Gynea

2. Physiological changes
during pregnancy and
diagnosis of pregnancy
SUBMITTED TO :-
DR. HARKIRAN NEHRA
DR. SANDEEP AHEER
DR.SUDHI KAUSHAL
SUBMITTED BY :-
ASHISH SHARMA

3. Physiological changes during pregnancy
During pregnancy there is progressive anatomical,
physiological and biochemical change not only
confined to the genital organs but also to all systems of the
body.
This is principally a phenomenon of maternal adaptation to
the increasing demands of the growing fetus.

4. GENITAL ORGANS
VULVA:-
 Becomes Hypertrophied,edematous, vascular
 Increased blood supply gives the bluish coloration of
the mucosa of vulva, cervix & ant. vaginal wall
VAGINA:-
 Vaginal walls become hypertrophied
 Hyperplasia and Chadwick sign
 Oedematous and vascular
 Increase blood supply and increase acidity (3.5 pH)

5. UTERUS:-
There is enormous growth of the uterus during
pregnancy.Changes occur in all the parts of the uterus
—body, isthmus and cervix
Length
 Non Pregnant - 7.5 c.m.
 Pregnant - 35 c.m.
. Weight
 Non Pregnant 60-70 gm.
 Pregnant 1000 - 1100 gm
. Capacity
 Non Pregnant 5-10 ml
 Increase by 500-1000 times

6. The perimetrium is the outermost layer of the uterus. It
does not totally cover the uterus. The myometrium or
muscle coat surrounds the cornua, lower uterine
segment and cervix during labour. The muscle layer is
involved in the contraction necessary to expel the
foetus at the end of the pregnancy.
During pregnancy, the muscle layer becomes more
differentiated and organised which take part in
expelling the foetus at term. Oestrogen is responsible
for the growth of the uterine muscle

7. Three layers of muscle fibres
 Longitudinal (Outer Hood like)
 Circular (Inner)
 Intermediate crisscross
Vascular system
Uterine artery diameter
increases

8.  Early - Pyriform
 12 weeks - Globular
 28 weeks -ovoid
 beyond 36 weeks - Spherical
SHAPE OF UTERUS
POSITION
Normal anteverted position is exaggerated up to 8
weeks.
Later on As the uterus enlarges to occupy the
abdominal cavity, it usually rotates on its long
axis to the right (dextrorotation)

9. Contractions (Braxton-Hicks)
The contractions are irregular, infrequent, spasmodic and
painless without any effect on dilatation of the cervix. In
abdominal pregnancy, Braxton-Hicks contraction is not felt.
ISTHMUS
 There are important structural and functional
changes in the isthmus during pregnancy.
 During the first trimester, isthmus hypertrophies and
elongates to about 3 times its original lenth
 With advancing pregnancy beyond 12 weeks, it
progressively unfolds from above,
 downward until it is incorporated into the uterine
cavity.

10.  The circularly arranged muscle fibers in the region
function as a sphincter in early pregnancy and thus
help to retain the fetus within the uterus.
 Incompetency of the sphincteric action leads to mid-
trimester abortion

11. CERVIX
 Hypertrophy and hyperplasia of glands
 Incresed vascularity
 Softening of the cervix
FALLOPIAN TUBE
Fallopian tube placed almost vertical by the side of
the uterus
OVARIES
Corpus luteum in ovaries maximum at 6- 8th week.
Ovarian and uterine cycles of menstruation remain
suspended

12. BREASTS CHANGES
 Hypertrophy and proliferation of breast
tissues
 Hypertrophy & proliferation of ducts- Estrogen
 Hypertrophy & proliferation of alveoli - Estrogen &
progesterone
NIPPLES AND AREOLA:
 The nipples become larger, erectile and deeply
pigmented. Variable number of sebaceous glands
(5–15) which remain invisible in the nonpregnant
state in the areola, become hypertrophied and are
called Montgomery’s tubercles. Those are placed
surrounding the nipples.

13.  Their secretion keeps the nipple and the areola
moist and healthy. An outer zone of less marked
and irregular pigmented area appears in second
trimester and is called secondary areola.
SECRETION:
 Secretion (colostrum) can be squeezed out of the
breast at about 12th week which at first
 becomes sticky
 Later on, by 16th week, it becomes thick and
yellowish. The demonstration of secretion from the
breast of a woman who has never lactated is an
important sign of pregnancy.
 In latter months, colostrum may be expressed from the

14. Hyperpigmentation
Melasma : Dark pigmentation/patch on face
Dark line from the umbilicas Linee Nigra: to the
pubic symphysis.
Areolar Pigmentation: Becomes darker
Striae Gravidarum (Stretch Marks)
Develops on the abdomen, thighs & breasts due to
dermal stretching.
CUTANEOUS CHANGES

15. Hematological System
Plasma &RBC changes
Plasma Volume: Increases by 50%, leading to
physiological anemia (Hb и 11 g/dL)
Red Blood Cell Mass: Increases by 20-30%
Coagulation Changes
Hypercoagulable State: Elevated clotting factors
(fibrinogen, factor VII, VIII, x) & reduced fibrinolysis
increases the risk of of thrombalis.
Immunity
Cellular immunity is suppressed (increased risk of
infections), but humoral Immunity remains active to
protect the fetus.

