for fourth year B.Sc(N) students

1. Physiological changes
&
Diagnosis of pregnancy
Prepared by,
Mrs. Royce Mathew

2. ►Duration of pregnancyDuration of pregnancy
 Averages 280 days or 40 weeks(10 lunarAverages 280 days or 40 weeks(10 lunar
months) from the 1months) from the 1stst
day of last menstrual periodday of last menstrual period
 Duration also divide in to three equal parts orDuration also divide in to three equal parts or
trimesters of slightly more than 13 weeks or 3trimesters of slightly more than 13 weeks or 3
calendar months.calendar months.
 Estimated date of confinement or deliveryEstimated date of confinement or delivery
calculated by nagele’s rulecalculated by nagele’s rule
►Another method of calculation of EDC is Mc Donald’sAnother method of calculation of EDC is Mc Donald’s
rule: after 24 weeks of gestation, the fundal heightrule: after 24 weeks of gestation, the fundal height
measurement will correspond to the week ofmeasurement will correspond to the week of
gestation plus 2 or 4 weeksgestation plus 2 or 4 weeks

3. Genital organs
Vulva- edematous, Superficial varicosities in multi
parous woman
Vagina- Walls become hypertrophied, edematous and
more vascular
secretion becomes copious, thin and curdy white,
pH more acidic due to conversion of glycogen to lactic
acid by Lactobacillus acidophilus- high estrogen
- Acidic pH prevent the multiplication of organism
But glycogen rich environment more susceptible for
fungal infection
- Jacquemier’s sign- Bluish discoloration of the

4. ►Leukorrhea- white or slightly gray mucoidLeukorrhea- white or slightly gray mucoid
discharge from the vagina, because ofdischarge from the vagina, because of
many exfoliated vaginal epithelial cellsmany exfoliated vaginal epithelial cells
caused by hyperplasia of normal pregnancy.caused by hyperplasia of normal pregnancy.
►The mucus fills the endo cervical canal,The mucus fills the endo cervical canal,
resulting in the formation of mucus plug-resulting in the formation of mucus plug-
Operculum.Operculum.
► It act as a barrier against bacterial infectionIt act as a barrier against bacterial infection
invasion during pregnancyinvasion during pregnancy

5. ►OvariesOvaries
 Progesterone called as hormone of pregnancyProgesterone called as hormone of pregnancy
must be present in adequate amount to sustainmust be present in adequate amount to sustain
pregnancypregnancy
 It suppress contraction and prevent tissueIt suppress contraction and prevent tissue
rejection of the fetusrejection of the fetus
 Corpus leutem secretes progesterone till 10-12Corpus leutem secretes progesterone till 10-12thth
week when the placenta is developedweek when the placenta is developed
 Ovulation ceases during pregnancy becauseOvulation ceases during pregnancy because
high circulating levels of estrogen andhigh circulating levels of estrogen and
progesterone, inhibit FSH and LHprogesterone, inhibit FSH and LH

6. Uterus
► Decidua- endometrium during pregnancy
► Myo metrium
► Progesterone and estrogen – decidua to
thicker, richer and more vascular at fundus
and in the upper body of uterus, usual site
of implantation
► Increase in weight - 60gm to 1000gm
► Increase in size - 7.5X 5 X2.5cm to
30X 23X 20 cm
► Estrogen cause growth of uterine muscle
(hypertrophy and hyper plasia) and
stretching beyond 20 weeks

7. Uterus able to stretch because progesterone cause
relaxation of smooth muscle
4 parts of the uterus are
Fundus-enlargement and thickening more at
fundus
Body ( Corpus- main portion between fundus and
Cx)
Isthmus ( neck) lower uterine segment
cervix- supra vaginal ( portion that extends inside
the uterus contains internal os) and vaginal (portion that
extends outside the uterus into vagina- the portion that
felt during vaginal examination)

8. ►Muscle layers
► - Outer longitudinal
► - Inner circular- involved in stretching of
lower uterine segment and cervix during
labour
► - Middle oblique layer (Intermediate)
criss -cross fashion- living ligature.
Strongest layer , helps to occlude blood
vessels running through the fibers

