Maternal cardiovascular dynamics

IV. The influence of gestational age on the maternal cardiovascular

response to posture and exercise

KENT UELAND, M.D.

MILES J. NOVY, M.D.

EDWARD N. PETERSON, M.D

JAMES METCALFE, M.D.

Seattle, Washington, and Portland, Oregon

Serial hemodynamic evaluations were carried out in I1 patients during pregnancy

and the postpartum period. The patients were studied at rest in the supine, lateral,
and sitting positions as well as during and after exercise on a bicycle ergometer. The
cardiac output was found to be elevated to peak levels as early as 20 to 24 weeks of
gestation and was maintained at this high level through the thirty-second week
of gestation. At 38 to 40 weeks there was a decline in cardiac output in all positions.
This fall was most pronounced in the supine position, in which the cardiac
output was found to be lower than in the same position during the
postpartum period. The heart rate increased only slightly during early gestation but
continued to rise throughout pregnancy in the supine and lateral positions.
Accordingly, The stroke volume showed a progressive decline from 20 to 24 weeks
of gestataon to term. The cardiovascular response to mild exercise was constant
throughout pregnancy and similar to that encountered in nonpregnant individuals.
However, moderate exercise indicated there is a progressive decline in circulatory
reserve as pregnancy advances. This is not attributed to any change in cardiac
function but rather to peripheral pooling of blood and obstruction to venous return
by the large gravid uterus. Following exercise cardiovascular function returned to
resting levels with equal rapidity during pregnancy and post partum.

D u R I N G P R E G N A N C P cardiac output addition, important effects of positional

increases by approximately 30 to 50 per cent. changes on maternal cardiovascular func-
Most authorities agree on the magnitude of tion have been demonstrated repeatedly31 ‘, ‘-
this change. However, the time at which ‘.“v lo, ‘R ” and must be given due considera-
it reaches maximum values has recently tion when interpreting data.
been questi0ned.l” In order to understand Pregnancy is often accompanied by com-
the cardiodynamic changes that occur plaints of easy fatigability and a decrease in
during pregnancy, serial studies should be exercise tolerance. These might be due to
performed in the same patients because there purely mechanical factors such as the enlarg-
is a wide variation between individuals. In ing uterus and changes in distribution of
weight. However, the increased demand
From the Department of Obstetrics and placed on the heart by pregnancy might re-
Gynecology, University of Washington
School of Medicine, and The University sult in a diminution in cardiac reserve and a
of Oregon Medical School Heart concomitant decreased capacity for exercise.
Research Laboratory.
The response of cardiac output to exercise
This investigation was supported in part
by Cardiovascular Program Project Grant during pregnancy, to the authors’ knowl-
No. HE 06 336 and Training Grant No. edge, has only been studied twice’> 5, Ifi and
HE 5499 National Heart Institute and
the Oregon Heart Association. never serially in the same group of patients.
Volume 104 Maternal cardiovascular dynamics 857
Number 6

This study was performed in order to eval- for a distance of approximately 10 cm. Fol-
uate ( 1) the influence of maternal posture on lowing these catheterization procedures time
cardiodynamics at various stages of preg- was allowed for the patients to stabilize be-
nancy, (2) the magnitude of the changes in fore continuing the study.
cardiac output, heart rate, and stroke vol- Arterial pressure was monitored contin-
ume during pregnancy, (3) the time sequence uously with a Statham pressure transducer.
of these changes, and (4) the effects of preg- Just prior to each determination of cardiac
nancy on the cardiovascular response to exer- output, the heart rate and blood pressure
cise. were recorded. Measurements of cardiac out-
put were performed (a) with the patient su-
Material and methods pine, (b) in the lateral decubitus position,
Serial cardiovascular studies were per- (c) sitting on a bicycle ergometer, (d) during
formed in 11 normal women at various stages exercise on the bicycle ergometer, and (e)
of pregnancy and again in the postpartum sitting on the bicycle ergometer 10 minutes
period. The periods of study were: 20 to 24 after exercise. Following each change in
weeks, 28 to 32 weeks, and 38 to 40 weeks position a period of at least 5 minutes was
of gestation and 6 to 8 weeks post partum. allowed in order to obtain a steady state.
All patients were fasting. The procedure and For each measurement a 5 mg. bolus of
its implications were carefully explained to indocyanine green dye was injected through
each patient in our search for volunteers. In the antecubital vein catheter while arterial
each patient two evaluations were carried blood was withdrawn from a brachial artery
out during pregnancy and a third in the post- through a continuously recording densitom-
partum period. At the time of each study a eter. Cardiac output was determined during
polyethylene catheter was inserted into a exercise after a 3 minute elapsed period of
large antecubital vein through a 16 or 18 uniform exercise on the bicycle ergometer. In
gauge needle. The brachial artery was 6 patients the exercise load was light (100
catheterized percutaneously with a Cournand k.p.m. per minute) whereas in 5 patients it
needle, nylon leader, and a polyethylene was moderate (200 k.p.m. per minute).
catheter which was threaded into the artery Plasma volume was determined at the end

