Chapter 2: Physiologic Changes of Pregnancy PDF

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY DIAGNOSIS OF PREGNANCY o A multigravida can feel quickening as early as 16 weeks. PRESUMPTIVE SI...

CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY DIAGNOSIS OF PREGNANCY o A multigravida can feel quickening as early as 16 weeks. PRESUMPTIVE SIGNS AND SYMPTOMS OF PREGNANCY o A primigravida usually cannot feel quickening until after Those signs and symptoms that are usually noted by the 18 weeks. patient, which impel her to make an appointment with a 7. SKIN CHANGES physician. Striae gravidarum (stretch marks) These signs and symptoms are not proof of pregnancy, but o These are marks noted on the abdomen and/or buttocks. they will make the physician and woman suspicious of o These marks are caused by increased production or pregnancy. sensitivity to adrenocortical hormones during pregnancy, They could easily indicate other conditions. not just weight gain. 1. AMENORRHEA (CESSATION OF MENSTRUATION) Linea nigra One of the earliest clues of pregnancy. o This is a black line in the midline of the abdomen that may run from the sternum or umbilicus to the symphysis 2. NAUSEA AND VOMITING (MORNING SICKNESS) pubis. Usually occurs in the early morning during the first 2 weeks of o This appears on the primigravida by the 3rd month and pregnancy. keeps pace with the rising height of the fundus. Usually spontaneous and subsides in 6 to 8 weeks or by the o The entire line may appear on the multigravida before the 12th to 16th week of pregnancy. third month. Hyperemesis gravidarum Chloasma (Melasma) o This is referred to as nausea and vomiting that is severe o This is called the "Mask of Pregnancy." and lasts beyond the 4th month of pregnancy. o It is a bronze type of facial coloration seen more on dark- o It causes weight loss and upsets fluid and electrolyte haired women. balance of the patient. o It is seen after the 16th wk of pregnancy. 3. FREQUENT URINATION 8. FATIGUE It is caused by pressure of the expanding uterus on the This is a common complaint by most patients during the first bladder. trimester. It subsides as pregnancy progresses and the uterus rises out of Fatigue may also be a result of anemia, infection, emotional the pelvic cavity. stress, or malignant disease. The uterus returns during the last weeks of pregnancy as the PROBABLE SIGNS OF PREGNANCY head of the fetus presses against the bladder. Those signs that are commonly noted by the physician upon 4. BREAST CHANGES examination of the patient. In early pregnancy, changes start with a slight, temporary These signs include uterine changes, abdominal changes, enlargement of the breasts, causing a sensation of weight, cervical changes, basal body temperature, positive pregnancy fullness, and mild tingling. test by physician, and fetal palpation. As pregnancy continues the patient may notice: 1. UTERINE CHANGES a) Darkening of the areola -- the brown part around the Position nipple. o By the 12th week, the uterus rises above the symphysis b) Enlargement of Montgomery glands –the tiny nodules or pubis, and it should reach the xiphoid process by the 36th sebaceous glands within the areola. week of pregnancy. c) Increased firmness or tenderness of the breasts. Size d) More prominent and visible veins due to the increased o The uterine increases in width and length approximately 5 blood supply. times its normal size. Its weight increases from 50 grams e) Presence of colostrum (thin yellowish fluid that is the to 1,000 grams. precursor of breast milk). Hegar’s Sign - This can be expressed during the second trimester o Softening of the lower uterine segment just above the and may even leak out in the latter part of the cervix. pregnancy. o When the uterine is compressed between examining 5. VAGINAL CHANGES fingers, the wall feels tissue paper thin. Leukorrhea o The Hegar's sign is noted by the 6th to 8th week of o This is an increase in the white or slightly gray mucoid pregnancy. discharge that has a faint musty odor. Ballottement o It is due to hyperplasia of vaginal epithelial cells of the o This is demonstrated during the bimanual exam at the cervix because of increased hormone level from the 16th to 20th week. pregnancy. o Ballottement is when the lower uterine segment or the o Leukorrhea is also present in vaginal infections. cervix is tapped by the examiner's finger and left there, 6. QUICKENING (FEELING OF LIFE) the fetus floats upward, then sinks back and a gentle tap This is the first perception of fetal movement within the is felt on the finger. uterus. o It usually occurs toward the 18th week. