PHYSIOLOGY OF PREGNACY

INTRODUCTION
 As soon as a woman gets pregnant, there is a
dramatic physiological adaptation to pregnancy in
various systems of the body especially in the
reproductive system so that her body can cope with
added work and nurture the fetus and prepare for
labour and lactation.
INTRODUCTION cont’d
 These changes are sometimes under-estimated but
the effects vary from one woman to another.
 It is imperative for Midwives to understand the
physiological changes that takes place during
pregnancy as this will enable her to identify
deviation from normal and will be able to provide
adequate care to the woman or take appropriate
step to solve her problems.
INTRODUCTION cont’d
 With pregnancy occurring, menstruation ceases and
appears some weeks or month after delivery.
 The hormone oestrogen and progesterone are
produced in large quantities and pregnancy is
divided into three trimester period each a three (3)
month period.
 Each trimester with predictable changes in mother
and foetus bring about a lot of changes in the
systems of the body.
CHANGES IN THE
REPRODUCTIVE SYSTEM
CHANGES IN THE BREAST

 The breast increases to about 5-10cm and weighs

about 900g.
 This is due to the growth of the glandular tissue
and the ducts of the breast as a result of their
stimulation by oestrogen and progesterone.
 There is increased blood supply to the breast so
dilated blood vessels are visible on the breast.
 At six (6) weeks a tingling sensation is felt,
becomes nodular and later heaviness is felt.
CONT’D
 At eight (8) weeks enlargement starts, veins begin
to enlarge and also the Montgomery tubercles also
enlarged and can be seen prominently at the
primary areolar.
 At 12 weeks the nipples are prominent and are a
pigmentation of the primary areolar.
 At 16 weeks there is a secondary areolar and a
colostrums are produced.
CHANGES IN THE UTERUS
 Before pregnancy the uterus is a small, almost
solid and pear shaped organ, measuring 7.5 x 5 x
2.5 cm and weighs about 60g. The pregnant uterus
increases in size and the usual pear shape becomes
globular at about 12th week.
 At 20th week the uterus becomes almost oval in
shape.
CONT’D
 The pregnant uterus at term is 30 x 22 x 20cm and
weighs about 1000g.
 During pregnancy the uterus becomes an
abdominal organ.
 The uterine growth and alteration in shape is due to
hyperplasia (increase in number of cell due to cell
division and hypertrophy (increases in size) at
different times.
CONT’D
 Oestrogen is responsible for the growth while
progesterone is responsible for keeping the uterus
relaxed.
 As gestation increases, and hyperplasia is less
important and hypertrophy accounts for most of the
growth.
 Hypertrophy and hyperplasia of the myometrial
cells lead to the formation and differentiation into 3
layers:
CONT’D
 Outer longitudinal fibers found in the upper
segment responsible for the contraction and retraction
during labor.
 Inner circular fibers found in the lower segment and
is responsible for the stretching and dilation of the
cervix during labor.
 Middle oblique fibers which are called living
ligatures and are found in the upper segments. They
are responsible for controlling bleeding after delivery.
CONT’D
 Perimetrium: the perimetrium is a thin layer of
peritoneum that protects the uterus.
 During pregnancy the double fold of perimetrium
(broad ligaments), hanging from the uterine tubes
down to the walls of the pelvis become longer and
widen with increased tension exerted on them as
the uterus enlarges and emerges out of the pelvis.
CONT’D
 The round ligaments provide some anterior support
for the enlarging uterus and undergoes
considerable hypertrophy and stretching during
pregnancy which may cause discomfort and strain.
 Endometrium: this thickens and is called decidua
in responds to HCG hormone to stimulate the
corpus luteum to produce oestrogen and
progesterone.
CONT’D
 The placenta takes over the responsibility of
producing the oestrogen and progesterone at
around 12 weeks of gestation.
 The normal ante version and ante flexion of the
uterus disappears after the 12th week of pregnancy.
 The arteries and the veins supplying the uterus
blood are greatly enlarged during pregnancy.
CONT’D
 As a result of increased cardiac output, blood flow
to the uterus is massively increased. Approximately
50ml/min at 10 weeks gestation and a maximum of
450-700ml at term.
 Braxton hicks contraction which are irregular,
generally painless contractions of the uterus, occur
intermittently throughout pregnancy.
 Hegar’s sign: Softening of the lower uterine
segment
CONT’D
CLINICAL ASSESMENT OF THE GROWING
UTERUS
 1ST- 12 weeks still a pelvic organ.

 12th week the fundus is at the upper border of the

symphysis pubis.
 16th week it is midway between the umbilicus and

the symphysis.
 At the 20th week the fundus reaches a finger

breadth below the level of the umbilicus.