7 ---\
_--- . *
----
_--- .\
. .
\ .
‘.

20-24 28-32 38-40 8-8

WEEKS GESTATION WEEKS POSTPARTUM

Fig. 1. The effect of gestational age and maternal posture on cardiac output.
 858 Ueland et al. July 15, 1969
Am. J. Obst. & Gynec.

Table I. Cardiac output, pulse rate, and stroke volume related to gestational age and maternal
___- ~--.---..- .____
Gestation
--____--..__-__
20-24 Weeks 28-32 Weeks
Sufiine Side -sitting Supine Side Sitting
Cardiac output (L./min.)
Range 5.3-7.1 5.8-8.5 4.6-7.3 3.6-8.5 4.9-9.6 4.5-9.8
Mean 6.4 6.9 5.9 6.1 7.0 6.4
Standard + 0.6 i 1.0 i 0.9 :t 1.4 f 1.4 5 1.5
deviation

Pulse rate (beats/min.)

Range 59-84 58-85 61-108 60-100 60-96 64-123
Mean 74.4 73.4 83.4 83.2 81.6 91.8
Standard t 10.5 t 9.5 -e 15.1 + 12.8 2 10.2 k 17.2
deviation

Stroke volume (ml./beat)

Range 76-105 75-121 43-95 59-128 55-123 53-131
Mean 88.3 94.5 73.6 76.7 87.5 72.4
Standard + 10.4 + 15.6 _+ 17.1 t 25.6 F 21.1 t 25.1
deviation

90

20-24 2632 38-40 6-8

WEEKS GESTATlON WEEKS POSTPARTUM

Fig. 2. The effect of gestational age and maternal posture on heart rate.

of the procedure in 6 patients using Evans and was maintained at a high level for a
blue dye as the indicator; in 5 patients radio- considerable length of time. Table I gives
active iodinated human serum albumin and the data regarding cardiac output, heart
the Volemetron were used for estimating rate, and stroke volume as related to gesta-
blood volume. Hematocrit values were ob- tional age and maternal posture.
tained on arterial blood. Fig. 1 graphically depicts our findings with
regard to cardiac output. Late in gestation
Results cardiac output declines toward nonpregnant
In this study it became apparent that car- levels, regardless of maternal position. In
diac output was elevated early in pregnancy the supine position the cardiac output is
 Volume 104 Maternal cardiovascular dynamics 859
Number 6

position

Post parturn
38-40 Weeks (6-8 Weeks)
Supine Side Sitting Supine Side Sitting

3.8-4.9 4.3-7.1 4.2-5.7 3.8-5.8 3.7-6.7 3.5-5.8

4.5 5.7 5.2 5.1 5.0 4.6
-t 0.5 5 1.0 t 0.6 2 0.7 * 0.9 f 0.8

75-96 68-96 80-105 57-81 57-81 72-100

85.8 83.2 89.4 69.5 69.6 81.3
+ 7.4 t 12.2 2 9.1 4 7.4 2 a.3 + a.1

40-60 56-81 52-62 60-87 61-86 40-80

52.2 69.0 57.8 72.8 71.0 56.5
5 6.9 2 8.9 i 4.3 2 8.2 + 7.9 2 10.4

20-24 22’32 38-40 s-e

WEEKS GEST..ION WEEKS POSTPARTUM

Fig. 3. The effect of gestational age and maternal posture on stroke volume.

lower at 38 to 40 weeks than at 6 to 8 weeks per minute higher than in the other positions
post partum. throughout pregnancy and post partum and
Fig. 2 depicts maternal heart rate. In the the maximum heart rate was found at 28 to
supine and lateral positions a progressive in- 32 weeks.
crease in heart rate was found throughout Fig. 3 shows stroke volume in relation to
gestation. In the sitting position the heart gestational age and maternal posture. In all
rate at rest was approximately 10 to 15 beats positions there was a continuous decline as
860 Ueland et al. July 15, 1969
Am. J. Ohst. & Gynec.

