2. A-Uterine change
1-Anatomical changes:
Size and softening: (Mainly due to hypertrophy & stretching)
At 12th weeks: the size is similar to fetal head. (Pelvic organ)
A t22 - 24th weeks: at the level of the umbilicus.
At 36th weeks: at the level of xiphisternum
Vascularity: increased
Change shape: Pear shaped to globular then ovoid.
Dextrorotation due to rectosigmoid.
Weight & capacity
Weight: from 50-7O gm 1000gm at full term (20 times)
Capacity: from 10ml to 5 liters (500-1000 times)
6. 3-Physiological Changes:
1-Uterine contractions in early pregnancy:
felt during P.V (Palmer's sign) These are irregular and painless.
2-Uterine contraction during the 2nd& 3rd trimesters :( Braxton -Hick's contraction)
They are: sporadic, unpredictable, non-rhythmic &< 25mm Hg.
As pregnancy advances: in frequency and intensity false labor pains. (No effects on cervical
dilatation & effacement).
3-Uteroplacental blood flow: till reaching 500 ml/ minute at term. 4-Isthmus: lower uterine
segment (late in pregnancy).
7. 1-Hypertrophy and softening (Goodell’s sign).
2-Increased vascularity
3-Blue or violet discoloration (Chadwick’s sign).
4-Cervical mucus plug closes the cervical canal discharged as bloody show with the onset of labor.
C. Vaginal and Vulval changes:
1-Hypertrophy and softening.
2- vascularity Varicose veins of the vulva (Kluge's sign).
3-Blue or violet discoloration (Chadwick’s sign).
4-Pulsation in the vaginal fornices (Osiander sign).
D. Ovarian Changes: size and softening.
Increased vascularity
Cesation of ovulation.
Corpus luteum degenerates at 12th week.
8. II. Changes in the breast
1- increased size and softening.
2- increased vascularity
3-Nipples & areola:
Nipples: become prominent, erectile and more sensitive
1ry areola around nipple (on 2nd month) + 2ry areola around both (on 5th month)
4-Montgomery's tubercles: hypertrophied sebaceous glands on 2nd month.
11. 1. CVS changes
1- Heart
-Apex: displaced upward and outward in the midclavicular line in the 4th interspace.
-Heart rate: increased 10-15 b/ min. to reach plateau of 90 b/ min. at the 32nd week.
-Stroke volume: increased
-Heart sounds: Widely split 1st heart sound (premature closure of the mitral valve).
Easily heard 3rd sound.
-Murmur: ejection systolic murmur (12 -20 weeks in 90% of women).
Soft diastolic murmur in 20% (transient).
(So, significance of murmurs during pregnancy must be assessed carefully)
12. cardiac changes
2- Cardiac output
- Begins to at 10 weeks & reach maximum 20 weeks then remain high till end of
pregnancy.
- Due to: H.R & S.V.
3-Blood volume:
- 30-50% above the non pregnant values.
-Begins to at 10 weeks & reach maximum 28-32 weeks then remain high till end of
pregnancy.
-Due to: plasma volume (30%) & red cell mass (15%) physiological hemodilution
(So anemia is diagnosed when Hb < 10 gm/dl).
13. 4-Blood pressure:
- 10-15 mmHg below the non pregnant values.
- gradually to reach a nadir in the late second trimester then again thereafter.
-Due To: decreased peripheral vascular resistance ( decreased sensitivity to angiotensin II).
Uteroplacental circulation and arteriovenous shunts in the placenta.
N.B: Supine hypotension syndrome (10%): In supine position the gravid uterus may compress IVC deacreas V.R and
COP
Aorta compresion decreases the iliac artery flow
Aortic and IVC compresion decrease the uterine perfusions.
It can be avoided by lying on the left side.
14.
15.
16. Veins:
- liability of varicose veins to occur pressure of the gravid uterus on the
pelvic veins.
- Smooth muscles relaxing effect of progesterone.