9. Blood supply
►Blood supply to uterus increased to meet
the growth of the fetus and uterus
 450-650 ml/mt at term
 Low maternal arterial pressure, contraction of
uterus and supine position are three factors
which known to reduce blood flow
 Doppler ultrasound done to find out uterine
blood flow especially in pregnancies
associated with decreased fetal blood flow
like PIH, IUGR, DM and multiple gestation
 Estrogen cause growth of new blood vessels

10. ►Braxton hicks contraction- painless uterine
contraction felt after 4th month. It facilitate
uterine blood flow through inter villous space of
placenta there by promote O2 delivery to fetus
►Braxton- Hicks who discovered
►It is the infrequent, spasmodic and pain less
contraction, the patient will not be aware of this
►During contraction complete closure of the
uterine veins and partial occlusion of arteries in
relation to inter villous space resulting
stagnation of blood

11. Changes in uterine shape
► 12th week – Uterus comes out of the pelvis
► 16th week- Uterus midway between symphysis pubis
and umbilicus
► 24th week- at umbilicus
► 28th week- mid way between xiphisternum and
umbilicus
► 36th week – at xiphisternum
► 40th week - 4 fingerbreadth below
xiphisternum
► Fundus enlarges more than the body

12. Fundal height measurement
36
32,40
28
24

13. Cervix- act as a effective barrier against infection, it
retains pregnancy
Progesterone- endo cervical cells secrete mucus
thicker and viscous during pregnancy and it forms a
cervical plug – operculum- provide protection from
infection
Length of cervix- 2.5 cm through out pregnancy
Softening of cervical tip is called Goodell sign – which
can be seen at 6th
week due to increase in
vascularity, hypertrophy and hyperplasia of the cells

14. ►Increased water content and vascularity ofIncreased water content and vascularity of
the areathe area
►Obvious change in the color andObvious change in the color and
consistency resulting in bluish purple colorconsistency resulting in bluish purple color
extend up to vagina and labia- chadwick’sextend up to vagina and labia- chadwick’s
signsign
►Before pregnancy Cx consistency similar toBefore pregnancy Cx consistency similar to
that of tip of nose and during pregnancy asthat of tip of nose and during pregnancy as
that of lipthat of lip
►Cervical softening is termed as goodell’sCervical softening is termed as goodell’s
signsign

15. Changes in the cardio vascular system
Maternal adjustment to pregnancy involves extensive
changes in the CVS
Heart
► The size may increase- Increase in work load
► CO starts to ↑ from 5th wk and reaches maximum by 30-
34 weeks, ad return to pre-labour values by one hr
following delivery and to the pre pregnant level by another
4 wks
► Blood pressure – Systemic vascular resistance decreases
due to smooth muscle relaxation( effect of progestrone)
► Supine hypotension syndrome- In late pregnancy gravid
uterus will compress the IVC in supine position → venous
return decreases →hypotension, tachycardia and syncope

16. ► CO lowest in sitting or supine positionCO lowest in sitting or supine position
► Highest in lateral or knee chest positionHighest in lateral or knee chest position
► CO increases due to increase in blood volume toCO increases due to increase in blood volume to
meet additional O2 demand.meet additional O2 demand.
► Increase in COIncrease in CO →→ increase in stroke volume andincrease in stroke volume and
HR to 15bpm.HR to 15bpm.
► Normal heart will able to cope up with thisNormal heart will able to cope up with this
► Uterine blood flow is increased from 50ml/mt toUterine blood flow is increased from 50ml/mt to
750ml@term, blood flow to skin & mucus750ml@term, blood flow to skin & mucus
membrane reaches Maximum 500ml/mt by 36membrane reaches Maximum 500ml/mt by 36thth
week. Heat sensation, sweating or stuffy noseweek. Heat sensation, sweating or stuffy nose
usually complained due to increased blood flowusually complained due to increased blood flow

