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PHYSIOLOGICAL CHANGES DUE TO PREGNANCY

Physiological changes that take place in a mothers body during pregnancy are associated with and caused by the effects of specific hormones. These changes enable her to nurture the fetus, prepare her body for labor and develop her breasts for production of milk during the puerperium. CHANGES IN THE REPRODUCTIVE SYSTEM The changes in pregnancy that take place in the reproductive system are a temporary adaptation to meet the needs and demands of the fetus. THE BODY OF UTERUS After conception the uterus develops to provide a nutritive and protective environment in which the fetus will develop and grow. CHANGES IN THE UTERINE SHAPE The uterus changes to globular shape to accommodate the growing fetus, increasing amounts of liquor and placental tissue. The lower part of the uterus, consisting of the isthmus, softens and elongates to three times its original length during the first trimester, giving the appearance of stalk below the globular upper segment. This is the beginning of the upper segments of uterus. By 12th week of pregnancy, the uterus rises out of pelvis and becomes upright. It is no longer anteverted and outflexed. It is about the size of a grape fruit and may be palpated abdominally above the symphysis pubis. By 16th week, the conceptus has grown enough to put pressure on the isthmus, causing it to open out so that the uterus become more globular in shape. By 20th week of pregnancy, the uterus becomes spherical in shape and has a thicker, more rounded fundus. As the uterus continues to rise in the abdomen, the uterine tubes, being restricted by attachments to the broad ligaments, becomes progressively more vertical. At 20 weeks fundus of the uterus may be palpated just below the umbilicus By 30 weeks the lower uterine segment can be identified. It is the portion of the uterus above the internal os of the cercix. The fundus can be palpated midway between the umbilicus and thee xiphisternum. The uterus reaches the level of the xiphisternum by 38 week. A reduction in fundal height, know as lightening, may occur at the end of the pregnancy when the fetus sinks into the lower pole of uterus. This is due to softening of the tissues of the pelvic floor and further formation of the lower uterine segment. In the primigravida, this also encourages the beginning of a gradual descend of the fetus into the pelvis and the head becomes engaged. In the multiparous women, descend often does not occur until labour begins.

When the formation of the lower uterine segment is complete in labour it measures approximately one- third of the uterus DECIDUA The decidua is the name given to the endometrium during pregnancy. Estrogen and progesterone, produced by the corpus luteum, causes the deciduas to become thicker, richer and more vascular at the fundus and in the upper body of the uterus, which are usual site of implantation. The deciduas provides a glycogen rich environment for the blastocyst until the placenta is formed. Once the placenta is formed, it is able to produce its own hormones. After 13 17 weeks of pregnancy th corpus luteum atrophies and becomes corpus albicans. MYOMETRIUM The myometrium is made up of smooth muscle fibres, held together by connective tissue. The muscle fibres grow upto 15 -20 times their non pregnant length. The hypertrophy and hyperplasia of the uterine muscle is due to the effect of estrogen and progesterone. The uterus continues to grow in this way for the first three months, after which the growth is related to distension by the growing fetus At term the uterus measures 30 x 23 x 20 cm and weighs 750 1000 gm. Individual muscle cell grows 17 -40 times. The walls of the myometrium becomes thicker in the first few mmonths of pregnancy, and as gestation advances, the walls become thinner owing to the gross enlargement of uterus, being only 1.5 cm thick or less at term. Throughout most of the pregnancy, the uterus generates small waves of irregular and usually painless contractility known as Braxton Hicks contractions. These are in frequent and non-rhythmic and facilitate the formation of the lower uterine segment. They usually increase in ferequency and intensity from about 36 week of pregnancy, causing some discomfort. These pre-labour contactions are associated with ripening of cervix and eventually becomes the contractions of labour as the effects of estrogen supersede those of progesterone. During pregnancy, the muscle laters become more differentiated and organized for their part in expelling the fetus. MUSCLE LAYERS The outer longitudinal layer of mmuscle fiber is thin. The middle layer of spiral myometrial fibers is thick, during labour the synchronous contraction and retraction of these fibers cause them to become heaped up in the upper uterine segment making it thicker and shorter in length while the lower uterine segment vecomes thinner and more stretched. The thickness of upper uterine segment acts as a piston to force the fetus into the receptive, passice lower uterine segment. Contraction of these muscle fivers ins necessary to entrap and enmesh bleeding vessels and ligate them after the placenta is delivered. The inner circular layer is thin and forms sphincters around the openings of the uterine tubes at the cornua, and around the lower uterine segment causes the cervix to become effaced and dialated. BLOOD SUPPLAY 2

