Cardio-Respiratory Physiological Adaptation

of Pregnancy
Mary P. O'Day

Significant physiological adaptations during pregnancy contribute to its successful outcome. These
occur early in the pregnancy and continue throughout gestation, with complete reversal after delivery.
Many changes that are normal during pregnancy are pathological should they occur in the nonpreg-
nant woman. Adequate understanding o f these normal changes is essential in the assessment of all
pregnancies and in the management of those with complications. This article reviews the cardiovascu-
lax and pulmonary changes that occur during a normal gestation.
Copyright 9 1997 by W.B. Saunders Company

ignificant physiological adaptations during
S pregnancy contribute to its successful out-
come. These occur early in the pregnancy and
continue t h r o u g h o u t gestation, with complete
reversal after delivery. Many changes that are
n o r m a l during p r e g n a n c y are pathological
should they occur in the n o n p r e g n a n t woman.
Adequate u n d e r s t a n d i n g of these n o r m a l
changes is essential in the assessment of all preg-
nancies and in the m a n a g e m e n t of those with
complications.
creased estrogen, renin, and angiotensin levels,
all of which p r o m o t e sodium resorption. Balanc-
ing this, increased glomerular filtration rate and
increased progesterone levels p r o m o t e sodium
excretion. T h e net effect is an overall retention
of approximately 1,000 m E q of sodium during
the course of the pregnancy. 4 This is equally dis-
tributed a m o n g the fetus and the maternal intra-
vascular a n d extravascular spaces.
Red Cell Mass

Cardiovascular Changes
Plasma/Blood Volume
Plasma volume increases as early at the 7th week
of gestation and plateaus at 32 weeks' gestation,
representing a 45% to 50% increase over non-
p r e g n a n t v a l u e s . 1'2 T h e volume increase is de-
p e n d e n t on the size and n u m b e r of fetuses, with
higher blood volumes observed with multiple
gestations and large fetuses. ~'4 However, the pres-
ence of a fetus is not required as maternal hyper-
volemia is observed in hydatidiform moles. 5
Several mechanisms are responsible for regu-
lating volume expansion. T h e r e is a twofold in-
crease in aldosterone levels, a 15 to 25 times
increase in deoxycorticosterone activity, and in-
Total red blood cell mass increases by 20% dur-
ing pregnancy, m o r e if iron s u p p l e m e n t a t i o n is
given. This increase reflects an increase in red
blood cell production, not prolongation of red
cell life. 1 Increased erythropoiesis is secondary
to increased prolactin, progesterone, chorionic
s o m a t o m a m m o t r o p i n , and erythropoietin lev-
els. 6'7 T h e disproportionately large increase in
plasma volume relative to red cell volume results
in a decrease of the maternal hematocrit due to
hemodilution, most notable in the third trimes-
ter-the so-called "physiological anemia of
pregnancy." Maternal red cell 2,3-diphospho-
glycerate concentrations increase during preg-
nancy, facilitating maternal to fetal oxygen trans-
fer. s

From the Division of Maternal-Fetal Medicine, Department of Obstet- Heart Rate

rics & Gynecology, The University of Texas Medical Branch, Galves-
ton, TX.
Address reprint requests to Mary P. O'Day, MD, Assistant Professor,
Department of Obstetrics & Gynecology, Division of Maternal-Fetal
Medicine, The University of Texas Medical B~'anch, 301 University
Blvd, Galveston, TX 77555-0587.
Copyright 9 1997 by W.B. Saunders Company
O146-0005/97/2104-0001505. 00/0
Maternal heart rate increases as early as the 7th
week o f gestation, a n d in late pregnancy averages
approximately 20% over p o s t p a r t u m values, g
The etiology of these changes are unclear, but
could be explained by blood volume expansion 1~
or h o r m o n a l changes. 1~

