Physiological Changes

During Pregnancy
introduction

• During pregnancy, a woman’s body changes in many

ways due to the effect of hormones. These changes can
sometimes be uncomfortable, but most of the time they are
normal and enable her to nourish and protect the fetus,
prepare her body for labour, and develop her breasts for
the production of milk.
• In this study session, you will learn about some of the changes that occur
during pregnancy in the uterus, cervix and vagina,

the cardiovascular system, gastrointestinal system, and urinary system, and

about changes in the breasts and skin. You will also learn about the implications
of all these changes for you as a health worker managing the health of pregnant
women. By understanding the normal changes of pregnancy, you can reassure
the woman if she is concerned, and also detect and intervene more quickly if you
notice any abnormalities. A basic knowledge of these changes and adaptations is
also critical for understanding the results of laboratory tests that may be
conducted at a health facility during the pregnancy.
When you have studied this session, you should be able to

• Describe physiological changes in the female reproduc tive system during pregnanc y and the
consequences of these changes for the pregnant woman.

• Describe the average changes in the pregnant woman ’s body weight.

• Discuss changes in the cardiovascular system during pregnanc y, and the effects on blood
pressure, cardiac output, blood volume and red blood cell concentration.

• Recognise normal and abnormal changes in the pregnant woman ’s respiration, digestion,
urinary system, skin and breasts, including the production of colostrum.
Changes in oestrogen and progesterone

• In Study Sessions you learned about the main female reproduc tive hormones , oestrogen and
progesterone, and their functions in preparing the uterus for pregnanc y. Oestrogen and
progesterone are also the chief hormones throughout pregnanc y.

• A woman will produce more oestrogen during one pregnanc y than throughout her entire life
when not pregnant. During pregnanc y, oestrogen promotes maternal blood flow within the uterus
and the placenta.
How does oestrogen play an important role in the
development of the fetus?

• By promoting maternal blood flow to the uterus and placenta it ensures that the fetus is
supplied with nutrients and oxygen for its development, and that waste products from the fetus
are removed in the mother ’s blood.

• A pregnant woman ’s progesterone levels are also very high. Among other effects, high levels
of progesterone cause some internal structures to increase in size, including the uterus,
enabling i t to accommodate a full -term baby. It has other effec ts on the blood v essels and joints ,
which we will discuss later in this study session.
Changes in the uterus, cervix and vagina
• The uterus

• After conception, the uterus provides a nutritive and protectiv e environment in which the fetus
will grow and develop. It increases from the size of a small pear in its non -pregnant state to
accommodate a full -term baby at 40 weeks of gestation. The tissues from which the uterus is
made continue to grow for the first 20 weeks, and it increases in weight from about 50 to 1,000
gm (grams ). After this time, it doesn ’t get any heavier, but it stretches to accommodate the
growing baby, placenta and amniotic fluid. By the time the pregnanc y has reached full term, the
uterus will have increased to about five times its normal size:

• In height (top to bottom) from 7.5 to 30 cm

• In width (side to side) from 5 to 23 cm

• In depth (front to back) from 2.5 to 20 cm.

• What causes these changes?
• The hormone progesterone is primaril y responsible.

• At 12 weeks ’ gestation (near the end of the first trimester, i.e. three -month period), the fundus
(upper margin of the body of the uterus) may be palpated (felt) through the abdomen above the
pubic bone (symphysis pubis). The size of the uterus usually reaches its peak at about 36
weeks’ gestation (see Figure 7.1).
Figure 7.1 Height of the uterus at various weeks of
pregnancy.
• After how many weeks of pregnanc y can the fundus be palpated at the height of the woman ’s
umbilicus (belly-button), according to Figure 7.1
• After how many weeks of pregnanc y can the fundus be palpated at the height of the woman ’s
umbilicus (belly-button), according to Figure 7.1
At about 20 weeks.
• The uterus may drop slightly as the fetal head settles into
the pelvis, preparing for delivery. Notice the position at 40
weeks of gestation, which is shown as a dotted line in
Figure 7.1. This dropping is referred to as ‘lightening’. It
is more noticeable in a primigravida (pregnant for the first
time) than in a multigravida (a woman who has been
pregnant previously, regardless of outcome).
• The cervix

• The cervix remains 2.5 cm long throughout pregnanc y. In late pregnanc y, softening of the cervix
occurs in response to increasing painless contractions of its muscular walls.

