OM

8 AM, 12/12/2006
2ND MBBS
TUE

Biochemical changes in Pregnancy

1
 Expectant mother ­-- more than one patient

Role of laboratory tests -

1. detection
2. evaluation
3. monitoring of pregnancy-for: normal / abnormal
Common tests- maternal blood
• Chorionic Gonadotropin (CG)
• hematocrit + Blood type
• glucose tolerance test
Screening tests: maternal serum-Triple test
1.  - fetoprotein (AFP)
2. Chorionic Gonadotropin (CG or hCG)
3. Unconjugated estriol (uE3)
Other tests:
• fetal lung maturity test
• amniotic fluid bilirubin
2
 Human Pregnancy:-Embryonic & fetal development; Role of
placenta; Effect of pregnancy on mother; Importance & composition of
AF

A. Embryonic and fetal development

280 days or 40 wks from 1st day of LMP

EDC or expected date of confinement [anticipated date of birth]

Trimesters – 13 wks each: 1st 0–13 ---------- 2nd 13–26 ---------- 3rd 26wks – term
OR 1st 0–12 ---------- 2nd13–28 ---------- 3rd 29–40 wks
Conception on day 14, fertilization in fallopian tubes→ zygote → morula → blastocyst
with yolk sac, implants into uterine wall on 5 th day after fertilization → → embryo
nourished by placenta→ cavity (amnion) with liquor amnii (amniotic fluid), protects
embryo → organogenesis → →
at 10 wks – fetus
at 13 wk – 13 gm -8 cm

* II trimester - rapid fetal growth - 700gm and 30cm

fetal organs begin to mature

* III trimester - fetal organs finish maturing

growth decelerates - 3200gm and 50gm

*Term: 37- 42 wks- normal labour & birth

3
 Corpus luteum

• After implantation- hCG and possibly hPL maintain the

growth and function of CL.

• Corpus luteum (CL)- secretes:

Progesterone, 17- α hydroxy progesterine, oestradiol
and androstenedione.

• CL secretes 40mg of progesterone per day.

• Function of CL is essential to maintain early pregnancy.

• At 6-8 weeks, transfer of functions of CL to Placenta.

(new endocrine
organ)
4
 B. The role of placenta

- Keeps maternal and fetal circulation separate

- Nourishes the fetus
- Eliminates fetal waste
- Produces several protein and steroid hormones vital to pregnancy

Placental hormones:
Steroids Hormones- Progesterone,Estradiol, estrone, estriol

Protein Hormones- hCG, hPL, ACTH, GnRH, CRF, Somatostatine, Inhibin,

Relaxin, ≈20 preg. specific proteins [Schwanerschaft’s protein]
Relaxin [peptide hormone mainly by corpus luteum, ovary but also produced by placenta and decidua]

Placental hormones:
- mostly in maternal circulation
- increases with increase in placental mass e.g. PL (but CG is an
exception, maximum at end of Ist trimester)

5
 Diagnostic value of Placental hormones

• Diagnosis of pregnancy-
hCG in plasma- RIA

• Follow up-
Trophoblastic tumours- β -subunit of hCG- RIA: H
mole, Choriocarcinoma

• Detection of function of feto-placental unit-

placetal insufficiency and status of fetus-in-utero: HPL and
Oestriol

6
 Chronic Gonadotropin [CG]–

• hCG or HCG [human CG]– old terminology, now k/a CG only

• Glycoprotein, Mol. Wt 38,000, produced by syncytiotrophoblast
of placenta
• Heterodimer of non-identical, non-covalently bound  [92 aa] and
 [145 aa] subunits
• Clearance - hepatic – 2 ml/ min/ m2
renal – 4 ml/ min/ m2

• Maintains function of corpus luteum – 1st six wks

• Half life- 24 hours
• Like other glycoprotein hormones (hLH, hTSH and hFSH), hCG
contains two different subunits, an  and a  -chain.
• The primary structures of the - subunits of these hormones are
virtually identical, while their - subunits, responsible for the
immunological and biological specificity, are different. Thus a
specific determination of hCG can only be made by the
determination of its ß component 7
Function of CG :
• Maintenance of Corpus Luteum till 6 weeks of pregnancy
• Acts as a stimulus for secretion of Progesterone by corpus
luteum, which in turn prevents preg loss by stopping
menstruation
• Stimulates leydig cells of male fetus to produce testosterone in
conjunction with fetal pituitary gonadotropins- development of male
external genitalia
• Immunosuppressive activity- inhibit maternal processes of
immunorejection of fetus as a homograft

Level of CG- [non-pergnant level- below 1 m IU/ml]

RIA detects: 8-9 days following ovulation
Blood and urine values reach maximum levels 100 IU/ml – 200
IU/ml [100,000 m IU/ml – 200,000 m IU/ml] between 60 – 70 days
of pregnancy- then falls – 10-20 IU/ml between 100-130 days –
thereafter constant throughout pregnancy with slight secondary
peak at 32 weeks 8
 Clinical significance of hCG
*Diagnosis and dating of Pregnancy –
• Confirmation of Pregnancy beyond 1st week.
• Serial determinations for diagnosis in the abnormalities of pregnancy.
• Diagnosis and Monitoring of gestational trophoblast tumor or other hCG
producing tumors.

