Maternal Adaptations

to Pregnancy

Catherine Torres-Jison, MD, FPOGS

Updated 2010 January
UTERUS
NonpregnantWoman
- almost solid structure weighing 70 g with a cavity
of 10 ml or less

During Pregnancy
- transformed into a relatively thin-walled muscular
organ of sufficent capacity to accommodate the
fetus, placenta and AF
UTERUS
At Term
- 500 to 1000x greater capacity than non-
pregnant uterus and may contain an average of 5
L (sometimes reaching 20 L)
- weighs approx. 1100g
- walls are 1.5 cm thick or less
UTERUS during pregnancy
Uterine enlargement involves stretching and
marked hypertrophy of existing muscle cells
Limited appearance of new muscle cells
Collagen fibrils surrounds the myometrium
transmitting the contractile force to the
connective tissues around it
UTERUS during pregnancy
Fibrous tissues and elastic tissues accumulates
in the external muscle layer forming a
network that increases the strength of the
uterine wall
Great increase in size and number of blood
vessels and lymphatics
Veins that drain the placental site transform
into large uterine sinuses
Nerve hypertrophy (e.g. Frankenhauser
cervical ganglion)
UTERUS during pregnancy
Uterine Hypertrophy is stimulated chiefly by
estrogen (perhaps by progesterone)
After 12 weeks, uterine enlargement primarily due
to pressure exerted by expanding products of
conception
Correlated with increase in polyamines, spermidine
and spermine (immediate precursor: putrescine)
which is probably metabolized by the enzyme
diamine oxidase prduced by the decidua at around
13-14 weeks
Arrangement of Uterine Muscle Cells
1. External hood-like layer which arches over
the fundus and extends into various
ligaments
2. Dense network of muscle fibers perforated
in all directions by blood vessels (main
portion)
3. Internal layer consisting of sphincteric-like
fibers around the orifices of the tubes and
internal os
Changes in Size, Shape & Position
First few weeks: pear-shaped
organ
3rd lunar month: globular and
spherical-shaped
Becomes more ovoid in shape
subsequently and starts to
become an abdominal organ
Dextrorotation happens
 Changes in Uterine Contractility

First Trimester
irregular, painless contractions
Second Trimester
Braxton Hicks contractions
sporadic and unpredictable,
non-rhythmic (5-25 mmHg), also
cause false labor pains (near term)
 Uteroplacental Blood Flow

The delivery of most substances essential for

growth and metabolism of the fetus and the
placenta, as well the removal of most
metabolic wastes, is dependent upon adequate
perfusion of the intervillous space
Reported values range from 450 to 650
mL/min late in pregnancy
Affected by uterine contractions
Control of Uteroplacental Blood Flow
Increase in maternal-placental blood flow
principally occurs by vasodilatation.

Increase in fetal-placental blood flow due to

continuing increase in placental vessels.

(Studies more extensively done in sheep.)

Control of Uteroplacental Blood Flow
Catecholamines (epinephrine,norepinephrine)
- cause significant decrease in placental perfusion due
probably to a greater sensitivity by the uteroplacental
vascular beds to these substances
Angiotensin II
- uterus has marked refractoriness (decreased
sensitivity) to this substance during pregnancy
maintaining a good uterine blood flow
- pregnancy-induced hypertension cases shows
decreased refractoriness to this substance
Control of Uteroplacental Blood Flow
Nitric Oxide /endothelium-derived relaxing factor
(EDRF)
- potent vasodilator released by endothelial cells
- inhibits platelet aggregation and adhesion to vascular
endothelial surfaces
- nitric oxide synthase (NOS) has been found in the
endothelium of the umbilical veins, amnionic
epithelium and cells of Wharton jelly
- decreases as pregnancy advances or in cases of PIH
 Cervical Changes
Pronounced softening and cyanosis
demonstrated as early as a month after
conception (Hegar Sign)
Due to increased vascularity and edema as well
as hypertrophy and hyperplasia of the cervical
glands
Undergoes a rearrangement of its collagen-rich
connective tissues producing a 12-fold reduction
in mechanical strength by term
Cervical Changes
Mucus plug a clot of very thick
mucus obstructs the cervical canal
soon after conception
Bloody show mucus plug being
expelled at or before the onset of
labor
Eversion glands covered by
columnar epithelium proliferate near
the os producing a red, velvety
appearance which tends to be friable
and has tendency to bleed on minor
trauma
Beading or ferning of cervical mucus
(progestrone effect)
Changes in the Ovaries and Fallopian
Tubes
Ovarian Function
- Ovulation ceases during pregnancy
- Maturation of new follicles are suspended
- Single corpus luteum present functions
maximally on the 6-7th week (5 weeks post-
ovulation) producing progesterone
Relaxin secreted by the corpus luteum,
placenta and decidua parietalis producing
uterine relaxation
Pregnancy Luteoma
- Exagerration of the
luteinization reaction of ovary
of normal pregnancy
- Not a true neoplasm but may
present as large abdominal
masses which regress after
delivery
- May recur in subsequent
pregnancies
- Maternal virilization is usual,
with a female fetus not usually
affected, but it can happen
Hyperreactio Luteinalis
- Also cause maternal virilization during pregnancy
- Similar cellular pattern like the luteoma
- Cystic
- Assoc. with an extremely high serum chorionic
gonadotropin level
 Changes in the Ovaries and Fallopian
Tubes

