OBSTETRICS

Maternal Adaptations to Pregnancy

Lecturer: Dr. Mercado | July 5, 2017
Transcribed by: PEA|KMA|GNC|PCD|ITE

O UTLINE
1. Introduction
2. Reproductive System

a. Uterus
b. Cervix
c. Ovaries
d. Vagina and Perineum
e. Skin
f. Breasts
g. Metabolic Changes
h. Hematologic Changes

3. Cardiovascular System

a. Heart

4. Respiratory Tract

a. Acid-base Equilibrium

5. Urinary System

a. Test of Renal Function

6. Gastrointestinal Tract

a. Maternal Physiology in Pregnancy: GI Changes

7. Endocrinologic

a. Thyroid Gland
b. Parathyroid Gland
c. Adrenal Gland

INTRODUCTION

• Understanding maternal physiology of

pregnancy remains a major goal of obstetrics.

REPRODUCTIVE SYSTEM
Uterus

• In the non-pregnant woman, the uterus weighs

• Uterine hypertrophy early in pregnancy probably
about 70 grams and with a cavity of 10 ml or
is stimulated by the action of estrogen and
less.
perhaps that of progesterone.
• Smooth muscle fibers of the myometrium
compress traversing blood vessels when • Hormone of pregnancy – HCG
contracted.

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 OBSTETRICS – Maternal Adaptations to Pregnancy
• Layers of the uterus
1. An outer hoodlike-layer, which arches over the
fundus and extends into the various ligaments.
2. An internal layer, with sphincter-like fibers
around the fallopian tube orifices and internal
os of the cervix.
3. A middle layer, composed of dense network
of muscle fibers perforated in all directions by
blood vessels.
* Dextrorotation
- with ascent from the pelvis, the uterus usually undergoes rotation
• Uterine enlargement is most marked in the
fundus.
Braxton-Hicks Contraction
Fundic height
- this is where we can appreciate uterine
enlargement after the level of the symphysis
pubis
* During the third trimester, we can appreciate or
palpate the fetus because of the thinning of the
uterine muscles. One positive sign of pregnancy
is when we can appreciate fetal movement.
• As the uterus rises, tension is exerted on the broad
and round ligament
• Hormone of pregnancy – HCG
• Fallopian tubes and the ovaries and round
ligaments are located slightly above the middle
uterus
* During C/S, you will notice the change in the location of
the round ligament.
Non-pregnant woman: below the uterus
Pregnant woman: rises above the uterus
• The position of the placenta also influences the
extent of the uterine hypertrophy
* Normally, the placenta should be fundally located.
• As uterus continues to enlarge, it contacts the
anterior abdominal wall, displaces the intestines
laterally and superiorly, and continues to rise,
ultimately reaching almost to the liver
with tilting to the right, probably due to presence of the
rectosigmoid colon on the left side
• Contractions appear unpredictably and
sporadically and are usually non rhythmic.
• Their intensity varies between approximately 5
and 25 mmHg
• Late in pregnancy, these contractions may
cause some discomfort and account for so-
called false labor
• The delivery of most substances essential for
growth and metabolism of the fetus and
placenta, as well as removal of most metabolic
wastes, is dependent on adequate perfusion of
the placental intervillous space.
• Umbilical artery – wastes and carbon dioxide
delivered from the baby
• Umbilical vein – oxygen, nutrients and hormones
delivered to the baby
• Placental perfusion is dependent on the
uterine blood flow, which is principally from
the uterine and ovarian arteries
• Uteroplacental blood flow increases progressively
during pregnancy, which estimates ranging from
450-650 mL/min near term.
• The progressive increase in maternal-placental
blood flow during gestation occurs principally by
means of vasodilation, whereas fetal blood flow
is increased by a continuing growth of placental
vessels.
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 OBSTETRICS – Maternal Adaptations to Pregnancy

Ovaries
• Corpus luteum functions maximally during the first
6-7 weeks of pregnancy
• Ovarian vascular pedicle increased during
pregnancy from 0.9 cm to approximately 2.6 cm
at term

Regulation of Uteroplacental Blood Flow

• Estradiol and progesterone
o Vascular refractoriness to the pressor
effects of infused angiotensin II
• Serves to increase uteroplacental blood flow
• Large conductance potassium channels
expressed in uterine vascular muscle