The uterine blood vessels increases in diameter and new vessels develop under the influence of estrogen, the blood supply to the uterus through the uterine and ovarian arteries increases to about 750 ml per minute at term to keep pace with its growth and also to meet the needs of the functioning placenta. THE FALLOPIAN TUBES The fallopian tubes on either side are more stretched out in pregnancy and is much more vascular. The uterine end of the tube is usually closed and the fimbriated end remains open. THE CERVIX The cervix remains tightly closed during pregnancy, providing protection to the fetus and resistance to pressure form above when the woman is in standing position. It acts as an effective barrier against infection during pregnancy. The mucus secreated by endocervical cells becomes thicker and more viscous during pregnancy. The thickened mucus froms forms a cervical plug called the operculum, which provides protection from ascending infection. Cervical vascularity increases during pregnancy and if viewed through a speculum, it looks bluish in colour. The cervix remains 2.5 cm long throughout pregnancy. In late pregnancy softening, or ripening of cervix occurs making it more distensible. The muscles of the fundus enhance tension in the outer longitudinal layer of muscles of the cervix contributing to the process of effacement or taking up of the cervix normally occurs in the primigravida during the last two weeks of pregnancy but does not usually take place in the multigravida until labour begins. THE VAGINA The estrogen causes changes in the muscle layer and epithelium of the vagina. The muscle later hypertrophies and the capacities of the vagina increases. Changes in the surrounding connective tissue make it more elastic. These changes enable the vagina to dilate during the second stage of labour. The epithelium becomes thicker with marked desquamation (peeling off) of the superficial cells, which increases the amount of normal vaginal white discharge, known as leukorrhea. The epithelial cells have high glycogen content. These cells interact with Doderleins bacillus, which is normally found in vaginal and produce a more acidic environment. The acid environment produce an extra degree of protection against some organisms and increasing susceptibility to others, such as candida albicans. The vagina becomes more vascular and appears violet in colour, probably due to increased blood supply. CHANGES IN THE CARDIOVASCULA SYSTEM In the cardiovascular system, profound changes take place during pregnancy. For the care of women with normal pregnancies as well as for the management of women with pre existing cardiovascular diseases, an understanding of these changes is important. THE HEART

The heart muscle, particularly the left ventricle, hypertrophies leading to enlargement of the heart. The growing uterus pushes the heart upwards and to the left. During pregnancy heart rate and stroke volume increases. This is due to increased blood volume and increased oxygen requirements of the maternal tissues and the growing fetus. The cardiac output increases markedly by the end of the first trimester. In the third trimester, a rise or fall or no changes at all has been shown to occur, depending on individual variations. Although the cardiac output increases markedly by the end of the first trimester. In pregnancy, the bold pressure does not rise because of the reduction in peripheral resistance. The capacity of veins and venules increases. Arterial walls relax and dilate due to the effect of progesterone. The increase production of vasodilator prostaglandin also contributes to this. During the mid trimester, changes in the blood pressure may cause fainting. In later pregnancy, hypotension may occur in 10% women in unsupported supine position. This is termed as the supine hypotensive syndrome. The pressure of the gravid uterus return. Cardiac output is reduced by 25 30 % and the blood pressure may fall 10 -15 %, which produces feeling of giddiness, nausea and even fainting. Poor venous constriction return in late pregnancy along with increased distensibility and pressure in the veins of the legs, vulva, rectum and pelvis can lead to edema in lower limbs, varicose veins and haemorrhoids. Blood flow increases to the uterus, kidneys, breasts and skin during pregnancy. Much o fthe increased cardiac output goes to the utero placental circulation, which is about 750 ml per minute at term. Regulation of uterine blood flow is critical importance to the welfare of the fetus. Hemorrhage uterine contractions and lying in the supine position in late pregnancy can all reduce uterine blood flow. Chronic impairment can lead to intrauterine growth retardation and ultimately fetal death. Renal blood flow increases during pregnancy. Blood flow to the capillaries of the skin and mucous membranes, the associated peripheral to hands and feet increases. The associated peripheral vasodilation causes women to sweat profusely at times. Some may suffer nasal congestion. There is increased blood flow to the breasts through out pregnancy and dilated veins may be seen on the surface of the breasts along with enlargement and tingling from early pregnancy.

