Normal Values in Pregnancy

Invasive Cardiac Monitoring Noninvasive Cardiac Monitoring Arterial Blood Gas Values Pulmonary Function Tests Liver Function Tests Electrolytes, Osmolality, and Renal Function 24-hour Urine Protein

Metabolic Markers and Lipids White Blood Cells Red Blood Cell Indices Iron, Folate, and Vitamin B12 Levels Platelet Count Fasting Homocysteine With and Without Folate Supplementation Coagulation Factor Levels

Coagulation Parameters Calcium Metabolism Thyroid Function Tests Adrenal Function Tests Umbilical Cord Blood Gas Values and Hematologic Parameters

Invasive Monitoring MEASURE Cardiac output Systemic vascular resistance Heart rate Pulmonary vascular resistance Colloid oncotic pressure Mean arterial pressure (MAP) Pulmonary capillary wedge pressure (PCWP) Central venous pressure (CVP) Left ventricular stroke work index VALUE (3638 WEEKS) 6.2 1.0 1,210 266 83 10 78 22 18.0 1.5 90.3 5.8 7.5 1.8 3.6 2.5 48 6 UNITS liters/minute dyne cm second5 beats/minute dyne cm second5 mm Hg mm Hg mm Hg mm Hg g mm2

Cardiac output is increased in pregnancy but is essentially unchanged over the course of pregnancy. Heart rate gradually rises 5 to 10 bpm over the course of pregnancy. References: Clark SL, Cotton DB, Lee W, et al: Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 161:1439, 1989. Spatling L, Fallenstein F, Huch A, et al: The variability of cardiopulmonary adaptation to pregnancy at rest and during exercise. Br J Obstet Gynaecol 99(Suppl 8):1, 1992.

Noninvasive Monitoring MEASURE Cardiac output (L/min) Stroke volume (mL) SVR (dyne cm second5) Heart rate (beats/min) Mean arterial pressure (mm Hg) 1018 WEEKS 7.26 1.56 85 21 966 226 87 14 87 7 1826 WEEKS 7.60 1.63 85 21 901 224 90 14 84 7 2634 WEEKS 7.38 1.63 82 21 932 240 92 14 84 7 3442 WEEKS 6.37 70 1,118 92 86 1.48 14 325 7 7

SVR, systemic vascular resistance. Reference: Van Oppen CA, Van Der Tweel I, Alsbach JGP, et al: A longitudinal study of maternal hemodynamics during normal pregnancy. Obstet Gynecol 88:40, 1996.

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Normal Values in Pregnancy

Third-Trimester Arterial Blood Gas Values NORMAL ALTITUDE Arterial pH Arterial Po2 (mm Hg) O2 Saturation (%) Arterial Pco2 (mm Hg) Sodium bicarbonate (mEq/L) 7.44 0.04 85 5 29.7 2.8 22.0 2.1 MODERATE ALTITUDE (1,388 M, PROVO, UT) 7.46 86.2 96 26.6 18.6 0.02 7.3 1 2.7 1.9

References: Hankins GD, Clark SL, Harvey CJ, et al: Third trimester arterial blood gas and acid base values in normal pregnancy at moderate altitude. Obstet Gynecol 88:347, 1988. Eng M, Butler J, Bonica JJ: Respiratory function in pregnant obese women. Am J Obstet Gynecol 123:241, 1975.

Pulmonary Function Tests 811 WEEKS Respiratory Rate (br/min) Tidal Volume (mL) 15 (1420) 640 (550710) 2023 WEEKS 16 (1518) 650 (625725) 2831 WEEKS 18 (1520) 650 (575720) 3640 WEEKS 17 (1618) 700 (660755)

(Median, 25th75th Percentile) Adapted from Spatling L, Fallenstein F, Huch A, et al: The variability of cardiopulmonary adaptation to pregnancy at rest and during exercise. Br J Obstet Gynaecol 99:1, 1992.

Mean Values Vital capacity First trimester Second trimester Third trimester Inspiratory capacity First trimester Second trimester Third trimester Expiratory reserve volume First trimester Second trimester Third trimester Residual volume First trimester Second trimester Third trimester 3.8 3.9 4.1 2.6 2.7 2.9 1.2 1.2 1.2 1.2 1.1 1.0 Liters Liters Liters Liters Liters Liters Liters Liters Liters Liters Liters Liters

Peak Flows (5th% Shown as Lower Limit of Normal) Stable Over Gestation PEAK FLOW (L/MIN) Standing Sitting Supine >320 >310 >300

Adapted from Harirah HM, Donia SE, Nasrallah FK, et al: Effect of gestational age and position on peak expiratory ow rate: a longitudinal study. Obstet Gynecol 105:372, 2005.

