MUHIMBILI UNIVERSITY OF HEALTH      AND ALLIED SCIENCESCHOOL OF NURSINGMATERNAL AND CHILD HEALTH NURSINGPRESENTERS: JOH...
• Common changes and adaptation that takes  place during pregnancy and their implication  on the pregnancy women and nursi...
PHYISIOLOGICAL CHANGES DURING              PREGNANCY• Maternal physiological changes in pregnancy are the  normal adaptati...
Changes in the cardiovascular• Profound changes takes place in cardiovascular  system that would normally be considered  p...
Heart• The heart enlarges by about 12% between early  and late pregnancy• Distension of the heart is chambers is due to  i...
• The improvement in myocardial contractility is  thought due to; lengthening of muscle fibers or to the reduction of in...
• By the mid pregnancy more than 90% of women  develop an ejection systolic murmur• This lasts until the first week of pos...
• This can give an exaggerated impression of the cardiac  enlargement and account for the left axial deviation  seen on el...
Cardiac output• The increase cardiac output range from 35 to 50% in  pregnancy, from the average of 5% before pregnancy  t...
• The increased cardiac output is due to Increased stroke volume Heart rate, which begin in the 7th week and by the  thi...
-Increased cardiac output results to effects on: stroke volume increase, Heart rate increases and  Heart enlarges• The ca...
Blood volume• The two major components are blood-plasma and red cell• The total maternal blood vol increases 30-50% in sin...
• Plasma volume in corresponding with blood volume,  increased by 50% over the coarse of pregnancy• In a normal first preg...
• Red cell mass which represent the total volume  of red cell in the circulation, increases during  pregnancy in response ...
Changes caused by increase plasma        volume in pregnancyin spite the increase in production of the red cells ,the   ma...
Immunity –HCG and prolactin suppress the immune response of   pregnancy women.• Serum levels of immunoglobulins IgA,IgG,Ig...
Summary of common blood values      and their changes                 Normal              Changes in        timing        ...
Blood pressure• As the co is raised but the arterial blood pressure is reduced  by 10%• The decrease in peripheral vascula...
• There decrease in diastolic BP but little changes in systolic• The systolic BP falls an average of 5-10mmhg by 24wks  ge...
• If the paravertebral vessels and other venacaver are  not well developed and perfused the women may  suffer from supine ...
Changes in gastrointestinal system. The gums become oedematous , soft , and spongy  during pregnancy ,probably owing the ...
 Dietary changes in pregnancy , such as aversion to  coffee, alcohol, and fried food is very common in  pregnancy as are ...
• Although in early pregnancy many women experience nausea , an  increase in appetite may also be noticed with the daily f...
• As pregnancy progress , the enlarging uterus displace the  stomach and intestine .• As a result the appendix is displace...
 Marked reduction of gastric and intestinal tone and  motility plus relaxation of the lower oesophageal sphincter  predis...
• Delayed emptying during labor Gastro  esophageal reflux disease (GERD) Esophageal  dysmotility Gastric compression due t...
 The gall bladder become dilated during  pregnancy and the rate of emptying is sluggish  owing to the effect of progester...
Changes in respiratory system.• Pregnancy is associated with marked change in  respiratory physiology.• Increase in cardia...
• Knowledge of the changes in the mechanical  aspects of ventilation in normal pregnancy is  of particular importance for ...
RESPIRATORY CHANGESAlteration in sub division of the lung volume are largely  due to alter in thoracic anatomy during preg...
• LUNG VOLUME AND PULMONARY FUNCTION  Elevation of the diaphragm decreases the volume of  the lungs in the resting state, ...
URINARY SYSTEM• Anatomic Changes Renal hypertrophy Dilation of  renal pelvis/calyces 15mm on the right in 3 rd  trimester ...
• . RENAL HEMODYNAMICS Renal blood flow  increases 50% GFR increases 50% (120cc/min  ◊ 180cc/m) Serum Creatinine and BUN l...
ENDOCRINE CHANGESEndocrine changes in pregnancy is complexThyroid Physiology Euthyroid state Increase in thyroxine-binding...
• Pituitary gland Enlarges due to proliferation of prolactin-secreting cells Enlargement makes it more susceptible to alte...
CHANGES IN METABOLISM• Pregnant prolonged fasting Increased utilization of  fat stores Lipolysis generates glycerol, fatty...
Diabetogenic effects of pregnancy HPL ◊ lipolytic and   anti-insulin Cortisol Prolactin Estrogen and   progesterone Fetal ...
WEIGHT GAIN• A gain of about 12kg is to be expected in the pregnant woman of  average build and can be accounted for by th...