CHANGE IN THE CARDIOVASCULAR SYSTEM:-

Heart and circulation:Anatomical changes:- The heart muscle, particularly the left ventricle, hypertrophies leads to enlargement of the heart. The growing uterus pushes the heart upwards and to the left. During pregnancy the heart rate and stroke
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volume(the amount of blood pumped by the heart with each beat) increases. This is due to the increased blood volume and increase oxygen requirement of the maternal tissues and the growing fetus. The cardiac output starts to increase from 10th week of the pregnancy reaches its peak 40% at about static till term when the observation is made at lateral recumbent position. In non-pregnant state, the cardiac output measures 4.5litres in first, second and third trimester respectively. The increase in cardiac output is caused by 1) Increased blood volume 2) To meet the additional O2 required due to increased metabolic activity during pregnancy 3) The increase in cardiac output is chiefly affected by increase in stroke volume and increase in pulse rate to about 15 mts.

Blood pressure:In spite of increased cardiac output, the value (systolic 110-120 mm Hg; diastolic 65-80mm Hg ) probably due to increased pool of blood in the uteroplacental circulation. Hypertensive women are likely to have a mid pregnancy drop.

Venous pressure:Antecubital venous pressure remains unaffected femoral venous pressure is markedly raised specially in the later months. It is due to pressure exerted by the gravid uterus on the common iliac veins, more on the right side due to dextra-rotation of the uterus. The Femoral venous pressure is raised from 8-10 cm of water in non-pregnancy in lying down position and to about 80-100 cm of water in standing position. This explains the fact that the
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physiological oedema of pregnancy subsides by rest alone. Dispensability of the veins is increased due to progesterone and there is stagnation of blood in the venous system specially below the uterus. These factors increase the tendency of varicosity and piles during pregnancy and precipitate peripheral venous thrombosis.

Supine hypotension syndrome (postural hypotension ):During late pregnancy, the gravid uterus produces a compression effect on the inferior venacava when the patient is in supine position. This results in opening up of the collateral circulation by means of paravertebral and azygos veins. In some cases when the collateral circulation fails to open up, the venous return of the heart may be seriously curtalised. This results in production of hypotension, tachycardia and syncope. The normal blood pressure is quickly restored by turning the patient to lateral position.

Distribution of blood flow:


Uterine blood flow is increased from 50 ml per minute in non-pregnant state to about 750ml near term. The increase is due to the combined effect of utero-plocental and feto-placental perfusion. Pulmonary blood flow (normal 6000ml/min) is increased by 2500ml per minute. Renal blood flow (normal 800ml ) increases by 400ml per minute at 16 wk and remains at this level till term. The blood flow through the skin and mucous membranes reaches a maximum of 500 ml/minute by 36th wk. heat sensation sweating or stuffy nose complained by the pregnant women can be explained by the increased blood flow.

