FISIOLOGI KEHAMILAN

Physiology changes associated

with pregnancy

Reproductive Tracts
Breast
Skin
Water and Electrolit
Hematology
Cardiovascular
System

Respiratory System
Gastrointestinal
System
Urinary System
Endocrine System
Metabolism
Skeleton

Reproductive Tracts

Uterus: from 50g-1100g

Isthmus uteri (lower segment of the

uterus) Hegar sign

Braxton Hicks contraction: sporadic,

irregular, asymmetrical, and painless, low
pressure, lasting < 30 sec

Reproductive Tracts

Cervix and vulva Chadwicks sign

congestion of the pelvic vasculature, cause
bluish or purplish discoloration of the cervix
and vulva

Leukorrhea: increase in vaginal discharge,

rich in glucose, lactic acid, low vaginal pH

Ovary: slightly enlarged, corpus luteum

regresses after 10 weeks gestation

Breasts

Early change
tenderness, tingling and heaviness
vascular engorgement leads to enlargement
Ductal growth due to estrogen
Alveolar hypertrophy due to progesteron
Enlargement and pigmentation of areolae
Montgomerys tubercles: enlargement of circumlacteal
sebaceous glands of the areola
Colostrum may be expressed later in pregnancy
Milk production
Estrogen, progesteron, prolactin, hPL, cortisol and
insulin
Lactation likely due to drop in estrogen and
progesterone after delivery

Skin

Spider angiomata (face, upper chest, and arm)

and palmar erythema
elevated estrogen levels
both regress after delivery

Striae gravidarum
Increased eccrine sweating and sebum
excretion
Hyperpigmentation
Melasma: mask of pregnancy

elevated estrogen and progesteron

Nevi may darken, enlarge or show increased

activity

rapidly changing nevi should be excised

Body Water

TBW increases from 6.5L to 8.5L

At term water content of fetus, placenta and
AF is 3.5L
BV, PV, RBC, extravascular, intracellular

Pregnancy is a condition of chronic

volume overload
Water retention exceeds Na retentiondecreased plasma osmolality

Hematology Blood
volume

Increases progressively from 6 to 8 weeks

gestation
maximum volume at 32 weeks - 45%
increase
possibly due to estrogen stimulation of
renin-angiotensin-aldosterone system

(Inc Prog, NO->Dec SVR->Dec MAP>Inc Na retention)

Hematology RBC mass

Red blood cell mass

increases by 250-450 cc by
term
Increased production
Possibly hormonally
mediated

Hematology - Iron

Maternal requirement is 1000mg

Increase maternal red cell mass : 500 mg
Fetal development : 300 mg
Compensate for normal iron loss : 200 mg

Normal pregnant woman needs to

absorb about 3.5 mg/day of iron
the goal of iron supplementation is
to prevent maternal iron deficiency
Iron is actively transported to the
fetus

Hematologic changes

IMPLICATIONS
The

increase in plasma volume and rbc

mass translates into a 45% increase in
circulating blood volume
may protect from hemodynamic
instability
may serve to dissipate fetal heat
production and provide increase renal
filtration
physiologic anemia of pregnancy
may function to decrease blood viscosity
may improve intervillous perfusion?

Hematology

LEUKOCYTES

Peripheral wbc rises progressively during

pregnancy

1st mean 9500/mm3 (3000-15,000)

2nd and 3rd mean 10,500 (6000-16,000)
Labor may rise to 20-30,000

Rise is due to increase in pmns

(demargination)

PLATELETS

Platelets experience a progressive decline but

should remain within normal range
Likely due to increased destruction

Hematology

COAGULATION FACTORS

Increased levels
Fibrinogen (Factor I)
Factors VII through X
No change in prothrombin

(Factor

II), Factors V and XII

Decline in platelet count, Factors
XI and XIII
Bleeding time and clotting time are

unchanged in normal pregnancy

Cardiovascular Cardiac output

Maternal cardiac output increases about

30-50% during pregnancy (mean 33%)
pregnancy maximum of 6 L/min
CO remains maximal until delivery
Earliest rise in CO is due to increase in SV
As pregnancy progresses

Gradual increase in mat HR (15-20 bpm rise)

SV declines to near non-pregnant levels
increase HR is what maintains the elevated CO

Cardiovascular Cardiac output

CO is position dependent

Lower when supine

IVC compression by the uterus reduces venous

return to the heart

At 38-40 weeks, there is a 25-30% fall in CO

when turning from the side to the back
Fall in CO is compensated by a rise in
peripheral vascular resistance

supine hypotensive syndrome (1-10% patients)

