MATERNAL PHYSIOLOGY

MATERNAL PHYSIOLOGY
Every organ system undergoes anatomical and
functional changes, biochemical and physiological
adaptation during pregnancy
Begin soon after fertilization and continue throughout
gestation in response to physical stimuli provided by
the fetus.
Returned almost completely to her prepregnancy state
after delivery and lactation.

REPRODUCTIVE TRACT
A. UTERUS
NONPREGNANT

PREGNANT

weight

70 g

1100 g at term

Capacity

10 ml

5 L-20 L

Shape

Pear shape for the first few weeks

Globular, almost spherical at 12 weeks
Ovoid shape rapid increase in length
than in width

Position

Dextrorotation- uterus contacts the ant.

Abdominal wall as it enlarge, displaces
the intestine laterally and superiorly.

PREGNANT UTERUS

marked hypertrophy of muscle cells

accumulation of fibrous tissue

increase in elastic tissue

walls of the corpus become considerably thicker

during the first few months of pregnancy, actually
thin gradually as gestation advances.(they are only
1 to 2 cm or even less in thickness)

Uterine hypertrophy early in pregnancy probably is stimulated by the

action of estrogen and perhaps that of progesterone
. It is apparent that hypertrophy of early pregnancy does not occur
entirely in response to mechanical distention by the products of
conception, because similar uterine changes are observed with ectopic
pregnancy
But after approximately 12 weeks, the increase in uterine size is
related predominantly to pressure exerted by the expanding products
of conception.

UTERUS
Uterine enlargement is most marked in the
fundus.
In the early months of pregnancy, the
fallopian tubes and the ovarian and round
ligaments attach only slightly below the
apex of the fundus
In later months, they are located slightly
above the middle of the uterus
The position of the placenta also
influences the extent of uterine
hypertrophy, because the portion of the
uterus surrounding the placental site
enlarges more rapidly than does the
rest.

ARRANGEMENT OF MUSCLE CELLS DURING

PREGNANCY
1. An outer hoodlike layer, which arches over the
fundus and extend into the various ligaments.
2. A middle layer, composed of a densed network of
muscle fibers perforated in all direction by blood vessels.
3. An internal layer, consisting of sphincter like fibers
around the orifice of the fallopian tubes and internal os of
the cervix

ARRANGEMENT OF MUSCLE
CELLS DURING PREGNANCY
The main portion of the uterine wall is formed by the
middle layer.
Each cell in this layer has a double curve so that the
interlacing of any two gives approximately the form of a
figure eight.
This arrangement is crucial because when the cells
contract after delivery, they constrict the penetrating
blood vessels and thus act as ligatures

Uterine Size, Shape, and Position

For the first few weeks, the uterus maintains its original
pear shape, but as pregnancy advances, the corpus and
fundus assume a more globular form, becoming almost
spherical by 12 weeks and assumes an ovoid shape.
By the end of 12 weeks, the uterus has become
too large to remain entirely within the pelvis.
With ascent of the uterus from the pelvis, it usually
undergoes rotation to the right. This dextrorotation
likely is caused by the rectosigmoid on the left
side of the pelvis. As the uterus rises, tension is
exerted on the broad and round ligaments.

Uterine Size, Shape, and Position

With the pregnant woman standing, the

longitudinal axis of the uterus corresponds to
an extension of the axis of the pelvic inlet.
When the pregnant woman is supine, the
uterus falls back to rest on the vertebral
column and the adjacent great vessels,
especially the inferior vena cava and aorta.

CONTRACTILITY
Braxton Hicks
irregular, painlesss contractions in the 1st trimester
Detected by bimanual examination in the 2nd trimester
Appear unpredictably and sporadically, non-rhythmic,
intensity varies approximately 5-25 mmHg
Contraction may occur as every 10-20 mins., assume
some degree of rhytmicity during the last week or two of
pregnancy.
*Late in pregnancy, it may cause discomfort and account
for FALSE LABOR

UTEROPLACENTAL BLOOD FLOW

Delivery of most substances essential for growth and
metabolism of the fetus
Removal of metabolic wastes
Placental perfusion is dependent on total uterine blood flow,
which is principally from the uterine and ovarian arteries.
Increases progressively, approximately 450-650 ml/min near
They found that uterine contractions, either spontaneous or
term.
induced, caused a decrease in uterine blood flow that was
approximately proportional to the intensity of the contraction

