Maternal physiological

changes during pregnancy

 During normal pregnancy, every organ system undergoes anatomical and
functional changes that can alter the criteria for diagnosis and treatment
of disease

 Many of physiological adaptations could be perceived as abnormal in the

nonpregnant woman

 Physiological adaptations of normal pregnancy can be misinterpreted as

pathological but can also unmask or worsen preexisting disease
Cardiovascular Changes
Cardiovascular System

 The earliest and most dramatic changes in maternal physiology

 These changes improve fetal oxygenation and nutrition

Cardiovascular System

Anatomic Changes

 The heart is displaced upward and to the left

 The apex is moved laterally

Cardiovascular System

Functional Changes
 The primary change is a marked increase in cardiac output (COP)
 Overall, COP increases from 30% to 50%, with 50% by 8 weeks of gestation
 In the first half of pregnancy, COP rises as a result of increased stroke
volume and, in the latter half of pregnancy, as a result of increased
maternal heart rate
 These changes in stroke volume are due to alterations in circulating blood
volume and systemic vascular resistance.
 However, late in pregnancy, cardiac output may decrease when venous
return to the heart is impeded because of vena caval obstruction by the
enlarging gravid uterus.
Cardiovascular System

 The uterus receives about 2% of the COP in the 1st trimester, increasing to up to
20% at term
 One-fifth of the COP goes through the uterus at term increasing the risk from
PPH substantially.
 COP increases significantly immediately after delivery, because venous return to
the heart is no longer blocked by the gravid uterus

 During pregnancy, arterial blood pressure follows a typical pattern.

 Physiologic changes in blood pressure in midpregnancy may be misunderstood
as hypotension unless allowance for gestational age is made.

 Resting maternal pulse increases as pregnancy progresses, increasing by 10 to

18 bpm over the nonpregnant value by term.
Cardiovascular System

Symptoms (inferior vena cava syndrome)

 Although most women do not become overtly hypotensive when lying supine, perhaps 1
in 10 has symptoms that include dizziness, light-headedness, and syncope.

Physical Findings (HYPERDYNAMIC STATE)

 an increased S2 split with inspiration
 distended neck veins
 low-grade systolic ejection murmurs (increased blood flow across the aortic and pulmonic valves)
 S3 gallop, or third heart sound, after midpregnancy.

Diastolic murmurs should not be considered normal in pregnancy (should always engender
evaluation for cardiac pathology).
Cardiovascular System

Diagnostic Tests
 Serial blood pressure assessment is an essential component of each
prenatal care visit. Its influenced by maternal position.

 CXR: cardiac silhouette can appear enlarged (misinterpretation of

cardiomegaly)

 ECGs: slight left-axis deviation
Respiratory Changes
Respiratory System

Anatomic Changes
 The diaphragm is elevated approximately 4 cm by late pregnancy due to
the enlarging uterus.
 The subcostal angle widens as the chest diameter and circumference
increase slightly
Respiratory System

Functional Changes
 Increase in total body oxygen consumption ( 20% greater than nonpregnant )

 The consequence of diaphragmatic elevation is a 20% reduction in the residual volume

and functional residual capacity plus a 5% reduction in total lung volume.

 Although the maternal respiratory rate is essentially unchanged, there is a 30% to 40%
increase in tidal volume due to a 5% increase in inspiratory capacity, resulting in a 30% to
40% increase in minute ventilation.
 Progesterone causes increased central chemoreceptor sensitivity to CO2, which results in
increased ventilation and a reduction in arterial pco2. The respiratory alkalosis that results
from a decreased arterial pco2 in pregnancy is compensated for by increased renal
excretion of bicarbonate, yielding the lower bicarbonate levels normally seen in
pregnancy, which means that maternal arterial pH is normal.
Respiratory System

Symptoms
 Dyspnea of pregnancy is a physiologic response to a low arterial pco2 but still requires evaluation as it may represent
respiratory or cardiac illness.
 Mucosal hyperemia results in increased amount of nasal secretions.

Physical Findings: no significant finding

Diagnostic Tests
 ABG: normally show a compensated respiratory alkalosis.
o Arterial pco2 : 27 to 32 mm Hg
o bicarbonate : 18 to 31 mEq/L should be considered normal.
o Maternal arterial pH : 7.40 to 7.45.

 CXR: prominent pulmonary vasculature(increased circulating blood volume)

Hematological Changes
Hematological Changes

 Maximize the oxygen-carrying capacity of the mother to enhance oxygen

delivery to the fetus.

 Minimize the effects of impaired venous return and blood loss associated
with labor and delivery.

 The primary anatomic adaptation is a marked increase in plasma volume,

red cell volume, and coagulation factors
Blood Volume
Hypervolemia 40-45%

 Begins to increase as early as the 6th week of pregnancy and reaches a

maximum at 30 to 34 weeks of gestation, after which it stabilizes.
 The mean increase is approximately 50% in singleton gestations and greater in
multiple gestations.
 Pregnancy induced hypervolemia has important functions

 It is leading to auscultatory changes as S1 splitting, auditory S3, systolic murmur

and occasionally, a transient diastolic murmur

 Red cell volume also increases during pregnancy, although to a lesser extent
than plasma volume, averaging about 450 mL. Maternal blood volume
increases 35% by term.
Iron Metabolism

Iron Requirements
 The normal pregnant patient requires a total of 1,000 mg of additional iron

 Because iron is actively transported to the fetus, fetal hemoglobin (Hgb)

levels are maintained regardless of maternal iron stores.

