Physiologic Changes

During Pregnancy

By Adissu.G
 Introduction
 During Normal Pregnancy, almost every organ system
undergoes anatomical and functional changes
 The understanding of these adaptations to pregnancy
remains a major goal of obstetrics
 Many of these physiological adaptations could be
perceived as abnormal in the non pregnant woman.
 For example, cardiovascular changes during
pregnancy may mimic thyrotoxicosis.
On the other hand, these same adaptations may lead to
ventricular failure if there is underlying heart disease.

Physiological adaptations of normal pregnancy can be

misinterpreted as pathological and can also unmask or
worsen preexisting disease.

 The normal values for several hematologic, biochemical,

and physiologic indices during pregnancy differ markedly
from those in the non pregnant range.
 CARDIOVASCULAR SYSTEM
 Heart
 Most important changes in cardiac function occur in the first 8 weeks.
 Heart rotates on its long axis in a left- upward displacement as a result of
diaphragm elevation
 Apical beat shifts laterally.

 Increased cardiac silhouette on radiographic studies

 Resting pulse rate increases about 10-15 beats/min

 Some cardiac sounds may be altered during pregnancy.

 systolic murmur in 90 percent of pregnant women

 continuous murmurs arising from the breast vasculature in 10%

 no definite changes in the aortic and pulmonary elements of the second sound
.
 CARDIAC OUTPUT

 Increased as early as the fifth week of pregnancy,

 Decrease systemic vascular resistance

 Increase in heart rate.

 Significantly raised Between weeks 10 and 20 .

 Reaches about 40% above non pregnant levels by 20 to 24 weeks, .
 Stroke volume increases 25–30% , reaching peak values at 12–24 weeks'
gestation

Elevations in cardiac output after 20 weeks depend critically on the rise

in heart rate.
 Higher in the lateral recumbent position than supine
20 % increase when the pregnant woman was moved from her back onto
her left side. .
 About 20% greater in twin pregnancy than for singletons as a result of
greater stroke volume .
 Increases in labor in association with painful contractions
 Increased, transiently, at delivery
 Blood Volume

Increases markedly during pregnancy.

Averaged about 40 to 45 percent above non pregnant levels
Expansion begins early in the first trimester, increases rapidly
in the second trimester, and plateaus at about the 30th week.
Volume expansion results from
 An increase in both plasma (50%)
 Erythrocytes (20-30%) averaging about 450 mL as a
result of ↑plasma erythropoietin levels
RBC mass begins to increase at the start of the second
trimester and continues to rise throughout pregnancy.
By the time of delivery it is 20% to 35% above non pregnant
levels.
.
 Causes for ↑in plasma volume
 Increased estrogen production by the placenta
 Progesterone - poorly understood mechanism
 Magnitude of the increase varies according to the size of the
woman, the number of prior pregnancies, and the number of
fetuses she is carrying.
 for example 50% in singleton pregnancies ,70% with a twin
gestation
 Important functions of the ↑
 Meet the demands of the enlarged uterus with its
greatly hypertrophied vascular system.
 Protect mother, and fetus, against deleterious
effects of impaired venous return in the supine
and erect positions.
 Safe guard the mother against the adverse effects
of blood loss associated with parturition.
 Blood Pressure

 Systemic arterial pressure declines slightly

 diastolic pressure decreases more markedly
 decrease begins in the first trimester, reaches its
nadir in mid pregnancy, and returns toward non
pregnant levels by term
 Pulse pressure widens
 Systolic and diastolic pressures (and mean arterial pressure)

increase to pre pregnancy levels by about 36 weeks .

Blood pressure, varies with posture

highest when the gravid woman is sitting and somewhat lower when she
is lying down

 When elevations in blood pressure are clinically detected during

pregnancy, it is customary to repeat the measurement with the patient lying
on her side.

 In the lateral position, the blood pressure cuff around the brachial artery
is raised about 10 cm above the heart.

This leads to a hydrostatic fall in measured pressure, yielding a reading

about 7 mmHg lower than if the cuff were at heart level, as occurs during
sitting or supine measurements.
 Venous pressure progressively increases in the lower
extremities, particularly supine, sitting, or standing
(femoral)
.
 Lying in lateral recumbency minimizes changes in venous
pressure

 venous pressure in the lower extremities falls immediately

after delivery.

 Venous pressure in the upper extremities is unchanged by

pregnancy.
 Hematologic System


Red Blood Cells
RBC mass expands by about 20-30%, or by 450 mL of erythrocytes
for average pregnant woman.