CONT…..• The pregnant women gains on the average approximatelly  2.5kg during the first 20 weeks of pregnancy.• During the...
SKELETAL CHANGES CONT…•  The pregnant woman has a different pattern of gait. The step  lengthens as the pregnancy progress...
Physiological changes in the   reproductive system     The body of the uterus
• After conception, the uterus develops to  provide a nutritive and protective  environment in which the fetus will develo...
Decidua• After embedding of the blastocyst there is  thickening and increased vascularity of the  lining of the uterus, or...
• Spontaneous labour is thought to result from  the activation of the decidua with resultant  prostaglandin release follow...
Myometrium• In early pregnancy uterine growth is due to  hyperplasia (increase in number due to  division) and hypertrophy...
• In the latter half of pregnancy the uterus expands  mechanically owing to distension of muscle cells  by the growing fet...
• By term the uterus has become a muscular sac  with soft, readily indentable walls of 0.5-1cm  or less in thickness, maki...
• It consists of a network of bundles of smooth  muscles.• These pass longitudinaly from the front of the  isthmus anterio...
• Each cell in this layer has a double curve so  that the interlacing of any two gives the  approximate form of a figure o...
• It forms sphincters around the openings of the  uterine tubes and around the internal cervical os.• The myometrium is bo...
• The collagenous connective tissue supports the  muscle fibres and provides a transmission  network for the tension devel...
• The contractile ability of the myometrium is  dependent on the interaction between two  contractile proteins,actin and m...
• Formation of gap junctions is promoted by  oestrogens and prostaglandins.• Uterine activity can be measured as early as ...
• By the third trimester the contractions may  become more rhythmic and noticeable,and  may reach a pressure of 20-40mmHg ...
• Typically, in the last few wks of pregnancy  prelabour occurs,in which further increase in  myometrial contractions caus...
The perimetrium• The perimetrium is a thin layer of peritoneum  that protects the uterus.• It provides a relatively inelas...
• The anterior and posterior folds open out so that  they are no longer in opposition and can  therefore accommodate the g...
Blood supply• As a result of increased cardiac output,the  uterine blood flow progressively increasses  almost tenfolds,fr...
• As the uterus grows and stretches however  the uterine spiral arteries become greatly  increased in diameter and uncoile...
12 week of pregnancy            th• By 12wks the uterus is about the size of a  grapefruit.• It is no longer anteverted an...
16 week of pregnancy           th• By 16th week the fetus has grown enough to  put pressure on the isthmus,causing it to  ...
20 week of pregnancy            th• At 20 weeks the fundus of the uterus can be  palpated at the level of the umbilicus.• ...
30 week of pregnancy           th• The lower uterine segment is still not  complete but can be defined as the portion  lyi...
• Assessment of fetal size by abdominal palpation  has been reported to be inaccurate as there is  considerable variabilit...
38 week of pregnancy            th• The uterus now reaches the level of the  xiphisternum.• The uterine tubes appear to be...
• This leads to reduction in fundal height known  as lightening releaving pressure on the upper  part of the abdomen but i...
SKIN CHANGES DURING     PREGNANCY
SKIN CHANGES DURING PREGNANCY• Skin changes will occurs from the third month  of pregnancy until full term.• The changes w...
The skin changes that are common        during pregnancy are:• Stretch marks,These are one of the most talked  about skin ...
Skin changes cont,• Mask of pregnancy ,This also referred to as melasma and  chlosma. Melasma causes dark splotchy spots t...
Skin changes cont,Acne If you have a problem with acne already,  your acne may become more irritated during  pregnancy. Th...
Skin changes cont,• Linea nigra is the dark line that runs from your  navel to your pubic bone. This is a line that may  h...
Skin changes cont,• Skin tags,These are very small, loose growths  of skin that usually appear under your arms or  breasts...
•END
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Changes to maternal

  1. 1. MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCESCHOOL OF NURSINGMATERNAL AND CHILD HEALTH NURSINGPRESENTERS: JOHN, SongomaMWASUBILA ,FabianNGUKA S MARIAMMUTEI PETERREGINA METHEW
  2. 2. • Common changes and adaptation that takes place during pregnancy and their implication on the pregnancy women and nursing education during ANC VISITS
  3. 3. PHYISIOLOGICAL CHANGES DURING PREGNANCY• Maternal physiological changes in pregnancy are the normal adaptations that a woman undergoes during pregnancy to better accommodate the embryo or fetus. They are physiological changes, that is, they are entirely normal, and include cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual
  4. 4. Changes in the cardiovascular• Profound changes takes place in cardiovascular system that would normally be considered pathological but in pregnancy are physiological.• Understanding of these changes is importance in care of women with normal pregnancies and management of women with pre-existing cardiovascular diseases whose health may be seriously compromised with the increased demand.