For date -first 8 wk of pregnancy rise in CG -geomatrically in maternal serum.

Detectable amount (5U/L) are present 8 to 11 day after conception, which
is in the 3rd week pregnancy measured by LMP.
25U/L on first day of missed period

Peaks at 08 to 10 week i.e. even ≥ 100 000 U/L [10 000 m IU/ml or 100 IU/ml].
Then declines in serum and urine and by end of second trimester 90%
reduction from peak- levels constant during third trimester.

Twins - 1.84 X URL.- approx double CG levels

At 16 week predicts Down’s syndrome – 2.04 X higher
Better double test (AFP + CG) or triple test (AFP + CG + uF3)

9
• Normal serum hCG levels during pregnancy are estimated to be :

During the first six weeks of pregnancy, serum hCG concentrations

have a doubling time of approximately two days.
After delivery, hCG levels fall rapidly and disappear completely after
a few days.

Slow rate of increase of hCG -in ectopic pregnancies

very high hCG concentrations - choriocarcinoma, trophoblastic or
nontrophoblastic neoplasms or hydatiform moles.

Ectopic hormone production, associated with the metastatic breast

cancer, tumours of the liver, stomach, lung, and uterus - often 10
results in the elevated hCG concentration both in men and in non
Test Test Time Positive on
Sensitivity taken

Immunological tests [Urine] 0.5 – 1 [IU/ml] 2 min. 2 days after the first
Agglutination inhibition test (URINE) missed period
[Latex test]
0.2 [IU/ml] 2 min. 2 – 3 days after the
Direct latex agglutination test (URINE) missed period

Two-site sandwitch 30-50 m IU/ml 4 - 5 min. On the Ist day of the

immunoassay [membrane (URINE) missed period
ELISA or Card tests] [28 th day of cycle]
ELISA 1 – 2 m IU/ml 2 – 4 hr 5 days before the missed
(Serum) period

RIA [β-subunit] 0.002 IU/ml 3 – 4 hr 8-9 days after ovulation

[m IU ?] [25 th day of cycle]

IRMA [immuno radiometric 0.05 m IU/ml 30 min As ELISA

assay] (Serum)
11
 Placental Lactogen (hPL)
– Homologus to GH; also k/a human chorionic somatomammotropin [HCS]
– Index of placental mass. Plasma conc of hPL ∞ Placental mass
– Level- detected at 5th wk- rises from 5μg/ml to 25 μg/ml until 36 weeks
– 1 to 2 gm/day near term- largest of any known hormone
Functions:
– Lactogenic, metabolic, somatotropic luteotropic, erythropietic and
aldosterone stimulating effects.
– Directly or in synergism with prolactin
– Preparing mammary gland for lactation
– Antagonize action of Insulin. [as↑maternal insulin causes protein
synthesis], hPL causes proteolysis, lipolysis and promotes tranfer of
glucose and amino acids to fetus
Placental steroids
• no 17 -hydrolxylase hence must be synthesized from C19 intermediates
• development of endometrium
• uterine growth
• uterine blood supply
12
• preparation of Uterus for labor
C. Maternal effects of Pregnancy

• large amount of estrogens, progeosterone, PL and corticosteroid

• Increase resistance to angiotensin

• predominance of lipid over glucose metabolism

• increased synthesis of thyroid and steroid binding proteins, fibrinogen and other
proteins

• blood volume increases by 45%

• 40% increase in TG, Chol, PhL and FFA

• Albumin , Globulin 

• ALP triples (heat stable)

• CK due to delivery
13
•
• Pregnancy is –

• A STATE OF HYPERVOLEMIA

• A STATE OF HAEMODILUTION

• A HYPERCOAGULABLE STATE

• AN ANABOLIC STATE

• A STATE OF RESPIRATORY ALKALOSIS

• IRON DEFICIENCY STATE

14
• Weight gain: 11 kg [24 lb]- 1 kg Ist trimester-5 kg each IInd and IIIrd
• Fetus 3.3, placenta 0.6, liquor 0.8, uterus 0.9, breasts 0.4kg= 6kg;
Increase in blood volume with ECF and accumulation of fat, protein≈5-6kg

• Retention of Na+ 20gm, K+ 10 gm and Cl-

• Retention of Na+- due to i. Oestrogen and progesterone, ii. Activation of
Renin AG system causing increased aldosterone→Na+ retention, iii. ADH

• Water retained- 6.5 L

• Fluid accumulation in tissue spaces- due to: i. ↓colloid osmotic tension

due to haemodilution- driving fluid out of vessels, ii.  venous pressure of
inf extremities- slight oedema of legs may occur

• Ideally wt gain with n BMI [20-26] is 11-16 kg

15
 Haematological Changes
Blood volume- ↑ 30 – 40 %
Plasma volume- ↑ 40 – 50 %
Red cell volume- ↑ 20 – 30 %
Total Hb- ↑ 18 – 20 %
Haemoglobin conc - apparent fall [↓Hb] due to haemodilution
Hematocrit (whole body)-↓ed

Adv of haemodilution-
1. ↓ blood viscosity- ensures optimum gaseous exchange b/t
maternal and fetal circulation- this is facilitated by ↓ oxygen
affinity of maternal Hb (HbA P50 26mmHg compared to HbF P50
20mm Hg with ↑O2affinity)
2. Protection of mother against adverse effects of blood loss
during delivery.

