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Obstetrics

Dr: Mahabad Lec: -1-


10-Oct-06

Physiologic changes of pregnancy

Objectives

 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

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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----
Hemodilution
 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
concentration

13.0 12.2 10.9 11.0 12.4


HB

Serum 90.0 106.5 75.3 56.0 57.1


iron

Serum 63.0 97.4 22.2 14.7 27.6


Ferritin

 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

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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

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

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• 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
falls.

 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

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 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

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 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