CHANGES IN HAEMATOLOGICAL SYSTEM:The blood volume:The increase in blood volume in pregnancy varies according to the size of the woman, the number of pregnancies she has had, her parity and whether the pregnancy is singleton ore multiple. The increase begins at about tenth week gestation and progresses upto 30th-34th week of gestation. The increase may be as much as 100 percent in some women. A higher circulating volume is required for the following functions: To provide extra blood flow for placental circulation. To supply the extra metabolic needs of the fetus. To provide extra perfusion of kidneys and other organs. To counterbalance the effects of increased arterial and venous capacity. To compensate for blood loss at delivery. There is increase in plasma volume, which reduces the viscosity of the blood and improves capillary blood flow. The total volume of red cells in the circulation increases as a result of increased production in response to the extra oxygen requirements of maternal and placental tissue. There is constant increase throughout the pregnancy from about tenth week resulting in total increase of 18-25percent As the increase in plasma volume is much greater than that of the redcell mass, hemodilution occurs. It is characterized by a lowered red cell count hemoglobin level. The hematocrit concentration or packed cell volume falls from an average non-pregnant figure of 35 percent to 29 percent at around 30th week. The effect is referred to as physiological anemia.
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Plasma protein:During the first 20 weeks of pregnancy, the plasma protein concentration reduces as a result of the increased plasma volume. This leads to lowered osmotic pressure, contributing to edema of the lower limbs seen in late pregnancy. In the absence of disease moderate edema of the lower limbs seen in late pregnancy. In the absence of disease moderate edema is seen as physiological.

Iron metabolism:Iron requirement increases significantly in the last trimester, during which time iron absorption from the gut is enhanced. The purpose of iron supplementation in pregnancy is to prevent iron deficiency in the mother, not to raise the hemoglobin.

Clotting factors:The clothing and fibrinolytic systems undergo major changes during pregnancy. Plasma fibrinogen (factor-1) increases from the third month of pregnancy progressively until term. Prothrombin (factor 2) increases only slightly. Factor 7,8,9 and 10 increase leading to change in coagulation time from 12-8 minutes. The capacity for clothing is thus increased in preparation for the prevention of hemorrhage at placental separation. So there is a higher risk of thrombosis, embolism.

White blood cells:The neutrophils increase in pregnancy, which enhances the bloods phagocytic and bactericidal properties. In the second and third trimester the action of the polymorph nuclear leukocytes may be depressed, perhaps
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accounting for the increased susceptibility of pregnant women to infection. The lymphocyte and monocyte numbers remain the same throughout pregnancy.

Immunity:Immune response is reduced in pregnancy. Levels of immunoglobulins Ig A, Ig G and Ig M decrease steadily from the 10th week to the 30th week and then remain at these levels until term resulting in reduced immune response. Antibody titers against viruses such as measles, influenza A and herpes simplex are reduced in proportion to the hem dilution effect, therefore viral resistance is uncharged.

CHANGES IN RESPIRATORY SYSTEM:The shape of the chest changes and the circumference increases in pregnancy by 6cm. As the uterus enlarges the diaphragm is elevated as much as 4cm and the ribcage is displaced upwards. The lower ribs flare out and may not always fully recover their original position after pregnancy. There is a progressive increase in oxygen consumption, which is caused by the increased metabolic needs of the mother and fetus. The mucosa of the respitatory tract becomes hyperemic and edematous, with hyper secretion of mucus which can lead to stuffiness and epistaxis. As a result women may suffer chronic cold during pregnancy. Long term use of nasal decongestant sprays should be avoided because of their effect on the mucosa.

Progesterone causes an increases in the sensitivity of the respiratory center to stimulation by carbondioxide. This causes a little hyperventilation and lowering of blood pco2. The alveolar co2 concentrations are lower than that in the non-pregnant woman that causes the maternal co2 tension to be lower, leading to respiratory alkalosis. The mild alkalemia facilitates oxygen release to the fetus. This facilitates transfer of co2 from the fetus to the mother. Hyper ventilation (over breathing) can lead to discomfort, dyspnea and dizziness. woman may complaint of shortness of breath, when their need to breathe become a conscious one. The changes however can cause some discomfort or inconvenience to the pregnant woman and diseases of the respiratory tract may be more serious during pregnancy.

CHANGES IN THE URINARY SYSTEM:Striking anatomical changes are seen in the kidneys and ureters. The kidneys increase in weight and lengthen by 1 cm. under the influence of progesterone the calyces and renal pelvis dilate. Renal blood flow increases by as much as 70-80 percent by the second trimester. After 30 weeks it decreases slowly although it is still above non-pregnant levels at term. The kidneys enlarge and glomerular filtration rate increases. The increases is maintained throughout the second trimester but decreases significantly during the last weeks of pregnancy. Plasma levels of urea, uric acid and creatinine fall in pregnancy although uric acid level return to non-pregnant level in late pregnancy.