Physiologic anemia of pregnancy

Because of grater plasma augmentation, hemoglobin
concentration and hematocrit decrease slightly during pregnancy

Maternal hemoglobin levels average 10.9 ± 0.8 (SD) g/dl in the
second trimester and 12.4 ± 1.0 g/dl at term.

White Blood Cells
Total blood leukocyte count increases from a pre pregnancy level of 4,300– 4,500/L to
5000–12,000/L in the last trimester
Counts in the 20,000–25,000/L range can occur during labor.
Primarily involves the polymorph nuclear form
The cause of the rise in the leukocyte count, has not been established.
Platelets
studies have reported increased production of platelets
accompanied by progressive platelet consumption.
counts fall below 150,000/L in 6% of gravidas in the
third trimester.
pregnancy-associated thrombocytopenia, which appears to
be caused by increased peripheral consumption,
resolves with delivery and is of no pathologic
significance.
Levels of prostacyclin (PGI2), a platelet aggregation inhibitor,
thromboxane A2, an inducer of platelet aggregation and a
vasoconstrictor are increased
 Clotting Factors

Circulating levels of several coagulation factors increase

Fibrinogen (factor I) and factor VIII levels increase markedly,

 factors VII, IX, X, and XII increase to a lesser extent.

Plasma fibrinogen concentrations begin to increase from non pregnant

levels (1.5–4.5 g/L) during the third month of pregnancy and
progressively rise by nearly 2-fold by late pregnancy (4–6.5 g/L).

 The high estrogen levels of pregnancy involved in the increased

fibrinogen synthesis by the liver.
 Respiratory system `

The major respiratory changes in pregnancy involve three factors:

 Mechanical effects of the enlarging uterus
 Increased total body oxygen consumption
 Respiratory stimulant effects of progesterone
 The diaphragm rises about 4 cm during pregnancy
Sub costal angle widens appreciably
The rib cage is displaced upward, increasing the angle of the ribs with the
spine.
Transverse diameter of the thoracic cage increases about 2 cm.
The thoracic circumference increases about 6cm, but not sufficiently to
prevent a reduction in the residual volume of air in the lungs created by the
elevated diaphragm.
 Pulmonary Function

The respiratory rate is little changed during pregnancy,

 The tidal volume, minute ventilatory volume, and minute oxygen uptake increase
as pregnancy advances.

The functional residual capacity and the residual volume of air are decreased as a
consequence of the elevated diaphragm

Lung compliance is unaffected by pregnancy.

The increased oxygen requirements tend to make respiratory diseases more

serious during gestation
 Lung volumes and capacities in pregnancy

Respiratory rate ------------ No significant change

Tidal volume(volume of air moved into or out of lungs during quiet breathing)
------------ Progressive ed 0.1-0.2 L,40%

Expiratory reserve volume(maximal volume of air that can be exhaled)

------------ ed 15% (0.55 L vs 0.65 L )

Residual volume( volume of air remaining in the lungs after exhalation)

------------ ed (0.77 vs 0.96 L )

Vital capacity (volume of air breathed out after deepest inhalation)------------ unchanged

Inspiratory capacity (total amount of air that can be drawn)------------ ed 5%

Functional residual capacity(volume in the lungs at the end expiratory position

------------ ed18%

Minute ventilation (inhaled/exhaled volume of gas per minuitue ------------ ed 40%

The enlarging uterus elevates the resting position of the
diaphragm resulting in
 less negative intra thoracic pressure and
 a decreased resting lung volume,
 a decrease in functional residual capacity
(FRC).
 No impairment in diaphragmatic or thoracic muscle
motion.
Hence, the vital capacity (VC) remains un changed
 OXYGEN CONSUMPTION AND VENTILATION

Total body oxygen consumption increases about 15% to 20% in

pregnancy.
 Half of this increase is accounted for by the uterus and its contents.
 The remainder is accounted for increased maternal renal and cardiac
work.
 Smaller increments are due to greater breast tissue mass and to increased
work of the respiratory muscles.
The elevations in both cardiac output and alveolar ventilation are
greater than those required to meet the increased oxygen consumption.
despite the rise in total body oxygen consumption, arteriovenous
oxygen difference and arterial PCO2 both fall. The fall in PCO2, indicates
hyperventilation.
 The respiratory stimulating effect of progesterone is probably responsible for the
disproportionate increase in minute ventilation over oxygen consumption.
 DYSPNEA OF PREGNANCY