17. Breasts:
Fullness, increased sensitivity, tingling, heaviness due to
increase in estrogen and progestrone
Size: increased size due to hypertrophy and proliferation of
ducts
- Nipple becomes larger, erectile and deeply pigmented.
- Sebaceous glands become hypertrophied and are called
Montgomery’s tubercles, placed around nipples and secretion
have protective role in keeping the nipple and areola moist and
healthy for breast feeding
- Outer zone is less marked and irregular pigmented area
appears in 2nd
trimester and is called secondary areola

18. ►Estrogen stimulate growth of mammaryEstrogen stimulate growth of mammary
ductal tissue and progesterone promotesductal tissue and progesterone promotes
growth of lobes, lobules and alveoligrowth of lobes, lobules and alveoli

19. ► although the development of mammary
gland is completed by mid pregnancy
lactation is inhibited by high estrogen level
►secretion (colostrum- yellow secretion) can
be squeezed out of the breast from 2nd
trimester.
► Demonstration of secretion from the
breast of a woman who has never lactated
is an important sign of pregnancy

20. Cutaneous changes
- are due to melanocyte stimulating hormone which
increased during pregnancy
Face -( Cholasma gravidarum or pregnancy mask) Extreme
form of pigmentation around cheek, forehead and around eyes
Breast-
Abdomen
Linea Nigra- (due to separation of under lying connective
tissue of the skin) it is the brownish black pigmented area from
symphysis pubis to umbilicus
straie gravidarum- Initially pink, but after delivery they
become glistering white appearance called striae albicans
Increase blood supply to skin leads to sweating

21. ►Straie represents the scar tissues in theStraie represents the scar tissues in the
deeper layer of the skindeeper layer of the skin
►Angiomas referred to vascular spiders, itAngiomas referred to vascular spiders, it
occurs as a result of elevated levels ofoccurs as a result of elevated levels of
circulating progesterone. They disappearcirculating progesterone. They disappear
after the deliveryafter the delivery
►Palmar erythema- are due to increasedPalmar erythema- are due to increased
estrogen levelsestrogen levels
►Gum hypertrophy may occurGum hypertrophy may occur
►Nail growth may be acceleratedNail growth may be accelerated
►Increased blood flow to the skin may causeIncreased blood flow to the skin may cause
increased perspirationincreased perspiration

22. Weight gain
Total - 11-12 kg
First trimester - 1Kg
Second trimester - 5 Kg
Third trimester - 5kg
Normal BMI ( 20-26) - 11-16 kg
BMI > 29 - up to 7 kg
BMI < 19 - up to 18 kg
Importance of weight checking
rapid weight gain
Stationary or falling weight

23. ►Maternal weight gain and nutrition duringMaternal weight gain and nutrition during
pregnancy directly proportional to fetus’spregnancy directly proportional to fetus’s
weight gainweight gain
►Adequate protein intake is essential forAdequate protein intake is essential for
meeting the demands of the pregnancymeeting the demands of the pregnancy
►BMR increase to 30% higher dependingBMR increase to 30% higher depending
upon pre pregnancy health statusupon pre pregnancy health status

24. Hematological changes
Blood volume- increased to 40-50% at 30-32 wks of
gestation. By 10th
12th
week starts to increase and
reaches maximum by 32th week.
Plasma Volume- increased to 50%
RBC and hemoglobin- increased to extent of 20-30%
Physiological anemia-
Increased blood volume because- to transport nutrients
and O2 to the placenta where they available for growing
fetus & to meet the demand of the expanded maternal
tissue in the uterus and breasts.