CONT’D
 At the 24th week it is at the level of the umbilicus.
 At the 30th- 32nd week it is midway between the
umbilicus and the xiphisternum.
 At the 36th- 38th week the fundus uteri is at the
level of the level of xiphisternum.
CHANGES IN THE CERVIX
 Remains 2.5cm throughout the pregnancy.
 It becomes softer and swollen after and during the
pregnancy under the influence of progesterone and
oestrogen. This is called “goodell’s sign”.
 Its increased vascularity gives it a bluish coloration
known as Chadwick's sign.
CONT’D
 When uterine activity increases, the cervix in
corporate into the lower uterine segment and
slowly ripens and dilates.
 The enzyme collagenase and prostaglandin are both
involved in cervical ripening.
 Effacement or taking up the cervix can occur in the
last 2 weeks of pregnancy.
THE VAGINA
 During pregnancy the vagina grows and the lumen
enlarges.
 The vagina epithelium becomes thicker and highly
vascularized and has a violet color.
 This is probably due to hyperemia, and pulsation is
felt at the lateral fornix
 Acid environment inhibits growth of bacteria but
allows growth of Candida albicans, leading to
increased risk of candidiasis (yeast infection).
CONT’D
 There is a desquamation of the superficial vaginal
mucosa cells.
 This is due to the release of more glycogen by the
epithelial cells which is acted upon by the
doderlein’s bacilli producing lactic acid and
hydrogen peroxide.
CONT’D
 An increase of vaginal discharge (leukorrhea)
which is in response to the estrogen-induced
hypertrophy of the vaginal glands.
 Relaxation of the vaginal wall and perineal body
which allows stretching of tissues to accommodate
the birthing process.
Fallopian Tubes and the Ovaries
 Blood supply to these organs increases.
 They become more vertical in position as the
growing uterus fills the abdominal cavity.
 The corpus luteum enlarges, producing high level
of oestrogen and progesterone in the first 10-12
weeks.
 Corpus luteum degenerates after the 12th week and
placenta take over its function. The ovaries
become dormant and no ova is produced.
THE VULVA

 The labia minora becomes pigmented and highly

vascularized.
 Chadwick’s sign Bluish coloration of cervix,
vaginal mucosa, and vulva
CHANGES IN THE
CARDIOVASCULAR SYSTEM
THE HEART
 The heart enlarges by about 12% between early and
late pregnancy.
 The heart chambers distends due to the increased
diastolic filling (particularly in the left ventricle).
 In late pregnancy the degree of vasodilation decreases
and the ejection fraction also diminishes.
 The growing uterus elevates the diaphragm and the
blood vessels are unfolded. By mid-pregnancy
majority of the women develop an ejection systolic
murmur.
CONT’D
 There is increased cardiac output. This makes
blood flow to the kidneys and the brains and
coronary arteries to remain unaffected.
 The increased cardiac output is due to the increase
in both stroke volume and heart rate.
 Heart rates are 10-15 beats per minute faster in a
pregnant woman than those of a non pregnant
woman.
THE BLOOD VESSELS