268 Seminars in Perinatology, Vol 21, No 4 (August), 1997: pp 268-275

 Cardio-RespiratoryPhysiologicalAdaptation of Pregnancy
Cardiac Output
Cardiac output, the p r o d u c t of h e a r t rate and
stroke volume, reflects the overall ability of the
heart to function. Cardiac output increases 30%
to 50% during n o r m a l pregnancy, with the ma-
jority of the increase occurring in the first trimes-
ter. 1214 A plateau is reached by the early third
trimester. 15 Increased stroke volume is predomi-
nantly responsible for t i e early increase in car-
diac output, 1S'16 possibly due to increased left
ventricular mass and b l o o d volume. 17 Studies
with subjects in the left lateral position showed
a small decline in cardiac o u t p u t toward term,
due to decreasing stroke volume. 1s2~ However,
the maternal heart rate increase continues,
maintaining cardiac o u t p u t in the late third tri-
mester. 16
Maternal position is critical in the assessment
of cardiac output. T u r n i n g to the supine position
can decrease cardiac o u t p u t by as m u c h as
25%. 21 This is due to venocaval compression by
the p r e g n a n t uterus, resulting in decreased ve-
nous return to the heart, in turn causing de-
creased stroke volume and cardiac output. Ap-
proximately 8% of w o m e n will show " s u p i n e
hypotensive syndrome," characterized by hypo-
tension, bradycardia, and syncope. 22 W o m e n
who are symptomatic have p o o r circulation in
the paravertebral vessels that usually serve as col-
lateral vessels to the vena cava. A generalized
vasoconstrictive response occurs, resulting in de-
creased blood flow in the uterine, umbilical, and
cerebral vasculature. 23'24
Blood Pressure
T h e r e are only m i n o r changes in systolic b l o o d
pressure during pregnancy. Diastolic blood pres-
sure reaches a nadir a r o u n d 28 weeks' gestation,
a n d increases to p r e p r e g n a n c y levels by term.
T h e position in which the bloott pressure is mea-
sured is of critical importance. Both systolic and
diastolic pressures are a b o u t 10 m m H g lower in
the left lateral r e c u m b e n t position than when
sitting or standing. If b l o o d pressure is taken in
the left lateral position, there will be a significant
difference between the u p p e r arm a n d lower
a r m reading. 25 To accurately d o c u m e n t blood
pressure trends, it is essential that the m e t h o d
of blood pressure m e a s u r e m e n t t h r o u g h o u t
p r e g n a n c y is consistent.
Controversy exists over the exact definition of
269
diastolic blood pressure. It is debatable whether
diastolic blood pressure is best m e a s u r e d at Kor-
o t k o f f p h a s e 4 (muffling) or phase 5 (final disap-
pearance) .26 If m e a s u r e d at phase 4, m e a n dia-
stolic pressure is a b o u t 13 m m H g higher than
phase 5. 27 Intra-arterial m e a s u r e m e n t s of dia-
stolic pressures were 15 m m H g lower than indi-
rect cuff s p h y g m o m a n o m e t r y . 2s Although early
studies of a u t o m a t e d b l o o d pressure devices
showed pressures significantly lower than direct
intra-arterial measurements, 29 adequate correla-
tion has b e e n shown between a u t o m a t e d and
manual m e r c u r y s p h y g m o m a n o m e t r y . 3~ Am-
bulatory 24-hour m o n i t o r i n g of blood pressure
and heart rate show expected diurnal varia-
tions, ~'s4 and may be of use in the prediction of
preeclampsia or other adverse pregnancy out-
comes.3~,35
Systemic Vascular Resistance
Systemic vascular resistance (SVR), the ratio of
cardiac output and m e a n arterial pressure, is a
measure of the tension required to eject b l o o d
into the circulation. It can be used to estimate
clinically the a m o u n t of i m p e d a n c e to cardiac
output. SVR decreases during pregnancy, reach-
ing a nadir at 14 to 24 weeks, then increasing to
n e a r n o r m a l levels at term. 16 T h e etiology of this
decrease in SVR is poorly understood. Signifi-
cant decreases in SVR are observed in the late
luteal phase of w o m e n who subsequently b e c a m e
pregnant, representing one of the earliest mater-
nal adjustments to pregnancy. 36 Earlier studies
hypothesizing that the uteroplacental circula-
tion acts as an arteriovenous shunt (thereby de-
creasing SVR) seems unlikely, because SVR de-
creases as early as 5 weeks' gestation, is More
likely, decreased SVR is due to peripheral vasodi-
lation f r o m circulating progesterone, prostaglan-
dins, prostacyclines, and nitric oxide. 37
Pulmonary Vascular Resistance
During pregnancy, there is little change in the
p u l m o n a r y artery pressure, as m e a s u r e d by the
p u l m o n a r y capillary wedge pressure (PCWP).
Because there is a d o c u m e n t e d increase in car-
diac output, m a i n t e n a n c e of PCWP would neces-
sitate a decreased p u l m o n a r y vascular resistance.