Cervix
• One month after conception, the cervix begins
to undergo pronounced softening and cyanosis
o Changes result from increased
vascularity and edema of the entire
cervix
o Hypertrophy and hyperplasia of the
cervical glands Relaxin
• Eversion – extension of the proliferating columnar • Protein hormone is secreted by the corpus
endocervical glands. luteum, decidua, and placenta.
o Represents columnar epithelium on the • Major biological actions appear to be
portion of the cervix remodelling of reproductive tract connective
o The consistency of the cervical mucus tissue to accommodate pregnancy parturition
changes during pregnancy (Park and colleagues, 2005).

Pregnancy Luteoma
• Described by Sternberg in 1963
• Ovarian tumor that developed during pregnancy
• Exaggerated luteinization reaction of the normal
ovary.

• Beading – when cervical mucus is spread and

dried in glass slide, it is characterized by
crystallization as a result of progesterone
• Ferning – arborization of the crystals, or is
observed as a result of amniotic fluid changes
secondary to estrogen
Theca-Lutein Cysts
• More changes of the cervix during pregnancy • Benign ovarian lesions resulting from
- Basal cells near the squamocolumnar exaggerated physiological follicle stimulation –
junction are likely to be prominent in size, termed hyperreactio luteinalis.
shape, and staining qualities estrogen induced • The reaction is associated with markedly
- Endocervical gland hyperplasia and elevated serum levels of hCG.
hypersecretory appearance – the Arias Stella
reaction

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 OBSTETRICS – Maternal Adaptations to Pregnancy

run from the pubis to the top of the abdomen.

Hyperpigmentation
• Develops in up to 90 percent of women
• Usually more accentuated in those with a darker
complexion.

Vascular Changes
• Angiomas
* You could encounter the Theca-Lutein Cysts and the Pregnancy - aka called vascular spiders
Luteoma during in cases of - minute, red elevations n the skin, particularly
common on the face, neck, upper chest, and
1. H-Mole
2. Molar cases arms, with radicles branching out from a central
3. Multiple gestation lesion

* During pregnancy, if you happen to see Theca Lutein Cysts or

Pregnancy Luteoma as big as 10 cm, DO NOT REMOVE! Wait for the
regression after the delivery because the ovary will go back to its
original size.

Vagina and Perineum

Chadwick Sign
• Increased vascularity and hyperaemia develop
in the skin and muscles of the perineum and
vulva
• Vaginal walls undergo striking changes in
Breasts
preparation for the distention that accompanies • Colostrum
labor and delivery o After the first few months a thick,
• Increase in mucosal thickness, loosening of the yellowish fluid can often be expressed
connective tissue, and hypertrophy of smooth from the nipples by gentle massage
muscle cells • Glands of Montgomery
o Scattered through the areolae are a
• The pH is acidic, varying from 3.5 to 6
number of small elevations which are
hypertrophic sebaceous glands

Metabolic Changes
• The metabolic adaptations encountered during
pregnancy serves to:
o Ensure fetal growth and development
o Provide adequate fetal stores
o Meet increased maternal needs
o Provide the necessary energy
• Initially, pregnancy is an anabolic state
Skin o Increased food intake and appetite,
decreased activity.
Blood Flow in the Skin
o 3.0 – 3.5kg of fat and 900 grams of
• Increased cutaneous blood flow in pregnancy
protein is synthesized – maternal weight
serves to dissipate excess heat generated by
gain
increased metabolism.
• Second half of the pregnancy is catabolic state
o More stored fat being utilized
Abdominal W all o Increase in insulin resistance
• Striae gravidarum or stretch marks o Decrease in serum glucose
- reddish, slightly depressed streaks commonly o Additional weight gain from the growing
develop in the abdominal skin and sometime in fetus and placenta
the skin over the breasts and thighs. o Influenced by hPL, estrogen and
progesterone
Linea Nigra o End effect – alteration in glucose
- a dark vertical line that appears on the metabolism to favor increased demand
abdomen in about three quarters of all
pregnancies. The brownish streak is usually
about a centimeter in width. The line runs
vertically along the midline of the abdomen
from the pubis to the umbilicus, but can also