  5. 5. Heart• The heart enlarges by about 12% between early and late pregnancy• Distension of the heart is chambers is due to increasing the myometrial hypertrophy but mainly due to increased diastolic filling in parallel with the increase in blood volume.• The wall thickness increases very little.• cardiac enlargement does not appear to be associeted with reduced myocardial efficiency as proportion of blood ejected during systole increases during early pregnancy.
  6. 6. • The improvement in myocardial contractility is thought due to; lengthening of muscle fibers or to the reduction of in after load associated with the marked peripheral vasodilatation that is characteristics of pregnancy• During the late pregnancy the degree of vasodilatation decreases and the ejection fraction also diminishes.
  7. 7. • By the mid pregnancy more than 90% of women develop an ejection systolic murmur• This lasts until the first week of postpartum• If unaccompanied by any abnormality it reflects the increased stroke output• 20% develop a transient diastolic murmur• 10% develop continuous murmurs heard over the base of the heart, own to increased mammary blood flow• The growing uterus elevate the diaphragm ,the great vessels are unfolded and the heart is correspondingly displaced upwards with the apex moved laterally to the left by about 15 degrees
  8. 8. • This can give an exaggerated impression of the cardiac enlargement and account for the left axial deviation seen on electrocardiogram in pregnancy.• And for the apex beat appearing in the fourth rather than the fifth intercostals space• These ECG and radiographic changes are similar to those of ischemic heart diseases but are considered normal for pregnancy women• The atrial or ventricular extra systoles are frequent and there is increased susceptibility to supraventricular tachycardia
  9. 9. Cardiac output• The increase cardiac output range from 35 to 50% in pregnancy, from the average of 5% before pregnancy to approximately 7l/min by 20th week of pregnancy• Thereafter the changes are less dramatic• The increased cardiac output allows blood flow to the kidney,brain and coronary arteries to remain unchanged, while the distribution to other organs varies as the pregnancy advances e.g• Uterus receives 3% co in early pregnancy and 17% co at term(400mls extral)• Breasts receives less than 1% of co early in gestation and 2% co at term.
  10. 10. • The increased cardiac output is due to Increased stroke volume Heart rate, which begin in the 7th week and by the third trimester it has increased by 10-20%• The heart rate are typically 10 -15 b/min faster than those of the non pregnancy.• Increased from about 75 to 90b/min.• Women with normal hearts are aware of irregularities in heart beat in pregnancy• Stroke vol increases by 10% during 1st half of pregnancy and 20% week of gestation until term.
  11. 11. -Increased cardiac output results to effects on: stroke volume increase, Heart rate increases and Heart enlarges• The cardiovascular system more than any other is extremely sensitive to changes.• Large variations in CO,PR,BP and regional blood flow may follow trivial changes of• i) posture• Ii) activities• III) anxiety
  12. 12. Blood volume• The two major components are blood-plasma and red cell• The total maternal blood vol increases 30-50% in singleton pregnancy with a mean of 33%• A higher circulating volume is required to:• Protect the mother and fetus against the harmful effects of impaired venous return in supine and erect position.• Meet the demand of enlarged uterus ,hypertrophied vascular system and placental perfusion• Supply the extra metabolic needs of the fetus• Perfuse other body organs• Safeguard the mother against excessive blood loss at delivery
  13. 13. • Plasma volume in corresponding with blood volume, increased by 50% over the coarse of pregnancy• In a normal first pregnancy it may increase by 1250mls above non pregnancy levels and subsequent pregnancies it may increases by about 1500mls• The increase is related to the size of the fetus size, being larger in multiple pregnancies.• It start in the first trimester, expands rapidly up until 32-34 weeks gestation, then in the last week of pregnancy it plateaus with very little changes.• The increase in plasma volume reduces the viscosity of blood, this increase capillary flow.
  14. 14. • Red cell mass which represent the total volume of red cell in the circulation, increases during pregnancy in response to oxygen requirements of maternal and placental tissue• Increase level of erythropoietin and other hormones involves in erythropoiesis• Increase of F cell during pregnancy and reactivation of maternal hemoglobin• The number of F cell reaches the a peak at 18-22 week usually retuning to normal by 8 week of postpartum .