Other changes in the ovary

- decidual reaction on the surface which may bleed
easily
- increased in ovarian vein caliber (from .9 cm to
2.6 cm diameter at term)
Fallopian Tubes
- flattened tubal mucosa epithelium
- decidual cells may develop in the stroma of
endosalpinx
 Vagina and Perineum
Chadwick sign characteristic violet color of the
vagina during pregnancy due to increased vascularity
and hyperemia
Vaginal walls considerably increase in thickness,
loosening of its connective tissue and hypertrophy of
smooth muscle cells that increase the length of the
wall
Hobnailed appearance of vaginal mucosa due to the
hypertrophy of the papillae
Vagina and Perineum
Increased vaginal and cervical secretions which are
thick, whitish with an acidic pH (between 3.5-6) due
to increased production of lactic acid from glycogen
in the vaginal epithelium by Lactobacillus acidophilus

Vaginal Cytology (Pap smear)

- navicular cells (small intermediate cells)
- vesicular or naked nuclei without cytoplasm
evident along with abundance of Lactobacillus
Abdominal Wall and Skin
Striae gravidarum or stretch marks
Diastasis recti separation of the rectus muscles due
the abdominal tension
Pigmentation
- linea nigra = highly pigmented abdominal midline
- chloasma or melasma gravidarum = brownish
patches on face or neck
- estrogen and progesterone have melanocyte-
stimulating effects in pituitary gland (intermediate
lobe)
Cutaneous vascular changes such as angiomas
(vascular spiders), nevus, telangiectasia, palmar
erythema due to hyperestrogenemia
 Breasts
Early weeks tenderness and tingling sensation
After the 2nd month increase in size and become
nodular resulting from mammary alveolar
hypertrophy
Larger, more pigmented nipples/areola
*hypertrophic sebaceous glands of
Montgomery
Veins become visible beneath the skin
Colostrum production
Metabolic changes
Weight gain
- attributable to uterus, conceptus, breast,
increased blood volume and extravascular cellular
fluid
- average of 12.5 kg (see table 8-1 in textbook)
 Metabolic Changes
Water Metabolism
- increased water retention is a normal physiological
alteration of pregnancy
- due to resetting of osmotic thresholds for thirst and
vasopressin secretion
- minimum amount that that average woman retains
during pregnancy is 6.5 L
- bipedal pitting edema due to partial occlusion of
vena cava by gravid uterus
 Metabolic changes
Protein Metabolism
- 1 kg of protein increase, half from fetus and
placenta, half from uterus, breast and maternal
blood
- actual nitrogen use is only 25% requiring an
increased protein intake in pregnancy
- an increased ingestion of fat and carbohydrates
needed to provide a positive nitrogen balance
Metabolic changes
Carbohydrate Metabolism
- pregnancy is potentially diabetogenic and is
characterized by:
- mild fasting hypoglycemia possibly due to increased
levels of insulin (direct stimulation from human
placental lactogen, progesterone and estrogen)
- postprandial hyperglycemia to insure
- hyperinsulinemia sustained
(peripheral resistence to insulin) postprandial supply
to fetus
Metabolic changes
Carbohydrate Metabolism
- accelerated starvation = pregnancy induced switch
in fuels from glucose to lipids (ensure a
continuous supply of glucose is available for
transfer to fetus)
- plasma glucagon concentration is supressed in
late pregnancy
Metabolic changes
Fat Metabolism
- plasma lipid levels increase continuously
throughout pregnancy (protects mother and fetus
during times of prolonged starvation or hard
physical exertion)
- increased specific activity of hepatic lipase induced
by progesterone -> increased concentrations of high
density lipoproteins
- placental cells have specific high-density
lipoprotein receptors
Metabolic changes
Fat Metabolism
- more intense ketonemia occurs from starvation in pregnant
women
- storage of fat occurs primarily during midpregnancy and
deposited mostly in central rather that peripheral sites
- there are some evidence of progesterone acting to reset a
lipostat in the hypothalamus
Metabolic changes
Mineral Metabolism
- considerable requirements for iron exceed amounts
available
- decreased calcium and magnesium levels
(bone turnover reduced during early pregnancy,
normal during late pregnancy and increased
postpartum lactating women)
- increase in copper and ceruloplasmin (due to
increased estrogens)
- little change in all other minerals except for
retention in amounts required for fetal
growth/maternal tissues
Metabolic changes
Acid-Base Equilibrium
- pregnant women hyperventilates normally causes
respiratory alkalosis by lowering PCO2 of the blood
- moderate reduction in plasma bicarbonate partially
compensates -> minimal pH increase -> shifts O2
dissociation curve to the left --> increases affinity of
maternal hemoglobin for O2 (Bohr effect)
- increase in blood pH (though minimal) stimulates
2,3-diphosphoglycerate in maternal erythrocytes >
counteracts Bohr effects -> O2 release to fetus
Metabolic changes
Plasma Electrolytes
- decrease serum concentration of sodium and
potassium despite large accumulations during
pregnancy
- postulated that progesterone counteracts the
natriuretic and kaliuretic effects of aldosterone
Hematological Changes of Normal
Pregnancy

