Physiological Changes During Pregnancy PDF

PHYSIOLOGICAL CHANGES DURING PREGNANCY Maternal & Neonatal Nursing Theory Third Stage 2nd semester / 2023-2024 Dr. Zainab Neamat AL Taee During pregnancy, a woman undergoes many physiologic and psychosocial changes. Her body adapts in response to the demands of...

PHYSIOLOGICAL CHANGES DURING PREGNANCY Maternal & Neonatal Nursing Theory Third Stage 2nd semester / 2023-2024 Dr. Zainab Neamat AL Taee During pregnancy, a woman undergoes many physiologic and psychosocial changes. Her body adapts in response to the demands of the growing fetus while her mind prepares for the responsibilities that come with becoming a parent. Physiologic changes initially indicate pregnancy; these changes continue to affect the body throughout pregnancy as the fetus grows and develops. Psychosocial changes occur in both the mother and father and may vary from trimester to trimester. Physiologic signs of pregnancy Pregnancy produces several types of physiologic changes that must be evaluated before a definitive diagnosis of pregnancy is made. The changes can be: presumptive (subjective) probable (objective) positive. 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 Presumptive signs of pregnancy are those that can be assumed to indicate pregnancy until more concrete signs develop. These signs include breast changes, nausea and vomiting, amenorrhea, urinary frequency, fatigue, uterine enlargement, quickening, and skin changes. A pregnant patient typically reports some presumptive signs.  Probable signs of pregnancy Probable signs of pregnancy strongly suggest pregnancy. They’re more reliable indicators of pregnancy than presumptive signs, but they can also be explained by other medical conditions. Probable signs include positive laboratory tests, such as serum and urine tests; positive results on a home pregnancy test; Chadwick sign; Goodell sign; Hegar sign; sonographic evidence of a gestational sac; ballottement; and Braxton Hicks contractions.  Positive signs of pregnancy Positive signs of pregnancy include sonographic evidence of the fetal outline, an audible fetal heart rate, and fetal movement that’s felt by the examiner. These signs confirm pregnancy because they can’t be attributed to other conditions. CHANGES IN GENITAL ORGANS Vulva Vagina Uterus Isthmus Cervix Fallopian Tubes Ovary  Vulva ▪ Oedematous ▪ More Vascular ▪ Superficial varicosities may appear specially in multiparae. ▪ Labia minora are pigmented and hypertrophied  Vagina ▪ Vaginal walls become hypertrophied, oedematous and more vascular. ▪ Increased blood supply of the venous plexus surrounding the walls gives the bluish coloration of the mucosa (Jacquemier’s sign) ▪ The length of the anterior vaginal wall is increased. ▪ Secretion becomes copious, thin and curdy white ▪ pH becomes acidic (3.5-6)  Uterus ▪ Non-pregnant state weighs about 60gm, with a cavity of 5-10 ml and measures about 7.5 cm in length, at term, weighs 900-1000 gm and measures 35cm in length ▪ Changes occur in all the parts of uterus body, isthmus and cervix. ▪ Increase in growth and enlargement of the body of the uterus Changes in the muscles (1)Hypertrophy and hyperplasia occur under the influence of the hormones (oestrogen & progesterone). (2)Stretching: The muscle fibres further elongate beyond 20 weeks due to distension by the growing fetus. The wall becomes thinner and at term, measures about 1.5cm or less. Arrangement of the muscle fibres 1) Outer longitudinal – follows a hood like arrangement over the fundus; some fibres are continuous with the round ligaments (2) Inner circular – It is scanty and have sphincter like arrangement around the tubal orifices and internal os (3) Intermediate – It is the thickest and strongest layer arranged in criss-cross fashion through which the blood vessels run. Apposition of two double curve muscle fibres give the figure of ‘8’ form, it called as living ligature. Vascular system of uterus ▪ Uterine artery diameter becomes double ▪ Blood flow increases by x8 at 20 weeks of pregnancy. ▪ Vasodilatation is mainly due to estradiol and progesterone. ▪ Veins become dilated and are valveless. ▪ Numerous lymphatic channels open up. ▪ Vascular changes are most pronounced at the placental site Weight Weight is due to the increased growth of the uterine muscles, connective tissues and vascular channels Shape ▪ Non pregnant pyriform shape is maintained in early months. ▪ Becomes globular at 12 weeks. ▪ As the uterus enlarge, the