• The vagina

• The vagina also becomes more elastic towards the end of pregnanc y. These changes enable it
to dilate during the second stage of labour, as the baby passes down the birth canal. (You will
learn all about this in the Labour and Delivery Care.)
Pregnancy-related changes in posture and joints
• A pregnant woman’s entire posture changes as the baby gets
bigger. Her abdomen transforms from flat or concave (dished) to
very convex (bulging outwards), increasing the curvature of her
back. The weight of the fetus, the enlarged uterus, the placenta and
the amniotic fluid (the bag of waters surrounding the baby),
together with the increasing curvature of her back, puts a large
strain on the woman’s bones and muscles. As a result, many
pregnant women get back pain. Too much standing in one place or
leaning forward can cause back pain, and so can hard physical
work. Most kinds of back pain are normal in pregnancy, but it can
also be a warning sign of a kidney infection.
• In addition, progesterone causes a loosening of
ligaments and joints throughout the body. Pregnant
women may be at greater risk of sprains and strains
because the ligaments are looser, and because their
posture has changed.
 Changes in body weight during pregnancy

Continuing weight increase in pregnancy is considered to be one favourable indication of maternal adaptation
and fetal growth. However, routine weighing of the mother during pregnancy is not now thought to be necessary,
because it does not correlate well with pregnancy outcomes. For example, there can be a slight loss of weight
during early pregnancy if the woman experiences much nausea and vomiting (often called ‘morning
sickness’). You will learn more about this and other minor disorders of pregnancy in Study Session , later The
expected increase in weight of a healthy woman in an average pregnancy, where there is a single baby, is as
follows
ct...
• About 2.0 kg in total in the first 20 weeks

• Then approximatel y 0.5 kg per week until full term at 40 weeks

• A total of 9 -12 kg during the pregnanc y.

• A woman who is pregnant with more than one baby will have a higher weight gain than a woman
with only one fetus. She will also require a higher calorie diet.

• A lack of significant weight gain may not be a cause for concern in some women, but it could be
an indication that the fetus is not growing properl y. Doctors and midwives may refer to this as
intrauterine growth restriction (IUGR) of the fetus.
Changes in the cardiovascular system

The cardiovascular system consists of the heart, the blood vessels (veins and arteries ) , and the
blood that circulates around the body. It is the transport system that supplies oxygen and

nutritive substances absorbed from the gastrointes tinal tract to all the cells, tissues and organs of
the body, enabling them to generate the energy they need to perform their functions. It also

returns carbon dioxide, the waste product of respiration, to the lungs, where it is breathed out.
The chemical processes that go on in the body generate many waste products , which the blood

transports to the kidneys and liver, where they are removed. Other functions of the cardiovascular
system include the regulation of body temperature, and the circulation and delivery of hormones
and other agents that regulate body functions. There are several significant changes in this
complex system during pregnanc y.
The heart

• The heart may increase in size during pregnanc y due to an increase in its workload.

Why do you think the workload of the heart has to increase?

• Because it has to pump blood through the placenta, fetus and the much larger uterus and
abdomen of the pregnant woman.
Changes in cardiac output during pregnancy

• Woman’s condition Cardiac output (litres per minute)

• non-pregnant, resting 2.5

• end of 1st trimester 5

• end of 2nd trimester 6

• full-term 7
• The increase in cardiac output is caused by two changes in how the heart functions:

• Increase in the resting heart rate, i.e. the number of heart beats per minute. The heart rate is
about 15 beats per minute higher in the pregnant woman.

• Increase in the stroke volume, i.e. the volume of blood pumped out of the heart in a single heart
beat. It is about 7 millilitres (ml) larger per heart beat in the pregnant woman.

• Cardiac output is calculated by multiplying heart rate and stroke volume.

• During the second trimester of pregnanc y, the mother ’s heart at rest is working 40% harder
than in her non -pregnant state. Most of this increase results from a more efficiently performing
heart, which ejects more blood at each beat.
• Blood volume

• Blood volume (the total volume of blood in the circulation, measured in litres) increases
gradually by 30 -50 % in the pregnant woman, so by full term she has about 1.5 litres more
blood than before the pregnanc y. A higher circulating blood volume is required to provide extra
blood flow through the placenta, so nutrients and oxygen can be delivered to the fetus. The
increase in blood volume is caused by two changes:

• Increase in the volume of blood plasma (the fluid part of the blood).

• Increase in the number of red blood cells in the circulation.