 The hormones oestrogen and progesterone has a

relaxation effect on the plain muscles of the blood
vessels.
 Therefore there is tendency of sluggish circulation
and viscosity of the veins especially veins of the
legs, rectum, anal canal, vulva.
Blood pressure:
 The B.P. slightly reaches it lowest point during the
2nd trimester. It gradually increases to its near pre-
pregnant levels by the end of the 3rd trimester.
 Supine hypotensive syndrome is a hypotensive
condition resulting from a woman lying on her
back in mid to late pregnancy.
CONT’D
 In a supine position, the enlarged uterus
compresses the inferior vena cava, leading to a
significant drop in cardiac output and blood
pressure, and resulting in the woman feeling dizzy
and faint.
 Pregnant women should be advised to lie on their
side and rise slowly when in a supine position to
decrease the risk of a hypotensive event.
HAEMATOLOGICAL SYSTEM
BLOOD
 Blood volume increases between 10-32weeks of
gestation. This also increases the cardiac output.
 The plasma increase is about 45-50% and the red
blood cell increases by 15-30% in women receiving
supplement giving rise to what is known as
haemodilution.
 There is also Physiological anemia of pregnancy, also
referred to as pseudoanemia of pregnancy, is due to
hemodilution.
CONT’D
 The RBC count increases 30% and RBC volume
increases 17% to 33% in response to increased
oxygen requirements of pregnancy.
 The increase in plasma volume is relatively larger
than the increase in RBCs and results in decreased
hemoglobin and hematocrit values.
CONT’D
 Iron-deficiency anemia, defined as hemoglobin of
less than11.0 g/dL and hematocrit less than 33%.
 Maternal iron stores are insufficient to meet the
demands for iron in fetal development.
 The white blood cell (WBC) count increases, with
values up to15,000 mm3 in the absence of infection.
 The increase is hormonally induced and similar to
elevations seen in physiological stress such as
exercise.
CONT’D
 Hypercoagulation occurs during pregnancy to
decrease the risk of postpartum hemorrhage.
 These changes place the woman at increased risk
for thrombosis and coagulopathies.
 Plasma fibrin increase of 40%
 Fibrinogen increase of 50%
 Coagulation inhibiting factors decrease.
RESPIRATORY SYSTEM
CONT’D
 The volume of air breathed each minute increases
to 30-40%.
 In addition progesterone decreases airway
resistance, permitting a 15-20% increase in oxygen
consumption as well as increase in carbon dioxide
production and in the respiratory functional
reserve.
 Increased cardiac output leads to increase in
pulmonary blood flow.
CONT’D
 The basal metabolic rate increases.
 There is improved gaseous exchange but some
women may complain of breathlessness as lung
bases are compressed.
 Nasal stuffiness and epistaxis may also occur
because of oestrogen induced oedema and vascular
congestion of the nasal mucosa.
URINARY SYSTEM
THE KIDNEYS
 During pregnancy, a woman’s kidneys excrete the
waste products from her body and that of the fetus.
 Also, her kidneys must be able to manage the
demands of increased renal blood flow.
 The kidneys increase in size, changes their
structure which ultimately affect their function.
CONT’D
 Urinary output gradually increases (about 60% to
80%).
 The specific gravity of urine decreases.
 The glomerular filtration rate (GFR) and renal
plasma flow begin to increase in early pregnancy.
 By the second trimester, both the GFR and the
renal plasma flow have increased by 30% to 50%,
and they remain at these levels for the duration of
the pregnancy.
CONT’D
 There is increased glomerular filteration rate (GFR)
coupled with impaired tubular reabsorption
capacity for filtered glucose thus resulting in the
excretion of glucose (glucosuria) at some time
during pregnancy in some women.
THE URETER AND BLADDER
 During the 1st trimester the enlarging uterus is still
a pelvic organ and presses against the bladder
bringing about urinary frequency.
 This decreases during the 2nd trimester when the
uterus becomes an abdominal organ and pressure
against the bladder lessens but reappears in 3rd
trimester when the presenting part descends into
the pelvis thereby pressing on the bladder and
reducing its capacity.
CONT’D
 Under the influence of progesterone, the calyxes
and renal pelvis dilate.
 The progesterone also relaxes the sphincters and
ureters, which along with pressure from the
pregnant uterus on the bladder causes a significant
number of women to experience some degree of
stress incontinence.
 There is increased risk of infection, mostly as a
result of vesicoureteric reflux (VUR).
CHANGES IN THE
DIGESTIVE SYSTEM
CONT’D
 Nausea and vomiting occur during the 1st trimester.
 Profuse salivation or hyperptyalism is an
occasional complaint in pregnancy.
 The gut is displaced by the growing uterus.
 Progesterone relaxes the gut i.e. both peristalsis and
sphincter.
 Indigestion, heart burn and constipation occur.
 An increased appetite may also be noticed.
MUSCULO-SKELETAL
SYSTEM
CONT’D
 Altered posture and center of gravity related to
distention of the abdomen by the expanding uterus
and reduced abdominal tone that shifts the center of
gravity forward.
 A shift in the center of gravity places the woman at
higher risk for falls.
 Altered gait (“pregnant waddle”): Hormonal
influences of progesterone and relaxin soften joints
and increase joint mobility.
CONT’D
 Lordosis: Abnormal anterior curvature of the lumbar
spine.
 The body compensates for the shift in center of gravity by
developing an increased curvature of the spine.
 Joint discomfort: Hormonal influences of progesterone and
relaxin soften cartilage and connective tissue, leading to joint
instability.
 Round ligament spasm: Estrogen and relaxin increase
elasticity and relaxation of ligaments and abdominal
distention stretches round ligaments causing spasm and pain.
CONT’D
 Pressure of the enlarging uterus on the abdomen
may cause the rectus abdominus muscle to
separate, producing diastasis recti.
 If the separation is severe and muscle tone is not
regained postnatally, subsequent pregnancies will
not have adequate support and the woman’s
abdomen may appear pendulous.
CONT’D
 Patient’s gait changes because of weight of the
pregnant uterus.
 Progesterone relaxes the joints and there is
increased Lordosis from growing pregnant uterus.
 The woman may complain of aches particularly
backache.
CONT’D
 The impact of all of the musculoskeletal
adaptations in pregnancy resulting in numerous
common discomforts of pregnancy can sometimes
be reduced if the woman maintains a normal body
weight and exercises regularly prior to and
throughout her pregnancy.
INTERGUMENTARY SYSTEM
CONT’D
 The intergumentary system includes the skin and
related structures such as hair, nails, and glands.
 Hormonal influences are primary factors in
intergumentary system adaptations during
pregnancy, with mechanical factors associated with
the enlarging uterus playing a lesser role in changes
associated with this body system.
CONT’D
 Anatomical and physiological changes include:
 Hyperpigmentation: Estrogen and progesterone
stimulate increased melanin deposition of light
brown to dark brown pigmentation.
 Linea nigra: Darkened line in midline of
abdomen
 Melasma (chloasma), also referred to as mask of
pregnancy, is a brownish pigmentation of the skin
over the cheeks, nose, and
CONT’D
 The skin of the abdomen stretches to accommodate
uterus and extra fat deposits on the patient.
 Stretching also occurs over the breast the breast
and thighs.
 Stretch marks known as striae gravidarum appear
as red stripes changing to glistening.
 Sometimes itching of the skin in pregnancy occur.
CONT’D
 There is pigmentation of the face known as “chloasma” or
mask pregnancy.
 The line extending from the pubis to the xiphisternum
become darker and is called Linear Nigra.
 Hot flashes, facial flushing, alternating sensation of hot and
cold
 Increased perspiration
 Angiomas (spider nevi)
 Palmar erythema: Pinkish-red mottling over palms of hands
 Increased oiliness of skin and increase of acne
NERVOUS SYSTEM
CONT’D
 Emotional instability is common.
 Anxiety, fear and even depression may be
manifested.
 She becomes very labile.
IMMUNE SYSTEM
CONT’D
 Immunologic competency during pregnancy
apparently decreases, probably to prevent a woman’s
body from rejecting the fetus as if it were a
transplanted organ.
 Immunoglobulin G (IgG) production is particularly
decreased, which can make a woman more prone to
infection during pregnancy.
 A simultaneous increase in the white blood cell count
may help to counteract the decrease in IgG response
IMMUNOLOGIC CHALLENGE OF
PREGNANCY

