changes during normal pregnancy

3. An indication of existance of something/an evidence that is
perceptible to physician.
•Skin pigmentation
•Epulis -4th month
•Breast changes
•Abdominal enlragement
•Uterine shuffle(bruit)
•Uterine contractions(Baxton Hicks sign)
•Leukorrhea
•Pelvic organ changes
•Pregnancy test
•Auscultaion of fetal heart
•Palpation of fetal outline
•Recognition of fetal movements
•Ultrasonography
•Fetal ECG

4.  Melanocyte stimulating hormone is elevated from
early pregnancy. Melanocyte stimultes
melanophores in pigmented areas.
 Areas already pigmented become more so
(nipples, external genitalia and anal region ).
 Some fresh pigmentation appears on face
CHOLASMA(Gr. Greenish tint of a growing shoot
or bud) after 16th week AND on Abdomen as
LINEA NIGRA,in most cases after 12th week
 STRIAE GRAVIDRUM -are depressed streaks on
skin on fat areas (abdomen, breast and thighs)
after delivery they regress and persist as STRIAE
ALBICANES –they are due to stretching , but
may also be associated with increased secretion
of ACTH affecting connective tissue

5. •Hypertrophic gingival papillae are often seen after first
trimester of pregnancy. It is also called as pregnancy
gingivitis
•It mostly occur in mandibular or maxillary areas of gum
•It appears in 2nd or 3rd month of 1st trimester
•It can arise due to poor oral hygiene
•It also occur due to hormonal changes
•The gums may become hipertrophic, hiperemic and
friable;this maybe due to increased systemic estrogen.
•Vitamin C deficiency also can cause tenderness and
bleeding of the gums.The gums should return to normal
in the early puerperium

6.  Engorgement of breast after 1st week of pregnancy
is caused by:
 estrogen –stimulation of mammary duct system and
 progesteron -stimulation of alveolar components
6-8 week
 Increased vascularity
 Sensation of heaviness almost like pain
 Nipple and surrounding area become more
pigmented(primray aerola)
 Montgomery’s tubercles –sebaceous gland which
become prominent as raised pink-red nodule on
aerola
16 _ 20 week
 Clear fluid –clostrum is secreted and may be
expressed
 Seconadry aerola-a mottles effect due to further

7. •Protuberance of lower abdomen
is usually evident after 14 to 15
week
•Reduction in fundal height occurs
between 38 to 40 weeks called as
LIGHTENING ,it is due to descent
of fetus s the lower segment and
cervix prepare for labour

8.  After 16th week, a rushing sound
synchronous with mother’s pulse can often
be heard bilaterally just above the
symphysis
 It is due to increased blood flow to the
uterus through arteries

9.  Uterus undergo irregular painless contractions
from 9th to 10th week onwards,which become
palpable by 20th week
 They have no rhythm but become more
frequent as pregnancy advances
 On bimanual examination irregular uterine
contractions may be felt
 They are usually not painful in contrast with
premature or actual labour
•Increased cervical mucous and pronounced
exfoliation of vaginal epithelial cells are caused by
augmented estrogen ,progesterone levels during
pregnancy

10.  Relaxin hormone loses the pelvic
ligaments thus providing space for
the fetus passage
 The joints and ligaments (fibrous
cords and cartilage that connect
bones) in the woman's pelvis
loosen and become more flexible.
This change helps make room for
the enlarging uterus and prepare
the woman for delivery of the baby.
As a result, the woman's posture
changes somewhat.
OTHER CHANGES.
 Softening of tip of cervix by 4th or
5th week Goodel’s sign
 Inreased pulsation in lateral
fornices by 8th week
 Darkening of vaginal skin –
Jacquemier’s sign by 8th week

11. Fetal heart sound can be listen by:
•fetoscope
•sonicate
•CTG
•Ultrsound
Fetal parts palpation by :
•Abdominal examination –after 24 weeks
a. Fundal grip
b. Lateral grip
c. Pelvic/pawlick’s grip
Recognition of fetal movement :
• Active movements are usually
palpable after 18th week
• By 16th-18th week passive
movements of fetus can be elicited
by abdominal and vaginal palpation

13. •Sound is orderly transmission of mechanical vibrations
through a medium
•Ultrasound is generated from crystals that have piezoelectric
property
•If crystal is stimulated it changes its width and generate
vibrations that travel into human body
•The waves are scattered and reflected back by differences in
sound properties between tissue or within tissue
•Ultrasound probe(transducer) have many crystals ,the
returning echoes to it are reconstructed by the computer and
presented as a picture
•full bladder is often required for the procedure when
abdominal scanning is done in early pregnancy. There may be
some discomfort from pressure on the full bladder. The
conducting gel is non-staining but may feel slightly cold and
wet. There is no sensation at all from the ultrasound waves.

