Maternal Physiology in pregnancy

Dr ERMIAS

Dr Ermias
R4

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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 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
 Goals
To understand the normal changes associated with pregnancy
The major maternal physiological adaptation to
pregnancy
1-Systemic changes:
-Blood volume homeostasis.
-cardio vascular system.
2-Respiratory changes.
3-urinary tract and renal function..
4-Reproductive organs.
6-endocrine changes.
Cardiovascular System

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• the heart rotates on its long axis, moving the apex
somewhat laterally, resulting in an increased cardiac
silhouette on radiographic studies, without a true change in
the cardiothoracic ratio
• 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 .
• Between weeks 10 and 20, plasma volume expansion
begins and preload is increased
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• Although true cardiomegaly is rare, physiologic
myocardial hypertrophy of the heart is
consistently observed

• Normal pregnancy induces no characteristic

electrocardiographic changes other than slight
left-axis deviation as a result of the altered heart
position.

• Left ventricular end-diastolic dimension increases

12%
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• left ventricular wall mass increases by 52%
(mild myocardial hypertrophy)

• atrial diameters increase bilaterally, peaking

at 40% above nonpregnant value.

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 Cardiac Output
• One of the most remarkable changes in pregnancy
is the tremendous increase in CO.
• CO increased significantly beginning in early
pregnancy, peaking at an average of 30% to 50%
above preconceptional values
• In twin gestations, CO incrementally increases an
additional 20% above that of singleton pregnancies
• CO peaks, most studies point to a range between
25 and 30 weeks

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• By term, the uterus receives 17% (450 to 650
mL/min) and the breasts 2%.
• The absolute blood flow to the liver is not
changed, but the overall percentage of CO is
significantly decreased.
• The decrease in CO in the supine position
compared with the lateral recumbent position
is 10% to 30%.
• CO is the product of SV and HR (CO = SV ×
HR), both of which increase during pregnancy
and contribute to the overall rise in CO.
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• An initial rise in the Heart rate occurs by 5
weeks’ gestation and continues until it peaks
at 32 weeks

• the maternal BP is decreased until later in

pregnancy as a result of a decrease in SVR that
nadirs midpregnancy and is followed by a
gradual rise until term

• The overall decrease in diastolic BP and MAP

is 5 to 10 mm Hg
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• Arterial pressure usually decreases to a nadir at 24 to 26 weeks and
rises thereafter.

• Diastolic pressure decreases more than systolic.

• BP is lowest in the lateral recumbent position, and the BP of the

right arm in this position is 10 to 12 mm Hg lower than the left arm

• Antecubital venous pressure remains unchanged during pregnancy

• However, in the supine position, femoral venous pressure rises

steadily, from approximately 8 mm Hg early in pregnancy to 24 mm
Hg at term

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• Pregnancy also alters normal heart sounds
• At the end of the first trimester, both
components of the first heart sound become
louder, and there is exaggerated splitting.
• The second heart sound usually remains
normal.
• Up to 80% to 90% of gravidas demonstrate a
third heart sound (S3) after midpregnancy
because of rapid diastolic filling.

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• Systolic ejection murmurs along the left
sternal border develop in 96% of pregnancies

• Diastolic murmurs have been found in up to

18% of gravidas, but their presence is
uncommon enough to warrant further
evaluation

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 The key physiological changes that occur
cardiac system
INCREASE DECREASE
blood volume systemic vascular resistance
(WHY)
cardiac output blood pressure
(30-50%)
stroke volume Pulmonary vascular resistance
10%
peripheral colloid osmotic pressure
vasodilatation
 Normal Changes That Mimic
Heart Disease
• Dyspnea is common to both cardiac disease and
pregnancy
• 75% of women experience it by the third
trimester.
• Unlike cardiac dyspnea, pregnancy-related
dyspnea does not worsen significantly with
advancing gestation
• Other normal symptoms that can mimic cardiac
disease include decreased exercise tolerance,
fatigue, occasional orthopnea, and chest
discomfort
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• Symptoms that should not be attributed to
pregnancy and need a more thorough
investigation include hemoptysis, syncope or
chest pain with exertion, progressive
orthopnea, or paroxysmal nocturnal dyspnea.
• Normal physical findings that could be mistaken
as evidence of cardiac disease include peripheral
edema, mild tachycardia, jugular venous
distention after midpregnancy, and lateral
displacement of the left ventricular apex

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 Effect of Labor and the Immediate
Puerperium
• greater increases in CO occur with labor and
in the immediate puerperium
• the CO increased 12% during the first stage of
labor.
• Second stage of labor, the CO during
contractions is 51%
• In the immediate postpartum period (10 to 30
minutes after delivery), CO reaches 80%.