 To meet maternal iron needs in a woman who is not anemic, 60 mg of

elemental iron is recommended daily.

 Its become large after mid pregnancy (most iron is used during this period)
and averages 6-7 mg/day
Leukocytes

 White blood cell counts typically increase slightly in pregnancy, returning to

nonpregnant levels during the puerperium.

 During labor, the white blood cell count may further increase, primarily from
increased granulocytes, presumably linked with stress-associated
demargination rather than a true disease-associated inflammatory
response.
Platelets

 Platelet counts may decline slightly but remain within the normal,
nonpregnant range.
Coagulation and Fibrinolysis

 The concentration of numerous clotting factors is increased during

pregnancy. Fibrinogen (factor I) increases by 50%, as do fibrin split products
and factors VII, VIII, IX, and X.

 Prothrombin (factor II) and factors V and XII remain unchanged.

 In contrast, the concentration of key inhibitors of coagulation, activated

protein C and protein S, decreases.
Hematological Changes

Functional Changes
 The compensated respiratory alkalosis of pregnancy causes a shift in the
maternal oxygen dissociation curve to the left, via the Bohr effect.
 In the maternal lungs, Hgb affinity for oxygen increases, whereas in the
placenta, the CO2 gradient between fetus and mother is increased, which
facilitates transfer of CO2 from fetus to mother.

 The risk of thromboembolism doubles during pregnancy, which is

considered a hypercoagulable state, and increases to 5.5 times the normal
risk during the puerperium.
Hematological Changes

Symptoms and Physical Findings

 Some edema is normal in pregnancy, and swelling of the hands, face, legs,
ankles, and feet may occur.

 This tends to be worse late in pregnancy and during the summer.

Hematological Changes

Diagnostic Tests
 Physiologic anemia: The disproportionate increase in plasma volume,
compared with red cell volume, results in a decrease in Hgb concentration and
hematocrit during pregnancy
 At term, the average Hgb concentration is 12.5 g/dL (14 g/dL in the
nonpregnant state)
 Values less than 11.0 g/dL are usually due to iron deficiency

 The leukocyte count: from 5,000 to 12,000/L (as much as 30,000/L during labor
and the puerperium).

 Fibrinogen: from 300 to 600 mg/dL in pregnancy, (compared with 200 to 400
mg/dL in the nonpregnant state.
Renal Changes
Renal System

 The renal system is the site of increased functional activity during

pregnancy to maintain fluid, solute, and acid–base balance in response to
the marked activity of the cardiorespiratory systems
Renal System

Anatomic Changes
 The primary change is enlargement and dilation of the kidneys and urinary
collecting system.
 The renal calyces, pelves, and ureters dilate during pregnancy because of
mechanical and hormonal factors.

 Mechanical compression of the ureters occurs as the uterus enlarges and rests
on the pelvic brim. Right ureter usually more dilated than left; due to
compression by gravid uterus and ovarian venous plexus
 Progesterone causes relaxation of the smooth muscle of the ureters and dilation
 As the uterus enlarges as pregnancy progresses, bladder capacity decreases.
Renal System

Functional Changes
 A result of an increase in renal plasma flow.
 Early in the first trimester, renal plasma flow begins to increase, and, at term,
it may be 75% greater than nonpregnant levels.

 The glomerular filtration rate (GFR) increases to 50% over the nonpregnant

 Urinary glucose excretion increases in virtually all pregnant patients. A trace

of glucose on routine prenatal dipstick evaluation is normal and is usually
not associated with glycemic pathology but should be watched closely for
further trends into true glucosuria.
Renal System

Functional Changes

 Amino acids and water-soluble vitamins, such as vitamin B12 and folate,
are also excreted to a greater extent compared with the nonpregnant
state.
 Increase all components of renin (T 1 0 X)-angiotensin (T 5X)-aldosterone
system; women with hypertensive disease more vulnerable
Renal System

Symptoms
 Urinary frequency: due to mass effect of gravid uterus
 Stress urinary incontinence (20%)
 Urinary stasis predisposes to an increased incidence of pyelonephritis in
patients with asymptomatic bacteriuria.
Physical Findings
 As pregnancy advances, pressure from the presenting part on the maternal
bladder can cause edema and protrusion of the bladder base into the
anterior vagina.
 No significant finding
Renal System

Diagnostic Tests
 Decrease in blood urea nitrogen (BUN) by 25% (8-10 mg/dL)
 Creatinine decrease 0.5-0.6 mg/dL at term (0.8 mg/dL in nonpregnant
women)
 Creatinine clearance increase by 30%
 Because glucosuria is common during pregnancy, quantitative urine
glucose measurements are often elevated but may not signify an
abnormal blood sugar.
 normal dilation of the renal collecting system resembling hydronephrosis on
US or IVP
Gastrointestinal Changes
Gastrointestinal (GI) System

 The anatomic and functional changes in the GI system that occur during
pregnancy are due to the combined effect of the enlarging uterus and the
hormonal action of pregnancy.

