MATERNAL

PHYSIOLOGY
Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
To download lecture deck
Reference
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY,
Dashe JS, Hoffman BL, Casey BM, Sheffield JS
(eds).William’s Obstetrics 24th edition; 2014; chapter 4;
Maternal physiology
Outline
1. REPRODUCTIVE TRACT
2. BREASTS

3. SKIN
4. METABOLIC CHANGES
5. HEMATOLOGICAL CHANGES
6. CARDIOVASCULAR SYSTEM

7. RESPIRATORY TRACT
8. URINARY SYSTEM
9. GASTROINTESTINAL TRACT
10. ENDOCRINE SYSTEM
REPRODUCTIVE
TRACT
 Uterus
◦ Nonpregnant: uterus weighs
approximately 70 g, mostly solid, and
has a cavity of 10 mL or less.
◦ During pregnancy: the uterus becomes
a relatively thin-walled muscular organ
to accommodate the fetus, placenta,
and amnionic fluid. (By the end of
pregnancy, the uterus is 500-1000x
greater than in the non- pregnant state)
◦ total volume of the contents at term:
approximately 5 L (but may be 20 L or
more); total weight: 1100 grams
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Uterus
◦ During pregnancy, uterine enlargement
involves stretching and marked
hypertrophy of muscle cells, whereas the
production of new myocytes is limited.
◦
◦ Accompanying the increase in myocyte
size is an accumulation of fibrous tissue,
particularly in the external muscle layer,
together with a considerable increase in
elastic tissue content à this network adds
strength to the uterine wall.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uterus
◦ The hypertrophy of early pregnancy does not
occur entirely in response to mechanical
distention by the products of conception,
because similar uterine changes are observed
with ectopic pregnancy

◦ Uterine hypertrophy early in pregnancy is

stimulated by estrogen and progesterone.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uterus
◦ after approximately 12 weeks, the
uterine size increase is due to
pressure exerted by the expanding
products of conception.
◦ In early pregnancy, the fallopian
tubes and the ovarian and round
ligaments attach only slightly below
the apex of the fundus.
◦ In later months, they are located
slightly above the middle of the
uterus.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uterus: Myocyte Arrangement
◦ Uterine musculature during
pregnancy is arranged in 3 strata: ■ Ligament
There are severa
◦ outer hoodlike layer: arches over the toward the pelvi
nal, and uterosa

fundus and extends into the various ligament corresp

lum testis (Acié

ligaments.
anterior to the
orientation can
puerperal sterili

◦ middle layer: dense network of muscle limit tubal mob

to tubal ligation
downward into
fibers perforated in all directions by blood terminate in the
artery, a branch

vessels. In nonpregnant
5 mm in diamet
separated by fibr
◦ internal layer: sphincter-like fibers around nancy, these lig
increase appreci

the fallopian tube orifices and internal

The broad lig
from the lateral

cervical os.
vertical sectionin
a triangular shap
are found at its b
into anterior and
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, FIGURE 2-11 Smooth muscle fibers of the myometrium compress consists of a fol
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology traversing blood vessels when contracted. terior leaves. Th
from each cornu
Uterus
◦ Most of the uterine wall is formed by the ■ Ligament

middle layer.
There are severa
toward the pelvi
nal, and uterosa

◦ Each cell in this layer has a double curve so

ligament corresp
lum testis (Acié
anterior to the

that the interlacing of any two gives orientation can

puerperal sterili

approximately the form of a figure eight.

limit tubal mob
to tubal ligation
downward into

◦ This arrangement is crucial because when

terminate in the
artery, a branch
In nonpregnant

the cells contract after delivery, they 5 mm in diamet

separated by fibr

constrict penetrating blood vessels and thus nancy, these lig

increase appreci

act as ligature.
The broad lig
from the lateral
vertical sectionin
a triangular shap
are found at its b
into anterior and
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, FIGURE 2-11 Smooth muscle fibers of the myometrium compress consists of a fol
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology traversing blood vessels when contracted. terior leaves. Th
from each cornu
 Uterus: Size, Shape, and Position
◦ < 12 wks AOG: the uterus is piriform or pear
shape.
◦ >12 wks AOG: the corpus and fundus become
globular and almost spherical
◦ As the uterus enlarges, it contacts the anterior
abdominal wall, displaces the intestines
laterally and superiorly, and ultimately reaches
almost to the liver.
◦ It usually rotates to the right (dextrorotation) -à
caused by the rectosigmoid on the left side of
the pelvis.
◦ As the uterus rises, tension is exerted on the
broad and round ligaments.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uterine Contractility
◦ Beginning in early pregnancy, the uterus
undergoes irregular contractions that are
normally painless.
◦ During the second trimester, these
contractions may be detected by bimanual
examination (Braxton Hicks contractions)
◦ These contractions are unpredictable,
infrequent, sporadic and nonrhythmic.
◦ their number increases during the last two
weeks of pregnancy à account for so-called
“false labor”