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• In both vaginal and elective cesarean
deliveries, the maximal increase in the CO
occurs 10 to 30 minutes after delivery and
returns to prelabor baseline 1 hour after
delivery

• Over the next 2 to 4 postpartum weeks, the

cardiac hemodynamic parameters return to
near preconceptional levels.

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 RESPIRATORY SYSTEM
• Upper Respiratory Tract
-During pregnancy, the mucosa of the nasopharynx
becomes hyperemic and edematous with
hypersecretion of mucus due to increased
estrogen.
- These changes often lead to marked nasal
stuffiness; epistaxis is also common
-Because of these changes, many gravid women
complain of chronic cold symptoms.
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• Mechanical Changes
-The subcostal angle increases from 68 to 103
degrees.

-the transverse diameter of the chest expands

by 2 cm, and the chest circumference expands
by 5 to 7 cm.

- As gestation progresses, the level of the

diaphragm rises 4 cm

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 Pulmonary Function
• tidal volume and resting minute ventilation increase
significantly as pregnancy advances
• Peak expiratory flow rates decline progressively as
gestation advances .
• Lung compliance is unaffected by pregnancy, but
airway conductance is increased and total pulmonary
resistance reduced, possibly as a result of
progesterone.
• The maximum breathing capacity and forced or timed
vital capacity are not altered appreciably
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• Oxygen Delivery
-Increasing progesterone levels drive a state of
chronic hyperventilation, as reflected by a 30%
to 50% increase in tidal volume by 8 weeks’
gestation.

- In turn, increased tidal volume results in an

overall parallel rise in minute ventilation,
despite a stable respiratory rate (minute
ventilation = tidal volume × respiratory rate).
-
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Functional residual capacity (FRC) is our “air tank” for apnea.

www.picture-newsletter.com/scuba-diving/scuba... from Google images

Pregnant Mother has a smaller “air tank”.

Non-pregnant
woman
The rise in minute ventilation, combined with a
decrease in FRC(20-30%), leads to a larger than
expected increase in alveolar ventilation (50%
to 70%).

-Chronic mild hyperventilation results in increased

alveolar oxygen (PAO2) and decreased arterial
carbon dioxide (PaCO2) from normal levels

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 HEMATOLOGIC CHANGES
• Plasma Volume and Red Blood Cell Mass Maternal blood
volume begins to increase at about 6 weeks’ gestation.

• Thereafter, it increases progressively until 30 to 34

weeks and then plateaus until delivery.

• The average expansion of blood volume is 40% to 50%

• Erythrocyte mass also begins to increase at about 10

weeks’ gestation
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• Without iron supplementation, RBC mass
increases about 18% by term

• Supplemental iron increases RBC mass

accumulation to 400 to 450 mL, or 30%.

• Because plasma volume increases more than

the RBC mass, maternal hematocrit falls.

• This so-called physiologic anemia of pregnancy

reaches a nadir at 30 to 34 weeks
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 Iron Metabolism in Pregnancy
• Iron absorption from the duodenum is limited to its
ferrous (divalent) state, the form found in iron
supplements.

• Ferric (trivalent) iron from vegetable food sources must

first be converted to the divalent state by the enzyme
ferric reductase.

• If body iron stores are normal, only about 10% of

ingested iron is absorbed
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• The iron requirements of gestation are about
1000 mg.

• This includes
-500 mg used to increase the maternal RBC mass
(1 mL of erythrocytes contains 1.1 mg iron)
- 300 mg transported to the fetus
- 200 mg to compensate for the normal daily
iron losses by the mother

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 Leukocytes
• The peripheral white blood cell (WBC) count rises
progressively during pregnancy.
• During the first trimester, the mean WBC count is
8000/mm3, with a normal range of 5110 to
9900/mm3.
• During the second and third trimesters, the
mean is 8500/mm3, with a range of 5600 to
12,200/mm3.
• In labor, the count may rise to 20,000 to 30,000
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 Platelets
• the average platelet count was decreased
slightly during pregnancy to 213,000/L
compared with 250,000/L in nonpregnant
control women.

• They defined thrombocytopenia as below the

2.5th percentile, which corresponded to a
platelet count of 116,000/mL

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 Coagulation System
• Pregnancy places women at a fivefold to six fold
increased risk for thromboembolic disease.
• markedly increased, including factors I, VII, VIII, IX, and
X.
• Factors II, V, and XII are unchanged or mildly increased
• levels of factors XI and XIII decline
• significant decrease in the levels of total and free
protein S from early in pregnancy but to have no effect
on the levels of protein C and antithrombin III

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 Urinary System
• The kidneys enlarge during pregnancy by 1 cm.

• The increase in urinary dead space is attributed

to dilation of the renal pelvis, calyces, and
ureters.

• Pelvicaliceal dilation by term averages 15 mm

(range, 5 to 25 mm) on the right and 5 mm
(range, 3 to 8 mm) on the left.
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• The right ureter is almost invariably dilated
more than the left

• From midpregnancy on, an elevation in the

bladder trigone occurs, with increased
vascular tortuosity throughout the bladder

• This can cause an increased incidence of

microhematuria.

