Maternal Physiology

CHAPTER IV
WILLIAMS
OBSTETRICS 25TH
EDITION

ALDILYN J. SARAJAN, MD, MPH

3rd Year OB-GYN Resident
ZCMC
REPRODUCTIVE TRACT
• UTERUS
– Weight: non pregnant
(70grams) to almost 1110
grams by term

– Volume: 5L to 20L or more

– Uterine enlargement involves

stretching and marked
hypertrophy of muscles cells
• most marked in the fundus
• Muscular layer – 3
distinct layers
– OUTER HOODLIKE
LAYER
– MIDDLE LAYER,
DENSE NETWORK
– INTERNAL
LAYER(SPHINCTER
-LIKE FIBER)
REPRODUCTIVE TRACT
• UTERUS

– Shape: pear (beginning) >

globular to almost spherical
(12 weeks gestation) > ovoid

– Dextrorotation

– Braxton Hicks contractions

REPRODUCTIVE TRACT
• UTERUS

- Uteroplacental blood flow

- 450 ml/min in the mid

trimester to nearly 500 to 750
ml/min min at 36 weeks
REPRODUCTIVE TRACT
• CERVIX

- Eversion
- proliferating columnar
endocervical glands onto the
ectocervical portion
- Mucus plug
- immunological barrier to
protect the uterine contents
against infection.
REPRODUCTIVE TRACT
• CERVIX

- Beading
- Ferning
- Arias- stella reaction
• Endocervical gland hyperplasia
and hypersectory appearance
REPRODUCTIVE TRACT
• OVARIES

- Corpus luteum
- Produces progesterone
- Function maximally during
first 6 to 7 weeks
- Decidua reaction
- Elevated patches of tissue
which bleed easily.
REPRODUCTIVE TRACT
• OVARIES

- Relaxin
- Protein hormone secreted by
the corpus luteum, decidua
and placenta
- Remodelling of reproductive
tract connective tissue to
accommodate pregnancy
REPRODUCTIVE TRACT
• OVARIES

- Theca-Lutein Cysts
(hyperreactio luteinalis)
- These benign ovarian lesions
reflect exaggerated
physiological follicle
stimulation

- The condition is self-limited

and resolves following
delivery.
REPRODUCTIVE TRACT
• Fallopian Tubes

- Myosalpinx
- little hypertrophy during
pregnancy

- Endosalpinx somewhat
flattens
• Vagina
– Chadwick sign
• Increased vascularity and hyperemia
develop in the skin and muscles of the
perineum and vulva (violet discoloration)
SKIN CHANGES
• ABDOMINAL WALL
– Striae gravidarum
– Diastasis recti- rectus
muscles separate in the
midline
– Hyperpigmentation
• Elevated levels of melanocyte-
stimulating hormone (MSH)
• Linea nigra
• Chloasma- mask of pregnancy
 BREAST CHANGES
• Breast enlargement due to fat deposition
• Areola widens and darkens
• Glands of Montgomery are prominent
• Colostrum
– Expressed as early as few months of
pregnancy, but usually expressed two days
after delivery
 METABOLIC CHANGES
• GENERAL CHANGES
– 3rd trimester- maternal basal metabolic rate is
INCREASED by 10 to 20%
– WHO (2004) estimate of additional energy
demands:
• 1st trimester- 85 kcal/ day
• 2nd trimester- 285 kcal/ day
• 3rd trimester- 475 kcal/ day
A. Weight Gain
- caused by
1. Uterus and its contents
2. Breasts
3. Increases in blood volume and extra
vascular extracellular fluid
4. Metabolic alteration that result in an
increase cellular water and deposition
of new fat and protein
–Average weight gain is ~12.5kg
or 27.5 lbs
• B. Water Metabolism
– Increased water retention induced by
resetting of osmotic thresholds for thirst
and vasopressin secretion
– Minimum amount of extra water= 6.5
Liters
• Water content of fetus, placenta & Amniotic
fluid= 3.5 L
• Maternal volume, uterus and breasts= 3.0L
– Pitting edema of ankles and legs
C. Protein Metabolism
– the products of conception, the uterus and
maternal blood are relatively rich in protein
rather than fat or carbohydrate

