1. Physiologic changes of pregnancy
. DINA AKEEL

2. AIMS
TO GAIN AN UNDERSTANDING OF THE PHYSIOLOGICAL CHANGES THAT OCCUR DURING PREGNANCY

4. Organ systems Cardiovascular system Pulmonary system Genital tract
Urinary system
Endocrine system
Gastrointestinal Tract
Skin

5. CHANGES ARE DUE TO ALTERATIONS IN HORMONAL PRODUCTION CIRCULATION
METABOLISM

6. HORMONES OESTROGEN Produced in corpus luteum
Produced by placenta after 12 weeks
Responsible for growth particularly of uterus and breasts

7. progesterone Produced in corpus luteum and then the placenta
Relaxes smooth muscle
Inhibits uterine contractions until uterus is prepared for labour
Regulates storage of body fat

8. Maternal changes - anatomical and physiological
Cardiovascular changes
increase in SV
increase in cardiac output
increase in HR at given work load
increase in blood volume (mostly during latter half of pregnancy)
Uterus may compress large blood vessels reducing venous return

9. Circulatory System
The cardiovascular system includes the heart, blood, arteries, and veins. It delivers oxygen and nutrients to all parts of the body, and to the growing baby. As a result, the pregnant soldier's heart becomes more efficient at pumping the blood to her body and to the baby.
When exercising, the soldier should not exercise to the point of exhaustion or breathlessness. This is a sign that your body cannot get the oxygen supply it needs, which effects the oxygen supply to the baby as well. The soldier should not engage in activities that involve low oxygen states, such as scuba diving or mountain climbing.
Is exercise safe for the baby?
One of the major concerns about exercise during pregnancy is the question of diversion of maternal blood flow away from the uterus to the skeletal muscles during moderate and vigorous activity. It is believed that in moderate recreational exercise, the diversion is approximately 50 percent and in competitive athletic events can be percent. There is no research documentation of harm to the fetus, from the diversion of uterine blood flow, in soldiers who participate in regular moderate-to-high intensity exercise.
The probable reason for this lack of detrimental fetal outcomes is the feto-protective, more-than-additive combination of increased blood plasma due to both aerobic training effect and pregnancy. This over-expansion reduces the fall in visceral gut blood flow and helps maintain fetal circulation during exercise. The increased red blood cells associated with exercise, as well as compensatory mechanisms of the placenta in well-conditioned, highly-fit soldiers, also helps account for the ability of the cardiovascular system to deliver needed nutrients.

10. Supine hypotension related to Venal cava syndrome
This leads to dizziness, air hunger, nausea

11. Total body water Increases 6-8 L Increases by 40 % Normal body water
2/3 intracellular
1/3 extracellular
¾ interstitial
¼ intravasular
2/3 increase is extravascular

12. Respiratory system Mechanical Consumption Stimulation diaphragm
Increase in needed oxygen
Stimulation
Progesterone stimulation

14. Physiologic changes - increase respiratory rate
RESPIRATORY SYSTEM
increase respiratory rate
increased oxygen consumption
common are nasal stuffiness, nosebleeds due to Increased vascular swelling to nose
Changes that occur in the resp system are necessary to meet the inc o2 needs of the dev fetus. See slide.
Hayfever symptoms
Increased vascular swelling to nose/ may cause nose bleeds, difficulty breathing etc,
Cool mist humidifiers
Commercially prepared saline spray
Capillaires inside the nose get engorged with blood during pregnancy causing nasal congestion and epistaxisis.
Diaphram elevates 4 cm.
Transverse diameter increases 2 cm.
Anterioposterior diameter increases 2cm.
Oxygen consumption increases 15-25%
Tidal volume increases 50%
Respiratory rate increases slightly
Increased vascularity entire upper tract 14

15. Respiratory Consumption O2 consumption Increases 15-20 %
50 % of this increase is required by the uterus
Despite increase in oxygen requirements, with the increase in Cardiac Output and increase in alveolar ventilation oxygen consumption exceeds the requirements. .

16. Physiologic changes - Digestive system slow due to progesterone
GASTROINTESTINAL
Digestive system slow due to progesterone
Nausea and vomiting
Ptyalism: increase salivation
Heartburn
Hemorrhoids
Prolonged gallbladder emptying time may lead to gall stones
Bile salt buildup may lead to itching.
Digestive system slow due to progesterone
May be due to increased HCG and estrogen
Many theories about cause of nausea
Gi changes are a result of the hormonal changes and inc fundal size puts pressure on internal organs
Ptyalism – inc salivation 16

17. Gastrointestinal Tract
Displacement of the stomach and intestines
Appendix can be displaced to reach the right flank
Gastric emptying and intestinal transit times are delayed secondary to hormonal and mechanical factors
Vascular swelling of the gums
Hemorrhoids due to elevated pressure in veins

