PHYSIOLOGICAL CHANGES IN PREGNANCY

Dr. Nizamuddin Abdul Aziz MBBS, MRCOG Obstetrician & Gynaecologist

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PHYSIOLOGICAL CHANGES IN PREGNANCY

1. General Changes 2. Metabolism 3. CVS 4. Respiratory System 5. Haematology 6. Renal System 7. GIT 8. Endocrine System 9. Nutrition

GENERAL 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 CHANGES
Uterus weight from 50g to 1kg at term length from 7.5cm to 35cm at term Hyperplasia & hypertrophy of myometrium- Oestrogen and Progesterone mediated. Gap junctions Hypertrophy of uterine arteries

Breasts Best evident is primigravida Marked hypertrophy and proliferation of ducts Hypertrophy of connetive tissue stroma Nipples become pigmented Sebaceous glands may be visible ( Montgomerys tubercles) Role of prolactin. Colostrum . Lactation 4

GENERAL CHANGES
Face Chloasma gravidarum :symmetrical hypermelanosis or pigmentation around cheek, forehead and eyes, disappears after delivery Due to in MSH secretion resulting in melanin deposition in dermis or epidermis Abdomen Linea nigra brownish black pigmentation area in the middle stretching from xiphisternum to symphysis pubis Striae gravidarum represents mechanical stretching of deeper layer of cutis and may develop in abdomen and breasts. Due to effect of corticosteriod, relaxin, oestrogen, abdominal distension, weight gain
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GENERAL CHANGES
Sebaceous gland activity acne and greasy skin Hirsutism seen Thickening of scalp hair during pregnancy-prolonged anagen phase. Post partum hair shedding hair enters telogen phasetelogen effluvium Palmar erythema and spider naevi may develop due to oestrogen effect.

Itchy papules develop pregnancy prurigo which would disappear after delivery
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METABOLISM
CALORIC REQUIREMENT
Normal caloric requirement in female 1600-2100 kcal/day. Well nourished individual or those whose diet is

supplemented no change in first 10 weeks of pregnancy.

Thereafter caloric requirement increases 50-100 kcal/day till

36 weeks.
200-300 kcal/day final 4 weeks of pregnancy

METABOLISM
WEIGHT GAIN
Weight gain 10-12 kg. Recommended wt gain BMI <20 is

12.5 -18kg, BMI 20-26 is 11.5-16kg

Comprises maternal body water (8 L ), fat and other tissues. At least 40% of weight gain is by fetus, amniotic fluid,

placenta and uterus.

Remaining weight gain in blood, breasts, body fat and

extracellular water retention

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METABOLISM

METABOLISM
Fall in weight during first trimester resulting from morning

sickness. Thereafter steady gain throughout pregnancy 0.4 kg/week.

Maternal weight gain has positive association with birthweight of infant

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METABOLISM
CARBOHYDRATE AND INSULIN RESISTANCE
Pregnancy brings about changes in hormones and insulin

resistance that leads to increase in blood glucose level.

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

after carbohydrate food is less than non pregnant state.

This in sensitivity stimulates glycogen synthesis and

storage, deposition of fat and transport of amino acids into cells.

After mid pregnancy, insulin resistance gradually develops.

This results in the increase in glucose level after carbohydrate food is higher than non pregnant state and the rise lasts longer.
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METABOLISM
Rise in maternal glucose beneficial for fetus. Despite higher and prolonged rise in postprandial glucose,

fasting glucose reduces below non pregnant state

Fasting plasma insulin level and reaches maximum level

about 32 weeks.
insulin resistance which persists till term, reduces

maternal utilization of glucose and induces glycogenolysis, gluconeogenesis as well as utilization of lipids as energy source.
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METABOLISM
Insulin resistance - secretion of diabetogenic hormones

- cortisol reduces peripheral insulin sensitivity - renin and aldosterone - hPL - Oestrogen and Progesterone - Glucagon and cathecolamines - Growth decrease
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METABOLISM
AMINO ACIDS
Required by mother and fetus for growth and energy. AA. Fall is most marked with gluconeogenic amino acids eg.

alanine.
Transport across placenta. insulin resistance in pregnancy accelerate AA uptake by

mother for gluconeogenesis.

Concentration of protein in maternal serum falls by 20

weeks, protein concentration has fallen from 7g to 6g/100ml. Most of this fall is in serum albumin. 15

METABOLISM
LIPIDS
3 fold increase in triglycerides and fatty acids. LDL (50%) HDL (10-20%) Total cholesterol falls by 5% in early pregnancy, reducing

lowest at 6-8 weeks. Thereafter there is progressive (20200%).

Hyperlipidaemic in normal pregnancy is not atherogenic

because the pattern is not that of atherogenesis.