14. Diagnosis and confirmation of early pregnancy.
 The gestational sac can be visualized as early as four and a half
weeks of gestation and the yolk sac at about five weeks. The
embryo can be observed and measured by about five and a half
weeks. Ultrasound can also very importantly confirm the site of
the pregnancy is within the cavity of the uterus.
Vaginal bleeding in early pregnancy.
 The viability of the fetus can be documented in the presence of
vaginal bleeding in early pregnancy. A visible heartbeat could
be seen and detectable by pulsed doppler ultrasound by about
6 weeks and is usually clearly depictable by 7 weeks. If this is
observed, the probability of a continued pregnancy is better
than 95 percent. Missed abortions and blighted ovum will
usually give typical pictures of a deformed gestational sac and
absence of fetal poles or heart beat.
 Fetal heart rate tends to vary with gestational age in the very
early parts of pregnancy. Normal heart rate at 6 weeks is
around 90-110 beats per minute (bpm) and at 9 weeks is 140-
170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is
associated with a high risk of miscarriage.

15. Determination of gestational age and assessment of fetal size.
 Fetal body measurements reflect the gestational age of the fetus. This is particularly true in
early gestation. In patients with uncertain last menstrual periods, such measurements must
be made as early as possible in pregnancy to arrive at a correct dating for the patient.
The following measurements are usually made:
a) The Crown-rump length (CRL) This measurement can be made between 7 to 13
weeks and gives very accurate estimation of the gestational age. Dating with the
CRL can be within 3-4 days of the last menstrual period. An important point to note
is that when the due date has been set by an accurately measured CRL, it should
not be changed by a subsequent scan. For example, if another scan done 6 or 8
weeks later says that one should have a new due date which is further away, one
should not normally change the date but should rather interpret the finding as that
the baby is not growing at the expected rate.
b) The Biparietal diameter (BPD) The diameter between the 2 sides of the head. This
is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about
9.5 cm at term. Different babies of the same weight can have different head size,
therefore dating in the later part of pregnancy is generally considered unreliable.
Dating using the BPD should be done as early as is feasible.
c) The Femur length (FL) Measures the longest bone in the body and reflects the
longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases
from about 1.5 cm at 14 weeks to about 7.8 cm at term.Similar to the BPD, dating
using the FL should be done as early as is feasible.
d) The Abdominal circumference (AC) The single most important measurement to
make in late pregnancy. It reflects more of fetal size and weight rather than age.
Serial measurements are useful in monitoring growth of the fetus. AC
measurements should not be used for dating a fetus.

16. Diagnosis of fetal malformation.
 Many structural abnormalities in the fetus can be reliably
diagnosed by an ultrasound scan, and these can usually be
made before 20 weeks. Common examples include
hydrocephalus, anencephaly, myelomeningocoele,
achondroplasia and other dwarfism, spina bifida,
exomphalos, Gastroschisis, duodenal atresia and fetal
hydrops. With more recent equipment, conditions such as
cleft lips/ palate and congenital cardiac abnormalities are
more readily diagnosed and at an earlier gestational age.
 First trimester ultrasonic 'soft' markers for chromosomal
abnormalities such as the absence of fetal nasal bone, an
increased fetal nuchal translucency (the area at the back of
the neck) are now in common use to enable detection of
Down syndrome fetuses.
 Ultrasound can also assist in other diagnostic procedures in
prenatal diagnosis such as amniocentesis, chorionic villus
sampling, cordocentesis (percutaneous umbilical blood
sampling) and in fetal therapy.


