The document summarizes the physical changes that occur in a woman's body during pregnancy. It discusses changes to various body systems including cardiovascular, respiratory, endocrine, gastrointestinal and others. It also discusses metabolic changes and increased nutrient needs during pregnancy. Diagnosis of pregnancy is discussed, including presumptive signs like nausea and fatigue, probable signs like missed periods and breast changes, and positive signs like detecting fetal heartbeat, movements and chorionic gonadotropin in urine or blood tests.

1. Changes in female’s body
during pregnancy

2. ► Changes in the organism
of the pregnant woman
are subordinated to one
central objective - normal
development of embryo
and fetus

3. Influence of embryo on the homeostasis
of pregnant woman
► Cardiovascular
system
► Secretory system
► Digestive system
► Central and
peripheral
nervous system
► Endocrine
system
► Basal
metabolism
► Skin and it’s
appendages
► Skeleton and the
bone system
► Immune system

4. Endocrine function of the
trophoblast
Early diagnostics of pregnancy is
based on determination of
chorionic gonadotropin in blood
and urine
► chorionic gonadotropin appears in the blood of
pregnant females from 2nd -3rd week of gestatuon,
which stimulates the function of “yellow body of
pregnancy” till 3rd month of gestation

5. Endocrine function of the trophoblast
►chorionic gonadotropin
►estradiol and estriol
►placental somatomammotropin
►progesteron
►thyrotropic hormone
►insulin-like factor
►STG and ACTH
►renin
►Angiotensin
►etc.

6. Endocrine changes
► increase in the level of
prolactin
► suppression of STG
secretion
Hypophysis

7. Endocrine changes
► in 35-40% of pregnant women
thyroid gland is enlarged due to
increasing of follicles number
and their hyperplasia
► in the first months of pregnancy
increasing of thyroid gland
function is noted
► in the second-half of pregnancy
it’s hypofunction sometimes
appears
Thyroid gland

8. Endocrine changes
► the level of glucocorticoids
and mineralocorticoids
rises
Adrenal glands

9. The mammary glands
► Increase in lobules size and
volume of the mammary
glands
► The number of alveoli and
lactiferrous ducts increases
► Significant increase of fat
tissue quantity
► By the end of the pregnancy
the colostrum (under the
effect of the prolactin) is
produced

10. Uterus
► Increase in the mass of womb from 50-60 g up to 1000 g
by the end of pregnancy
► Lengthening of separate muscular fibers in 15 times
► Increase of vascularization
► Softening of the cervix and it’s cyanosis
► Reduction of vaginal pH

11. Covers of the body
► Stretching of abdominal wall
► Abundant deposits of fat on
pubis, buttocks and mammary
glands
► Pigmentation of the skin (by
melanin)
► Stria gravidarum
► Varicose veins
► Smoothing and protrusion of
the umbilicus

12. Skeleton
► Change in the center of gravity - proud gait
of the pregnant females
► Widening of the lower aperture of the chest
► Loosening of the cartilages
► Divergence of pubic branches to the sides up
to 2 cm

13. Changes in the central nervous system
► Reduction of cortex irritabiliity during
the first 3-4 months of pregnancy and
an increase in the irritabiliity after 4
months of pregnancy
cortex

14. Changes in nervous system
► Changes of the tone
vegetative system
1. sleepiness
2. unbalanced state
3. change of mood
4. change in the taste
5. hypersalivation
6. vomiting
7. tendency to the vertigo
Limbic system

15. Changes of the cardiovascular
system
► increase of heart rate (10-20%)
► increase in the cardiac output
(10%)
► increase of the volume of
circulating blood
► physiological hypertrophy of the
left ventricle

16. Changes of the cardiovascular
system
► decrease of average BP
(10%)
► reduction in general
peripheral vascular resistance
(35%)
► hypotensive syndrome 15%
► disturbance of venous return
to the heart in the position of
pregnant on the back

17. Uteroplacental blood flow
Uteroplacental blood flow varies from 500 to 700 ml/min

18. Hematologic changes
DECREASE
► number of erythrocytes
► level of hemoglobin
► value of hematocrit
► concentration of folic acid in the
plasma
INCREASE
► number of leukocytes
► ESR
► concentration of fibrinogen

19. Changes in the lungs ventilation
► change in the anatomy of chest
► increased respiratory volume
► increased respiratory rate (10%) -
contributes to the establishment of the
lower partial pressure of carbon dioxide
(pCO2)
► hyperventilation
► increased oxygen intake by maternal
organism and growing fetus