This decrease has b e e n c o n f i r m e d by invasive
studies using p u l m o n a r y artery catheter monitor-
ing ~8 and noninvasive D o p p l e r echocardiogra-
270
phy. 39 T h e ' d e c r e a s e in p u l m o n a r y vascular resis-
tance is most likely secondary to vasodilation and
expansion of the p u l m o n a r y arterioles and capil-
laries.
Colloid Osmotic Pressure
Colloid osmotic pressure (COP) describes the
ability of the interstitial and vascular spaces to
retain fluid. Albumin is the m a j o r protein con-
tributing to plasma osmotic pressure, due to its
inability to cross the s e m i p e r m e a b l e vascular en-
dothelium. Colloid osmotic pressure decreases
with advancing gestational age, reaching a nadir
a b o u t 36 weeks' gestation. This trend parallels
the decrease in maternal serum albumin levels.
The decrease in the albumin concentration is
most likely responsible for the decreasing COP
observed during pregnancy, a~
Colloid osmotic pressure may have clinical ap-
plication in the prediction of p u l m o n a r y edema.
Weil et al postulated that a decrease in the COP
(keeps fluid in the p u l m o n a r y capillaries) or an
increase in the PCWP (forces fluids out of the
p u l m o n a r y capillaries) would result in pulmo-
nary edema. 41 F r o m this, the concept of a COP-
PCWP gradient was proposed. Rackow et al re-
ported the increased risk of p u l m o n a r y e d e m a
in those patients with a COP-PCWP gradient less
than 4 m m Hg. 42 P u l m o n a r y e d e m a may also be
related to decreases in the COP-PCWP gradient
in pregnancies complicated by preeclampsia. 43'44
In n o r m a l pregnancy, the COP-PCWP gradi-
ent is reduced due to n o r m a l decreases in COP.
Therefore, gravid w o m e n may be predisposed to
the d e v e l o p m e n t of p u l m o n a r y edema, particu-
larly in situations that alter p u l m o n a r y capillary
permeability. 38
Regional Blood Flow
The increase in cardiac output in n o r m a l preg-
nancy is distributed to several organ systems. Re-
nal blood flow progressively increases, reaching
50% above n o n p r e g n a n t levels by midgesta-
t i o n . 45 The glomerular filtration rate increases
45% above n o n p r e g n a n t values, and that in-
crease is maintained for the duration of the preg-
nancy. 46 The increase in glomerular filtration is
thought to result f r o m the general vasodilation
of pregnancy as well as from the increasing renal
blood flow.
Uterine blood flow increases tenfold to ap-
Ma U P. O'Day
proximately 500 m L / m i n at term, accounting
for 17% of cardiac output. 47 Skin perfusion in-
creases slowly until 20 weeks, then sharply rises
between 20 and 30 weeks. 48 Blood flow to the
breast tissue doubles. T h e r e a p p e a r s to be no
change in b l o o d flow to the liver or brain.
Hemodynamic Measurements
Central h e m o d y n a m i c m e a s u r e m e n t s obtained
with p u l m o n a r y artery catheters provide the
" g o l d standard" values to which other measure-
m e n t techniques are compared. Although the
invasive nature of central m o n i t o r i n g limits its
use during n o r m a l pregnancy, data on hemody-
namic changes in normal late gestation we_re ob-
tained by Clark et al and is summarized in Table
1.3a Indications for central m o n i t o r i n g with pul-
m o n a r y artery catheters is limited to obstetric
patients with severe hypertension, oliguria, or
p u l m o n a r y edema. 49
Several different techniques exist for echocar-
diographic estimates of cardiac function and
output. M-mode echocardiographic assessment
of ventricular function is possible, but cannot be
p e r f o r m e d accurately on some patients. 5~ Im-
p e d a n c e cardiography uses the changes in elec-
trical i m p e d a n c e that occur in the chest cavity
during the cardiac cycle to calculate stroke vol-
ume. Studies have shown significant difficulties
with this technique, which is not suitable for as-
sessing cardiovascular changes during preg-
nancy) 1
Two-dimensional echocardiography with con-
tinuous- and pulsed-wave D o p p l e r has improved
the accuracy of echocardiographic measure-
ments. This technique has b e e n validated in
b o t h n o n p r e g n a n t 52 and p r e g n a n t patients. In
pregnancy, D o p p l e r has b e e n assessed using si-
multaneous noninvasive and invasive hemody-
namic m o n i t o r i n g and shown to be compara-
ble. 53'54 In practice, as cardiac function can be
calculated reliably by a variety of echocardio-
graphic techniques, combination of M-mode
a n d D o p p l e r may provide m o r e complete infor-
mation than a single m e t h o d alone. 55
Pulmonary Changes
Anatomic Changes
Thoracic configuration changes early during
pregnancy. The transverse diameter of the tho-
 Cardio-Respiratory PhysiologicalAdaptation of Pregnancy 271