CONTROL OF UTEROPLACENTAL
BLOOD FLOW
Increase in maternal-placental blood flow vasodilatation
Increase fetal-placental blood flow- growth of placental vessels
Estrogen-vasodilatation
Cathecolamines-vasoconstriction
Nitric Oxide/EDRF vasodilatation

Regulation of Uteroplacental Blood Flow

In contrast, normal pregnancy is

characterized by vascular refractoriness
to the pressor effects of infused
angiotensin II
Large-conductance potassium
channels expressed in uterine vascular
smooth muscle also contribute to
uteroplacental blood flow regulation
through several mediators, including
estrogen and nitric oxide

B. CERVIX
SOFTENING AND CYANOSIS of the cervix 1 month after
conception:
1.increased vascularity and edema of the entire cervix
2.hypertrophy and hyperplasia of the cervical gland
Glands undergo marked proliferation, by the end of
pregnancy they occupy approximately half of the entire
cervical mass.
Although the cervix contains a small amount of smooth
muscle, its major component is connective tissue.

Cervical eversion of pregnancy as

viewed through a colposcope

PROLIFERATING COLUMNAR ENDOCERVICAL GLANDS.

This tissue tends to be red and velvety and bleeds even with minor
trauma, such as with Pap smear sampling.

B. CERVIX
MUCUS PLUG - copius amounts of a tenacious mucus
that obstruct the cervical canal soon after conception,
At the onset of labor, if not before, this mucus plug is
expelled, resulting in a BLOODY SHOW.

In most pregnant women, when cervical mucus is

spread and dried on a glass slide, it is characterized by
crystallization, or beading, as a result of progesterone.
In some women, arborization of the crystals, or
ferning, is observed as a result of amnionic fluid
leakage

B. CERVIX
During pregnancy, basal cells near the
squamocolumnar junction are likely to be
prominent in size, shape, and staining
qualities. These changes are considered to
be estrogen induced.
In addition, pregnancy is associated with
both endocervical gland hyperplasia and
hypersecretory appearancethe AriasStella reactionwhich makes the
identification of atypical glandular cells on
Pap smear particularly difficult

C. OVARIES
Ovulation ceases during pregnancy
Maturation of new follicles is suspended
Only a single corpus luteum of pregancy can be found in
the ovaries of a pregnant women.
Corpus luteum functions maximally during the first 6-7
weeks of pregnancy 4 to 5 weeks postovulationand
thereafter contributes relatively little to progesterone
production

C. OVARIES

Indeed, even bilateral

oophorectomy at 16 weeks has
been reported to result in an
otherwise uneventful pregnancy
Interestingly in such cases, FSH levels
do not reach perimenopausal levels
until approximately 5 weeks
postpartum

C. OVARIES
DECIDUAL REACTION
on and beneath the surface of the ovaries, similar
to that found in the endometrial stroma, is common
in pregnancy and is usually observed at cesarean
delivery
bleed easily and may, on first glance, resemble
freshly torn adhesions.
Similar decidual reactions are seen on the uterine
serosa and other pelvic, or even extrapelvic,
abdominal organs.
these findings likely represent cellular detritus from
the endometrium that has passed through the
fallopian tubes.
DIAMETER OF THE OVARIAN VASCULAR PEDICLE INCREASED
DURING PREGNANCY FROM 0.9 CM TO APPROXIMATELY 2.6 CM
AT TERM

Relaxin

protein hormone is secreted by the corpus

luteum, decidua, and placenta in a pattern
similar to that of human chorionic gonadotropin
(hCG)
expressed in a variety of nonreproductive tissues,
including brain, heart, and kidney
remodeling of reproductive tract connective tissue
to accommodate pregnancy parturition
appears to be an important factor in the initiation of
augmented renal hemodynamics and decreased
osmolality associated with pregnancy
Despite its name, serum relaxin levels do not
correlate with increasing peripheral joint laxity
during pregnancy

PREGNANCY LUTEOMA
- solid ovarian tumor that developed during
pregnancy and and was composed of large
acidophilic luteinized cells.
-Size range from microscopic to over 20cm in
diameter; solid, complex appearing unilateral
mass with cystic features that correspond to areas
of hemorrhage.
-May result in maternal virilization, but usually
female fetus is not affected.
This is presumably because of the protective role of
the trophoblast with its high capacity to convert
androgens and androgen-like steroids to estrogens

