physiologic changes pregnancy

8/2/2019 Physiologic Changes Pregnancy

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PHYSIOLOGICALPHYSIOLOGICAL

CHANGES INCHANGES IN

PREGNANCYPREGNANCY

Dr. Nizamuddin Abdul AzizDr. Nizamuddin Abdul AzizMBBS, MRCOGMBBS, MRCOG

Obstetrician & GynaecologistObstetrician & Gynaecologist

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1. General Changes

2. Metabolism

3. CVS

4. Respiratory System

5. Haematology

6. Renal System

7. GIT

8. Endocrine System

9. Nutrition

PHYSIOLOGICAL CHANGES IN

PREGNANCY

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GENERAL CHANGESGENERAL CHANGES

Vulva

Superficial varicosites may appear

Labia minora are pigmented and hypertrophied

Vagina

blood supply of venous plexus Surrounding walls give bluish colouration of mucosa -

JACQUEMIERS SIGN /CHADWICKS SIGN

Secretion in vaginal secretion pH is acidic (3.5-6)

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GENERAL CHANGESGENERAL CHANGES UterusUterus

weight from 50g to 1kg at termweight from 50g to 1kg at term length from 7.5cm to 35cm at termlength from 7.5cm to 35cm at term Hyperplasia & hypertrophy of myometrium- Oestrogen andHyperplasia & hypertrophy of myometrium- Oestrogen and

Progesterone mediated. Gap junctionsProgesterone mediated. Gap junctions Hypertrophy of uterine arteriesHypertrophy of uterine arteries

BreastsBreasts

Best evident is primigravidaBest evident is primigravida

Marked hypertrophy and proliferation of ductsMarked hypertrophy and proliferation of ducts Hypertrophy of connetive tissue stromaHypertrophy of connetive tissue stroma

Nipples become pigmentedNipples become pigmented

Sebaceous glands may be visible ( Montgomerys tubercles)Sebaceous glands may be visible ( Montgomerys tubercles)

Role of prolactin. Colostrum . LactationRole of prolactin. Colostrum . Lactation 44


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Face

Chloasma gravidarum :symmetrical hypermelanosis orpigmentation around cheek, forehead and eyes, disappearsafter delivery

Due to in MSH secretion resulting in melanin depositionin dermis or epidermis

Abdomen

Linea nigra brownish black pigmentation area in the

middle stretching from xiphisternum to symphysis pubis Striae gravidarum represents mechanical stretching ofdeeper layer of cutis and may develop in abdomen andbreasts. Due to effect of corticosteriod, relaxin, oestrogen,abdominal distension, weight gain

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Sebaceous gland activity acne and greasy skinSebaceous gland activity acne and greasy skin

Hirsutism seenHirsutism seen

Thickening of scalp hair during pregnancy-prolonged anagenThickening of scalp hair during pregnancy-prolonged anagen

phase. Post partum hair shedding hair enters telogen phase-phase. Post partum hair shedding hair enters telogen phase-telogen effluviumtelogen effluvium

Palmar erythema and spider naevi may develop due toPalmar erythema and spider naevi may develop due to

oestrogen effect.oestrogen effect.

Itchy papules develop pregnancy prurigo which wouldItchy papules develop pregnancy prurigo which would

disappear after deliverydisappear after delivery 66


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METABOLISMMETABOLISMCALORIC REQUIREMENTCALORIC REQUIREMENT

Normal caloric requirement in female 1600-2100 kcal/day.Normal caloric requirement in female 1600-2100 kcal/day.

Well nourished individual or those whose diet isWell nourished individual or those whose diet is

supplemented no change in first 10 weeks of pregnancy.supplemented no change in first 10 weeks of pregnancy.

Thereafter caloric requirement increases 50-100 kcal/day tillThereafter caloric requirement increases 50-100 kcal/day till

36 weeks.36 weeks.

200-300 kcal/day final 4 weeks of pregnancy200-300 kcal/day final 4 weeks of pregnancy

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METABOLISMMETABOLISM

WEIGHT GAINWEIGHT GAIN

Weight gain 10-12 kg. Recommended wt gain BMI


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Fall in weight during first trimester resulting from morningFall in weight during first trimester resulting from morning

sickness. Thereafter steady gain throughout pregnancysickness. Thereafter steady gain throughout pregnancy

0.4 kg/week.0.4 kg/week.

