OB-GYNE MATERNAL PHYSIOLOGY

AY 2021-2022 MARIE CHRISTINE VALERIE R. MENDOZA, M.D.

Reproductive Module 04/04/2022

TOPIC OUTLINE
I. Reproductive Tract
a. Uterus
i. Uterine Contractility
ii. Uteroplacental Blood Flow
b. Cervix
c. Ovaries
i. Theca Lutein Cysts
d. Vagina and Perineum
II. Breast
III. Skin
IV. Metabolic Changes
a. Weight Gain
b. Water Metabolism
c. Protein Metabolism
d. Carbohydrate Metabolism
e. Fat Metabolism
Fig 1. Uterus - term pregnancy
V. Hematologic Changes
a. Pregnancy-induced Hypervolemia
● Pregnant uterus becomes a thin-walled muscular organ to
b. Iron Metabolism
accommodate the fetus, the placenta and the amniotic fluid
c. Immunological Functions
● For the uterus, there is a limited production of new muscle cells
d. Coagulation and Fibrinolysis
● Uterine enlargement
VI. Cardiovascular System
o Stretching and hypertrophy of muscle cells –
a. Hemodynamic Function in Late Pregnancy
stimulated by estrogen and progesterone (rises during
b. Circulation and Blood Pressure
pregnancy)
c. Renin, Angiotensin, and Plasma Volume
o Limited production of new myocytes
d. Cardiac Natriuretic Peptides
● Increase in myocyte size: accumulation of fibrous tissue +
VII. Respiratory Tract
increase in elastic tissue content
a. Pulmonary Function
b. Physiological Dyspnea
VIII. Gastrointestinal Tract
IX. Liver and Gallbladder
X. Urinary System
a. Renal Function Tests
b. Bladder
XI. Endocrine System
a. Placenta
b. Growth Hormone
c. Prolactin
d. Thyroid
e. Parathyroid Gland
XII. Musculoskeletal System
XIII. Central Nervous System
Fig 2. Uterine enlargement

● Uterus becomes globular and spherical by 12 weeks AOG and

LEGEND:
continues to grow until it displaces the intestines laterally and
Clinical Guide
PPT Lecturer Book superiorly, and ultimately reaches the liver
Correlation/SGDs Questions
● ❖ a. Uterine Contractility

REPRODUCTIVE TRACT
● Uterus, cervix, ovaries, fallopian tubes, vagina & perineum

UTERUS
● Prepregnancy – 70 grams
● Term pregnancy – 1100 grams

Fig 3. Uterine muscle contractions

● Contractions can already be experienced during the second
trimester (these are irregular, sporadic and not painful)
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● Early in pregnancy or during the second trimester, if contractions
are felt, they may be isolated to just one area of the uterus
● As the patient goes into labor, the whole uterus acts in
cooperation to facilitate labor
● True labor – contractions are regular, they come at a certain
interval, very strong, very painful
● Braxton Hicks Contractions
o Third trimester
o Irregular, painless contractions
o Increases in frequency as pregnancy nears term
especially during the last week or two
o "False labor"
o One of the early signs that labor is about to commence
is the presence of bloody show which may include the
mucus plug
● Cervical mucus beading
o Due to the influence of progesterone
● Ferning
o Can be seen if the bag of water has already ruptured
● Arias-stella Reaction – endocervical gland hyperplasia and
hypersecretory appearance

b. Uteroplacental Blood Flow

● Placental perfusion depends on total uterine blood flow
● Ultrasound is used to study the uterine arterial blood flow
o 450 ml/min to nearly 500-760 ml/min at 36 weeks
● Uterine contractions can lower uterine blood flow proportionally
to contraction intensity
● Arteries widen and elongate but their contractile function is
preserved

CERVIX
● Softening and cyanosis from increased vascularity and edema of
the entire cervix together with hypertrophy and hyperplasia of the
cervical glands Fig 5. Ferning & beading
● Connective tissue remodeling that decreases collagen and
proteoglycan concentrations and increases water content -> OVARIES
cervical ripening
● Ovulation and maturation of new follicles cease
● Non pregnant patient – cervix is firm
● Corpus luteum - functions during first 6-7 weeks AOG
● During pregnancy, due to connective tissue remodeling and water
o Primary organ needed for the support of the placenta
retention, the cervix feels soft especially when it's nearing labor
o Relaxin – secreted by the corpus luteum and aids in
or delivery
many maternal physiologic adaptations such as renal
● Allows the cervix to maintain pregnancy to term, dilate to aid
hemodynamics and increasing arterial compliance
delivery and repair following parturition so that a successful
● Ovarian vascular pedicle diameter increases (from 0.9 cm to 2.6
pregnancy can be repeated
cm at term)
● The cervical glands undergo marked proliferation, and by the end
of pregnancy, the glands may occupy up to half of the cervix
a. Theca Lutein Cysts
● Through speculum examination, in a non pregnant cervix, the
● Result from exaggerated physiological follicle stimulation
squamous epithelium usually occupies a larger part of the external
● Commonly found with GTD but can be found in uncomplicated
cervix
pregnancies and thought to result from an exaggerated response
● During pregnancy, due to the effects of hormones, the glands
of the ovaries to normal levels of circulating HCG
proliferate and hypertrophy – they move outwards → cervical
eversion