25. ► 5 major changes in blood flow occur during5 major changes in blood flow occur during
pregnancypregnancy
 Blood flow altered to include uteroplacental unit. AboutBlood flow altered to include uteroplacental unit. About
500-600 ml/ mt is required to perfuse the uterus and500-600 ml/ mt is required to perfuse the uterus and
placenta at termplacenta at term
 Renal plasma blood flow increases up to 75% to removeRenal plasma blood flow increases up to 75% to remove
the increased metabolic wastes generated by motherthe increased metabolic wastes generated by mother
and fetusand fetus
 Woman’s skin requires increased circulation to dissipateWoman’s skin requires increased circulation to dissipate
heat generated by increased metabolism duringheat generated by increased metabolism during
pregnancypregnancy
 Blood flow the breast increases resulting in engorgedBlood flow the breast increases resulting in engorged
and dilated veinsand dilated veins
 Wt. of the expanded uterus on the inferior vena cava andWt. of the expanded uterus on the inferior vena cava and
iliac veins partially obstucts blood return from the leg,iliac veins partially obstucts blood return from the leg,
and blood pools in the deep and superficial veins. Itand blood pools in the deep and superficial veins. It
causes stasis of blood and venous distention.causes stasis of blood and venous distention.

26. Advantages of haemo dilution
► ↓blood viscosity ensure adequate gaseous exchange
between the maternal and fetal circulation
► protect mother against adverse effect of blood loss
during delivery
Total protein- Increases from 180gm to 230 gm at term
► Blood coagulation factors- hyper coagulable state, all
coagulation factors( I, VII, VIII,IX, X) increased, to
control blood loss and haemostasis after separation of
placenta
► Fibrynolytic decreases during pregnancy
► Platelet count may decrease slightly

27. ►Blood componentsBlood components
 Iron absorption and iron binding capacityIron absorption and iron binding capacity
increased during pregnancy, ironincreased during pregnancy, iron
supplementation is needed for Hb synthesis andsupplementation is needed for Hb synthesis and
erythrocyte production to prevent iron deficiencyerythrocyte production to prevent iron deficiency
anemiaanemia
 Erythrocyte production increases by 30% withErythrocyte production increases by 30% with
supplementation and 18% withoutsupplementation and 18% without
supplementationsupplementation
 Leukocyte increases during pregnancy toLeukocyte increases during pregnancy to
12,000-15,000 cells/mm312,000-15,000 cells/mm3

28. Metabolic changes- increased to meet the need of growing fetus
Protein metabolism- +ve Nitrogen balance through out
pregnancy. At term fetus and placenta contains about 500gm of
protein. Breakdown of amino acid to urea suppressed, the
blood urea levels falls 15-20%.
Pregnancy is a anabolic state
CHO metabolism - insulin secretion increased. Increased
transfer of glucose to baby . Hypertrophy and hyperplasia of β
cells sensitivity to insulin receptor decrease specially at term.
GFR of glucose increase to exceed the tubular reabsorption. So
glycosuria detected in 50% of cases
Fat- average 3-4 Kg of the fat stored during pregnancy. Especially
at abdominal wall, breast, hip and thigh. HDL increase by 15%.
LDL is utilized for placental steroid synthesis

29. ► Iron – actively transported to placenta. IronIron – actively transported to placenta. Iron
requirement during pregnancy is 1000mg ( fetus,requirement during pregnancy is 1000mg ( fetus,
placenta- 300 mg, increase RBC- 400, 200 mgplacenta- 300 mg, increase RBC- 400, 200 mg
loss in normal route)loss in normal route)
► Iron requirement more in the third trimesterIron requirement more in the third trimester
► Calcium metabolism- increased demands of CA byCalcium metabolism- increased demands of CA by
growing fetus to 28gm.growing fetus to 28gm.
 80% of which in 380% of which in 3rdrd
trimester. Daily requirement duringtrimester. Daily requirement during
pregnancy 1-1.5gm.pregnancy 1-1.5gm.
 Ca absorption from kidney increased due to increasedCa absorption from kidney increased due to increased
level of 1,25 dihydroxy vitamin D3. Calicitonin levellevel of 1,25 dihydroxy vitamin D3. Calicitonin level
increased 20%. It protect maternal skeleton fromincreased 20%. It protect maternal skeleton from
osteoporosisosteoporosis

30. ► Systemic changes
► Respiratory system
- elevation of diaphragm by 4 cm at term
- hyper ventilation causes change in acid-base
balance, slight increase in pH indicate that
pregnancy is a state of compensatory respiratory
alkalosis.
-These changes facilitate the transport of CO2
from the fetus and transport O2release from
mother to the baby
- O2 consumption rises to 20-40% to provide
increased demand of the mother and baby, for
this progestrone causes hyperventilation slightly
by deep breathing. And this causes rise in tidal
volume 30-40%