REGRESS AFTER DELIVERY, THEY MAY RECUR IN

SUBSEQUENT PREGNANCIES

PREGNANCY LUTEOMA
PREGNANCY LUTEOMA

VIRILIZATION

Theca-Lutein Cysts
benign ovarian lesions result from exaggerated
physiological follicle stimulationtermed
hyperreactio luteinalis.
Although the cellular pattern of hyperreactio
luteinalis is similar to that of a luteoma, these
usually bilateral cystic ovaries are moderately
to massively enlarged.
The reaction is associated with markedly elevated
serum levels of hCG.
And not surprisingly, theca-lutein cysts are found
frequently with gestational trophoblastic disease

Theca-Lutein Cysts
They are also more likely to be found
a. large placenta such as with diabetes, Disoimmunization, and multiple fetuses
b.chronic renal failure as a result of reduced
hCG clearance
c. hyperthyroidism as a result of the
structural homology between hCG and
thyroid-stimulating
d. uncomplicated pregnancies

Theca-Lutein Cysts
Although usually asymptomatic, hemorrhage
into the cysts may cause abdominal pain.
Maternal virilization may be seen in up to 25
percent of women
Changes including temporal balding, hirsutism,
and clitoromegaly are associated with
massively elevated levels of
androstenedione and testosterone.
The diagnosis typically is based on
sonographic findings of bilateral enlarged
ovaries containing multiple cysts in the
appropriate clinical settings.
The condition is self-limited, and resolution
follows delivery.
In some women, increased ovarian
responsiveness to gonadotropin can be

D. FALLOPIAN TUBES
Undergoes little hypertrophy during pregnancy
Epithelium of tubal mucosa becomes flattened
Very rarely, the increasing size of the gravid uterus, especially in the
presence of paratubal or ovarian cysts, may result in fallopian tube torsion

E.VAGINA AND PERINEUM

Increase in vascularity and hyperemia develop in the skin and
muscles of the perineum and vulva.
Increase in the thickness of the mucosa, loosening of the connective tissue,
hypertrophy of the smooth muscle cell, papillae of the vaginal mucosa
undergo hypertrophy, creating a fine, hobnailed appearance.
Cervical discharge is thick, white
Ph is acidic -3.5 6
results from increased production of lactic acid from glycogen in the
vaginal epithelium by the action of Lactobacillus acidophilus.

F. SKIN
STRIAE GRAVIDARUM- reddish, slightly depressed
streaks commonly developed in the skin of the abdomen
and thighs, breasts.
DIASTASIS RECTI- rectus muscles separate in the
midline due to tension.
LINEA ALBAbecomes especially pigmented

LINEA NIGRA- midline abdominal skin, markedly

pigmented, assuming a brownish- black color.

CHLOASMA/MELASMA GRAVIDARUM- irregular

brownish patches of varying size on the face and neck.

Hyperpigmentation
Pigmentation of the areolae and genital skin
may also be accentuated.
These pigmentary changes usually disappear, or at
least regress considerably, after delivery.
Oral contraceptives may cause similar
pigmentation.
Very little is known of the nature of these
pigmentary changes, although melanocytestimulating hormone, a polypeptide similar to
corticotropin, has been shown to be elevated
remarkably from the end of the second month of
pregnancy until term.
Estrogen and progesterone also are reported to
have melanocyte-stimulating effects


CHADWICK SIGN increased vascularity of the vagina
resulting to violet color characteristics.

VAGINAL EPITHELIAL CELLS DURING PREGNANCY

Small intermediate cells, called navicular cells by
Papanicolaou, are found in abundance in small, dense
clusters. These ovoid cells contain a vesicular, somewhat
elongated nucleus.
Vesicular nuclei without cytoplasm, or so-called naked
nuclei, are evident along with an abundance of
Lactobacillus

G. VASCULAR CHANGES

VASCULAR SPIDERS - minute red elevations on the

skin particularly common on the face, neck, upper chest,
arms and radicles branching out from a central lession,
designated as NEVUS, TELANGIECTASIS, ANGIOMA.

PALMAR ERYTHEMA- consequence of the

hyperestrogenemia, disappear shortly after pregnancy.

