTTING FACTORS, EXCEPT FACTORS
XI AND XIII

 PHYSIOLOGICAL INCREASE IN PLASMA

VOLUME  INCREASED CONSENTRATION
REPRESENT A MARKED INCREASED IN
PRODUCTION OF THESE PROCOAGULATS
 COAGULATION (2)

 FIBRINOGEN CONCENTRATION INCREASE

ABOUT 50% TO AVERAGE ABOUT 450
MG/DL, WITH RANGE FROM 300-600

 THE INCREASE IN THE CONCENTRATION

OF FIBRINOGEN UNDOUBTEDLY
CONTRIBUTES GREATLY TO THE
STREAKING INCRREASE IN THE
ERYTHROCYTE SEDIMENTATION RATE
 6. CARDIOVASCULAR SYSTEM

 HEART

 CARDIAC OUTPUT
 HEART
 THE APEX OF THE HEART IS MOVED
SOMEWHAT LATERALLY

 INCREASE IN THE SIZE OF THE CARDIAC

SILHOUETTE SEEN IN RADIOGRAPHS

 SOME DEGREE OF BENIGN PERICARDIAL

EFUSSION  MAY INCREASE THE CARDIAC
SILHOUETTE

 THE RESTING PULSE RATE INCREASE ABOUT

10 BEATS/MIN
 HEART (2)
 SOME OF THE CARDIAC SOUNDS MAY BE
ALTERED

 INDUCES NO CHARACTERISTIC
CAHANGES IN ELECTROCARDIOGRAM,
(ECG) OTHER THAN SLIGHT DEVIATION
OF THE ELECTRICAL AXIS TO THE LEFT
 AS A RESULT OF THE ALTERED
POSITION OF THE HEART
 CARDIAC OUTPUT
 ARTERIAL BLOOD PRESSURE AND
VASCULAR RESISTANCE DECREASE
WHILE BLOOD VOLUME, MATERNAL
WEIGHT, AND BASAL METABOLIC RATE
INCREASE

 CARDIAC OUTPUT AT REST, INCREASE

SIGNIFICANTLY BEGINNING IN EARLY
PREGNANCY
 CARDIAC OUTPUT (2)
 CONTINUES TO INCREASE AND REMAINS
ELEVATED DURING THE REMAINDER OF
PREGNANCY

 MAXIMAL  IMMEDIATELY AFTER DELIVERY

 IN LATE PREGNANCY  APPRECIABLY

HIGHER WHEN THE WOMAN IS IN THE
LATERAL RECUMBENT POSITION THAN
WHEN SHE IS SUPINE
 7. RESPIRATORY TRACT
 AN INCREASED AWARENESS OF A DESIRE TO
BREATHE  PHYSIOLOGICAL DYSPNEA 
INCREASE TIDAL VOLUME THAT LOWERS THE
BLOOD PCO2 SLIGHTLY

 RESPIRATORY RATE  LITTLE CHANGED

 TIDAL VOLUME, MINUTE VENTILATORY

VOLUME, AND MINUTE OXYGEN UPTAKE
INCREASE APPRECIABLY AS PREGNANCY
ADVANCE (TABLE 1)
TABLE 1
 8. URINARY SYSTEM
 PLASMA CONCENTRATIONS OF CREATININE AND
UREA NORMALLY DECREASE  CONSEQUENCE
OF THEIR INCREASE GLOMERULAR FILTRATION

 GLUCOSURIA  NOT NECESSARILLY ABNORMAL

 PROTEINURIA  NORMALLY NOT EVIDENT

DURING PREGNANCY, EXCEPT OCCASIONALLY IN
SLIGHT AMOUNTS DURING OR SOON AFTER
VIGOROUS LABOR
 URINARY SYSTEM (2)

 HEMATURIA  IF NOT THE RESULT OF

CONTAMINATION DURING COLLECTION,
IT COMPATIBLE WITH A DIAGNOSIS OF
URINARY TRACT DISEASE

 CREATININE CLEREANCE  USEFUL TEST

TO ESTIMATE RENAL FUNCTION IN
PREGNANCY
TABLE 2
 NORMAL HYDRONEPHORIS AND
HYDROURETER

 AFTER THE UTERUS RISES COMPLETELY

OUT OF THE PELVIS  REST UPON THE
URETER, COMPRESSING THEM AT THE
PELVIC BRIM

 URETERAL DILATATION GREATER ON

THE RIGHT SIDE  85%

 FREQUENTLY LATERAL DISPALCEMENT

 BLADDER
 OBJECTIVE MEASURE OF URINARY
FREQUENCY AND TOTAL DAILY URINARY
OUTPUT  INCREASE

 URINARY INCONTINENCE

 LOSS OF URINE  HIGH IN DIFFERENTIAL

DIGNOSIS OF THE WOMAN PRESENTING
WITH A QUESTION OF RUPTURED
MEMBRANES
 9. GASTROINTESTINAL TRACT
 THE STOMACH AND INTESTINES  DISPLACED BY
THE ENLARGING UTERUS