  15. 15. Changes caused by increase plasma volume in pregnancyin spite the increase in production of the red cells ,the marked increase plasma volume causes dilution of many circulating factors (hemoglobin conc and haematocrit conc decrease ).1.Haemodilution physiological anemia, decrease in concentration of plasma protein and decrease in concentration of immunoglobulin2.Incraeased cardiac output stroke volume increase, Heart rate increases and Heart enlarges
  16. 16. Immunity –HCG and prolactin suppress the immune response of pregnancy women.• Serum levels of immunoglobulins IgA,IgG,IgM decreases from 10th week and reach the lowest levels at 30wk until term.• Iron-The increased cell mass and needs of the developing fetus and placental lead increase requirement for iron in pregnancy• Iron demands increase from 2 to 4 mg daily• A healthy diet supply 10 to 14mg iron per day(5-10%) are absorbed and provide sufficient iron.• The purpose of iron supplementation is to maintain iron stores in order to prevent the development of true anemia
  17. 17. Summary of common blood values and their changes Normal Changes in timing range(nonpregnanc pregnancy yProtein(total) 65-85g/l 10g/l decrease By 20 week then stablealbumin 35-48g/l 10g/l decrease Mostly by 20 week then gradualfibrinogen 2.5-4 2g/l rise Progressively from3rd monthplatelates 150-400x 10 3/mm Slight decrease No significance changeClotting factors 6-10min Little changes Little change until 3-5 days of pregnancyWbc count 4-11x10 9/l 9x10 9/l From 2 month rises and reach Peak at 30 week then plateausRed cell 4.5x10 12/l 3.8x 10 12/l Decreanes progressively tovolume 30-40 week
  18. 18. Blood pressure• As the co is raised but the arterial blood pressure is reduced by 10%• The decrease in peripheral vascular resistance begins at 5wks gestation reaches maximum in the 2nd trimester(21%reduction)• And then gradually rises as the term approaches. but still slightly remain low to compensate with increased co• Reduced vascular resistance is thought due to mechanism controlling vascular activities(vasodilatation)• Agent responsible e.g. vasodilator( prostacyclin and nitric oxide),vasoconstrictor thromboxane A2
  19. 19. • There decrease in diastolic BP but little changes in systolic• The systolic BP falls an average of 5-10mmhg by 24wks gestation• Diastolic BP increases significantly during the 2nd half of pregnancy to levels that are at least equivalent to those of non pregnancy state• Posture can have major effects in BP e.g. supine position decrease CO 25%• Compression of the inferior vena caver by the enlarging uterus during 2nd and 3rd trimesters reduce venous return, decrease stroke vol and CO•
  20. 20. • If the paravertebral vessels and other venacaver are not well developed and perfused the women may suffer from supine hypotensive syndrome consisting hypotension, bradcardia, dizziness, light headedness, nausea and even syncope if she will remain too long.• the proper management should immediately if the conditions above happened eg changing Position, take vital sign, manage hypotension.
  21. 21. Changes in gastrointestinal system. The gums become oedematous , soft , and spongy during pregnancy ,probably owing the effect oestrogen , which can lead to bleeding when mildly traumatised as with a toothbrush. epulis or gingivitis ( focal, highly vascular swelling ) develop ; it is caused by growth of gum capillary . It is usually regress spontaneously after delivery . Profuse salivation or ptyalism is an occasional complaint in pregnancy it is caused by stimulation of salivary gland due to ingestion of starch .
  22. 22.  Dietary changes in pregnancy , such as aversion to coffee, alcohol, and fried food is very common in pregnancy as are craving for salted and spiced foods ; these are perhaps due to a dulling of sense of taste in pregnancy .• pica the term given to bizarre craving for and compulsive , secret chewing of food or ingestion of non food substances (e.g. ice , coal , disfectants ) . The mechanism of these for the dietary changes are poorly understood and usually of no significance to the pregnancy unless the material consumed inhibits iron absorption
  23. 23. • Although in early pregnancy many women experience nausea , an increase in appetite may also be noticed with the daily food intake increasing by up to 200kcal .• The hypothalamus , which controls the total body fat , reset by progesterone so that the new of fat store is achieved both by eating more and expending less energy . This facilitates the women to enter the third trimester with some 3.5kg of fat store accumulated , which provides an energy bank for the last trimester when fat storage practically stop but energy is required for the growth of the fetus .• Many women notice an increase in thirst in pregnancy because of the resetting of osmotic thresholds for thirst and vasopressin. This contributes towards a fall in plasma osmolality , leading to increase of water retention which is normal physiological alteration in pregnancy .HCG may influence osmoregulation
  24. 24. • As pregnancy progress , the enlarging uterus displace the stomach and intestine .• As a result the appendix is displaced upwards and laterally so that appendicitis can mistaken for pyelonephritis . At term the stomach attain vertical position rather than normal its normal horizontal ones .• These mechanical forces lead to increased intragastric pressure and change in the angle of the gastro- oesophageal junction , leading to greater oesophageal reflux .• The upward displacement of the stomach when the uterus is unusually large (as in multiple pregnancy or polyhydramnios ) makes many of the most annoying symptoms of pregnancy more difficult to treat
  25. 25.  Marked reduction of gastric and intestinal tone and motility plus relaxation of the lower oesophageal sphincter predispose to- heartburn- constipation and- hemorrhoids Around 80% of women experience some degree of heartburn during pregnancy , usually in the third trimester. It is thought to be due to small increase in intragastric pressure combined with decreased lower oesophageal sphincter tone , allowing gastric acid to reflux into the lower oesophagus. Although the true etiology remains unclear ,the combined influence of progesterone and oestrogen is probably responsible.