 These changes produce a number of pregnancy-related symptoms that

can range from mild discomfort to severe disability.
Gastrointestinal System

Anatomic Changes
 The primary change related to pregnancy is the displacement of the
stomach and intestines due to the enlarging uterus.

 Although the stomach and intestines change in position, they do not

change in size.

 The liver and biliary tract also does not change in size, but the portal vein
enlarges due to increased blood flow.
Gastrointestinal System

Functional Changes (Due to hormonal action of progesterone and estrogen)

 Generalized smooth muscle relaxation
 Transit time in the stomach and small bowel increases significantly

 Intestinal motility —» constipation

 Lower esophageal sphincter tone —> reflux
 Gallbladder contractility —> gallstones and cholestasis
 Estrogen also stimulates hepatic biosynthesis of proteins such as fibrinogen;
ceruloplasmin; and the binding proteins for corticosteroids, sex steroid
Gastrointestinal System

Symptoms: earliest and most obvious symptoms of pregnancy

 Nausea and vomiting of pregnancy (NVP), or “morning sickness
 hyperemesis gravidarum
 Pica: intense craving for foods or nonfoods (e.g., clay)
 Ptyalism is excessive production of saliva
 Gastroesophageal reflux: worsens as pregnancy advances
 Constipation: mechanical obstruction of the colon by the enlarging uterus,
reduced intestinal motility and increased water absorption from GIT
 Generalized pruritus: from intrahepatic cholestasis and increased serum bile
acid concentrations.
Gastrointestinal System

Physical Findings
 Hemorrhoids: due to constipation, mass effect of enlarging uterus, and
increased venous blood flow
 Gingival disease: edematous gums bleed more easily with brushing
Diagnostic Tests
 Total serum alkaline phosphatase concentration is doubled, mainly due to
increased placental production.
 Serum cholesterol levels increase
 serum albumin level are lower: due to hemodilation.
 No changes to alanine aminotransferase, aspartate aminotransferase, amylase,
lipase, 7 -glutamyl transpeptidase
Endocrine System
Endocrine System

Anatomy
Enlargement of thyroid gland
No change in size of adrenal glands
Endocrine System

Functional changes
 hCG stimulates thyroid, causes transient rise in free thyroxine (T4) in early
pregnancy
 Increase Serum cortisol, free cortisol, and serum aldosterone
 Decrease Dehydroepiandrosterone (DHEA) due to increased hepatic
metabolism, conversion to estrogen
 Increase Insulin resistance, possibly due to human placental lactogen’s
insulin antagonism
 Increase Lipids, lipoproteins, apolipoproteins: fat stored centrally in early
pregnancy
 Musculoskeletal System

 Lumbar lordosis (anterior convexity of lower spine)

a. Maintains center of gravity as uterus grows
b. High frequency of low back pain

 Exacerbation of hernia defects (e.g., umbilical hernias)

 Separation of pubic symphysis

a. Typically occurs at 28-30 weeks, mediated by relaxin
b. Can have unsteady gait, increase frequency of falls
Skin

Anatomy
 a. increase Estrogen and progesterone cause skin changes
i. Vascular spiders (spider angiomata) on upper torso, face, arms
ii. Palmar erythema, present in 50% of patients

 b. Striae gravidarum >50% of patients

i. Occur on lower abdomen, breasts, thighs
ii. Appear pink/purple, eventually turn pale
iii. No effective preventive therapy; cannot be eliminated
Skin

Anatomy
 c. Hyperpigmentation
i. Occurs on any skin surface; commonly involves umbilicus, perineum, face
(melasma), and lower abdomen (linea nigra)
ii. Nevi can increase in size, resolve postpartum
Reproductive Tract

 Uterus
i. Increases in size from 70 g (nonpregnant) to 1,100 g at term due to hypertrophy
of myometrium
ii. Uterine cavity accommodates up to 5 L (nonpregnant = <10 mL)
 Vagina: increase blood flow
 Vulva: may develop venous varicosities (typically resolve postpartum)

 Leukorrhea: An increase in vaginal transudation as well as stimulation of the

vaginal epithelium results in a heavier vaginal discharge

 The epithelium of the endocervix everts onto the ectocervix, which is associated
with a mucus plug.
Breast

Anatomy
 a. increase Size over course of pregnancy
i. Rapidly over the first 8 weeks, steadily thereafter
ii. Total enlargement is usually 25%-50%
iii. Nipples increase in size and pigmentation
 b. increase Blood flow to support lactation

Functional changes
 a. Estrogen —» ductal growth
 b. Progesterone —¥ alveolar hypertrophy
 c. Colostrum: thick yellow fluid expressed from nipples in late pregnancy
 d. Lactation dependent on interplay of estrogen, progesterone, prolactin, hPL, cortisol, and insulin