shape once more becomes pyriform or ovoid by 28 weeks ▪ Changes to spherical beyond 36th week Position ▪ Normal anteverted positions exaggerated up to 8 weeks ▪ The enlarged uterus may lie on the bladder ▪ Afterwards, it becomes erect, the long axis of the uterus conforms a tendency of ante version ▪ Primigravidae with good tone of the abdominal muscles, it is held firmly against the maternal spine. Contractions (Braxton-Hicks) : Irregular, infrequent, spasmodic and painless without any effect on dilatation of the cervix. Endometrium : structural and secretory activity of the endometrium increase Isthmus ▪ During the first trimester isthmus hypertrophies and elongates to about 3 times its original length ▪ Becomes softer  Cervix Hypertrophy and hyperplasia of the elastic and connective tissues. Cervix becomes bulky. Vascularity is increased. Softening of the cervix (Goodell’s sign) Squamous cells also become hyperactive Mucosal changes simulate basal cell hyperplasia. Secretion is copious and tenacious (physiological leucorrhoea of pregnancy). During pregnancy, the cervix is closed. A mucus plug forms over the cervix ,providing a protective barrier between the vagina and the uterine contents.  Fallopian Tube ▪ Total length is increased ▪ Tube becomes congested ▪ Muscles undergo hypertrophy  Ovary ❖ Growth and function of the corpus luteum reaches its maximum at 8th week Hormones, estrogen and progesterone secreted by the corpus luteum maintain the environment for the growing zygote ❖ Control the formation and maintenance of decidua of pregnancy ❖ Inhibit ripening of the follicles.  BREAST CHANGES ▪ Increased size of the breasts ▪ Marked hypertrophy and proliferation of the ducts (oestrogen and progesterone) ▪ Vascularity is increased ▪ The nipples become larger, erectile and deeply pigmented ▪ Sebaceous glands (5-15) become hypertrophied and are called Montgomery’s tubercles ▪ Outer zone of less marked and irregular pigmented area appears in the second trimester and is called secondary areola ▪ Secretion (colostrum) can be squeezed out of the breast at about 12th week Increased Deposition of fat High Oestrogen lead to increase number of ducts Progesterone & hPL (Human placental lactogen) increase number of alveoli Prolactin milk production & secretion Colostrum begin to form Newborn Suckling stimulates anterior & posterior Pituitary gland hormone secretion  Integumentary Changes Skin changes: darkening of the areolae, darkening patches on the face (melasma, former chloasma), linea alba becomes lineanigra on the abdomen, related to increased melanin. (chloasma gravidarum or pregnancy mask): an extreme form of pigmentation around the cheek, forehead and around the eyes Abdomen Linea nigra : a brownish black pigmented area in the midline stretching from the xiphisternum to the symphysis pubis Straie graviderum :slightly depressed linear marks with varying length and breadth found in pregnancy Striae on the abdomen and legs caused by-skin stretching as pregnancy advances;. As the uterus increases in size, the abdominal wall must stretch cause rupture and atrophy of small segments of the connective layer of the skin. This leads to pink or reddish streaks (striae gravidarum) *Erythematous changes on the palms and face in some women  HEMATOLOGICAL CHANGES Blood volume ▪ Due to increased vascularity of the enlarging uterus, Blood volume is markedly raised during pregnancy ▪ The blood volume starts to increase from about 6th week, expends rapidly thereafter to maximum 40- 50% above the non-pregnant level at 30-32 weeks. Plasma Volume ▪ Starts to increase at 6 weeks of pregnancy ▪ Rate of increase almost parallels to that of blood volume ▪ Reached to the extent of 50% ▪ Total plasma volume increases to the extent of 1250 ml. RBC And Haemoglobin ▪ The RBC mass is increased to the extent of 20-30% ▪ Increase demand of oxygen transport during pregnancy ▪ Disproportionate increase in plasma and RBC volume produces state of haemodilution (fall in haemocrit) ▪ Hb fall is about 2 gm.% from the non-pregnant value. Leucocytes And Immune System In the second and third trimester, the action of the polymorphoneuclear leukocytes may be depressed, perhaps accounting for the increased of pregnant women to infection Total plasma protein increases from the normal 180 gm (non-pregnant) to 230 gm. Due to haemodilution (increase plasma volume), the plasma protein concentration falls from 7 gm.% to 6 gm.