• 500 g of protein: fetus and placenta at term

• 500 g of protein: contractile protein in the uterus,

glands of the breasts, hemoglobin and plasma protein
in the maternal blood
D. Carbohydrate Metabolism
– Mild fasting hypoglycemia, postprandial
hyperglycemia and hyperinsulinemia
– Pregnancy- induced state of peripheral
insulin resistance occurs to ensure a
sustained postprandial supply of
glucose to the fetus
• Progesterone and estrogen
• Placental lactogen may increase lipolysis
and liberation of free fatty acids.
– Rapid change from postprandial to a
fasting state
E. Fat Metabolism
– Increase in Lipids, Lipoproteins and
apolipoproteins
– Increased lipid synthesis and food
intake
INCREASED levels during DECREASED
the third trimester
Triacylglycerol After delivery:
VLDL a) Lipids
LDL b) Lipoproteins
HDL c) Apolipoprotein

During 3rd trimester:

Fat storage
• Leptin
– Secreted by adipose
tissue, some by placenta
• LEPTIN
– Plays a role in body fat
and energy expenditure deficiency
regulation – Anovulation
– Helps regulate fetal – Infertility
growth • Elevated Leptin
– Pre eclampsia
– Gestational
HPN
• Ghrelin
– Secreted primarily by the stomach in
response to hunger
– Cooperates with leptin in energy
homeostasis modulation
– Expressed also in placenta and likely
has a role in fetal growth and cell
proliferation
F. Electrolytes and Minerals
INCREASED DECREASED UNCHANGED

•Iodine •Sodium Serum

requirement •Potassium phosphate
•Iron •Total serum
requirement Calcium
•magnesium
HEMATOLOGICAL CHANGES
A. BLOOD VOLUME
– Functions of hypervolemia:
• Meets the metabolic demands of the enlarges
uterus and its great hypertrophied vascular
system
• Provides abundant nutrients and elements to
support the growing placenta and fetus
• Protects the mother and fetus against deleterious
effects of impaired venous return in the supine
and erect positions
• Safeguards the mother against the adverse
effects of parturition- associated blood loss
B. Hemoglobin Concentration &
Hematocrit
• Moderate erythroid hyperplasia is
present in the bone marrow
• Hemoglobin and hematocrit
DECREASES slightly
• Whole blood viscosity DECREASES
• Hgb concentration at term averages 12.5 g/dl
• 6% of pregnant women:
<11 g/dl  abnormal level
 due to iron
deficiency rather than to
hypervolemia of
pregnancy
C. Iron REQUIREMENT
• 1000mg : required for normal
pregnancy
300mg: actively 200mg: lost 500mg: required
transferred to the through normal for the increase in
fetus and placenta excretion routes, total circulating
primarily by GIT erythrocyte volume
(approximately
450mL)

– iron requirement during the 2nd half of

pregnancy: average 6-7 mg/ day
D. IMMUNOLOGIC FUNCTION:
SUPPRESSED ACTIVITY
• T- Helper (Th) 1 cells
– Decrease secretion of IL- 2, interferon-
g and TNF- B
– Suppressed TH1 response is requisite
for pregnancy continuation
• T- cytotoxic (Tc) 1 cells
– Decreased secretion of IL- 2,
interferon- g and TNF- B
• IMMUNOLOGIC FUNCTION:
UPREGULATED ACTIVITY
– Th2 cells- increase secretion of IL- 4, IL- 6
and IL- 13
– IgA and IgG in cervical mucus increase
– IL-1B in cervical and vaginal mucus is
increased during the 1st trimester
• Leukocytes
– Beginning 2nd trimester
• PMN leukocytes chemotaxis and adherence
functions are DECREASED
– Leukocyte count are HIGHER (upper value up
to 15, 000/uL)
– Labor and early puerperium levels:>25,000/uL
– 3rd trimester
• Granulocytes and CD8 T lymphocytres are
increased
• Monocytes and CD4 T lymphocytes are decreased
• IMMUNITY FUNCTION: IMMUNITY
MARKER
– C- reactive protein- INCREASED
throughout pregnancy
– ESR- INCREASED due to elevated
plasma globulins and fibrinogen
– C3 and C4- INCREASED during the 2nd
and 3rd trimesters
– Procalcitonin- INCREASED at the end
of the 3rd trimester until the first few
postpartum days
E. COAGULATION AND FIBRINOLYSIS

