Module 6, Systematic Changes during Pregnancy

Reproductive System Changes

 During pregnancy, the internal genital tract/ reproductive systems undergone

anatomical and physiological changes to accommodate the changes and development of
the fetus.
 These changes presented as below:

Uterus

 With pregnancy progression, the uterus leaves the pelvic and ascends to the abdominal
cavity
 The abdominal content displaced in response to the increased size of the uterus which is
five times more than normal
 This increases in the size of uterus associated with an increase of blood supply to the
uterus and uterine muscle activity,
 Uterus increases in size till the 38 weeks after that the funds level starts to descend
preparing for delivery.
 Its weight increases from 50mg to 1000mg after that it doesn't get heavier any more
and only stretches to accommodate the fetus size, and associated with an increase in the
thickness and length of the fundus.

Cervix

The enlarged mucus glands of the cervix during pregnancy secretes a mucus plug called
“operculum”, act as a seal for the uterus and protect it from ascending infection, and act as
a barrier between the vagina and cervix. Later in pregnancy before delivery, there is a
softening of the cervix in response to the increasing uterine contractions .

Vagina

during pregnancy there is an increase in the blood supply to the vagina, its colour change from
pink to purple, and becomes more elastic in the second trimester [
Musculoskeletal Changes

Postural Changes

 The overall equilibrium of the spine and pelvis alters as the pregnancy progresses [7]
 There is still confusion as to the exact nature of any associated postural adaptation.
With weight gain, increased blood volume, and ventral growth of the fetus,
 The centre of gravity no longer falls over the feet, increase in anteroposterior and
medial -

Articular Changes

 Altered levels of relaxin, oestrogen, and progesterone during pregnancy result in an

alteration to collagen metabolism, this laxity is due to the break down of collagen in the
targeted tissue and replaces it by a modified form that contains higher water content .
 That increases connective tissue pliability and extensibility.
Therefore, ligamentous tissues are predisposed to laxity with resultant reduced
passive joint stability, ligament laxity reaches its maximum at the second trimester [9].
 The symphysis pubis and sacroiliac joints are particularly affected to allow for the birth
of the baby. Ligamentous laxity may continue for six months postpartum.
Biomechanical changes of the spinal and pelvic joints may involve an increase in sacral
promontory, an increase in lumbosacral angle, a forward rotatory movement of the
innominate bones, and downward and forward rotation of the symphysis pubis.
 The normal pubic symphyseal gap of 4–5 mm shows an average increase of 3 mm
during pregnancy
 Pelvic joint loosening begins around 10 weeks, with maximum loosening near term.
Joints should return to normal at 4–12 weeks postpartum.
 The sacrococcygeal joints also loosen. By the last trimester, the hip abductors,
extensors, and the ankle plantar flexors increase their net power during gait and there is
an increase in load on the hip joints of 2.8 times the normal value when standing and
working in front of a worktop. As the uterus rises in the abdomen the rib cage is forced
laterally and the diameter of the chest may increase by 10–15 cm. [2]

Neuromuscular Changes

 During pregnancy, the enlarged uterus results in elongation of the abdominal muscles
and separation of the linea alba.
 Passive joint instability (as seen in pregnancy) alters afferent input from joint
mechanoreceptors and probably affects motor neuron recruitment.
 A decrease in muscle stiffness and thus active stability of joints may result from
alteration of muscle spindle regulation and this is applicable particularly to muscles
around the pelvic girdle .
 These changes may lead to poor recruitment of the muscles responsible for pelvic girdle
stability (particularly gluteus medius and Maximus) and result in decreased tension
of these muscles during walking, perhaps resulting in pelvic girdle pain

Cardiovascular changes

 The heart adapts to the increased cardiac demand that occurs during pregnancy in
many ways.
 Cardiac output increases throughout early pregnancy, and peaks in the third trimester,
usually to 30-50% above baseline.
 Estrogen mediates this rise in cardiac output by increasing the pre-load and stroke
volume, mainly via a higher overall blood volume (which increases by 40–50%).
 The heart rate increases, but generally not above 100 beats/ minute.
 Total systematic vascular resistance decreases by 20% secondary to the vasodilatory
effect of progesterone. Overall, the systolic and diastolic blood pressure drops 10–
15 mm Hg in the first trimester and then returns to the baseline in the second half of
pregnancy. 
 All of these cardiovascular adaptations can lead to common complaints, such as
palpitations, decreased exercise tolerance, and dizziness. [10]

Respiratory Changes

 Respiratory changes during pregnancy are important to accommodate and meet the
demands of mother and fetus, there are changes in all lung volumes, changes in the
upper airway respiratory tract, and breathing pattern.
 There is increasing oedema in the upper airway tract, which in this case, smaller
endotracheal tube when intubation is necessary intervention will be needed.
Elevated diaphragm for about 4cm is a clinical presentation with pregnant women
because of the enlarged uterus.
 Ligaments connecting ribs to sternum like other ligaments that affected by relaxin and
progesterone hormones and become lax during pregnancy, so the subcostal angel and
chest circumference increase from 5-7cm and this is associated with lower chest
compliance.
 Lung Volumes change as follows; functional residual capacity decreases by 10-25%,
expiratory reserve volume  15-20%, and residual volume decreased by 20-25%, and the
total lung capacity decrease. In addition, an increase in the respiratory capacity by 5-
10%, respiratory rate by 1-2 breaths more than normal, and an increase in the tidal
volume 30-50%.