Fig 6. Theca lutein cysts

VAGINA AND PERINEUM

● There is greater vascularity and hyperemia developing in the skin
and muscles of perineum and vulva, underlying connective tissue
soften
● Chadwick sign
o Violaceous appearance
Fig 4. Cervical eversion

● Mucus plug
o Mucus rich in immunoglobulins and cytokines – serves
as a protective function for the inside of the uterus

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Fig 7. Chadwick sign

Fig 9. Striae gravidarum
● Vaginal walls
o Increase in mucosal thickness o Diastasis recti: In the midline, rectus muscles separate
o Loosening of connective tissue (weak point) due to the enlarging uterus
o Smooth muscle cell hypertrophy ● Hyperpigmentation
● Thick white discharge o Develops in 90% of women
o Increased volume of cervical secretions within the o More accentuated in those with a darker complexion
vagina o Linea alba → linea nigra
o Increased production of lactic acid from glycogen in
the vaginal epithelium (pH 3.5-6) – due to lactobacillus
o Increased risk for VVC

BREAST
● Early weeks of pregnancy – breast enlargement and increased
tenderness
● Increased size and pigmentation of the nipple and areola
● Prepregnancy breast size and the volume of breast milk do not
correlate
● Colostrum - expressed from the nipples by gentle massage after
the first few months/few hours of delivery
o Contain a lot of immunologic factors that are helpful to
the baby to serve as protection

Fig 10. Linea nigra

o Chloasma or Melasma Gravidarum ("mask of

pregnancy") – irregular patches on face and neck,
usually disappear after delivery
o Pigmentary changes usually disappear or regress after
delivery

Fig 8. Breast anatomy

SKIN
● Abdominal wall
o Striae gravidarum (stretch marks)
Reddish, slightly depressed streaks
commonly develop beginning after
midpregnancy
• May not be localized in the abdomen and
can also appear on buttocks and thighs
Fig 11. Chloasma

● Vascular Changes
o Angiomas called vascular spiders – commonly on face,
neck, chest, and arms

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Fig 12. Angiomas
o Palmar erythema -not clinically significant
o Usually disappear right after pregnancy
METABOLIC CHANGES
WEIGHT GAIN
● Uterus and its contents
● Breasts
● Blood volume
● Extracellular fluid
● Average weight gain: 12.5 kg (27.5 pounds)
Fig 13. Additional energy demands during normal pregnancy
WATER METABOLISM
● Fall in plasma osmolality → increased water retention
● Water content of fetus, placenta and amniotic fluid at term: 3.5
liters
● Water content of maternal blood volume, uterus and breasts: 3
liters
PROTEIN METABOLISM
● At term, the normally grown fetus and placenta together weight
about 4kg and contain approx. 500g of protein, or about half of
the total pregnancy increase.
The remaining 500g is added to the uterus as contractile protein,
to the breasts primarily in the glands, and to the maternal blood
as hemoglobin and plasma protein.
● Amino acid concentration is higher in the fetal compartment
compared to maternal compartment → this allows the facilitated
diffusion of nutrients and materials across the placenta
● Products of conception, uterus and maternal blood are relative
rich in protein rather than fat or carbohydrate
● Fetus, placenta, uterus, breasts, maternal blood
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MATERNAL PHYSIOLOGY
Fig 14. Plasma osmolality
CARBOHYDRATE METABOLISM
● Pregnancy-induced state of peripheral insulin resistance
o Mild fasting hypoglycemia, postprandial
hyperglycemia and hyperinsulinemia
o Progesterone, GH, prolactin and cortisol, leptin –
contribute to the insulin resistance
● Constant postprandial supply of glucose to the fetus
● "Accelerated starvation”
FAT METABOLISM
● Maternal hyperlipidemia
o Plasma concentration of free fatty acids, triglycerides
and cholesterol are higher in the fasting state as a result
of the increased insulin resistance
o Estrogen also has contribution
o More progressive during first two trimester – having
higher appetite
o Third trimester – fat storage declines
● From increased insulin resistance and estrogen stimulation
● Average 3-4 kg of fat stored in the abdominal wall, breasts, hips
and thighs
Fig 15. A woman that has a normal pregnancy will have a normal birth
HEMATOLOGIC CHANGES
PREGNANCY-INDUCED HYPERVOLEMIA
● Hypervolemia associated with pregnancy averages 40 – 45 %
above the non-pregnant blood volume after 32-34 weeks age of
gestation
● Pregnancy-induced Hypervolemia
1. Meet the metabolic demands of the enlarged uterus
and its greatly hypertrophied vascular system
2. Provide abundant nutrients and elements to support
the rapidly growing placenta and fetus
3. Increased intravascular volume protects the mother
and fetus against the deleterious effects of impaired
venous return in the supine and erect positions
4. Safeguard the mother against the adverse effects of
parturition-associated blood loss
● Maternal blood volume begins to increase during the 1st trimester
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● By 12 weeks, plasma volume expands by ~15% compared with o Except factors XI, XIII
pre-pregnancy volume ● Increased absolute plasma fibrinogen
● It is during the mid-trimester that maternal blood volume grows
the most then rises at a slower rate by the third trimester
● During this time of blood volume expansion, blood volume and
erythrocyte number rise, although more plasma volume is usually
added to the maternal circulation
● Plateau during the last weeks of pregnancy