16. Cardiovascular System
Hemodynamic Changes
1. Blood Volume: Increases by 40-50% by mid-pregnancy,
peaking at ~32 weeks. This expansion prevents maternal
hypotension & prepares for blood lass dining delivery
(normal loss:~500 ml in vaginal delivery, "looome in
cesarean section)
2. Cardiac Output: Rises by 30-50%, peaking in the 2nd
trimester due to increased stroke volume & heart rate.
3. Heart Rate: Increases by 10-15 bpm to maintain higher
Cardiac Output.
4. Systemic Vascular Resistance (SVR): Decreases due to
progesterone-induced smooth muscle relaxation & placental
shurrting, leading to lower blood pressure during early
pregnancy.

17. Anatomical Changes
1. Heart Position: Elevated & Rotated due to the
expanding uterus.
2. Systolic Murmurs: Heard in 90% of the pregnant
women due to increased bood flow but usually
benign.
 Salvation may seen to increase due to swallowing
difficulty.
 Gastrointestinal mobility may be reduced during
pregnancy due to increase progesterone.
 More commonly gastric acidity is reduced.
 Appendix displaced.
CHANGES IN GASTROINTESTINAL SYSTEM

18. Respiratory System
Functional Changes
1. Tidal Volume: Increases by 30-40%
2. Minute ventilation: Increases by 40% due to increased
tidal volume, causing mild hypenentilation and respiratory
alkalosis (Pa(02:30mmtly)
3. Oxygen Consumption: Increases by 20-30% to meet
maternal & fetal metabolic demands.
Anatomical Changes
1. Diaphragm Elevation: Rises by "Yem due to uterine
enlargment but does not impair lung expansion.
2. Thoracic Circumference: Expands by ~ 5-7cm
compensating for reduced vertical lung space.

19. Renal System
Functional Changes
 Glomerular Filtration Rate (GPR): Increases by
~50%, leadin leading to lower serum
creatinine. (0.5-0.7 mg/dL) & blood vrea
Nitrogen.
 Renal blood Flow: Increares due to systemic
vasodilation.
 Renin-Angiotencion System: Activated to
maintoin blood pressure despite decreased
SVR.

20. Structural Changes
 Kidney: Increases in size by 1-1.5cm due to
increased workload.
 Hydronephrosis: Ureters dilates under the
influence of progesterone, predisposing to
urinary stasis & infections.
 Clinical Manifestration
 Frequency & Nocturia: Common due to
increased filtration & pressure on the
bladder.

21. Musculoskeletal System
Skeletal Changes
Lordosis: To compensate for altered center of gravity
due to uterine growth.
Pelvic Joint Relatation: Medicated by relaxin &
progesterone, facilitating Labour.
WEIGHT GAIN
The total weight gain during the course of a
singleton pregnancy for a healthy woman averages
11 kg

22. Endocrine System
Placental Hormones
 Human Chorionic Gonadotropin (hCG): Peaks at
lo weeks, supporting the corpus luteum to
maintain progesterone production.
 Human Placental Lactogen (HPL): Promotes
lipolysis & insulin resistance, ensuring a steady
glucose supply to the fetus.
Ovarian Hormones
 Progesterone: Relaxes smooth musdes, reducing
uterine contractility and promoting vasodilatin
 Estrogen: Stimulates uterine growth, enhances blood
flow, and prepares the mammary glands for lacation-

23. Thyroid Function
 Total T3/T4 Levels: Increases due to elevated
thyroid-binding globulin. Free T3/T4 levels remain
normal.
 Basal Metabdic Rate (BMR): Rises by ~20%.
Insulin Resistance
 Increases in the second & third trimesters due to
placental hormones contributing to gestational
diabetes in predisposed individuals.