20. Changes in the gases of the
arterial blood
► Reduction in pCO2 (on 15-20%) -
contributes to the passage of
carbonic acid dioxide of the fetus
through the placenta
► increase in pO2
► increase in the delivery of oxygen to
tissues
► increase in the excretion of
bicarbonates

21. Volume of liquid in the organism
► Delay of liquid (from 8 to 10 kg of
the body mass)
Factors, which facilitate the delay of
the liquid
► Delay of sodium chloride in the
tissues
► reconstruction of osmoregulation
(increase of ACTH and
mineralocorticoids)
► reduction of the thirst threshold
► decrease of oncotic pressure in
plasma

22. Consequences of the liquid delay
► Decrease in the level of
hemoglobin
► reduction of hematocrit value
► reduction of albumin
concentration in the plasma
► increased cardiac output
► increase of kidneys blood flow

23. Changes in the function of the kidneys
► the extension of renal pieli
► disturbance of tone and contracting
ability of muscles of minor renal
calyces and urethras
► increase nephritic blood flow (60-
75%)
► increase filtration (50%)
► acceleration of the clearance of the
majority of substances
► glucosuria serves as the version of
the standard

24. Gastrointestinal tract
During the pregnancy:
► rises appetite
► increases a quantity of
eaten food
► it is strengthened the
function of all digestive
glands
► it is activated
exchange of
substances

25. Gastrointestinal tract
► a decrease and the
distortion of taste
► Is reduced stomachic
acidity
► is lowered the tone of
stomach and its
evacuatory capability -
doubly the hypotonia
of bowels
► haemorrhoid

26. Gastrointestinal tract
► Is strengthened the blood
circulation of the liver
► is lowered antitoxic function
► in the end of the pregnancy
the liver it displaces upward
and toward the rear due to
the growing uterus
Liver

27. Metabolism
► Increase of the mass of body on
the average to 9-10 kg to the
40th week of the pregnancy:
► the mass of fetus - 3300 g
► the mass of placenta - 650 g
► the mass of amniotic liquid - 800
g
► the mass of increased uterus -
900 g
► 3-5 days prior to the labor the addition of the mass of body
stops in view of the reducing of an increase fetus weight,
partial suction of amniotic waters and regressive changes in the
placenta

28. Metabolism
► basal metabolism rises by 20%
► the pregnant woman of medium
height (155-165 cm) and with the
average mass of body (55-65 kgf)
with the easy muscular work must
obtain in the average 3000-3200
kcal during the day
► he need for the additional energy
is 150 kcal during the day in the
first and on 350 kcal during the
day in the second and third terms
of the pregnancy

29. Metabolisms
► strengthening plastic
processes in the organism
(predominance of the
processes of assimilation
above the processes of
dissimilation
► the daily need for the basic
forms of the nourishment:
proteins - 110-120 g
carbohydrates - 300-400 g
fats - 75-83 g

30. Protein metabolism
► The activation of anabolic
hormones leads to
strengthening of the
synthesis of ribonucleic
acid (RNA), which causes
an increase in the
synthesis of proteins, in
particular ferments, in the
ribosomes

31. Metabolism. Proteins
► A deficiency in the proteins in the diet of pregnant
females leads to the development:
1. the heavy forms of preeclmpsia and eclampsia
2. anemia
3. vomiting
4. worsening in the flow of the hypertensive syndrome
► To every 100 g of the proteins, eaten by mother, approximately
1 g enter to fetus
► Need of pregnant female for the proteins - 1,5 g on 1 kg of the
mass of body during the day

32. The valuable proteins, in which the products of
the animal origin, are rich are especially
recommended by pregnant female:
► boiled meat
► egg
► milk
► cheese
► cottage cheese
► fish
The proteins of plant origin must not exceed 50% of
total quantity of proteins of those entering the
organism of pregnant female with the food

33. Metabolism.
FATS
Changes in the fat metabolism during
pregnancy it is evinced by the increased
assimilation of fats with reduction in the
process of their oxidation, which leads to:
► to accumulation in the blood of ketosis bodies,
and acetoacetic acid
► to an increase of the deposit of fat in different
organs and tissues (the adrenal glands, the
placenta, in the breast glands)