  26. 26. • Delayed emptying during labor Gastro esophageal reflux disease (GERD) Esophageal dysmotility Gastric compression due to enlarging uterus Decrease sphincter tone• Small bowel Motility is reduced due to progesterone allowing for more efficient absorption Large bowel• Decreased transit times allows for both water and sodium absorption Increased portal hypertension leading to dilation wherever there are portosystemic venous anastomoses
  27. 27.  The gall bladder become dilated during pregnancy and the rate of emptying is sluggish owing to the effect of progesterone. Bile may become thickened with the increase risk obstetric cholestasis.• Incomplete emptying of the gall bladder may result in retention of cholesterol crystal prerequisite for gall stone
  28. 28. Changes in respiratory system.• Pregnancy is associated with marked change in respiratory physiology.• Increase in cardiac output lead to substantial increase in pulmonary blood flow.• The blood volume expansion and vasodilation of pregnancy result in hyperaemia and oedema of the upper respiratory mucosa which predispose pregnancy women to nasal congestion , epistaxis and change in voice• Nasal decongestant spray should be used with caution because of their long term effect on the mucosa.
  29. 29. • Knowledge of the changes in the mechanical aspects of ventilation in normal pregnancy is of particular importance for understand the management chronic respiratory disease.• Up to 70% of pregnancy women with no underlying disease experience dyspnea which caused by enlarging uterus .sensitivity of respiratory centre to co2 increase due to effect of progesterone and oestrogen.
  30. 30. RESPIRATORY CHANGESAlteration in sub division of the lung volume are largely due to alter in thoracic anatomy during pregnancy . As uterus enlarges , the of diaphragm rises 4cm and the rib cage displaced upward . The shape of the chest changes as the anteroposterior and transverse diameter each increase by about 2cm resulting in expansion chest Chest circumference expands 5-7 cm Subcostal angle increases from 68 to 103 degrees Transverse diameter increases 2cm Level but excursion is not impeded Respiratory muscle function is not affected by pregnancy
  31. 31. • LUNG VOLUME AND PULMONARY FUNCTION Elevation of the diaphragm decreases the volume of the lungs in the resting state, reducing Total Lung Capacity by 5% and FRC by 20% FRC mainly decreased by RV Vital capacity does not change Spirometry is not changed in pregnancy FEV1 is unchanged Peak flow is unchanged . Chronic hyperventilation Progesterone induced Minute volume is increased . Tidal volume is increased by 30-40% Respiratory rate is unchanged Increased early in the first trimester
  32. 32. URINARY SYSTEM• Anatomic Changes Renal hypertrophy Dilation of renal pelvis/calyces 15mm on the right in 3 rd trimester 5mm on the left Predisposition to pyelonephritis in the presence of asymptomatic bacteriuria Dilation of ureters to 2 cm . Mechanical compression Progesterone-induced smooth muscle relaxationBLADDER CHANGES Bladder trigone elevation occurs with increased vascular tortuousity throughout the bladder leading to microhematuira Decrease bladder capacity Increased frequency of urinary incontinence
  33. 33. • . RENAL HEMODYNAMICS Renal blood flow increases 50% GFR increases 50% (120cc/min ◊ 180cc/m) Serum Creatinine and BUN levels decrease Glycosuria occurs due to exceding of maximum tubular reabsorptive capacity No increase in proteinuria UTI Pre-existing renal disease PET
  34. 34. ENDOCRINE CHANGESEndocrine changes in pregnancy is complexThyroid Physiology Euthyroid state Increase in thyroxine-binding globulin . Decrease in circulating pool of extra-thyroidal iodide Slight thyromegalyFree T4 and T3 remain normal Small amounts of TRH eachT4 cross the placenta Fetal thyroid active by 12 weeks gestationAdrenal function Increases in corticosteroid-binding globulin Increases in free cortisol Zona fasciculata is increased Marked increase in CRH from placental sources Delayed plasma clearance of cortisol due to renal changes Resetting of hypothalamic-pituitary sensitivity to cortisol feedback on ACTH production