Blood Volume
- increases markedly (about 40-45% of
nonpregnant volume) from both plasma and
erythrocytes (comprise 33% or 450 mL)
- serves to meet the demands of the enlarged
fetus and its hypertrophied vascular system to
protect against deleterious effects of impaired
venous return in supine and erect positions as
well as blood loss during parturition
Hematological Changes of Normal
Pregnancy
- 2-3x increase in maternal plasma erythropoietin
- Moderate erythroid hyperplasia in bone marrow
- Slightly elevated reticulocyte count
- Atrial natriuretic peptide produces significant
natriuresis and diuresis and decreases renin
secretion causing vasodilation
- Brain natriuretic peptide more potent vasodilator
of placental vasculature (produced in atrial
myocytes and amnion cells)
 Hematological Changes of Normal
Pregnancy

Hemoglobin Concentration And Hematocrit

- decrease slightly
- average 12.5g/dL at term
- abnormal if below 11 g/dL (consider iron
deficiency
 Hematological Changes of Normal
Pregnancy

Iron Metabolism
- iron stores: 300 mg
- total iron content (Normal adult) : 2-2.5g
- iron required during pregnancy: 1 g
(300 mg actively transferred to fetus and
placenta, 200 mg lost thru excretion, 500 mg in
circulating erythrocytes) and averages 6-7 mg/day
during the 2nd half of pregnancy (requiring
exogenous iron)
Hematological Changes of Normal
Pregnancy
Iron Metabolism
- hemoglobin production in fetus will not
be impaired because placenta obtains iron
from mother in amounts sufficient for fetal
needs even if the mother has severe iron-
deficiency anemia
- the amount of iron absorbed from diet,
together with that mobilized from stores, is
usually insufficient to meet the pregnancy
demands.
Hematological Changes of Normal
Pregnancy
Blood Loss
- the average blood loss associated with
caesarean section or with vaginal delivery of
twins is about 1000 mL or nearly twice lost
with the delivery of a single fetus
- Majority of loss comes from placental
implantation site, placenta itself, episiotomy
wounds and lacerations and lochia
 Hematological Changes of Normal
Pregnancy