Fig 17. Changes in coagulation factors during pregnancy

CARDIOVASCULAR SYSTEM

Fig 16. Changes in total blood volume & its components

IRON METABOLISM
● Total iron content of normal adult women: 2-2.5 g (most of this is
incorporated in hemoglobin or myoglobin)
Fig 18. Cardiovascular system during pregnancy
● Iron stores of normal women: 300 mg
● Required iron normal pregnancy: 1000 mg
● Cardiac output
o Actively transferred to fetus and placenta: 300 mg
o Increased as early as 5th week
o Lost through various normal excretion routes
o Peak at 20-32 weeks AOG (30-50 percent above
(primarily GI system): 200 mg
baseline)
o 500 mg: increased in total circulating erythrocytes
● Underlying cardiac conditions may worsen → have closer
volume
monitoring
● Puerperium
● Reduced systemic vascular resistance
o Average blood loss vaginal delivery of a single fetus:
● Increased heart rate
500-600 ml
o Resting pulse rate increases ~10-15 beats/min during
o Average blood loss of CS or vaginal delivery of twins:
pregnancy
1000 ml
● Plasma volume expansion begins between 10-20 weeks AOG
● Preload increased
IMMUNOLOGICAL FUNCTIONS
● Pregnancy is a proinflammatory and anti-inflammatory condition
● Associated with various humoral and cell mediated immunologic
functions – to accommodate the foreign fetus
● Changes in the CD4 T lymphocyte populations in pregnancy shifts
from TH1 to TH2 mediated immunity to accommodate the fetus
● 3 immunological phases:
1. Early pregnancy - proinflammatory
2. Mid pregnancy - anti-inflammatory; period of rapid
fetal growth and development
3. Parturition - influx of immune cells into the
myometrium to promote recrudescence of an
inflammatory process
● Immunological functions (all are markedly elevated in response
to tissue trauma or inflammation)
o C reactive protein
o Erythrocyte sedimentation rate Fig 19. Heart displacement during pregnancy
o Complement factors C3 and C4 ● Heart is displaced to the left and upward - due to enlarging uterus
o Procalcitonin ● Larger cardiac silhouette
● May have some degree of benign pericardial effusion
COAGULATION AND FIBRINOLYSIS ● Left ventricular mass expansion ~30-35% near term
● Augmented but remain balanced to maintain hemostasis ● Ventricular function remains normal
● Lower platelet concentration due to hemodilution or the increase
in plasma volume HEMODYNAMIC FUNCTION IN LATE PREGNANCY
● Splenomegaly – up to 50%, cause is unknown ● Increased heart rate, stroke volume and cardiac output
● Increased clotting factors

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● Decreased vascular and pulmonary vascular resistance, colloid PHYSIOLOGICAL DYSPNEA

osmotic pressure ● Decreased tidal volume
● Pregnancy is not a continuous "high-output" state ● Decreased blood PCO2
● Connected to the increase in cardiac output
CIRCULATION AND BLOOD PRESSURE
● Changes in posture
● Blood pressure is higher in the supine position compared to left
lateral recumbent (because in LLR position, we relieve the
pressure from the uterus to the great vessels – the aorta and
inferior vena cava

Fig 22. Physiological dyspnea in pregnancy

GASTROINTESTINAL TRACT
● As the uterus enlarges, it displaces the stomach, intestines
cephalad and other adjacent organs
Fig 20. Blood pressure during pregnancy