Table II. Statistical analysis of data on maternal cardiac output, heart rate and
stroke volume as related to posture and gestational age*

20-24 Weeks’ gestation _______ 28-32 Weeks’ gestation 38-40 Weeks’ gestation
% Change P % Change P % Change P -
Cardiac output
Supine + 25.7 < 0.0025 + 21.5 II. s. .- 11.8 n. s.
Side + 38.3 < 0.0005 + 40.7 < 0.0005 t 15.3 I,. s.
Sitting -+ 29.5 < 0.005 t 39.3 < 0.0025 i 12.9 11.s.
Heart rate
Supine + 7.0 n. s. + 19.7 < 0.005 i- 23.4 < 0.0005
Side f 5.4 n. s. + 17.2 < 0.005 f 19.5 n. s.
Sitting t 2.5 n. s. t 12.9 n. s. + 9.9 n. s.
Stroke volume
Supine f 21.2 < 0.005 t 5.3 n. s. - 28.2 < 0.0005
Side + 33.0 < 0.0025 + 23.2 n. 5. - 2.8 n. s.
Sitting + 30.2 n. s. + 28.1 n. s. i 2.3 II. s.
- __-
*Results expressed in per cent change from nonpregnant values. p > 0.01 not significant (n.s.).

Table III. Effects of mild exercise on maternal cardiodynamics at several gestational

ages (5 patients)
___ -. _.c_I --. --_-
Ge.Ftation Post partum
20-24 Weeks 28-32 Weeks 38-40 Weeks* - (6-8 Weeks) .-
Sitting Exercise Sitting 1 Exercise Sitting Exercise Sitting Exercise
Cardiac output (L./min.)
Range 4.6-7.3 8.8-12.1 4.5-7.3 7.2-l 1.5 5.5-5.7 9.2-l 1.1 3.5-5.8 5.6-10.9
Mean 5.9 10.4 5.9 9.9 5.6 10.1 4.8 8.2
Standard
deviation 2 1.2 2 1.3 +_ 1.0 ?I 1.5 + 0.1 2 1.0 i 0.9 +_ 1.9
Pulse rate (beats/min.)
Range 61-108 94-126 64-116 98-132 88-105 1’0-136 72-l 00 95-128
Mean 88.0 114.6 91.3 116.0 96.5 128.0 84.6 111.4
Standard
deviation f 15.4 + 11.4 k 15.6 ?. 11.9 2 8.5 +_6.4 c 7.1 +_12.7
Stroke volume (c.c.)
Range 43.0-94.7 79.5-96.0 46.9-113.2 63.8-117.3 54.0-6’.:! 76.7-81.6 40.3-80.3 58.5-88.1
Mean 70.3 90.5 67.6 87.5 58.1 79.2 57.9 73.0
Standard
deviation +_19.2 +_ 6.5 2 21.6 i 17.1 i4.t -.-__ +_2.5 +_13.3 2-__ 9.9
.*Denotes 2 patients.

pregnancy advanced. At 38 to 40 weeks in very much higher than post partum. Signifi-
the supine position the stroke volume was cant increases occurred in both cardiac out-
smaller than in the postpartum period. put and stroke volume at 38 to 40 weeks
Table II summarizes the statistical analysis when the patient’s position was changed from
of the cardiovascular changes at rest. The the supine to the lateral decubitus.
importance of maternal position in late preg- Table III summarizes the maternal cardio-
nancy is clearly evident. In the supine posi- vascular responses to mild exercise (100
tion the cardiac output at 38 to 40 bveeks’ k.p.m. per minute). The increment in cardiac
gestation was nearly 12 per cent below the output with standard exercise appears to be
postpartum vaIue and the stroke volume was of the same magnitude throughout pregnancy
28 per cent lower while the heart rate was and post partum (approximately 75 per
Volume 1n4 Maternal cardiovascular dynamics 861
Number 6