Table 1. Central Hemodynamic Changes in Pregnancy3s

Te~n %
Parameters Pregnancy Postpartum Change
Heart rate (beats/min) 83 _+ 10 71 _+ 10 +17
Cardiac output (L/min) 6.2 + 1.0 4.3 + 0.9 +43
Mean arterial pressure (mm Hg) 90.3 _+ 5.8 86.4 _+ 7.5 NS
Systemic vascular resistance (dyne" cm" sec -5) 1,210 _+ 266 1,530 _+ 520 -21
Pulmonary vascular resistance (dyne. cm" sec -5) 78 + 22 119 _+ 47 -34
Colloid osmotic pressure (ram Hg) 18 _+ 1.5 20.8 + 1.0 NS
Pulmonary capillary wedge pressure (ram Hg) 7.5 _+ 1.8 6.3 _+ 2.1 NS
Central venous pressure (mm Hg) 3.6 _+ 2.5 3.7 + 2.6 NS
M e a s u r e m e n t s a r e m e a n _+ s t a n d a r d d e v i a t i o n .
NS, n o t s i g n i f i c a n t at P < .05.

rax and the chest circumference increase. 56 The
level of the diaphragm increases about 4 cm.
However, diaphragmatic excursion is increased,
despite the enlarging uterus. 57 Changes in the
chest wall configuration peak about 37 weeks
and slowly return to normal after delivery. The
u p p e r airway is affected by the increased vasodi-
lafion of pregnancy, resulting in mucosal edema,
nasal stuffiness, increased secretions, and nose
bleeds.
Lung Volumes
In the second half of pregnancy, there are sev-
eral significant changes in lung volumes and ca-
pacifies (Fig 1).5s~6~These adaptations are sum-
marized as follows:
Tidal volume (VT): The quantity of air exhaled
during normal breathing. VT increases by as
much as 40% during pregnancy.
Minute volume (Ve): The total volume of air
leaving the lung each minute. V~ is a p r o d u c t of
VT and the respiratory rate. While respiratory
rate remains unchanged, the increased VT
results in a 40% increase in VE, p r o d u c i n g a
relative "hyperventilation" in pregnancy. The
hyperventilation is due to the effects of proges-
terone, which acts as a respiratory stimulant and
increases respiratory drive during pregnancy.
Alveolar ventilation (VA): The volume of air
available for gas exchange each minute. The dif-
ference between VE and VA represents gas that
remains in the anatomic dead space.
Expiratory reserve volume (ERV): The m a x i m u m
quantity of air that can be exhaled after the end
of a normal breath. This decreases by 15% at
the end of gestation.
Residual volume (RV): The gas remaining in the
lung after maximal exhalation. This decreases by
20% at the end of gestation.
Functional residual capacity (FRC): The sum of
ERV and RV. This represents the volume of air
remaining in the lung after a normal breath.
The FRC decreases about 18% by the end of
gestation, due to the effects of the enlarging
uterus.
Vital capacity (VC): The a m o u n t of air that can
be exhaled after a maximal inspiration. This re-
mains u n c h a n g e d during pregnancy.
Inspiratory capacity (IC): The m a x i m u m
a m o u n t of air that can be inspired after a normal
exhalation. Inspiratory capacity increases 5% to
10% as pregnancy progresses and preserves the
VC and total lung capacity t h r o u g h o u t preg-
nancy. This also indicates that diaphragmatic ex-
cursion is preserved.
Lung Functions
Although lung volumes are decreased during
pregnancy, routine spirometric tests that assess
air flow are essentially unchanged. The one-sec-
o n d forced expiratory volume (FEV1) is the vol-