17. Placental localization.
 Ultrasonography has become indispensible in the localization of the site of the
placenta and determining its lower edges, thus making a diagnosis or an exclusion of
placenta previa. Other placental abnormalities in conditions such as diabetes, fetal
hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be
assessed.
Multiple pregnancies.
 In this situation, ultrasonography is invaluable in determining the number of fetuses,
the chorionicity, fetal presentations, evidence of growth retardation and fetal
anomaly, the presence of placenta previa, and any suggestion of twin-to-twin
transfusion.
Hydramnios and Oligohydramnios.
 Excessive or decreased amount of liquor (amniotic fluid) can be clearly depicted by
ultrasound. Both of these conditions can have adverse effects on the fetus. In both
these situations, careful ultrasound examination should be made to exclude
intraulterine growth retardation and congenital malformation in the fetus such as
intestinal atresia, hydrops fetalis or renal dysplasia.
Other areas.
 Ultrasonography is of great value in other obstetric conditions such as:
 a) confirmation of intrauterine death.
b) confirmation of fetal presentation in uncertain cases.
c) evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata
and ovarian cyst.

18. 1st trimester

19. 2nd trimester

21. 3rd trimester

22. Any subjective evidence of diseases or of patient’s condition / such evidence
as perceived by the patient.
 Amenorrhea
 Nausea and vomiting
 Increase appetite for pickles n etc—5th month ,28 wk
 Pain, cramping in legs at 5 month
 Breast tenderness and tingling (discussed earlier)
 Stretch marks and linea nigra (discussed earlier)
 Increased tiredness
 Increase sleep
 Fatigue
 Urine frequency and urgency
 Constipation
 Quickening at 16-20 week in primiparas and as early as 14th week in multi
paras
 Metabolic effectsdue to compensatory mechanism as fetus requirements
enhancing day by da
 Pedel edema at 6 month relaxin looses ligament
 Insomnia at 9th month

23. Amenorrhea
•Conception is usually followed by cessation of menses due to
rising titer of HCG
Nausea and vomiting
•In early months many women suffer gastric upset
especially in morning
•Cause is unknown but raised level of estrogen n HCG in
circulation have been blamed
•Gastric motility is reduced due to progesterone , and in
early pregnancy the lower esophageal sphincter is
relaxed
Urine frequency and urgency
•Estrogen and progesterone ↑ turgescence of bladder
and urethra
•Bladder irritability ,nocturia and urine frequency are
common in 1st trimester
Constipation
It is due to :
•Changing in food habits
•Hormone mediated hypo-active peristalsis(progesteron)
•In later pregnancy it is caused by enlarged uterus which

24. EPULIS Local
infection
Dental calculus Vitamin C
deficiency
LACTIFEROUS
SECRETIONS
Persistent
manual breast
stimulation
Residual fluid
from previous
pregnancy
Galactorrohea
ABDOMINAL
ENLAGREMENT
obesity Relaxation of
abdominal
muscles
Pelvo-
abdominal
tumor
acsitie
s
Ventral
hernia
LEUKORRHEA Infection of
vagina /cervix
Tumor of vagina
/cervix
Psychically
induced
excessive
cervical mucus
CHANGES IN SIZE,
SHAPE &
COSISTENCY OF
CERVIX & UTERUS
Premenstural
engorgement
Uterine tumor Tubo-ovarian
cyst
Cervic
al
stenosi
s
Pyometra

25. AMENORRHEA Psychic factor Endocrine
factor
Metabolic
factor
Asherman’s
syndrome
Systemic
diseases
NAUSEA &
VOMITING
Emotional
disorder
GIT
disorder
acute infection
BREAST
TEND
ERNESS
Premenstural
symptoms
Hyper -
estrinism
Chronic cystic
mastitis
pseudocysis
URINE
FREQUENCY
UTI cytocele Pelvic tumors Emotional
tension
↑use of
chocolate
QUICKENING Increased
peristalsis
flatulence Abdominal
muscle
contractions
Shifting
abdominal
contents

26. Signs &
symptoms
Uterine fibroids Ovarian cyst Distended
bladder
pregnancy
Mass
consistency
Soft hard soft Depend on
G/A
Pregnancy
test
-ve -ve -ve +ve
Amenorrhea -ve -ve -ve +ve
Morning
sickness
-ve -ve -ve +ve
Breast
Tenderness
± ± -ve +ve
Frequency of
micturition
± ± ↓ ↑
Size of
abdominal
wall
↑ Unequally
increase
↑ Enlarge
gradually
Fetal
movement
-ve -ve -ve +ve
Abdominal
tenderness
+ve +ve +ve +ve