Immunological and Leukocyte Function

- suppression of humoral and cellularly mediated
immunological functions to accommodate the
foreign semiallogeneic fetal graft.
- decreased in humoral antibodies (to herpes
simplex, measles, influenza A) due to hemodilution
- -interferon often absent
- depressed leukocyte function -> susceptible to
infections but improvement in autoimmune dse.
Hematological Changes of Normal
Pregnancy
- Blood Leukocyte Count in Pregnancy:
5000 12,000/ mL
- During Labor and Early Pueperium:
up to 25,000/mL (average 14-16,000)

C-reactive protein this acute phase serum

reactant is increased
Leukocyte alkaline phosphatase - increased
Hematological Changes of Normal
Pregnancy
Blood Coagulation

INCREASED
- Plasma fibrinogen (I)
- VII (proconvertin)
- VIII (antihemophilic
globulin)
- IX (Christmas factor)
- X (Stuart factor)
- II (prothrombin) - slight
DECREASED
- XI (plasma thromboplastin
antecedent)
- XIII ( fibrin-stabilizing
factors)
- Platelet concentration
 Cardiovascular System

Heart
- displaced to the left and upward by the growing uterus and
is somewhat rotated on its long axis (increased size in
cardiac silhouette in radiographs)
- resting pulse rate increase 10-15 bpm
- little change in the inotropic state during pregnancy except
in multifetal pregnancies
Cardiovascular System
Changes in cardiac Sounds:
1. Exaggerated splitting of the first heart sound with
increased loudness of both components with an
easily heard third sound
2. Systolic murmur in 90 % of pregnant women, soft
diastolic murmur on 20% (probably due to
increased breast vasculature)

No characteristic changes in ECG findings except a

slight deviation to the left of the axis due to
altered position.
Cardiovascular System
Cardiac output
- increased
- appreciably higher in lateral recumbent position than
when supine due to uterine impediment (as high as 1100
mL- 20%)
- increased even more during labor
- returns to normal soon after delivery
 Cardiovascular System
Factors Controlling Vascular Reactivity
renin, angiotensin II, aldosterone
- in PIH, increased sensitivity to angiotensin II was due to
a vessel wall refractoriness not change in blood volume
Prostaglandins production in the arteriolar endothelium
affects (increase) the vessel wall refractoriness to
angiotensin II
Progesterone and metabolites delay the loss of
pregnancy acquired refractoriness to angiotensins after
delivery
Cardiovascular System
Factors Controlling Vascular Reactivity
Cyclic AMP accumulation within vascular smooth
muscle leads to relaxation
Calcium reduces vascular refractoriness
Endothelins
Endothelin 1 most potent vasoconstrictor identified
Reduce cardiac output, renal blood flow, glomerular filtration,
increase intracellular Ca
Cardiovascular System
Circulation
arterial blood pressure
- affected by posture of pregnant woman
- Decreases to a nadir at midpregnancy then increases
Venous blood pressure
- Retarded during pregnancy (except in lateral
recumbent position)
- Attributed to the occlusion of pelvic veins and inferior
vena cave by the uterus
 Cardiovascular System

Supine Hypotensive Syndrome large pregnant

uterus compress on the venous system lowering
cardiac filling and output

Supine Pressor Test

- an increase of more than 20 mmHg in diastolic
blood pressure from lateral to a supine position
determines a pregnant womans tendency to develop
Pregnancy-induced hypertension
Respiratory Tract
- Diaphragm rises about 4 cm during pregnancy
- Transverse diameter of thoracic cage increase by 2 cm
- Thoracic circumference increase by 6 cm
- Amount of O2 delivered into the lungs by increased
tidal volume exceeds oxygen needs imposed by the
pregnancy
- This, together with increased O2 capacity of
hemoglobin -> decreased maternal atriovenous oxygen
difference
Respiratory Tract
Tidal volume, minuteventilatory volume, minute
oxygen uptake increase
Maximum breathing capacity, forced or timed
vital capacity unchanged
Functional residual capacity, residual volume of
air decreased (due to diaphragm elevation)
Lung compliance unaffected
Airway conductance increased
Total pulmonary resistance reduced
Respiratory Tract
Physiological Dyspnea
- increased tidal volume which lowers blood
PCO2 slightly, paradoxically causing dyspnea

