NORMAL PREGNANCY

DR. ACHALA SAHAI SHARMA

MS, MICOG, FMAS
ASSOCIATE PROFFESOR
G.R.MEDICAL COLLEGE
• Pregnancy literally means (being with the child).

• Normal pregnancy average duration is counting from first day

of last menstrual period is about 280 days and 10 lunar months
or 40 weeks.

• Ovulation delivery interval is 267 days (as ovulation occurs on

13th or14th day in 28 days cycle.

• The EDD (Expected date of delivery) is calculated by counting

back 3 months and adding 7 days or by counting forward 9
months and 7 days. This rule is known as NAEGELE’S rule.

• Delivery taking place before and after 280 days is termed as

preterm and post term delivery respectively.
Terminology
Duration= 40 weeks (calculated from first day of last
menstrual period)
3 Trimesters of Equal Length-
1st- Conception to 14 weeks
2nd- 14-28 weeks
3rd- 28-42 weeks
Term pregnancy requires completion of at
least 37 weeks.
Physiology
Cardiovascular
20-30% rise: red cell volume
30-40% rise: circulating blood volume
40-50% rise : plasma volume ( diminished hematocrit)
40%  in CO
17%  in resting HR
20%  in SVR
 BP
 of diaphragm displaces heart  and to the leftlarger
cardiac silhouette on CXRleft axis deviation on EKG (Also,
small benign pericardial effusioncardiac silhouette)
RESPIRATORY TRACT

• Pregnancy induces hyperventilation.

• Respiratory rate increases.

• Tidal volume increases.

• Pco2 decreases.

• Vital capacity and breathing capacity are not altered.

• Diaphragm is elevated in later months due to

enlargement of uterus.

• Functional residual capacity of lungs reduces.

Gastro –intestinal tract:
Gastric reflux 2º to delayed gastric emptying,  intestinal
motility, and  lower esophageal sphincter tone.
Gallbladder emptying delayed and less efficient risk of
cholesterol stone formation: cholestasis
 Stomach and intestine are displaced due to enlarging uterus
resulting in heart burn due to gastric secretions (excess)
 Gums are hypertrophic and softening occur
 Haemorrhoids may develop.
 Liver functions are altered:
a) Alkaline phosphates activity increases.
b) Albumin globulin ratio decreases.
c) Total serum proteins reduces.
Genitourinary tract:
 renal blood flow
 kidney size
 GFR (up to 50% by 2nd trimester) results in 
BUN/Creat.
Hematopoietic High Fe requirements

40-45%  circulating Reticulocyte count  2nd

blood volume 2º to  half of preg.

plasma volume and # of Leukocyte counts range
erythrocytes 5000-12000 cells/µL
HgB conc.  2º to Leukocyte function 
dilutional intravascular 2nd trimester so 
volume but should not susceptibility to
 below 11g/dL infection.
 coagulation factors
 ESR
Slight  platelets
Endocrine
Hyperinsulinemia and fasting hypoglycemia 2º
to changes in carbohydrate metabolism
Postprandial hyperglycemia 2º to altered
response to glucose ingestion.
Thyroid with  vascularity and mild hyperplasia
but clinically detectable goiter is not normal.
(Free thyroxine and TSH to assess thyroid
function during pregnancy)
Uterus
 uterine weight (701100g)
 intrauterine volume (105000mL)
12 weeks uterus expands into abdominal cavity
MATERNAL PHYSIOLOGY IN PREGNANCY

Uterus:-
• Enormous increase in size.(6.5 cm long, 30gms weight normal)
30 cm long 1000gms weight at term.

• Hypertrophy and Hyperplasia of uterine muscle fibers (5 times to

10 times) due to the action of estrogen and progesterone in first 3
months then in later months distention is mainly mechanical due to
expanding products of conception.

• Original pear shaped uterus changes to globular form and spherical

at third month then to oval.

• Two types of contractions are manifested in uterus in pregnancy:

a) Braxton-Hicks contractions (irregular).
b) Uterine contractions (regular).
These contractions increase at the time of labor facilitating delivery.
CHANGES IN CERVIX
• Softening of cervix due to increased vascularity and oedema, hyperplasia
of cervical glands.
• Bluish coloration

CHANGES IN OVARIES AND TUBES

• Corpus leuteum increases if pregnancy occurs and ovulation ceases.
• Ovarian blood vessels increases enormously

CHANGES IN VAGINA
• Increased vascularity
• Violet coloration and increase secretion
• Hypertrophy of neucosa and muscle layer
• Vaginal secretions becomes acidic to prevent infections. (Doderlien Baccili)
CHANGES IN BREASTS

• Tenseness and tingling in breasts in early month especially

in primi gravida.
(Hormonal)

• They become nodular with engorgement of veins.

• Nipples become larger, erectile and discharges yellowish

thin fluid in later months. (Colostrum)

• Areola becomes larger, pigmented and darker.

• Sebaceous glands hypertrophies and form glands of

montgomry.
METABOLIC CHANGES
Weight gain:-

• Average total weight gain in pregnancy is about 11 kgs(24 pounds).

half of it increases in 2nd trimester, half in second and 1kg in first.
weight gain in last trimester is about half kg in one week.
• Few days before delivery there is slight decrease in weight.