Cardiovascular Cardiac output

Distribution of CO

First trimester and non-pregnant state

Uterus receives 2-3%

By term
Uterus receives 17%
Breasts 2%

Reduction of the fraction of CO going to the

splanchnic bed and skeletal muscle
CO to the kidneys, skin, brain and coronary
arteries does not change

Cardiovascular Arterial
BP

BP varies with position

Peripheral vascular resistance falls during

pregnancy
Progesterones smooth muscle relaxing effect
?heat production by the fetus vasodilatation

The reduction in PVR may lead to a

progressive fall in systemic arterial bp
during the first 24 weeks of pregnancy

Gradual rise after 24 weeks non-pregnant

levels by term

Cardiovascular Venous system

Venous compliance increases during

pregnancy
decrease in flow velocity and stasis
progesterone effects on smooth muscle
Forearm venous pressure increases by 40-50%
Calf venous pressures are always higher

due to the enlarging uterus

Cardiovascular - LV
function

Left ventricular dimensions and volume

increase during pregnancy

most parameters of LVF are the same as in the

non-pregnant state
Ejection fraction, rate of internal diameter

shortening, percentage of fractional shortening,

and ventricular wall thickness

Bottom line: preservation of myocardial

function

Cardiovascular changes

Stroke volume
+30%
Heart rate
+15%
Cardiac output
+40%
Oxygen consumption
+20%
SVR (systemic vascular resistance) -5%
Systolic BP
-10mmHg
Diastolic BP
-15mmHg
Mean BP
-15mmHg

Respiratory system

UPPER RESPIRATORY TRACT

Hyperemic mucosa of nasopharynx

Estrogen-mediated
nasal stuffiness and epistaxis

Polyposis of nose and sinuses may occur and regress

after delivery
chronic cold

MECHANICAL CHANGES

Configuration of thoracic cage changes early in

pregnancy
Increase in subcostal angle, transverse diameter and

circumference of chest

With advancing gestation, the level of diaphragm is

pushed up

Changes in pulmonary function

tests during pregnancy

Serial
Serialmeasurements
measurementsofoflung
lungvolume
volumecompartments
compartmentsduring
duringpregnancy.
pregnancy.Functional
Functional
residual
residualcapacity
capacitydecreases
decreasesapproximately
approximately2020percent
percentduring
duringthe
thelatter
latterhalf
halfofof
pregnancy,
pregnancy,due
duetotoa adecrease
decreaseininboth
bothexpiratory
expiratoryreserve
reservevolume
volumeand
andresidual
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Redrawn
Redrawnfrom
fromProwse,
Prowse,CM,
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Gaensler,EA,
EA,Anesthesiology
Anesthesiology1965;
1965;26:381.
26:381.

Respiratory system

LUNG VOLUME AND PULMONARY

FUNCTION

30-40% increase in tidal volume (Amount of

air I and E with each breath)
30-40% increase in minute ventilation (likely P4

mediated)

ERV falls by 20%

Vital capacity and inspiratory reserve volume
remain unchanged

Respiratory system

LUNG VOLUME AND PULMONARY

FUNCTION
Respiratory rate is unchanged
Due to elevation of the diaphragm

Total lung volume decreases (diaphragm) by 5%

Residual volume decreases (RV) by 20%
FRC is reduced 20%

No change in FEV1 or the ratio of FEV1 to

forced vital capacity

Respiratory system

GAS EXCHANGE
Minute ventilation rises 30-40% by late
pregnancy
O2 consumption increases only 15-29%

Results in higher PAO2 (alveolar) and PaO2 (arterial)

Normal PaO2: 104-108 mmHg

Fall in PACO2 and PaCO2 levels

Normal PaCO2 level: 27-32 mmHg
Increases gradient of CO2 facilitating transfer from fetus
to mother

Arterial pH remains unchanged

Increased bicarbonate excretion via kidneys

Respiratory system

DYSPNEA OF PREGNANCY

Common complaint
60-70% of patients
late first or early second trimester

Likely due to various factors

reduced PaCO2 levels
awareness of increased tidal volume of

pregnancy

Renal system

ANATOMY

Kidney enlargement
increased renal vascular and interstitial volume, R>L

Ureteral and renal pelvis dilatation by 8 weeks

Right > left
mechanical compression by uterus and ovarian venous
plexus
smooth muscle relaxation by progesterone

Implications
Increased incidence of pyelonephritis
difficulty in interpreting radiographs
interference with studies