Increase respiratory effort in pregnancy likely

induced primarily by progesterone and estrogen
to a lesser degree.
Urinary System
Kidney slight increase in size
-increased GFR (glomerular filtration rate) and
RPF (renal plasma flow)
- Urinary flow and sodium excretion affected by
posture
- Increased excretion of amino acids and
vitamins
Renal Function Tests
creatinine clearance useful to estimate renal
function
Urinary System
Urinalysis
- glucosuria (N, consider DM if recurrent)
- proteinuria (evident only after labor)
- hematuria (compatible with UTI)

Hydronephrosis/hydroureter
- due to pressure effects of uterus
- may also be due to progesterone effect
Urinary System
Bladder
- Elevated bladder trigone and thickening of its
posterior (intraureteric) margin due to
elnarged uterus, hyperemia and hyperplasia of
pelvic organs
- Reduced bladder capacity
- Maximal intraurethral pressure increased
Gastrointestinal Tract
Stomach and intestines displaced by uterus, the
appendix displaced upward sometimes near the right
flank (clinical significance)
Delayed gastric emptying and intestinal transit times
(progesterone, decreased motilin)
Pyrosis (heartburn) reflux of acid secretions into
the lower esophagus
Gums hyperemic and softened, easily bleeds
epulis of pregnancy highly vascular
swelling of gums
Hemorrhoids caused by constipation, venous
pressure
 Liver and Gallbladder
Liver
- no distinct anatomical changes but hepatic function
test similar to certain hepatic diseases
- increase in total alkaline phosphatase
- decrease in plasma albumin but increased total
albumin due to greater volume of distribution
- reduced plasma cholinesterase activity
- leucine aminopeptidase elevated (oxytocinase
activity)
Liver and Gallbladder
Gallbladder
- sluggish during pregnancy (impaired contraction
and high residual volume)
- progesterone inhibits cholecystokinin-mediated
smooth muscle stimulation -> stasis -> formation of
cholesterol stones
- retained bile acids cause intrahepatic cholestatis
and pruritus gravidarum
- cholestasis linked to high level of estrogen
circulation
Endocrine System
Pituitary Gland
- enlarges by 135%
- not essential for maintainance of pregnancy
- hormones:
Growth Hormone slightly increased
Prolactin markedly increased (10x), ensure lactation
-lipotrophin potent endogenous opioid (metabolized from
proopiomelanocortin)
Endocrine System
Thyroid Gland
3 Modifications is Thyroid Hormones:
- marked increase in thyroxine-binding globulin in
response to high estrogen levels
- excess production of placental thyroidal
stimulatory factors
- decreased availability of iodide for the maternal
thyroid
 Endocrine System
Thyroid Gland
- moderate enlargement due to hyperplasia and
increased vascularity
Thyroid Hormones
- TBG (thyroxine-binding globulin) increase 2x
- Total T4 (thyroxine) increase at 6-9 wks but
normalizes after the 1st trimester
- T3 (triiodothyronine) more pronounced up to 18
wks then plateaus
* high serum gonadotropin levels are assoc. with
thyroid stimulation
Endocrine System
Fetal Thyroid Gland
- fetus dependent to maternal thyroxine in 1st
trimester
Hormones:
- reverse triiodothyronine formed from
monodeiodination of thyroxine in fetal membranes
and placenta, 3-5x more than maternal levels