 Pregnancy provides the following unique

challenges to the mother’s immune system:
1. Maternal tissues and blood are in intimate and
prolonged contact with the semiallogeneic fetus.
2. Pregnancy is established in the uterus, a
specialized organ with its own mucosal barrier
(the decidua)
CONT’D

3. Impact of the fetal–placental unit on maternal immunity

increases with advancing gestation.
4. Hormones and cytokines released by the fetus and/or placenta
impact maternal immune function.
5. Deported placental and fetal cells are released into the
maternal bloodstream.
 These challenges require appropriate adaptations of the
maternal immune response for the establishment and
maintenance of successful pregnancy.
ENDOCRINE SYSTEM
General Physiological Changes

 Significant alterations in pituitary, adrenal, thyroid,

parathyroid, and pancreatic functioning occur in
pregnancy.
 For example, the hormonal production activity and
size of the thyroid gland increase during pregnancy
in support of maternal and fetal physiological needs
 There is an increase in pancreatic activity during
pregnancy to meet both maternal and fetal needs
related to carbohydrate metabolism.
Pregnancy-Specific Hormones

 The hormones of pregnancy are responsible for most of the

physiological adaptations and physical changes seen
throughout the entire pregnancy.
 The placental hormones are initially produced by the corpus
luteum of pregnancy.
 Once implantation occurs, the fertilized ovum and chorionic
villi produce hCG.
 The function of the high hCG level in early pregnancy is to
maintain the corpus luteum and its production of
progesterone and, to a lesser extent, estrogen until the
placenta develops and takes over this function.
CONT’D
 After the development of a functioning placenta, the
placenta produces most of the hormones of
pregnancy including estrogen, progesterone, human
placental lactogen (hPL), and relaxin.
 Each of these hormones plays a role in the
physiology of pregnancy, resulting in specific
alterations in nearly all body systems, to support
maternal physiological needs, maintenance and
progression of the pregnancy, and fetal growth and
development.
WEIGHT CHANGES
 Total weight gain during pregnancy is 11-12kg.
 From 0-20weeks, she gains about 2kg i.e. 0.5kg per
month.
 From 20-40weeks, she gains 0.5kg weekly.
 Her metabolism also increases.
DEPOSITION OF WEIGHT GAIN IN
PREGNANCY

 The breast 0.5kg

 Fat 3.5kg
 Placenta 0.6kg
 Foetus 3.4kg
 Amniotic fluid 0.6kg
 Increase uterus 0.9kg
 Blood volume 1.5kg
 ECF 1kg
Total= 12kg
FACTORS THAT INFLUENCE WEIGHT GAIN
DURING PREGNANCY

 Maternal oedema
 Maternal metabolic rate
 Dietary intake
 Vomiting or diarrhoea
 Amount of amniotic fluid
 The size of the foetus