INCREASE DECREASE
Fibrinogen Activated PTT (slight)
Factor VII tPA
Factor X Antithrombin III
Plasminogen Protein C
Total protein S
• PLATELETS
– Average platelet count slightly
DECREASED from 250,000/ul (non-
pregnant) to 213, 000/uL (pregnant)
– Factors for thrombocytopenia:
• Hemodilution
• Increased platelet consumption
• Production of thromboxane A2 (platelet
aggregation)
CARDIOVASCULAR SYSTEM
• 5th weeks AOG
– Cardiac output is increased- reduced
systemic vascular resistance and
increased heart rate (10bpm above
resting heart rate)
• 10 to 20 weeks AOG
– Plasma volume expansion begins and
preload is increased
• HEART
– Displaced to the left and upward rotated
somewhat on its long axis
– The apex is moved somewhat laterally from
its usual position
• Large cardiac silhouette on chest radiograph
• Some degree of benign pericardial effusion, may
increase the cardiac silhouette
– No characteristic changes on ECG other than
slight left axis deviation as a result of the
altered heart position
• Cardiac Sounds
– Exaggerated splitting of the 1st heart sound
with increased loudness of both components
– No definite changes in the aortic and
pulmonary elements
– Systolic murmur in 90% of pregnant patients
• Intensified during inspiration
• Disappears shortly after delivery
• Cardiac Output
– Mean arterial pressure and Vascular
resistance decrease, while blood volume and
basal metabolic rate increase
– Lateral recumbent position
• Cardiac output at rest is INCREASED
• Fetal oxygen saturation is approximately 10%
higher in labouring women
– Late pregnancy in supine position
• diminished cardiac output
– 1st stage of labor- Cardiac output
increases moderately
– 2nd stage of labor- greater increase in
cardiac output with vigorous expulsive
efforts
• CIRCULATION & BLOOD PRESSURE
– Brachial artery pressure when sitting is lower
than that when in lateral recumbent position
– Arterial pressure usually decreases to a nadir at
24 to 26 weeks
• Diastolic pressure decreases more than the systolic
– Component of the RENIN- ANGIOTENSIN-
ALDOSTERONE AXIS are increased in normal
pregnancy
• Renin produced by kidney and placenta
• Angiotensinogen produced by maternal and fetal
liver
– Increase is partly due to high levels of estrogen during
normal pregnancy
 PROSTAGLANDIN VASOACTIVE SUBSTANCE
ENDOTHELIN NITRIC OXIDE
•Renal medullary •Potent Potent vasodilator
prostaglandin E2 vasoconstrictor
synthesis I •Stimulates secretion
• Increased of ANP, aldosterone
(natriuretic) and catecholamines
•PROSTACYCLIN •Vascular sensitivity to
(PGI2) endothelial -1 is not
• Endothelium altered during normal
• Increased during pregnancy
late pregnancy
and regulates
blood pressure
and platelet
function
 PULMONARY SYSTEM
– Diaphragm rises
about 4cm during
pregnancy
– Subcostal angle
widens
– Thoracic
circumference
increases about 6cm
– Diaphragmatic
excursion is actually
greater in pregnancy
 UNCHANGED INCREASED DECREASED
Respiratory rate is Airway conductance is Peak expiratory flow
essentially unchanged increased possibly as rates decline
a result of progressively as
progesterone gestation advances
Lung compliance is Amount oxygen Total pulmonary
unaffected by delivered into the resistance reduced
pregnancy lungs by the increased possible as a result of
tidal volume clearly progesterone
exceeds o2
requirements imposed
by pregnancy