References: Gazioglu K, Kaltreider NL, Rosen M, Yu PN: Pulmonary function during pregnancy in normal women and in patients with cardiopulmonary disease. Thorax 25:445, 1920. Puranik BM, Kaore SB, Kurhade GA, et al: A longitudinal study of pulmonary function tests during pregnancy. Indian J Physiol Pharmacol 38:129, 1994.

LIVER FUNCTION TESTS

WEEK 12 Total alkaline phosphatase (IU/L) Gamma glutamyl transferase (IU/L) Aspartate transaminase (AST, IU/L) Alanine transaminase (ALT, IU/L) Total bilirubin (IU/L) 42 (1788) 7 (218) 9 (418) 9 (430) 4 (112) WEEK 32 82 (46165) 6 (320) 9 (521) 8 (222) 4 (29) INTRAPARTUM 97 (48249) 9 (579) 11 (5103) 12 (5115) 4 (210)

Medians, Range Sixty-six women with uncomplicated pregnancies followed longitudinally. Reference: van Buul EJA, Steegers EAP, Jongsma HW, et al: Haematological and biochemical prole of uncomplicated pregnancy in nulliparous women; a longitudinal study. Neth J Med 46:73, 1995.

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ELECTROLYTES, OSMOLALITY, AND RENAL FUNCTION

12 WEEKS Total osmolality (mosmol/kg) Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L) Creatinine clearance (ml/24 hours) Blood urea nitrogen (BUN) Serum albumin (g/L) Urine volume (mL/24 hours) 267279 133141 3.54.3 102108 76188 1.74.4 3747 7502,500 20 WEEKS 269285 136142 3.54.3 103111 88168 1.95.3 3442 8502,400 28 WEEKS 273283 135143 3.54.4 104112 40192 1.94.2 3142 7502,700 38 WEEKS 271289 135141 3.64.5 102111 52208 1.84.6 3139 5503,900

5th95th Percentile Adapted from van Buul EJA, Steegers EAP, Jongsma HW, et al: Haematological and biochemical prole of uncomplicated pregnancy in nulliparous women; a longitudinal study. Neth J Med 46:73, 1995.

24-Hour Urinary Protein (mg/24 Hours) First trimester Second trimester Third trimester 80.0 60.6 116.7 69.3 115.3 69.2

Mean SD Reference: Higby K, Suiter J, Phelps JY, et al: Normal values of urinary albumin and total protein excretion during pregnancy. Am J Obstet Gynecol 171:984, 1994.

METABOLIC MARKERS AND LIPIDS

416 WEEKS Uric acid (mg/dL) Creatinine (mg/dL) Total cholesterol (mg/dL) Triglycerides Free fatty acids (mEq/L) 3.21 0.10 0.58 0.03 153.5 3.8 70.1 4.5 0.42 0.03 1624 WEEKS 3.48 0.13 0.50 0.04 194.0 5.2 109.6 5.8 0.34 0.02 2434 WEEKS 3.49 0.11 0.50 0.03 218.3 6.4 139.6 6.9 0.21 0.02 TERM 4.72 0.13 0.57 0.03 220.4 8.4 159.0 8.1 0.67 0.04

Medians SD Reference: Lain KY, Markovic N, Ness RB, Roberts JM: Effect of smoking on uric acid and other metabolic markers throughout normal pregnancy. J Clin Endocrinol Metab 90:5743, 2005.

White Blood Cell Count (109/L) 18 Weeks 32 Weeks 39 Weeks 8.8 (5.613.8) 9.7 (6.015.7) 9.4 (5.815.1)

(Mean 1.96 SD) Reference: Nils Milman, unpublished data, personal communication.

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Normal Values in Pregnancy

RED BLOOD CELL INDICES

Red Cell Indices In Iron-Treated Women (66 mg Elemental Iron as Fumarate) Red blood cell count (1012/L) First trimester (913 wk) Second trimester (1922 wk) Third trimester (3134 wk) Term (3943 wk) Hemoglobin (g/dL) First trimester (913 wk) Second trimester (1922 wk) Third trimester (3134 wk) Term (3943 wk) Hematocrit (%) First trimester (913 wk) Second trimester (1922 wk) Third trimester (3134 wk) Term (3943 wk) >3.45 >3.29 >3.23 >3.54 >11.1 >10.64 >10.47 >11.5 >33 >32 >31 >34 Mean cell volume (MCV, , 5th95th percentile) First trimester (913 wk) 88101 Second trimester (1922 wk) 89104 Third trimester (3134 wk) 90104 Term (3943 wk) 90102 Mean corpuscular hemoglobin (MCH, pg) First trimester (913 wk) Second trimester (1922 wk) Third trimester (3134 wk) Term (3943 wk) >30.1 >29.9 >30.2 >30.1