Water Metabolism:-

• In pregnancy there is water retention, water content of feotus, placenta,

amniotic fluid is about 3.5 Lt. and approx. 3.5 Lt. of water accumulates
due to increase in blood volume and size of uterus and breasts.
• Total amount is 6.5 Lt. and mostly in last two trimesters.
• There is increase in sodium retention; Water retention.
BASAL METABOLIC RATE:-
• BMR ranges between 5% to 25%.

• Larger the foetus greater is the BMR.

PROTIEN METABOLISM:-
• There is increased secretion of amino acids due to increased
glomerulo filtration rate.

Carbohydrate Metabolism:-
• Circulating insulin level increases in pregnancy.
resulting in to low fasting levels of blood sugar below 60mg%.

FAT METABOLISM:-
• Blood lipids increase during pregnancy. (reason not known)

MINERALS:-
• Demand of Iron increases.
BLOOD ELECTROLYTES

Respiratory Alkalosis results

• lowering PCO2 of blood

• K and Na also decreases.

• Ca and Mg also decreases.

HAEMATOLOGICAL CHANGES

• Blood volume increases by 30-50% of normal to fulfill the demand of

enlarging uterus.

• It safeguards the mother against the adverse effects of blood loss at

parturition.

• Hb% below 10gms percent during pregnancy is pathological. 1 gm

of Hb contains 3.4 gms. of iron. ( Iron deficiency anaemia develops)

• Average iron requirement in pregnancy is about 3 mg per day.

• Leucocytes normal is 5000 to 12000/ml increases duriong labor and in early
puerperium to levels of 20000 or more.

• Fibrinogin increases resulting into increased ESR.

• Blood coagulation factor increases from 300 mg to 450 mgms. In later months
of pregnancy.

• Other factors of clotting also increases.

CARDIOVASCULAR SYSTEMS:

• Heart enlarges by 10% in pregnancy due to hypertrophy or dilatation or both.

• Cardiac output increases to 40%.

• Pulse rate increases.

• Stoke volume also increases.

• Blood pressure should not increase in normal pregnancy. If it increases by

ENDOCRINE GLANDS

Pituitary, thyroid, parathyroid and adrenals hypertrophy due to increased

Estrogen and progesterone in blood.

NERVOUS SYSTEM

• Emotional disturbances

• Abnormal cravings. (Pica)

SKIN
• Striae gravidarum on abdomen and thighs.

• Pigmentation of nipples and areola.

• Skin in midline of abdomen darkens.( Linea Nigra)

• Brownish patches on face. (Chloasma)

• Vascular spiders may develop.

MUSCULAR SKELETAL SYSTEM

• Progressive Lordosis- compensatory.

• Increased mobilty of sacroiliac, sacrococcygeal, and pubic joints.

DIAGNOSIS OF PREGNANCY
• Enlargement of abdomen (gradual), corresponding to the period of
amenorrhoea.

• Change in size, shape and consistency of uterus and cervix.

• Braxton-hicks contractions; irregular painless contractions.

• Ballottement (Mid-pregnancy).
• Palpable foetal parts in later halves of pregnancy.

• Increased level of HCG in urine in early pregnancy.

• Changes in breasts.

• Pigmentation of skin.

• Morning sickness, bladder irritability, quickening.

POSITIVE SIGNS
• Foetal movements

• FHS

• X-ray, ulterasound.

A sexually matured female may be married or unmarried coming to you with

Amenorrhoea must be investigated for pregnancy.
Making the Diagnosis
Serum and/or Urine HCG
HCG is a glycoprotein produced by trophoblast after
implantation.
Composed of alpha and beta subunits with beta subunit
unique to HCG.
ELISAs detect beta-HCG in urine as low as 10-
20mIU/mL approx. 1 week after conception
<1% false negative rate on nondilute urine.
Making the Diagnosis Cont.
+ pregnancy test does not confirm a normal
intrauterine pregnancy!!!!
+ beta-HCG can be found in ectopic, recent
spontaneous or induced abortion, and HCG
secreting tumors (molar pregnancies).
Pelvic ultrasonography after 4-5 weeks gestation
for definitive diagnosis
Serial beta-HCG levels useful- level doubles every
1.4-2.0 days following implantation in early
pregnancy if not ectopic or nonviable pregnancy.
Making the Diagnosis Cont.
Pelvic Ultrasonography
Gestational Sac-
5.5-6 weeks gestation- transabdominal
4-5 weeks gestation- transvaginal
Cardiac Activity-
6 weeks gestation
Abdominal Discomfort-Differential
Diagnosis
Early
Must pregnancy-
include all possiblities for nonpregnant and pregnant
 Vascular cong. Of pelvic tissue, round ligament tension
women!!!

Late pregnancy-
1st trimester-
 Braxton-Hicks (irregular, palpable contractions)
 Ectopic and threat. Abortion
Appendicitis- location of pain upward and rightward
Late 2nd/3rd trimester-
Cholelithiasis- may cause cholecystits or pancreatitis
 Premature labor, abruption, uterine rupture
THANK YOU!