Maternal weight gain has positive association withMaternal weight gain has positive association with

birthweight of infantbirthweight of infant

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CARBOHYDRATE AND INSULIN RESISTANCECARBOHYDRATE AND INSULIN RESISTANCE

Pregnancy brings about changes in hormones and insulinPregnancy brings about changes in hormones and insulinresistance that leads to increase in blood glucose level.resistance that leads to increase in blood glucose level.

In first half of pregnancy, the increase in blood glucose levelIn first half of pregnancy, the increase in blood glucose level

after carbohydrate food is less than non pregnant state.after carbohydrate food is less than non pregnant state.

ThisThis in sensitivity stimulates glycogen synthesis andin sensitivity stimulates glycogen synthesis and

storage, deposition of fat and transport of amino acids intostorage, deposition of fat and transport of amino acids into

cells.cells.

After mid pregnancy, insulin resistance gradually develops.After mid pregnancy, insulin resistance gradually develops.

This results in the increase in glucose level afterThis results in the increase in glucose level after

carbohydrate food is higher than non pregnant state and thecarbohydrate food is higher than non pregnant state and the

rise lasts longer.rise lasts longer.1111


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Rise in maternal glucose beneficial for fetus.Rise in maternal glucose beneficial for fetus.

Despite higher and prolonged rise in postprandial glucose,Despite higher and prolonged rise in postprandial glucose,

fasting glucose reduces below non pregnant statefasting glucose reduces below non pregnant state

Fasting plasma insulin levelFasting plasma insulin level and reaches maximum leveland reaches maximum level

about 32 weeks.about 32 weeks.

insulin resistance which persists till term, reducesinsulin resistance which persists till term, reduces

maternal utilization of glucose and induces glycogenolysis,maternal utilization of glucose and induces glycogenolysis,

gluconeogenesis as well as utilization of lipids as energygluconeogenesis as well as utilization of lipids as energy

source.source.

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Insulin resistance - secretion of diabetogenic hormonesInsulin resistance - secretion of diabetogenic hormones

- cortisol- cortisol reduces peripheral insulin sensitivityreduces peripheral insulin sensitivity

- renin and aldosterone- renin and aldosterone

- hPL- hPL

- Oestrogen and Progesterone- Oestrogen and Progesterone

- Glucagon and cathecolamines- Glucagon and cathecolamines

- Growth decrease- Growth decrease

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AMINO ACIDSAMINO ACIDS

Required by mother and fetus for growth and energy.Required by mother and fetus for growth and energy.

AA.AA.

Fall is most marked with gluconeogenic amino acids eg.Fall is most marked with gluconeogenic amino acids eg.

alanine.alanine.

Transport across placenta.Transport across placenta.

insulin resistance in pregnancy accelerate AA uptake byinsulin resistance in pregnancy accelerate AA uptake by

mother for gluconeogenesis.mother for gluconeogenesis.

Concentration of protein in maternal serum falls by 20Concentration of protein in maternal serum falls by 20

weeks, protein concentration has fallen from 7g to 6g/100ml.weeks, protein concentration has fallen from 7g to 6g/100ml.

Most of this fall is in serum albumin.Most of this fall is in serum albumin. 1515


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LIPIDSLIPIDS

3 fold increase in triglycerides and fatty acids.3 fold increase in triglycerides and fatty acids. LDL (50%)LDL (50%)

HDL (10-20%)HDL (10-20%)

Total cholesterol falls by 5% in early pregnancy, reducingTotal cholesterol falls by 5% in early pregnancy, reducing

lowest at 6-8 weeks. Thereafter there is progressivelowest at 6-8 weeks. Thereafter there is progressive (20-(20-

200%).200%).

Hyperlipidaemic in normal pregnancy is not atherogenicHyperlipidaemic in normal pregnancy is not atherogenic

because the pattern is not that of atherogenesis.because the pattern is not that of atherogenesis.

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LIPIDSLIPIDS

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CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

Heart rotated forward and pushed upwards as diaphragmHeart rotated forward and pushed upwards as diaphragm

rises.rises.