  35. 35. • Pituitary gland Enlarges due to proliferation of prolactin-secreting cells Enlargement makes it more susceptible to alterations in blood flow, ie PPH Prolactin levels are increased (ten times higher at term) to prepare breasts for lactationPancreas and Fuel Metabolism Physiologic glucose intolerance to insure continuous transport of nutrients from mother to fetus Fasting hypoglycemia Postprandial hyperglycremia Hyperinsulinemia
  36. 36. CHANGES IN METABOLISM• Pregnant prolonged fasting Increased utilization of fat stores Lipolysis generates glycerol, fatty acids and ketones for gluconeogenesis and fuel More HPL, less insulin results in increased utilization of fat stores Maternal response to starvation Hypoglycemia, hypoinsulinemia Hyperlipidemia, hyperketonemia Maternal response to feeding Hyperglycemia, Hyperinsulinemia, Hyperlipidemia, Resistance to insulin Insulin secretion increases throughout Insulin resistance increases to 50-80% in third trimester Borderline pancreas function leads to GDM
  37. 37. Diabetogenic effects of pregnancy HPL ◊ lipolytic and anti-insulin Cortisol Prolactin Estrogen and progesterone Fetal glucose levels are 20 mg/dl less than maternal values Placental glucose transport is carrier mediated facilitated transport that is energy independentLipids and lipoproteins increase in pregnancy Total cholesterol, LDL, HDL and triglycerides all increase Necessary as precursors for steroid genesis does not appear to lead to atherosclerosis unless pre-existing hyperlipidemia
  38. 38. WEIGHT GAIN• A gain of about 12kg is to be expected in the pregnant woman of average build and can be accounted for by the following:• Fetus…………………..3.4kg• Placenta……………..0.6kg• Amniotic fluid……..0.8kg• Blood volume……….1.5kg• Weight of uterus……0.9kg• Weight of breasts…..0.4kg• Extracellular fluid……1.4kg• Fat …………………………3.5kg• Total………………………..12.5kg
  39. 39. CONT…..• The pregnant women gains on the average approximatelly 2.5kg during the first 20 weeks of pregnancy.• During the second 20 weeks, a gain of appr• oximatelly 9kg (0.45kg per week).Many factors are involved, including the metabolic rate of an individual, fluid balance, and the uterine contents eg twins, polyhydromnious• Inadequate weight gain during the first 20 weeks could be due to poor nutrition often in conjunction with smoking or to condition such as severe anaemia or pyelonephritis.• During the second 20 weeks, it may be due to fetal growth retardation and when fetal death occurs.• Oligohydromnious is a less common cause.
  40. 40. SKELETAL CHANGES CONT…• The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture. On average, a womans foot can grow by a half size or more during pregnancy.• In addition, the increased body weight of pregnancy, fluid retention, and weight gain lowers the arches of the foot, further adding to the foots length and width.• The influences of increased hormones such as estrogen and relaxin initiate the remodeling of soft tissues, cartilage and ligaments. Certain skeletal joints such as the pubic symphysis and sacroiliac widen or have increased laxity.• NOTE: It is the bones and not the teeth that are the store house for calcium, so it is no longer believed that the woman’s teeth decay during pregnancy because calcium is being withdrawn from them
  41. 41. Physiological changes in the reproductive system The body of the uterus
  42. 42. • After conception, the uterus develops to provide a nutritive and protective environment in which the fetus will develop and grow.
  43. 43. Decidua• After embedding of the blastocyst there is thickening and increased vascularity of the lining of the uterus, or decidua.• Decidualisation,influenced by progesterone and oestradiol,is most marked in the fundus and upper body of the uterus (the usual sites of implantation).• The decidua is now believed to maintain quiescence of the uterus during pregnancy.
  44. 44. • Spontaneous labour is thought to result from the activation of the decidua with resultant prostaglandin release following withdrawal of placental hormones.• The decidua and trophoblast also produce relaxin,which appears to promote myometrial relaxation and may have a role to play in cervical ripening and rupture of fetal membranes.
  45. 45. Myometrium• In early pregnancy uterine growth is due to hyperplasia (increase in number due to division) and hypertrophy(increase in size) of myometrial cells under the influence of oestrogen.• As gestation increases, hyperplasia is less important and hypertrophy accounts for most of the growth of the uterus.