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LIPIDS

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CARDIOVASCULAR SYSTEM
Heart rotated forward and pushed upwards as diaphragm

rises. Apex beat shifts to the 4th ICS Systolic ejection murmurs are common in mid pregnancy Palpitations, loud 1st heart sound, 3rd heart sound

ECG:
left axis deviation Low QRS complex Flattened or even inverted T wave in lead III

PAC ,VE
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CARDIOVASCULAR SYSTEM
Total peripheral vascular resistance reduces by 6 weeks of

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

Cardiac output by 50% from baseline of 4-5 l/min to

7l/min

Heart rate by 10% Stroke volume by 10% (10 to 20 mls )

Most changes reach maximum value by end of first trimester

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CARDIOVASCULAR SYSTEM

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CARDIOVASCULAR SYSTEM
Small fall in systolic and greater fall in diastolic blood pressure during first half of pregnancy resulting in in pulse pressure The blood pressure steadily rises in 2nd half of pregnancy back to pre-pregnant state as term approaches Plasma volume by 50-60% from baseline of 2600mls. Plasma volume expansion is greater in multiple pregnancy Bigger plasma volume expansion, bigger the birth weight of the baby. Conversely plasma volume expansion is less in smaller babies as in pre-eclampsia and IUGR.

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CARDIOVASCULAR SYSTEM

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CARDIOVASCULAR SYSTEM
Total extracellular fluid volume increase by 16% Venous pressure in the legs from 9cm H2O in early pregnancy to 24cm H2O at term Mechanical pressure of uterus on iliac veins In late gestation pressure of fetus head also contributes. Combination of pressure and distensibility of veins predispose to varicose veins of the legs, vulva, rectum and pelvis

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CARDIOVASCULAR SYSTEM
Pulmonary resistance falls in early pregnancy

Pressure in the pulmonary arteries, capillaries and right ventricle does not change because the pulmonary circulation is able to absorb high flow rate without change of pressure.

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RESPIRATORY SYSTEM
Neck and oropharyngeal tissues are affected by weight

gain in pregnancy Airway oedema and difficult visualisation of larynx during intubation Vascularity of respiratory mucosa increases Nasal mucosa is oedematous , vascular and tends to bleed

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RESPIRATORY SYSTEM
Vital capacity remained unchanged Tidal volume 40% Inspiratory capacity Expiratory reserve Residual volume FRC Peak expiratory flow rate unchanged. FEV1 unchanged. Respiratory rate unchanged Diaphragm raises and breathing is more diaphragmatic in nature

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RESPIRATORY SYSTEM

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RESPIRATORY SYSTEM
oxygen consumption of 30 40 ml /min in late pregnancy from baseline of 300ml/min partitioned between mother (extra cardiac, renal, respiratory work, breast development) and fetoplacental unit (a third ) Pulmonary blood flow in tandem with cardiac output. Minute ventilation 30- 50 % - achieved by tidal volume whereas respiratory rate remains consistent.Perceived as shortness 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 pregnant 28 state

RESPIRATORY SYSTEM
pCO2 activates carbonic anhydrase Renal compensation ensues by excretion of bicarbonate. Plasma bicarbonate falls to 18-22mmol/L (from 24-28 mmol/L in non pregnancy) pH is maintained at 7.4 to7.45 Fall in maternal pCO2 allows more efficient CO2 transfer from fetus (pCO2 of 55mmHg) alveolar ventilation results in pO2 from 96.7 to 101.8mmHg (12.9-13.6kPa) Rightward shift of maternal oxyhemoglobin dissociation curve caused by 2, 3 DPG in erythrocytes in pregnancy facilitates oxygen unloading to fetus ( which has much lower pO2 25-30mmHg and leftward shift of oxy hemoglobin dissociation curve) 29

RESPIRATORY SYSTEM

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COMPOSITION OF BLOOD - Haematology

Plasma volume 50% Red cell mass 20-30% depending on Fe intake Packed cell volume (from 36% early pregnancy to 32%) MCHC Red cell count , Hb Rise 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 - Haematology

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COMPOSITION OF BLOOD - Haematology

Bone marrow - Hyperplastic with immature erythryoid precursors Total white cell count Neutrophil count to a peak at 33 weeks then stabilise Eosinophil, basophil and monocyte count remain unchanged Lymphocyte count remains unchanged but their function is suppressed therefore more susceptible to infection Platelet count remains within normal non-pregnant range 8-10% normal pregnancies, platelet count falls below 150x109/L without ill effects on mother or fetus. Probably resulting from physiological fibrinolysis within uteroplacental 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, XII Fibrinogen ( x 2), von Willebrand factor Antithiombin III (inhibitor of coagulation) unchanged Activated protein C resistance, protein S activity D dimer, ESR due to fibrinogen level PAI 1 and PAI 2 , Alpha 2 antiplasmin

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RENAL SYSTEM
Anatomic Changes Kidneys increase in size 1-2 cm in length Dilatation of renal pelvis, renal calyces, and the ureters and these remain enlarged for several weeks after pregnancy. Predisposes to UTI Caused by progesterone and compression of ureters by enlarging uterus.