 Dyspnea is a common symptom in pregnancy,

experienced at some time during pregnancy by
as many as 60% to 70% of women.
 The underlying pathophysiology remains
unclear.
 The marked change in PCO2 to unusually low
levels may result in the sensation of dyspnea.
 PCO2 decreases from 40 to 35
 URINARY TRACT

 urinary collecting system, undergoes marked dilation ,

as is readily seen on intravenous urograms
 Begins in the 1st trimester, is present in 90% of women
at term,
 Persist until the 12th to 16th postpartum week.
 Progesterone appears to produce smooth muscle
relaxation in various organs, including the ureter.
 As the uterus enlarges, partial obstruction of the ureter
occurs at the pelvic brim in both the supine and the
upright positions.
 More on the right side probably b/c of dilated ovarian
venous pluxus
Clinical significance
Retained urine leads to
collection error
Mistaken for obstructive
uropathy
More virulent upper
urinary tract infection
 Elective pyelography
should be postpone after
12 weeks post partum
RENAL BLOOD FLOW AND GLOMERULAR
FILTRATION RATE

 Increase early in pregnancy,

 Achieve a plateau at about 40% above non
pregnant levels by mid gestation, and then remain
unchanged to term.
 As was true for cardiac output, reach their peak
relatively early in pregnancy, before the greatest
increase in intravascular and extracellular volume
occurs.
 The elevated GFR is reflected in lower serum
levels of creatinine and urea nitrogen,
 Clinical significance

 Serum creatinine and urea nitrogen values decrease during

normal gestation( < 0.8 mg /dl creatine ) ,( 1.4mg/dl BUN)
 Increase protein, amino acid, and glucose excretion
Tests of renal function
 serum creatinine and urea nitrogen levels
decrease from a mean of 0.7 and 1.2
mg/dL to 0.5 and 0.9 mg/dL,
respectively,
 whereas values of 0.9 and 1.4 mg/dL suggest
underlying renal disease and should prompt
further evaluation
 Urine analysis
Glucosuria is not necessarily abnormal.
 Increase in glomerular filtration,together with impaired
tubular reabsorptive capacity for filtered glucose, accounts
in most cases for glucosuria
 For these reasons alone, about one sixth of all pregnant
women should spill glucose in the urine.
The possibility of diabetes mellitus should not be ignored
when it is identified.
Proteinuria normally is not evident
Albumin excretion is minimal and ranges from 5 to 30
mg/day.
 RENAL TUBULAR FUNCTION

500 to 900 mEq of sodium are retained during pregnancy,

Sodium balance is maintained with precision.
 Pregnant women given high or low sodium diets are able to demonstrate
decreases or increases in sodium tubular reabsorption, respectively, which
maintain sodium and fluid balance.
 About 350 mEq of potassium are retained during pregnancy for
fetoplacental development and expansion of maternal red cell mass.

Pregnancy causes compensated respiratory alkalosis with chronic losses of

renal bicarbonate.
These reductions in the renal buffering capacity predispose pregnant women to
severe metabolic acidosis (ketoacidosis or lactic acidosis).
 Bladder
Few significant anatomical changes in the bladder before 12 weeks.
Bladder trigone eleveted and causes thickening of its posterior, or
intraureteric, margin.

 The bladder mucosa undergoes no change other than an increase in the

size and tortuosity of its blood vessels.

Bladder pressure in primigravidas increased from 8 cm H O early in

2
pregnancy to 20 cm H2O at term.

To preserve continence, maximal intraurethral pressure increased

from 70 to 93 cm H2O.

.
 Gastrointestinal system

Mouth

PH and the production of saliva is unchanged

Ptyalism, associated with the loss of 1 to 2 L of saliva per day.

inability of the nauseated woman to swallow normal amounts of saliva
pregnancy does not cause or accelerate the course of dental caries.
hypertrophied , hyperemic , spongy friable gums
bleed after tooth brushing,
gingivitis of pregnancy