Mean cell hemoglobin concentration (MCHC, g/dL) First trimester (913 wk) >32.6 Second trimester (1922 wk) >31.7 Third trimester (3134 wk) >32.2 Term (3943 wk) >31.9

<5th Percentile Shown as Lower Limit of Normal Personal communication, N. Milman; Based on Milman N, Agger OA, Nielsen OJ: Iron supplementation during pregnancy. Effect on iron status markers, serum erythropoietin and human placental lactogen. A placebo controlled study in 207 Danish women. Dan Med Bull 38:471, 1991.

Iron, Folate, and Vitamin B12 Levels Mean Ferritin (ug/L) First trimester (mean 12.6 wk) Third trimester (32 wk) Term (38 wk) 46.8 2.5 20.8 1.3 21.7 1.6

Platelet Count (109/L) First trimester (12 wk) Third trimester (28 wk) Term (38 wk) 240 (170310) 250 (150360) 240 (140370)

Mean Total Iron Binding Capacity (TIBC, umol/L) First trimester (mean 12.6 wk) 59.3 0.6 Third trimester (32 wk) 73.8 0.9 Term (38 wk) 77.7 0.9 Folate (umol/L) First trimester (mean 12.6 wk) Third trimester (32 wk) Term (38 wk) B12 First trimester (mean 12.6 wk) Third trimester (32 wk) Term (38 wk) 6.7 0.3 6.4 0.3 6.9 0.4 345.6 8.9 259.3 6.0 241.8 6.5

Median (5th95th percentile) Adapted from van Buul EJA, Steegers EAP, Jongsma HW, et al: Haematological and biochemical prole of uncomplicated pregnancy in nulliparous women; a longitudinal study. Neth J Med 46:73, 1995.

Fasting Homocysteine With and Without Folic Acid Supplementation (Various Doses) (mmol/L) 8 WEEKS Unsupplemented Supplemented 6.48 1.30 6.32 1.34 20 WEEKS 5.22 1.29 4.18 1.32 32 WEEKS 5.16 1.32 4.42 1.37

Means 1SD Reference: Murphy MM, Scott JM, McPartlin JM, FernandezBallart JD: The pregnancy-related decrease in fasting plasma homocysteine is not explained by folic acid supplementation, hemodilution, or a decrease in albumin in a longitudinal study. Am J Clin Nutr 76:614, 2002.

Coagulation Factors 1115 WEEKS Factor Factor Factor Factor VII X V II 111 (60206) 103 (62169) 93 (46188) 125 (70224) 2125 WEEKS 150 (80280) 115 (74177) 82 (66185) 125 (73214) 3135 WEEKS 162 (84312) 123 (78194) 82 (34195) 115 (74179) 3640 WEEKS 171 (87336) 127 (72208) 85 (39184) 115 (68194)

(% of Standards Shown, Mean and Range) Reference: Stirling Y, Woolf L, North WRS, et al: Haemostasis in normal pregnancy. Thromb Haemost 52:176, 1984.

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COAGULATION PARAMETERS AND TESTING

Coagulation Parameters in Normal Pregnancy and Puerperium (n = 117) 10 WEEKS INR PTT (sec) Fibrinogen (mg%) Antithrombin III Protein C (%) Protein S (%) PAI (AU/mL) 0.97 0.08 27.0 2.7 412.5 69.5 101.5 12.7 99.4 21.3 64.1 15.8 10.3 4.7 20 WEEKS 0.91 0.06 26.9 2.7 463.9 83.9 101.4 10.3 107.5 24.9 62.1 14.2 11.3 5.0 30 WEEKS 0.88 0.07 27.1 2.9 538.8 107.3 104.2 12.5 99.3 26.0 54.0 13.3 20.5 7.3 36 WEEKS 0.87 0.07 27.5 2.8 556.9 113.3 102.8 13.5 94.9 25.5 51.7 17.9 22.4 7.5

INR, international normalized ratio; PAI, plasminogen activator inhibitor; PTT, partial thromboplastin time. (Mean SD) Reference: Cerneca F, Ricci G, Someone R, et al: Coagulation and brinolysis changes in normal pregnancy. Increased levels of procoagulants and reduced levels of inhibitors during pregnancy induce a hypercoagulable state, combined with a reactive brinolysis. Eur J Obstet Gynecol Reprod Biol 73:31, 1997.

