C

E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Position Anteverted; Dextrorotated - towards

anteflexed the right which is due to
Outline the rectosigmoid on the
left side of the pelvis;
I. Introduction important to consider
II. Reproductive Tract during cesarean section
III. Changes During Pregnancy

• By the end of 12 weeks, the uterus has become too

Maternal Physiology large to remain entirely in the pelvis, the uterus then
becomes an abdominal organ
• Adaptation of mother to the pregnancy • Myometrium surrounding the placental site grows
• Pregnancy related changes are prompted by stimuli more rapidly than the rest.
provided by the fetus and placenta • By term, the myometrium is 1-2cm thick with soft,
• Understanding of pregnancy adaptations is essential to readily indentable walls allowing palpation of the
avoid misinterpretation fetus (Leopold’s Maneuver)
• Some physiological changes during pregnancy can
unmask or worsen preexisting disease

Reproductive Tract

Pregnant Uterus
• Uterine hypertrophy early in pregnancy is stimulated by
action of estrogen and progesterone
• After 12 weeks, uterine growth is secondary to pressure
exerted by the expanding uterus
• Uterine enlargement is marked most in the fundus

Non-pregnant Pregnant
Weight 70g 1100g at term
Capacity 10ml or less 5-20 liters
1-2 cm thick at term:
muscular sac within soft
Figure 1: Leopold’s Maneuver
indentable walls
Shape Arrangement of Muscle Cells During Pregnancy

1. Outer Hoodlike Layer

• Arches over the fundus
• Extends into various ligaments
2. Middle Layer
Globular to spherical – • Dense network of muscle fibers perforated in all
at 12 weeks directions by blood vessels
Pear-shaped - first 3. Internal Layer
Ovoid-shaped – >12
few weeks
weeks; rapid increase in • Sphincter like fibers around the orifice of the
length than width; rises fallopian tubes & internal os of the cervix.
out of the pelvic cavity

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Regulation of Uteroplacental Blood Flow

• Increase in maternal-placental blood flow
o Vasodilatation - reduced uterine vascular
Obstitatips resistance
Outer Hoodlike Layer - Over the fundus
Middle Layer - dense network of Muscle fibers VASODILATION VASOCONSTRICTION
Internal Layer - sphincter like fibers around the fallopian
tubes and • Estrogen • Nicotine (leads to
• Progesterone smaller babies of
Internal os of the cervix
• Relaxin smoker mothers)
• Nitric Oxide • Catecholamines
• Adipocytokines – • Angiotensin II
Contractility CHEMRIN, leptin,
resistin, adiponectin
Braxton Hicks
• Irregular, painless contractions
• Unpredictable, sporadic, non-rhythmic, and intensity Cervix
varies approximately 5-25 mmHg
• Has small amount of smooth muscle, mainly connective
• Early in pregnancy uterus contracts and these may be
tissue component
perceived as mild cramps
• Late in pregnancy discomfort account for false labor
Softening & Cyanosis
• Until near term, these contractions are infrequent but
their number rises during the last two weeks. At this time, • Increased vascularity and edema of the entire cervix
the uterus may contract as often as 10 to 20 minutes • Hypertrophy and hyperplasia of the cervical gland à
and with some degree of rhythmicity.
Cervical Eversion
o Proliferating columnar endocervical glands

Uteroplacental Blood Flow

• Delivery of substances and waste removal dependent on

perfusion of placental intervillous space
• Approximately 450-750 ml/min near term
• Increased venous caliber and distensibility

Figure: 3: Cervical Eversion

Mucus Plug

• Produced by endocervical mucosal cells

• Copious amounts of a tenacious mucus that obstruct the
cervical canal
• Acts as immunological barrier to protect uterine
contents against infection
Figure 2 : Different physiological states of the uterus • At the onset of labor, this mucus plug is expelled,
resulting in a bloody shadow

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Physiologic Cervical Changes

● Prominent Basal cells near Squamo-columnar junction (size,
shape and staining): Estrogen–induced
● Arias-Stella reaction: Endocervical gland hyperplasia and
hypersecretory appearance
○ Makes identification of atypical glandular cells on PAP
smear difficult
Figure 4: Picture shows presence of mucus plug in the cervix ○ Teenagers - columnar epithelium is exposed

Ovaries
CERVICAL MUCUS ASSESSMENT
• Ovulation ceases during pregnancy due to inhibition of
FSH
• Maturation of new follicles is suspended

Beading Mucus Plug

Progesterone Corpus Luteum
Pattern (Normal)
● Functions maximally the first 6-7 weeks of pregnancy for
progesterone production
● Relaxin secreted by the corpus luteum, decidua & placenta
that acts similar like HCG
○ Aid in remodeling of reproductive tract
Amniotic Ferning connective tissue to accommodate labor.
Fluid Estrogen Pattern
● Surgical removal of the corpus luteum before 7 weeks
prompts a rapid fall in progesterone and spontaneous
abortion. After this time, however, corpus luteum excision
ordinarily does not cause abortion.

Theca Lutein Cysts

• Exaggerated physiological follicle stimulation

(hyperreaction luteinalis)
• Usually bilateral, moderately or massively enlarged
ovaries
• Usually linked with markedly ­ serum hCG levels
• Usually asymptomatic; Maternal virilization-30%
o Temporal balding, hirsutism & clitoromegaly
Figure 5: (R) Ferning or Aborization Pattern, (L) Beading Pattern § Associated with ­ androstenedione
and testosterone
o Hemorrhage into cyst à acute abdominal pain
• Fetal virilization is rare
Obstitatips
Fallopian Tubes
Beading – Progesterone; Poor Crystalization
● Undergoes little hypertrophy during pregnancy
Ferning – Amniotic Fluid Leakage; Ice-like Crystals
● Epithelium of tubal mucosa becomes flattened
● Decidualization may be seen
● Lose their role after fertilization
● Discharge is due to being in a “hyperestrogenic state”
meaning increase in lactic acid

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

○ Vaginal lengthening
○ Post vaginal wall and hiatal relaxation
○ Increase levator hiatal area
Vagina and Perineum ○ Greater elastase activity during first trimester
● One of the
● Increase in vascularity and hyperemia develop in the skin complications is
and muscles of the perineum and vulva. associated with an
uncomplicates
spontaneous vaginal
delivery is Pelvic
Organ Prolapse

Figure 8: Pelvic Organ Prolapse

Cystocele
Figure 6: Cervix • Attenuation of the anterior vaginal support after vaginal
delivery can lead to prolapse bladder.
Stress Urinary Incontinence
● Chadwick’s sign: violet • Can worsen during pregnancy
discoloration of the vagina • Because urethral closing pressure do not rise sufficiently
due to increased to compensate for altered bladder support
vascularity • Risk factors: maternal age >30, obesity, smoking,
○ Increased vaginal constipation and GDM
secretions
○ Thick, white Breast
○ Vaginal pH is
acidic: 3.5 – 6.0
○ Increased
production of
lactic acid

Figure 7: Chadwick’s Sign Figure 9: Breast

• Because of an acidic pH of the vagina during pregnancy,
there is an increase risk of vulvovaginal candidiasis during ● Breast enlarge, tender - ