Obstetrics

Physiological Changes During Pregnancy

Dr.KH.SHOAIB IBNE ZAMAN
Physiological changes during Pregnancy:
1.Haemodynamic changes
2.Cardiovascular changes
3.Changes in hormonal activity
4.Weight gain
5.Changes in the breast
HEMATOLOGICAL CHANGES
BLOOD VOLUME: During pregnancy, there is increased vascularity of the enlarging uterus with the
interposition of uteroplacental circulation. The activities of all the systems are increased. Blood volume is
markedly raised during pregnancy. The rise is progressive and inconsistent. All the constituents of blood
are affected with increased blood volume. The blood volume starts to increase from about 6th week,
expands rapidly thereafter to maximum 40–50% above the nonpregnant level at 30–34 weeks. The level
remains almost static till delivery.
PLASMA VOLUME: It starts to increase by 6 weeks and it plateaus at 30 weeks of gestation. The rate of
increase almost parallels to that of blood volume but the maximum is reached to the extent of 50%. Total
plasma volume increases to the extent of 1.25 liters. The increase is greater in multigravida, in multiple
pregnancy and with large baby.
RBC AND HEMOGLOBIN: The RBC mass is increased to the extent of 20–30%. The total increase in
volume is about 350 ml. This increase is regulated by the increased demand of oxygen transport during
pregnancy. RBC mass begins to increase at about 10 weeks and continues till term without plateauing. Iron
supplementation increases the RBC mass by 30%. Reticulocyte count increases by 2%. Erythropoietin
level is raised.
LEUKOCYTES and IMMUNE SYSTEM: Neutrophilic leukocytosis occurs to the extent
of 8,000/mm3 and even to 20,000/mm3 in labor. The increase may be due to rise in the
levels of estrogen and cortisol. The major change in the immune system is the modulation
away from cell-mediated cytotoxic immune response toward increased humoral and innate
immune responses.
TOTAL PROTEIN: Total plasma protein increases from the normal 180 g (nonpregnant) to
230 g at term. the normal albumin:globulin ratio of 1.7:1 is diminished to 1:1.
Blood coagulation factor:
1.Fibrinogen level is raised.
2.Erythrocyte sedimentation rate (ESR) gives a much higher value (fourfold increase)
during pregnancy.
3.The clotting time does not show any significant change.
CARDIOVASCULAR SYSTEM
ANATOMICAL CHANGES: Due to elevation of the diaphragm consequent to the
enlarged uterus, the heart is pushed upward and outward with slight rotation to left.
CARDIAC OUTPUT: The cardiac output (CO) starts to increase from 5th week of
pregnancy and reaches its peak 40–50% at about 30–34 weeks. Thereafter the CO remains
static till term when the observation is made at lateral recumbent position. CO is lowest in
the sitting or supine position and highest in the right or left lateral or knee chest position.
Cardiac output increases further during labor (+50%) and immediately following delivery
(+70%) over the pre-labor values. MAP also rises. There is squeezing out of blood from
the uterus into the maternal circulation (auto transfusion) during labor and in the
immediate postpartum. CO returns to pre-labor values by 1 hour following delivery and to
the pre-pregnant level by another 4 weeks time.
The increase in Cardiac Output is caused by:
1.Increased blood volume.
2.To meet the additional O2 required due to increased metabolic
activity during pregnancy. CO is the product of SV and HR (CO =
SV × HR). The increase in CO is chiefly affected by increase in
stroke volume and increase in pulse rate to about 15 per minute. A
normal heart got enough reserve power to cope with the increased
load but a damaged heart fails to do so .
Changes in blood pressure:
In pregnancy smooth muscle relaxation occurs (Due to
progesterone,Prostaglandin,ANP,NO)

Decreased systemic peripheral vascular resistance(21%)