Apex beat shifts to the 4Apex beat shifts to the 4thth ICSICS

Systolic ejection murmurs are common in mid pregnancySystolic ejection murmurs are common in mid pregnancy

Palpitations, loud 1Palpitations, loud 1stst heart sound, 3heart sound, 3rdrd heart soundheart sound

ECG:ECG: left axis deviationleft axis deviation

Low QRS complexLow QRS complex

Flattened or even inverted T wave in lead IIIFlattened or even inverted T wave in lead III

PAC ,VEPAC ,VE

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Total peripheral vascular resistance reduces by 6 weeks ofTotal peripheral vascular resistance reduces by 6 weeks of

gestation and reaches a nadir of 30% below non pregnantgestation and reaches a nadir of 30% below non pregnantvalue by mid pregnancy.value by mid pregnancy.

Cardiac outputCardiac output by 50% from baseline of 4-5 l/min toby 50% from baseline of 4-5 l/min to7l/min7l/min

Heart rateHeart rate by 10%by 10%

Stroke volumeStroke volume by 10% (10 to 20 mls )by 10% (10 to 20 mls )Most changes reach maximum value by end of firstMost changes reach maximum value by end of firsttrimestertrimester

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Small fall in systolic and greater fall in diastolic blood pressureSmall fall in systolic and greater fall in diastolic blood pressure

during first half of pregnancy resulting induring first half of pregnancy resulting in in pulse pressurein pulse pressureThe blood pressure steadily rises in 2The blood pressure steadily rises in 2ndnd half of pregnancy backhalf of pregnancy back

to pre-pregnant state as term approachesto pre-pregnant state as term approaches

Plasma volumePlasma volume by 50-60% from baseline of 2600mls.by 50-60% from baseline of 2600mls.Plasma volume expansion is greater in multiple pregnancyPlasma volume expansion is greater in multiple pregnancy

Bigger plasma volume expansion, bigger the birth weight of theBigger plasma volume expansion, bigger the birth weight of the

baby.baby.Conversely plasma volume expansion is less in smaller babiesConversely plasma volume expansion is less in smaller babies

as in pre-eclampsia and IUGR.as in pre-eclampsia and IUGR.

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Total extracellular fluid volume increase by 16%Total extracellular fluid volume increase by 16%

Venous pressure in the legsVenous pressure in the legs from 9cm H2O in earlyfrom 9cm H2O in earlypregnancy to 24cm H2O at termpregnancy to 24cm H2O at term

Mechanical pressure of uterus on iliac veinsMechanical pressure of uterus on iliac veins

In late gestation pressure of fetus head also contributes.In late gestation pressure of fetus head also contributes.

Combination ofCombination of pressure andpressure and distensibility of veinsdistensibility of veinspredispose to varicose veins of the legs, vulva, rectum andpredispose to varicose veins of the legs, vulva, rectum and

pelvispelvis

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Pulmonary resistance falls in early pregnancyPulmonary resistance falls in early pregnancy

Pressure in the pulmonary arteries, capillaries and rightPressure in the pulmonary arteries, capillaries and right

ventricle does not change because the pulmonary circulation isventricle does not change because the pulmonary circulation is

able to absorb high flow rate without change of pressure.able to absorb high flow rate without change of pressure.

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RESPIRATORY SYSTEMRESPIRATORY SYSTEM

Neck and oropharyngeal tissues are affected by weightNeck and oropharyngeal tissues are affected by weight

gain in pregnancygain in pregnancy

Airway oedema and difficult visualisation of larynx duringAirway oedema and difficult visualisation of larynx during

intubationintubation

Vascularity of respiratory mucosa increasesVascularity of respiratory mucosa increases

Nasal mucosa is oedematous , vascular and tends toNasal mucosa is oedematous , vascular and tends to

bleedbleed

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Vital capacity remained unchangedVital capacity remained unchanged

Tidal volumeTidal volume40% Inspiratory capacity Expiratory reserve

Residual volume FRCFRCPeak expiratory flow rate unchanged. FEV1 unchanged.Peak expiratory flow rate unchanged. FEV1 unchanged.