H. BREASTS
Breast tenderness and tingling in the early weeks of
pregnancy
Increase in size and delicate veins become visible just
beneath the skin.
Nipples become considerably larger, more deeply
pigmented, more erectile.
COLOSTRUM-thick yellowish fluid
GLANDS OF MONTGOMERY:
-small elevations in areola
-hypertrophic sebaceous glands

METABOLIC CHANGES
By the third trimester, maternal basal
metabolic rate is increased by 10 to 20
percent compared with that of the
nonpregnant state.
This is increased by an additional 10
percent in women with twin gestations

WEIGHT
GAIN

attributable to uterus and

its contents, the breast
increase in blood
volume and
extravascular
extracellular fluid.
Approximate weight gain
during pregnancy is 12.5
kg or 27.5 lbs.
Increase in cellular and
water deposition of new fat
and protein, MATERNAL
RESERVES

Analysis of Weight Gain Based on

Physiological Events during Pregnancy

WATER METABOLISM

INCREASED WATER RETENTION IS NORMAL PHYSIOLOGICAL

ALTERATION OF PREGNANCY. IT IS MEDIATED, AT LEAST IN
PART, BY A FALL IN PLASMA OSMOLALITY OF
APPROXIMATELY 10 MOSM/KG

At term, the water content of the fetus, placenta, amniotic fluid

amounts to about 3.5 L.
Another 3 L accumulates as a result inccreases in the maternal
blood volume and in the size of the uterus and breast.
Minimum amount of extra water that the average women
accrues during normal pregnancy is about
6.5 L.
Pitting edema of the ankles and legs is seen in most pregnant
women, caused by an increase in venous pressure below
the level of the uterus as a consequence of partial
occlusion of the vena cava.

PROTEIN METABOLISM
products of conception, the uterus, and maternal blood
are relatively rich in protein rather than fat or
carbohydrate.

about 4
kg and contain approximately 500 g of
protein, or about half of the total pregnancy increase.

At term, the fetus and placenta together weigh

The remaining 500 g is added to the uterus as

contractile protein, to the breasts primarily in the glands,
and to the maternal blood as hemoglobin and plasma
proteins.

CARBOHYDRATE
METABOLISM
NORMAL PREGNANCY:
Mild fasting hypoglycemia
Postprandialhyperglycemia
Hyperinsulinemia

CARBOHYDRATE METABOLISM
The mechanism(s) responsible for insulin resistance is
not completely understood. Progesterone and estrogen
may act, directly or indirectly, to mediate this
resistance
The pregnant woman changes rapidly from a
postprandial state characterized by elevated and
sustained glucose levels to a fasting state
characterized by decreased plasma glucose and some
amino acids.
Simultaneously, plasma concentrations of free fatty
acids, triglycerides, and cholesterol are higher.

FAT METABOLISM
Increase: lipids, lipoproteins, apolipoproteins
*Fat is deposited mostly in the central rather than
peripheral sites.
LEPTIN-peptide hormone, secreted by adipose tissue,also
produced by the placenta, plays a key role in the
regulation of body fat, and energy expenditure.
During pregnancy, leptin levels progressively increase,
peaking during the second trimester to plateau at term in
concentrations 3-4 X than those in nonpregnant women.

ELECTROLYTE AND MINERAL METABOLISM

Normal Pregnancy 1000 mEq of Na retained
300 mEq of K retained
Decreased total serum Calcium,Magnesium
Unchanged level of Ionized Calcium, Phosphate
GFR of Na and K is increased, the excretion of these
electrolytes is unchanged during pregnancy as a result of
enhanced tubular resorption.

HEMATOLOGICAL CHANGES
BLOOD VOLUME
-Markedly increased during pregnancy
-begins to increase during the 1st trimester
-results in increase plasma and erythrocytes (plasma >
erythrocytes)
-average increase in the erythrocyte volume is 450 ml.
-moderate hyperplasia in the bone marrow
-reticulocyte count is slightly elevated.

IMPORTANT FUNCTIONS OF PREGNANCY INDUCED

HYPERVOLEMIA

To meet the demands of the enlarged uterus with its

greatly hypertrophied vascular system.
To protect the mother, and in turn the fetus, against the
deleterious effects of impaired venous return in the
spine and erect positions.
To safeguard the mother against adverse effects of
blood loss associated with parturition.