31. 2.Urinary system
- Dilatation of ureter and renal pelvis
- renal plasma flow ↑by 50-70%
-GFR ↑by 50% through out pregnancy
Bladder- marked congestion and hypertrophy of
the muscles of the wall
► Urinary frequency results initially from increased
bladder sensitivity and later from compression
bladder
► Capacity of kidney to excrete water during the
early weeks of pregnancy than in later months.
The pooling of fluid in legs in the later part of
pregnancy decreases the renal blood flow and
GFR- physiologic edema

32. ► Normally kidneys reabsorb almost all of theNormally kidneys reabsorb almost all of the
glucose and other nutrients from the plasmaglucose and other nutrients from the plasma
filtratefiltrate
► In pregnancy tubular reabsorption of glucose isIn pregnancy tubular reabsorption of glucose is
impaired so that glycosuria occursimpaired so that glycosuria occurs
► Proteinuria does not occur in normal pregnancyProteinuria does not occur in normal pregnancy
► Stagnated urine is excellent medium for growthStagnated urine is excellent medium for growth
and multiplication of microorganism.and multiplication of microorganism.
 In addition the urine of the pregnant woman containsIn addition the urine of the pregnant woman contains
more nutrients, including glucose, there by increasingmore nutrients, including glucose, there by increasing
pH, this makes pregnant woman more susceptible forpH, this makes pregnant woman more susceptible for
UTIUTI

33. 3. GIT
- Gums become congested and spongy and may tend to bleed
because of the estrogen causes hyperemia
- Muscle tone and mobility of entire GIT decreased due to
high progesterone level
- Cardiac sphincter relaxed and regurgitation of acid gastric
content into esophagus may produce oesophagitis and heart
burn
-decreased gut motility- helps in the maximum absorption of
the nutrients from the gut BUT this will lead to constipation,
exacerbate the hemorrhoids due to the relaxing effect of
progesterone
- Nausea and vomiting due to increased hCG level

34. ► Increased salivation – ptyalism( stimulationIncreased salivation – ptyalism( stimulation
of the salivary gland by ingestion of starch)of the salivary gland by ingestion of starch)
► delayed gastric emptying – helps in maximumdelayed gastric emptying – helps in maximum
absorption of nutrientsabsorption of nutrients
►Delayed emptyingDelayed emptying → slow emptying→ slow emptying →→
increased stomach acidityincreased stomach acidity → heart burn( pyrosis)→ heart burn( pyrosis)
►Appetite- picaAppetite- pica

35. 4. Liver and gall bladder- although no histological
change, functions may depressed. Functional
change may occur due to effects of progesterone
( serum alkaline phosphatase rises to 2-4 times,
serum albumin and total protein falls gradually) Gall
bladder become hypotonic, and emptying time
prolonged. Bile become thicker and cholesterol
crystals may be retained. Reduced gall bladder tone
leads to retain bile salts- itching( pruritus)
5. Nervous system
- Compression of the median nerve underneath the
carpal ligament over the wrist joint leading to pain
and paraesthesia in the hands and arm- carpel
tunnel syndrome
tension head ache is common

36. Skeletal changes
- Relaxation of pelvic ligaments and muscles
occur because of influence of estrogen and relaxin,
maximum during last weeks of pregnancy
- Symphysis pubis widens 4mm by 32 wks
gestation
- Increased mobility of pelvic joints facilitate
vaginal delivery
- Posture of pregnant woman alters to
compensate for the enlarging uterus anteriorly, woman
lean backward to exaggerating normal lumbar
curvature causing progressive lordosis

37. Endocrine system
1.Placental hormone
a.Estrogen & Progestrone – Breast changes,
skin pigmentation and uterine enlargement
b. Chorionic gonadotrophin – Immunological
pregnancy tests, immuno suppressive
activity, stimulate both adrenal and placental
steroidgenesis
c. Human placental lactogen – Antagonises
insulin action, stimulate growth of breast