19. Physiologic changes - BMR increases by 20-25 % during pregnancy
METABOLISM
BMR increases by % during pregnancy
Recommended weight gain – lb
Overweight – lb
Underweight – lb
Need for increased iron, calcium, fat, and protein
1ST TRI 3-4 LBS/MONTH
2ND 1 LB /WK
3RD 8-10 TOTAL TRI 19

20. Genital Tract Increased vascularity and hyperemia Increased secretions
Vagina
Perineum
Vulva
Increased secretions
Characteristic violet color of the vagina
Chadwick’s sign
Increased length to the vaginal wall
Hypertrophy of the papillae of the vaginal mucosa

21. Changes in the cervix Length remains the same Increase in width
Softening after third month due to oestrogen
Increased vascularity
Increased cervical mucosa
Increased glandular function

22. uterus grows to 30x23x20 at term weight increases to 900gms hypertrophy.. Oestrogen causes cells to increase until 20 weeks gestation Hyperplasia:- number of cells increase under the influence of oestrogen .

23. Relative Uterus Size During Pregnancy
Figure 28.15

24. PLASMA VOLUME
Increases from 10th week of pregnancy
variable related to parity, fetal weight and number
Reaches maximum level approx 50% above non-pregnant levels at weeks then maintained

25. 50% rise in plasma volume
20% rise in red cell mass
Heamodilution: Physiological anaemia
Most apparent at weeks

26. RENAL SYSTEM DILATION OF THE RENAL VESSELS
DUE THE EFFECTS OF PROGESTERONE
INCREASED RENAL BLOOD FLOW
GFR INCREASES BY 60% IN EARLY PREGNANCY

27. Urinary Changes
Kidneys grow and filter more blood as the blood volume increases
Become more susceptible to bladder and kidney infections
Bladder becomes compressed causing frequent urination and incontinence
Help for frequent urination:
Keep drinking large amounts of water
Plan for bathroom breaks before the urge arises
Avoid drinking a lot of fluids before bed
Expect to have frequent urination day and night
Do Kegel exercises regularly
If burning, pain or blood occurs upon urination, tell your health care provider

28. Wajed Hatamleh RN, MSN, PhD.
Physiologic changes -
URINARY TRACT
Increased glomerular filtration rate
Frequency
Infection : Smooth muscle of bladder relaxes/stasis
Urinary tract changes result form the inc blood volume and glom filtration rate and inc fundal size puts pressure on internal organs
More susceptible to infection dt dec blood flow and traumaGFR raises by 50%
Increased renal clearance leads to lowered BUN and nonprotein nitrogen values.
Renal plasma blood flow increases 50%
Glomerular Filtration Rate increases
Bicarbonate increased excretion
Creatinine increased excretion
Renal pelves and ureters dilate
Smooth muscle of bladder relaxes/stasis
Sugar may spill at 160/protein PIH
Wajed Hatamleh RN, MSN, PhD. 28

29. Hydration is a major concern during maternal exercise.
WATER, WATER, WATER
Hydration is a major concern during maternal exercise.
Provide a ready source of water
Encourage frequent water breaks
Hydration is a major concern during maternal exercise. ELs must provide a ready source of water for pregnant soldiers and encourage frequent water breaks.
EMPHASIZE THIS!
Water contributes to the cooling process
Ensures adequate increase in blood volume
Drink before and during and after exercise
Consume at least 2 quarts of water or other fluid per day
Very active soldiers should drink water until their urine is clear
During hot, humid weather, exercise should only be done in a cooled or air-conditioned room.

30. Skin changes
Chloasma or melasma gravidarum
Striae
Linea nigra

31. Skin Changes Stretch marks
Dark pigmented line on there abdomen which is called Linea Nigra
Pigment changes on their face and neck
Small blood vessels in the face, neck and upper chest
MOST OF THESE RESOLVE AFTER PREGNANCY
Stretch marks are common over breasts, abdomen and hips
Many woman get a dark pigmented line on the abdomen called a Linea Nigra which resolves after pregnancy
Occasionally, women will have pigment changes on their face and neck. This also resolves after pregnancy.
Small blood vessels may appear in the face, neck, and upper chest. These are more common in white women and less common in women of other skin colors. These usually resolve after pregnancy.

32. Melasma

33. Melasma

34. Melasma Also known as the mask of pregnancy
More common in dark skin people
More pronounced in the summer
Fades a few months after delivery
Repeated pregnancy can intensify
Can occur in normal non-pregnant women with harmless hormonal imbalances or women on OCPs or depo

35. Striae

36. Striae Reddish slightly depressed Breasts, thighs, and abdomen
In future pregnancies they appear as glistening, silver lines

37. Linea nigra