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uteroplacental Blood Flow
◦ Uteroplacental blood flow was found to
increase progressively during
pregnancy. Estimates range from 450 to
650 mL/min near term
◦ Uterine veins increase caliber and
distensibility to accommodate the
massively increased uteroplacental
blood flow.
◦ Uterine contractions cause a decrease
in uterine blood flow approximately
proportional to the contraction intensity.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Uteroplacental Blood Flow
◦ Maternal-placental blood flow
progressively increases during
gestation principally by means of
vasodilation (secondary to estrogen,
progesterone and relaxin)
◦ Normal pregnancy is also
characterized by vascular
refractoriness to the pressor effects of
infused angiotensin II and nor-
epinephrine à this insensitivity also
serves to increase uteroplacental
blood flow
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Cervix pregnant

◦ As early as 1 month after conception,

the cervix begins to undergo
pronounced softening and cyanosis
(bluish discoloration) (Chadwick sign)

◦ increased vascularity and edema of

the entire cervix, together with
hypertrophy and hyperplasia of the
cervical glands

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Non-pregnant
 48 Maternal Anatomy and Physiology

concomitant mean Doppler velocimetry was increased eightfold.

Recall that blood flow within a vessel increases in proportion to

Cervix
the fourth power of the radius. Thus, slight diameter increases
in the uterine artery produces a tremendous blood flow capac-

SECTION 2
ity increase (Guyton, 1981). As reviewed by Mandala and Osol
(2011), the vessels that supply the uterine corpus widen and
elongate while preserving contractile function. In contrast, the
spiral arteries, which directly supply the placenta, widen but
completely lose contractility. This presumably results from endo-
vascular trophoblast invasion that destroys the intramural mus-
◦ Cervical eversion of pregnancy
cular elements (Chap. 5, p. 93).
The vasodilation during pregnancy is at least in part the con-

◦ àextension, or eversion, of the

sequence of estrogen stimulation. For example, 17β-estradiol
has been shown to promote uterine artery vasodilation and
reduce uterine vascular resistance (Sprague, 2009). Jauniaux
proliferating columnar and colleagues (1994) found that estradiol and progesterone,
as well as relaxin, contribute to the downstream fall in vascular
endocervical glands. resistance in women with advancing gestational age.
The downstream fall in vascular resistance leads to an accel- pregnant
eration of flow velocity and shear stress in upstream vessels. In
◦ à tends to be red and velvety
turn, shear stress leads to circumferential vessel growth, and
nitric oxide—a potent vasodilator—appears to play a key role
FIGURE 4-1 Cervical eversion of pregnancy as viewed through
a colposcope. The eversion represents columnar epithelium on
and bleeds even with minor
regulating this process (p. 61). Indeed, endothelial shear stress,
estrogen, placental growth factor (PlGF), and vascular endo-
the portio of the cervix. (Photograph contributed by Dr. Claudia
Werner.)

trauma, such as with Pap

thelial growth factor (VEGF)—a promoter of angiogenesis—all
augment endothelial nitric oxide synthase (eNOS) and nitric

smear sampling.
oxide production (Grummer, 2009; Mandala, 2011). As an glands (Straach, 2005). Although the cervix contains a small
important aside, VEGF and PlGF signaling is attenuated in amount of smooth muscle, its major component is connec-
response to excess placental secretion of their soluble recep- tive tissue. Rearrangement of this collagen-rich connective
tor—soluble FMS-like tyrosine kinase 1 (sFlt-1). As detailed in tissue is necessary to permit functions as diverse as mainte-
Chapter 40 (p. 735), increased maternal sFlt-1 levels inactivate nance of a pregnancy to term, dilatation to aid delivery, and
and decrease circulating PlGF and VEGF concentrations and repair following parturition so that a successful pregnancy can
have been shown to be an important factor in preeclampsia be repeated (Timmons, 2007; Word, 2007). As detailed in
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey
pathogenesis. Chapter BM,
21 (p. 410), the cervical ripening process involves
Sheffield JS (eds).William’s Obstetrics 24 th edition; 2014; chapter 4; Maternal physiology
Normal pregnancy is also characterized by vascular refracto- connective tissue remodeling that decreases collagen and pro-
riness to the pressor effects of infused angiotensin II and nor- teoglycan concentrations and increases water content com- Non-pregnant
epinephrine (p. 61). This insensitivity also serves to increase pared with the nonpregnant cervix. This process appears to
uteroplacental blood flow (Rosenfeld, 1981, 2012). Recent be regulated in part by localized estrogen and progesterone
Cervix
◦ “Mucus plug” àcopious tenacious mucus
that obstruct the cervical canal soon
after conception.
◦ à rich in immunoglobulins and cytokines
and may act as an immunological barrier
to protect the uterine contents against
infection
◦ At the onset of labor, if not before, this
mucus plug is expelled, resulting in a
“bloody show”.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 the way. In
may comp