38. Pituitary GlandPituitary Gland
► Production of FSH and LH stopped due toProduction of FSH and LH stopped due to
high estrogen and progesteronehigh estrogen and progesterone
►Increased production of GHIncreased production of GH
►Serum prolactin produced by the anteriorSerum prolactin produced by the anterior
pituitary glandpituitary gland
►Later pregnancy post. Pituitary produceLater pregnancy post. Pituitary produce
Oxytocin but the action inhibited byOxytocin but the action inhibited by
progesterone , oxytocin also stimulate milkprogesterone , oxytocin also stimulate milk
ejection reflex after child birthejection reflex after child birth

39. Thyroid and parathyroid glandThyroid and parathyroid gland
► Enlarges to an extent to increases the BMR toEnlarges to an extent to increases the BMR to
20%.20%.
► Early in pregnancy T4 rises, along withEarly in pregnancy T4 rises, along with
corresponding increase in thyroxine bindingcorresponding increase in thyroxine binding
globulinglobulin
► Both T3 & T4 cross the placenta, thyroid hormoneBoth T3 & T4 cross the placenta, thyroid hormone
are necessary for the development of the fetal CNSare necessary for the development of the fetal CNS
because fetus does not synthesize thyroid hormonebecause fetus does not synthesize thyroid hormone
till 12 weeks of gestationtill 12 weeks of gestation
► If sufficient supply of Iodine not present goiterIf sufficient supply of Iodine not present goiter
( thyroid hypertrophy) can occur.( thyroid hypertrophy) can occur.
► Parathyroid gland, which is necessary for the CaParathyroid gland, which is necessary for the Ca
metabolism , will increase in size during pregnancymetabolism , will increase in size during pregnancy
because the Ca is important for fetal growth.because the Ca is important for fetal growth.

40. ►Adrenal glandAdrenal gland
 Activity increased in pregnancy asActivity increased in pregnancy as
increased levels of corticosteroids andincreased levels of corticosteroids and
aldosterone are producedaldosterone are produced
 Cortisol regulates CHO and proteinCortisol regulates CHO and protein
metabolismmetabolism
 Aldosterone regulates the absorption ofAldosterone regulates the absorption of
sodium from the distal tubules of thesodium from the distal tubules of the
kidneykidney
► Pancreas- increased production of thePancreas- increased production of the
insulininsulin

41. ►Corpus leutem- the yellow body left on theCorpus leutem- the yellow body left on the
surface of the ovary and formed from thesurface of the ovary and formed from the
remains of grafian follicle after the dischargeremains of grafian follicle after the discharge
of the ovum. If it retrogress menstruationof the ovum. If it retrogress menstruation
occurs but it persist for several months ifoccurs but it persist for several months if
pregnancy supervenes. It secretes 40mg ofpregnancy supervenes. It secretes 40mg of
progesterone /day. After the implantationprogesterone /day. After the implantation
hCG and possibly hPL secretion byhCG and possibly hPL secretion by
stncytiotrophoblast cells maintain growthstncytiotrophoblast cells maintain growth
and function of corpus leutem. At 6-8 wksand function of corpus leutem. At 6-8 wks
transfer of functions of corpus leutem to thetransfer of functions of corpus leutem to the
placentaplacenta

42. Placental endocrinologyPlacental endocrinology
►6-8 weeks transfer of functions of corpus6-8 weeks transfer of functions of corpus
luteum to the placentaluteum to the placenta
►Hormones of the placentaHormones of the placenta
 Protein hormonesProtein hormones
►Human chorionic gonadotrophin (hCG)Human chorionic gonadotrophin (hCG)
►Human placental Lactogen (hPL)Human placental Lactogen (hPL)
 steroid hormonessteroid hormones
►EstrogenEstrogen
►progesteroneprogesterone