34. Metabolism.
FATS
The consumption of fats during pregnancy
must be limited - in average 1,5 g on 1 kg of
the mass of body during the day
► Better to use the fusible fats, which are
contained in the milk and the dairy products
(cream, sour cream, butter, cheeses), and also
vegetable oils
The complete limitation of fats is undesirable, since the fat-
soluble vitamins, which play important role in the development
of the fetus enter with them into the organism

35. Metabolism
CARBOHYDRATES
► Lability of the content of
sugar in the blood
(certain of its increase in
higher than the limits of
physiological standard)
► Periodic appearance of
sugar in the urine
(strengthening the
permeability of nephritic
epithelium)

36. Metabolism
CARBOHYDRATES
► With the food the pregnant female must consume during the
day of 350-400 g of the carbohydrates, in which the products
of the plant origin: bread, sugar, groats, vegetables, fruits
► From the animal products only milk contains the
carbohydrates in the form of milk sugar (lactose)
► Major portion of the carbohydrates in the food ration must
compose polysaccharides - starch, which, being slowly split
and being mastered, lengthens the period of saturation and
coating power expenditures simultaneously
► The increased use of carbohydrates with pregnant
woman leads to a sharp increase in the mass of fetus
body (4 kg and more)

37. Vitamins and minerals
► The increased need of the
vitamins and the
microelements is observed
during pregnancy, because for
the normal increase and
development of fetus it is
insufficient entering from the
maternal organism of oxygen,
proteins, fats, carbohydrates
and water; be required even
complementary factors for the
cellular metabolism - vitamins
and minerals

38. DIAGNOSIS OF PREGNANCY
► The endocrinological, physiological,
and anatomical alterations that
accompany pregnancy give rise to
symptoms and signs that provide
evidence that pregnancy exists.
These symptoms and signs are
classified into three groups:
► presumptive evidence
► probable signs
► positive signs of pregnancy

39. PRESUMPTIVE EVIDENCE OF
PREGNANCY
► 1. Nausea with or without vomiting.
This so-called morning sickness of pregnancy usually commences
during the early part of the day but passes in a few hours,
although occasionally it persists longer and may occur at other
times.
This disturbing symptom usually begins about 6 weeks after the
commencement (first day) of the last menstrual period, and
ordinarily disappears spontaneously 6 to 12 weeks later.
The cause of this disorder is unknown but seems to be associated
with higher levels of selected forms of hCG (variations in
glycosylation) with the greatest thyroid-stimulating capacity.
Chorionic gonadotropin, especially isoforms with relatively
diminished amounts of sialic acid, act via the thyroid-stimulating
hormone (TSH) receptor to accelerate iodine uptake

40. 2. Disturbances in urination.
► During the first trimester, the
enlarging uterus, by exerting
pressure on the urinary bladder,
may cause frequent micturition.

41. 3. Fatigue
► Easy fatigability is such
a frequent
characteristic of early
pregnancy that it
provides a noteworthy
diagnostic clue.

42. Probable signs
► 1. Cessation of menses. The abrupt cessation of menstruation in a
healthy reproductive-age woman who previously has experienced
spontaneous, cyclical, predictable menses is highly suggestive of
pregnancy. There is appreciable variation in the length of the ovarian
(and thus menstrual) cycle among women, and even in the same woman.
It is not until 10 days or more after the time of expected onset of the
menstrual period, therefore, that the absence of menses is a reliable
indication of pregnancy. When a second menstrual period is missed, the
probability of pregnancy is much greater.
► 2. Changes in the breasts.
► 3. Discoloration of the vaginal mucosa. During pregnancy, the vaginal
mucosa usually appears dark bluish or purplish-red and congested; this is
the so-called Chadwick sign
► 4. Increased skin pigmentation and the development of abdominal striae.

43. Probable signs
► 5. Enlargement of the abdomen.
► 6. Changes in the shape, size, and consistency of the
uterus.
► 7. Anatomical changes in the cervix.
► 8. Braxton Hicks contractions. During pregnancy, the
uterus undergoes palpable but ordinarily painless
contractions at irregular intervals from the early stages of
gestation. These contractions, referred to as Braxton Hicks
contractions, may increase in number and amplitude when
the uterus is massaged.

44. Positive signs of pregnancy
► 1. Identification of fetal heart action separately
and distinctly from that of the pregnant woman.
► 2. Perception of active fetal movements by the
examiner.
► 3. Recognition of the embryo and fetus any time
in pregnancy by sonographic techniques or of the
more mature fetus radiographically in the latter
half of pregnancy.
► 4. Detection of chorionic gonadotropin.