IRON METABOLISM
iron requirements of normal pregnancy total approximately 1000 mg.
300 mg are actively transferred to the fetus and placenta
200 mg are lost through various normal routes of excretion, primarily
the GIT.
average increase in the total volume of circulating erythrocytes
about 450 mL during pregnancy when iron is availableuses another
500 mg of iron, because 1 mL of normal erythrocytes contains 1.1 mg
of iron
during the second half of pregnancy, IRON requirement is averaging
6 to 7 mg/day
Hemoglobin production in the fetus, is not impaired, because the
placenta obtains iron from the mother even when the mother has
severe iron deficiency anemia.
The amount of iron absorbed from diet, together with that mobilized
from stores, is usually insufficient to meet the maternal demands
imposed by pregnancy.

BLOOD LOSS
bleeding from the placental implantation site, the
episiotomy or lacerations, and in the lochia.
NSD of a single fetus-estimated blood loss of 500-600
ml
CS of twins-estimated blood loss of 1000ml

IMMUNOLOGICAL AND LEUKOCYTE FUNCTIONS

pregnancy has been assumed to be associated with
suppression of a variety of humoral and cell-mediated
immunological functions in order to accommodate the
"foreign" semiallogeneic fetal graft
suppression of T-helper (Th) 1 and T-cytotoxic (Tc) 1
cells, which decreases the secretion of interleukin,
interferon, TNF

COAGULATION
In normal pregnancy, the coagulation cascade is in an
activated state
increased concentrations of all clotting factors, except factors
XI
and XIII, increased levels of high-molecular-weight fibrinogen
complexes.
fibrinogen concentration increases about 50 percent to
average about 450 mg/dL late in pregnancy, with a range
from 300 to 600 mg/dL.
The percentage of high-molecular-weight fibrinogen is
unchanged, increase in the erythrocyte sedimentation rate.
High-molecular-weight soluble fibrinfibrinogen complexes
circulate in normal pregnancy, and D-dimer serum
concentrations increase
average platelet count is decreased slightly during pregnancy

REGULATORY PROTEINS
natural inhibitors of coagulation, include protein C,
protein S, and antithrombin
Inherited or acquired deficiencies of these and other
natural regulatory proteins, collectively referred to as
thrombophilias, account for more than half of all
thromboembolic episodes during pregnancy
Protein C- unchanged
Protein S- decrease
Antithrombin-constant

CARDIOVASCULAR SYSTEM
The most important changes in cardiac function occur in
the first 8 weeks of pregnancy
Cardiac output is increased as early as the fifth week of
pregnancy, and this initial increase is a function of
reduced systemic vascular resistance and an increase in
heart rate.
Between weeks 10 and 20, notable increases in plasma
volume occur such that preload is increased.
Reduced in systemic vascular resistance and increase in
heart rate and preload
Vascular capacity increases

Change in cardiac outline that occurs in pregnancy. The blue lines

represent the relations between the heart and thorax in the
nonpregnant woman, and the black lines represent the conditions
existing in pregnancy

HEART

resting pulse rate increases about 10 beats/min during pregnancy

as diaphragm becomes elevated, the heart is displaced to the left
and upward, while at the same time it is rotated somewhat on its long
axis
apex of the heart is moved laterally from its position in the normal
nonpregnant state, and an increase in the size of the cardiac
silhouette is found in radiographs
ECG- slight left-axis deviation
exaggerated splitting of the first heart sound, increased loudness of
both components
Loud easily heard third sound
Systolic murmur in 90 percent of pregnant women that was
intensified during inspiration in some or expiration in others, and
disappeared very shortly after delivery
Left ventricular size is increased
In multifetal pregnancies, compared with singletons, maternal
cardiac output is greater by approximately 20 percent because of a
greater stroke volume

CARDIAC OUTPUT
arterial blood pressure and vascular resistance decrease
while blood volume, maternal weight, and basal
metabolic rate increase.
cardiac output at rest, when measured in the lateral
recumbent position, increases significantly beginning in
early pregnancy
arterial blood pressure decreases to a nadir at about
midpregnancy and rises thereafter
Diastolic pressure decreases more than systolic

HEMODYNAMIC FUNCTION IN LATE PREGNANCY

Increase in heart rate, stroke volume and cardiac output
Systemic vascular and pulmonary vascular resistance decreased

Cardiac output during three stages of

gestation, labor, and immediately postpartum
compared with values of nonpregnant women

CIRCULATION AND BLOOD

PRESSURE
Usually, arterial blood pressure decreases to a nadir at about midpregnancy
and rises thereafter. Diastolic pressure decreases more than systolic
blood flow in the legs is retarded during pregnancy except when the lateral
recumbent position is assumed.
elevated venous pressure returns to normal when the pregnant woman lies
on her side and immediately after delivery.
development of varicose veins in the legs and vulva, as well as
hemorrhoids.

