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Dr: Mahabad Lec: -1-


Physiologic changes of pregnancy


 Symptoms and physical findings of each organ system

 Physiologic versus pathologic changes
 Diagnostic tests and interpretations during physiological changes

Organ systems

 Cardiovascular system
 Pulmonary system
 Genital tract
 Urinary system
 Endocrine system
 Gastrointestinal Tract
 Skin

Cardiovascular system

 Total Body water

 Cardiac Output

Total body water

 Increases 6-8 L
 Increases by 40 %
 Normal body water
• 2/3 intracellular
• 1/3 extracellular
 ¾ interstitial
 ¼ intravasular
 2/3 increase is extravascular

Physiologic anemia of pregnancy

 Physiologic intravascular change

 Plasma volume increases 50-70 %
• Beginning by the 6th wk
 RBC mass increases 20-35 %
• Beginning by the 12th wk
 Disproportionate increase in plasma volume over RBC volume----
 Despite erythrocyte production there is a physiologic fall in the hemoglobin
and hematocrit readings

Patients without overt anemia & not given supplementation

Non 1st 2nd 3rd deliv

preg Tri Tri Tri

13.0 12.2 10.9 11.0 12.4


Serum 90.0 106.5 75.3 56.0 57.1


Serum 63.0 97.4 22.2 14.7 27.6


 Wide standard deviation Williams 21ed

Iron deficiency anemia

 With erythropoiesis of pregnancy, iron requirements increase.

 Because large amounts of iron may not be available from body stores and may
not be in the diet
 Supplementation is recommended to prevent iron deficiency anemia
 At term, Hemoglobin less than 10.0 is usually due to iron deficiency anemia
rather than the hemodilution of pregnancy

Normal Iron Requirements

 Total body iron content average in normal adult females is 2gm

 Iron requirement for normal pregnancy is 1 gm
• 200 mg is excreted
• 300 mg is transferred to fetus
• 500 mg is need for mom
 Total volume of RBC inc is 450 ml
 1 ml of RBCs contains 1.1 mg of iron
 450 ml X 1.1 mg/ml = 500 mg
 Daily average is 6-7 mg/day
 Small intervals between pregnancies are most concerning

Cardiovascular system

 Total Body water

 Cardiac Output

Cardiac output (CO=HR X SV)

 Begins to increase by the 5th wk

 Rise of 40 % by 20-24 wks
 Initial increase is a function of
• The increase in heart rate
• Reduced systemic vascular resistance
 By 10- 20 wks the increase in CO is reflected mainly by the increase in SV
• The notable increase in plasma volume or preload contributes to the
increase SV
 As pregnancy advances to term, the HR continues to increase but the SV falls
to close to normal levels, this accounts for the fall in CO to near non-pregnant
levels at term

Interpretation of tests during pregnancy

• Elevation of diaphragm
 Heart to be displaced to the left and upward
• Increase in the cardiac silhouette
 benign pericardial effusion
 Echocardiogram

• Increased left ventricular wall mass
• Increased end diastolic dimensions
• Increase in EDV and therefore inc in SV
 Electrocardiogram
• Slight left axis deviation

Respiratory system

 Mechanical
• diaphragm
 Consumption
• Increase in needed oxygen
 Stimulation
• Progesterone stimulation

 Mechanical
 Diaphragm rises 4 cm
 Less negative intrathoracic pressure
 Dec FRC-Functional Residual Capacity
 volume after passive expiration
 Dec ERV-Expiratory Reserve Volume
 max volume expired after expiration
 Dec RV-Residual Volume
 volume after max expiration
 No impairments in diaphragmatic or thoracic muscle motion
 Lung compliance remains unaffected

 Consumption
 O2 consumption Increases 15-20 %
 50 % of this increase is required by the uterus
 Despite increase in oxygen requirements, with the increase in Cardiac
Output and increase in alveolar ventilation oxygen consumption
exceeds the requirements.
 Therefore, arteriovenous oxygen difference falls and arterial PCO2

 Stimulation
 Progesterone is known to directly stimulate ventilation
 Progesterone increases the sensitivity of the respiratory centers to CO2
 Also, it is thought to reduce total pulmonary resistance

 Minute ventilation = RR X Tidal volume

 Tidal Volume-increases
• Volume of air Inspired and expired with each breath

 Minute ventilation-increases
• Volume inspired or expired in 1 min
 RR- remains unchanged
 Vital capacity-remains unchanged
• Max volume that can be forcibly inspired after max expiration

Physiologic changes

 Dyspnea-increase in desire to breathe

• 70 % of pregnant women experience this
• Occurs during 1st trimester without mechanical factors
• No change on PFTs
• The lower PCO2 then paradoxically causes dyspnea
• The marked change or marked decline in PCO2 results in the sensation
of dyspnea

Genital Tract

 Increased vascularity and hyperemia

• Vagina
• Perineum
• Vulva
 Increased secretions
 Characteristic violet color of the vagina
• Chadwick’s sign
 Increased length to the vaginal wall
 Hypertrophy of the papillae of the vaginal mucosa

 Uterine hypertrophy of the myocytes

 Hypertrophy can cause venous compression

• Can result in fall in venous return
• Furthermore a fall in CO
• Physiologic compensation
 Rise in peripheral resistance to minimize fall in blood pressure

 Without Physiologic compensation

 Supine hypotensive syndrome can occur with a gravid uterus
• Symptoms-Nausea, dizziness, syncope
 Can be relieved with position changes

Gravid uterus has limited autoregulation

 Uterine blood flow is Increased 100 ml/min to 1200 ml/min
 Because uterine vessels are maximally dilated little autoregulation can occur
to improve flow during perfusion pressure changes
 When maternal Cardiac output declines, blood flow is shifted away from the
uteroplacental circulation to the maternal brain, kidney and heart.

Urinary System-Dilation

 Calyces, renal pelves, and ureters undergo marked dilatation

 More prominent on the right
 Partial obstruction of the ureters can occur at the pelvic brim
 Progesterone produces smooth muscle relaxation which is thought to cause the
relaxation noted

Urinary System-inc GFR

 GFR and renal plasma flow increases 40 % by mid-gestation

 Plateaus, then remains unchanged until term
 Elevated GFR is reflected in the lower serum levels of creatinine and blood
urea nitrogen
 NL GFR 120-160 ml/min

Urinary System-Proteinuria

 Normally not evident

 Average is 115 mg/day
 260 mg/day is in 95 percent confidence limit
 Therefore, our 300 mg screen would exceed most normal variations