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W eight Gain
• Hytten (1991) reported that the average weight
gain during pregnancy is approximately 12.5kg or
27.5 lb.
W ater Metabolism
• Increased water retention is a normal
physiological alteration of pregnancy
• It is mediated by a fall in plasma osmolality of
approximately 10 mOm/kg induced by a
resetting
• of osmotic thresholds for thirst and vasopressin
secretion.
• 3.5 L – water content of the fetus, placenta and
amniotic fluid at term
• 3.0 L – accumulates as a result of increases in the
maternal blood volume and in the size of the
uterus and breasts.
• Pitting edema of the ankles and legs –
accumulation of fluid caused by increased
venous pressure below the level of the uterus as
a consequence of partial vena cava occlusion
OBSTETRICS – Maternal Adaptations to Pregnancy
• Decrease in interstitial colloid osmotic pressure
induce by normal pregnancy also favors edema
late in pregnancy (Oian and co-workers, 1985)
Carbohydrate Metabolism
• Normal pregnancy is characterized by mild
fasting hypoglycemia, postprandial
hyperglycemia and hyperinsulinemia.
• Consider a pregnancy – induced state of
peripheral insulin resistance
o Progesterone and Estrogen
o Plasma levels of placental lactogen
o Increased concentration of circulating
free fatty acids
o Increased levels of hPL, lead to
diabetogenic state and decreased
plasma glucose tolerance
o Most prominent between the 24th to 28th
week of gestation
o Increasing prolactin levels contribute to
insulin resistance
o Accelerated starvation – pregnancy
induced switch in fuel from glucose to
lipids
Fat Metabolism
• The concentration of lipids, lipoproteins, and
apolipoproteins in plasma increase appreciably
during pregnancy
• The storage of fat occurs primarily during
midpregnancy
• In early pregnancy, increased estrogen and
progesterone lead to:
o Increased fat synthesis
o Fat cell hypertrophy
o Lipolysis inhibition
o Anabolic fat storage early in pregnancy
• In late pregnancy, Human Somatomammotropin
(HCS) promotes lipolysis and fat mobilization.
• Increase in plasma fatty acid and glycerol
concentration is consistent with mobilization of
lipid stores.
• Anabolic to catabolic state: promotes the use of
lipids as a maternal energy source while
preserving glucose and amino acids.
• The enhanced lipolysis and ketogenesis allow
pregnant women to utilize stored lipid into
subsidize energy needs and minimize protein
catabolism
Cholesterol is used by the placenta for sterols synthesis.
Fatty acids are used for placental oxidation and
membrane formation.
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• Maternal hyperlipidemia is one of the most
consistent and striking changes to take place in
lipid metabolism during late pregnancy
o HDL- increases by 12th week of gestation
in response to estrogen and remains
elevated throughout pregnancy
o Total and LDL- decrease initially, increase
in second and third trimester.
o VLDL and triglycerols - decrease in the
first 8 weeks of gestation, continuously
increase until term
* Not routinely screened. But if patient has chronic hypertension, lipid
levels should be monitored. (Treatment is diet modification. This is
because most drugs for hyperlipidemia are contraindicated during
pregnancy).
Leptin
• It has a key role in the regulation of body fat and
energy expenditure.
• Maternal serum leptin levels increase and peak
during the second trimester and plateau until
term in concentrations two to four times higher
than those in non-pregnant women.
Electrolyte and Mineral Metabolism
• During normal pregnancy, nearly 1000 mEq of
sodium and 300 mEq of potassium are retained.
• The glomerular filtration of sodium and potassium
is increased. The excretion of these electrolytes is
unchanged during pregnancy as a result of
enhanced tubular resorption.
• Serum concentrations are decreased slightly
because of expanded plasma volume.
• Total serum calcium levels decline during
pregnancy
• Serum magnesium levels also decline during
pregnancy
• Serum phosphate levels are within the
nonpregnant range
* If magnesium levels are not normal, this is usually a finding
in patients with pre-eclampsia. We have to give magnesium
to patients to prevent pre-eclampsia.
Hematologic Changes
Blood Volume
• Starts to expand before 4th week of pregnancy
and continues to increase until the middle of the
third trimester (32 to 34 weeks).
• 40 to 50 % above the pre-pregnancy level.
Pregnancy-induced hypervolemia has important
functions:
1. To meet the metabolic demands of the enlarged
uterus with it greatly hypertrophied vascular
system
2. To provide an abundance of nutrients and
elements to support the rapidly growing
placenta and fetus.
3. To protect the mother and in turn the fetus,
against the deleterious effects of impaired
venous return in the supine and erect positions
OBSTETRICS – Maternal Adaptations to Pregnancy
4. To safeguard the mother against the adverse
effects of blood loss associated with parturition.
• Maternal blood volume begins to increase during
the first trimester
• 12 menstrual weeks - plasma volume expands by