Cervix
should be r
tion. If the
up or held

■ Ovarie
◦ poor crystallization, or beading of cervical Ovulation

mucus when it is spread and dried on a follicles is s

nant wome
glass slide (progesterone effect) of pregnan
contributes
observation
◦ In some women, an arborization of crystals, the corpus
Removal re
or ferning, is observed as a result of one levels a

amnionic fluid leakage

time, howe
cause abort
does not ca
◦ During pregnancy, basal cells near the in such cas
not reach p
squamocolumnar junction are likely to be
FIGURE 4-2 Cervical mucus arborization or ferning. (Photograph
contributed by Dr. James C. Glenn.) postpartum
An extra
prominent in size, shape, and staining of the ovari
at cesarean
qualities (estrogen induced) beading.
g In some women, an arborization of crystals, or ferning, is ily and ma
observed as a result of amnionic fluid leakage (Fig. 4-2). Similar dec
◦ Arias-Stella reaction àendocervical gland During pregnancy, basal cells near the squamocolumnar other pelvi
2010). The
junction are likely to be prominent in size, shape, and stain-
hyperplasia and hypersecretory ing qualities. These changes are considered to be estrogen result of p
induced. In addition, pregnancy is associated with both endo- similar to p
appearance during pregnancy cervical gland hyperplasia and hypersecretory appearance—the described in
Arias-Stella reaction—which makes the differentiation of these The enor
and atypical glandular cells on Pap smear particularly difficult delivery is s
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, (Connolly, 2005). eter of the o
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology from 0.9 c
Pelvic Organ Prolapse that flow in
 Ovaries
◦ Ovulation ceases during pregnancy, and
maturation of new follicles is suspended.
◦ the single corpus luteum found in pregnant
women functions maximally during the first 6
to 7 weeks of pregnancy
◦ surgical removal of the corpus luteum before
7 weeks AOG à rapid fall in maternal serum
progesterone levels and spontaneous
abortion
◦ (After this time, however, corpus luteum
excision ordinarily does not cause abortion,
and even bilateral oophorectomy at 16 weeks
does not cause pregnancy loss)
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Theca-Lutein Cysts
◦ benign ovarian lesions resulting from exaggerated
physiological follicle stimulation—termed hyperreactio
luteinalis
◦ associated with markedly elevated serum levels of hCG.

◦ found frequently with gestational trophoblastic disease,

large placenta such as with diabetes, anti-D
alloimmunization, and multifetal gestations

◦ reported in chronic renal failure as a result of reduced

hCG clearance and in hyperthyroidism as a result of the
structural homology between hCG and thyroid-
stimulating hormone (TSH)
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Theca-Lutein Cysts
◦ usually asymptomatic
◦ hemorrhage into the cysts may cause abdominal
pain
◦ Maternal virilization may be seen in up to 30% of
women à temporal balding, hirsutism, and
clitoromegaly are associated with massively
elevated levels of androstenedione and
testosterone.
◦ This condition is self-limited, and resolution follows
delivery.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Vagina and Perineum
◦ Chadwick sign –violaceous/purplish color of
vaginal walls due to increased vascularity
◦ increased volume of cervical secretions
within the vagina during pregnancy consists
of a somewhat thick, white discharge.
◦ pH is acidic, varying from 3.5 to 6. is results
from increased production of lactic acid
from glycogen in the vaginal epithelium by
the action of Lactobacillus acidophilus.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
BREASTS
 Breasts
◦ In the early weeks of pregnancy, women often
experience breast tenderness and paresthesias.
◦ After the second month, the breasts increase in
size, and delicate veins become visible just
beneath the skin.
◦ the nipples become considerably larger, more
deeply pigmented, and more erectile.
◦ After the first few months, a thick, yellowish fluid—
colostrum—can often be expressed from the
nipples by gentle massage.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
SKIN
Abdominal Wall