Respiratory rate unchangedRespiratory rate unchanged

Diaphragm raises and breathing is more diaphragmatic inDiaphragm raises and breathing is more diaphragmatic innaturenature

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RESPIRATORY SYSTEMRESPIRATORY SYSTEM oxygen consumption of 30 40 ml /min in late pregnancyoxygen consumption of 30 40 ml /min in late pregnancyfrom baseline of 300ml/min partitioned between motherfrom baseline of 300ml/min partitioned between mother(extra cardiac, renal, respiratory work, breast development)(extra cardiac, renal, respiratory work, breast development)and fetoplacental unit (a third )and fetoplacental unit (a third )

Pulmonary blood flowPulmonary blood flowin tandem with cardiac output.Minute ventilation 30- 50 % - achieved by tidal volumewhereas respiratory rate remains consistent.Perceived asshortness of breath

Driven by progesterone mainly

pCo2 because of the above. pCO2 at term 30mm Hg (4kPa)compared to 35-40mm Hg (4.7 5.3 kPa) in non pregnantstate

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pCO2 activates carbonic anhydraseRenal compensation ensues by excretion of bicarbonate.

Plasma bicarbonate falls to 18-22mmol/L (from 24-28 mmol/Lin non pregnancy) pH is maintained at 7.4 to7.45

Fall in maternal pCO2 allows more efficient CO2 transferfrom fetus (pCO2 of 55mmHg) alveolar ventilation results in pO2 from 96.7 to101.8mmHg (12.9-13.6kPa)

Rightward shift of maternal oxyhemoglobin dissociation curvecaused by 2, 3 DPG in erythrocytes in pregnancy facilitates oxygen unloading to fetus ( which has much lowerpO2 25-30mmHg and leftward shift of oxy hemoglobin

dissociation curve) 2929


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COMPOSITION OF BLOOD -COMPOSITION OF BLOOD - Haematology

Plasma volumePlasma volume 50%

Red cell mass 20-30% depending on Fe intake

Packed cell volume (from 36% early pregnancy to 32%)(from 36% early pregnancy to 32%)

MCHCMCHC

Red cell count , HbRed cell count , Hb

Rise in red cell mass results fromRise in red cell mass results from both no of red cell and

size of red cell.

MCV from 82-85fl to 87-88fl.(femtoliters )Advantage of the large red cell better transport of O2 & CO2

Disadvantage reduce deformability in capillary circulation

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COMPOSITION OF BLOOD -COMPOSITION OF BLOOD - Haematology

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COMPOSITION OF BLOOD -COMPOSITION OF BLOOD -HaematologyBone marrow

- Hyperplastic with immature erythryoid precursors

Total white cell countNeutrophil count to a peak at 33 weeks then stabiliseEosinophil, basophil and monocyte count remain unchangedLymphocyte count remains unchanged but their function issuppressed therefore more susceptible to infection

Platelet count remains within normal non-pregnant range8-10% normal pregnancies, platelet count falls below150x109/L without ill effects on mother or fetus.

Probably resulting from physiological fibrinolysis withinuteroplacental circulation to maintain blood flow

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COAGULATION

Normal pregnancy is a state of continuing low grade

hypercoagulopathy

factors VII, VIII , IX, X, XIIFibrinogen ( x 2), von Willebrand factorAntithiombin III (inhibitor of coagulation) unchanged

Activated protein C resistance, protein S activityD dimer,ESR due to fibrinogen levelPAI 1 and PAI 2 ,PAI 1 and PAI 2 , Alpha 2 antiplasminAlpha 2 antiplasmin

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Anatomic ChangesAnatomic Changes

Kidneys increase in size 1-2 cm in lengthKidneys increase in size 1-2 cm in length

Dilatation of renal pelvis, renal calyces, and the ureters andDilatation of renal pelvis, renal calyces, and the ureters and

these remain enlarged for several weeks after pregnancy.these remain enlarged for several weeks after pregnancy.

Predisposes to UTIPredisposes to UTI

Caused by progesterone and compression of ureters byCaused by progesterone and compression of ureters by

enlarging uterus.enlarging uterus.

Physiological ChangesPhysiological Changes

Effective renal plasma flowEffective renal plasma flow 80% in mid pregnancy and80% in mid pregnancy and

then falls to 65% above non pregnant value by term.then falls to 65% above non pregnant value by term.

