MATERNAL

PHYSIOLOGY
Chukwuma I. Onyeije, M.D.
Atlanta Perinatal Associates
Clinical Assoc. Professor
Morehouse School of Medicine
http://maternalfetalmedicineblog.com
http://onyeije.net/present
Objectives
• Detail normal physiologic changes in the
following maternal systems:
– Cardiovascular
– Respiratory
– Renal
– Hematologic
– Gastrointestinal
– Reproductive systems.
• Describe the implications for these changes
for normal and abnormal pregnancies.
Objectives
• Review nutritional requirements
normal pregnancy

• Review components and reasons for

the medical evaluation at the first
prenatal visit

• Give the reason for routine laboratory

tests obtained early in pregnancy.
BULLET POINTS:

Dilutional anemia of
pregnancy:

Lower hematocrit due to

expansion of plasma volume
which is greater than the
increase in red blood cell
mass
BULLET POINTS:

Pregnancy is a
Hypercoagulable state:

Increased risk for venous

clotting episodes
BULLET POINTS:

Hegar's sign:

Cervix appears bluish

and engorged
 BULLET POINTS:
MSAFP
(Maternal serum
alpha-fetoprotein)

Screening test of maternal blood

done in the early second trimester to
screen pregnant women for fetal
anomalies and chromosomal
abnormalities
BULLET POINTS:

Bacterial vaginosis:
Bacterial infection of the
vagina associated with
preterm labor and birth
BULLET POINTS:
Rhogam:

An antibody preparation
of anti-Rh factor given to
Rh negative women to
prevent Rh
isoimmunization
BULLET POINTS:
Neural tube defect (NTD):

An abnormality in closure of
the neural tube, resulting in
a spectrum of anomalies
from anencephaly (no
cranium or cerebrum) to
spina bifida
BULLET POINTS:
Intrauterine growth restriction
(IUGR): pathological
condition of abnormal
placentation resulting in an
undergrown fetus

Small-for-gestational age
(SGA): the lower 10% of
birthweights
BULLET POINTS:
Large-for-gestational age
(LGA): the upper 10% of
birthweights

Macrosomia: an
abnormally large infant
(usually > 4000 gm)
 The primary goal of
prenatal care is to
deliver a healthy term
infant without impairing
the mothers health and
to identify and
optimally treat the
high-risk mother.
 The vast majority of
pregnancies are
uncomplicated.

Excessive intervention
during pregnancy can
result in less than
optimal outcome
 THE
CARDIOVASCULAR
SYSTEM:
 THE CARDIOVASCULAR
SYSTEM:

• Cardiac output increases 30-50%

• Stroke volume increases about 10- 15%
• Pulse increases about 15-20 bpm
• Systolic ejection murmur and S3 gallop
are seen in 90% of pregnant women
CARDIAC OUTPUT DURING
PREGNANCY
Peripheral vascular
resistance falls

Blood pressure falls

during the second
trimester and then
returns to normal
during the third
trimester
 CLINICAL
SIGNIFICANCE:

Many of the NORMAL

effects of pregnancy
mimic heart failure
(edema, gallops, dyspnea,
distended neck veins,
abnormal cardiac
silhouette on CXR, EKG
changes).
 THE
RESPIRATORY
SYSTEM:
Lung volumes changes in pregnancy
 NO CHANGE:

Respiratory rate,
Vital capacity,
Inspiratory reserve volume
 DECREASED:
Functional residual capacity
Expiratory reserve volume
Residual volume
Total lung capacity
INCREASED:
Inspiratory capacity
Tidal volume
 BLOOD GASES:
CLINICAL
SIGNIFICANCE:

The normal pregnant

woman has a
compensated respiratory
alkalosis and a diminished
pulmonary reserve.
 THE
RENAL
SYSTEM:
 ANATOMIC RENAL
CHANGES:
Kidneys increase in size and
weight,

Dilatation of ureters (R > L)

Bladder becomes an intra-

abdominal organ
 HEMODYNAMIC
RENAL CHANGES:

GFR increases 50%,

Renal plasma flow

increases by 75%

Creatinine clearance
increases to 150-200
cc/min
METABOLIC RENAL CHANGES
BUN and serum creatinine
decrease by 25%

Increase in tubular
reabsorption of sodium

Increase in glucose
excretion
METABOLIC RENAL CHANGES

Plasma osmolarity decreases

about 10 mOsm/kg H2O

Marked increase in renin and

angiotensin levels, BUT
markedly reduced vascular
sensitivity to their
hypertensive effects
CLINICAL SIGNIFICANCE of
RENAL CHANGES
:
Pregnant women are at
increased risk for prone to
pyelonephritis

Pregnant women are at

increased risk for bladder
rupture during abdominal
trauma.
 THE
HEMATOLOGIC
SYSTEM
 Plasma volume
and RBC mass