Thyroidreleasing hormone highest conc. in

hypothalamus, not increased in normal pregnancy
but may stimulate fetal pituitary to produce
thyrotropin
Endocrine System
Parathyroid Glands
- decrease in plasma Ca and Mg stimulate release of
parathyroid hormone and vice versa
parathyroid hormone
increase extracellular fluid calcium and decrease
phosphate
- decrease during 1st trimester and increase
progressively throughout the remainder of
pregnancy probably due to increase plasma volume,
increased GFR and fetal transfer of calcium
- lowers calcium concentration in pregnant woman
Net result: physiological hyperparathyroidism to
supply fetus with adequate calcium
Endocrine System
Paratyhroid Gland
Calcitonin
increased by Ca, Mg, gastrin, pentagastrin,
glucagon, pancreoxymin and food ingestion
- oppose parathormone and vit. D to protect
skeletal calcification during times of calcium
stress (pregnancy and lactation)
 Endocrine System
Parathyroid Gland
Vitamin D
- hormone synthesized in the skin and converted into 25-
hydroxyvitamin D3 by liver
- converted to the biologically active 1,25-
dihydroxyvitamin D3 in the kidney, decidua and placenta
- stimulates resorption of Ca from bone and absorption in
the intestines
- release is facilitated by parathyroid hormone and low Ca
and phosphate plasma levels
- opposed by calcitonin
Endocrine System
Adrenal Glands
Hormones:
Cortisol
increase in circulating levels but much are bound to
transcortin
- decreased metabolic clearance
Aldosterone
- increased as early as 15 weeks, further elevated by
restricted sodium intake
- this affords protection againsts the natriuretic effect of
progesterone and ANP
 Endocrine System
Adrenal Glands
Hormones:
Deoxycorticosterone
- striking increase in maternal plasma levels in the
last few weeks of pregnancy
- primarily from the fetal adrenal glands
Dehydroepiandrosterone sulfate decreased
Androstenedione and Testosterone increased
Musculoskeletal System
Progressive lordosis shifts center of gravity back to
the lower extremities
Increased mobility of sacroiliac, sacrococcygeal,
pubic joints (hormonal)
Aching, numbness and weakness of upper
extremities noted due to marked lordosis with
anterior flexion of the neck and slumping of
shoulder girdle -> traction on median and ulnar
nerves
Eyes
Decreased introcular pressure due to increased
vitreous outflow
Decreased corneal sensitivity and increased
thickness due to edema
Krukenberg spindles brownish red-opacities on
the posterior surface of the cornea (probably
hormonal)
Thank you very much.

Have a nice day.

Quiz 20100104: True or False
1. A hobnailed appearance in the vaginal mucosa is significant of vaginal wall
pathology during pregnancy.
2. Hegar Sign is predominant only after the late first trimester.
3. Fallopian tube lumen increases 2-3fold in diameter during pregnancy.
4. Striae gravidarum and linea nigra will spontaneously resolve after delivery.
5. Breast glands increase in number and size during pregnancy.
6. There is accelerated starvation in pregnancy.
7. A hemoglobin level of 10g/dl connotes iron deficiency.
8. A systolic murmur is considered within normal for most pregnant women.
9. A supine-pressor test can determine a pregnant womans tendency to
develop pregnancy-induced hyper tension.
10. Dyspnea is usually abnormal in pregnant women.
Quiz 20100104: Answers
1. A hobnailed appearance in the vaginal mucosa is significant of vaginal wall
pathology during pregnancy. - false
2. Hegar Sign is predominant only after the late first trimester.-F
3. Fallopian tube lumen increases 2-3fold in diameter during pregnancy. - false
4. Striae gravidarum and linea nigra will spontaneously resolve after delivery. - false
5. Breast glands increase in number and size during pregnancy.-F
6. There is accelerated starvation in pregnancy. - true
7. A hemoglobin level of 10g/dl connotes iron deficiency. - true
8. A systolic murmur is considered within normal for most pregnant women. - true
9. A supine-pressor test can determine a pregnant womans tendency to develop
pregnancy-induced hyper tension. - true
10. Dyspnea is usually abnormal in pregnant women. - false
QUIZ 20081202:
Supply a change in the ffg organs/ systems
during pregnancy:
Skin Respiratory tract
Eyes Gastrointestinal tract
Vagina Urinary tract
Cervix Cardiovascular system
thyroid Endocrine Glands
 Quiz: matching type (write the corresponding letter to the
numbered item)
A B
1. Krukenberg spindles a. Vagina
2. Reverse triiodothyronine b. Ovaries
3. Chadwick sign c. Respiratory tract
4. Luteuma of pregnancy d. Blood loss in twin pregnancy
5. Linea nigra e. Mask of pregnancy
6. Accelerated starvation f. Carbohydrate metabolism
7. 1000 mL g. Eyes
8. 450 ml h. Volume of circulating erythrocytes
9. Chloasma i. Fetal thyroid gland
10. Bohr Effect j. Abdominal skin
Answers
6. F
1. G 7. D
2. I 8. H
3. A 9. E
4. B 10. c
5. J