epulis of pregnancy
focal highly vascular swelling

May bleed profusely

Regress spontaneously after delivery
 Stomach
 Tone and motility are decreased
 Scientific evidence regarding delayed gastric emptying is
inconclusive.
 Emptying time longer in pregnant women with heartburn
 Increased delay is seen in labor
 increase in gastro esophageal reflux disease and dyspepsia
 Reflux of acidic secretions into the lower esophagus
 Decreased lower esophageal tone
 Lower intra esophageal pressure
 Higher intra gastric pressures
 Esophageal dysmotility
 gastric compression from the enlarged uterus
 decreased risk of peptic ulcer disease
 increased placental histaminases synthesis
 increased gastric mucin production
 reduced gastric acid secretion
 enhanced immunologic tolerance of Helicobacter
pylori
Intestines
 Reduced motility of small intestine
Increased oral -cecal transit time
increased water and sodium absorption in the colon
Unchanged absorption of nutrient from small bowl
Increased absorption of calcium and iron
The appendix, is displaced upward and somewhat laterally
 Gallbladder
 Increased fasting and residual volumes
 Increased cholesterol saturation
Liver
 no distinct changes in liver morphology
 increase in diameter of the portal vein and its blood flow
Changes in laboratory measurements of liver function
 serum albumin and total protein levels fall during
gestation
 serum alkaline phosphatase activity rises
 serum concentrations fibrinogen, ceruloplasmin,
transferrin, and binding proteins for corticosteroids, sex
steroids, thyroid hormones, and vitamin D increased
 Unchanged serum levels of bilirubin,AST ,ALT , and
lactate dehydrogenase
 Reproductive Tract
Uterus

 almost-solid
Non pregnant uterus
structure
 weighing about 70 g
 cavity of 10 mL or less
Pregnant uterus
 a relatively thin-walled
muscular organ .
 total volume of the contents at
term averages about 5 L but
may be 20 L or more,
 by end of pregnancy the uterus
has achieved a capacity that is
500 to 1000 times greater than
in the non pregnant state.
 by term weighs approximately
1100 g
 cont….

 uterine enlargement involves

 stretching and marked hypertrophy of muscle cells

 limited production of new myocytes
 accumulation of fibrous tissue, particularly in the external muscle layer
considerable increase in elastic tissue
 Uterine enlargement is most marked in the fundus
 the fallopian tubes , ovarian and round ligaments attach slightly above the middle of the
uterus
 cervix
begins to undergo pronounced softening and cyanosis early in
pregnancy
increased vascularity and edema of the entire cervix,
hypertrophy and hyperplasia of the cervical glands.
contains a small amount of smooth muscle
 major connective tissue.
glands undergo marked proliferation and occupy approximately
half of the entire cervical mass at term

 extension, or eversion, of the proliferating columnar endocervical

glands red and velvety and bleeds even with minor trauma
,
 Continued…

 mucosal cells produce copious amounts of a tenacious mucus

 obstruct the cervical canal soon after conception
 is rich in immunoglobulin and cytokines
 expelled at the onset of labor resulting in a bloody show
 consistency of the cervical mucus changes
spread and dried on a glass slide, is characterized by crystallization,
or beading, as a result of progesterone.
 arborization of the crystals, or ferning, is observed as a result of
amniotic fluid leakage

 basal cells near the squamocolumnar junction are likely to be

prominent in size, shape, and staining qualities. considered to be
estrogen induced.
 Vagina and Perineum

 increased vascularity in the skin and muscles of the perineum and vulva
 softening of the underlying abundant connective tissue.
 Increased vascularity of vagina results in the violet color characteristic of
the Chadwick sign.
 Considerable increase in
 thickness of the mucosa,
 loosening of the connective tissue

 hypertrophy of smooth muscle cell

 papillae of the vaginal mucosa

 Increased volume of secretions thick, white discharge.

 pH is acidic, varying from 3.5 to 6,
 Skin

 Striae gravid arum or stretch marks

 reddish, slightly depressed streaks
 in the skin of the abdomen ,breasts and thighs.
 In multiparous women, in addition to the reddish striae
 glistening, silvery lines representing
 cicatrices of previous striae are seen.

 Linea alba

 becomes markedly pigmented

 brownish-black color
 called linea nigra
 Continued…..

chloasma or melasma gravid arum

Irregular brownish patches of varying size on face neck
 called mask of pregnancy.
 Pigmentation of the areola and genital skin may also be accentuated

 pigmentary changes usually disappear, or at least regress after

delivery

 Melanocyte-stimulating hormone, is bleived to cause this changes

 Estrogen and progesterone also are reported to have melanocyte-

stimulating effects.
 Vascular changes
 Spider angioma
 minute, red elevations on the skin,
 with radicles branching out from a central lesion
 particularly on the face, neck, upper chest arms
 develop in two thirds of white women
 10 percent of black women.

Palmar erythema
 encountered in two thirds of white women
 one third of black women.

no clinical significance disappear shortly after

pregnancy.

 most likely the consequence of the hyperestrogenemia.

 Breasts

In the early weeks breast tenderness and tingling.