Table IV. Moderate exercise, gestational age, and maternal cardiodynamics

Gestation Post partum

20-24 Weeks 28-32 Weeks 38-40 Weeks (6-8 Weeks)
(2 patients) (5 patients) (3 patients) (5 patients)
Sitting 1 Exercise Sitting Exercise Sitting Exercise Sitting Exercise
Cardiac output (L./min.)
Range 5.7-6.0 12.5-13.3 5.3-8.0 9.0-l 7.5 4.2-5.6 6.9-10.7 3.6-5.6 7.3-10.6
Mean 5.9 12.9 6.9 12.6 4.9 a.4 4.3 a.9
Standard
deviation i: 0.2 2 0.6 + 1.8 f 2.7 2 0.6 + 1.7 10.7 + 1.3
Pulse rate (beats/min.)
Range 68-76 107-138 74-138 96-154 80-93 i 19-128 72-87 109-150
Mean 72.0 122.5 92.4 135.2 84.7 124.3 78.0 138.8
Standard
deviation + 4.0 f 15.5 + 18.9 + 20.5 ?r 5.9 -I 3.9 2 5.0 + 15.3
Stroke volume (G.c.)
Range 79.3-83.8 90.6-124.3 52.6-130.7 67.0-129.7 51.5-61.1 54.8-83.5 47.9-63.8 51.0-97.4
Mean 81.6 107.5 78.1 95.7 57.6 67.1 55.1 65.7
Standard
deviation + 2.3 + 16.8 * 27.7 t 25.1 f 4.4 f 12.1 2 6.1 + 16.7

cent). However, with moderate exercise (200 vated. This did not appear to be related
k.p.m. per minute) as shown in Table IV the to either the amount of exercise or the ges-
rise in cardiac output seems to be progres- tational age and may have been a postural
sively smaller as the pregnancy advances: at effect.
20 to 24 weeks an increase of nearly 120 No statistically significant conclusions could
per cent was encountered, at 28 to 32 be drawn from the blood volume and hema-
weeks the increase was only 83 per cent, tocrit determinations because of the different
and at 38 to 40 weeks it had declined to 71 techniques used. The data tend to support
per cent. Six to 8 weeks following delivery previous findings of a rapid rise in blood
the increase was greater than 106 per cent. volume and plasma volume early in preg-
The magnitude of the increase in heart rate nancy followed by more gradual increases
with mild exercise was similar throughout later in pregnancy. A relative hemodilution
pregnancy and in the postpartum period was also apparent.
(approximately 25 to 30 beats per minute) .
This was also true during moderate exer- Comment
cise, although the absolute rise was greater As early as 1915 cardiac output was meas-
(approximately 50 beats per minute). Dur- ured during pregnancy and was found to be
ing mild exercise the increase in stroke vol- significantly increased.13 Since that time
ume was of the same magnitude throughout many reports have appeared on the subject
pregnancy and in the postpartum period of cardiovascular physiology during preg-
(approximately 20 c.c.) . During moderate nancy utilizing a variety of experimental tech-
exercise, however, the rise in stroke volume niques. 1, 6-8, 12, 1% 15, 17, 18, 23 Most of the
became progressively smaller as pregnancy early studies showed a gradual rise in car-
advanced. Hemodynamic evaluation in the diac output as pregnancy progressed, that
sitting position 10 minutes after both mild reached peak values between 26 and 34 weeks
and moderate exercise showed that the car.. of gestation and then gradually declined to
disc output had consistently returned to nor- nonpregnant levels late in pregnancy.l, 2v 6r ‘9
mal. The heart rate, on the other hand, I7 At its peak cardiac output increased 30 to
showed a tendency to remain slightly ele-, 50 per cent above nonpregnant values. Sev-
 July 15, 1969
862 Ueland et al.
Am. J. Obst. & Gynec.

Table V. Serial measurements of cardiac output (L./min.) during pregnancy

--

Investigator No. of patients Experimental design Position

Adams,1 1954 Evans blue dye, antecubital vein, femoral Supine
(94 dete%nations) artery (multiple sampling)

de Schwartz: +amendia, Evans blue dye, axillary vein, femoral or Supine

and Taquml,’ 1964 (48 dete?ninations) brachial artery

Roy and associates,ls 1966 Indigo carmine dye, antecubital vein, Supine
(82 dete%nations) femoral artery (continuous recording
densitometer)

Walters, MacGregor, and Coomassie blue dye, antecubital vein, Supine

Hills,23 1966 ( 1332 dzkminations) photoelectric earpiece (probably)

Lees and associates,12 1967 5 Indocyanine green dye, intrathoracic Supine

(25 determinations vein, root of aorta (continuous recording Lateral
supine, 50 lateral) densitometer)

Ueland and associates, 11 Indocyanine green dye, antecubital vein, Supine

1968 (32 determinations brachial artery (continuous recording Lateral
supine, 32 lateral) densitometer) --
*Second trimester.