SUPINE HYPOTENSION
with the woman in the supine position, the large pregnant uterus
consistently compresses the venous system that returns blood from the
lower half of the body resulting to reduced cardiac filing and decreased
cardiac output.
SUPINE HYPOTENSIVE SYNDROME significant arterial hypotension

RENIN, ANGIOTENSIN, PLASMA VOLUME

all components of this sytem are increased
Renin is produced by both the maternal kidney and the
uteroplacental unit, and increased renin substrate
(angiotensinogen) is produced by both maternal and fetal liver
renin-angiotensin system is important in early blood pressure
maintenance

CARDIAC NATRIURETIC PEPTIDE

regulate blood volume by producing significant natriuresis and
diuresis.
plasma levels of ANP during normal gestation are maintained in
the nonpregnant range despite the increased plasma volume
important in allowing the expansion of the extracellular fluid
volume that leads to increase in plasma aldosterone
concentrations characteristic of normal pregnancy

Hydronephrosis. A. Plain film from the 15-minute image of an intravenous

pyelogram (IVP). Moderate hydronephrosis on the right (arrows) and mild
hydronephrosis on the left (arrowheads) are both normal for this 35-week gestation. B.
Axial MR image from a study performed for a fetal indication.

PROSTAGLANDINS
Increased production of prostaglandins play a role in control of the
vascular tone.
Prostaglandin E2 synthesis in the renal medulla is increased markedly
in late pregnancy
principal prostaglandin of endothelium, also is increased in late
pregnancy

PROGESTERONE
prostaglandin-mediated vascular responsiveness to angiotensin II may
be progesteone related

ENDOTHELIN
produced in endothelial cells and vascular smooth muscle and is a
potent vasoconstrictor that regulates local vasomotor tone
endothelin receptors are present in pregnant and nonpregnant
myometrium, amnion, amnionic fluid, decidua, and placental tissue
stimulate secretion of ANP, aldosterone, and catecholamines.

BLOOD FLOW IN SKIN

Increased cutaneous blood flow serves to dissipate excess
heat generated by increased metabolism

RESPIRATORY TRACT
diaphragm rises about 4 cm during pregnancy
subcostal angle widens appreciably as the transverse
diameter of the thoracic cage increases about 2 cm
thoracic circumference increases about 6 cm
Diaphragmatic excursion is actually greater during
pregnancy than when nonpregnant

PULMONARY FUNCTION
INCREASE

DECREASE

1. Tidal Volume

1.Functional
1.Maximum
residual capacity
breathing capacity
2.Residual
2.timed vital capacity
Volume

1. Minute
Ventilatory
Volume
3.Minute oxygen
uptake
4.Airway
conductance
5.Critical Closing
Volume
6.Total
Oxygen
carrying
capacity

3.Total
Pulmonary
Resistance

SAME

ACID BASE EQUILIBRIUM

increased awareness of a desire to breathe is common
even early in pregnancy
mechanism of physiological dyspnea:
increase TV

PCO2

DYSPNEA

induced in large part by progesterone and to a lesser

degree by estrogen.
compensate for the resulting respiratory alkalosis, plasma
bicarbonate levels decrease from 26 to about 22 mmol/L.
As a result, blood pH is increased only minimally.
increase shifts the oxygen dissociation curve to the left
and increases the affinity of maternal hemoglobin for
oxygenthe Bohr effectthereby decreasing the
oxygen-releasing capacity of maternal blood.
the hyperventilation that results in a reduced maternal
PCO2 facilitates transport of carbon dioxide from the fetus
to the mother but appears to impair release of oxygen
from maternal blood to the fetus

URINARY SYSTEM
KIDNEY
Kidney size increases slightly during
pregnancy
glomerular filtration rate and renal plasma
flow increase glomerular filtration rate and
renal plasma flow increase
Amino acids and water- soluble vitamins are
lost in the urine of pregnant women in
much greater amounts than in nonpregnant
women