◦ striae gravidarum or stretch

marks - reddish, slightly
depressed streaks
commonly develop in the
abdominal skin and
sometimes in the skin over
the breasts and thighs.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Abdominal wall
◦ Diastasis recti à rectus muscles
separate in the midline when the
muscles of the abdominal walls do
not withstand the tension to which
they are subjected.
◦ If severe, a considerable portion of
the anterior uterine wall is covered
by only a layer of skin, attenuated
fascia, and peritoneum to form a
ventral hernia
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Hyperpigmentation
◦ linea nigra à linea alba takes on dark brown-black
pigmentation
◦ chloasma or melasma gravidarum à “mask of
pregnancy”; irregular brownish patches of varying
size appear on the face and neck
◦ these pigmentary changes usually disappear, or at
least regress considerably, after delivery. (Oral
contraceptives may cause similar pigmentation)
◦ Pigmentary changes due to markedly increased
levels of melanocyte-stimulating hormone. Estrogen
and progesterone also are reported to have
melanocyte-stimulating effects.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Vascular changes
◦ Angiomas/ ”vascular spiders” à minute, red skin
elevations, with radicles branching out from a
central lesion
◦ common on the face, neck, upper chest, and
arms
◦ Palmar erythema is encountered during
pregnancy in approximately two thirds of white
women and one third of black women.
◦ **these two conditions are most likely due to
hyperestrogenemia.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
METABOLIC
CHANGES
◦ By the third trimester, maternal basal metabolic rate is
increased by 10 to 20 percent compared with that of
the non- pregnant state.

◦ World Health Organization (2004): additional total

pregnancy energy demands associated with normal
pregnancy are approximately:
◦ First trimester: 85 kcal/day
◦ Second trimester: 285 kcal/day
◦ Third trimester: 475 kcal/day
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
Weight Gain

◦ Most of the normal increase in weight during

pregnancy is attributable to the uterus and its
contents, the breasts, and increases in blood
volume and extravascular extracellular fluid.
◦ A smaller fraction results from metabolic
alterations that increase accumulation of
cellular water, fat, and protein—so- called
maternal reserves.
◦ average weight gain during pregnancy is
approximately 12.5 kg or 27.5 lb

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Water Metabolism

◦ Increased water retention is a normal physiological

alteration of pregnancy.
◦ minimum amount of extra water that the average woman
gains during normal pregnancy is approximately 6.5 L.
◦ water content of the fetus, placenta, and amnionic fluid
=3.5 L.
◦ increases in maternal blood volume and in the size of the
uterus and breasts = 3L

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 4; Maternal physiology
Water Metabolism

◦ pitting edema of the ankles and legs

à (may amount to a liter or so)
◦ à caused by increased venous
pressure below the level of the uterus
as a consequence of partial vena
cava occlusion.
◦ à A decrease in interstitial
colloid osmotic pressure induced
by normal pregnancy also favors
edema late in pregnancy
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 4; Maternal physiology
Carbohydrate Metabolism
◦ Normal pregnancy is characterized by mild fasting hypoglycemia,
postprandial hyperglycemia, and hyperinsulinemia
◦ pregnancy-induced state of peripheral insulin resistance à to ensure a
sustained postprandial supply of glucose to the fetus.
◦ Progesterone and estrogen may act, directly or indirectly, to mediate this
insulin insensitivity
◦ “Accelerated starvation” à pregnancy-induced switch in fuels from glucose to
lipids
◦ pregnant woman changes rapidly from a postprandial state characterized
by elevated and sustained glucose levels to a fasting state characterized by
decreased plasma glucose and high plasma concentrations of free fatty
acids, triglycerides, and cholesterol
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
Fat Metabolism
◦ Increased insulin resistance and estrogen stimulation during
pregnancy are responsible for the maternal hyperlipidemia.
◦ increased lipid synthesis and food intake contribute to maternal
fat accumulation during the first two trimesters.
◦ in the third trimester, however, fat storage declines or ceases due
to enhanced lipolytic activity à favors maternal use of lipids as
an energy source and spares glucose and amino acids for the
fetus.
◦ After delivery, the concentrations of these lipids, as well as
lipoproteins and apolipoproteins decrease
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
 Mineral metabolism
◦ Iodine requirements increase during normal pregnancy for several reasons:

◦ 1) maternal thyroxine (T4) production increases to maintain maternal euthyroidism

and to transfer thyroid hormone to the fetus early in gestation before the fetal
thyroid is functioning

◦ 2) fetal thyroid hormone production increases during the second half of

pregnancy àcontributes to increased maternal iodine requirements because
iodide readily crosses the placenta.