Renal system

RENAL HEMODYNAMICS

Effective renal plasma flow (ERPF) and GFR

increase
Filtration fraction falls
Returns to normal by late third

Endogenous creatinine clearance increases

Begins by 5 weeks

Renal system

METABOLITES
increased GFR decline in serum urea and
creatinine
BUN 8-9 mg/dl by end 1st
Decline in serum creatinine

0.7 mg/dl by end 1st

0.5-0.6 mg/dl by term

Early decline in serum uric acid levels

nadir at 24 weeks
same as nonpregnant level at end of pregnancy due

to increased reabsorption of urate

Renal system

SALT AND WATER METABOLISM

Plasma osmolality begins to decline by 2

weeks after conception
reduction in serum sodium and other anions

Sodium loss during pregnancy

50% rise in GFR
Progesterone: natriuresis

Renal tubular reabsorption of Na+ increases

(aldosterone, estrogen and
deoxycorticosterone)
Sodium homeostasis

Renal system

NUTRIENT EXCRETION

Increase in glucose excretion

1-10 g glucose excretion per day
Due to 50% increase in GFR
implications
inability to use urine glucose
susceptibility of pregnant women to UTI

Increase in amino acid excretion during

gestation
no increased protein loss (100-300 mg/24 hr)

Increased urinary loss of folate and vitamin

B12

Gastrointestinal - Appetite

Increase early 1st

Increase intake 200 kcal by end 1st

RDA: 300 kcal/day during pregnancy

Sense of taste may be blunted

Pica

check for poor weight gain and refractory

anemia
South - clay or starch (laundry or cornstarch)
UK coal
Also soap, toothpaste and ice pica

Gastrointestinal - Mouth

Unchanged pH or production of saliva

Saliva production is unaltered

Ptyalism usually in women with HEG
due to inability to swallow
Can lose up to 1-2 L of saliva per day
Decreasing starchy foods might help

Gums edematous and soft

May bleed after brushing

Epulis gravidarum

regress 1-2 mos after delivery

excise if persistent or excessive bleeding

Gastrointestinal - Stomach

Decreased tone and motility

Conflicting info about delayed gastric

emptying
Reduced tone of the gastroesophageal
junction sphincter

progesterone
possibly due to decreased levels of motility

Increased intraabdominal pressure leads to

acid reflux

Lower incidence of PUD

may be due to decreased gastric acid secretion

delayed emptying, increase in gastric mucus,
and protection of mucosa by prostaglandins

Gastrointestinal - Small
bowel

Reduced motility of small

bowel
increased

transit time in
the third trimester and
postpartum

Enhanced iron absorption

as

a response to increased
iron needs

Gastrointestinal - Colon

Constipation

Mechanical obstruction by the uterus

Reduced motility (p4)
Increased water absorption

Portal venous pressure is increased

Dilation of gastroesophageal vessels

issue in those with preexisting esophageal varices

Dilation of hemorrhoidal veins

hemorrhoids

Gastrointestinal Gallbladder

Fasting and residual volumes double in

2nd and 3rd

Slower rate of emptying

Biliary cholesterol saturation increases

and chenodeoxycholic acid decreases

increased risk gallstone formation

Gastrointestinal - Liver

Liver does not enlarge

Hepatic blood flow remains unchanged

Spider angiomata and palmar erythema

CO to the liver decreases by ~35%

elevated estrogen levels

Lab data

Drop in serum albumin

Rise in serum alkaline phosphatase
placental production and some hepatic production
Rise in serum cholesterol, fibrinogen, ceruloplasmin,
binding proteins for corticosteroids, sex steroids,
thyroid hormones, and vitamin D
No change in serum bilirubin, AST, ALT, protime and 5
nucleotidase
Rise in GGT is controversial

Gastrointestinal system

NAUSEA AND VOMITING

Morning sickness complicates 70% of

pregnancies
Onset 4-8 weeks up to 14-16 weeks
Cause?

Relaxation of smooth muscle of stomach, elevated

levels of steroids and hCG

Rx supportive: reassurance, support, and avoiding
triggers

HEG

weight loss, ketonemia, electrolyte imbalance and

dehydration
possible renal or hepatic damage
IVF, antiemetics
NPO
continue IV

Gastrointestinal change

Morning sickness
hyperremesis gravidarum (weight loss,
ketonemia and electrolyte imbalance)

Dietary craving: pica

Decreased gastrointestinal motility: reflux and

heartburn

Gallbladder function, cholestasis

Hyperemia and softening of the gums (epulis)