45. Positive signs of pregnancy
►DETECTION OF CHORIONIC
GONADOTROPIN. The presence of chorionic
gonadotropin (hCG) in maternal plasma and
its excretion in urine provides the basis for
the endocrine tests for pregnancy. This
hormone can be identified in body fluids by
any one of a variety of immunoassay or
bioassay techniques.

46. ► FETAL HEART ACTION. Hearing or observing the
pulsations of the fetal heart assures the diagnosis
of pregnancy. Fetal heart contractions can be
identified by auscultation with a special fetoscope,
by use of the Doppler principle with ultrasound,
and by sonography.

47. The fetal heartbeat
► can be detected by auscultation with a
stethoscope by 17 weeks, on average,
and by 19 weeks in nearly all
pregnancies in non-obese women. The
fetal heart rate at this stage and beyond
ranges from 120 to 160 bpm and is
heard as a double sound resembling the
tick of a watch under a pillow.

48. PERCEPTION OF FETAL
MOVEMENTS.
► Detection by the examiner of fetal movements can
occur after about 20 weeks. Fetal movements vary
in intensity from a faint flutter early in pregnancy
to brisk motions at a later period; the latter are
sometimes visible as well as palpable.
Occasionally, somewhat similar sensations may be
produced by contractions of the abdominal
muscles or intestinal peristalsis, although these
should not deceive an experienced examiner.

49. ULTRASONIC RECOGNITION OF
PREGNANCY.
► The use of transvaginal sonography has
revolutionized imaging of early pregnancy and its
growth and development. A gestational sac may be
demonstrated by abdominal sonography after only 4
to 5 weeks' menstrual age. By 35 days, all normal
sacs should be visible, and after 6 weeks, a
heartbeat should be detectable. By 8 weeks, the
gestational age can be estimated quite accurately.
Up to 12 weeks, the crown-rump length is predictive
of gestational age within 4 days.

50. PROCEDURES FOR PRENATAL CARE
The American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (1997) have
defined prenatal care as follows:
"A comprehensive antepartum care program that involves a
coordinated approach to medical care and psychosocial
support that optimally begins before conception and
extends throughout the antepartum period."
The content of such comprehensive care includes
► assessments during preconception,
► at initial presentation for pregnancy care,
► during follow-up prenatal visits.

51. PRECONCEPTIONAL CARE
►A comprehensive preconceptional care
program has the potential to assist women
who want to get pregnant by reducing risks,
promoting healthy lifestyles, and improving
readiness for pregnancy.

52. INITIAL PRENATAL EVALUATION
► Prenatal care should be initiated as soon as there is a
reasonable likelihood of pregnancy. This may be as early
as a few days after a missed menstrual period, especially
for the woman who desires pregnancy termination, but it
should be no later than the second missed period for
anyone. The major goals are:
1. To define the health status of the mother and fetus.
2. To determine the gestational age of the fetus.
3. To initiate a plan for continuing obstetrical care.

53. Recommended Components of the
Initial Prenatal Care Visit
► Risk assessment to include genetic, medical, obstetrical,
and psychosocial factors
► Estimated due date
► General physical examination
► Laboratory tests: hematocrit (hemoglobin), urinalysis, urine
culture, blood grouping, Rh, antibody screen, rubella
status, syphilis screen, Pap smear, HbsAg testing; offer
HIV testing
► Patient education, e.g., use of seatbelts, avoidance of
alcohol and tobacco
► HbsAg = hepatitis B surface antigen; HIV = human
immunodeficiency virus.

54. DEFINITIONS.
• Primipara: a woman who has been delivered only once of a fetus or
fetuses who reached viability. Therefore, completion of any pregnancy
beyond the stage of abortion (Chap. 33, p. 856) bestows parity upon the
mother.
• Multipara: a woman who has completed two or more pregnancies to
viability. It is the number of pregnancies reaching viability, and not the
number of fetuses delivered, that determines parity. Parity is not greater
if a single fetus, twins, or quintuplets were delivered, nor lower if the
fetus or fetuses were stillborn.
• Nulligravida: a woman who is not now, and never has been pregnant.

55. DEFINITIONS.
• Gravida: a woman who is or has been pregnant, irrespective
of the pregnancy outcome. With the establishment of the
first pregnancy, she becomes a primigravida, and with
successive pregnancies a multigravida.
• Nullipara: a woman who has never completed a pregnancy
beyond an abortion. She may or may not have been
pregnant or have had a spontaneous or elective abortion(s).
• Parturient: a woman in labor.
• Puerpera: a woman who has just given birth.