◦ 3)Beginning in early pregnancy, the iodide GFR increases by 30 to 50%

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
HEMATOLOGIC
CHANGES
Blood Volume
◦ Pregnancy-induced hypervolemia has several important
functions:
◦ 1) To meet the metabolic demands of the enlarged uterus and its greatly
hypertrophied vascular system.
◦ 2) it provides abundant nutrients and elements to support the rapidly
growing placenta and fetus.
◦ 3) protects the mother and the fetus against the deleterious effects of
impaired venous return in the supine and erect positions.
◦ 3) it safeguards the mother against the adverse effects of parturition-
associated blood loss.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th
edition; 2014; chapter 4; Maternal physiology
Hemoglobin Concentration and
Hematocrit
◦ Because of great plasma augmentation, hemoglobin
concentration and hematocrit decrease slightly during
pregnancy (dilutional anemia)
◦
◦ Hemoglobin concentration at term averages 12.5 g/dL, and in
approximately 5 percent of women, it is below 11.0 g/dL

◦ thus, a hemoglobin concentration below 11.0 g/dL, especially

late in pregnancy, should be considered abnormal and usually
due to iron deficiency rather than pregnancy hypervolemia.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
Iron requirements
◦ Normal pregnancy total iron
requirement: 1000 mg
◦ about 300 mg are actively transferred
to the fetus and placenta,
◦ 200 mg are lost through various
normal excretion routes, primarily the
gastrointestinal tract.
◦ increase in the total circulating
erythrocyte volume (=450 mL) à
requires another 500 mg.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Iron requirements
◦ most iron is used during the latter half of
pregnancy àaverages 6 to 7 mg/day
◦ without supplemental iron, the optimal
increase in maternal erythrocyte volume will
not develop, and the hemoglobin
concentration and hematocrit will decrease as
plasma volume increases
◦ however, fetal red cell production is not
impaired because the placenta transfers iron
even if the mother has severe iron deficiency
anemia
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Immunological Functions
◦ pregnancy can be divided into three distinct
immunological phases:
◦ 1)early pregnancy is pro-inflammatory. During implantation and
placentation, the blastocyst invades endometrial tissue, and trophoblasts
replace the endothelium and vascular smooth muscle of the maternal
blood vessels à create a veritable “battleground” of invading cells, dying
cells, and repairing cells.
◦ 2) midpregnancy is anti-inflammatory. During this period of rapid fetal
growth and development, the predominant immunological feature is
induction of an anti-inflammatory state.
◦ 3) parturition is characterized by an influx of immune cells into the
myometrium to promote recrudescence of an inflammatory process.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
Immunological Functions

◦ suppression of T-helper (Th) 1 and T-cytotoxic (Tc) 1 cells,

which decreases secretion of interleukin-2 (IL- 2),
interferon-γ, and tumor necrosis factor-β (TNF-β).
◦ à explains pregnancy-related remission of some autoimmune disorders
such as rheumatoid arthritis, multiple sclerosis, and Hashimoto thyroiditis—
which are Th1-mediated diseases

◦ upregulation of 2 cells to increase secretion of IL-4, IL-6,

and IL-13

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
CARDIOVASCULAR
SYSTEM
 Heart 58 Maternal Anatomy and Physiology

2007). Moreover, in a study of 77 recently delivered gravidas,

◦ heart is displaced
Gayer to the
and coworkers (2012) foundleft andsize was
that splenic
upward andlarger
68-percent is compared
rotated on
with that its longcontrols.
of nonpregnant
The cause of this splenomegaly is unknown, but it might follow
axis. the increased blood volume and/or the hemodynamic changes of
SECTION 2