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 RENAL HEMODYNAMICS
• By the end of the first trimester, GFR is 50%
higher than in the nonpregnant state
• The creatinine clearance in pregnancy is greatly
increased to values of 150 to 200 mL/min
(normal,120 mL/min)
• Serum creatinine decreases from a nonpregnant
level of 0.8 mg/dL to 0.5 mg/dL by term
• Values of 0.9 mg/dL suggest underlying renal
disease and should prompt further evaluation
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 Urinalysis

• Glucosuria during pregnancy may not be abnormal

• Proteinuria normally is not evident during

pregnancy except occasionally in slight amounts
during or soon after vigorous labor

• Urinary protein and albumin excretion increases

during pregnancy, with an upper limit of 300 mg
of proteinuria.
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 Gastrointestinal Tract
• As pregnancy progresses, the stomach and intestines
are displaced by the enlarging uterus
• The appendix, for instance, is usually displaced upward
and somewhat laterally as the uterus enlarges. At
times, it may reach the right flank
• Pyrosis (heartburn) is common during pregnancy and is
most likely caused by reflux of acidic secretions into
the lower esophagus
• The gums may become hyperemic and softened during
pregnancy (epulis gravidarum)
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Appetite
• Most women experience an increase in
appetite throughout pregnancy.
• In the absence of nausea or “morning
sickness,” women eating according to appetite
will increase food intake by about 200
kcal/day by the end of the first trimester.
• The recommended dietary allowance calls for
an additional 300 kcal/day

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Mouth
-The pH and the production of saliva are probably
unchanged during pregnancy.

-Ptyalism, an unusual complication of pregnancy,

most often occurs in women suffering from
nausea and may be associated with the loss of 1
to 2 L of saliva per day

-the gums swell and may bleed after tooth brushing

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• Pregnancy causes a decreased risk for peptic
ulcer disease but, at the same time, causes an
increase in gastroesophageal reflux disease
and dyspepsia in 30% to 50% individuals

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• Liver
-Unlike in some animals, there is no increase in
liver size during human pregnancy
-Total alkaline phosphatase activity almost
doubles
-The concentration of serum albumin decreases
during pregnancy
-. By late pregnancy, albumin concentrations may
be near 3.0 g/dL compared with approximately
4.3 g/dL in nonpregnant women
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• Gallbladder
-During normal pregnancy, the contractility of
the gallbladder is reduced, leading to an
increased residual volume

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 Gastrointestinal
• Slowed GI motility
– Constipation, early satiety
• Relaxation of LES
– GERD
• Nausea / vomiting
– Often proportional to HCG level
• Liver / gallbladder
– Biliary stasis, cholesterol saturation
• More stones
– Coagulation factors
– Increased binding proteins (thyroid, steroid, vitamin D)
 Musculoskeletal System
• Progressive lordosis is a characteristic feature
of normal pregnancy.

• The sacroiliac, sacrococcygeal, and pubic joints

have increased mobility during pregnancy

• The bones and ligaments of the pelvis undergo

remarkable adaptation during pregnancy
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• Lordosis
– keep center of gravity over the legs
– back pain…
• Relaxin
– relaxation of the pubic symphysis and sacroiliac
joints
• facilitates vaginal delivery but may lead to discomfort
• Implications
– unsteadiness of gait and trauma from falls
 Skin
• Hyperpigmentation
• Melasma: “mask of pregnancy”
– elevated e2 and p4
• Nevi may darken, enlarge or show increased activity
– rapidly changing nevi should be excised
• Hairs in telogen phase decrease in late pregnancy
– increases after delivery
– hair loss 2-4 mos pp
– re-growth in 6-12 mos
• Masculinization of the skin rarely occurs
– evaluate for possible luteomas of pregnancy (which
regress after delivery)
Centrofacial type of melasma

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telogen effluvium

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 Eyes

• Most pregnant women demonstrate a

measurable but slight increase in corneal
thickness
• Brownish-red opacities on the posterior
surface of the cornea—Krukenberg spindles—
have also been observed with a higher than
expected frequency during pregnancy

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 Central Nervous System
• Women often report problems with attention,
concentration, and memory throughout
pregnancy and the early postpartum period.
• Pregnancy does not appear to impact
Cerebrovascular auto regulation

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 Sleep

• Beginning as early as about 12 weeks and

extending through the first 2 months
postpartum, women have difficulty going to
sleep, frequent awakenings, fewer hours of
night sleep, and reduced sleep efficiency .

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 REFERENCES
• Gabbe 6th ed
• William 23rd ed
• UpToDate 21.2 ed

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 Hope not to have overloaded
you !

06/10/2011
THANK YOU

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