56. NORMAL DURATION OF
PREGNANCY.
►The mean duration of pregnancy calculated
from the first day of the last normal
menstrual period is very close to 280 days,
or 40 weeks.
►It is customary to estimate the expected
date of delivery by adding 7 days to the
date of the first day of the last normal
menstrual period and counting back 3
months (Naegele rule).

57. OBSTETRICAL EXAMINATION.
►HISTORY.
►PSYCHOSOCIAL SCREENING.
►SMOKING DURING PREGNANCY.
►ALCOHOL AND STREET DRUGS DURING
PREGNANCY.
►DOMESTIC VIOLENCE SCREENING.

58. OBSTETRICAL
EXAMINATION.
 Inspection of external genitalia
 Speculum examination
 Manual or bimanual examination (the
consistency, length, and dilatation of the cervix;
to the fetal presenting part, especially if late in
pregnancy; to the bony architecture of the pelvis;
and to any anomalies of the vagina and
perineum, including cystocele, rectocele, and
relaxed or torn perineum. The vulva and
contiguous structures are also carefully
inspected.

59. OBSTETRICAL EXAMINATION.

60. HIGH-RISK PREGNANCIES.
► 1. Preexisting medical illness.
► 2. Previous poor pregnancy outcome, such as
perinatal mortality, preterm delivery, fetal-growth
restriction, malformations, placental accidents, or
maternal hemorrhage.
► 3. Evidence of maternal undernutrition.

61. SUBSEQUENT PRENATAL VISITS
RETURN VISITS.
Traditionally the timing of subsequent prenatal
examinations has been scheduled at intervals of 4
weeks until 28 weeks
every 2 weeks until 36 weeks
weekly thereafter
This visits are acceptable in uncomplicated
pregnancies. Conversely, women with complicated
pregnancies often require return visits at 1- to 2-
week intervals.

62. SUBSEQUENT PRENATAL VISITS
FETAL HEART SOUNDS. In essentially all
pregnancies, the fetal heart can first be
heard between 16 and 19 weeks. The ability
to hear unamplified fetal heart sounds will
depend upon several factors, including
patient size and the examiner's hearing
acuity.

63. SUBSEQUENT PRENATAL VISITS
►FUNDAL HEIGHT. Measurement of the
height of the uterine fundus above the
symphysis can provide useful information.
Jimenez and co-workers (1983)
demonstrated that between 20 and 31
weeks the fundal height in centimeters
equaled the gestational age in weeks. The
bladder must be emptied before making the
measurement.

64. PRENATAL SURVEILLANCE. At each return
visit steps are taken to determine the well-
being of both the mother and her fetus.
Fetal
1. Heart rate(s).
2. Size—actual and rate of change.
3. Amount of amnionic fluid.
4. Presenting part and station (late in pregnancy).
5. Activity.

65. PRENATAL SURVEILLANCE.
Maternal
• Blood pressure—actual and extent of change.
• Weight—actual and amount of change.
• Symptoms, including headache, altered vision, abdominal pain, nausea
and vomiting, bleeding, fluid from vagina, and dysuria.
• Height in cm of uterine fundus from symphysis.
• Vaginal examination late in pregnancy often provides valuable
information:
• Confirmation of the presenting part.
• Station of the presenting part
• Clinical estimation of pelvic capacity and its general configuration
• Consistency, effacement, and dilatation of the cervix.

66. LABORATORY TESTS.
► GESTATIONAL DIABETES.
► CHLAMYDIA TRACHOMATIS
► BACTERIAL VAGINOSIS.
► GROUP B STREPTOCOCCUS.
► Determination of maternal serum alpha-
fetoprotein concentration at 16 to 18 weeks (15 to
20 weeks is acceptable) is recommended to screen
for open neural-tube defects and some
chromosomal anomalies.

67. NUTRITION
► • In general, advise the pregnant woman to eat what she wants in amounts
she desires and salted to taste.
► • Make sure that there is ample food to eat, especially in the case of the
socioeconomically deprived woman.
► • Ensure that she is gaining weight, with a goal of about 25 to 35 pounds in
women with a normal body mass index.
► • Periodically, explore the food intake by dietary recall. In this way, the
occasional nutritionally absurd diet will be discovered.
► • Give tablets of simple iron salts that provide at least 30 mg of iron daily. Give
folate supplementation before and in the early weeks of pregnancy.
► • Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks to
detect any significant decrease.