  46. 46. • In the latter half of pregnancy the uterus expands mechanically owing to distension of muscle cells by the growing fetus and placenta.• The dimensions of the uterus vary considerably,however depending on the age and parity of the woman.• During the first few weeks of pregnancy the uterus walls become thicker and less firm growing from 1cm to 2.5cm by 4 months.
  47. 47. • By term the uterus has become a muscular sac with soft, readily indentable walls of 0.5-1cm or less in thickness, making palpation of the fetus relatively easy.• Hyperplasia and hypertrophy of the myometrium cells leads to the three layers of myometrium becoming more clearly defined.• Muscle layers:The outer longitudinal layer of muscle fibres is thin.
  48. 48. • It consists of a network of bundles of smooth muscles.• These pass longitudinaly from the front of the isthmus anteriorly over the fundus and into the vault of the vagina posteriorly,and extend to the round transverse ligaments.• The thicker middle layer comprises interlocked spiral myometrial fibres that are perforated in all directions by blood vessels.
  49. 49. • Each cell in this layer has a double curve so that the interlacing of any two gives the approximate form of a figure of eight.• Due to this arrangement ,contraction of these cells after delivery causes constriction of the blood vessels.• The inner circular layer is arranged concentrically around the longitudinal axis of the uterus and bundle formation is diffuse.
  50. 50. • It forms sphincters around the openings of the uterine tubes and around the internal cervical os.• The myometrium is both contractile(can lengthen and shorten) and elastic(can enlarge and stretch)to accommodate the growing fetus and allow involution following the birth.• Thin sheets of connective tissues composed of collagen,elastic fibres,fibroblasts and mast cells separate the interconnecting bundles.
  51. 51. • The collagenous connective tissue supports the muscle fibres and provides a transmission network for the tension developed by contraction of the smooth muscles elements.• Around the bundles of smooth muscles cells are blood and lymphatic vessels and nerve cells.• The myometrial smooth muscle cells increase in pregnancy up to 15-20 times their non pregnancy length or from 0.05-0.6mm.
  52. 52. • The contractile ability of the myometrium is dependent on the interaction between two contractile proteins,actin and myosin.• The interaction of actin and myosin brings about contraction,whereas their separation brings about relaxation under the influence of intracellular free calcium.• The coordination of synchronous contractions across the whole organ is due to the presense of the gap junctions that connect myometrial cells and provide connections for electrical activity.
  53. 53. • Formation of gap junctions is promoted by oestrogens and prostaglandins.• Uterine activity can be measured as early as 7 wks gestation.• Contractions facilitates uterine blood flow through the intervillous spaces of the placenta,promoting oxygen delivery to the fetus.
  54. 54. • By the third trimester the contractions may become more rhythmic and noticeable,and may reach a pressure of 20-40mmHg occurin every 10-20mins but usually cease with walking and exercise.• Braxiton Hicks contractions are usually painless but may cause some discomfort when their intensity exceeds 15mmHg,accounting for the so called false-labour.
  55. 55. • Typically, in the last few wks of pregnancy prelabour occurs,in which further increase in myometrial contractions cause the muscle fibres of the fundus to be drawn up.• The actively contracting upper uterine segment becomes thicker and shorter in length.• The prelabour contractions allow the pacemaker activity of the fundus to promote the coordinated,fundal-dominant contractions necessary for labour.
  56. 56. The perimetrium• The perimetrium is a thin layer of peritoneum that protects the uterus.• It provides a relatively inelastic base upon which the myometrium develops tension to increase intrauterine pressure’• It does not totally cover the uterus,being deflected over the bladder anteriorly to form the uterovesical pouch,and over the rectum posteriorily to form the pouch of Douglas.
  57. 57. • The anterior and posterior folds open out so that they are no longer in opposition and can therefore accommodate the greatly enlarged uterine and ovarian arteries and veins.• The round ligaments(contained within the hanging folds of perimetrium)provide some anterior support for the enlarging uterus and undergo considerable hypertrophy and stretching during pregnancy,which may cause discomfort or strain.
  58. 58. Blood supply• As a result of increased cardiac output,the uterine blood flow progressively increasses almost tenfolds,from approximately 50ml/min at 10wks gestation and reaching a maximum of 450-700ml/min at term.• 80% perfuses the placenta and 20% perfuses the myometrium.• The uterine arteries course along the lateral walls of the uterus giving off 9-14 branches,each of which penetrates the outer third of the myometrium.