era1 recent serial investigations, however, output between the supine and lateral posi-
suggest that cardiac output rises as early as tions late in pregnancy (p < 0.01) .
the first trimester of pregnancy?? lZs 23 and In 1959 Kobbe15 reported on the physical
that this change is of the same magnitude working capacity of 22 women at various
as reported earlier but is maintained at its stages of pregnancy. She exercised her pa-
high Ieve for a longer period of time. Thus, tients on a bicycle ergometer in order to
the idea of a transient peak is not justified. minimize the influence of increasing body
Table V summarizes our data and those of weight during pregnancy upon the work
all serial studies. The fall in cardiac output, load. She found that the pulse response to
shown by most of the data, as pregnancy graded work on the bicycle ergometer re-
nears term is greatly influenced by the ma- mained approximately constant throughout
ternal posture in which the determinations pregnancy, a finding which suggested that
were performed. Lees and associatesI found women compensate for the increased circu-
no decline in cardiac output late in preg- latory load of pregnancy without significantly
nancy; their patients were studied in the decreasing their cardiac reserve for muscu-
lateral position. We found a decline in all lar work. Two subsequent reports dealt with
positions (supine, sitting, and lateral) but the maternal hemodynamics at rest and at exer-
drop in cardiac output was much more pro- cise during pregnancy21 I6 in 46 normal wom-
nounced when the patients were studied in en at various stages of gestation who were
the supine position. studied by cardiac catheterization. Exercise
The increasing influence of the enlarging NXS performed using a bicycle ergometer
uterus as pregnancy advances is apparent with the patients in the supine position. None
from our data; a change in position from the of the patients was studied serially. During
supine to lying on the side produced no exercise the increase in cardiac output was
change in cardiac output in nonpregnant related to each 100 C.C. increment in oxygen
patients, but a rise of 8 per cent occurred at consumption and was within the established
20 to 24 weeks’ gestation, 13.6 per cent at normal limits for nonpregnant individuals.
28 to 32 weeks’ gestation, and 28.5 -per cent This finding was interpreted as an indica-
(p < 0.01) at term. Lees and associateP tion that there was no impairment in myo-
also found a significant difference in cardiac cardial reserve during pregnancy. However,
Volume 104 Maternal cardiovascular dynamics 863
Number 6

Weeks of pregnancy
Weeks post partum
8-12 16-24 26-34 38-40 (6-8)
- 5.7 - 7.3 6.3 - 8.3 5.5 - 5.8 6.3

7.8 7.1 - 8.9 6.9 - 7.5 6.0 4.8

5.9 5.7 - 7.1 7.6 5.8 5.5

7.0 6.3 6.2 - 6.6 5.6 5.3

6.1 6.1” 5.3 -

6.1 6.2 6.3 -

- 6.4 6.1 4.5 5.1

- 6.9 7.0 5.7 5.0

review of the published graph of cardiac However, the response was not consistent
output at rest and during exercise shows and could not be duplicated in another nor-
that a smaller rise in cardiac output occurs mal patient who exhibited a normal exercise
with exercise late in pregnancy in agreement performance prior to the leg wrapping. This
with our present data in patients undergoing difference in response may be related to the
moderate exercise (Table V) . These findings amount of inferior vena caval obstruction
suggest that there is a progressive decline in produced by the large gravid uterus and to
circulatory reserve as pregnancy advances. the adequacy of collateral circulation.
The data of Bruce and Johnson5 indicate The fact that cardiac output rises early in
that the decline in circulatory reserve is not pregnancy affirms the accepted opinion that
related to impaired cardiac function but maternal hemodynamic changes are not due
rather is due to peripheral pooling of blood. entirely (or even predominantly) to the
They demonstrated improved exercise toler- metabolic and nutritional needs of the fetus;
ance in the upright position in a patient it has recently been shown that estrogens
late in pregnancy with a normal heart by can induce similar hemodynamic changes.21
merely wrapping her legs with Ace bandages.

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T;mywald, E.: J. Clin. Invest, 34: 1524,, 9. Howard, B. K., Goodson, J. H., and Mengert,
W. F.: Obst. &. Gynec. 1: 371, 1953.
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100: 203, 1968. 72: 513, 1965.
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Barcia, R.: AM. J. OBST. & GYNEC. 95: 795, Brit. M. J. 1: 532, 1964.
1966. 12. Lees, M. M., Taylor, S. H., Scott, D. B., and
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Bahatia, M. L.: AM. J. OBST. & GYNEC. 96:
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