RENIN, ANGIOTENSIN, AND PLASMA VOLUME

● RAAS is intimately involved in blood pressure control via sodium
and water balance
● Renin and angiotensin are produced by the maternal and fetal
kidney, placenta, and liver
● Elevated angiotensinogen levels are important in the first
trimester blood pressure maintenance

CARDIAC NATRIURETIC PEPTIDES

● ANP and BNP
● Regulate blood volume by provoking natriuresis, diuresis and
vascular smooth muscle relaxation

RESPIRATORY TRACT
● Elevation of diaphragm up to 4 cm
● Subcostal angle widens – as high as more than 100 degrees
● Thoracic circumference increases about 6 cm Fig 23. GIT during pregnancy

PULMONARY FUNCTION ● Patients may complain about reflux

● Decreased functional residual capacity (20-30%) ● Decreased gastric motility → constipation
● Decreased residual volume (15-20%)
● Increased tidal volume
● Increased resting minute ventilation
● Increased oxygen consumption
● No change: respiratory rate

Fig 21. Respiratory tract during pregnancy Fig 24. Reflux

● Progesterone causes relaxation of the lower esophageal sphincter

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● Increased reflux GROWTH HORMONE

● Pyrosis (heartburn) - common during pregnancy ❖ GH and lactogen act together to regulate fetal growth
● 1st trimester - secreted predominantly from maternal pituitary
LIVER AND GALLBLADDER gland
● Liver ● 6 weeks - placental concentrations become detectable
o Does not enlarge ● 20 weeks - placenta is the principal source
o ALP doubles ● Placental GH - placental lactogen to regulate fetal growth
o AST, ALT, GGT and bilirubin are slightly lower
o Serum albumin declines PROLACTIN
● Gallbladder ● Increased markedly during normal pregnancy
o Reduced contractility ● Tenfold greater at term
o Progesterone potentially impairs contraction by ● Drop after delivery
inhibiting CCK-mediated smooth muscle stimulation ● Ensure lactation

URINARY SYSTEM THYROID

● Kidneys ● Serum TSH and HCG levels vary with gestational age
o Increased size (by 1 cm) o Alpha subunits are identical
o Increased GFR o HCG has intrinsic thyrotropic activity, can cause
o Increased renal plasma flow thyroid stimulation
o Due to increased GFR and renal plasma flow, pregnant o Undergoes moderate enlargement during pregnancy
women experience urinary frequency and nocturia ● TBG rise and increase levels of T4 and T3 but do not affect free
● Ureteral dilatation T4 and T3 levels

RENAL FUNCTION TESTS PARATHYROID GLAND

● Creatinine decreases from 0.7 to 0.5 mg/dl
● Day - accumulate water as dependent edema
● Night - mobilize fluid with diuresis
● Urinalysis:
o Glucosuria may not be abnormal
o Hematuria - contamination, common after difficult
labor
o Proteinuria - 300 mg/dl (value above this → suspect
preeclampsia)
BLADDER
● Increased frequency of micturition
o Enlarging uterus
o Engagement of the head
● Calcium needed for fetal growth and lactation is partly derived
from the maternal skeleton
● Parathyroid hormone release may be increased – in order to
supply more calcium to the fetus
● Calcitonin – opposes the action of the parathyroid hormone in
order to protect the maternal skeleton
● Fetal skeleton requires about 30 grams of calcium primarily
during the third trimester
● Adrenal gland - undergo little, if any, morphologic change
MUSCULOSKELETAL SYSTEM
● Progressive lordosis – shifts the center of gravity back over the
lower extremities in order to compensate for the anterior position
of the enlarging uterus → stress on pelvis and lower back
● Increased mobility of the sacroiliac, sacrococcygeal and pubic
joints

CENTRAL NERVOUS SYSTEM

● Memory, attention and concentration problems are often
reported during pregnancy and early puerperium
● Sleep - 12 weeks AOG to 2 months postpartum: difficulty falling
asleep, frequent awakening, fewer hours of night sleep and
reduced sleep efficiency
o Greater disruption is encountered postpartum and may
contribute to postpartum blues or to frank depression

Fig 25. Urinary bladder REFERENCES:

● Cunningham, F. (2022). Williams Obstetrics (26th edition). New
ENDOCRINE SYSTEM York: McGraw Hill.
● Dra. Mendoza’s Lecture
PLACENTA
● Acts as a temporary endocrine gland during pregnancy
● Produces large amounts of estrogen and progesterone by the 10-
12th week of pregnancy
● Functions:
o Maintain the growth of the uterus and fetus
o Helps control uterine activity
● Increased hormonal level and basal metabolic rate
● Posterior pituitary: oxytocin → labor
● Anterior pituitary: prolactin → breast milk production
● Parathyroid gland increases in size to meet increased
requirements for calcium

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