ADAPTATIONS DURING PREGNANCY

Presumptive (subjective) pregnancy signs

• Amenorrhea (4 weeks)

• Breast tenderness/enlargement (3-6 weeks)

• Nausea/vomiting (4-14 weeks)

• Fatigue (12 weeks)

• Urinary frequency (6-12 weeks)

• Percieved uterine enlargement (7-12 weeks)

Probable (objective) pregnancy signs

• Positive pregnancy test (4-12 weeks)—-HCG in blood or urine

• Goodell’s sign (5 weeks)

• Chadwick’s sign (6-8 weeks)

• Hegar’s sign (6-12 weeks)

• Abdominal enlargement (14 weeks)

• Ballottement (16-28 weeks)

• Braxton Hicks contractions (16-28 weeks)

Goodell’s sign

softening of the vaginal portion of the cervix due to increased blood flow and vascularization

Chadwick’s sign

a bluish discoloration of the cervix, vagina, and vulva

Hegar’s sign

softening of the isthmus (lower part) of the uterus, making it feel compressible and distinct from the cervix during a pelvic exam

Positive (diagnostic) pregnancy signs

• Ultrasound verification of intrauterine embryo or fetus (4-6 weeks)

• Auscultation of fetal heart tones via doppler (10 to 12 weeks)

• Fetal movement felt by experienced children (20 weeks)

Cervical Changes

• softening (Goodell) ; increased vascularization (Chadwick)

• mucus plug formation

• ripening (softening and effacement) about 4 weeks before birth

Vaginal Changes

• increased vascularity & thickening; vault lengthens

• secretions more acidic, white, thick; leukorrhea

Ovaries Changes

• enlargement until 12th -14th week

• cessation of ovulation

Breasts Changes

• fuller, larger, more tender; more vascular/visible veins/straie

• nipples & areolae more erect/pigmented

• production of colostrum

Uterus Changes

• Increase in length, width, depth, volume, weight

• Large increase in uterine blood flow to support placental growth & meet muscle oxygen demands

• Enhanced contractility – Braxton Hicks

• Ascent out of pelvis & into abdomen after 12 weeks

• Fundal height by 20 weeks’ gestation at level of umbilicus

Vena Cava Syndrome

• lying supine—heavy uterus compresses inferior vena cava

• reduction of venous return—-decreased cardiac output/BP

• Symptoms: dizzy, weak, nausea. syncopal episode

• AKA “supine hypotension”

• Solution—-lie on left side

Cardiovascular Changes

• 40-50% increase in blood volume

More plasma than RBCs, = physiologic anemia (hemodilution), drop in H&H levels

• 30-50% ↑ in cardiac output & venous return; HR ↑10-15 BPM by 32 weeks; May hear a split S1 (“luh-uh-dub”)/S2 (lub-duh-ub”) or an S3 (“lub-dub-dub”)

• Slight ↓ in diastolic BP 24-32 wks

Respiratory Changes

• slightly increased respirations; most apparent in 3rd TM

• 30-40% in O2 consumption & tidal volume by full term

• Rib cage expands to compensate for growing uterus

• Nasal congestion/rhinitis/epitaxis

• increase in fibrin/fibrinogen/other clotting factors, leads to hyper coagulable state

Gastrointestinal Changes

• Gums: hyperemic (engorged blood), swollen, friable; dental problems; gingivitis; ptyalism

• Slowed gastric emptying; lower esophageal sphincter relaxation= reflux

• decreased peristalsis/smooth muscle relaxation; prolonged gallbladder emptying

• nausea and vomiting

• constipation + increased venous pressure + pressure from uterus = hemorrhoids

Genitourinary Changes

• dilation of renal pelvis; elongation, widening, increase in curve of ureters——increased risk for UTIs

• increase in GFR= increased urine flow and volume, especially while lying down/side-lying

Musculoskeletal Changes

• softening/stretching of ligaments holding sacroiliac joints & symphysis pubis

• forward shifting of center of gravity

• increase in lumbrosacral curve (lordosis)

• waddle gait

Integumentary Changes

• Hyperpigmentation of nipples, areolae, umbilicus, perineum, axillae

• Melasma/chloasma; linea nigra; striae gravidarum

• Varicosities; vascular spiders

• palmar erythema

• decreased hair growth; increased nail growth

Endocrine Changes

• Thyroid: slight enlargement; increased thyroid secretion; 25% increase in metabolic rate

• Pituitary: substantial enlargement; decrease in TSH, GH, inhibition of FSH & LH; increase in prolactin, MSH, oxytocin

• Pancreas: insulin resistance due to hPL in 3rd TM

• Adrenals: increase in cortisol & aldosterone

• Placental secretion: hCG, hPL, relaxin, progesterone, estrogen

Immune Changes

• Adaptive immunity somewhat suppressed (protective response to foreign bodies)—-pregnant people tend to get sicker when they contract the flu, COVID

• influence the course of chronic diseases——hormonal/immune changes; added stress on the body

Antepartum Nutrition

• eat wide variety of food: fruit, veggies, whole grains, proteins; more vitamins, mineral, fiber

• decreased saturated fat/trans fat, cholesterol, empty sugars—-Pregnant people need about an extra 300 calories per day

• WATER and EXERCISE

• Increased iron demand: need iron to make hemoglobin (protein found on RBCs) which carries O2 to the fetus

• Folic acid needed to prevent neural tube defects

Recommendation: Daily prenatal vitamin containing > 27 mg iron (ferrous sulfate) and 400-800 mcg folic acid

Food Concerns

• Fish, shellfish & mercury levels

Avoid meaty fish high up in the food chain

Aim for ≥ 2 servings/week of low mercury fish

• Listeriosis : Bacteria (listeria) passed to fetus through placenta with/without noticeable illness; can result in miscarriage/preterm or stillbirth

Avoid: Unpasteurized dairy products, soft cheeses, cold cuts/hot dogs, lox, pâté, sushi, unwashed produce, raw juices/sprouts

• Artificial sweeteners

• Caffeine

• Cook foods thoroughly

Special Nutritional Considerations

• Dietary variations; gluten-free; vegetarian/vegan; lactose intolerance

• Cultural variations (i.e fish-heavy diets, goat/buffalo milk)

• Pica: compulsive ingestion of non-food substances——specific cravings; exact cause unknown; underreported

• Baritraic surgery can lead to malaabsoprtion issues—-need increased monitoring

• Lack of food access, adolescents, eating disorders

Weight Gain in Pregnancy

• should be slow and steady; dieting/overeating never recommended

• poor or excessive weight gain= risk for pregnancy outcomes

Emotional Responses to Pregnancy

• Ambivalence (mixed feelings)

• Introversion (reflective)

• Acceptance

• Mood swings

Partner Concerns

• Family-centered emphasis

• partner’s reaction to pregnancy and changes

• Couvade syndrome, ambivalence

• Acceptance of roles (second trimester)

• preparation for the reality of new role (third trimester)