• The volume of blood plasma increases after about the sixth week of pregnanc y. It reaches its
maximum level of approximatel y 50% above non -pregnant values by the second trimester, and
maintains this until full term.
Iron, haemoglobin and anaemia

• Iron is present in all cells and has several important functions, including oxygen transport and
storage in the human body. It is the critical component of the oxygen -carr ying substance
haemoglobin, found in all red blood cells. It is the iron in haemoglobin that makes these cells
appear red. If the diet is too low in iron, the person cannot make enough red blood cells. Iron is
also involved in the storage and release of oxygen in the muscles.

• Anaemia is most accuratel y defined as a low concentration of haemoglobin in the blood, but it is
often referred to as a low concentration of red blood cells. Too little iron in the diet is the
leading cause of anaemia.
ct..
• The measurement of haemoglobin is expressed using its chemical symbol (Hb), and its weight
in grams (gm) per decilitre (dl) of blood. A decilitre equals 10 millilitres (ml). The World Health
Organization recommends that the pregnant woman ’s haemoglobin should not fall below 11
grams of haemoglobin per decilitre of blood (Hb 11g/dl). (You will learn more about anaemia and
its treatment later .)

• Although there is a constant increase in the number of red blood cells in the circulation during
pregnanc y, the increase in the volume of blood plasma is much larger. So even though the
pregnant woman has more red blood cells than before she was pregnant, they are diluted in the
much larger volume of blood plasma.
Q

• What effect will this have on the concentration of red blood cells and haemoglobin in the
pregnant woman ’s blood, compared to her non -pregnant self?
A

• The concentration of red blood cells and haemoglobin will fall because they are more dilute, so
the woman’s blood will be slightly anaemic

• This effect is referred to as physiological anaemia. It explains why iron in the diet, or from iron
tablets, is so important during pregnanc y.
Blood pressure in pregnancy

• We said earlier that progesterone causes the ligaments and joints to loosen during pregnanc y.
It also acts with some other natural chemicals in the body to cause the muscular walls of the
blood vessels to relax slightly. The result is that there is less resistance to the flow of blood
around the body, because the s ame v olume of blood is ci rc ulating i n slightl y wi der blood vess els .
Blood pressure (BP) refers to how hard the blood is ‘pushing’ on the walls of the major blood
vessels as it is pumped around the body by the heart.
Q

• What effect will the slight relaxation of the blood vessel walls have on the pregnant woman ’s
blood pressure?
A

It will be lower than in her pre -pregnant state, because the same volume of blood has more space
in which to circulate.

Lower blood pressure is particularl y common in early pregnanc y. Many women report occasionally
feeling dizzy in the first trimester, because less blood and less oxygen is being pumped to the
brain. Progesterone can also cause a sudden larger relaxation in the blood vessels, resulting in
an acute feeling of dizziness, or even a brief loss of consciousness (passing out).

Another cause of dizziness can result from lying flat on the back. This is more common after 24
weeks of pregnanc y, but it can happen earlier during twin pregnancies , or conditions that increase
the volume of amniotic fluid (waters surrounding the fetus). When a pregnant woman is lying flat
on her back, the weight of her uterus and its contents compresses the large blood vessel (vena
cava) leading from her lower body to the heart. When this blood vessel is squashed, the blood
flow back to the heart is reduced, which in turn leads to a reduction in the blood flow out of the
heart to the rest of the body.
Q

• If there is suddenly less blood leaving the heart, what will happen to the woman ’s blood
pressure, and how will she feel as a result?
A

• Lying flat on her back can result in a sudden and dramatic drop in blood pressure, and
dizziness or loss of consciousness may occur because not enough oxygen is reaching her brain.
After the first trimester, pregnant women are recommended not to lie on their back.
 Exercise and blood flow in pregnancy

• The weight gain in pregnant women increases the workload on the body from any physical
activity. Steady, non -violent exercise is good for the mother because it prepares her body for
labour (Figure 7.2), but sudden strong exercise, or working for too many hours without a break,
may make her feel dizzy. This is because the reduced blood pressure and slight physiological
anaemia cannot keep pace with the demand of her body for more oxygen.
• Having too much or too little exercise should be avoided in pregnancy.

• pregnant woman should not do exercises where she is lying on her back, due
to the compression of the major blood vessels returning blood to her heart.
Strong exercise may lead to decreased blood flow to the uterus because blood
is diverted to the muscles, but this has not been shown to have any long -term
effects on the baby. Pregnant women should not exercise vigorously in hot
weather, or if it makes them breathless, or if there are known risk factors such
as a history of miscarriage.
Oedema in pregnancy
• Oedema is pronounced ‘ee dee mah’.