24. DIAGNOSIS OF PREGNANCY
SIGN OF PREGNANCY
Presumptive sign / Possible sign
 Amenorrhoea
 Fatigue
 Breast enlargement
 Striae gravidarum
 Linea Nigra
 Morning sickness

25. Probable sign
 Goodell sign - Softening of cervix
 Hegar sign- Lower part of uterus is empty and soft
in early pregnancy
 Piskacek's sign - Unequal growth of uterus due to
lateral implantations.
 Palmar sign - Irregular contraction of uterus
 Chadwick/Jacquimier sign - Bluish discolouration
of vagina or cervix.
 Braxton hicks contraction - Infrequent, non
rhythmic, painless

26. Definitive sign/Positive sign
Cardiac activity seen in USG
Gestational sac visible in USG
Fetal heart sound by Doppler and Stethoscope
Fetal parts felt

27. Diagnosis of pregnancy in first trimester
Symptoms
Amenorrhea Absence of menstruation
Fatigue
Morning sickness Nausea & vomiting it starts in abot 4-
6weeks of pregnancy and may continue till about the 16th
week
frequency of micturation due to
Pressure exerted on the bladder
By the growing uterus
Breast discomfort in the form of
feeling of fullness and ‘pricking sensation’ is evident as
early as 6–8th week specially in primigravidae.

28. SIGNS
Breast changes Dark pigmented area in nipple & areola
enlargement and prominence of veins
Montgomery’s tubercles are prominent. Thick yellowish
secretion (colostrum) can be expressed as early as 12th
week
Uterus remains a pelvic organ until 12th week, it may be just
felt per abdomen as
a suprapubic bulge.

29. Jacquemier's /Chadwick's sign Dusky hue Bluish
discoloration of the vestibule and anterior vaginal wall at
8 weeks
Goodell's sign Softening of the cervix at 6 weeks
Osiander's sign Increased pulsation felt through the
lateral fornices at 8th weeks
Palmer's Sign Regular and rhythmic uterine contraction
at 4-8 weeks
Piskacek's Sign Asymmetrical enlargement of the uterus
Hegar's Sign Upper part of the
body is enlarged by the growing
fetus Lower part is empty and soft

30. IMMUNOLOGICAL TESTS FOR DIAGNOSIS OF
PREGNANCY
Principle: Pregnancy tests depend on detection of the
antigen (hCG) present in the maternal urine
or serum with antibody either polyclonal or monoclonal
available commercially

31. ULTRASONOGRAPHY: Intradecidual gestational
sac (GS) is identified as early as 29 to 35 days of
gestation.
Diagnosis of pregnancy in second
trimester
SYMPTOMS:
The subjective symptoms — such as nausea, vomiting and
frequency of micturition usually subside, while amenorrhea
continues. The new features that appear are:
“Quickening” (feeling of life) denotes the perception of
active fetal movements by the women.
It is usually felt about the 18th week, about 2 weeks
earlier in multiparae

32. Progressive enlargement of the lower abdomen by the
growing uterus
ABDOMINAL EXAMINATION
Inspection:
(1) Linear pigmented zone (linea nigra) extending from the
symphysis pubis to ensiform cartilage may be visible as
early as 20th week
(2) Striae (both pink and white) of varying degree are
visible in the lower abdomen, more towards the flanks

33. External ballottement is usually elicited as early as
20th week when the fetus is relatively smaller than the
volume of the amniotic fluid It is difficult to elicit in
obese patients and in cases with scanty liquor amnii. It
is best elicited in breech presentation with the head at
the fundus.

34. Fundal heightis increased with progressive
enlargement of the uterus. Approximate duration of
pregnancy can be ascertained by noting the height of
the uterus in relation to different levels in the abdomen.
Palpation:
 The uterus feels soft and elastic and becomes
ovoid in shape.
  Braxton-Hicks contractions are evident, the
features
  Palpation of fetal parts can be felt distinctly by
20th week. Th e fi ndings are of value not only to
diagnose pregnancy but also to identify the
presentation and position of the fetus in later
weeks.
  Active fetal movements can be felt at intervals

35. Auscultation
Fetal heart sound (FHS) is the most conclusive clinical
sign of pregnancy. With an ordinary
stethoscope
VAGINAL EXAMINATION
 The bluish discoloration of the vulva, vagina
and cervix is much more evident, so also
softening of the cervix.
  Internal ballottement can be elicited
between 16–28th week

36. INVESTIGATIONS (Imaging Studies)
Sonography:Routine sonography at 18–20 weeks
permits a detailed survey of fetal anatomy, placental
localization and the integrity of the cervical canal
Magnetic Resonance Imaging (MRI): MRI can be used
for fetal anatomy survey, biometry and
evaluation of complex malformations

37. Diagnosis of pregnancy in Third Trimester (29-40
weeks)
In the last three months (third trimester) the woman's
normal daily activities start becoming tedious because of her
size. She finds bending difficult.
Symptoms
 Enlargement of abdomen is progressive in later
part of pregnancy,
 Lightening also takes place and
 Frequency of micturition may be there

38. Signs
 Uterine shape becomes more globular.
 Fundal height continues to grow as described
earlier.
 Braxton-Hicks contraction are more evident.
 Foetal movement are easily palpable and also can
be noticed on inspection.
 Foetal parts can be palpable.
 Auscultation reveals a regular foetal heart rhythm
Investigations
Sonography and X-rays