43. Human chorionic gonadotrophin (hCG)Human chorionic gonadotrophin (hCG)
 It is a glycoproteinIt is a glycoprotein
 Chemically and functionally similar to LHChemically and functionally similar to LH
 Placental GnRH have control over the hCGPlacental GnRH have control over the hCG
formationformation
► FunctionsFunctions
 Act as stimulus for secretion of progesteroneAct as stimulus for secretion of progesterone
 Stimulates Leydig cells of male fetus to produceStimulates Leydig cells of male fetus to produce
testosteronetestosterone
 Immuno suppressive activityImmuno suppressive activity
 Stimulate maternal thyroidStimulate maternal thyroid

44. ► Levels of hCGLevels of hCG
 Half life is 24 hoursHalf life is 24 hours
 By radio immuno assay it can be detected in the serumBy radio immuno assay it can be detected in the serum
or urine as early as 8-9 days following ovulationor urine as early as 8-9 days following ovulation
 Blood and urine values reaches the maximum betweenBlood and urine values reaches the maximum between
60-70 days of pregnancy60-70 days of pregnancy
 Concentrations falls slowly reaching to low levelConcentrations falls slowly reaching to low level
between 100-130 daysbetween 100-130 days
 Then the level remain constant with slight increase in 32Then the level remain constant with slight increase in 32
weeksweeks
► High levels of hCG in multiple pregnancy,High levels of hCG in multiple pregnancy,
hydatidiform mole, chorio carcinoma, pregnancyhydatidiform mole, chorio carcinoma, pregnancy
with down syndromewith down syndrome
► hCG disappear after 2 weeks following deliveryhCG disappear after 2 weeks following delivery

45. Human placental lactogenHuman placental lactogen
► chemically and immunologicaly similar tochemically and immunologicaly similar to
pituitary growth hormone and prolactinpituitary growth hormone and prolactin
► first detected in 5first detected in 5thth
weekweek
►Level rises from 5Level rises from 5µg/ml to 25µg/ml until 36µg/ml to 25µg/ml until 36
weeksweeks
►Plasma concentration proportional toPlasma concentration proportional to
placental massplacental mass

46. Estrogen – site of production isEstrogen – site of production is
syncytiotrophoblastsyncytiotrophoblast
►First detected at 9 weeks(0.05First detected at 9 weeks(0.05nn g) andg) and
gradually increase to 30 ng at termgradually increase to 30 ng at term
►Low estriol in case ofLow estriol in case of
 Fetal deathFetal death
 Fetal anomalies( anencephaly, down syndrome)Fetal anomalies( anencephaly, down syndrome)
 Hydatidiform moleHydatidiform mole

47. ► Functions of estrogenFunctions of estrogen
 Estrogen cause the hypertrophy and hyperplasia ofEstrogen cause the hypertrophy and hyperplasia of
uterine myometrium thus uterine growthuterine myometrium thus uterine growth
 Hypertrophy and proliferation breast ducts and glandsHypertrophy and proliferation breast ducts and glands
for the preparation offor the preparation of
 Estrogen sensitizes the myometrium to oxytocin andEstrogen sensitizes the myometrium to oxytocin and
PGs, it ripen the cervixPGs, it ripen the cervix
 Hyper pigmentation and vascular changes in the skin,Hyper pigmentation and vascular changes in the skin,
increased activity of salivary gland, and hyperemia ofincreased activity of salivary gland, and hyperemia of
the gums and nasal mucus membranesthe gums and nasal mucus membranes

48. ►ProgesteroneProgesterone
►Average levels of plasma progesteroneAverage levels of plasma progesterone
 At 12At 12thth
week- 25ngweek- 25ng
 2828thth
weekweek - 80ng- 80ng
 At termAt term - 300ng- 300ng
► low progesteronelow progesterone
 Ectopic pregnancyEctopic pregnancy
 AbortionAbortion
► high levelshigh levels
 Hydatidiform moleHydatidiform mole
 Rh iso immunizationRh iso immunization
► after delivery plasma progesterone decreaseafter delivery plasma progesterone decrease
rapidly and not detectable after 24 hoursrapidly and not detectable after 24 hours

