Physiologic and

psychosocial
adaptations to
pregnancy
chari v. rivo
 s will
Learning objectives 2

so n , t h e s t ud e nt
In this les
learn:
methods of promoting
 presumptive, probable, acceptance of
and positive signs of pregnancy
pregnancy
 ways in which the ♦ psychosocial changes
major body systems that occur during each
are affected trimester.
bypregnancy
 Physiologic signs of pregnancy
3

➜Presumptive (subjective)
➜Probable (objective)
➜Positive
 4

 Neither presumptive nor probable

signs confirm pregnancy because
both can be caused by other medical
conditions; they simply suggest
pregnancy, especially when several
are present at the same time
Presumptive Signs of
Pregnancy
 6
➜Signs that can be assumed to indicate
pregnancy
- Breast changes - fatigue
- Nausea and vomiting - Uterine enlargement
- Amenorrhea - Quickening
- Frequent urination - Linea nigra
- Striae Gravidarum - Melasma
• Breast changes – darker areola, Montgomery glands elevate 7

• N/V – morning sickness that usually stops at 1st tri

• Urinary frequency – happens in 1st tri and last tri, when
lightening occurs
• Fatigue – body works hard to manufacture placenta and to
adjust to the physical demands of pregnancy
• Quickening – first fetal movement at felt between 14-26 weeks
but typically felt between 18 and 22 weeks
• Skin changes: 8

• Linea nigra – dark line from umbilicus to mons pubis that

develops at 3rd month (primi) and before 3rd month for
multigravida
• Melasma – chloasma; mask of pregnancy; darkened areas on
the face, cheeks, nose that appears after 16th week; fades
after childbirth
• Striae gravidarum – stretch marks; red or pinkish streaks
that appear on the abdomen and thighs
 9
Linea nigra and striae
gravidarum are two skin
changes that occur during
pregnancy. Both fade after
pregnancy, with striae
gravidarum fading to
glistening silvery lines.
 10
SIGN Weeks from Other possible
implantation causes
Breast changes, including 2 • Hormonal contraceptives
feelings of tenderness, • Hyperprolactinemia
fullness, or tingling, and induced by tranquilizers
enlargement or darkening of • Infection
areola • Prolactin-secreting
pituitary tumor
• Pseudocyesis
• Premenstrual syndrome
 11
SIGN Weeks from Other possible
implantation causes
Feeling of nausea or 2 • Gastric disorders
vomiting upon arising • Infections
(morning sickness) • Psychological disorders,
such as pseudocyesis
and anorexia nervosa
 12
SIGN Weeks from Other possible
implantation causes
Amenorrhea 2 •Anovulation
• Blocked endometrial cavity
• Endocrine changes
• Illness
• Medications
(phenothiazines, Depo-
Provera)
• Metabolic changes
• Stress
 13
SIGN Weeks from Other possible
implantation causes
Frequent urination 3 • Emotional stress
• Pelvic tumor
• Renal disease
• Urinary tract infection

Fatigue 12 • Anemia
• Chronic illness
• Depression
• Stress
 14
SIGN Weeks from Other possible
implantation causes
Uterine enlargement in 12 • Ascites
which the uterus • Obesity
can be palpated over the • Uterine or pelvic tumor
symphysis pubis

Quickening (fetal movement 18 • Excessive flatus

felt • Increased peristalsis
by the woman)
 15
SIGN Weeks from Other possible
implantation causes
Linea nigra (line of dark 24 • Cardiopulmonary disorders
pigment • Estrogen-progestin
on the abdomen) hormonal contraceptives
• Obesity
• Pelvic tumor
Melasma (dark pigment on 24
the face)