pregnancy, which are subsequently discussed. Sonographically,

the echogenic appearance of the spleen remains homogeneous
throughout gestation.
◦ the apex is moved somewhat
laterally from its usual
CARDIOVASCULAR SYSTEMposition and
produces a larger
During pregnancy cardiac
and the puerperium, thesilhouette
heart and circula-
in chest
tion radiographs
undergo remarkable physiological adaptations. Changes
in cardiac function become apparent during the first 8 weeks
of pregnancy (Hibbard, 2014). Cardiac output is increased
as early as the fifth week and reflects a reduced systemic vas-
cular resistance and an increased heart rate. Compared with
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
prepregnancy
Sheffield JS (eds).William’s measurements,
Obstetrics brachial
24th edition; systolic4; blood
2014; chapter pressure,
Maternal physiology FIGURE 4-8 Change in cardiac radiographic outline that occurs
diastolic blood pressure, and central systolic blood pressure in pregnancy. The blue lines represent the relations between
are all significantly lower 6 to 7 weeks from the last menstrual the heart and thorax in the nonpregnant woman, and the black
lines represent the conditions existing in pregnancy. These are
Heart
◦ Many of the normal cardiac sounds are modified during pregnancy:
1. an exaggerated splitting of the first heart sound and increased
loudness of both components
2. a loud, easily heard third sound
3. systolic murmur intensified during inspiration in some or expiration in
others and that disappeared shortly after delivery.
4. A soft diastolic murmur may also be noted transiently
5. continuous murmurs arising from the breast vasculature in 10
percent.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 4; Maternal physiology
Cardiac output
◦ mean arterial pressure and vascular resistance decrease
(beginning midpregnancy)
◦ blood volume and basal metabolic rate increase.
◦ As a result, cardiac output at rest, when measured in the lateral
recumbent position, increases significantly beginning in early
pregnancy
◦ During late pregnancy in a supine woman, the large uterus
compresses venous return from the lower body and may also
compress the aorta à cardiac filling may be reduced and
cardiac output diminished.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
 Circulation and blood pressure
◦ Arterial pressure usually decreases to a nadir at 24 to 26 weeks and
rises thereafter.
◦ venous blood flow in the legs is retarded during pregnancy due to
occlusion of the pelvic veins and inferior vena cava by the enlarged
uterus à the elevated venous pressure returns to normal when the
pregnant woman lies on her side and immediately after delivery
◦ à these alterations contribute to the
dependent bipedal edema,
varicose veins in the legs and vulva,
and hemorrhoids that may predispose
to deep-vein thrombosis during
pregnancy
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Supine Hypotension

◦ supine compression of the great vessels by

the uterus causes significant arterial
hypotension, sometimes referred to as the
supine hypotensive syndrome
◦ when supine, uterine arterial pressure—and
thus blood flow—is significantly lower than
that in the brachial artery.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Renin, Angiotensin II, and Plasma
Volume
◦ All components of the Renin-Angiotensin-Aldosterone system are
increased in normal pregnancy
◦ à Renin is produced by both the maternal kidney and the placenta, and
increased renin substrate (angiotensinogen) is produced by both maternal
and fetal liver.
◦ à Elevated angiotensinogen levels result, in part, from increased estrogen
production during normal pregnancy
• Normal normotensive pregnant women are “angiotensin resistant” (became and
stayed refractory to the pressor effects of infused angiotensin II)

• Conversely, those who ultimately became hypertensive lost this refractoriness..

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th
edition; 2014; chapter 4; Maternal physiology
RESPIRATORY TRACT
 to 700  mL during pregnancy. This capacity is composed of compliancee is unaffected by pregnancy. Airway conductancee is
expiratory reserve volume—which
e decreases 15 to 20 percent increased and total pulmonary resistancee reduced, possibly as a
or 200 to 300 mL—and residual volume—which
e decreases 20 result of progesterone. The maximum breathing capacityy and

Chest wall
to 125 percent or 200 to 400 mL. FRC and residual volume forcedd or timed vital capacityy are not altered appreciably. It is
decline due to diaphragm elevation, and significant reductions unclear whether the critical closing volume—the lung volume

◦ subcostal angle increases, as does

the anteroposterior and transverse 4 cm

diameters of the chest wall and 68.5

5° 103.5°
5°

chest wall circumference.