GFRGFR 45% by 945% by 9thth week and thereafter by only 5-10% andweek and thereafter by only 5-10% and

only falls slightly to term.only falls slightly to term.3535



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Serum creatinine and ureaSerum creatinine and urea .Creatinine clearance.Creatinine clearance 25%25%

Total body waterTotal body water 20% during pregnancy with20% during pregnancy with in plasmain plasma

osmolality by 10 mOsmol/kgosmolality by 10 mOsmol/kg

Pregnant women accumulate 950 mmol of Na.Pregnant women accumulate 950 mmol of Na.

GFR tends to excrete more Na at distal tubules.GFR tends to excrete more Na at distal tubules.

Compensated for by activation of renin-angiotensin-Compensated for by activation of renin-angiotensin-

aldosterone mechanism which enhances distal tubularaldosterone mechanism which enhances distal tubularreabsorption of Nareabsorption of Na

Pregnant women tend to accumulate 350 mmol of K duringPregnant women tend to accumulate 350 mmol of K during

pregnancy despitepregnancy despite GFR and activation of RAS.GFR and activation of RAS.

Mechanism uncertain.Mechanism uncertain. 3636



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Serum uric acid falls by 25% in early pregnancy and returnsSerum uric acid falls by 25% in early pregnancy and returns

back to normal in 2back to normal in 2ndnd half of pregnancyhalf of pregnancy

Glycosuria may be present because quantity of filteredGlycosuria may be present because quantity of filtered

glucose exceeds the maximum reabsorption capacity ofglucose exceeds the maximum reabsorption capacity of

proximal tubuleproximal tubule

Excretion of amino acidExcretion of amino acid in pregnancy due to quantityin pregnancy due to quantity

filtered exceeding the tubular reabsortionfiltered exceeding the tubular reabsortion

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Protein excretionProtein excretion in pregnancy due toin pregnancy due to GFR. In lateGFR. In late

pregnancy total protein excretion (upper limit) of


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GASTROINTESTINAL SYSTEM

Pregnancy gingivitis

Salivary secretion Na ,pH and proteins

Gastric secretion is . Gastric motility is . Small intestine

and large intestine motility is result in absorption of

salt, waterconstipation

Heartburn (reflux) intragastric pressure withoutintragastric pressure without

concomittentconcomittent in tone of oesophogeal cardiac sphincterin tone of oesophogeal cardiac sphincter

Delayed gastric emptying gastric aspirationDelayed gastric emptying gastric aspiration

Bile reflux into stomach because of pyloric sphincterBile reflux into stomach because of pyloric sphincter

incompetent aluminum hydroxideincompetent aluminum hydroxide

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Liver function

Plasma albumin

Globulin

Fibrinogen

Alkaline phosphatase mostly is enzyme of placental

origin

Gamma glutamyl transpeptidase no charge

AST

ALT

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Gall bladderin size and empties more slowly

Stasis of bile (cholestasis) in biliary cannaculi generalised

pruritus responds cholestyramineresponds cholestyramine

Cholestasis is probably hormonal because same effects is

observed in patients on OCP or HRT

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ENDOCRINE

Placenta produces

hCG

hPLhPL

ACTHACTH

OestradiolOestradiol

ProgesteroneProgesterone

PTH related proteinsPTH related proteins

ReninRenin

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ENDOCRINE

PLACENTAL HORMONES

hCG glycoprotein has 2 sub units and alpha and beta

subunits produced by the trophoblasts

Function of hCG maintain secretion of progesterone by corpus luteum of

pregnancy

immunosuppressive actively which may inhibit maternalprocess of immmunorejection of fetus as a homograft

Stimulates Leydig cells of male fetus to produce testosterone(in conjunction with fetal pituitary gonadotrophins) thus isindirectly involved in development of male external germtalia.