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Protein and amino acids are less efficiently reabsorbed and as a result found in much greater amounts in the urine of pregnant women. Proteinuria does not usually occur in normal pregnancy. Glucose excretion increases as a result of increased glomerular filtration rate of glucose. Glycosuria is therefore quite common in pregnancy and is not usually related to a high blood glucose level. Glycosuria can be a cause of urinary tract infection. Urinary output is diminished because of an enhanced tubular reabsorption of water. An accompanying increase in the reabsorption of sodium is seen, which is possibly due to hormonal effect. The urine of pregnant women is more alkaline due to the alkalemia of pregnancy. In early pregnancy, increased production of urine cause frequency of micturition. In late pregnancy, frequency is caused by pressure of the growing uterus on the bladder. The uterus become relaxed and are dilated, elongated and kinked or curved due to the influence of progesterone. This along with compression of the uterus against the pelvic brim, can result in stasis of the urine in the uterus leading to bacteriuria and infection of the urinary tract. Hydroureter and hydronephrosis may be associated with stasis of urine. The muscle of the bladder is relaxed owing to raised levels of progesterone. In late pregnancy, frequency of micturition once more reappers due to pressure on the bladder as the presenting part descends down the pelvis stress incontinence may be an annoying symptom in late pregnancy due to urethral sphincter weakness.

CHANGES IN THE GASTROINTESTINAL SYSTEM:11

In the mouth, the gums become edematous, soft and spongy which can bleed when mildly traumatized as with a tooth brush. Increased salivation (ptyalism) us a common complaint in pregnancy. This problem seems to be associated with nausea, which prevents women from swallowing their saliva. Around 4-8 weeks, most women start complaining of nausea and vomiting, which may continue until about 14-16 weeks. Relaxation of the smooth muscles of the stomach, and hypomotility may also contribute causing weight loss in early pregnancy. Muscle tone and motility of the entire gastrointestinal tract are diminished due to high progesterone level. Cardiac spinster is relaxed and regurgitation of acid gastric content into the oesophagus may produce chemical oesophagitis and heart burn. Occasionally vomiting may become excessive. Excessive vomiting is common in multiple pregnancy or hydatidiform more and hence excessive hormone levels are thought to be the cause for it. In earlier period of pregnancy, a change in the sense of taste can occur. It can be metallic taste in the mouth, distaste for something usually enjoyed or craving for a food usually not taken. Craving for unnatural substances. Such as coal, wall plaster, mud etc. This is termed as pica. Many women notice an increase in thirst during pregnancy. This may be due to plasma osmolarity and raising levels of prolactin. An increase in appetite is also experienced by most of women, which may be due to the fall in plasma glucose and amino acids in early pregnancy. There is dimished gastric secretion and delayed emptying time of the stomach. Atonicity of the gut leads to constipation is, more in pregnancy, as the passage of food through the intestines is so much slower that there is
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increased absorption of water from the colon. A high residue diet, which helps to the problem and along with mechanical obstruction by the uterus. Constipation may worsen hemorrhoids, which are caused by the increased pressure in the veins below the level of the enlarged uterus. The gallbladder increases in size and empties more slowly during pregnancy. Stagnation of bile which is almost physiological in pregnancy, is probably a hormonal effect and can lead to pruritis or gallstone formation. There are many changes in liver function that mimic liver disease; therefore lives function tests in pregnancy should be interpreted with caution common alterations are Serum albumin level fall progressively throughout pregnancy and at term are 30 percent lower than the non-pregnant level. Serum alkaline phosphates levels risk progressively and at term are at two to four times the non-pregnant values. Serum cholesterol levels are raised two-fold by the end of pregnancy. Many liver proteins are raised. Fibrinogen levels are raised 50 percent by the end of the second trimester.

CHANGES IN METABOLISM
There is increased food intake during pregnancy which leads to gastrointestinal changes such as alteration in metabolism of carbohydrate, protein, fat. These changes brought by human placental lactogen, ensure that glucose is readily available for body and brain growth in the developing fetus and protects against nutritional deficiencies. Fasting plasm glucose concentration falls during the first trimester, rises between 16 and 32 weeks, then falls again towards term.