27. Weight Gain
 Overall gain = ~12.5kg
◦ Foetus = 3.5kg
◦ Placenta = 0.65kg
◦ Uterus = 1kg
◦ Breasts = 0.5kg
◦ Blood and fluid retention = 2kg
◦ Maternal fat = 4kg
Cardiovascular Changes
Blood volume
 Total blood volume increases by 1.5L
(40%)
 Total plasma volume increases by
1.25L (45%)
 Total red blood cell mass increases by
between 240ml (18% - without iron
supplements) and 400ml (30% - with
iron supplements)
◦ Haemocrit falls (40% to 31%)
◦ Haemoglobulin concentration falls from
13.5% to 11-12%
◦ Results in dilutional anaemia of
physiological anaemia of pregnancy
 White blood cell concentration
increases from 7000/ul to 10-11,000/ul
 Platelet turnover increases
 Total plasma proteins increase, but
concentration decreases
 Globulin increases, albunin:globulin
ratio falls
Cardiac Output
 Cardiac output increases by
approximately 1.5L/min
◦ Stoke volume increases from 64ml to 71ml
◦ Heart rate increases from 70bpm to 85bpm
 Total peripheral resistance falls
 Blood pressure falls during first
trimester, but returns to normal by term
Maternal changes during pregnancy

28. Cardiac distribution
 Increased flow to:
 uterus (from 50ml/min to
700ml/min, 90% to placenta)
 breasts
 kidneys (30%)
 skin
 Venous pressure in lower body
increased due to:
 mechanical pressure of uterus
 haemodynamic effect of increased
flow to uterus
 veins more distensible (valves
weakened) due to progesterone
Renal Changes
 Increased blood flow (40%)
 Increased plasma flow (45%)
 Increased glomerular filtration rate
(50% - due to increased plasma
flow and reduction in colloid
osmotic pressure)
 Reduced levels of creatine and
urea in plasma
 Failure to reabsorb all filtered
glucose - glycosuria
 Amino acid excretion increased
 Increased sodium retention (largely
due to activation of renal
angiotensin system)
 Increased water retention
 In bladder frequency (both day and
night)
◦ Due to increased GFR, compression
by uterus and hyperaemia
◦ severe by week 6 then subsides
until late pregnancy
Respiratory Changes
 Minute ventilation increases
 Respiratory rate constant
 Tidal volume increases - promoted
by softening of thoracic ligaments
and rising of diaphragm by 4cm
 Functional residual volume
decreases (reduces dilution of
breath)

29. Gastrointestinal Changes
 Progesterone induces cravings
 Increased absorption of calcium and iron
 lower and upper intestines raised
 decreased motility of GIT (increased
absorption, but leads to constipation)
 reduced tone of lower oesophageal
sphincter (due to progesterone, leads to
heartburn)
 increased volume and contraction of gull
bladder (leads to kidney stones)
Metabolic Changes
 Metabolism increases in general.
Changes in:
 Carbohydrates (decrease in glucose
levels in first trimester, increase in
insulin resistance in third trimester due
to human placental lactogen - induces
metabolism of fat into glycogen which is
diffused over placenta, but increases
peripheral insulin sensitivity)
 Proteins (amino acid concentration falls
due to active transport over placenta,
require high fibre diet to compensate)
 Fat (fatty acids become main energy
source and stores increase by 4kg)
CHANGES OF SELECTED GLANDS OF
THE ENDOCRINE SYSTEM
 a. Parathyroid Gland. This gland
increases in size slightly. It meets the
increased requirements for calcium
needed for fetal growth.
 b. Posterior Pituitary. Near the end of
term, the posterior pituitary will begin to
secrete oxytocin that was produced in
the hypothalamus and stored there. It
will serve to initiate labor.
 c. Anterior Pituitary. At birth, the
anterior pituitary will begin to secrete
prolactin. This stimulates the production
of breast milk.
 d. Placenta. The placenta acts as a
temporary endocrine gland during
pregnancy. It produces large amounts of
estrogen and progesterone by 10 to 12
weeks of pregnancy. It serves to
maintain the growth of the uterus, helps
to control uterine activity, and is
responsible for many of the maternal
changes in the body.

30. healthy diet
good rest
proper exercise
decrease stress level
good care of baby
regular visit to doctor
are some measures to continue
normal pregnancy