ume of gas exhaled in one second by a forced
exhalation after a full inspiration. This simple,
informative, and inexpensive test is often abnor-
mal in patients with lung disease and remains
normal in pregnancy. This test is most useful in
diagnosis and m a n a g e m e n t of dyspnea during
pregnancy.
Total airway resistance is u n c h a n g e d o r
slightly decreased during pregnancy, possibly
due to hormonally mediated relaxation of airway
smooth muscle. Although lung compliance re-
mains unchanged, chest wall compliance de-
creases, resulting in a decrease in total respira-
272 Mary P. O'Day

t j L

Inspiratory l inspir~a
reserve
volume reset
2050 volur
I
205
O
O Inspiratory o
Inspiratory
capacity I o
capacity
II 2500 CO

2650
o~
t-I

~
O o~

~>

..1
Expiratory Expiratory
reservevolume reservevolume
700 Functional 550
~f
I~
residual
capacity
I'
1700 Residual
C~

Residual 1 volume
volume 8OO
1000
tf t ~ Elevationof diaphragm
Nonpregnant Gravida at term

Figure 1. Lung volume changes in pregnancy. (Reprinted with permission. 59)

tory compliance in late gestation. The effect of
decreased chest wall compliance is greater than
that of decreased airway resistance. Therefore,
the total work of breathing increases, resulting
in a 50% increase in oxygen consumption. 61
Gas Exchange
Pregnancy results in significant changes in gas
exchange. The increased ventilation of preg-
nancy results from the aforementioned changes
in the mechanics o f breathing,~ the increased
progesterone levels, and the increase in basal
metabolic rate. The increased alveolar ventila-
tion enhances gas exchange in the lung: both
resting oxygen consumption (Vo2) and carbon
dioxide exhalation (Vco2) increase 20% to 40%
by term. 62 The increase in Vo2 results from the
increased oxygen demands of the fetus, pla-
centa, and maternal organs. At sea level, the arte-
rial oxygen pressure (PAP2) ranges from 101 to
104 m m Hg in healthy women near term, 63 al-
though it can be lower in women living at higher
altitudes. 64
The increase in Vco2 results in a decrease in
the arterial carbon dioxide pressure (Pace2) is
associated with a chronic respiratory alkalosis.
Increased renal excretion of bicarbonate main-
tains the arterial blood p H between 4.40 and
4.46 and the serum bicarbonate between 18 and
22 m E q / L . 5s'64 A compensated respiratory alka-
losis, with a low Pace2 and bicarbonate, is there-
fore normal in pregnancy.
Even though alveolar ventilation is enhanced,
intrapulmonary shunting still exists during preg-
nancy. Intrapulmonary shunting (Oo/O~) refers
to a ventilation-perfusion mismatch, in which a
portion of the pulmonary blood flow does not
contact functioning alveoli (Q~), relative to total
pulmonary blood flow (O~). In n o n p r e g n a n t
people, the normal range for Q~/O~ is 2% to
5%. This shunt is due to venous drainage into
the left side of the heart and to the fact that not
all alveolar units are always fully functional. The
clinical effect of an intrapulmonary shunt is to
change the PaP2 and the hemoglobin satura-
tion. Shunt values of 5% to 15% are often associ-
ated with exertional dyspnea: higher shunt val-
 Cardio-Respiratory PhysiologicalAdaptation of Pregnancy 2 73