approximately 15% compared with that of
prepregnancy
• Blood volume expansion results from an increase
in both plasma and erythrocytes
• Plasma and red cell volume increase, but the
plasma volume expands by 50%, while the red
cell mass increases only 20-30%
• Hematocrit declines from about 45% to 35%
“physiologic anemia”
* During delivery there is 500 mL blood loss for normal delivery and
1000 mL during caesarean section.
Iron Requirements
• Approximately 1000 mg of iron required for
normal pregnancy.
o About 300 mg are actively transferred to
the fetus and placenta
o 200 mg are lost through various normal
routes of excretion, primarily the
gastrointestinal tract
• Iron requirement becomes large after
midpregnancy and averages 6-7 mg/day
Leukocytes
• Although the leukocyte count varies
considerably during pregnancy, it ranges from
5,000 - 12,000/uL.
• During labor and early puerperium, it may
become markedly elevated, attaining levels of
25,000/L or even more; however, it averages
14,000 - 16,000/uL.
* Check signs and symptoms of patient, before diagnosing
infection.
Coagulation and Fibrinolysis
• During normal pregnancy, both coagulation and
fibrinolysis are augmented but remain balanced
to maintain hemostasis.
• Evidence of activation includes increased
concentration of all clotting factors, except
factors Xi and XIII, and increased levels of
highmolecular- weight fibrinogen complex.
• During normal pregnancy, fibrinogen
concentration increases approximately 50%.
• It averages 450 mg/dL late in pregnancy, with a
range of 300-600 mg/dL.
* This compensates for blood loss, preventing DIC.
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CHANGES IN MEASURES OF HEMOSTASIS DURING NORMAL
PREGANCY
* The end product of the coagulation cascade is FIBRIN FORMATION,
and the main function of the fibrinolytic system is to remove excess
fibrin. TISSUE PLASMINOGEN ACTIVATOR (tPA) converts plasminogen
into plasmin, which causes fibrinolysis and produces fibrin
degradation products such as D-dimers.
Platelets
• Normal pregnancy also involves changes in
platelets.
• Decreased platelet concentration are partially
due to the effects of hemodilution.
CARDIOVASCULAR SYSTEM
• Marked hemodynamic alterations:
o Increase in cardiac output
o Increase plasma volume
o Reduction in vascular resistance
o Reduction in arterial pressure
• Changes in cardiac function become apparent
during the first 8 weeks of pregnancy.
* Between weeks 10 and 20, plasma volume expansion begins and
preload is increased.
Cardiac Output
• Cardiac output is increased as early as the fifth
week and reflects a reduced systemic vascular
resistance and an increased heart rate.
• The resting pulse rate increases about 10
beats/min during pregnancy (Stein and
coworkers, 1999), followed by increased stroke
volume.
OBSTETRICS – Maternal Adaptations to Pregnancy
• Increase in cardiac output is accompanied by a
modest decrease in mean blood pressure- from
a decline in diastolic pressure.
o The increase in cardiac output and
decrease in arterial blood pressure result
from a pronounced decrease in total
peripheral resistance.
• During the first stage of labor, cardiac output
increases moderately.
• During the second stage, with vigorous expulsive
efforts, it is appreciably greater.
• The pregnancy-induced increase is lost after
delivery, at times dependent on blood loss.
Heart
• As the diaphragm becomes progressively
elevated, the heart is displaced to the left and
upward and rotated somewhat on its long axis.
• The apex is moved somewhat laterally from its
usual position.
Normal cardiac sounds are altered during pregnancy
1. An exaggerated splitting of the first heart sound
with increased loudness of both components.
2. No definite changes in the aortic and pulmonary
elements of the second sound
3. A loud, easily heard third sound
Hemodynamic Function in Late Pregnancy
• Systemic vascular and pulmonary vascular
resistance both decreased significantly, as did
colloid osmotic pressure.
• Pulmonary capillary wedge pressure and central
venous pressure did not change appreciably
between late pregnancy and the puerperium.
Renin, Angiotensin II and Plasma Volume
• Involved in renal control of blood pressure via
sodium and water balance.
• All components of this system are increased in
normal pregnancy (Bentley-Lewis and co-
workers, 2005)
• Renin is produced by both the maternal kidney
and the placenta and increased rennin substrate
(angiotensinogen) is produced by both maternal
and fetal liver.
• Nullipara who remained normotensive became
and stayed refractory to the pressor effects of
infused angiotensin II.
• The vascular responsiveness to angiotensin II may
be progesterone related.
Cardiac Natriuretic Peptides
• Atrial natriuretic peptide (ANP) and B-type
natriuretic peptide (BNP)
• Secreted by cardiomyocytes in response to
Chamberwall stretching
• Regulate blood volume by provoking natriuresis,
dieresis,
• and vascular smooth-muscle relaxation (Cleric
and Emdin, 2004)
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 OBSTETRICS – Maternal Adaptations to Pregnancy

