Physiologic changes of

pregnancy

By Dr Bereket .W, OB/GYN –Sp

June 6/2022
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• The anatomical, physiological, and biochemical adaptations to
pregnancy are profound.
• Many of these remarkable changes begin soon after
fertilization and continue throughout gestation, and most occur
in response to physiological stimuli provided by the fetus and
placenta
• Physiological adaptations of normal pregnancy can be
misinterpreted as pathological but can also unmask or worsen
preexisting disease.

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 Reproductive truct
• In the nonpregnant woman, the uterus weighs approximately 70 g and a
cavity of 10 mL or less.
• During pregnancy, the total volume of the contents at term averages
approximately 5 L but may be 20 L or more.
• By the end of pregnancy, the uterus has achieved a capacity that is 500
to 1000 times greater than in the nonpregnant state ant it weighs nearly
1100 g.
• During pregnancy, uterine enlargement involves stretching and marked
hypertrophy of muscle cells, whereas the production of new myocytes
is limited.
• By term, the myometrium is only 1 to 2 cm thick. The uterus is
changed into a muscular sac with thin, soft, readily indentable walls
through which the fetus usually can be palpated.
• Uteroplacental blood flow 450-650ml/min

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.cont..

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Cervix

• As early as 1 month after conception, the cervix begins to undergo

pronounced softening and cyanosis.
• These changes result from increased vascularity and edema of the entire
cervix, together with hypertrophy and hyperplasia of the cervical glands.
• Although the cervix contains a small amount of smooth muscle, its major
component is connective tissue
• There is marked softening of the cervix(Goodell’s sign) as early as 6weeks
Ovaries
• Ovulation ceases during pregnancy, and maturation of new follicles is
suspended. The single corpus luteum found in pregnant women functions
maximally during the first 6 to 7 weeks of pregnancy—4 to 5 weeks
postovulation

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Vagina
– Edematous,vascular and bluish hue (Jacquemier
sign/chadwick sign)
– PH decrease 3.5-6
Breast
Increased size of the breasts becomes evident even in early
weeks. (estrogen and progestron)
Nipples become larger,erectile and deeply pigmented
Montgomery’s tubercles (5-15)
Colostrum -12weeks

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 skin

• Chloasma gravidarum or
pregnancy mask

• Linea nigra-brownish black

pigmented area
melanocyte stimulating
hormone
• Striae gravidarum

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Weight gain

• The products ofconception

—the placenta, fetus, and
amniotic fluid —comprise
approximately 35% to 59%
• The average weight gain in
pregnancy is 10 - 12 kg.
• The increase occurs mainly
in the second and third
trimester at a rate of 350 -
400 gm/ week

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 Cardiovascular system
Heart
 Displaced upward and to the left
 Increased cardiac silhouette and straightening of the left-sided
heart border and increased prominence of the pulmonary
conus
 Eccentric cardiac hypertrophy
 No change is evident in the cardiothoracic ratio

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 Cardiac output
Cardiac output
̶30-50% increase above the preconceptional value
• At 5 weeks 10% raise
• By 12weeks 34-39% raise
✔ 75% of the total raise in pregnancy has already occured at
12 weeks
• Peaks in between 25 and 30 weeks
• Twins 20% above that of singletons
• Most of the increase in COP directed to uterus, placenta and
breasts

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Effect of position COP

• Knee-to-chest position
• Standing
• Supine
• Sitting
• Lateral

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Arterial BP and Systemic Vascular Resistance
• SVR
̶Decreased in pregnancy
• Why?
 1. Progesterone mediated smooth muscle relaxation
 2. Vasorelaxation via nitric oxide mediated pathway
 3. Blunting of vasoreponsiveness to vasoconstrictors such as
Angiotension-II and Norepinephrine
• Arterial BP
̶Falls in pregnancy
SBP falls by 5-10mmHg
DBP falls by 10-15mHg

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Venous pressure
̶ Remains unchanged in upper extremities
̶Rises progressively in the lower extremities
• Femoral venous pressure 10cmH2O at 10weeks raises to
25cmH2O at term
✔ Elevated femoral vein pressure leads to
o Edema
o Varicose vein
o Hemorrhoids
o DVT

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• Normal changes that mimic heart diseases
̶ Dyspnea
• Pregnancy related
1. Starts at 20 weeks
2. 75% experience it by 3rd trimester
3. Doesnt worsen with advancing gestation
4. Doesnt occur at rest
̶ Other changes
• Decreased exercise tolerance
• Fatigue
• Occasional orthopnea
• Syncope
• Chest discomfort