Table 2, Third-Trimester Blood Gas and Acid Base m a y b e m o r e i m p o r t a n t t h a n p o s i t i o n in t h e in-

Levels Relative to Maternal Position 64 t e r p r e t a t i o n o f n o r m a l b l o o d gas a n d a c i d b a s e
Left Lateral Supine Knee-Chest values. N o r m a l p h y s i o l o g i c a l r e s p o n s e to t h e rel-
ative h y p o x i a o f h i g h a l t i t u d e s is h y p e r v e n t i l a -
pH 7.46 +_ 0,02 "7.45 _+ 0.02 7,46 +_ 0.02 tion, p o l y c y t h e m i a , i n c r e a s e d levels o f 2,3,-di-
Paco2 (mm Hg) 26.6 _+ 2.7 26.7 _+ 2.1 26.7 _+ 1.2
Pao2 (ram Hg) 86.2 -+ 7,3 86.7 -+ 7.2 89,5 -+ 5:9 p h o s p h o g l y c e r a t e , a n d a shift to t h e r i g h t in t h e
HCO3 (mEq/L) 18.6 _+ 1.9 18.8 -+ 1.4 17.3 _+ 1.6 o x y g e n d i s s o c i a t i o n curve, a l l o w i n g i n c r e a s e d ox-
Saoz 0.96 -+ 0.01 0,96 -+ 0.0 0.96 -+ 0.0 y g e n r e l e a s e to tissues. All t h e s e a d a p t a t i o n s oc-
HCO3 = bicarbonate; SaO2 = saturated arterial hemoglobin c u r in n o r m a l p r e g n a n c y as well, a n d o f t e n a r e
level. superimposed on altitude-induced changes. Nor-
Data are mean + standard deviation.
m a l values o f PaO2 r a n g e f r o m 60.75 m m H g f o r
w o m e n living at 4,200 m e t e r s to 101.2 m m H g f o r
ues o f t e n r e q u i r e o x y g e n s u p p l e m e n t a t i o n o r w o m e n living at sea level. 67 T a b l e 3 s u m m a r i z e s
m e c h a n i c a l v e n t i l a t i o n . H a n k i n s et al have n o r m a l b l o o d gas a n d a c i d b a s e levels for h e a l t h y
s h o w n t h a t n o r m a l , h e a l t h y w o m e n at t e r m have t e r m w o m e n living at d i f f e r e n t altitudes. D u e to
Q a / Q , values a l m o s t t h r e e times h i g h e r t h a n flatness o f t h e o x y g e n d i s s o c i a t i o n curve, if Po2
t h o s e r e p o r t e d for n o n p r e g n a n t subjects. 65 This values a r e a b o v e 60 m m Hg, o x y g e n s a t u r a t i o n
is m o s t likely s e c o n d a r y to a l t e r a t i o n s o f l u n g a n d c o n c e n t r a t i o n will c h a n g e very little u n d e r
volumes and ventilation-perfusion mismatches normal circumstances.
that are normal during pregnancy.
Dyspnea
M a t e r n a l p o s i t i o n m a y b e i m p o r t a n t in t h e
a s s e s s m e n t o f p u l m o n a r y f u n c t i o n . Awe et al66 D y s p n e a is a very c o m m o n c o m p l a i n t d u r i n g
s h o w e d t h a t c h a n g i n g f r o m a sitting to s t a n d i n g p r e g n a n c y . A p p r o x i m a t e l y 50% o f w o m e n c o m -
p o s i t i o n c a n d e c r e a s e PaO2 to less t h a n 90 m m p l a i n o f b r e a t h l e s s n e s s by 20 weeks' gestation,
Hg. T h e y a t t r i b u t e d this d i f f e r e n c e to a c h a n g e i n c r e a s i n g to 75% by 31 weeks'. 6s T h e d y s p n e a
in t h e a l v e o l a r - a r t e r i a l (A-a) g r a d i e n t , w h i c h in- c a n n o t b e c o r r e l a t e d with a n y single p a r a m e t e r
c r e a s e d f r o m 14.3 sitting to 20 in t h e s u p i n e of respiratory function; therefore, those women
p o s i t i o n . H a n k i n s e t al have r e p o r t e d o n t h e ef- who complain of dyspnea may only be more
fects o f m a t e r n a l p o s i t i o n in h e a l t h y w o m e n at aware o f t h e i n c r e a s e d v e n t i l a t i o n o f p r e g n a n c y .
t e r m living at a m o d e r a t e a l t i t u d e (1,400 m e - Because dyspnea, fatigue, lower-extremity e d e m a ,
ters). 64 T h e s e f i n d i n g s a r e s u m m a r i z e d - i n T a b l e a n d b i b a s i l a r atelectasis a r e n o r m a l f i n d i n g s in
2. N o s i g n i f i c a n t effects o f m a t e r n a l p o s i t i o n pregnancy, the diagnosis of cardiopulmonary
were n o t e d f o r any b l o o d gas o r a c i d b a s e p a r a m - disease in p r e g n a n c y c a n b e c h a l l e n g i n g .
eters. A d d i t i o n a l l y , a l t h o u g h t h e A-a g r a d i e n t in- P r e g n a n c y creates a h y p e r d y n a m i c state t h a t
c r e a s e d f r o m 2.53 sitting to 6.56 s u p i n e , all val- results in s i g n i f i c a n t c h a n g e s in c a r d i a c a n d pul-
ues w e r e b e l o w t h e n o r m a l A-a g r a d i e n t o f 15. monary function. Many of these changes are
T h e a l t i t u d e at w h i c h p r e g n a n t w o m e n live c o m m o n to n o r m a l p r e g n a n c y a n d h e a r t disease.