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Insulin secreation correspondingly rises in the second trimester and then falls to non pregnant levels towards term. As HPL levels rise with advancing pregnancy,insulin resistence increases leading the diabetogenic effect of pregnancy. As a result a glucose load takes longer time to reach a maximal plasm concentration. When the maximum concentration is reached, it is higher than normal and remains elevated for longer allowing more time for placental exchange. A continuous supply of glucose must be available to transfer to the fetus. Pregnant women should not fast or skip meals for the following reasons: Maternal blood glucose levels are critically important for the fetal wellbeing. Fasting in pregnancy produces a more intense ketosis, known as accelerated starvation,that may be dangerous to fetal health. As the nutritional demands of the fetus increases in the second half of pregnancy and insulin resistence increases, mobilization of fat stores laid down in the first half of pregnancy occurs providing the mother with extra energy. However, because of the increased concentration of fatty acids resulting from this process, the mother is more prone to ketosis. Even an overnight fast of 12 hours will result in hypoglycaemia and increased production of ketone bodis. Restriction of carbohydrate in any diet may be avoided and the mother may be encouraged to take bed time snacks. Plasma albumin concentration is reduced due to increased plasma volume level. This causes reduction of colloid osmotic pressure resulting in limb oedema in late pregnancy. Plasm aminoacid concentratins also fall because aminoacids are used to makeglucose. Plasma calcium concentrations fall as a result of both fetal needs and the normal hemodilation of pregnancy. If the intake of vitamin D is sufficient, calcium absorption from the intestines increases by the end of second trimester, which provides for fetal needs as well as protecting the mothers skeleton. Pregnant clients should therefore be advised to increase their calcium intake by about 70%. Maternal weight changes:
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A continuing weight increases in pregnancy is considered to be a favourable indicator for maternal adaptation and fetal growth. Analysis of studies on weight gain in pregnancy suggests the following as the expected increase in primigravida. 4kg in first 20weeks 8.5kg in second 20weeks 12.5kg approximate total The average weight gain in multigravida is approximately 1kg less than in the primigravda. There is a wide range of normality in weight gain and many factors influence it which include maternal oedema, maternal metabolic rate,dietary intake vomiting or diarrhea, amount of amniotic fluid and size of the fetus. Maternal age, pre-pregnancy body size, parity and diseases like diabetes and hypertension also seem to influence the pattern of weight gain. SKELETAL CHANGES: Relaxation of pelvic ligaments and muscles occurs because of the influence of oestrogen and relaxin. This reaches the maximum during the last weeks of pregnancy allowing the pelvis to increase its capacity in readiness to accommodate the fetal presenting part at the end of pregnancy and in labor. The ligaments of the symphysis pubis and the sacroiliac joints loosen. The symphysis pubis widens by about 4mm by 32weeks gestation and the sacroccygeal joints loosens, allowing the coccyx to be displaced backwards. Increased mobility of the pelvic joints facilitates vaginal delivery . It also results in a rolling gait in late pregnancy, which is the likely cause of backache and ligamental pain. Posture of the pregnant women alters to compensate for the enlarging uterus anteriorly. The woman leans backward s exaggerating the normal lumbar curve and causing a progressive lordosis which shifts her center of gravity back over her legs which leads for back pain , shoulder pain , unsteadiness of gait and tendency to fall. The teeth are prone to decay during pregnancy due to calcium deficiency resulting from increased demand calcium by growing fetus.
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SKIN CHANGES: Increased activity of the melanin stimulating hormone from the pituitary causes varying degrees of pigmentation in pregnant women from the end of second month until term. The depth of pigmentation varies according to skin color and race. The areas most commonly affected are the areolae of breast, the abdominal midline, the perineum and the axillae. On the breasts darkening of the nipple, primary areola and secondary areola are seen. In face the irregular brownish discolorations of the forehead, nose,cheeks and neck known as the mask of pregnancy or cholasma usually develops in second half of the pregnancy in about 50-70% of woman. It regresses completely after delivery. In most of the women , a narrow line of dark skin pigmentation appears