 GASTRIC EMPTYING AND INTESTINAL TRANSIT

TIMES  DELAYED  HORMONAL OR
MECHANICAL FACTORS

 PYROSIS (HEARTBURN)  REFLUX OF ACIDIC

SECRETIONS INTO THE LOWER ESOPHAGUS

 HEMORROIDS  CONSTIPATION AND THE

ELEVATED PRESSURE IN VEINS BELLOW THE
LEVEL OF THE ENLARGED UTERUS
 10. ENCOCRINE SYSTEM

 PITUITARY GLAND

 THYROID GLAND

 FETAL THYROID GLAND

 PARATHYROID GLAND
 PITUITARY GLAND

 ENLARGED BY APPROXIMATELY 135%

 INCIDENCE OF PITUITARY PROLACTINOMAS  NOT

INCREASED

 PRINCIPAL FUNCTION OF MATERNAL SERUM

PROLACTIN  TO ENSURE LACTATION

 PROLACTIN LEVELS  INCREASED 10 FOLD AT TERM

 EARLY LACTATION  PULSATILE BURST OF

PROLACTIN SECRETION APPARENTLY IN RESPONSE
TO SUCKLING
 THYROID GLAND
 MODERATE ENLARGEMENT OF THE
THYROID  HYPERPLASIA OF
GLANDULAR TISSUE AND INCREASE
VASCULARITY

 PREGNANCY INDUCES A MARKED

INCREASE IN CIRCULATING LEVELS OF
THE MAJOR THYROXINE TRANSPORT
PROTEIN, THYROXINE-BINDING
GLOBULIN (TBG)  IN RESPONSE TO
HIGH ESTEROGEN LEVELS
 THYROID GLAND (2)

 HIGH SERUM CHORIONIC GONADOTROPIN

LEVELS ARE ASSOCIATED WITH THYROID
STIMULATION  CONSISTENT WITH A
THYROTROPIN-LIKE EFFECT OF
CHORIONIC GONADOTROPIN
 FETAL THYROID GLAND
 AS THE FETAL THYROID BECOMES
AUTONOMOUS AT ABOUT 10 WEEKS, THERE IS
GRADUAL “MATURATION” THAT PROGRESS TO
TERM

 AT LEAST DURING THE 1ST TRIM.  THE FETUS

IS DEPENDENT ON MATERNAL THYROXINE

 LATER  MINIMAL TRANSFER OF THYROID

HORMONS FROM THE MATERNAL INTO THE
FETAL COMPARTEMENT
FIG. 3
 PARATHYROID GLAND
 ACUTE OR CHRONIC DECREASE IN PLASMA
CALCIUM OR MAGNESIUM  STIMULATE THE
RELEASE OF PARATHYROID HORMONE (PTH)

 INCREASE CALCIUM AND MAGNESIUM PLASMA :

SUPRESS PTH LEVELS

 PTH PLASMA CONCENTRATION:

- DECREASE DURING THE FIRST TRIM.
- INCREASE PROGRESSIVELY REAMAINDER OF
PREGNANCY
 PARATHYROID GLAND (2)

 INCREASED LEVEL  RESULT FROM THE

LOWER CALCIUM CONCENTRATION IN NORMAL
PREGNANT WOMAN

 DUE TO INCREASED PLASMA VOLUME,

INCREASED GLOMERULAR FILTRATION RATE,
AND MATERNAL-FETAL TRANSFER OF CALCIUM

 PHYSIOLOGICAL HYPERPARATIROIDISM OF
PREGNANCY
 11. MUSCULOSKELETAL SYSTEM

 PROGRESSIVE LORDOSIS  CHARACTERISTIC

FEATURE OF NORMAL PREGNANCY

 INCREASED MOBILITY OF SACROILIAC,

SACROCOCCYGEAL, AND PUBIC JOINTS 
HORMONAL CHANGES

 ALTERATION OF MATERNAL POSTURE

 DISCOMFORT IN THE LOWER PORTION OF THE

BACK
 MUSCULOSKELETAL SYSTEM (2)

 LATE PREGNANCY  ACHING,

NUMBNESS, AND WEAKNESS  IN THE
UPPER EXTREMITIES

IT POSSIBLY IS FROM THE MARKED

LORDOSIS WITH ANTERIOR NECK
FLEXION AND SLUMPING OF THE
SHOULDER GIRDLE, WICH IN TURN
PRODUCE TRACTION ON THE ULNAR AND
MEDIAN NERVES
 Daftar Pustaka:
1. William Obstetri edisi 23.

2. Obstetri Fisiologi, FK. UNPAD

Bandung.