MATERNAL ADAPTATIONS TO PREGNANCY

UTERUS (Anatomic Changes) Nonpregnant: Weight: 70 grams Volume: 10 ml Pregnant: Weight: 1100 grams Volume: 5-20 L stretching and hypertrophy of existing muscle cells Asymmetrical uterine enlargement, more marked in the fundus From its original pearl shape, assume a more globular form then later almost spherical as pregnancy advances Rises out of pelvis as pregnancy advances LUNGS (Anatomic Changes): The gradual migration of the uterus cephalad causes the diaphragm to move upward and thus encroach on the lungs.. LUNGS (Physiologic Changes): RESPIRATORY ADAPTATIONS o Increase in AP and transverse thoracic diameter o Tidal volume increased by 40% o Increased respiratory rate by 15% o Raise in alveolar ventilation by 70% (a pregnant woman has respiratory alkalosis and a diminished pulmonary reserve) RESPIRATORY ALKALOSIS

HEART (Anatomic Changes): The upward movement of the diaphragm also causes the heart to be displaced laterally and anteriorly. o Increase in the size of cardiac silhouette o Slight deviation of the electrical axis to the left CARDIOVASCULAR ADAPTATIONS (Physiologic Changes): Uterine enlargement causes compression of the inferior vena cava and the aorta, resulting in maternal hypotension and fetal distress. HEMATOLOGICAL CHANGES BLOOD VOLUME o Blood Volume increases by 40% at term o Plasma>erythrocyte, resulting in lower haemoglobin Increased eryhtropoiesis (33% or 450 mL) o 1 ml of normal erythrocyte contains 1.1 mg of iron o Iron requirement for normal erythropoiesis: 500 mg o Total iron content of normal adult women: 200-250 mg o Iron Deficiency: 300mg- for normal erythropoiesis 300 mg- for the fetus and placenta 200 mg- obligatory losses 800 mg Only 1 mineral, IRON, provides any demonstrated benefit 7 mg/day imposed by pregnancy 30 mg/day to prevent anemia during pregnancy INCREASE in MATERNAL BLOOD VOLUME o Cardiac output increases about 39-50 % (from 4.5-6.0L/min) o Stroke volume increases about 10-15% o Pulse increases about 15-20 bpm o Systolic ejection murmur and S3 gallop common in about 90% of pregnant women Many of the effects of the cardiovascular system mimic heart failure (edema, gallops, dyspnea, distended neck veins, abnormal cardiac silhouette on CXR, EKG chnges)

COMPENSATED

Renal excretion Of bicarbonate O2 saturation is close to 100% Oxygenation id improved

correction of PH

METABOLIC ADAPTATIONS: 1. Weight Gain -total weight gain in primigravidas = 12.5 KILOS -increase in breast size Increase in mothers fluid volume Placenta Increase in blood supply to the placenta Amniotic fluid Infant at birth Increase in size of the uterus and supporting ________ Mothers fat sources

2-3lbs 4-5 lbs 1-2 lbs 4-4.5 lbs 2 lbs 7-8lbs 2-2.5 lbs 7.8 lbs 30-35 lbs

-mild fasting hypoglycaemia -postprandial hyperglycemia -hyperinsulinemia B-cell hypertrophy, hyperplasia and hypersecretion Pregnancy-induced state of peripheral resistance to insulin; -increased insulin response to glucose -reduced peripheral uptake of glucose -suppressed glucagon response 5. Fat Metabolism Plasma lipids increase continuously throughout gestation -LDL peaks at 36 weeks -HDL peaks at 25 weeks, decrease until 32 weeks RENAL SYSTEM (Physiologic changes): GFR increases 50% Renal plasma flow increases by 75% Creatinine clearance increases to 150-200 cc/min METABOLIC ADAPTATIONS BUN and serum creatinine decreases by about 25% Plasma osmolarity decreases about 10mOsm/kg H2O Increase in tubular reabsorption of sodium Marked increase in rennin and angiotensin levels, but markedly reduced vascular sensitivity to their hypertensive effects Increase in glucose excretion Plasma Electrolytes o Nearly 1000 mEq of sodium and 300 mEq of potassium are retained despite increase in GFR o Progesterone counteracts the natriuretic and kaliuretic effects of aldosterone thus fractional excretion of sodium and potassium are decreased

2. Water Metabolism Increase water retention o Mediated by a fall in plasma osmolality of approximately 10mOsm/kg -resetting osmotic threshold for thirst and vasopressin secretions o 6.5 L minimum amount of extra water that is retained Pitting edema of ankles and legs o Caused by an increase in venous pressure below the level of the uterus as a consequence of partial occlusion of the vena cava by the gravid uterus o Caused by a decrease in interstitial colloid osmotic pressure 3. Protein Metabolism Increased daily requirement for protein 500 g = fetus and placenta 500g = uterus as contractile protein Breasts primarily in the glands Maternal blood in the form of haemoglobin and plasma proteins 4. Carbohydrate Metabolism Pregnancy is potentially diabetogenic Normal pregnancy:

CERVIX (Anatomic Changes): Hegars Sign Hypertrophy and hyperplasia of the cervical glands causes increase in cervical mucous secretions OVARIES (Anatomic Changes): Ovulation ceases Corpus Luteum of pregnancy o Functions maximally during the first 6-7 weeks of pregnancy VAGINA (Anatomic Changes): Chadwick sign (increased vascularity and hyperaemia) SKIN (Anatomic Changes): Striae gravidarum Linea negra Chloasma/ melasma gravidarum BREAST (Anatomic Changes): As a result of hypertrophy of mammary alveoli: o Breasts increase in size and become nodular o Delicate veins become visible o Areola and nipples become more deeply pigmented o Areola become broader, nipples become larger and erectile