URINALYSIS
The appreciable increase in glomerular filtration, together with
impaired tubular reabsorptive capacity for filtered glucose, accounts
in most cases for glucosuria
Even though glucosuria is common during pregnancy, the possibility
of diabetes mellitus should not be ignored when it is identified.
Proteinuria normally is not evident during pregnancy except
occasionally in slight amounts during or soon after vigorous labor.
Hematuria, if not the result of contamination during collection, most
often suggests a diagnosis of urinary tract disease

URETERS
the uterus rises completely out of the pelvis, it rests upon the
ureters, laterally displacing and compressing them at the pelvic
brim.
ureteral dilatation to be greater on the right side
Elongation accompanies distention of the ureter

BLADDER
the increased size of the uterus, together with the hyperemia
that affects all pelvic organs, and the hyperplasia of the
muscle and connective tissues, elevates the bladder trigone
and causes thickening of its posterior, or intraureteric,
margin.
To compensate for reduced bladder capacity, absolute and
functional urethral lengths increased by 6.7 and 4.8 mm,
respectively.
To preserve continence, maximal intraurethral pressure
increased from 70 to 93 cm H2O. Still, the majority of women
experience urinary incontinence during pregnancy.
the pressure of the presenting part impairs the drainage of
blood and lymph from the base of the bladder, often
rendering the area edematous, easily traumatized, and
probably more susceptible to infection.

GASTROINTESTINAL TRACT
As pregnancy progresses, the stomach and intestines are displaced
by the enlarging uterus. As the result of the positional changes in
these viscera, the physical findings in certain diseases are altered.
gastric emptying time may be prolonged
Pyrosis (heartburn) is common during pregnancy and is most
likely caused by reflux of acidic secretions into the lower esophagus
OTHER REASONS WHY PYROSIS IS COMMON DURING
PREGNANCY
1.altered position of the stomach
2. lower esophageal sphincter tone is decreased
3.intraesophageal pressures are lower, intragastric pressures higher
in pregnant women.
4.esophageal peristalsis has lower wave speed and lower
amplitude.
gums may become hyperemic and softened during pregnancy

EPULIS OF PREGNANCY

- A focal highly
vascular swelling of the gums develops occasionally but typically
regresses spontaneously after delivery

pregnancy does not incite tooth decay

Hemorrhoids are fairly common during pregnancy

LIVER
Total alkaline phosphatase activity in serum almost doubles
during normal pregnancy, but much of the increase is
attributable to heat-stable placental alkaline phosphatase
isozymes.
Serum aspartate transaminase, alanine transaminase, glutamyl
transferase, and bilirubin levels-decrease
The concentration of serum albumin decreases during pregnancy
Leucine aminopeptidase activity- increase

GALLBLADDER
contractility of the gallbladder is reduced
progesterone impairs gallbladder contraction by
inhibiting cholecystokinin-mediated smooth muscle
stimulation, the primary regulator of gallbladder contraction.
Impaired gallbladder contraction leads to stasis, and this,
associated with the increased cholesterol saturation
of pregnancy, explains the increased prevalence of
cholesterol stones in multiparous women.
propensity for pregnancy to cause intrahepatic
cholestasis and
pruritus gravidarum from retained bile salts.
Intrahepatic cholestasis has been linked to high circulating
levels of estrogen, which inhibit intraductal transport of bile
acids

PITUITARY GLAND
During normal pregnancy the pituitary gland enlarges by
approximately 135 percent. Although it has been suggested
that the increase may be sufficient to compress the optic
chiasma and reduce visual fields, changes in vision during
normal pregnancy are minimal.
The maternal pituitary gland is not essential for maintenance
of pregnancy

GROWTH HORMONE
first trimester, secreted predominantly from the maternal
pituitary gland, and concentrations in serum and amnionic
fluid are within nonpregnant values of 0.5 to 7.5 ng/Ml
By about 17 weeks, the placenta is the principal source

PROLACTIN
Maternal plasma levels increase markedly during the course of
normal pregnancy
Serum concentration levels are usually 10-fold greater at term
about 150 ng/mLcompared with normal nonpregnant women.
after delivery, decreases even in women who are breast feeding
pulsatile bursts of prolactin secretion occur apparently in
response to suckling
estrogen stimulation increases the number of anterior pituitary
lactotrophs and may stimulate the release of prolactin from these
cells
amnionic fluid prolactin impairs the transfer of water from the
fetus into the maternal compartment, thus preventing fetal
dehydration during late pregnancy when amnionic fluid is
normally hypotonic.