-Peripheral edema is more common, particularly late in pregnancy.
17.
18. 6-Changes in Coagulation:
smooth muscles relaxing effect of progesterone.
-Pregnancy is hypercoagulable state incidence of
thromboembolic diseases 6 times.
-Due to coagulation factors II, V, VII, VIII, IX, X and XII
Decrease fibrinolytic activity.
19.
20. Respiratory Changes
A-Anatomical changes:
1-Subcostal angle widens.
2-Diaphragm is elevated by 4 cm.
3-Transverse diameter of the thoracic cage increases by 2 cm.
4-Thoracic circumference increases by 6 cm.
B-Physiological changes:
1-Decreased Residual volume: by 15 to 20 % (due to elevation of the diaphragm).
2-Hyperventilation PO2 & PCO2.
3-Mild respiratory alkalosis: Arterial pH slightly to 7.44.
4-Dyspnea is a common complaint in at least 50% of all pregnant women by the 20th week of gestation and 75% by
the 30 week ( tidal volume PO2).
21. Urinary Changes
A-Anatomical Changes:
1-Kidney: size.
2-The collecting system from the renal calyces: dilatation.
3-Ureter : dilatation & compression at the level of the pelvic brim.
4-The bladder: relaxes and its capacity may double.
B-Physiological changes:
1- By the 4th month of gestation, (RPF) and (GFR) 30-50 % above normal.
2- Dcreased serum creatinine & serum urea and creatinine clearance.
3- Glycosuria and aminoaciduria due to lowering of renal blood threshold.
4- Level of aldosterone & angiotensin, but with no in activity.
22. Significance of urinary changes:
1. incidence of pyelonephritis.
2. incidence of UTI due to:
Relaxant effects of progesterone and relaxin.
Hypertrophy of the lower ureter.
Pressure on right ureter by dilated right ovarian vein.
Dextrorotation of the uterus.
3. Frequency of micturition.
4. Creatinine Clearance test: is the useful one for renal function during pregnancy.
23.
24. Gastrointestinal Change & liver & G.B
1-Ptyalism: i.e., salivation.
2-Pica: where the patient desires or refuses certain foods or odors.
3-Pyrosis (Heart burn): due to regurgitation of stomach contents.
4-Palmar erythema: may occur.
5-Hypochlorhydria: due to regurgitation of alkaline intestinal chyle into stomach.
6-Hypotonia of gall bladder: susceptibility to gall stones.
25. 7-Hyperemic gums: & may bleed + epulis formation.
8-Hemorrhoids: due to constipation + high venous pressure (by uterine compression).
9-Spider nevi: may occur.
10-SGPT & SGOT: no change, while alkaline Phosphatase inccreases (mostly placental).
11-Morning sickness: nausea and sometimes vomiting occurring during early morning.
12-Constipation: due to press of uterus on pelvic colon + progesterone relaxing effect.
26. Skin Changes
1-Pigmentations:
Of: Face (chloasma of pregnancy) nipples, areola, and perineum & Midline anterior
abdominal skin (linea nigra)
Because of: High estrogen and progesterone levels. Precursors of adrenal hormones.
2-Stria:
Rubra (red): stretching of skin appearance of subcutaneous blood vessels.
Albicans (white): due to fibrosis in stria rubra.
nigra (black): due to stretching + melanocytic activity.
3-Itching Pruritis: due to bilirubin & bile salts.
Pruritic Urticarial Papules & Plaques (occurs over the trunk)
4-Spider nevi
5-palmer erythema: may occur.
27.
28.
29. Endocrinal Changes
1- Pituitary gland:
- increased Prolactin : (10 times of the non- pregnant levels).
- Oxytocin: is released at the end of pregnancy and may play a role in onset of labor
2-Adrenal glands:
-Cortisol:
-Aldosterone : Na and water retention
3-Thyroid gland:
-Increased Thyroid activity is doubled due to: The effects of placental thyrotropin.