% Blood Coagulation Factor Pregnancy is a hypercoagulable state. Plasma fibrinogen (factor 1) increases from the third month of pregnancy  METABOLIC CHANGES General Metabolic Changes ▪ Total metabolism is increased due to the needs of the growing fetus and the uterus ▪ Basal metabolic rate is increased to the extent of 30% higher than that of the average for the non- pregnant women. Protein Metabolism ▪ Positive nitrogenous balance throughout pregnancy ▪ At term, the fetus and the placenta contain about 500 gm. of protein and the maternal gain is also about 500 gm. Carbohydrate Metabolism ▪ Insulin secretion is increased in response to glucose and amino acids. ▪ Hyperplasia and hypertrophy of beta cells of pancreas. ▪ Increased insulin level favours lipogenesis (fat storage).This mechanism ensures continuously supply of glucose to the fetus Fat Metabolism ▪ An average of 3-4 kg of fat is stored during pregnancy mostly in the abdominal wall, breasts, hips and thighs Iron Metabolism ▪ Iron is absorbed as ferrous (Fe²⁺) from duodenum and jejunum and is released into the circulation as transferrin (iron transporting glycoprotein in serum) ▪ Only 10 % of ingested iron is absorbed ▪ Total iron requirement during pregnancy is estimated approximately 1000mg ▪ In the absence of iron supplementation, there is drop in haemoglobin, serum iron and serum ferritin (blood protein that contains iron ) concentration at term pregnancy Weight Gain ▪ In early weeks, the patient may lose weight because of nausea and vomiting ▪ During subsequent months, the weight gain is progressive until the last one or two weeks, when the weight remains static ▪ The minimum weight gain during the course of a singleton pregnancy for a ▪ healthy woman averages 11 kg Distributed to 1 kg in first trimester and 5 kg each in second and third trimester  The total weight gain at term is distributed approximately as : Reproductive weight gain Net maternal weight gain : 6 kg : 6 kg Fetus – 3.3 kg Increases in blood placenta –0.6 kg volume – 1.3 kg liquor – 0.8 kg Increases in uterus – 0.9 kg breast -0.4 kg, extracellular accumulation of the fat fluid – 1.2 kg and protein – 3.5 kg Skeletal system ▪ Relaxation of pelvic ligaments and muscles occurs because of the influence of estrogen and relaxtin reaches maximum during last weeks of the pregnancy ▪ Increased lumber lordosis during later months of the pregnancy due to enlarged uterus backache and wadding gait Lordosis Skeletal system: 1. Softening of all ligaments and joints, especially symphysis pubis and sacroiliac joint, caused by increased hormonal action of estrogens and relaxin. lower spine and helps enlarge the birth canal 2. Leg cramps may occur from an imbalance of calcium (hypocalcemia) in the body and from pressure of the gravid uterus on nerves supplying lower extremities To relieve sudden cramp in the calf muscle in the sitting position, woman may be advised to hold the knee straight and stretch the calf muscle by pulling the foot upwards (dorsiflexion). Stand firmly on the affected leg and stride forward with the other leg.  SYSTEMIC CHANGES Respiratory System Shape of the chest and the circumference increases in pregnancy by 6 cm Progressive increase in oxygen consumption, which is caused by the increased metabolic needs of the mother and fetus. The mucosa of the nasopharynx becomes hyperaemic and oedematous (Nasal congestion and epistaxis may occur as a response to increased estrogen levels. A state of hyperventilation occurs during pregnancy leading to increase tidal volume 40% The woman feels shortness of breath Pregnancy is a state of respiratory alkalosis  CARDIOVASCULAR CHANGES The Heart : ▪ muscle, particularly the left ventricles, hypertrophies leading to enlargement of the heart ▪ The growing uterus pushes the heart upward and to the left ▪ During pregnancy the heart rate and stroke volume (the amount of the blood pumped by heart with each beat) increases due to the increase blood volume and oxygen requirement of the maternal tissues and growing fetus Cardiac Output : ▪ increases markedly by the end of the first trimester. ▪ In the third trimester, a rise, fall or no change at all has been showed to occur, depending on individual variables. ▪ lowest in the sitting or supine position and highest in the right or left lateral position or knee chest position. ▪ The capacity of veins and venules increases. ▪ Arterial walls relax and dilate due to the effect of progesterone. The increase production of vasodilator prostaglandin also contributes