Decreased blood pressure(In spite of large increases in cardiac output

CARBOHYDRATE METABOLISM:
Transfer of increased amount of glucose from mother to the fetus is needed throughout
pregnancy. Insulin secretion is increased in response to glucose and amino acids. There is
hyperplasia and hypertrophy of beta cells of pancreas. Sensitivity of insulin receptors is
decreased (44%) especially during later months of pregnancy. Plasma insulin level is
increased due to a number of contra insulin factors. These are: estrogen, progesterone,
human placental lactogen (hPL), cortisol, prolactin, free fatty acids, leptin, and TNFa.
There is increased tissue resistance to insulin. This mechanism ensures continuous supply
of glucose to the fetus. Increased insulin level favors lipogenesis (fat storage). During
maternal fasting, there is hypoglycemia, hypoinsulinemia, hyperlipidemia and
hyperketonemia. Lipolysis generates free fatty acids (FFA) for gluconeogenesis and fuel
supply. Plasma glucagon level remains unchanged.
Overall effect is maternal fasting hypoglycemia (due to fetal
consumption) and postprandial hyperglycemia and
hyperinsulinemia (due to anti-insulin factors). Oral glucose
tolerance test may show an abnormal pattern. This helps to
maintain a continuous supply of glucose and FFA to the fetus. As
maternal utilization of glucose is reduced, there are
gluconeogenesis and glycogenolysis. Glomerular filtration of
glucose is increased to exceed the tubular absorption threshold
(normal 180 mg%). So glycosuria is detected in 50% of normal
pregnant women.
PROTEIN METABOLISM:
There is a positive nitrogenous balance throughout pregnancy. At
term, the fetus and the placenta contain about 500 g of protein and
the maternal gain is also about 500 g chiefly distributed in the
uterus, breasts and the maternal blood. As the breakdown of amino
acid to urea is suppressed, the blood urea level falls to 15–20 mg%.
Blood uric acid and creatinine level, however, either remain
unchanged or fall slightly. Amino acids are actively transported
across the placenta to the fetus. Pregnancy is an anabolic state.
FAT METABOLISM: An average of 3–4 kg of fat is
stored during pregnancy mostly in the abdominal wall,
breasts, hips and thighs. Plasma lipids and lipoproteins
increase appreciably during the latter half of
pregnancy due to increased estrogen, progesterone,
hPL and leptin levels.
NERVOUS SYSTEM: [NICE TO KNOW]
Some sorts of temperamental changes are found during pregnancy and in the
puerperium. Nausea, vomiting, mental irritability and sleep disorders are
probably due to some psychological background. Postpartum blues,
depression or psychosis may develop in a susceptible individual.Compression
of the median nerve underneath the flexor retinaculum over the wrist joint
leading to pain and paresthesia in the hands and arm (Carpal tunnel
syndrome) may appear in the later months of pregnancy. Similarly,
paresthesia and sensory loss over the anterolateral aspect of the thigh may
occur. It is due to compression of the lateral cutaneous nerve of the thigh.
CALCIUM METABOLISM AND SKELETAL SYSTEM:
During pregnancy there is increase in the demand of calcium by the growing fetus to the
extent of 28 g, 80% of which is required in the last trimester for fetal bone mineralization.
Daily requirement of calcium during pregnancy and lactation averages 1–1.5 g. Maternal total
calcium levels fall but serum ionized calcium level is unchanged. Fifty percent of serum
calcium is ionized which is important for physiological function. Calcium absorption from
intestine and kidneys are doubled due to rise in the level of 1, 25 dihydroxy vitamin D3.
Pregnancy does not cause hyperparathyroidism.
Calcitonin levels increase by 20%. Calcitonin protects the maternal skeleton from
osteoporosis. Maternal serum phosphate level is unchanged. There is increased mobility of the
pelvic joints due to softening of the ligaments caused mainly by hormone. This along with
increased lumbar lordosis during later months of pregnancy due to enlarged uterus produces
backache and waddling gait.
HUMAN CHORIONIC GONADOTROPIN (hCG):
hCG is a glycoprotein. Its molecular weight is 36,000–40,000
daltons. It consists of a hormone nonspecific a (92 amino acids)
and a hormone specific b (145amino acids) subunit. hCG is
chemically and functionally similar to pituitary luteinizing
hormone. The a subunit is biochemically similar to LH, FSH and
TSH whereas the b subunit is relatively unique to hCG. Placental
GnRH may have a control on hCG formation.
Functions:
(1) It acts as a stimulus for the secretion of progesterone by the corpus luteum of pregnancy. Rescue
and maintenance of corpus luteum till 6 weeks of pregnancy is the major biological function of hCG.
(2) hCG stimulates Leydig cells of the male fetus to produce testosterone in conjunction with fetal
pituitary gonadotropins. It is thus indirectly involved in the development of male external genitalia.
(3) It has got immunosuppressive activity, which may inhibit the maternal processes of
immunorejection of the fetus as a homograft.
(4) Stimulates both adrenal and placental steroidogenesis.
(5) Stimulates maternal thyroid because of its thyrotropic activity.
(6) Promotes secretion of relaxin from the corpus luteum.
Level of hCG at different periods of pregnancy:
hCG is produced by the syncytiotrophoblast of the placenta and secreted into the blood of
both mother and fetus. The plasma half-life of hCG is about 36 hours. By
radioimmunoassay, it can be detected in the maternal serum or urine as early as 8–9 days
post fertilization. In the early pregnancy, the doubling time of hCG concentrations in
plasma is 1.4–2 days. The blood and urine values reach maximum levels ranging from
100 IU/mL to 200 IU/mL between 60 and 70 days of pregnancy. The concentration falls
slowly reaching a low level of 10–20 IU/ml between 100 and 130 days. Thereafter, the
levels remain constant throughout pregnancy with a slight secondary peak at 32 weeks.
High levels of hCG could be detected in—
1.Multiple pregnancy.
2.Hydatidiform mole or choriocarcinoma.
3.Relatively high in pregnancy with a trisomy 21 fetus
(Down’s syndrome). Plasma lower levels are found in
ectopic pregnancies and in spontaneous abortion. hCG
disappears from the circulation within 2 weeks following
delivery.
PANCREAS:-
PHYSIOLOGICAL CHANGES IN PREGNANCY: During pregnancy
there is hypertrophy and hyperplasia of the b cells of islets of Langerhans
in maternal pancreas. In pregnancy, there is hyperinsulinemia
particularly during third trimester which coincides with the peak
concentration of placental hormones. Several antinsulin factors (hPL)
and other factors (CRP, IL-6, TNF-a and leptin) decrease insulin
sensitivity and increase insulin resistance. Maternal blood glucose level
is increased in the second half of pregnancy.This helps increased transfer
of glucose from the mother to the fetus through the placenta.
WEIGHT GAIN:

In normal pregnancy, variable amount of weight gain is a constant

phenomenon. In early weeks, the patient may lose weight because
of nausea or vomiting. During subsequent months, the weight gain
is progressive until the last 1 or 2 weeks, when the weight remains
static. The total weight gain during the course of a singleton
pregnancy for a healthy woman averages 11 kg (24 lb). This has
been distributed to 1 kg in first trimester and 5 kg each in second
and third trimester.
How weight should be gain during Pregnancy:
Components of weight gain:
Reproductive weight gain(6kg):
-Fetus: 3.3kg
-Placenta: 0.6kg
-Liquor: 0.8kg
-Uterus: 0.9kg
-Breast: 0.4kg
Maternal weight gain(6kg):
-Blood volume: 1.3kg
-ECF: 1.2kg
-Fat(mainly) & protein: 3.5kg
Thank You