Striae Gravidarum (red 24

streaks on the abdomen)
Probable Signs of
Pregnancy
 17
➜Signs that strongly suggest pregnancy, more
reliable than presumptive
- Laboratory tests - Sonographic evidence
- Home pregnancy tests - ballotement
- Chadwick sign - Braxton Hicks
- Goodell sign contractions
- Hegar sign
 18
• Laboratory test – hCG detection (blood or urine); hCG appear
in the serum as early as 24 to 48 hours after implantation; hCG
declines after 80th day of gestation
• Home pregnancy tests – 97% accurate
• Chadwick Sign - bluish coloration of the mucous membranes of
the cervix, vagina, and vulva. It can be observed at 6 to 8 weeks’
gestation by bimanual examination.
 19
• Goodell Sign– softening of the cervix that occurs at 6 to 8
weeks’ gestation. The cervix of a nonpregnant woman typically
has the same consistency as the tip of the nose; the cervix of a
pregnant woman feels more like an earlobe.
• Hegar sign– softening of the uterine isthmus that can be felt on
bimanual examination at 6 to 8 weeks’ gestation. As pregnancy
advances, the isthmus becomes part of the lower uterine
segment. During labor, it expands further.
• Ultrasonography– a characteristic ring indicating the 20
gestational sac is visible on sonographic evaluation
• ballotement – passive movement of the fetus. It can be identified
at 16 to 18 weeks’ gestation.
• Braxton Hicks Contraction - uterine contractions that begin
early in pregnancy and become more frequent after 28 weeks’
gestation. Typically, they result from normal uterine
enlargement that occurs to accommodate the growing fetus.
Sometimes, however, they may be caused by a uterine tumor.
 SIGN Weeks from Other possible 21

implantation causes
Serum laboratory tests 1 • Cross-reaction of
revealing the pres- luteinizing hormone
ence of human chorionic (similar to hCG)
gonadotropin • Hydatidiform mole
(hCG) hormone
Chadwick sign (vagina 6 • Hyperemia of cervix,
changes color from vagina, or vulva
pink to violet)
Goodell sign (cervix softens) 6 • Estrogen-progestin
6 hormonal contraceptives
 SIGN Weeks from Other possible 22

implantation causes
Hegar sign (lower uterine 6 • Excessively soft uterine
segment softens) walls
Sonographic evidence of gestational 6 none
sac
in which characteristic ring is evident
Ballottement (fetus can be felt to rise 16 • Ascites
against abdominal wall when lower • Uterine tumor or polyps
uterine segment is tapped on during
bimanual
examination)
 SIGN Weeks from Other possible 23

implantation causes
Braxton Hicks contractions 20 GI distress
(periodic uterine tightening) • Hematometra
• Uterine tumor
Palpation of fetal outline through 20 • Subserous uterine
abdomen myoma
Positive Signs of
Pregnancy
➜Signs that confirm pregnancy because they 25

can’t be attributed to other conditions

- Fetal outline by UTZ

- Audible FHT
- Fetal movement felt by the examiner
 26
• Ultrasonography – fetal outline visible at 8th week; fetal heart
movement maybe visualized as early as 7 weeks gestation
• Fetal Heart Rate - Fetal heart sounds may be heard as early
as the 10th to 12th week by Doppler ultrasonography.
• Fetal movement – felt around 16-20 weeks, other at 20 -24
weeks
 27
SIGN Weeks from Other possible
implantation causes
Sonographic evidence of 8 None
fetal outline

Fetal heart audible by 10-12

Doppler ultrasound

Palpation of fetal movement 20

through
abdomen
 28

Physiologic changes
in the body system
 29
• Reproductive system
• Enlarged labia majora and minora, clitoris,
vaginal introitus due to increased vascularity
• Pressure on vessels in the perineal area can cause
varices.
 30
• Ovaries
• Ovarian follicles cease to mature
• Ovulation stops
• Chorionic villi begin to produce hCG to maintain
corpus luteum, which produces estrogen and
progesterone until placenta is functional (8-10
weeks)
 31
• Uterus
• Nulliparous: 60-70 g; Parous: 100 g
• 1st Tri – lengthens and enlarges due to elevated
Estrogen and Progesterone
• Hypertrophy and hyperplasia of myometrial
cells
• At 12 weeks, uterus reaches the level of
symphysis pubis
• Uterus 32