Hemorrhoid

Appendix displaced

Endocrine System

Estrogen
Progesteron
hCG

Function of hCG

Prevent involution of the corpus luteum at the end

of the monthly female sexual
Instead, it causes the corpus luteum to secrete even
larger quantities of its sex hormonesprogesterone
and estrogensfor the next few months.
These sex hormones prevent menstruation and
cause the endometrium to continue to grow and
store large amounts of nutrients.
Human chorionic gonadotropin also exerts an
interstitial cellstimulating effect on the testes of
the male fetus, resulting in the production of
testosterone

Function of Estrogen

Enlargement of the mothers uterus

Enlargement of the mothers breasts and growth of
the breast ductal structure
Enlargement of the mothers female external
genitalia.
Relax the pelvic ligaments of the mother, so that
the sacroiliac joints become relatively limber and
the symphysis pubis becomes Elastic allow
easier passage of the fetus through the birth canal.
Affect many general aspects of fetal development
during pregnancy, for example, by affecting the
rate of cell reproduction in the early embryo.

Functions of Progesteron

Causes decidual cells to develop in the

uterine endometrium.
Decreases the contractility of the pregnant
uterus preventing uterine Contractions.
Increases the secretions of the mothers
fallopian tubes and uterus to provide
appropriate nutritive matter for the
developing morula and blastocyst.
Helps the estrogen prepare the mothers
breasts for lactation.

Rates of secretion of estrogens and progesterone, and

concentration of human chorionic gonadotropin at
different stages of pregnancy.

Endocrine - Thyroid

The normal pregnant woman is euthyroid

Changes in thyroid morphology and lab indices

Serum TSH decreases early in gestation

role of hCG stimulating the thyroid

Rise in TBG leads to rise in total T4 and total T3

rises to pre-pregnancy levels by end of first

T4 increases early in gestation

Estrogen-induced increase in TBG

Decreased circulating extrathyroidal iodide
Thyroid enlargement usually not detected by exam
Normal thyroidal uptake of iodide

active hormones free T4 and free T3 are unchanged

Free T4 is the most reliable method of evaluating thyroid

function in pregnancy

Endocrine - Adrenal glands

Expansion of the zona fasciculata

Plasma corticosteroid-binding globulin (CBG)

rises

increased production and delayed clearance

Plasma DOC (deoxycorticosterone) rises

due to enhanced liver synthesis

Free plasma cortisol rises

site of glucocorticoid production

fetoplacental unit

DHEAS (dehydroepiandrosterone) decreases

Testosterone is slightly elevated

Increased SHBG and androstenedione

Endocrine - Pancreas

Hypertrophy and hyperplasia of the B cells

Fasting associated with accelerated starvation

maternal hypoglycemia, hypoinsulinemia and

hyperketonemia
due to diffusion of glucose by the fetoplacental unit

Feeding response

hyperglycemia, hyperinsulinemia,
hypertriglyceridemia and reduced tissue sensitivity
to insulin
glucose response greater during pregnancy
peripheral resistance to insulin: diabetogenic effect
of pregnancy.

hPL and cortisol mediated

greater insulin resistance as the pregnancy advances

Endocrine - Pancreas

Fetus primarily depends on glucose

Facilitated diffusion
carrier-mediated but not energy

dependent process

Active transport of amino acids to

the fetus

Ketones diffuse freely across the

placenta

Endocrine - Pituitary

The pituitary gland enlarges in

pregnancy
proliferation

of chromophobe cells
on the anterior pituitary
stalk remains midline

Skeleton

Lordosis

keep center of gravity over the legs

back pain

Relaxin

relaxation of the pubic symphysis and

sacroiliac joints

facilitates vaginal delivery but may lead to

discomfort

Implications

unsteadiness of gait and trauma from falls

Skeleton

Total serum calcium declines throughout

pregnancy until 34-36 weeks

due to the fall in serum albumin

Serum ionized calcium is constant and

unchanged

Physiologic hyperparathyroidism

increased gut absorption

decreased renal losses
no bone loss seen in bone density studies

preservation due to calcitonin?

Rate of bone turnover and remodeling

increases throughout pregnancy

twice as great at term

Metabolism

Basal metabolism rate, BMR : +15-20%

Weight gain : 12.5 kg ( 24 pons)
o Fetus : 3400 g

o Placenta : 650 g
o
o
o
o
o
o

Amniotic : 800 g
Uterus : 960 g
Plasma, red cells : 1450 g
Mammary glands : 405 g
Extracellular, extravascular water : 1480 g
Deposition of fat and protein : 3345 g

Insulin resistance

Conclusion

Understanding maternal physiology is

crucial in understanding the changes and
clinical scenarios associated in pregnancy
This knowledge will help us distinguish
the physiologic and pathologic processes
during pregnancy
This knowledge will also improve
patients education about their
pregnancy

Selamat
Belajar