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ENDOCRINE

PLACENTAL HORMONE

Human placental lactogen (hPL)

Lactogenic

Promotes mammary gland growth(alveoli ) in preparation of

lactation Also regulates maternal glucose, protein and fat levels, so

that this is always available to fetus

Steriod hormones

Oestrogen

Progesterone

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ENDOCRINE

PLACENTAL HORMONE

Sex Steriod hormones

a) Together they play role in maintenance of pregnancy.Oestrogen and progesterone causes hypertrophy andhyperplasia of uterine myometrium thereby capacity,vascularity and blood flow to uterus

b) Development of breasts. Hypertrophy and proliferation ofducts are due to oestrogen.Proliferation of glandularalveoli influenced by progesterone and hPL

c) Steroids are involved in a complex pathway in the initationof normal labour

d) Progesterone is necessary to maintain endometrial liningof uterus during pregnancy. Prevents preterm labour byreducing myometrial contraction

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ENDOCRINE

Hypothalamus and pituitary

Pituitary weight 30%- headache and increasedsensitivity of gland to haemorrhage (aided by lack of direct

arterial blood supply to anterior pituitary)

Prolactin by term level 10-20x more than non pregnantwomen. Oestrogen stimulates and hPL inhibits prolactin

ACTH- Dexamethone does not suppress this ,palcental synthesis

CRH placental origin Suppression of hGH by hPL

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ENDOCRINE

Adrenal glands

in width of zona fasciculata total and free cortisol aldosterone Weaker mineralocorticoid 11 deoxycortisol is also Plasma cathecolamines fall from 1st to 3rd trimester

Thyroid Gland

Plasma iodide because of GFR Slight thyromegaly due to follicular hyperplasia

Small fall in TSH in 1st trimester followed by raise thereafter

TBG (x 2) Free T3 and free T4 remain normal. Majority of pregnant

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ENDOCRINE

Parathyroid glands

Extracellular free calcium acts on the parathyroid cells toregulate secretion of PTH

PTH 1,25 dihydroxyvitD

RENAL

SYNTHESIS

Absorption ofcalcium form gut

Absorption ofcalcium form kidneys

Mobilisation of

calcium from bones

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ENDOCRINE

In pregnancy 1,25 dihydroxycholecalciferol providing the

calcium requirement in pregnancyPTH are of two types :

iPTH and PTHrP

iPTHin pregnancy but PTHrP

Renal Hormones

Activation of renin-angiotensin system

renin & angiotensin II by the end of 1st trimester and thanplateau thereafter angiotensinogen occurs till termPancreas

size and number of Beta cells of islets of Langerhans 4949

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NUTRITIONNUTRITION

IronIron

a) Needed for:a) Needed for:

-- expansion of red cell massexpansion of red cell mass

- fetus and placenta- fetus and placenta

- replace blood loss at delivery- replace blood loss at deliveryb) Iron requirements double during pregnancy.b) Iron requirements double during pregnancy.

c) Estimated total iron needed in pregnancy is 1000mg.c) Estimated total iron needed in pregnancy is 1000mg.

d) Mother transfers 200-300mg iron to fetus.d) Mother transfers 200-300mg iron to fetus.

e) Iron absorptione) Iron absorption in pregnancy by 20-40%.in pregnancy by 20-40%.

f) RDA for iron in pregnancy is 30 mg/day.f) RDA for iron in pregnancy is 30 mg/day.5050

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NUTRITIONNUTRITION

CalciumCalcium

a)a) Calcium requirementCalcium requirement by 33% in pregnancy.by 33% in pregnancy.

b)b) Net transfer across placenta is 25-30 g (active).Net transfer across placenta is 25-30 g (active).

c)c) RDA for calcium in pregnancy is 1200mg.RDA for calcium in pregnancy is 1200mg.

Folic acid.Folic acid.

a)a) ImportantImportant incidence of NTD.incidence of NTD.

b)b) RDA 400mcg/day starting from preconceptionRDA 400mcg/day starting from preconception

- 5mg/day if previous child has NTD- 5mg/day if previous child has NTD

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RDAs of Nutrients During PregnancyRDAs of Nutrients During Pregnancy

Non pregnant Pregnant

Energy (kcal) 2200 2500

Protein (g) 44-50 60

Calcium (mg) 800 1200

Iron (mg) 15 30

Folate (mcg) 180 400

Zinc (mg) 12 15

Phosphorus 800 1200

Vitamin D 5 10

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Thank youThank you

physiologic changes pregnancy

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