 We will find an increase in oxygen consumption by 30% and the metabolic rate by 15%
in pregnant women, but they still have a lower oxygen reservoir due to the lower rate of
functional residual capacity FRC, and are more prone to hypoxic, hyperventilation and
dyspnea are common in pregnancy.
 In addition these changes there is an increase in PaO2 to facilitate the transfer of
oxygen from mother to fetus and lower PaCo2 to facilitate the transfers of carbon
dioxide from fetus to mother [11][4].

Gastrointestinal changes
 Progesterone causes smooth muscle relaxation which slows down GI motility and
decreases lower oesophagal sphincter (LES) tone.
 The resulting increase in intragastric pressure combined with lower LES tone leads to
the gastroesophageal reflux commonly experienced during pregnancy.
 Nausea and vomiting of pregnancy, commonly known as “morning sickness”, is one of
the most common GI symptoms of pregnancy. It begins between the 4 and 8 weeks of
pregnancy and usually subsides by 14 to 16 weeks.
 The exact cause of nausea is not fully understood but it correlates with the rise in the
levels of human chorionic gonadotropin, progesterone, and the resulting relaxation of
the smooth muscle of the stomach [12]. also, constipation and haemorrhoids can occur
during pregnancy.

Renal changes

 A pregnant woman may experience an increase in the size of the kidneys and ureter due
to the increased blood volume and vasculature.
 Later in pregnancy, the woman might develop physiological hydronephrosis and
hydroureteronephrosis, which are normal.
 There is an increase in glomerular filtration rate associated with an increase in
creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
 There is also an increase in sodium retention from the renal tube so oedema and water
retention is a common sign in pregnant women [11].
 In the third trimester when the fetus starts to engage in the pelvis, there is an increased
frequency of urination, incontinence.

Nutrition

 During pregnancy, both protein metabolism and carbohydrate metabolism are affected.

 One kilogram of extra protein is deposited, with half going to the fetus and placenta,
and another half going to uterine contractile proteins, breast glandular tissue, plasma
protein, and haemoglobin.
 An increased requirement for nutrients is given by fetal growth and fat deposition.
 Changes are caused by steroid hormones, lactogen, and cortisol.
 Pregnant women require a caloric increase. also there's a weight gain of 20 to 30 lb (9.1
to 13.6 kg).[13]

Problems may have during pregnancy

1. Pelvic floor dysfunction.

 2. Rib pain.
3. Nerve compression syndromes.
4. Carpal tunnel syndrome.
5. Muscle cramps.
6. Symphysis pubis dysfunction
7. Morning sickness.
8. Edema.
9. Pre-eclampsia
10.Back pain.

Exercises And Contraindications For It

For regular exercisers Consult your doctor or midwife before beginning exercise.

Exercise at a moderate level most days for 30 minutes or more also discontinue contact
sports and activities which carry a high risk of falling or abdominal trauma, avoid scuba
diving.

Self regulate both the level of intensity and duration of exercise, aiming to keep the core
temperature below 38°C. and aim for low impact activity..Wear suitably supportive
footwear to reduce musculoskeletal stresses. Maintain adequate fluid intake to prevent
dehydration, and avoid exercise during hot and humid weather, or with pyrexia. Warm up
and cooldown for at least five minutes. Do not use developmental stretching (because of the
effects of relaxin). Brisk walking has fewer risk of falling.

Seek professional advice on specific exercises (e.g. for the pelvic floor muscles). Avoid
ballistic exercise, low squats, crossover steps, and rapid changes of direction. Do not
exercise in supine after 16 weeks gestation, to avoid aortocaval compression. Eat to
appetite, without calorific restriction. Work towards crosstraining to avoid overtraining,
and stop exercise before fatigue sets in.

In addition to the above, women not used to regular exercise should be advised:

not to start an exercise programme until >13 weeks gestation; to consider beginning with
nonweightbearing exercises, such as aquanatal classes; to progress from simple and basic
levels of exercise, increasing exercise tolerance gradually, under the supervision of a
suitably qualified professional.

Contraindications :

 Cardiovascular
 Respiratory
 Renal or thyroid disease
 Diabetes (type 1, if poorly controlled)
 The history of miscarriage, premature labour, et al growth restriction,
 Cervical incompetence;
 Hypertension,
 Vaginal bleeding,
 Reduced fetal movement,
 Anaemia,
 Breech presentation,
 Placenta praevia. [2]
All women should stop exercising immediately and seek advice from a doctor if they
experience: abdominal pain. vaginal bleeding.shortness of breath, dizziness, faintness,
persistent severe headache, palpitations or tachycardia; PGP, which may also lead to
difficulty in walking.