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY 2. CERVICAL CHANGES PHYSIOLOGIC CHANGES DURING PREGNANCY Goodell's sign Physiologic changes that occur during pregnancy are the basis o The cervix is normally firm like the cartilage at the end of for the signs and symptoms used to confirm pregnancy. the nose. They can be categorized as: o The Goodell's sign is when there is marked softening of 1. Local (i.e., confined to the reproductive organs) the cervix. 2. Systemic (i.e., affecting the entire body). o This is present at 6 weeks of pregnancy. LOCAL CHANGES Formation of a mucous plug (Operculum) UTERINE CHANGES o This is due to hyperplasia of the cervical glands as a result Length grows from approx. 6.5 to 32 cm. of increased hormones. o It serves to seal the cervix of the pregnant uterus and to Depth increases from 2.5 to 22 cm. protect it from contamination by bacteria in the vagina. Width expands from 4 to 24 cm. Weight increases from 50 to 1,000 gms. 3. BRAXTON-HICK'S CONTRACTIONS Early pregnancy – uterine wall thickens from 1 cm to 2 cm. This involves painless uterine contractions occurring End of pregnancy – the wall thins to become supple and only throughout pregnancy. about 0.5 cm thick. It usually begins about the 12th week of pregnancy and Due partly to formation of new muscle fibers in the uterine becomes progressively stronger. myometrium. (Progesterone) These contractions will, generally, cease with walking. Principally due to stretching of existing muscle fibers. Do not cause the cervix to dilate. (Estrogen) 4. POSITIVE PREGNANCY TEST BY THE PHYSICIAN Uterus is able to withstand the stretching of its muscle fibers Even if the test is positive, it could be the result of ectopic due to formation of fibroelastic tissue between fibers that pregnancy or a hydatidiform mole (an abnormal growth of a binds them together. fertilized ovum). Volume of uterus increases from about 2 ml to more than 5. FETAL OUTLINE PALPATION 1,000 ml. This is a probable sign of early pregnancy. Uterus can hold a 7 lb fetus and 1,000 ml of amniotic fluid for a The physician can palpate the abdomen and identify fetal total of about 4,000 gms. parts. Hegar’s sign It is not always accurate. o Softening of the lower uterine segment. Ballotement POSITIVE SIGNS OF PREGNANCY o “To toss about” Those signs that are definitely confirmed as a pregnancy. o Fetus can be felt to bounce and rise in the amniotic fluid. They include fetal heart sounds, ultrasound scanning of the Braxton Hick Contractions fetus, palpation of the entire fetus, palpation of fetal o “Practice contractions” movements, x-ray, and actual delivery of an infant. o Also plays a role in ensuring the placenta receives 1. FETAL HEART SOUNDS adequate blood. 5 weeks CERVICAL CHANGES o Echocardiography can demonstrate a heartbeat. Goodell’s Sign 6th to 7th week o Softening of the cervix. o An ultrasound can reveal a beating fetal heart. o The cervix of the uterus becomes more vascular and 10th to 12th week of gestation edematous than usual causing it to soften in consistency o Able to detect fetal heart sounds through Doppler. (due to estrogen). 