Thyrotropic effect of HCG
- Increased thyroxin binding globulin (TBG).
- Increased total serum thyroxine (free and bound); but no change in free thyroxine (T3 & T4)
4-Parathyroid gland:
physiological hyperparathyroidism.
30. Skeletal & nervous Changes
1-Progressive lumbar lordosis .
2-Softening of the pelvic joints and pelvic ligaments increased mobility.
3- Increased incidence of carpal tunnel syndrome: due to fluid retention.
4- Increased incidence of Bell's palsy.
31. Metabolic Changes
1- Protein metabolism
- +ve N2 balance.
- Increased daily requirements for protein intake during pregnancy.
2-Fat Metabolism
- Fat is stored as depot fat (about 4 Kg at 30 w and little is stored after that)
- increased level of total lipids and cholesterol: intake
conversion of glucose to fat.
-increased LDL peaks at 36 weeks gestation while HDL peaks at 25 weeks gestation.
32. 3-Carbohydrate Metabolism
increase Insulinase enzyme of the placenta.
- Weight gain during pregnancy:
- Normal pregnancy is characterized by: Mild fasting hypoglycemia.
Postprandial hyperglycemia.
Hyperinsulinemia (B cells hyperplasia).
- Pregnancy is potentially diabetogenic due to: estrogen, progesterone and HPL.
Peripheral insulin resistance.
33. 4-Water & electrolytes metabolism:
-H2o: the minimum amount of extra water retained during pregnancy is 6.5 liters
3.5 liters (Fetus, placenta & AF)
3 liters (Maternal bl. volume, uterus & breast)
-Fe: supplementation of iron during pregnancy may be essential.
-Calcium and Mg: increased demands & level in blood.
-Na & K: levels decrease due to hemodilution.
34.
35.
36. Immune system changes
1- cell mediated and humoral immunity (immuno-suppressive state).
2- Interferon is absent in pregnancy
3- Increased Leukocyte count (5000- 14000) but depresed. increased possibility to
infection
4- Increased C-reactive protein.
38. Antenatal Care
Definition:
-Program of preventive obstetrics in which regular visits are used to detect & manage any health problems and complications during pregnancy.
Objectives:
1-To assure that every wanted pregnancy should result in delivery of a healthy baby.
2-Promotion of medical, physical & mental health of the mother, by avoiding& treating
medical or obstetric conditions that are dangerous to the mother or child
3-Ensure adequate dietary intake for both the mother & the fetus.
4-Instructions for the hygiene of pregnancy & preparation for breastfeeding.
39. Frequency of Visits (The median number of visits made by women is 13)
During the first 7 months every month.
During the 8th month Every 2 weeks.
During the 9th month weekly.
40. The Initial Visit:
The goals:
1-Detection of high risk pregnancy.
2-Determine the gestational age and expected date of delivery.
3-To define the health status of the mother and fetus.
4-Initiate a plan for continued care until delivery.
It includes:
A. Diagnosis of pregnancy and accurate dating.
B. History: Personal, menstrual, obstetric, present, past, family history.
C. Physical Examination: General, abdominal & local examination.
41. D. Investigation:
1-Routine initial screening: CBC / Blood grouping & Rh factor /Urine analysis:
for albumin & sugar / RBS /Abs for S &HBV & rubella.
2-Specialized screening tests: HIV for high risk groups / Hb electrophoresis
3-Midtrimester screening tests: (if patient first seen during mid trimester) MSAFP (maternal serum
alpha-feto-protein)
1 hour glucose screening at 24 – 28 W in potentially diabetic women.
repeat Hb at 26-30 W
42. E. Obstetric diagnosis: gravidity, parity, number of abortions, gestational age in weeks , lie, presentation, position,
associated obstetric or medical complications.
F. Risk factors: preexisting medical diseases, previous pregnancy complications
e.g., perinatal mortality IUGR obstetric bleeding, evidence of poor nutrition.