Neutrophilic leucocytosis 10 – 15,000/cu mm even 20,000 in labour

due to oestrogen and cortisol 16
• Total protein 180 gm [non preg]→↑ 230 gm near term
• Plasma protein 7gm/dl [non preg] →↓6 gm/dl near term due
to haemodilution
• Marked fall in Plasma albumin from 4.3 to 3 gm/dl[↓30%]
• Slight rise in globulin 2.7 to 3 gm/dl
• A:G ratio [n= 1.5 :1 to 2.5 :1] decreased to 1:1

Clotting factors: Pregnancy is a hypercoaguable state

• Fibrinogen level ↑ by 50%
• ESR markedly raised 4 times due to ↑ Fibrinogen and
globulin
• ↑ activity of factors II, VII, VIII, IX, X
17
 Metabolic changes: Pregnancy is an anabolic state
• BMR ↑ to 30% or higher
• Protein Metabolism: positive nitrogen balance,
• 500 gm maternal gain of protein and 500 gm fetus + placenta
• breakdown of amino acid to urea is suppressed→ ↓ Bl urea 15-20mg%

• Lipid Metabolism: hyperlipidemia of preg is not atherogenic

• 3-4 kg fat stored most in abdominal wall, breasts, hips, thighs. Plasma lipids and lipoproteins
increase due ti increase in oestrogen, progesteron, hPL
• HDL level ↑ by 15%; total lipid and TG ↑ by 50%, LDL ↑ by 40%
• LDL- utilised for placental steroid synthesis
• ↑ LPLipase activity

• Iron: total iron requirement in preg is 1000 mg- fetus+placenta 300mg and expanded red cell
mass 400 mg [total ↑in red cell volume -350 ml and 1 ml contains 1.1mg of iron]
• S. Ferretin level reflect body iron stores
• Preg- S iron and ferretin levels both fall
• However placenta transfer iron from mother in sufficient amt to maintain Hb conc of fetus
• No correlation b/t Hb concentrations of mother and fetus

18
Carbohydrate Metabolism:
• Transfer of glucose from mother to fetus is required
• ↑Insulin secretion- hyperplasia and hypertrophy of beta cells pancreas
• Decreased sensitivity to insulin receptors
• ↑ plasma insulin level due to contra-insulin factors= oestrogen,
progesterone, hPL, cortisol, prolactin, free fatty acids and Increased tissue
resistance to Insulin → ensures continuous supply of glucose to fetus
• ↑ plasma insulin level→favours lipogenesis

• Overall effect:
Maternal fasting hypoglycemia [due to fetal consumption]
Post prandial hyperglycemia and hyperinsulinemia
Decreased maternal utilization of glucose; ↑ gluconeogenesis and

glycogenolysis

• ↓ renal threshold for glucose [n 180 mg/100ml non preg] → glycosuria

in 50% of normal pregnant women
19
 Renal function

• increased GFR to 170 ml/min/1.73 m2 by 20 wk

• increased clearance of urea, creatinine and uric

acid. →↓ in serum
• At term- decreases towards non pregnant side and
uric acid absorption increases dramatically

• glucosuria up to 1000 mg/d due to ↑ GFR

→↓renal threshold
• proteinuria up to 300 mg/d

20
 Endocrine changes
• till 50 days corpus luteum of maternal ovary and after that placenta
maintains progesterone

• PTH increase 40%

• No change is free ionized calcium and calcitonin
• Vit. D – increases

  cortisol and DHEAS (dehydroepiandrosterone)

  aldosterone and deoxy cordicosterone

  estrogen → and 10 fold  of prolactin

• Also due to  estrogen →  LH and FSH (undetectable)

• No change in TSH but high level of TBG raises T4 and T3 but slight
decrease in FT4 (II and III)
  Thyroglobulin in (III).

21
Alpha fetoprotein [AFP]
Having -electrophoretic motility hence named.
A glycoprotein 70,000
Produced initially by fetal yolk sac in liver, Traces in gut
and kidneys.
Max concentration at about 16 wk i.e. 30,00000 and then
declines to 5000 to 120000 ng/ml at term
The rise and fall in concentration of AFP in AF is parallels
that of serum but concentration is lower (-20000 at
16 wk).
Maternal serum AFP is detectable at 12 wk and rises 15%
to peak at 25 wk – 250 ng/mL and slowly declines until
term.
Maternal serum AFP is elevated 25 to 95% cases of neural
tube defect and low in about 30% of cases of Down’s
syndrome.

[Amniotic fluid- next lecture]

22
THANKS

23