49. ► Functions of progesteroneFunctions of progesterone
 Maintaining the endometrial layer for implantation of theMaintaining the endometrial layer for implantation of the
fertilized ovumfertilized ovum
 Preventing spontaneous abortion by relaxing thePreventing spontaneous abortion by relaxing the
smooth muscles of the uterussmooth muscles of the uterus
 Helping to prevent tissue rejection of the fetusHelping to prevent tissue rejection of the fetus
 Stimulating the development of the lobes and lobules inStimulating the development of the lobes and lobules in
the breastthe breast
 Facilitating the deposit of maternal fat stores to provideFacilitating the deposit of maternal fat stores to provide
reserve of energy for pregnancy and lactationreserve of energy for pregnancy and lactation
 Relaxing smooth muscles of the uterus, and otherRelaxing smooth muscles of the uterus, and other
smooth musclessmooth muscles
 Increase respiratory sensitivity to CO2, stimulatingIncrease respiratory sensitivity to CO2, stimulating
ventilationventilation
 Suppressing the immunologic response, preventingSuppressing the immunologic response, preventing
rejection of the fetusrejection of the fetus

50. Diagnostic value of placentalDiagnostic value of placental
hormonehormone
►Diagnosis of pregnancyDiagnosis of pregnancy
►Follow up of trophoblastic tumorsFollow up of trophoblastic tumors
►Detection of function of feto placental unitDetection of function of feto placental unit

51. Diagnosis of pregnancy
1st
trimester
- Amenorrhoea- placental sign
- Morning sickness
- frequency of micturition
- Breast discomfort, fatigue
Objective
- Breast changes- valuable for primi
- Jacquemier’s sign - Osiander’s sign
- Goodell’s sign

52. ►Endocrine
- hCG in urine 2-3 days, blood 2 days after
missing period
►USG
-Uterine sac 29-35 days
- Embryonic movement 7 weeks, FHS- 10th
week

53. Second trimester
-Quickening
- progressive Abdominal growth
-palpation of fetal parts by 20th
week
- Active fetal movement after 20th
week
- Cholasma
- Breast changes- secondary aerola,
montgomery tubercle, colostrum

54. ►Abdominal examinationAbdominal examination
 Inspection- linea nigra, straieInspection- linea nigra, straie
 Palapation- fundal height increasesPalapation- fundal height increases
►Braxton hicks contractionBraxton hicks contraction
►Active fetal movementsActive fetal movements
► USGUSG

55. ► Third trimester
 Symptoms
►Amenorrhea
►Enlargement of the abdomen
►Lightening
►Frequency of micturition
►Fetal movements
 signs
►Cutaneous changes
►Uterine shape changes from cylindrical to spherical
►Fundal height
►Fetal movements
►Palpation of fetal parts
►FHS
►USG

56. Sign time of occurrence Differential
diagnosis
Possible ( Presumptive)
1. Early breast changes 3-4 wks Contraceptive pill
2. Amenorrhoea 4 wks Hormonal imbalance
Emotional stress, illness
3.Morning sickness 4-14 wks GI disorders, pyrexial illness
cerebral irritation
4. Bladder irritability 6-12 wks UTI, Pelvic tumour
5. Quickening 16-20 wks Intestinal movement -wind

57. Sign Time of occurrence Differential diagnosis
Probable signs
Presence of hCG in
- blood 4-12 wks Hydatidiform mole
- urine 6-12 wks Chorio carcinoma
Softened Isthmus 6-12 wks
(hegar’s sign)
Bluening of vagina 8 wks+ Pelvic congestion
(Jacquemier’s sign)
Pulsation in fornices 8 wks
(Osiander’s sign)
Uterine growth 8 wks+ Uterine growth
Braxton Hicks contractions 16 wks
Ballottement of fetus 16 wks

58. Sign Time of occurance Differential diagnosis
Positive signs
Visulization of fetus by
- Ultra sound 6 wks+
- X-Ray 16 wks +
FHS by,
- Ultra sound 6 wks + No
- fetal stethoscope 20-24 wks+ alternative
Fetal movements changes
- Palpable 22 wks+
- Visible Late pregnancy
Fetal parts palpable 24 wks +