Maternal Adaptations:

PHYSIOLOGY OF PREGNANCY
Jimemah Celeen P. Garbosa, MD
Physiologic Changes
A. Reproductive
B. Breasts
C. Skin
D. Hematological
E. Cardiovascular
F. Respiratory Tract
G. Urinary system
H. Gastrointestinal tract
I. Endocrine
A. Reproductive --weighs 1100 gm at term
--marked stretching & hypertrophy of
cells
1. Uterus --increase in fibrous & elastic tissues
--from 10 ml to 5L capacity

• estrogen causes hypertrophy

• increase in size due to products
• dextrorotation
• tension on broad & round ligaments
• Braxton Hicks contraction
A. Reproductive
• from Convex fundus
to becoming dome shape
1. Uterus
• Insertion of the ligaments (rounds,
uteroovarian)

• Fallopian tubes elongates

• Location from pelvis to abdominal

organ

• Size/shape/position
A. Reproductive Increase in:
• vascular dilatation
• blood flow
2. Uteroplacental • nitric oxide & eNOS
Blood Flow
Caused by:
o endothelial shear stress
o estrogen and progesterone

o VEGF*
o relaxin
A. Reproductive
● corpus luteum- 6-7 weeks
● increase caliber of ovarian veins
3. Ovaries
• secretes RELAXIN:
-remodels reproductive tract tissues
-renal hemodynamics
-uterine artery compliance
A. Reproductive
• cyanosis, softening
• hypertrophy & hyperplasia of glands =
4. Cervix eversion
• bleeds easily
• produce copious mucus beading
• Arias Stella Reaction
A. Reproductive
• increased vascularity & hyperemia
Chadwick sign
4. Vagina &
Goodell sign:______
Perineum
Hegar sign:________

• increased mucosal thickness

• loosening of connective tissues
• muscle cell hypertrophy
• secretions-acidic- glycogen
B. Breasts
• paresthesia
• tenderness
• Glands of Montgomery
• Colostrum: 2nd day by postpartum
C. Skin - striae gravidarum (depressed streaks)

- diastasis recti-muscles separate

1. Abdominal Wall - ventral hernia

Strongest associated risk factors:

- weight gain during pregnancy
- younger maternal age
- family history
C. Skin - accentuated with darker complexion

- linea nigra (linea alba)

2.Hyperpigmentation - chloasma or melasma gravidarum-
mask of pregnancy
3. Vascular changes

- presence of angiomas (vascular spiders)

- palmar erythema
- increased cutaneous blood flow to
dissipate heat generated by increased
metabolism
D. Hematological
system - Hypervolemia of 40-45 % at 32-34
weeks
- due to increase of plasma & red cell
mass
1. Blood volume - moderate erythroid hyperplasia
- reticular count increase
- hemoglobin slightly decreases
- < 11 g/dl
- whole blood viscosity decreases
- Iron requirement in pregnancy- 1000 mg
>300 mg go to fetus, placenta > 200 mg are
obligatory losses

During pregnancy:
- serum iron & ferritin are decreased
- Iron requirement averages 6-7 mg/day
- fetal red cell production is not impaired
- half of iron stores is lost during puerperium

- 500 ml is lost for single vaginal delivery

- 1000 ml is lost for twin delivery or
cesarean section
D. Hematological
system Three Immunological phases:

a. Proinflammatory- early
- invasion of blastocyst
2. Immunologic
functions b. Anti-inflammatory- mid pregnancy
- rapid growth & development of fetus

c. Inflammatory-parturition
- influx of immune cells in myometrium
D. Hematological
• leukocytosis (15,000- 25,000 /μL)
system • increased granulocytes & CD8 T
lymphocytes
• decrease of CD4 T lymphocytes &
monocytes
2. Immunologic
functions
D. Hematological
1. Leukocyte alkaline phosphatase –
system increased
2. C reactive protein- rises rapidly in
response to tissue trauma & inflammation
3. Erythrocyte sedimentation rate (ESR)-
3. Inflammatory increased due to increased globulins &
Markers fibrinogen
4. Complement factors C3 & C4 - increased
5. Procalcitonin – increased until 1st post
partum days. Also high in bacterial infections
D. Hematological
During normal pregnancy:
system ⇒ Coagulation & fibrinolysis are augmented
but balanced to maintain homeostasis.
- increase of factors I, VIII , thromboxane A2
- decrease of the following:
1. platelet concentrations - < 2.5th percentile
4. Coagulation & 2. Protein C, free protein S
Fibrinolysis - levels of antithrombin is constant
E. Cardiovascular
During pregnancy,
System - decrease in systemic vascular resistance &
meanarterial pressure (MAP)
- increase in cardiac output, as early as 5th
wk AOG