• 2nd Tri – corpus and fundus become globe-shaped

• At 20-22 weeks, uterus is at the umbilicus, at this
stage, Braxton hicks contraction may occur as a
response to uterine muscle stretch and to help move
blood quickly through the intervillous spaces of the
placenta
• Uterus 33

• 3rd Tri – fundus is at xiphoid process

• At 38-40 weeks, fetus descends (lightening) causing
decrease in fundal height
 34
This illustration shows
approximate fundal heights at
various times during
pregnancy. The times
indicated are in weeks. Note
that between weeks 38 and
40, the fetus begins to
descend into the pelvis.
• Uterus 35

• Endometrial development:
• Decidua capsularis – covers the blastocyst
• Decidua basalis – lies directly under the blastocyst
and forms part of the placenta
• Decidua vera – lines the rest of the uterus
• Uterus 36

• Vascular growth
• Blood vessels and lymphatics increase in number
and size
• By the end of pregnancy, an average of 500 ml of
blood may flow through the maternal side of the
placenta each minute
 37

Because one-sixth of the body’s blood

supply is circulating through the uterus at
any given time, uterine bleeding during
pregnancy is always potentially serious and
can result in major blood loss.
• Uterus 38

• Cervical Changes
• the cervix consists of connective tissue, elastic fibers,
and endocervical folds
• Cervix softens during pregnancy
• Becomes edematous or may bleed easily on
examination or sexual activity
• Uterus 39

• Cervical Changes
• hormonal stimulation causes the glandular cervical
tissue to increase in cell number and become
hyperactive, secreting thick, tenacious mucus whch
thickens into a mucoid weblike structure, eventually
forming a mucus plug that blocks the cervical canal
and protects against bacteria and other substances
• Vagina 40

• Estrogen stimulates vascularity, tissue growth and

hypertrophy in the vaginal epithelial tissue
• White, thick, odorless, and acidic vaginal secretions
increase. The acidity of these secretions helps
prevent bacterial infections but, unfortunately, also
fosters yeast infections, a common occurrence
during pregnancy.
• Vagina 41

• development of a bluish color due to increased

vascularity
• hypertrophy of the smooth muscles and relaxation of
connective tissues, which allow the vagina to stretch
during childbirth
• lengthening of the vaginal vault
• possible heightened sexual sensitivity.
• Breast 42

• In addition to the presumptive signs that occur in the

breasts during pregnancy (such as tenderness, tingling,
darkening of the areola, and appearance of Montgomery
tubercles), the nipples enlarge, become more erectile, and
darken in color.
• Secondary areola - patches of brownish discoloration
appear on the skin adjacent to the areola that indicate
pregnancy if the patient has never breast-fed an infant
• Breast 43

• Mammogenesis - breasts increase in size and weight and

there is a proliferation of ductular sprouting, branching and
lobular formation, which forms the glandular system under
the influence of human placental lactogen (hPL), estrogen
and progesterone
• Secretion of colostrum – a yellowish, viscous fluid, high in
protein, antibodies, and minerals, but low in fat and sugar
• Breast 44

• colostrum may be secreted as early as week 16 of pregnancy,

but it’s most common during the last trimester. It continues
secreting until 2 to 4 days after delivery and is followed by
lactogenesis stage 2, triggered by the rapid drop in mother’s
progesterone levels causing the onset of copious secretion of
the milk.
• Breast changes are more pronounced in a primigravida
patient than in a multigravida patient
 45
Dramatic
changes appear
in the breasts of
a pregnant
patient because
of increased
estrogen and
progestin
production.
• Endocrine System 46

• Placenta - a finite, endocrine organ that produces large

amounts of estrogen, progesterone, hCG, hPL, relaxin, and
prostaglandins
• Estrogen – causes breast and uterine enlargement,
palmar erythema (redness in the palm)
• Progesterone – maintains endometrium by inhibiting
contractions; prepares breast for lactation
• Endocrine System 47