Plasma volume increases by about

50%

RBC volume increases by about

30%
 Plasma volume
and RBC mass

END RESULT:

”Dilutional anemia of
pregnancy",

Average hemoglobin during

pregnancy is 11.5 g/dl
Plasma volume
and RBC mass
 OTHER
HEMATOLOGIC
CHANGES:

WBC count increases

Platelet count
decreases, but stays
within normal limits
COAGULATION SYSTEM:

Pregnancy is a
"hypercoagulable state"

Increased levels of
fibrinogen, factor VII-X

The placenta produces a

plasminogen activator
inhibitor
CLINICAL SIGNIFICANCE:

Blood loss is well-tolerated

during labor.

However: maternal vital signs

DO NOT change for blood
loss of up to 1500 cc,

Therefore: vital signs cannot

be trusted as an indicator of
blood loss.
 THE
GASTROINTESTINAL
AND REPRODUCTIVE
SYSTEMS
Gastrointestinal System

Decreased motility, due to

influence of progesterone

Reduced gastric acid

secretion
Gastrointestinal System

CLINICAL SIGNIFICANCE:

A pregnant woman is
considered to have a full
stomach even if she has had
nothing to eat or drink for
several hours.

Peptic ulceration is rare during

pregnancy.
 Reproductive System

Weight of the Uterus

increases from 70 gm to
1100 gm

Blood flow: increases to

about 750 cc/min, or 10-
15% of cardiac output
 NUTRITIONAL
CONSIDERATIONS
DURING
PREGNANCY
PREGNANCY WEIGHT GAIN BY
ORGAN SYSTEM:

Fetus: 7 pounds
Placenta and amniotic fluid-- 3 pounds
Blood volume-- 4 pounds
Breasts-- 2 pounds
Maternal fat-- 4 pounds

ANTICIPATED TOTAL: 20 pounds

 Average weight gain

THERE IS NO SUCH
THING AS “OPTIMAL”
WEIGHT GAIN

Normal BMI: 20 lbs

Underweight BMI: 30 lbs
Overweight BMI 16 lbs
Daily dietary requirements

Calories: Increased 15% to ~

2200 cal/day

Protein: An additional 10 to 30 gm
/day ~ 75 gm/day total

Iron supplementation 30 to 60 mg
per day
Calcium: 1200 mg needed per
day, usually provided by a quart
of milk per day or 2 Tums/day,

Folate: supplement 200 to 400

mcg per day

In women with a prior history of

having a baby with a neural tube
defect, supplementing with 4 mg
per day (4000 mcg) has been
shown to decrease the risk of a
recurrence in the next pregnancy
The pregnant patient is
best served by having a
healthy balanced diet
with iron and folate
supplementation.

Only rarely are other

vitamin supplements
necessary
PRENATAL CARE
 The first
prenatal visit

Decide: Is this
patient normal
or high-risk?
16.0%

#REF!

1/7
RISK FOR DOWN SYNDROME
(AND OTHER CHROMOSOMAL ABNORMALITIES)

1/9
12.0% BASED ON MOTHER'S AGE

1/12
1/15
8.0%

1/20
1/24
1/30
1/40
4.0%

1/50
1/65
1/80
1/100
1/130
1/200

1/170
1/270
1/320
1/340
1/450

1/370
1/385
1/500

0.0%
15- 2 5- 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
24 29
 COMMON
COMPLAINTS
OF
PREGNANCY
Nausea and
vomiting:
usually
dissipates
by 15
weeks
Constipation:
common
throughout
pregnancy
Heartburn: often
worsens as
pregnancy
progresses
 Vaginitis:
treat only if
symptomatic
Varicose veins: treat
symptomatically
Headaches
Lower extremity
edema is very
common
 Backache:
Lordosis is common with
change in the center of
gravity
Faintness and light-
headedness
 Carpal
tunnel
syndrome
REVIEW QUESTIONS:
 Whichof the following
INCREASES in
pregnancy?
FRC
ERV
RV
TV
 During which of the
following states is
the blood pressure
lowest?
First trimester
Second trimester
Third trimester
Non pregnant
 All
of the following are
increased in pregnancy
except:
Renal plasma flow
GFR
Serum creatinine
Tubular sodium
resorption
CONCLUSION:

–Understanding maternal
physiology is crucial in
understanding the
changes associated in
pregnancy
CONCLUSION:

–This knowledge will help

us distinguish the
physiologic and pathologic
processes during
pregnancy
–This knowledge is also
necessary to improve
patient education about
pregnancy
 For More Information and Other
Maternal-Fetal Lectures, Please
Visit:

http://maternalfetalmedicineblog.com
http://onyeije.net/present

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