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• Changes that need investigation
̶ Hemoptysis
̶ Syncope
̶ Chest pain
̶ Progressive orthopnea
̶ PND
• On physical exam
̶ Peripheral edema
̶ Mild tachycardia
• Heart rate increased 15-20 beats above the non-gravid
state)
̶ Jugular venous distension after midpregnancy
̶ Lateral displacement of the left ventricular apex

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• Changes in heart sounds
̶Become loud
̶Exagerated splitting
̶S3 gallop
̶S4
-Systolic ejection murmur
̶Diastolic murmur
• Suspect heart pathology
̶Continuous murmur

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• Effects of labor on COP
̶12% during the first stage
̶End of first stage of labor 51% above baseline term
pregnancy levels
 ECHO
increased left atrial and ventricular diameters
 ECG –left axis deviation
 CXR-straightening of left heart border
NB- none of the arrhythmias are normal during pregnancy,rather
their presence indicates heart disease during pregnancy

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 Hematologic changes
• Plasma Volume and Red Cell Mass
̶ Plasma volume
• Physiologic advantages?
✔ Protective for possibility of hemorrhage
✔ Prevents hypotension in the dilated CVS
• Increases steadily till 30 weeks and then plateus
• Average expansion 40-50%
Red cell mass
• Increases steadily till delivery
• Without iron supplementation 18%
With iron supplementation 30%

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• Total iron requirments in pregnancy
̶1000 mg
 500 mg -used to increase maternal RBC

 300mg- transported to the fetus

200mg –daily loss by the mother
 Platelets
̶Mild decrease in platelete count during pregnancy
 Leucocystes
̶There is an increase in leucocyte count in pregnancy
• Why?
✔ Estrogen and cortisol level raise in pregnancy and has
an effect on
WBC production
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• Pregnancy-induced hypervolemia?
 it meets the metabolic demands of the enlarged uterus and
its greatly hypertrophied vascular system
 it provides abundant nutrients and elements to support the
rapidly growing placenta and fetus
 It protects the mother, and in turn the fetus, against the
deleterious effects of impaired venous return in the supine
and erect positions
 it safeguards the mother against the adverse effects of
parturition-associated blood loss

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Changes in total blood volume and its components

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 Coagulation system

• Platelets : (controversial)
• Fibrinogen : 50 % to 300-600 mg/dl
• Factor VIII : tripled
• Factor VII & factor X : doubled
• Factor XI & factor XIII : slight decreased
• Fibrinolytic activity : decreased
• Therefore pregnancy is a hypercoagulative state.
• Increased risk of venous thromboembolism both during
pregnancy and the puerperium.
• The fibrinolytic activity is depressed
• The risk of thromboembolism is increased by approximately 2
times during pregnancy and by 5.5 times during the puerperium.

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 Immunology
• Must adapt to accept ‘allograft’
• Immune response altered, but not deficient
• Modulates away from cell-mediated cytotoxic effects
-Progesterone effect
-NK cells decrease by 30%
• Enhanced humoral / innate immunity
Immunoglobulins still active
IgG crosses placenta
• More susceptible to CMV, HSV, Varicella, Malaria
• Decrease in symptoms of some autoimmune disorders

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 Respiratory system
• Elevation of the diaphragm by 4 cm.
• Total lung capacity is reduced by 5%
• Diaphragmatic excursion is increased by 1–2 cm
• Total pulmonary resistance is reduced
• The subcostal angle increases from 68° to 103°, the transverse
diameter of the chest expands by 2 cm and the chest
circumference increases by 5–7 cm.
• The mucosa of the nasopharynx becomes hyperemic and
edematous. This may cause nasal stuffiness and rarely epistaxis.
• A state of hyperventilation occurs during pregnancy leading to
increase in tidal volume and therefore respiratory minute volume
by 40% It is probably due to progesterone acting on the
respiratory center and also to increase in sensitivity of the center
to carbon dioxide. The woman feels shortness of breath
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• Lung volume and pulm functions
 Tidal volume increases by 30-40%
 Expiratory reverse vol decreases by 20%
 Vital capacity and resp rate are unchanged
 Minute vol increases by 30-40%
• Gas exchange
  Increased PAO2 and PaO2
 Increased PACO2 and PaCO2
  PH is maintained normal (7.4-7.45)
 Serum Bicarbonate is decreased

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 Urinary system
Anatomic changes
• ̶ Kidneys- increase in size by 1cm
reasons –increased renal vasculature
-increased interstitial volume
-increased urinary dead space
Glomerular filtration rate (GFR) and renal plasma flow increase
early in pregnancy.
The GFR increases as much as 25 percent by the second week
after conception and 50 percent by the beginning of the second
trimester

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• Pelvicalyceal dilitation
• Reasons?
✔ Mechanical compression by uterus and ovarian venous
plexus
✔ Smooth muscle relaxation by progesterone
-Right side 5-25MM
-Left side 3-8mm
Consequences of dlilation
̶Increased risk of infection
̶Makes urinary radiograph interpretation difficult