43. The Repeat Visits:
Ask about warning symptoms Weight of the patient
Look for edema
Measure blood pressure
Abdominal examination (especially measuring fundal height) Investigation:
MSAFP 16-18 W in selected cases
1 hour glucose screening at 24 – 28 W in potentially diabetic women. Urine analysis
for glucose & protein in each visit in 3rd trimester.
44. Health education:
1- Warning symptoms.
2- Diet with pregnancy.
3- Weight gain during pregnancy. 4- Other advices.
45. 1-Warning symptoms:
-The pregnant woman must immediately report if any of the following symptoms occur:
-Vaginal bleeding.-Escape of fluid from the vagina. -Blurring of vision.-Severe headache.
-Persistent epigastric pain.-Persistent vomiting. -Swelling of the face, fingers and limbs. -Preterm labor. -Chills and Fever.
46. 2-Diet with pregnancy:
- Pregnancy as it is a hyperdynamic & hypermetabolic state special diet constitution for a
healthy mother & fetus.
-Instructions about diet:
1- Advise mothers to eat what she wants in the amounts she desires. 2- Ensure adequate
weight gain.
3- Periodically explore the food intake by asking her. Re-check the Hb level at 25-32 weeks.
4- Fe: 30-60 mg of iron daily.
5- Ca: 2 glasses of milk are sufficient. Supplementation is of no benefit. 6- CHO: restricted
in DM & obesity. Salt: restricted in: PET, hypertension,
heart disease.
47. -Important daily requirements:
1-Calories: 2500 K Cal/day. (300 K Cal more than non pregnant)
2-Proteins: 65 gm/day
3-Calcium: 1gm/day
4-Fe: 30-60 mg/day (diet contains 15mg, so external supply is essential)
Throughout pregnancy: 1000mg
(500 for blood cell mass 300 for fetus &placenta 200 for uterus)
-Recommended daily diet:
1- Protein: meat or fish 120 gm / day.
2- Milk: 0.75 Liter / day. Egg: 1 / day.
3- Bread: 2 - 3 slices. Potato or rice: 2/ day. 4- Fresh vegetables and
fruits.
5- Salt intake: No increase or decrease.
48. Effect of malnutrition:
A-Maternal:
Loss of weight.
Abortion.
Anemia (Fe).
Vomiting (B6).
Post partum hge (Ca & vit. K ).
PET.
Preterm labor. Tetany (Ca). Goiter (I).
B-Fetal: IUGR. IUFD.
Fetal anemia L.B.W.
49. 3-Weight gain during pregnancy:
-Total weight gain: about 11-12 Kg.
-Rate of weight gain: (1/2 kg/week or 2 kg/month after the first trimester)
The 1st trimester: No or 1kgm due to nausea, vomiting & loss of appetite. The 2nd
trimester: + 5 kg.
The 3rd trimester: + 5 kg.
50. -Sources of weight gain:
Fetus: 3-4 Kg. Placentas: 1/2 Kg.
Amniotic fluid volume: 1 1/2 Kg . Blood volume: 1 1/2 Kg. Uterine growth: 1/2 Kg. Breast growth: 1/2 Kg.
Protein retention: 2 Kg. Water retention: 2 Kg.
-Clinical importance:
-Under weight gain: malnutrition IUGR IUFD
-Over weight gain: occult edema
51.
52.
53. 4-Other advices:
- Daily fetal movements count.
- Work, exercise, coitus, traveling: no contraindications except:
Placenta previa Threatened abortion
Threatened preterm labor multiple pregnancy after 28 weeks. PPROM
-Immunization:
Live attenuated viral vaccines as MMR & polio are contraindicated. Inactivated viral
vaccines as influenza and rabies are safe.
Inactivated bacterial vaccines as cholera & toxoids as tetanus are safe. Igs e.g.,
hepatitis & tetanus can be given whenever needed.