• Important!If a pregnant woman experiences severe oedema, including swelling of the face, this
is a danger sign that requires immediate referral to the nearest health facility.

• A combination of the slight increase in the permeability of the smallest of blood vessels (they
allow more fluid to leak out into the tissues), the additional weight of the uterus, and the
downward force of gravity, slow down the rate at which blood is pumped back to the heart from
the lower half of the body. Fluid often collects in the tissues of the legs and feet of pregnant
women after the first trimester, instead of being absorbed into the blood circulation. The
swelling caused by this collection of fluid is called oedema.
ct..
• It is a common condition in pregnant women, particularl y if they stand for a long time during the
day. Oedema of the hands may also occur. Advise the woman to rest frequentl y and to elevate
(raise) her feet and legs while sitting. This will improve the return of blood to her heart and
decrease swelling of the legs.
Respiratory changes
During pregnanc y, the amount of air moved in and out of the lungs increases by nearly 50% due
to two factors :

• each breath contains a larger volume of air

• the rate of breathing (breaths per minute) increases slightly.

• During pregnanc y, many women find they get short of breath (cannot breathe as deeply as
usual). This is because the growing baby crowds the mother ’s lungs and she has less room to
breathe. But if a woman is also weak and tired, or if she is short of breath all of the time, she
should be checked for signs of sickness, heart problems, anaemia or poor diet. Get medical
advice if you think she may have any of these problems.
Changes in the gastrointestinal system in pregnancy

• As you may remember from your high school biology, food and fluids enter the gastrointes ti nal
system in the mouth, pass through the oesophagus, stomach and intestines, and solid waste
exits at the anus. This very long tube from mouth to anus is often called the ‘gut’. Proteins,
fats and carbohydrates in our diet are broken down (digested) in the gut into units small enough
to be absorbed from the intestines into nearby blood vessels. It is also the route by which
nutritious substances, such as vitamins and minerals, enter the body.

• During pregnanc y, the muscles in the walls of the gastrointes ti nal system relax slightly, and the
rate at which food is squeezed out of the stomach and along the intestines is slowed down.
Q

• Can you think of a reason why slowing down the passage of food through the gastrointestinal
system might be beneficial in pregnanc y?
A
• It increases the time available for digestion, and it maximises the absorption of nutrients from
the diet.

• Undesirable effects also result from slow emptying of the stomach, and slow movement of food
through the gut.

• Can you suggest one of these undesirable effects?

 • Many pregnant women experience constipation (difficulty in passing stools).

The growing baby crowds the mother’s stomach and can

cause indigestion and heartburn. She may also feel short of
breath because the baby crowds her lungs.
Figure 7.3
• Many women also have nausea in the first months of pregnanc y. A burning feeling, or pain in
the stomach or between the breasts, is called indigestion (or ‘heartburn ’, although the heart
is not involved). It happens because as the pregnanc y progresses , the growing baby crowds the
mother’s stomach and pushes it higher than usual (Figure 7.3). The acids in the mother ’s
stomach that help digest food are pushed up into her chest, where they cause a burning feeling.
This is not dangerous and usually goes away after the birth.

• If the mother has difficulty with nausea or indigestion, advise her to eat small, frequent meals.
The mother should not lie down flat for 1 to 2 hours after eating, because this may cause these
symptoms. In Study Session 12 you will learn more about minor disorders of pregnancy such as
these, and how to help the woman manage them.
 Changes in the urinary system during pregnancy

• The urinary system consists of the kidneys (a pair of organs on either side of the abdomen near
the back), the tubes connecting the kidneys to the bladder where urine is stored, and a tube
called the urethra that passes urine out of the body. The kidneys extrac t waste from the blood
and turn it into urine. They must work extra hard to filter the mother ’s own waste products
from her blood, plus those of the fetus, and get rid of them in her urine. Therefore, there is also
an increase in the amount of urine produced during pregnanc y.
• Needing to urinate (pee) often is normal, especially in the first and last months of pregnanc y.
This happens because the growing uterus presses against the bladder. In late pregnanc y, a
woman often has to get up during the night to urinate, because fluid retained in the legs and
feet during the day (oedema) is absorbed into the blood circulation when her legs are raised in
bed. The kidneys extrac t the excess fluid and turn it into urine, so the bladder fills more quickly
at night.
Skin changes

• Changes in the woman ’s hormones, and mechanical stretching of her growing abdomen and
breasts, are responsible for several changes in the skin during pregnancy.