• Placenta
• Relaxin – secreted primarily by the corpus luteum;
inhibits uterine activity; soften the cervix, softens
collagen in body joints
• Human chorionic gonadotropin (hCG) – secreted by the
trophoblast cells of the placenta; stimulates progesterone
and estrogen synthesis until placenta assumes role
• Endocrine System 48

• Placenta
• Human chorionic somatomammotropin or hPL –
promotes fat breakdown (lipolysis) providing alternate
source of energy so that glucose is available for fetal
growth
• hPL, along with estrogen, progesterone, and cortisol,
inhibits the action of insulin, resulting in an increased
insulin need throughout pregnancy.
• Endocrine System 49

• Placenta
• Prostaglandins - ound in high concentration in the
female reproductive tract and the decidua during
pregnancy; They affect smooth muscle contractility to
such an extent that they may trigger labor at the
pregnancy’s term.
• Endocrine System 50

• Pituitary Gland
• High estrogen and progesterone levels in the placenta
stop the pituitary gland from producing FSH and LH
• Increased production of growth hormone and
melanocyte-stimulating hormone causes skin pigment
changes.
• Endocrine System 51

• Pituitary Gland
• Late in pregnancy, Posterior PG begins to produce
oxytocin, which stimulates uterine contractions during
labor
• Prolactin production also starts late in pregnancy as the
breasts prepare for lactation after birth
• Endocrine System 52
• Thyroid Gland
• 2nd Month – increased thyroxine-binding protein, causing total
thyroxine (T4) levels to rise
• Unbound t4 doesn’t increase – no hyperthyroidism
• Presence of increased BMR, cardiac output, PR, vasodilation, and
heat intolerance due to thyroid changes
• 20% increase in BMR in 2nd and 3rd tri
• 25% increase in BMR by term
• Changes return to prepregnant level within 1 week after childbirth
• Endocrine System 53

• Thyroid Gland
• Increased estrogen levels augment circulating amounts
of triiodothyronine (T3)
• Increased T3 levels doesn’t lead to hyperthyroidism
because much of these hormone is bound to proteins and
therefore unfunctional
• Endocrine System 54

• Parathyroid Gland
• Increased hormone production during third trimester to as
much as twice the pre-pregnancy level
• Parathyroid hormone increases calcium absorption from
food, calcium conservation by kidneys, release of calcium
from bones and Stimulates cells in the kidney to transforms
weaker forms of vitamin D into the form that is strongest at
absorbing calcium from the intestines
• Endocrine System 55

• Adrenal Gland
• Increased production of corticosteroids and aldosterone
• Increased corticosteroid levels suppress inflammatory
reactions and help reduce rejection of the foreign protein
of the fetus
• Corticosteroids also help regulate glucose metabolism in
the woman
• Endocrine System 56

• Adrenal Gland
• Increased aldosterone promote sodium reabsorption and
maintain osmolarity of retained fluid which indirectly
helps safeguard the blood volume and provide adequate
perfusion across placenta
• Endocrine System 57

• Adrenal Gland
• Increased aldosterone promote sodium reabsorption and
maintain osmolarity of retained fluid which indirectly
helps safeguard the blood volume and provide adequate
perfusion across placenta
• Endocrine System 58

• Pancreas
• In response to increased glucocorticoids produced by the
adrenal glands, insulin production increases
• Insulin is less effective than normal because estrogen,
progesterone, and hPL all act as antagonists to it
• Despite insulin’s diminished action and increased fetal
demands for glucose, maternal glucose levels remain fairly
stable because the mother’s fat stores are used for energy.
• Respiratory System 59

• Anatomic Changes (biochemical changes)

• Diaphragm rises by approx. 4cm, which prevents the lungs
from expanding during inspiration, diaphragm compensates
by increasing excursion (outward expansion) ability