  59. 59. • As the uterus grows and stretches however the uterine spiral arteries become greatly increased in diameter and uncoiled to provide the necessary extra length and to accommodate the increased uteroplacental blood flow.
  60. 60. 12 week of pregnancy th• By 12wks the uterus is about the size of a grapefruit.• It is no longer anteverted and anteflexed and has risen out of the pelvis and become upright.• The fundus may be palpated abdominally above the symphysis pubis.• The uterus usually inclines and rotates to the right so that the left margin of the uterus faces anteriorly.
  61. 61. 16 week of pregnancy th• By 16th week the fetus has grown enough to put pressure on the isthmus,causing it to unfold so that the uterus becomes more spherical in shape.• The isthmus and cervix develop into the lower uterine segment,which is thinner and contains less muscle and blood vessels than the corpus and is the site of incision for the majority of caeserian sections.
  62. 62. 20 week of pregnancy th• At 20 weeks the fundus of the uterus can be palpated at the level of the umbilicus.• From this stage of gestation until term the uterus becomes more cylindrical or ovoid in shape and has a thicker,more rounded,dome-shaped fundus.• As the uterus continues to rise in the abdomen,the uterine tubes become progressively more vertical,which causes increasing tension on the broad and round ligaments.
  63. 63. 30 week of pregnancy th• The lower uterine segment is still not complete but can be defined as the portion lying between the line of attachment of the uterovesical pouch of peritoneum superiorly and the internal os inferiorly.• At 30 weeks the fundus may be palpated mdway between the umbilicus and the xiphisternum.
  64. 64. • Assessment of fetal size by abdominal palpation has been reported to be inaccurate as there is considerable variability in the site of the umbilicus.• Consequently symphysis-fundal height measurements have become common practice.• However,a recent trial compairing the two methods found no differences in any of the outcomes measured and concluded that there is insufficient evidence to evaluate the use of symphysis-fundal height measurement during anc
  65. 65. 38 week of pregnancy th• The uterus now reaches the level of the xiphisternum.• The uterine tubes appear to be inserted slightly above the middle of the uterus.• As the upper segment muscle contractions increase in frequency and strength the lower uterine segment develops more rapidly and is stretched radially which along with cervical effacement and softening of the tissues of the pelvic floor,permits the fetal presentations.
  66. 66. • This leads to reduction in fundal height known as lightening releaving pressure on the upper part of the abdomen but increasing pressure in the pelvis,which may lead to constipation,urinary frequency and sometimes increased vaginal discharge.• This also encourages further descent of the fetus into the pelvis.
  67. 67. SKIN CHANGES DURING PREGNANCY
  68. 68. SKIN CHANGES DURING PREGNANCY• Skin changes will occurs from the third month of pregnancy until full term.• The changes which occurs are such as sudden new glow on the face or pinkish,reddish streaks on stomach,but not all every pregnant women will experience skin changes.The skin changes that are common during pregnancy are
  69. 69. The skin changes that are common during pregnancy are:• Stretch marks,These are one of the most talked about skin changes that can occur during pregnancy. Almost 90% of pregnant women will experience stretch marks. Stretch marks appear as pinkish or reddish streaks running down your abdomen and/or breasts.• Exercising and applying lotions that contain vitamin E and alpha hydroxy acids have been said to help in the prevention of stretch marks.
  70. 70. Skin changes cont,• Mask of pregnancy ,This also referred to as melasma and chlosma. Melasma causes dark splotchy spots to appear on your face. These spots most commonly appear on your forehead and cheeks and are a result of increased pigmentation.• When you become pregnant your body produces more hormones, which causes an increase in your pigmentation. Nearly 50% of pregnant women show some signs of the "mask of pregnancy".• This is minimised or prevented by avoiding sun exposure.
  71. 71. Skin changes cont,Acne If you have a problem with acne already, your acne may become more irritated during pregnancy. The extra hormones in your body cause your oil glands to secrete more oil, which can cause breakouts.• This is reduced through keeping strict cleansing routine. It is a good idea to use fragrance free soap to avoid nausea. Cleanse your face every night and every morning.
  72. 72. Skin changes cont,• Linea nigra is the dark line that runs from your navel to your pubic bone. This is a line that may have always been there, but you may have never noticed it before because it was a light color.• During pregnancy this line darkens and is possibly caused by the imbalance in hormones. It usually appears around the fourth or fifth month of pregnancy.• After pregnancy this line will fade.
  73. 73. Skin changes cont,• Skin tags,These are very small, loose growths of skin that usually appear under your arms or breasts.• After pregnancy the skin tags may disappear.
  74. 74. •END
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