• Linea nigra

• This dark line may appear between the umbilicus (belly -button) and the symphysis pubis (pubic
bone); in some pregnant women it may extend as high as the sternum (the bone between the
breasts). It is a hormone -i nduced excess production of brown material (pigment) in the skin
cells in this area. After delivery, the line begins to fade, though it may never completel y
disappear.
 Mask of pregnancy (chloasma)

• Some women produce a brownish pigmentation of the skin over the face and forehead, known
as the ‘mask of pregnanc y ’ (or chloasma). It gives a bronze look. It begins about the 16th
week of pregnanc y and gradually increases, but it usually fades after delivery.

• Stretch marks

• As the woman’s weight increases, stretching of the skin occurs over areas of maximal
growth — the abdomen, thighs and breasts. Pink or brownish stretch marks may appear in some
women, which can be quite dramatic. They usually fade after delivery, although they never
completely disappear.

• Sw eat glands

• Activity of the sweat glands throughout the body usually increases during pregnanc y, which
causes the woman to perspire (sweat) more profusel y than usual, particularl y in hot weather or
during physical work.
 Changes in the breasts

• In early pregnanc y, the breasts may feel full or tingle, and they increase in size as pregnanc y
progresses . The areola around the nipples (the circle of pigmented skin) darkens and the
diameter increases. The Montgomery ’s glands (the tiny bumps in the areola) enlarge and tend
to protrude (stick out more). The surface blood vessels of the breast may become visible due to
increased circulation, and this may give a bluish tint to the breasts.
ct
• By the 16th week (during the second trimester) , the breasts begin to produce colostrum. This is
the precursor of breastmilk . It is a yellowish secretion from the nipples, which thickens as
pregnancy progresses . It is extremel y high in protein and contains antibodies (special proteins
produced by the mother ’s immune system) that help to protect the newborn baby from
infection. Near the end of pregnanc y, the nipples may produce enough colostrum to make wet
patches on the woman ’s clothes. Reassure her that this is normal and a good sign. After the
baby is born, colostrum is produced for about the first three days, before the proper milk begins
to flow. Make sure that the mother breastfeeds the colostrum to her baby, so he or she gets all
the nutrients and antibodies it contains.
• you will meet some signs of these physiological changes in pregnanc y again, when you learn
how to diagnose whether a woman is pregnant, and how to gather information about her
‘pregnanc y history’.
Summary of Study
In Study Session 7, you have learned that:

• Oestrogen and progesterone are the chief pregnanc y hormones .

• High levels of progesterone cause some internal structures to increase in size, including the
uterus which changes from the size of a small pear in its non -pregnant state to five times its
normal size at full term.

• The expected increase in weight of the mother in an average pregnanc y is 9 -12 kg.

• A higher circulating blood volume is required to provide extra blood flow through the placenta to
the fetus, and the mother also produces more red blood cells.

• The increase in blood volume exceeds the increase in red blood cells, so they are diluted in the
much larger volume of blood plasma, causing physiological anaemia. This is one reason why
iron supplementation is so important in pregnanc y.
 ct..
• Lower blood pressure is particularl y common in early pregnanc y because progesterone causes
a slight relaxation in the blood vessels. This can cause dizziness and perhaps even a brief loss
of consciousness.

• A reduction in blood flow back to the heart may lead to oedema — swelling due to fluid
collecting in the legs and feet.

• During pregnanc y, many women get short of breath because the growing baby crowds the
mother’s lungs and she has less room to breathe. She may also experience indigestion as her
stomach is pushed higher.

• During pregnanc y, the muscles in the walls of the gastrointes ti nal system relax slightly, and the
rate at which food moves along the gut is slowed down. This maximises the absorption of
nutrients into the mother ’s blood, which is good for the fetus, but the mother may also
experience nausea or constipation.
ct..
• Needing to urinate often is normal, especially in the first and last months of pregnanc y, because
the growing uterus presses against the bladder. At night, the bladder fills more quickly as fluid
(oedema) that collected in the legs during the day is re -absorbed.

• Changes in the woman ’s hormones, and mechanical stretching of her growing abdomen and
breasts, can cause stretch marks in the skin of these areas during pregnanc y. Other skin
changes may include brown pigmentation and increased sweating.

• In the second trimester, the breasts begin to produce colostrum — a yellowish secretion that
thickens as pregnanc y progresses . It is rich in proteins and maternal antibodies, and should
always be fed to newborn babies.