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Renal hemodynamics
• ̶Increased
• Reason
✔ Nitric oxide and relaxin levels are increased in pregnancy
• ̶Effective renal plasma flow 75%
• Serum creatinine,BUN,uric acid –decrease
• Renal Tubular Function and Excretion of Nutrients
̶Glucose
• Excretion increases
• Glycosuria
✔ Can be normal in pregnancy
If repetative -screen for GDM
̶Proteinuria
• Excretion increases
• Normal upper limit 300 mg per 24 hours
̶Ca2+ and amino acids excretion increases
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 GIT
• Appetite increase –RDA (300Kcal/day)
• Blunted sense of taste
Pica –bizare behavior for strange foods
-clay,starch,toothpaste and ice

Mouth-PH and production of saliva unchanged during pregnancy

Ptyalism –excessive production of saliva per day(1-2) litres
-linked to nausea
Gingivitis of pregnancy
Periodental disease

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Stomach
̶Smooth muscle relaxing effects of progesterone and estrogene
• Decreased tone and motility of the stomach
• Decreased gastroesophageal sphincter
̶Increased (delayed) gastric emptying
̶Pregnancy reduces PUD
1. Placental histamines increased
2. Increased gastric mucin production
3. Decreased acid secretion
4. Immunologic tolerance of H.pylori

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GERD increased in pregnancy
1. Esophageal dysmotility
2. Gastric compression by uterus
3. Decrease in gastroesphageal sphincter
4. Estrogen increase gastric acid reflex
Intestines
̶Decreased motility
• Why?
✔ Smooth muscle relaxing effect of progesterone
✔ Estrogen induced neuronal synthesis of nitric oxide
̶Small bowel -absorbtion
• Unchanged
• Exception
✔ Fe and Ca2+
̶large bowel –absorbtion
• Increased H20 and Na+
Constipation
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 liver
• Size is unchanged
• Many of the clinical signs associated with liver disease are
seen during pregnancy
 Spider angioma
 Palmar erythema
 Decreased serum albumin
 Increased alkaline phosphates
 Increased cholesterol level
• Bilurbin, ALT, AST are unchanged

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Gall bladder
̶Pregnancy favors formation of gallstones
• Increased gastric emptying time
• Increased cholesterole production
• Decreased chenodeoxycholic acid
̶10% of pregnant mothers have gallstones
• Most of them do not require surgery

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Nausea and vomiting of pregnancy
• Nausea and vomiting (morning sicknes) complicates 70% of
pregnancies
• Onset is b/n 4-8 week continuing up to 14-16 wks
• Cause is not well understood
– Relaxation of smooth muscle, elevated HCG and steroid
Hormones may play a Role.
Treatment is mainly supportive
– Reassurance
– Psychological support
– Avoidance of food triggering vomiting
– Frequent small foods

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Hyperemesis Gravidarum
Is a more pernicious form of nausea and vomiting associated
with
– Weight loss
– Ketonemia
– Electrolyte imbalance
– Dehydration and
– Possibly hepatic and renal damage
• Daignosis is by exclusion
• Hospitalization is usually required with
– Parentral infusion for fluid and electrolyte replacement and
calorie.
– Use of ant emetics

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• Pancreas
Pregnancy has a diabetogeenic effect
Carbohydrate metabolism –increased peripheral resistance
against insulin
-Pregnancy hormones Human placental lactogen, cortisol,
estrogen, progesterone and glucocrticoids

• The Pituitary
-Oxytocin, ADH, ACTH, thyrotropin, prolactin, and MSH
all increase
MSH: linea nigra, chloasma gravidarum, and
pigmentation around the umbilicus

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Thyroid Function
• Gland enlarges in many - GFR/iodine excretion and
decrease in plasma anorganic iodide levels
• Increased TBG (via liver) - placental estrogen synthesis and
secretion which binds more thyroxine (T4)
• Increased total T4 and T3
free levels unchanged; bound/inactive fraction rises
• HCG suppresses TSH because of its activity

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 CNS

• Memmory
• Eye
• Sleep

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 Other adaptations

• “I can’t see my feet!!!”

Altered center of gravity
Altered gait
Greater joint laxity
Widening of symphysis pubis
Affects other joints
Thorax; widened costovertebral angle
• Fatigue / somnolence

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 Pregnancy – not a disease

• Profound changes in physiology and anatomy

• Affects most organ systems
• Can dramatically impact disease states, susceptibility, and
treatment
• Almost all of us will encounter and treat pregnant women
Even if you don’t know it
• Under-appreciation of changes will lead to suboptimal
treatment or outright mistakes

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thanks!!

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