Prostaglandins o Minute Ventilation – increases about 30
• Renal medullary prostaglandin E2 synthesis is to 40% due to increased tidal volume.
increased markedly during late pregnancy and is o Arterial pO2 also increases from 100 to
presumed to be natriuretic Prostacyclin (PGI2) 105 mmHg
o Carbon dioxide production increases
approximately 30%, but diffusion
Prostacyclin (PGI2)
capacity also increases, and with
• The principal prostaglandin of endothelium, also
alveolar hyperventilation, the pCO2
increased during late pregnancy and regulates
decreases from 40 to 32 mmHg
blood pressure and platelet function.
o Residual Volume – decreases
approximately 20% from 1500 mL to
Endothelin approximately 1200 mL
• Endothelin-I is a potent vasoconstrictor o The expanding uterus and increased
producedin endothelial and vascular smooth abdominal pressure cause chest wall
muscle cellsand regulates local vasomotor tone. compliance to be reduced by third

Nitric Oxide
• This potent vasodilator is released by endothelial
cells and may have important implications for
modifying vascular resistance during pregnancy.

RESPIRATORY TRACT
• Diaphragm rises about 4 cm during pregnancy
• Subcostal angle widens appreciably as the
transverse diameter of the thoracic cage
lengthens approximately 2 cm
• Thoracic circumference increases about 6 cm

Acid-base Equilibrium
• Physiological dyspnea – is thought to result from
increased tidal volume that lowers the blood
pCO2 slightly, which paradoxically causes
dyspnea
• Increased respiratory effort, and in turn the
reduction in pCO2, during pregnancy is most
likely induced in large by part by progesterone
and to a lesser degree by estrogen
• Plasma bicarbonate levels decrease from 26 to
approximately 22 mmol/L to compensate for
respiratory alkalosis
• Plasma pH increases from 7.4 to about 7.46
• Functional Residual Capacity (FRC) decreases by
• Arterial PO2 increases slightly from about 103 to
approximately 20 to 30% or 400 to 700 mL during
107 mmHg
pregnancy
o Composed of expiratory reserve volume
- which decreases 15 to 20% or 200 to
URINARY SYSTEM
300 mL
o Residual volume – which decreases 20 to
125% or 200 to 400 mL
• FRC and residual volume decline due to
diaphragm elevation
• Some of the physiological changes induced by
pregnancy were recently summarized by Wise
and associates (2006):
o Vital Capacity and Inspiratory Capacity
– increase by approximately 1100 mL
o Expiratory Reserve Volume – decreases
from 1300 mL to approximately 1100 mL
o Tidal Volume – increases approximately
40% as a result of the respiratory stimulant
properties of progesterone

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 OBSTETRICS – Maternal Adaptations to Pregnancy

Test of Renal Function
• Serum creatinine levels decrease during normal • Associated with greater residual gallbladder
pregnancy from a mean of 0.7 to 0.5 mg/dL volumes in both the fasting and fed states
• Values of 0.9 mg/dL suggest underlying renal
disease and should prompt further evaluation • Sex steroids may be responsible