THYROID GLAND
IMPORTANT CHANGES IN THYROID ECONOMY DURING PREGNANCY
Pregnancy induces a marked increase in circulating levels of the major
thyroxine transport protein, thyroxine-binding globulin, in response to high
estrogen levels.
Second, several thyroidal stimulatory factors of placental origin are produced
in excess.
Third, pregnancy is accompanied by a decreased availability of iodide for the
maternal thyroid.
thyroid undergoes moderate enlargement caused by glandular hyperplasia
and increased vascularity
thyroxine-binding globulin increases
Total serum thyroxine (T4) increases
Thyroid-releasing hormone (TRH) levels are not increased during normal
pregnancy
hCG has intrinsic thyrotropic activity, and thus, high serum levels cause
thyroid stimulation.

Relative changes in maternal

thyroid function during pregnancy

PARATHYROID GLANDS
plasma concentrations decrease during the first
trimester and then increase progressively
throughout the remainder of pregnancy
physiological hyperparathyroidism in
pregnancy to supply the fetus with adequate
calcium

CALCITONIN AND CALCIUM

Pregnancy and lactation cause profound calcium
stress, and during these times, calcitonin levels
are appreciably higher than in nonpregnant women.

VITAMIN D AND CALCIUM

Vitamin D, a hormone that is synthesized in the skin or
ingested, is converted by the liver into 25hydroxyvitamin D3. This form then is converted in the
kidney, decidua, and placenta to 1,25dihydroxyvitamin D3, serum levels of which are
increased during normal pregnancy
ADRENAL GLANDS
maternal adrenal glands undergo little, if any,
morphological change

CORTISOL
-the metabolic clearance rate of cortisol is lower during
pregnancy
-half-life is nearly doubled over that for nonpregnant
women

ALDOSTERONE
maternal adrenal glands secrete considerably increased
amounts of aldosterone

the increased aldosterone secretion during normal

pregnancy affords protection against the natriuretic effect of
progesterone and atrial natriuretic peptide

DEOXYCORTICOSTERONE
-Maternal plasma levels of this potent mineralocorticosteroid
progressively increase during pregnancy
-levels of deoxycorticosterone and its sulfate in fetal blood
are appreciably higher than those in maternal blood

DEHYDROEPIANDROSTERONE SULFATE
-levels circulating in maternal blood and excreted in the urine
are decreased during normal pregnancy

ANDROSTENEDIONE AND TESTOSTERONE

Maternal plasma levels of these androgens are increased
during pregnancy
Maternal plasma androstenedione and testosterone are
converted to estradiol in the placenta,which increases their
clearance rates
plasma production rate of maternal testosterone and
androstenedione during human pregnancy are increased

 MUSKULOSKELETAL SYSTEM
-Progressive lordosis is a characteristic feature of normal
pregnancy

lordosis shifts the center of gravity back over the lower

extremities.
The sacroiliac, sacrococcygeal, and pubic joints have increased
mobility during pregnancy.
-Joint mobility may contribute to the alteration of maternal
posture, and in turn causes discomfort in the lower back, and
bothersome late in pregnancy.( aching, numbness, and
weakness
also occasionally are experienced in the upper
extremities)

the marked lordosis with anterior neck flexion and slumping of the
shoulder girdle, in turn produce traction on the ulnar and median
nerves

Symphyseal diastasis. Marked widening of the pubic

symphysis (arrows) consistent with diastasis after
vaginal delivery

EYES
Intraocular pressure decreases during pregnancy, attributed in part to
increased vitreous outflow
Corneal sensitivity also is decreased
* Krukenberg spindles - Brownish-red opacities on the posterior surface
of the cornea

CNS
Women often report problems with attention, concentration, and memory
throughout pregnancy and the early postpartum period
Beginning as early as about 12 weeks, and extending through the first 2
months postpartum, women have difficulty going to sleep, frequent
awakenings, fewer hours of night sleep, and reduced sleep efficiency
During normal pregnancy, the frequency and duration of sleep apnea
episodes were decreased significantly compared with those postpartum
greatest disruption of sleep is encountered postpartum and may contribute
to postpartum blues.

THANK
YOU!