Physiological changes in Pregnancy & its Anaesthetic implications

Dr. Shailendra.V.L. MBBS, DA, MD. Specialist in Anaesthesia, Bukariya General Hospital.
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Introduction

Rapidly growing fetus Rising levels of progesterone, oestrogen, prostaglandin & HCG Increasing size of uterus All systems undergo changes Placenta
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Changes in the pregnant patient

Changes due to uterine enlargement Changes to support the foetus

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Changes in the systems

Cardiovascular System Respiratory System Haemopoietic System Hepatic System Renal System Gastro-intestinal System Metabolism & Nutrition Central Nervous System

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Changes in uterus

Uterine blood flow increases from 50 ml/ min to 700 800 ml /min Uterine weight increases from 30-60 g to 1000 g

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Uterine blood flow

Uterine Blood Flow - UBF: Uteroplacental vascular bed is passive capacitance bed Intervillous blood flow exhibits no auto regulation UBF dependent on mean arterial pressure, aorto-caval compression & cardiac output
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Cardiovascular system
Changes in the cardiovascular system: Intravascular fluid volume: + 35% Plasma volume: + 45% Erythrocyte volume: + 20% Cardiac Output: + 40% Stroke volume: + 30% Heart rate: + 15% Peripheral Circulation: Systolic BP: no change Diastolic BP: - 15% Systemic Vascular Resistance: - 15% Femoral venous pressure: + 15% 7 24 October 2013

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Cardiovascular system

Mean arterial pressure: MAP: -Inspite of increase of cardiac output, MAP is maintained due to concomitant decrease in peripheral resistance
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Cardiovascular system
Compression of Inferior Venacava: IVC: - In supine position the gravid uterus compresses the IVC and decreases the CO without fall in the blood pressure called as Concealed caval compression. - Reasons for no fall in blood pressure are: - Reflex vaso constriction - Diversion of blood through paravertebral venous plexus 24 October 2013 10

Cardiovascular system
8 to 15% of pregnant women have Overt Caval Compression (supine hypotensive syndrome) Hypotension Sweating Bradycardia Pallor Nausea Vomiting Prevention of SHS: (aim is to displace the uterus) Providing left lateral tilt 15 degrees Placing wedge under the right buttock

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Cardiovascular system

Poseiro Effect: Uterine artery is compressed during uterine contractions & by the presenting part of the fetus reducing the UBF

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Cardiovascular system
Physiological Anaemia in Pregnancy: Total red cell mass increase by 30% (250450ml) Plasma volume increase by 50% (about 1250ml) Overall increase of 40% blood volume with fall in haematocrit
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Cardiovascular system
Heart rate: increases by about 15 beats

/min Arterial pressure: minimal change noted Heart Size: Gravid uterus pushes the diaphragm cepahalad & displaces the heart.
ECG shows false left axis deviation Chest X ray shows (false) cardiac dilatation
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Respiratory system
Changes in the respiratory system: Minute volume: + 50% Tidal volume: + 40% Breathing rate: + 10% FRC: - 20% Expiratory reserve volume: - 20% Residual volume: - 20% Oxygen consumption: + 20%
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Respiratory system
Edematous mucosa of upper resp tract:

Smaller Et tubes Gentle suctioning & larngoscopy Decreased FRC, ERV,RV: Increased O2 consumption: Pre-oxygenation prior to induced apnea Rate of fall in PaO2 per minute of apnea is 159mm hg in pregnant and 59 mm hg in non-pregnant state
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Haemopoietic system

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Physiological anemia of pregnancy Fibrinogen, factors VII, VIII and X increased Makes the blood hypercoaguable & increases the risk of thromboembolism This hypercoaguability along with uterine inversion helps in reducing blood loss after delivery
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Gastro-intestinal system

Decrease in lower oesophageal tone Delay in gastric emptying: - Pylorus is pushed upwards & forwards making it non-dependent - Relaxant effect on gastric smooth muscle Increased intragastric pressure
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Hepatic system

No alterations in the liver function Serum cholinesterase activity Does not interfere with the suxamethonium (Scoline)R metabolism

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Renal system
Renal plasma flow Glowmerular filtration rate Tubular reabsorbtion rate Blood Urea Nitrogen 40%

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Metabolism & Nutrition

Basal metabolic rate: by 15 to 20% Weight gain upto 11 kgs Serum protein concentration Albumin concentration Drugs are less bound to serum proteins thereby increasing the fre drug availability
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Nervous system
in minimum alveolar concentrations exaggerated lumbar lardosis contribute

to cephalad spread of the local anaesthetic engorged epidural plexus of veins will decrease the amount of the local anaesthetic in epidural blocks engorged epidural veins will block the inter-vertebral foramina and prevent the escape of the local anaesthetic
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Placental functions

Metabolism Endocrine secretion Human chorionic gonadotrophin Human chorionic somatotrophin Progesterone Estrogen Molecular transfer
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Placental blood flow

Placental Blood Flow = 500-700ml/min ( approximately 10% of the Cardiac output) Maternal blood pressure Maternal cardiac output Vasomotor tone of the uterine vessels Pathological changes of the placenta State of uterine contraction
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Placental drug transfer

Passive-diffusion is the mechanism Q/t = {k x A x (Cm-Cf)} / D Q: quantity of free drug (non ionized & non protein bound) crossing to placenta t : per unit of time k: diffusional coefficient of the drug A: total area available for transfer Cm-Cf: difference between maternal & fetal drug concentrations D: distance across the membrane
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Placental transfer of drugs

Diffusion Coefficient depends on:

molecular weight spatial configuration degree of ionization lipid solubility Most anaesthesia drugs cross the placental barrier except the muscle relaxants because of their large size molecule (quaternary ammonia 24 October 2013 compounds) 30

Anaesthetic implications

Pre-anaesthetic considerations: Starvation Respiratory infection Prophylaxis against pulmonary aspiration

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Anaesthetic implications

General Anaesthesia: Posture Tracheal Intubation Placental transfer of drugs Pre oxygenation

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Anaesthetic implications

Regional Anaesthesia: Posture Technique Vasopressors Oxygen supplementation

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Summary
Cardiovascular changes
Respiratory changes Gastro-intestinal changes Haemopoietic changes Placental transfer of drugs

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Bibliography
Anaesthesia & Co-existing diseases-Stoelting

Short Practice of Anaesthesia Churchill Davidson

Refresher Course Lectures, Manipal, ISA 1989

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Thank you
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