to this. Blood Pressure ▪ During the mid-trimester, changes in blood pressure may occur causing fainting(Decrease ▪ Bl.Pressure) ▪ In later pregnancy, hypotension may occur in 10% of women in unsupported supine position. This termed as “supine hypotensive syndrome” The pressure of gravid uterus compresses the vena cava, reducing the venous return Cardiac output is reduced by 25-30 percent and the blood pressure may fall by 10-15 %. Supine Hypotensive Syndrome 48 Regional Distribution Of The Blood Flow ▪ Uterine blood flow is increased from 50 ml per minute in non-pregnant state about 750 ml near Term. ▪ Pulmonary blood flow (normal 600ml/min) is increased by 2500 ml per minute ▪ Renal blood flow (normal 800 ml) increases by 400 ml per minute at 16th week remains at this level till term ▪ Heat sensation, sweating or stuffy nose complained by the pregnant women can be explained by the increased blood flow Urinary System kidney ▪ Dilatation of the ureter, renal pelvis and calyces. The kidneys enlarge in length by 1 cm. ▪ Renal plasma flow is increased by 50-75%, maximum by the 16 weeks and is maintained until 34 weeks. Thereafter it falls by 25%. ▪ Glomerular filtration rate (GFR) is increased by 50% all throughout the pregnancy Ureter ▪ ureters become atonic due to high progesterone level. ▪ Dilatation of the ureter above the pelvic brim with stasis is marked on the right side specially in primigravidae.  Bladder ▪ Increased frequency of micturition is noticed at 6-8 weeks of pregnancy which subside after 12 weeks and In late pregnancy, frequency of micturition once more reappears due to pressure on the bladder as the presenting part descends down the pelvis. ▪ Stress incontinence may observe in late pregnancy due to urethral sphincter weakness Gastointestinal (Alimentary )System ▪ Gums become congested and spongy and may bleed to touch (Hypertrophy and hyperaemia of the gum) ▪ Risk of peptic ulcer disease is reduced. ▪ Increase salivation Gastric emptying is prolong ▪ Gastroesophageal reflux heart burn (80%) ▪ Constipation: Atonicity of the gut leads to constipation Liver and gall bladder Liver functions are depressed High blood cholesterol level during pregnancy, favour stone formation  Changes In The Endocrine System Placental Hormones ▪ Placenta produces several hormones ▪ The high levels of estrogen and progesterone produced by the placenta are responsible for breast changes, skin pigmentations and uterine enlargement in the first trimester ▪ βHCG: Human Chorinonic gonadotrophin is the basis for the immunologic pregnancy tests ▪ stimulates the growth of the breasts Pituitary Hormones ▪ The secretion of prolactin, adrenocorticotrophic Hormone(ACTH), thyrotrophic hormone and melanocyte-stimulating hormone increases ▪ FSH and LH secretion is greatly inhibited by placental progesterone and estrogen. ▪ Pituitary gland: enlarged, increase production by 15-fold but the effects of prolactin are suppressed during pregnancy. Posterior pituitary gland releases in ▪ low-frequency pulses throughout pregnancy. At term the frequency of pulses increases which stimulates uterine contractions Thyroid Function ▪ Gland increases in size by about 13% due to hyperplasia of glandular tissue and increased vascularity ▪ Increased uptake of iodine during pregnancy ▪ Pregnancy can give the impression of hyperthyroidism, thyroid function is basically normal ▪ The basal metabolic rate is increased mainly because of increased oxygen consumption by the fetus and the work of the maternal heart and lungs psychological changes ▪ Temperamental changes are found during pregnancy and in the puerperium ▪ Nausea, vomiting, mental irritability and sleeplessness are probably due to some psychological background ▪ Postpartum blues, depression or psychosis may develop in a susceptible individual  Common Psychosocial Changes That Occur With Pregnancy (Emotional) 1. Ambivalence about pregnancy and parenting. (Partners may also feel ambivalent if they are not well prepared for parenthood or have had little experience ,not have as strong a support network. 2. Acceptance of biologic fact of pregnancy; usually occurs during first trimester. 3. Acceptance of growing fetus as distinct from self; usually occurs during second trimester. 4. Preparing for Parenthood Preparation for birth; usually occurs during 3rd trimester. 5. Mood swings. 6. Anxiety related to birth and adult Responsi bilities. Place of sleeping , buying clothes, choosing a name for the infant, ect…