Table 3. Studies of Arterial Blood Gas and Acid Base Values in Pregnant Women 64

Altitude Pao2 Pacoz

(m) Investigator Position (mm Hg) (mm Hg) pH HC03
1i.5 Awe 66 (Baylor, Houston) Sitting 101.2 + 7.0
Supine 94.6 __+8.8
152-304 Templeton 63 Semi- 101.8 + 1.0 30.4 _+ 0.6 7.43 _+ 0.006
(Aberdeen) recumbant
150 Sobrevilla67 Supine 91.0 _+ 2.09 32:26 _+ 1.06 7.397 _+ 0.12 19.46 + 0.63
(Lima, Peru)
1,388 Hankins 64 (Provo, Utah) Sitting 91.1 _+ 7.3 26.4 _+ 2.2 7.46 _+ 0.03 18.4 _+ 0.8
Supine 86.7 _+ 7.2 26.7 + 7.2 7.45 + 0.02 18.8 + 1.4
4,200 Sobrevilla67 (Cerro de Supine 60.75 _+ 2.02 24.54 _+ 1.48 7.432 _+ 0.11 15.88 -- 0.76
Pasco, Peru)
274 Mary P. O'Day
Recognition and understanding of the maternal
cardiopulmonary adaptations are essential for
management of normal pregnancies and, more
importantly, of the critically ill gravid patient.
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