Changes in Your Body During Pregnancy: First Trimester

The first trimester of pregnancy can be exciting and scary. A person’s body goes through a lot of
changes. Some of these changes may begin before you even know or confirm you are
pregnant. It can help to know what to look for and expect so you can prepare.

How do I know I’m pregnant?

A missed period is often the first sign of pregnancy. You may have some other physical signs as

well. These include mild cramping and a little bleeding when the fertilized egg implants itself in

your uterus.

If you’ve missed your period and think you may be pregnant, you can take a home pregnancy

test. These tests are very accurate if you take them a few days after you expected to get your

period. Call your doctor if the test is positive.

Why do I feel so tired?

Feeling very tired is another common symptom of early pregnancy. Your body is working hard to

adjust to all the new physical changes. This can cause extreme fatigue. You may need to sleep

longer than usual at night. If possible, you can take short naps during the day. Your energy will

most likely return in the second trimester of pregnancy.

What is morning sickness?

Morning sickness consists of nausea and vomiting. It is caused by pregnancy hormones.

Many pregnant people have it to some degree in their first trimester. Despite what it sounds,

morning sickness can occur at any time of day. Certain foods or smells might make you feel sick

and sometimes vomit. Some people seem to feel sicker when their stomachs are empty.

Morning sickness usually goes away by the second trimester.

There are over-the-counter vitamins and herbal supplements that may help with morning

sickness. Taking vitamin B6 may help with nausea, even though it may not prevent vomiting.

Ginger supplements also may relieve nausea.

What other changes can I expect during the first trimester?

Frequent urination. Towards the end of the first trimester, you will feel like urinating more

often. This is because your growing uterus pushes on your bladder. You may even leak a little

urine when you cough or sneeze.

Lightheadedness. Your body is working overtime to make extra blood to support your baby.

This can cause you to feel dizzy or lightheaded. Hunger, weakness, or stress can cause these

symptoms as well.

Heart Burn: The muscles that break down food become more relaxed during pregnancy.
Hormone changes also slow down this process. Food also stays in your stomach longer

to give your body more time to absorb nutrients. All these things can cause or worsen

heartburn.
Constipation. You should be taking a daily prenatal vitamin that contains iron. The iron in the

vitamin can lead to constipation. The slow process of breaking down food also can cause

constipation, gas, and bloating. Your doctor may suggest taking fiber supplements or a stool

softener to provide relief. Make sure you drink plenty of water (about eight glasses per day). Tell

your doctor if you have severe problems. They may switch you to a different prenatal vitamin.

Visible veins. Your body makes extra blood and your heart pumps faster to meet the needs of

pregnancy. This can cause the blue veins in your belly, breasts, and legs to become more

Constipation: You should be taking a daily prenatal vitamin that contains iron. The iron in

the vitamin can lead to constipation. The slow process of breaking down food also can cause

constipation, gas, and bloating. Your doctor may suggest taking fiber supplements or a stool

softener to provide relief. Make sure you drink plenty of water (about eight glasses per day). Tell

your doctor if you have severe problems. They may switch you to a different prenatal vitamin.

Visible veins. Your body makes extra blood and your heart pumps faster to meet the
needs  of pregnancy. This can cause the blue veins in your belly, breasts, and legs to become

more noticeable. You may develop spider veins on your face, neck, or arms. These are tiny

blood vessels that branch out from a central area, like the legs of a spider.

Skin changes. You may notice that your skin looks more rosy and shiny. Some people
call this a “pregnancy glow.” It is caused by increased blood circulation. Pregnancy hormones

can cause extra oil on your skin. It may cause you to have flares of acne.
Breast changes. Most people notice changes in their breasts early in pregnancy.
The hormones in your body change to prepare for breastfeeding. As this occurs, your

breasts may feel tender and swollen. You might notice small bumps forming in the area

around your nipples. Your breasts will continue to grow and change throughout your

pregnancy. They may feel even bigger and fuller later on.

Vaginal changes. The lining of your vagina will become thicker and less sensitive. You
may notice a thin, white discharge. This is normal during pregnancy. Mild vaginal bleeding

(spotting) is also normal and common. However, you should call your doctor if you have vaginal

bleeding. If the bleeding is heavy or painful, go to the emergency room.

A growing belly. Your waistline will begin to expand as your baby and uterus grow
larger. Depending on your size before pregnancy, you may not notice this change until the

second trimester. It is normal to gain no or little weight in your first trimester.

Emotional symptoms. Your hormones are on overload during pregnancy. You might

feel moody, forgetful, or unable to focus. Fatigue and stress can increase these symptoms.

Things to consider

Keep in mind that each pregnancy experience is unique. Even the same person may

have different changes in their multiple pregnancies. For each change, your symptoms

may be mild or severe. Do not worry if the changes do not happen at a certain time.

Talk to your doctor if you have any concerns.

When to see your doctor

Contact your doctor if you think or know you are pregnant. They will make an

appointment to confirm your pregnancy and talk to you about prenatal care.

You should also contact your doctor if your morning sickness and vomiting are severe

enough to cause weight loss.

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