Physiological changes in

pregnancy

-Systemic Changes
• Pregnancy represents a serious challenge to all
body systems

• Changes essential to support and protect the

developing fetus and also to prepare the mother
for parturition.

• No major problems for healthy women

• Significant strain on already compromised

systems, threatening the lives of both mother
and fetus.
• Optimize outcomes in complex, high-risk
obstetric patients.

• Earliest observed changes - peripheral

vasodilatation

• Causes fall in systemic vascular

resistance and triggers physiological
changes in the CVS and renal systems
 Cardiovascular physiology
1.Blood volume

• Plasma increases rapidly up to 10% above baseline by 7

weeks of gestation

• plateaus by 32 weeks at 45–50%.

• Red cell mass expansion also occurs but to a lesser degree

• Dilutional anemia of pregnancy

 Non Pregnancy percentage
pregnant (term)
Plasma 2600ml 1250ml 50%
volume
RBC volume 1400ml 240ml 18%(without fe )
400ml 30%(with fe)
haematocrit 38% 32%

Decrease blood viscosity ensures optimal gaseous exchange between

maternal and fetal circulation

Protection against adverse effect of blood loss during delivery

Decrease viscosity –decrease resistance to flow of blood increase in

cardiac output without much increase in cardiac work load.
2.Immunological &leukocyte functions

• Decrease in humoral and cell-mediated immunity

to accommodate foreign semiallogeneic fetus
• Neutrophilic chemotaxis/adherence decrease
from 2nd trimester
• Cervical mucus IgG,IgA higher ~10fold
• Leucocyte count 5000-12000/microlit
• ESR elevated
• Complement C3 and C4elevated during 2nd and
3rd trimester
3)COAGULATION

• Coagulation cascade is in activated state

• Increase in all clotting factor except XI and XIII

increase level of fibrinogen-by 50%~450mg/dl

• Fibrinolytic activity is reduced

• Slight decrease in platelet counts,

• clotting time uneffected

Heart rate
• increases by up to 20% in the third
trimester
• problem in rate-dependent conditions such
as mitral stenosis
Cardiac output
• Increase by 40-50% -begins at 5th wk
• reaching a plateau at 32 weeks
• Decrease systemic vascular resistance
• Increase in heart rate and stroke volume

Blood pressure
• Decrease peripheral resistasnce- ↓dBP
• Rises pre-pregnancy in 3rd trimester
• Blood flow in legs retarded...enlarged uterus
compressing IVC,
-responsible for pedal edema
-development of varicose veins in legs and vulva
-predispose to DVT

• SUPINE HYPOTENSION:
Enlarged uterus compression venous system
impairs blood return from lower
extrimity...decreased cardiac filling...decrease
cardiac output..supine hypotension syndrome
Heart size
• Eccenteric hypertrophy
• Ventricular chamber size increase
• Heart is pushed upward and outward ,left rotation-LAD
• Slight pericardial effusion
• Splitting & loud first heart sound
• Loud third heart sound
• Systolic murmur in 90%

Central hemodynamics
No significant change in CVP,MAP, PCWP
 Intrapartum CVS changes
A.First stage of labor
With contraction, 300-500ml blood expelled
Increase CO and BP
Depends on maternal position and pain

B.Second stage of labor

Bearing down effort- diminished venous return
↓stroke vol so ↑HR to maintaine CO
 Post partum
• Sudden ↑blood vol and CO
• Mobilization of extravascular fluid into circulation
• Hazardous time for cardiac patient-
 Renal system
• Increased renal size- 1cm greater in radiographs

• Dilation of pelves,calyces resembles hydronephrosis on

and ureters usg and IVP

 Increase renal hemodynamics GFR and renal plasma flow

increase -50%
Serum creatinine and urea nitrogen values decrease
Protein, amino acid, glucose excretion increase
Creatinine >0.8- suspicious
• Changes in acid-base renal bicarbonate threshold
metabolism decreases

Serum bicarbonate and Pco2 are 4-5meq/L & 10mmhg low

A Pco2 -40mm hg represents CO2 retention.

• Renal water handling Serum Osmolality decreases

10mOsm/L
• URETER
-dilatation of ureter above pelvic brim occurs due
to enlargement of uterus compressing them at
pelvic brim & due to effect of progesteron
-Right>left
-elongation,kinking and outward displacement of
ureter
• BLADDER
-marked congestion with hypertrophy of muscles

-increase frequency of micturition 6-8 wks

subsides after 12 wks,in late pregnancy again
frequency due to pressure on bladder as
presenting part descends

-stress urinary incontinence occurs-weak sphincter

 Respiratory system
• Transverse diameter thoracic cage-increase2cm
• 0xygen consumption increases 45ml/min
• R.R is changed a little
• Tidal volume increases from 500 to700ml,minute
ventillatory vol increases by 40%,minute o2
intake increases
• physiological dyspnoea -occurs due to increase
in tidal volume that lowers blood Pco2
• Increase respiratory effort –mediated by
progesteron
• FRC(ERV+RV)decreses by 500ml
• RV decreases
• Lung compliance uneffected
• Total pulmonary resistance uneffected
 GIT
• Gums become soft,congested

• Pyrosis (heart burn)-decrease in tone of

lower esophageal sphincter

• Muscle tone and motility of entire GIT

diminished--bloating and constipation

• Gastric emptying time unchanged

• LIVER-alkaline phosphotase-activity doubles-
increase is due to heat stable placental alkaline
phosphatase isoenzymes

• AST/ALT/gamma GT/bilirubin level

DECREASES

• Gall bladder contractility reduced- increase

serum cholesterol –increase stone formation
 Endocrine system
Thyroid
• Iodide deficiency due to inadequate intake and increased
renal clearance.
• Significant but reversible hormone-driven changes
• Moderate enlargement due to glandular cellular and
vascular hyperplasia.
• TSH falls in the first trimester, returning slowly to normal
by term.
• Circulating levels of free T3 and T4 remain fairly
constant throughout pregnancy
• Changed Thyroid function tests
(1) Oestrogen-mediated increase in thyroid
globulin binding;

(2) Thyroid stimulation due to effect of HCG,and

(3) Reduced availability of iodide due to feto-

placental losses and increased renal clearance
Pituitary
 Increasing in size by 135%
 Prolactin levels increase throughout pregnancy,
peaking at term

Parathyroid hormone
Concenttration decreases during 1st trimester then
progressively increase throughout pregnancy
-increase level due to low calcium concentration
-estrogen block action of PTH on bone resorption
-net result is physiological hyperparathyoidism
• Calcitonin levels higher than in nonpregnant
state

Adrenal glands
-cortisol level is increased due to decrease
metabolic clearance
-aldosterone level increased,by 3rd trimester
1mg/day.
CHANGES IN EYES
• Decrease in intraocular pressure
• Corneal senstivity decreases
• Increase in corneal thickness due to edema
• Transient loss of accomodation
 Metabolic changes
• Total pregnancy energy demand -80,000kcal.
• Weight gain:12.5 kgs

Water metabolism
-water retention 6.5lit

-3.5lit fetus/placenta/amniotic fluid,3 lit blood vol,uterus and

breasts

-Accumulation of fluid in lower extremities-pedal edema-

-increased venous pressure below the level of
uterus/decrease in interstitial colloid osmotic pressure
Protein metabolism
Total plasma protein increase 180 to 230gm,

-haemodilution leads to fall 7 to 6gm%

-A:G ratio decreased to 1:1. from 1.7:1