Physiological Changes in Pregnancy

Physiological Changes in Pregnancy

·        During pregnancy there are progress anatomical and physiological changes.

·        These changes do not only occur at the genital organs but also to all the system of the body.

·        This is due to increasing demands of the growing fetus.

I. Changes in genital organs

1. Vulva

·        It becomes edematous and hyperemic.

·        The labia minora become pigmented and hypertrophied

2. Vagina

·        It becomes hypertrophied vascular and edematous

·        The vaginal secretions becomes copious, thin and curly white

·        The ph becomes more acidic.

3. Uterus

·        There is increase in size of uterus

·        It measures 35 cms in length and 900-1000 gms

·        Changes occur in all the parts of uterus.

·        The uterine muscles undergo hypertrophied and hyperplasia.

·        The fondues enlarged more than the body if the uterus.

·        The 3 distinct layers of uterus muscles can be made out.

·        In a turn the uterus differentiates into an active upper segment which is more muscular and a passive lower segment which is least muscular.

·        The cervix is deviated to the left side (levo-rotation), bringing it closer to the ureter due to lateral obliquity.

II. Breast

·        There is increase in the size of the breast due to hypertrophy and proliferation of the ducts alveoli.

·        The vascularity increase which result in the appearance of bluish veins running under the skin.

·        The nipples becomes larger, erectile and are deeply pigmented

·        The sebaceous glands which remains invisible in the non-pregnant state becomes hypertrophied over the areola during pregnancy and are called as Montgomery‘s tubercles

·        Secondary areola is seen in the 2nd trimester

·        Secretions may also been seen at about 12 weeks of pregnancy

·        Breast weight is increased approximately to 500-800 gm

III. Endocrine system

·        Changes are brought about by progesterone, estrogen and relaxin hormones

a. Effects of progesterone

·        Reduction in tone of smooth muscles resulting in nausea, reduced peristalsis, constipation, bladder toned is decreased, dilation of veins and decreased diastolic pressure

·        Increase in body temperature

·        Increased storage of fats

·        Development of breast, alveolar and glandular milk producing cells

b. Effects of estrogen

·        Increased growth of uterus and breast ducts

·        Increased levels of prolactin for lactation

·        Maternal calcium metabolism

·        Higher levels may result in increased vaginal glycogen resulting in “thrush”.

c. Effects of relaxin

·        Replacement of collage in pelvic joints, capsules, cervix, resulting in greater extensibility and pliability

·        Inhibition of myometrial activity

·        Helps in distension of uterus and provides additional supporting connective tissues.

·        Has a role in cervix ripening

IV. Cutaneous changes

·        There is formation of chlosma gravidarum or pregnancy mark in the form of pigmentation around the cheek which is patchy or diffused and it disappears after delivery

·        It also shows formation of linea nigra which is a brownish black pigmentation in the midline of the abdomen stretching from the xiphisternum to the pubic symphysis. It usually disappears after delivery.

·        Striae gravidarum are slightly depressed linear marks with varying length and breath. These are seen just below the umbilicus

·        These are pinkish during delivery which becomes glistening white after pregnancy and is then called as striae albicans

V. Weight gain

·        A pregnant lady puts on about 10-12 kg of weight

·        In early pregnancy the lady may loose weight due to nausea and vomiting but later the weight gain is progressively increased to about 2 kg every month

VI. CVS changes

·        Increase in blood volume by 40%

·        Increase in plasma level than red cells and Hb level falls by 80%. This is called as dilution anemia or physiological anemia due to pregnancy

·        During 3rd trimester, the weight of fetus may compress the aorta and IVC against the lumbar spine in lying position causing dizziness, unconsciousness and is called as pregnancy hypotensive syndrome.

·        Increase in cardiac output by 40%

·        Stroke volume increased by 30%

·        Heart rate increased by 30%

·        Heart rate increased by 15 beats/min

VII. Respiratory system

·        Respiratory rate increases from 15-18 breath/min (hyperventilation)

·        Alveolar ventilation increases

·        Tidal volume increases up to 40%

·        Diaphragm is raised by 40 mm

·        Chest diameter is increased by 20 mm

·        CO₂ tension is decreased

·        PaO₂ – 92 mm of Hg

·        PaCO₂ – 30 mm of Hg

VIII. GIT and urinary system

·        respiratory rate increases from 15 to 18 breath/min(Hyperventilation)

·        Alveolar ventilation increases.