Physiological Changes Effective renal plasma flow 80% in mid pregnancy and then falls to 65% above non pregnant value by term. GFR 45% by 9th week and thereafter by only 5-10% and only falls slightly to term.
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RENAL SYSTEM
Serum creatinine and urea .Creatinine clearance 25% Total body water 20% during pregnancy with in plasma

osmolality by 10 mOsmol/kg
Pregnant women accumulate 950 mmol of Na. GFR tends to excrete more Na at distal tubules. Compensated for by activation of renin-angiotensin-

aldosterone mechanism which enhances distal tubular reabsorption of Na

Pregnant women tend to accumulate 350 mmol of K during

pregnancy despite GFR and activation of RAS. Mechanism uncertain.

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

back to normal in 2nd half of pregnancy

Glycosuria may be present because quantity of filtered

glucose exceeds the maximum reabsorption capacity of proximal tubule

Excretion of amino acid in pregnancy due to quantity

filtered exceeding the tubular reabsortion

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RENAL SYSTEM
Protein excretion in pregnancy due to GFR. In late

pregnancy total protein excretion (upper limit) of < 300mg/24hrs is acceptable

Urinary calcium excretion is 2-3 x higher in pregnancy

(despite concentration of 1,25 dehydrocholecalaciferol)

frequency and nocturia

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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, water constipation

Heartburn

(reflux) intragastric pressure without concomittent in tone of oesophogeal cardiac sphincter Delayed gastric emptying gastric aspiration Bile reflux into stomach because of pyloric sphincter incompetent aluminum hydroxide
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GASTROINTESTINAL SYSTEM
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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GASTROINTESTINAL SYSTEM
Gall bladder in size and empties more slowly Stasis of bile (cholestasis) in biliary cannaculi generalised

pruritus responds cholestyramine

Cholestasis is probably hormonal because same effects is

observed in patients on OCP or HRT

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ENDOCRINE
Placenta produces
hCG hPL ACTH Oestradiol Progesterone PTH related proteins Renin

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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 maternal process of immmunorejection of fetus as a homograft Stimulates Leydig cells of male fetus to produce testosterone (in conjunction with fetal pituitary gonadotrophins) thus is indirectly 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 and hyperplasia of uterine myometrium thereby capacity, vascularity and blood flow to uterus b) Development of breasts. Hypertrophy and proliferation of ducts are due to oestrogen.Proliferation of glandular alveoli influenced by progesterone and hPL c) Steroids are involved in a complex pathway in the initation of normal labour d) Progesterone is necessary to maintain endometrial lining of uterus during pregnancy. Prevents preterm labour by reducing myometrial contraction
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ENDOCRINE
Hypothalamus and pituitary Pituitary weight 30%- headache and increased sensitivity of gland to haemorrhage (aided by lack of direct arterial blood supply to anterior pituitary)

Prolactin by term level 10-20x more than non pregnant women. 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 47 women are euthyroid

ENDOCRINE
Parathyroid glands Extracellular free calcium acts on the parathyroid cells to regulate secretion of PTH
Absorption of calcium form gut RENAL

PTH
SYNTHESIS

1,25 dihydroxyvitD

Absorption of calcium form kidneys

Mobilisation of calcium from bones

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ENDOCRINE
In pregnancy 1,25 dihydroxycholecalciferol providing the calcium requirement in pregnancy PTH are of two types : iPTH and PTHrP iPTH in pregnancy but PTHrP Renal Hormones Activation of renin-angiotensin system renin & angiotensin II by the end of 1st trimester and than plateau thereafter angiotensinogen occurs till term Pancreas size and number of Beta cells of islets of Langerhans

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NUTRITION
Iron a) Needed for:

expansion of red cell mass - fetus and placenta - replace blood loss at delivery
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b) Iron requirements double during pregnancy. c) Estimated total iron needed in pregnancy is 1000mg. d) Mother transfers 200-300mg iron to fetus. e) Iron absorption in pregnancy by 20-40%. f) RDA for iron in pregnancy is 30 mg/day.
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NUTRITION
Calcium a) Calcium requirement by 33% in pregnancy. b) Net transfer across placenta is 25-30 g (active). c) RDA for calcium in pregnancy is 1200mg.

Folic acid. a) Important incidence of NTD. b) RDA 400mcg/day starting from preconception - 5mg/day if previous child has NTD

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RDAs of Nutrients During Pregnancy

Non pregnant Energy (kcal) Protein (g) Calcium (mg) Iron (mg) Folate (mcg) Zinc (mg) Phosphorus Vitamin D 2200 44-50 800 15 180 12 800 5 Pregnant 2500 60 1200 30 400 15 1200 10

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Thank you

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