Calcium Metabolism 1316 WEEKS Total calcium (mmol/L) Ionized calcium (mmol/L) 2.252.35 1.101.20 2124 WEEKS 2.152.30 1.051.20 2932 WEEKS 2.102.25 1.101.15 >37 WEEKS 2.052.25 1.051.15

( 1 SD) Adapted from Pitkin RM, Reynolds WA, Williams GA, Hargis GK: Calcium metabolism in normal pregnancy: a longitudinal study. Am J Obstet Gynecol 133:781, 1979.

811 WEEKS Calcitonin (ng/L) Parathyroid hormone (ng/L) 1,25 Dihydroxy Vitamin D (ng/L) 73101 715 5878

2023 WEEKS 79108 4.512 94122

2831 WEEKS 87113 515 98136

>37 WEEKS 83109 1017 94150

Adapted from Seki K, Makimura N, Mitsui C, et al: Calcium-regulating hormones and osteocalcin levels during pregnancy: a longitudinal study. Am J Obstet Gynecol 164:1248, 1991.

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Normal Values in Pregnancy

TSH (mIU/L) and Free T4 (ng/dL) by Race (means, IQ range)1 BLACK First trimester TSH Free T4 Second trimester TSH Free T4 Third trimester TSH Free T4 Delivery TSH Free T4 0.9 (0.41.6) 1.0 (0.91.1) 1.0 (0.61.5) 0.9 (0.81.0) 1.2 (0.91.9) 0.8 (0.70.9) 2.1 (1.33.1) 0.8 (0.70.9) WHITE 1.3 (0.82.0) 1.0 (0.91.1) 1.6 (1.02.2) 0.9 (0.81.0) 1.5 (1.42.1) 0.8 (0.70.9) 2.8 (2.04.4) 0.8 (0.70.9)

Screening and Diagnostic Thresholds across Pregnancy2 TSH >2.5 mIU/L requires further workup for hypothyroidism Total T4 <100 nmol/L (7.8 /dL) diagnostic of hypothyroidism T4, thyroxine; TSH, thyroid-stimulating hormone. References: 1. Walker JA, Illions EH, Huddleston JF, Smallridge RC: Racial comparisons of thyroid function and autoimmunity during pregnancy and the postpartum period. Obstet Gynecol 106:1365, 2005. 2. Mandel SJ, Spencer CA, Hollowell JG: Are detection and treatment of thyroid insufciency in pregnancy feasible? Thyroid 15:44, 2005.

Sequential Measurements of Plasma CRH, ACTH, Cortisol, Aldosterone, and Urinary Free Cortisol during Pregnancy WEEKS OF GESTATION 1115 2125 3135 3640 CRH (PG/ML) 115 145 1,570 4,346 56 30 349 754 ACTH (PG/ML) 8.8 2.8 9.8 1.5 12.1 2.0 18.6 2.6 CORTISOL (mG/DL) 10.5 20.0 22.0 26.0 1.4 1.1 1.2 1.1 DHEAS (mG/DL) 102 85.1 62.6 63.8 14 9.0 6.8 7.1 ALDOSTERONE (PG/ML) 412 487 766 1,150 63.6 42.8 94 170 URINARY FREE CORTISOL (mG/24 H) 54.8 7.3 84.4 8.4 105 8.8 111 8.7

ACTH, adrenocorticotrophic hormone; CRH, corticotrophin-releasing hormone; DHEAS, dehydroepiandrosterone. Reference: Goland R, Jozak S, Conwell I: Placental corticotropin-releasing hormone and the hypercortisolism of pregnancy. Am J Obstet Gynecol 171:1287, 1994.

Umbilical Cord Blood at Delivery ARTERY pH Pco2 (mm Hg) Po2 (mm Hg) Base decit (mmol/L) 7.067.36 27.868.3 9.841.2 0.515.3 VEIN 7.147.45 24.056.3 12.345.0 0.712.6

White blood cell count (109/L) Red cell count (1012/L) Hemoglobin (g/dL) Hematocrit (%) MCV () Platelet count (109/L) Reticulocyte count (109/L)

11.116.2 4.134.62 15.317.2 45.250.9 107.4113.3 237321 145.8192.6

Reference: Eskes TKAB, Jongsma HW, Houx PCW: Percentiles for gas values in human umbilical cord blood. Eur J Obstet Gynecol Reprod Biol 14:341, 1983.

25th75th Percentile Reference: Mercelina-Roumans P, Breukers R, Ubachs, J, Van Wersch J: Hematological variables in cord blood of neonates of smoking and non-smoking mothers. J Clin Epidemiol 49:449, 1996.