·        Tidal volume increases up to 40%

·        Diaphragm is raised up to 40mm

·        Chest diameter is increased by 2mm

·        CO₂ tension is decreased

·        PaO₂—92mm of Hg

·        PaCo₂ __ 30mm of Hg

VIII. GIT and Urinary system:

·        Nausea and vomiting due to response by human chronic Gonadotrophin (HCG)

·        Delayed gastric emptying and thus shows constipation

·        Increased concentration of bile in gall bladder

·        There is increased in the size and weight of kidney and dilation of the renal pelvis

·        Dilation of uterus causes pooling and stagnation of urine resulting in U.T.I.

IX. Musculoskeletal system

·        Increased joint laxity

·        Increased lumbar lordosis due it change in COG and pelvic tilting

·        The distance between the two rectus abdominal muscles widens and the linea alba may split under the strain called as Diastasis Recti

·        Edema of ankle due to water retention

·        Compression of nerves causing carpel tunnel syndrome

X. Psychological and emotional changes

·        Mood swings

·        Depression

·        Anxiety

Physiotherapy Management in Incontinence of Urine

Definition: Involuntary loss of urine which is objectively demonstrable and is a social or hygienic problem.

Physiotherapy Management

 Aims:

·         To restore the function of urethrovesicle muscles

·         Strengthening the support of the uterus

·         Advise obese patient to control diet

Means of treatment

a. Pelvic floor contractions: Sitting position or leaning forward to support the forearm on knees
e.g.

·         Stopping passing urine

·         stopping passing breaking wind

·         Stopping yourself blowing off/farting

·         Fasting and slow contractions

·         Bracing exercises

Duration
As long as the muscles becomes weak and fatigued.


b. Perinometer/Kegel’s exercise

·         Kegel device is a pneumatic device which helps to measure the pressure inside the vagina and to motivate the women to practice pelvic floor exercises

·         A compressible air filled rubber cuff was inserted into the vagina which is connected to a manometer by a rubber tubing

·         Ask the women to contract her pelvic floor several times and note the highest reading in the dial. Also, note the length of time for which she could hold her contractions.

·         It is useful as biofeedback and for motivation

·         Take care that intra-abdominal pressure is not measured rather than pelvic floor

c. Foley’s catheter

·         An air filled catheter is inserted into the vagina and the patient is asked to contract and hold the catheter against the traction given by the therapist

d. Vaginal cones

·         It consists of 5-9 small cones or cylinders ranging from 10 gm to 100 gm

·         They are made up of lead coated with plastic and a nylon string is attached at one of the tapered ends

·         It is a size of a tampon

·         The lightest cone is inserted first and ask the patient to hold and walk for 15 min

·         Once the cone is retained for 15 min without slipping progression is made to the next cone

·         This helps to activate the motor units to support the cones and to increase woman‘s awareness of her ability to contract the pelvic floor muscles voluntarily.

e. Elevator exercises: Ask the patient to imagine going up in an elevator and contract her pelvic floor by gradually increasing the intensity as the lift goes up by and floor and then to relax gradually as the lift comes down by floor

·         Pelvic tilting with rotations in supine position.

·         About 8-12 fast contractions followed by 3-4 slow –short contractions can be done.

f. General exercises

·         Pelvic tilting

·         Pelvic rotation

·         Pelvic rocking

·         Functional training

·         Squatting exercise

·         Postural correction exercise

g. Faradism: Faradism (surged) is used in re-education of pelvic floor muscles

·         Levator ani muscles can be contracted using vaginal or anal electrode

·         Pulse width: 0.1 – 7 m/s

·         Frequency: 0.5 – 40 Hz

h. Interferential therapy: It improves patient‘s cortical awareness and ability to perform voluntary contractions For genuine stress incontinence parameters:

·         Sweep: 10 -40 Hz

·         Carrier wave: 2000 Hz

·         Duration: 15 mins

·         Intensity: maximally tolerable

Parameters for urge or frequent incontinence

·         Sweep: 5 -10 Hz

·         Carrier wave: 2000 Hz

·         Duration: 30 mins

·         Intensity: maximum

Four pole method

·         Two electrodes are applied on abdomen just above the lateral portion of inguinal ligament (A1, B1)

·         Two electrodes are applied on medial to the ischial tuberosity on either side of the anus (A2, B2)

Two pole method

·         One medium size electrode over the anus covering the posterior fibers of levator ani muscle.

·         2^nd small size electrode is placed centrally below the pubic symphysis.

i. Bladder retraining

·         It is used in frequency urgency without leakage incontinence

·         Contract pelvic floor muscles every time before voiding

·         Distraction by companion, games TV, music

·         Perineal pressure by hand

·         Cross leg standing

·         Maximus gluteus contractions in standing