in the midline of the abdomen from the symphysis to the umbilicus called as linea nigra. As maternal size increases, stretching occurs in the collagen layer of the skin, particularly over the breasts, abdomen, thighs and occasionally buttocks. The areas of maximum stretch become thin and stretch marks known as striae gravidarum. Hair growth increases during pregnancy over face, scalp and body. The excess hair shed after delivery. A rise in body temperature of 0.5c with an increased blood supply causing vasodilation makes woman feel hotter and sweaty. Many women develop angiomas during pregnancy, which are red elevations on the skin of the face, neck, arms and chest. Palmar erythema, which is reddening of the palms, is another frequent occurrence. Both are likely to be due to high levels of oestrogen and disappear after delivery. BREAST CHANGES: The changes are more obvious in primigravidae than multiparae. The breast increase in size and sensitiveness , and bluish discoloration appears in the form of streaks. The nipple become more erectile with the areola more deeply pigmented. Montagomerys tubercles appears in the primary
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areola and even secondary areola after 5th month. After first trimester , a little clear , sticky fluid may be expressed from the nipples, which later becomes yellowish in color is known as colostrums. CHANGES IN THE ENDOCRINE SYSTEM Placental hormones Placenta produces several hormones. These hormones cause a number of physiological changes that aid in the diagnosis of pregnancy. The high levels of estrogen and progesterone produced by the placenta are responsible for breast changes, skin pigmentations,and uterine enlargement in the first trimester. Chorionic gonadotrophin is the basis for the immunologic pregnancy tests. Human placental lactogen stimulates the growth of the breasts,has lactogenic properties and effects a number of metabolic changes. The secretions of HPL and HCG by the fetoplacental unit alters the function of the mothers endocrine organs either directly or indirectly. Raised estrogen levels increase production of globulins that bind thyroxine and corticosteroids and the sex steroids. As a result the total plasma content of these hormones is increased but the levels of free hormones are not necessarily raised. Pituitary hormones The secretion of prolactin, adrenocorticotrophic hormone, thyrotrophic hormone and melanocyte- stimulating hormone increases. Follicle stimulating hormone and luteinizing hormone secretion is greatly inhibited by placental progesterone and estrogen. The effects of prolactin secretion are suppressed during pregnancy. Following delivery of placenta , plasma concentrations of prolactin decrease, but is subsequently secreted in pulsatile bursts with sucking to stimulate milk production. The posterior pituitary gland releases oxytocin in low frequency pulses throughout pregnancy. At term the frequency of pulses increases which stimulates uterine contractions. Thyroid function
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In normal pregnancy the thyroid gland increases in size by about 13% due to hyperplasia of glandular tissue and increased vascularity an increased uptake of iodine during pregnancy , which may be due to compensate for renal clearance of iodine leading to a reduced level of plasma iodine. Although pregnancy can give the impression of hyperthyroidism, thyroid function is basically normal. The basal metabolic rate is increased mainly because of increased oxygen consumption by the fetus and the work of the maternal heart and lungs. Rising levels of T4 andT3 may also contribute to the increased metabolic rate. Adrenal glands The adrenal gland is stimulated by estrogen to produce increasing levels of total and free plasma cortisol and other corticosteroids including ACTH from 12th week to term. Because of the stimulus of progesterone and estrogen there is large increase in the concentration of renin by the adrenal cortex in the first 12 weeks of pregnancy. This activates the renin angiotensin system, which is associated with maintaining blood pressure.it also balances the salt losing effect of progesterone by enhancing aldosterone secretion from the adrenal cortex. Aldosterones effects of promoting sodium absorption are most likely to be the key factor in maintaining the delicate balance of salt and water excretion. Imbalance of these substances can cause pregnant women to reabsorb excess sodium from renal tubules and therefore to retain fluid, which can cause hypertension. High levels of angiotension ii would also cause the blood pressure to rise. NERVOUS SYSTEM The nervous system is in a more excitable condition in pregnant women.Temperamental changes are frequently noticed. Mood changes and symptoms of psychosis may develop in those with a family history.

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