18 to 20 weeks of pregnancy Operculum o Fetal heartbeat can be heard through an ordinary o A mucus plug forms to seal out bacteria and help prevent stethoscope as early as infection in the fetus and membranes. o The normal fetal heart rate is 120 to 160 beats. VAGINAL CHANGES 2. ULTRASOUND SCANNING OF THE FETUS Chadwicks Sign The gestation sac can be seen and photographed. o The resulting increase in circulation (due to estrogen) An embryo as early as the 4th week after conception can be changes the color of the vaginal walls from their normal identified. light pink to a deep violet. The fetal parts begin to appear by the 10th week of gestation. Leukorrhea 3. PALPATION OF THE ENTIRE FETUS o Increase in the activity of the epithelial cells. Palpation must include the fetus head, back, and upper and Change of vaginal ph lower body parts. o Fall from ph of greater than 7 (an alkaline ph) to 4 or 5 This is a positive sign after the 24th week of pregnancy if the (acid ph) woman is not obese. o Under the influence of estrogen, the vaginal epithelium and underlying tissues increase in size as they become 4. PALPATION OF FETAL MOVEMENT enriched with glycogen where Lactobacillus acidophilus This is done by a trained examiner. (Doderlein bacillus) grow freely and produce lactic acid. It is easily elicited at 20th – 24th week of pregnancy. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY OVARIAN CHANGES C. CARDIOVASCULAR SYSTEM Cessation of ovulation. CHANGES IN THE BREASTS Feeling of tingling, fullness or tenderness in her breast (due to high estrogen). Increase of the breast size. Areola of the nipple darkens and its diameter increase from about 3.5 cm to 5 or 7.5 cm. Montgomery’s tubercles o The sebaceous glands of the areola become enlarged and protuberant, which keeps the nipple supple and helps to prevent nipples from cracking and drying during lactation. Increase in blood volume o To provide for an adequate exchange of nutrients in the placenta. Pseudoanemia o Plasma volume increases faster than RBC, concentration of hemoglobin and erythrocytes may decline. Iron, Folic acid, Vitamin needs o Fetus requires 350 – 400 mg of iron to grow. o Increase in the mother’s circulatory RBC mass requires an additional 400 mg of iron. o Total requirement for iron = 800 mg o Lack of folic acid has been linked to increased risk for neural tube disorders in fetuses. o Foods high in folic acid: ▪ Spinach, asparagus, legumes SYSTEMIC CHANGES Peripheral blood flow A. INTEGUMENTARY SYSTEM o During 3rd tri, blood flow to lower extremities is impaired due to pressure of gravid uterus to veins and arteries. Striae gravidarum o Can lead to edema and varicosities of the vulva, rectum, Diastasis legs. o Rectus muscles separate. Supine Hypotension Syndrome o Abdominal wall unable to withstand the tension created o Weight of growing uterus presses the vena cava against by the enlarging uterus. the vertebrae, obstructing the blood flow from the lower Linea nigra extremities. o Brown line from umbilicus to symphysis pubis. o This causes a decrease in blood return to the heart, and Melasma consequently, decreased cardiac output and hypotension o “Mask of pregnancy“. (lightheadedness, faintness, palpitation). o Due to melanocyte-stimulating hormone. o Can result in fetal hypoxia. Vascular spiders Increased fibrinogen (necessary for clotting) o Due to increase of estrogen. o Due to increased estrogen. B. RESPIRATORY CHANGES o Safeguard against major bleeding. Congestion or “Stuffiness“ of the nasopharynx o Pre-pregnancy - 300 mg/dL o Due to increased estrogen level o Pregnancy - 450 g/dL Dyspnea (end of 3rd trimester) Increased WBC o Enlarging uterus places pressure upward toward the lungs o Protective mechanism. and elevates the diaphragm. o Reflection of the woman’s increased blood volume. Residual volume (air remaining in the lungs after expiration) Protein level decreased o Up to 20% by the pressure of the diaphragm. o Indicating the amount of protein used by the fetus. Tidal volume (volume of air inspired) D. GASTROINTESTINAL SYSTEM o Up to 40%. Heartburn (pyrosis) o O2 consumption by 20%. o Due to: Mild hyperventilation ▪ Reflux of stomach contents into the esophagus and a o To blow off excess CO2 being shifted to her by the fetus. relaxed cardioesophageal sphincter caused by the Temperature