Uteruss
Ut
(37
(37 week
ekks))

◦ These changes compensate for

the 4-cm elevation of FIGURE
the4-12 Chest wall measure-
diaphragm so that total lung
ments in nonpregnant (A) and
pregnant women (B). With
↑5–7 cm

capacity is not significantly

pregnancy, the subcostal angle
increases, as does the anteropos-
terior and transverse diameters
reduced of the chest wall and chest wall
circumference. These changes com-
2 cm

pensate for the 4-cm elevation of

the diaphragm so that total lung
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
capacity is not significantly reduced.
Sheffield JS (eds).William’s Obstetrics 24 edition; 2014;
th chapter 4; Maternal physiology
(Redrawn from Hegewald, 2011, A B
with permission.)
 6 6
Pulmonary Not
pregnant
Pregnant
(7–9 mos.)
function 5 5

IRV
The most significant changes are: 4 IC IRV 4
IC

Volume (L)

Volume (L)
V
1) reduction in functional residual FVC
capacity (FRC) expiratory 3 VT FVC 3
reserve volume (ERV) and VT
TLC TLC
residual volume (RV)

V
2) increases in inspiratory capacity 2 ERV 2
(IC) and tidal volume (VT). ERV
FRC
1 FRC 1
RV RV
◦ C u n n in g h a m F G , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e J S , H o ffm a n B L, RV RV
C a se y B M , S h e ffie ld J S (e d s).W illia m ’s O b ste tric s 2 4 th e d itio n ; 2 0 1 4 ; c h a p te r 4 ;

0 0
M a te rn a l p h y sio lo g y

FIGURE 4-13 Changes in lung volumes with pregnancy. The most significant changes are reduction in functional residual capacity (
and its subcomponents, expiratory reserve volume (ERV) and residual volume (RV), as well as increases in inspiratory capacity (IC)
 Pulmonary function
Maternal Phy

6 6
Not Pregnant
pregnant (7–9 mos.)
◦ Increased minute ventilation is 5 5
caused by several factors: IRV
4 IC IRV 4
1. enhanced respiratory drive primarily IC

Volume (L)

Volume (L)
V
due to the stimulatory action of FVC
VT
3 FVC 3
progesterone TLC VT
TLC
2. low expiratory reserve volume

V
2 ERV 2
3. compensated respiratory alkalosis FRC
ERV

1 FRC 1
RV RV
RV RV
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology 0 0
FIGURE 4-13 Changes in lung volumes with pregnancy. The most significant changes are reduction in functional residual capacity
and its subcomponents, expiratory reserve volume (ERV) and residual volume (RV), as well as increases in inspiratory capacity (IC
tidal volume (VT). (Redrawn from Hegewald, 2011, with permission.)
Acid–Base Equilibrium

◦ “Physiological dyspnea” - An increased awareness of a desire to

breathe which should not interfere with normal physical activity
◦ result from increased tidal volume that lowers the blood Pco2 slightly and
paradoxically causes dyspnea.
◦ increased respiratory effort during pregnancy, and in turn the reduction in
Pco2, is likely induced in large part by progesterone and to a lesser degree
by estrogen.
◦ Progesterone appears to act centrally, where it lowers the threshold and
increases the sensitivity of the chemoreflex response to CO2

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th
edition; 2014; chapter 4; Maternal physiology
URINARY SYSTEM
Kidney
◦ Kidney size increases approximately 1.5 cm
◦ GFR and renal plasma flow increase early in
pregnancy à result from two principal
factors:
1. hypervolemia-induced hemodilution lowers the
protein concentration and oncotic pressure of
plasma entering the glomerular
microcirculation.
2. renal plasma flow increases by approximately
80 percent before the end of the first trimester
◦ as a consequence of this elevated GFR, pregnant
women report urinary frequency during
pregnancy

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s
Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Renal Function Tests

◦ Serum creatinine levels decrease during normal pregnancy from

a mean of 0.7 to 0.5 mg/dL à Values of 0.9 mg/dL or greater
suggest underlying renal disease and should prompt further
evaluation.
◦ Creatinine clearance increases
◦ During the day, pregnant women tend to accumulate water as
dependent edema, and at night, while recumbent, they
mobilize this fluid with diuresis.
◦ à causes nocturia, and urine is more dilute than in
nonpregnant women.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
urinalysis
◦ Glucosuria during pregnancy may not be abnormal due to
increase in GFR, together with impaired tubular reabsorptive
capacity for filtered glucose, BUT when glucosuria is identified,
the possibility of diabetes mellitus should not be ignored.

◦ Hematuria most often suggests urinary tract disease. Hematuria is

common after difficult labor and delivery because of trauma to
the bladder and urethra.