Maximum breathing Total hgb mass Maternal

capacity and forced or arteriovenous oxygen
timed vital capacity difference is
are not altered decreased due to
increased total oxygen
carrying capacity
• ACID BASE EQUILIBRIUM
– Physiologic dyspnea
• increased tidal volume that lowers the blood PCO2
slightly, which paradoxically causes dyspnea.
– Progesterone :
• Lowers the threshold and increases the sensitivity
of the chemoreflex response to CO2
• Increased respiratory effort, reduction in PCO2
– To compensate for resulting respiratory
alkalosis, plasma bicarbonate levels decrease
from 26 to approximately 22mmol/L
– shift oxygen dissociation curve to the
left.
• increases the affinity of maternal hemoglobin
for oxygen, thereby decreasing the oxygen-
releasing capacity of maternal blood
– Slight pH increase
• increase in 2,3 diphosphoglycerate in maternal
blood which shifts the curve back to the right
– Reduced PCO2 from maternal hyperventilation aids
CO2 (waste) transfer from the fetus to the mother
while also facilitating O2 release to the fetus
URINARY SYSTEM
A. Kidney
- kidney size increases slightly during
pregnancy
- GFR and renal plasma flow increase
early in pregnancy
- elevated GFR persists until term, but
renal plasma flow decreases during
late
pregnancy
tests of renal function:
1. Serum creatinine: decreased from 0.7 
0.5 mg/dl
2. Urea Nitrogen: decreased from 1.2  0.9
mg/dl
3. URINALYSIS:
a. Glucosuria- may not be abnormal
b. Protenuria- Not evident during pregnancy
c. Albumin excretion is minimal and ranges
from 5 to 30mg/day
d. Hematuria- contamination during collection
B. Ureters
– Ureteral dilatation greater on the
right side
1. left ureter is cushioned by the
sigmoid colon
2. dextrorotation of the uterus
3. Right ovarian complex lies obliquely
over the right ureter
– Ureteral elongation and curvature
formation occurs due to distention
C. BLADDER
– Bladder trigone is elevated by >12 weeks:
• Increased uterine size
• Hyperemia
• Hyperplasia of bladder’s muscle and connective tissue
– Elevation of trigone causes thickening of posterior,
or intraureteric origin
– Increase in size and tortousity of its blood vessels
– Bladder pressure (primigravidas) increased from 8
cm H2O (early pregnancy) to 20 cm H2O ( at term)
– Absolute and functional urethral lengths increased
GASTROINTESTINAL SYSTEM
• GIT changes
– Appendix displaced upward and laterally
as the uterus enlarges and it may reach
the flank
– Gastric emptying time is unchanged
• Prolonged: During labor and administration
of analgesic agents
• General anesthesia: Regurgitation and
aspiration during delivery
– Pyrosis (heartburn)- reflux of acidic secretions
into the lower esophagus due to:
• Altered position of the stomach
• Decreased LES tone
• Intraesophageal pressures are lower compared to
intragastric pressures
– Gums may become hyperemic and softened
and may bleed when mildly traumatized as
with toothbrush
• Epulis of pregnancy
– Hemorrhoids are fairly common due to
constipation and elevated pressure in veins
below the level of the enlarged uterus
• LIVER
– INCREASED levels:
• Total alkaline phosphatase- almost doubles
• Total albumin
• Serum Globin
– DECREASED levels:
• AST
• ALT
• GCT
• Bilirubin
• Serum albumin
• GALLBLADDER
– Progesterone inhibits CCK- mediated smooth
muscle stimulation which impairs gallbladder
contraction
• Increased residual volume and stasis
• Increased bile cholesterol saturation
– Intrahepatic cholestasis in pregnancy
• high circulating levels of estrogen, which inhibit
intraductal transport of bile acid
– Pruritus gravidarum is due to retained bile
salts
 ENDOCRINE SYSTEM
• Pituitary Gland: GROWTH HORMONE
– Enlarges by approximately 135 %
– Not essential for maintenance of pregnancy
• First trimester- secreted predominantly from
maternal pituitary gland
• At 17 weeks AOG- placenta
– MATERNAL growth hormone
• Correlate positively with birthweight and negatively
with fetal growth restriction and uterine artery
resistance
– PLACENTA growth • PROLACTIN
hormone – Increases prolactin
• Secreted by level
syncitiotrophoblasts • Estrogen stimulation
increases the number
• Major determinant
of anterior pituitary
of maternal insulin lactotrophs
resistance after • TRH
midpregnancy • Serotonin
• Fetal growth – Inhibits prolactin
progresses in the secretion: Dopamine
complete absence (prolactin- inhibiting
of placental growth factor)
hormone
• Functions of prolactin:
– Ensure lactation
– Initiates DNA synthesis and mitosis of
glandular epithelial cell and presecretory
alveolar cells of the breast (early pregnancy)
– Increases the number of estrogen and
prolactin galactopoiesis, and production of
casein, lactalbumin, lactose and lipids
– Prevent fetal dehydration
• THYROID GLAND
– Thyroid hormone production
INCREASED by 40 to 100% to meet
maternal and fetal needs
• Thyroid Hormones
– INCREASED:
» Total serum thyroxine: at 6 to 9 weeks
(plateau at 18 weeks)
» Free serum T4- peak along with hCG levels
and return to normal
» Total triiodothyronine (T3)- up to 18 weeks
and plateau
• Thyroid – releasing Hormone
(TRH)
–Not increased
–Crosses the placenta and may
stimulate the fetal pituitary to
secrete thyrotropin
• TSH and hCG has identical a-
subunit
– hCG has intrinsic thyrotropic activity and
cause thyroid stimulation
• ADRENAL GLAND

INCREASED DECREASED
Cortisol DHEA-S
Aldosterone
Deoxycorticosterone
Androstenedione
Testosterone
MUSCULOSKELETAL SYSTEM
• progressive lordosis; characteristic
feature of normal pregnancy
 CNS
• MEMORY
– Pregnancy –related memory decline
• Transient and quickly resolved following delivery
– Decreased Mean Blood Flow in the middle and posterior cerebral
arteries
• EYES
– Corneal sensitivity is decreased
– Krukenberg spindles
• Brownish red opacities on the posterior surfaces of the
cornea
– Decreased in intraocular pressure
• Greater vitreous outflow