action of relaxin and progesterone. o Slight increase due to progesterone. LAMAGON | BSN 2A  CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107 CHAPTER 2: PHYSIOLOGIC CHANGES OF PREGNANCY Flatulence, constipation o hCG o Slow emptying time of the stomach, slow intestinal ▪ Secreted by the trophoblast cells of the placenta in peristalsis. early pregnancy. o Due to relaxin and progesterone. o hPL Nausea and vomiting ▪ Antagonist to insulin which allows more glucose to o Due to: become available for fetal growth. ▪ Increased hCG, estrogen and progesterone levels. o Relaxin ▪ Decreased glucose levels (glucose being used by the ▪ Secreted primarily by corpus luteum. growing fetus) = FBS 95 mg/dL or lower ▪ Inhibit uterine activity. Hyperptyalism ▪ Soften the cervix and collagen in joints. o Increase in saliva formation. o Prostaglandins o A local response to increased levels of estrogen. ▪ Affect smooth muscle contractility. Subclinical jaundice ▪ They may be the trigger that initiates labor at term. o Due to decreased emptying of bile from the gallbladder o Pituitary Gland that leads to reabsorption of bilirubin into the maternal ▪ Production of GH & MSH. bloodstream causing generalized itching. ▪ Oxytocin is produced by post. pituitary gland late in o Increased tendency to stone formation due to additional pregnancy needed to aid in labor. cholesterol incorporated in bile. ▪ Prolactin begun late in pregnancy to prepare for Hypertrophy of gumlines and bleeding of gingival tissue when lactation. they brush their teeth. ▪ Thyroid & Parathyroid ▪ Thyroid gland enlarges early in pregnancy causing E. URINARY SYSTEM increased basal body metabolic rate by 20%. Fluid retention ▪ Parathyroid glands are necessary for calcium o Under the influence of progesterone, there is an increased metabolism. response of the angiotensin-renin system in the kidney, o Adrenal Glands leading to increase aldosterone production. ▪ Levels of corticosteroids and aldosterone. o The renin-angiotensin-aldosterone system (RAAS) plays ▪ Aids in suppressing an inflammatory reaction. an important role in regulating blood volume and ▪ Help reduce the possibility of a woman’s body systemic vascular resistance which together influence rejecting the fetus. cardiac output and arterial pressure. ▪ Help regulate glucose metabolism. o Renin is released primarily by the kidneys, stimulates the ▪ Aldosterone aids in promoting sodium formation of angiotensin in blood and tissues which in reabsorption and maintaining osmolarity in the turn stimulates the release of aldosterone from the amount of fluid retained. adrenal cortex. o Pancreas o Aldosterone aids in Na reabsorption. ▪ Production of insulin in response to higher levels o Water is retained to aid the increase in blood volume, and of glucocorticoid produced by the adrenal glands. as a ready source of fluid for the fetus. ▪ The glucose level of fetus is 30mg/100ml. Renal function ▪ Pregnant woman should keep her diet high in o Gradual Increase in urine output by 60–80%. calories and should never go longer than 12 hrs. o Specific gravity of urine decreases. between meals. o Glomerular filtration rate (GFR) and renal plasma flow. ▪ In early pregnancy, FBS is 80–85 mg/100 ml. o Increased by 30 – 50% by 2nd trimester. H. IMMUNE SYSTEM Ureter and Bladder function o Due to progesterone during pregnancy, ureters increase in Immunoglobulin G (IgG) is decreased making the woman more diameter, bladder capacity increases to 1,500 ml. prone to infection during pregnancy. IgG comprise 80% of the antibodies in adults (main type of F. SKELETAL SYSTEM antibody). Gradual softening of pelvic ligaments and joints due to: o Ovarian hormone relaxin and placental progesterone. Lordosis (“pride of pregnancy”) o Forward curve of the spine. G. ENDOCRINE SYSTEM Placenta o Estrogen ▪ Causes breast & uterine enlargement. ▪ Causes palmar erythema. o Progesterone ▪ Maintains endometrium. ▪ Inhibits uterine contractility. ▪ Aids in the development of the breasts for lactation. LAMAGON | BSN 2A