- increase in heart rate by 10 beats

1. Circulation
- increase in preload
- affected by maternal posture
E. Cardiovascular
• displaced left & upward & rotated on its
System axis
• exaggerated splitting of the S1
2. Heart • soft diastolic murmur in 20%
• loud S3
• continuous murmur- from mammary
vessels
E. Cardiovascular
System

2. Heart
E. Cardiovascular
• supine position diminishes cardiac output
System • left lateral position improves
• for multiple gestations increase by 20%
• during 1st & 2nd stage of labor –increased

3. Cardiac Output
E. Cardiovascular
System
E. Cardiovascular
venous blood flow is retarded during
System pregnancy due to pelvic vessels & IVC
occlusions
• prone to develop dependent edema &
varicose veins of legs, vulva as well as
hemorrhoids
4. Circulations
• predispose to deep vein thrombosis
• arterial pressure decreases to nadir at 24-
26 wks
E. Cardiovascular
• supine compression of the great vessels
System causes significant arterial hypotension
• when supine, uterine arterial pressure is
lower than brachial artery
• seen in 10% of women

5. Supine
Hypotension
E. Cardiovascular
• normal pregnancy is refractory to the
System pressor effects of infused angiotensin II

• renin is increased

( produced by maternal kidney & placenta)

6. Renin,
• angiotensinogen ( renin substrate) is also
Angiotensin II increased

(produced by maternal & fetal liver)

E. Cardiovascular
Two species:
System 1. Atrial natriuretic pepetides (ANP)
2. Beta type natriuretic peptide (BNP)
7. Cardiac Natriuretic - regulate blood volume by promoting
natriuresis, diuresis and vascular smooth
peptides muscle relaxation
- not increased during pregnancy but seen in
preclampsia
E. Cardiovascular
PGE2 is increased, its role is natriuretic
System - PGI2 is increased, the principal
prostaglandin of endothelium, acts to
8. Prostaglandins regulate blood P & platelet
function
F. Respiratory tract
 Increased lung volumes/capacity in the
F. Respiratory tract following:
1. Inspiratory capacity
2. Tidal volume
3. Minute respiratory volume

Decreased lung volumes:

1. Functional residual capacity
2. Expiratory reserve volume
3. Residual volume
 NO CHANGE- total lung capacity, RR
F. Respiratory tract Resting Minute Ventilation is enhanced by:
1. stimulatory action of progesterone

2. low expiratory reserve volume

- diaphragm rises by 4 cm during pregnancy
- thoracic circumference increase by 6 cm
- greater diaphragmatic excursion during
pregnancy

3. compensated respiratory alkalosis

 Pulmonary Function
Increased:
F. Respiratory tract - Peak expiratory flow rate,

- airway conductance

- Decreased:
- total pulmonary resistance
Unchanged:
- lung compliance, maximum breathing
capacity, forced vital capacity
Oxygen Delivery
- oxygen consumption is increased
by 20% but during labor it can
increase to 40-60 %
- maternal arteriovenous oxygen
difference is decreased
 • increased kidney size, hydronephrosis
• elevated GFR (hyperfiltration) due to:
G. Urinary system - decreased oncotic pressure & low
proteins
- increased renal plasma flow

• Glucosuria-not normal
• Hematuria – sign of infection or
contamination
• Proteinuria - if passage of >300 mg/day
• Ureteral compression more at the right
 During the day, pregnant women tend to
accumulate water as dependent edema
G. Urinary system
at night, while recumbent, they mobilize this
fluid with diuresis

This reversal of the usual nonpregnant

diurnal pattern of urinary flow causes
nocturia, and urine is more dilute than in
nonpregnant women.
 - increased in size
- hyperplasia of bladder muscle elevate
G. Urinary system trigone causing to thicken its posterior
- at the end of pregnancy, entire base of
Bladder bladder is pushed forward & upward
becoming concave from being convex
 -transient gingivitis (pregnancy gingivitis)

H. Gastrointestinal - epulis gravidarum- pyogenic granuloma

tract - Heartburn (pyrosis) – caused by reflux of
acidic secretions

- Gastric emptying time is unchanged but

may be prolonged during labor (aspiration
& regurgitation)

- Hemorrhoids: common - due to increase

pressure below uterus
 - no increase in liver size

H. Gastrointestinal - decrease albumin (hemodilutional)

tract - total alkaline phospatase – doubles

- decreased of the following:

Liver a. serum aspartate transaminase
b. alanine transaminase
c. gamma glutamyl transpeptidase

- d. bilirubin
 ● gallbladder contractility is reduced
and leads to increased residual volume
H. Gastrointestinal ● progesterone potentially impairs
tract gallbladder contraction by inhibiting
cholecystokinin (CCK)

Gallbladder
● Impaired emptying
● subsequent stasis
● increased bile cholesterol saturation
 H. Gastrointestinal
tract

A 34-year-old G2P1 presents with

diffuse itching involving her
abdomen and upper extremities at
34 weeks' gestation.
 Intrahepatic Cholestasis
of Pregnancy (ICP) is a
condition in which the
normal flow of bile is
affected by the increased
amounts of pregnancy
hormones.

INTRAHEPATIC CHOLESTASIS OF PREGNANCY

HCG
 Pituitary enlarges by 135%
- due to estrogen-stimulated hypertrophy
I. Endocrine and hyperplasia of lactotrophs
- Prolactin increased 10 folds at term
1.Pituitary Gland - Thyroid- increase in size to meet
maternal/fetal needs
- FT4 increases, crosses the placenta
- TSH does not cross
 - gonadotrophs are decreased
- somatotrophs are suppressed
I. Endocrine - corticotrophs & thyrotrophs are constant
- secrete growth hormone during 1st trime
1.Pituitary Gland - later then secreted by placenta ( by 8th
wks)

Placental growth hormone:

-Major determinant in maternal insulin
resistance
-serum levels correlate with birth weight
-plateaus secretion after 28 weeks and
reach baseline by 36 weeks AOG
 - increased levels & 10- fold at term
I. Endocrine - initiates DNA synthesis of glandular
epithelial cells & presecretory alveolar cells
PROLACTIN of the breast
- increases the number of estrogen &
progesterone receptors in breasts
- promotes mammary alveolar RNA
synthesis & galactopoiesis
 -moderate increase in size & vascularity
- Increased by 40-100% to meet maternal &
I. Endocrine fetal needs
- Thyroid binding globulin is increased as
influenced by estrogen
- TBG increases the total T4 & T3 levels but
Thyroid gland not FT4 & FT3
- fetal secretion of thyroid hormones ensues
at 20 wks
- hCG has a thyrotropin like activity &
stimulates maternal free T4 secretion
- Thyrotropin releasing hormone is not
increased during pregnancy
I. Endocrine
Action is on bone resorption, intestinal
Parathyroid hormone absorption &kidney reabsorption

increase extracellular fluid calcium &

decrease phosphate levels

fetal skeleton mineralization requires

approximately 30 g of calcium, primarily
during the third trimester
 ● undergo little morphological change

I. Endocrine ● cortisol secretion is increased but bound

to transcortin (CBG)

Adrenal glands ● increased secretion of aldosterone by 15

wks

● aldosterone gives protection against

natriuretic effect of progesterone & ANP
has a role in modulating trophoblastic
growth & placental size
 Water metabolism
Metabolic - Increased water retention
- mediated by fall in plasma osmolality of 10 Osm /kg
Changes due to the reset threshold for thirst & vasopressin
secretion
- water content of placenta, fetus & AF accumulates
to 3.5 L
- increase from blood volume, breast & uterus
amounts to 3.0 L
- average accrues during normal pregnancy is 6.5 L
- edema in legs is caused by increased venous
pressure below the level of uterus caused by partial
vena cava occlusion & decreased interstitial colloid
oncotic pressure
 Carbohydrate metabolism
Metabolic - characterized by mild fasting hypoglycemia, postprandial
hyperglycemia & hyperinsulinemia
Changes
- pregnancy is a state of peripheral insulin resistance
- pregnant women can change rapidly from a postprandial
state to a fasting state called Accelerated starvation

Fat metabolism
levels of lipids, lipoproteins & apolipoproteins are
increased due to increased insulin resistance & estrogen
stimulation
maternal hyperlipidemia during late gestation VLDLs,
LDLs, HDLs are increased
Metabolic
Changes Protein metabolism
- amino acids levels are in fetal than
maternal
- products of conception, uterus & maternal
blood are rich in protein
- at term the fetus & placenta contains 500
gm of protein while the rest go to uterus,
breast blood as hemoglobin & plasma
proteins
 ● Progressive lordosis
MUSCULOSKELETAL
SYSTEM
“This is a super-important quote”

- From an expert
END