PHYSIOLOGICAL CHANGES OF

PREGNANCY
METABOLISM

Basal Metabolic Rate

 ↑ 10-20%: due to rapidly growing foetus and placenta

Weight Gain
Average is 12.5kg over the pregnancy
 Uterus + contents + breast
 ↑Blood volume
 ↑Fat deposition for maternal reserves
 Oedema and fluid retention: ↓venous return (caval occlusion) + ↓serum osmolality (haemodilution) + ↓serum colloid
osmotic pressure (haemodilution + ↑use)

Protein
 ↓albumin: Foetus + placenta take 500g

Carbohydrate
Glucose needed for foetus
 Fasting hypoglycaemia
 Hyperinsulinaemia
 Postprandial hyperglycaemia:↑progesterone and oestrogen  peripheral insulin resistance  available for foetus

Fat
 ↑ FFAs, triglyceride, cholesterol: Placental lactogen ↑lipolysis + FFAs
 ↑lipoprotein + apolipoprotein
o ↑FAT SOLUBLE VITAMINS (see water soluble vitamins in Urinary)

Iron
 1000mg required: obligate losses + ↑ loss to foetus, placenta, ↑RBCs

SKIN

Hyperpigmentation
↑oestrogen + progesterone  ↑MSH
 Linea nigra (linea alba)
 Chloasma/melasma gravidarum (face + neck)
 Areolae + genitals

Striae
Collagen fibre disruption in subcuticular zone
 Striae gravidarum (abdomen, breasts, thighs)
 Striae albicans (silver due to previous striae in multiparous women)

↑Cutaneous blood flow (↑BMR  ↑heat) + ↑Oestrogen

 Angiomas (vascular spiders) + Palmar erythema
MSK

 Diastasis recti- divarication of the rectus muscles due to enlarging uterus

BREAST

 Early tenderness + paraesthesia

 ↑size

Nipples
 Larger
 ↑pigmentation
 More erectile
 Colostrum may discharge

Areolae
 Broad, pigmented
 ↑Glands of Montgomery (multiple small elevations)

CARDIOVASCULAR

Hypervolaemia
↑1.25L plasma (first pregnancy), 1.5L (subsequent pregnancies): 40-45%
 1st trimester: 15% increase
 2nd trimester: Most rapid increase
 3rd trimester: slow rise – peaks at 32-34 weeks

↑RBCs: 450mL
 ↑reticulocytes
 Moderate erythroid hyperplasia in bone marrow
Still haemodilution as plasma ↑ more
 ↓Hb
 ↓RBC
 ↓PCV

Platelets
Slightly low:↑consumption + haemodilution
 ↑Coagulation + ↑Fibrinolysis
o Balanced but overall ↑clotting
o Clotting time does not change
o ↑clotting factors (except XI + XIII)
o ↑D-dimer: ↑fibrinolysis

Cardiac Output
↑of 1.5L/min to 6L/min
 ↑HR of 10-15bpm resting
 ↓Systemic vascular resistance = ↓afterload
 ↑Blood volume = ↑preload

Displacement
  Up and laterally due to diaphragm
 Slight left axis deviation on ECG
 12% enlargement (mostly due to increased filling)

Heart sounds
 Exaggerated + louder split 1st HS
 Loud 3rd HS
 90% have systolic murmur
 20% have soft diastolic murmur
 Continuous murmur heard from breast vasculature in 10%

Supine position
↓filling  ↓CO in supine position
 1/3 ↓uterine blood-flow
 LL oedema + haemorrhoids + varicose veins + DVT

IMMUNOLOGICAL

 ↑WBCs- neutrophils
 Constant eosinophil, basophil, monocyte
 Constant lymphocytes
 ↑CRP, ↑ESR

Immunosuppression
 ↑bacterial, viral and parasitic infections :TH1 (helper) and Cytotoxic T cell suppression for pregnancy

 ↑TH2
 ↑IgA & IgG in cervical mucous

Pregnancy defies laws of transplant rejection

 Mother continues to respond and destroy other foreign antigens
 Mother confers passive immunity to the foetus i.e. placenta is not an impermeable immunological barrier
 Foetus carries paternal antigens capable of stimulating maternal antibodies – yet, mother does not reject the foetus

Spleen enlargement

Thymus involution

RESPIRATORY

Diaphragm rises 4cm

 ↓Total lung capacity 200mL
o Residual volume ↓200-300mL
o Tidal volume ↑150-200Ml (40%): Progesterone lowers CO2 chemoreflex threshold  compensatory TV↑
 Respiratory Rate remains constant
=Physiological dyspnoea (with no pulmonary/cardiac abnormality)

RENAL

Enlarged kidneys
 ↑vascular volume + 70% ↑renal parenchyma
↑GFR
 25% by 4 weeks, 50% by end of 1st trimester
o URINARY FREQUENCY
o ↓serum creatinine
o Glycosuria = normal
o Proteinuria not expected, significant = >300mg/day

Acid-Base balance
Compensated respiratory alkalosis
 ↑ TV = physiological hyperventilation with constant RR  alkalosis
 Bicarbonate levels decrease from 26  22 to compensate
 pH minimally more alkali
o  ↑oxygen affinity
o  Stimulates 2.3-diphosphoglycerate in maternal RBC  O2 release to the foetus

↑UTIs
 Ureteric dilatation + reflux

Urinary retention
 Retroverted gravid uterus compresses bladder neck + urethra  acute urinary retention in early pregnancy (<14-16wk)

RAAS
 ↑Renin: produced by chorion, decidua, uterus, ovaries
 ↑Angiotensin
o ↑angiotensinogen: produced by maternal and foetal liver
o ↑ACE: also in placenta  ↑Angiotensin II
 ↑Aldosterone: ↑secretion from angiotensin

GASTROINTESTINAL

Gums
 Hyperaemia and softened gums
 Epulis: focal vascular swellings

Stomach
 ↓gastric secretion, gastric motility
 Gastric emptying time prolonged during labour and after analgaesia  ↑aspiration risk under GA
 Reflux: displacement of LES through diaphragm

Bowels
 Constipation: ↓motility + ↑water and Na+ reabsorption
 Haemorrhoids: Venous pressure + constipation

Liver
 No increase in size
 Blood flow increases
 ALP doubles
 AST, ALT, GGT, bilirubin lower

Gallbladder
 ↓contractility: progesterone  inhibits cholecystokinin SM stimulation
 Pruritis gravidarum: ↑oestrogen  inhibit intraductal transport of bile acids  retained bile salts
 Cholelithiasis: GB stasis  ↑saturation  ↑incidence of cholesterol gallstones
ENDOCRINE

Pituitary
 Enlarged by 135%
 GH predominantly from the pituitary in 1st trimester, then from the placenta
 Prolactin steadily rises

Thyroid
 Enlarges in 70% of women,↑production by 40-100%
 Iodine subject to:
o ↑urinary excretion
o Transfer to foetus
o ↑iodine uptake: compensatory follicular enlargement

Adrenals
 Constant size + functional changes
 ↑serum cortisol: ↓metabolic clearance
 ↑androgens
 Constant catecholamines