◦ Significant proteinuria is defined as a protein excretion rate of at

least 300 mg/day
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition;
2014; chapter 4; Maternal physiology
Ureters
◦ Enlarged uterus rests on the ureters, which laterally
displaces and compresses them at the pelvic brim à
Ureteral dilatation found to be greater on the right
side in 86 percent of women:
1. Unequal dilatation may result from cushioning of
the left ureter by the sigmoid colon and/or from
greater right ureteral compression exerted by the
dextrorotated uterus.
2. right ovarian vein complex lies obliquely over the
right ureter and may contribute significantly to
right ureteral dilatation.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
GASTROINTESTINAL
TRACT
 GI tract
◦ Pregnancy gingivitis à gums may
become hyperemic and softened and
may bleed when mildly traumatized;
regresses spontaneously after delivery.

◦ Abdominal PE findings in certain diseases

are altered (as the stomach and intestines
are displaced by the enlarging uterus)
◦ appendix, for instance, is usually displaced
upward and somewhat laterally as the uterus
enlarges.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 GI tract
◦ Pyrosis (heartburn) is caused by reflux of acidic
secretions into the lower esophagus:
1. altered stomach position
2. esophageal sphincter tone is decreased.
3. intraesophageal pressures are lower and intragastric
pressures higher in pregnant women.
4. Decreased esophageal peristalsis secondary to
progesterone effect

◦ Hemorrhoids are caused by constipation and elevated

pressure in veins below the level of the enlarged
uterus.
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Gallbladder
◦ Progesterone impairs gallbladder contraction by
inhibiting cholecystokinin-mediated smooth
muscle stimulation (primary regulator of
gallbladder contraction)
◦ Impaired emptying, subsequent stasis, and an
increased bile cholesterol saturation of
pregnancy contribute to the increased
prevalence of cholesterol gallstones in multiparas
(Cholestasis of pregnancy)

◦ pruritus gravidarum from retained bile salts.

◦ Intrahepatic cholestasis has been linked to high
circulating levels of estrogen
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
ENDOCRINE SYSTEM
 Pituitary gland
◦ pituitary gland enlarges by approximately 135
percent (primarily caused by estrogen-stimulated
hypertrophy and hyperplasia of the lactotrophs) à
increase in prolactin
◦ gland involutes rapidly thereafter and reaches
normal size by 6 months postpartum
◦ maternal pituitary gland is not essential for
pregnancy maintenance
◦ Many women have undergone
hypophysectomy, completed pregnancy
successfully, and entered spontaneous labor
while receiving compensatory glucocorticoids,
thyroid hormone, and vasopressin
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Thyroid gland
◦ thyroid gland undergoes moderate
enlargement during pregnancy caused by
glandular hyperplasia and increased
vascularity.
◦ normal pregnancy does not typically cause
significant thyromegaly à thus any goiter
should be investigated.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
 Free
e T4 1
Thyrotropin

Thyroid function
0
0
Maternal Physiology 69
FIGURE
Mother 6
Fetus mone
Singleton pregnancy 132 tw
Twin pregnancy 97.5th solid b
5
TBG pregna

CHAPTER 4
solid b
TBG
4 4.0 singlet

TSH (mU/L)
thresho
Total T4 Total T4
on the
3
represe
identifi
2 value o
hCG Thyrotropin 50th

Free
e T4 1
Free T4 2.5th have e
Thyrotropin 0.4 free T
Total T3
0 The
0 10 20 30 40 appear
Gestational age (weeks) Free T3
bolic s
FIGURE 4-18 Gestational age-specific sively
10 20 thyroid-stimulating
30 hor- 40
mone (TSH) normal curves derived from 13,599 singleton and of this
Fetus Week of pregnancy
132 twin pregnancies. Singleton pregnancies are represented with fetal m
◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 4; Maternal physiology FIGURE
solid blue 4-17 Relative
lines and changes in with
twin pregnancies maternal
dashed and fetalThe
lines. thyroid-
non- along
TBG associated
pregnant analytes
reference across
values pregnancy.
of 4.0 Maternal
and 0.4 mU/L changes include
are represented as metab
Iodine Status

◦ Iodine requirements increase during normal

pregnancy.
◦ In women with low or marginal intake,
deficiency may manifest as low thyroxine and
increased TSH levels.
◦ For the fetus, early exposure to thyroid
hormone is essential for the nervous system
◦ Severe deficiency leads to cretinism.

◦ Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 24th edition; 2014; chapter 4; Maternal physiology
Outline
1. REPRODUCTIVE TRACT
2. BREASTS

3. SKIN
4. METABOLIC CHANGES
5. HEMATOLOGICAL CHANGES
6. CARDIOVASCULAR SYSTEM

7. RESPIRATORY TRACT
8. URINARY SYSTEM
9. GASTROINTESTINAL TRACT
10. ENDOCRINE SYSTEM
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