After the second month,

 breasts increase in size,
 veins become visible just beneath the skin.
 nipples become larger, deeply pigmented, and erectile.
After the first few months
 colostrum a thick, yellowish fluid expressed from the nipples
by gentle massage.
 areola become broader and deeply pigmented.
 glands of Montgomery,
 a number of small elevations Scattered through the areola
 hypertrophic sebaceous glands.
prepregnancy breast size and volume of milk production do
not correlate
 Metabolic Changes
 are numerous and intense.
the additional energy demands have been estimated to be 300
kcal/day
Water Metabolism
 Average women retains about 6.5 L water during normal pregnancy

fetus, placenta, and amniotic fluid amounts to about 3.5 L.

 increases in the maternal blood volume , in the size of the uterus and
the breasts amounts another 3L

Studies in well-nourished term women suggest that maternal body

water, rather than fat, contributes more significantly to infant birth
weight
 Protein Metabolism

 protein required
growth and repair of the fetus, placenta, uterus, and breasts,
increased maternal blood volume
 second half of pregnancy, 1000 g of protein are
deposited, 5 to 6 g/day
 Continued….

 At term, the fetus and placenta weigh 4 kg and contain 500 g of

protein

 The remaining 500 g is added

 uterus as contractile protein,
 breasts primarily in the glands,
 maternal blood as hemoglobin and
plasma proteins.

 breakdown of maternal muscle is not required

 Carbohydrate Metabolism

 Normal pregnancy
 mild fasting hypoglycemia
 postprandial hyperglycemia
 hyperinsulinemia
 after an oral glucose meal, gravid women demonstrate
 prolonged hyperglycemia and hyperinsulinemia
 greater suppression of glucagon
This response is consistent with a pregnancy-induced state
of peripheral resistance to insulin
 ensure a sustained postprandial supply of glucose to
the fetus
 insulin action in late normal pregnancy is 50 to 70 percent
lower than that of healthy, non pregnant women
 Progesterone and estrogen may act, directly or indirectly,
to mediate this resistance.
 Continued…
 Plasma levels of placental lactogen increase with gestation
 characterized by growth hormone–like action
 increased lipolysis with liberation of free fatty acids
 increased concentration of circulating free fatty acids
 facilitate increased tissue resistance to insulin.
pregnant woman changes rapidly from a postprandial state
to a fasting state
 During fasting, the plasma concentrations of free fatty
acids, triglycerides, and cholesterol are higher.
 when fasting is prolonged in the pregnant woman, these
alterations are exaggerated and ketonemia rapidly appears
 Fat Metabolism

concentrations

 lipids
 lipoprotein in plasma increase appreciably
 apolipoproteins
storage occurs primarily during mid pregnancy
 deposited mostly in central rather than peripheral sites.

Later in pregnancy maternal fat storage decreases.

progesterone reset a lipostat in the hypothalamus

 LDL-C levels peak at approximately week 36,

HDL-C peaks at week 25, decreases until week 32, and remains constant then after
increase is believed to be caused by estrogen.
 Electrolyte and Mineral Metabolism

 sodium and potassium

 1000 mEq of sodium and 300 mEq of potassium are retained
 glomerular filtration of sodium and potassium is increased,
 excretion unchanged as a result of enhanced tubular
reabsorption
 serum concentrations decreased slightly
 remain near the range of normal for non pregnant women
Calicum
Total serum calcium levels decline
serum ionized calcium, remain unchanged
During the third trimester,
 200 mg of calcium are deposited in the fetal skeleton per day
 Dietary intake of sufficient calcium especially important in
pregnant adolescents
 Continued…
 Serum magnesium
 state of extracellular magnesium depletion.
 both total and ionized magnesium are decreased
 serum phosphate levels are within the non pregnant range

With respect to most other minerals, pregnancy induces

little change in their metabolism other than their
retention in amounts equivalent to those used for
growth of fetal and, to a lesser extent, maternal tissues

 An important exception, is the considerably increased

requirement for iron
 Weight Gain

increase in weight
 the uterus and its contents
 the breasts
 blood volume and extra vascular extracellular
fluid.
 increase in cellular water new fat and protein,

 the average weight gain during

pregnancy is approximately 12.5 kg
Analysis of Weight Gain Based on Physiological Events during Pregnancy

  Cumulative Increase in Weight (g)

Tissues and Fluids 10 20 Weeks  30 Weeks  40 Weeks 
Weeks 
Fetus 5 300 1,500 3,400
Placenta 20 170 430 650
Amniotic fluid 30 350 750 800

Uterus 140 320 600 970

Breasts 45 180 360 405
Blood 100 600 1,300 1,450
Extra vascular fluid 0 30 80 1,480

Maternal stores (fat) 310 2,050 3,480 3,345

  Total 650 40,00 8,500 12,500

Thank you!!!