GASTROINTESTINAL TRACT 1. Inhibiting gallbladder contraction in

• Gastrointestinal function may be altered during pregnant women
pregnancy 2. Promoting precipitation of cholesterol
o Anatomical changes crystals
o Physiological changes 3. Stone formation
o Functional changes
• Change in motility – most alterations in GI ENDOCRINOLOGIC
function observed in normal pregnancy • Placenta
• Amplitude and duration of esophageal muscle - main endocrine organ during pregnancy
contraction in pregnant and non-pregnant - produces
appear to be similar
• Velocity of peristaltic waves in the distal 1. HCG 7. HCT
esophagus has been found to be decreased by 2. hPL 8. PTH
approximately 1/3 3. Estrogen 9. TRH
• Resting lower esophageal sphincter pressures 4. Progesterone 10. GnRH
progressively decrease during gestation and 5. Adrenocorticotropin 11. LHRH
then return to normal after delivery 6. Proopiomelanocortin 12. GHRH
• It is due to inhibition of smooth muscle
contraction by progesterone * HCT – Human Chronionic Thyrotropin
• Transit time of intestinal contents is prolonged
• hCg – synthesized principally in the
during gestation
syncytiotrophoblast.
• Pyrosis (heartburn) – is common during
o Detectable in the plasma of pregnant
pregnancy and is most likely caused by reflux of
women within 8 to 10 days after the
acidic secretions into the lower esophagus
midcycle surge of LH that precedes
ovulation
Maternal Physiology in Pregnancy: Digestive o Maximal levels at 10 weeks
Tract Changes • hPL – detected in trophoblast as early as the
• Gingivitis of pregnancy: vascular swelling of the second and third week after fertilization of the
gums can lead to the development of pyogenic ovum
granulomas o Concentrated in the syncytiotrophoblast
• Epulis gravidarum – regress 1 to 2 months after o Lipolysis and an increase in the levels of
delivery; excise of persistent or excessive circulating free fatty acids providing a
bleeding source of energy for maternal
metabolism and fetal nutrition
o Anti-insulin – increase levels of insulin
favoring protein synthesis
• Pregnancy is a hyperestrogenic state.
• Biosynthesis of estrogen takes place in the
placenta.
• Progesterone synthesis is accomplished by
utilization of maternal LDL in the
syncytiotrophoblast after 6 to 8 weeks

* In the small bowel, delayed transit is most pronounced in the third
trimester and associated with slowing of the migrating motor
complex.
• Progesterone – possibly, also to those of
endogenous opioids.
• Pregnancy also causes alterations in bile
composition.
1) Cholesterol supersaturation
2) Decreased cheno-deoxycholic acid
3) Increased cholic acid concentrations
4) Increased in bile acid pool
Thyroid Gland
• Physiological changes of pregnancy cause the
thyroid gland to increase production of thyroid
hormones by 40 to 100 percent to meet maternal
and fetal needs (Smallridge and associates,
2005)
• Anatomically, the thyroid gland undergoes
moderate enlargement during pregnancy
caused by glandular hyperplasia and increased
vascularity

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 OBSTETRICS – Maternal Adaptations to Pregnancy

Alterations in Thyroid Physiology and Function
during Pregnancy
• Total serum thyroxine (T4) increases sharply
beginning between 6 and 9 weeks and reaches
a plateau at 18 weeks.
• The fetus is reliant on maternal thyroxine, which
crosses the placenta in small quantities to
maintain normal fetal thyroid function.
• Thyrotropin-releasing hormone (TRH) is secreted
by the hypothalamus and stimulates thyrotrope
cells of the anterior pituitary to release
thyroidstimulating hormone TSH or thyro-tropin.

Adrenal Gland
• In normal pregnancy, unlike their fetal
counterparts, the maternal adrenal glands
undergo little, if any, morphological change.
• The serum concentration of circulating cortisol is
increased, but much of it is bound by transcortin,
the cortisol binding globulin.
• During early pregnancy, the levels of circulating
adrenocorticotropic hormone (ACTH), also
known as corticotropin, are reduced strikingly. As
pregnancy progresses, ACTH and free cortisol
levels rise equally and strikingly.

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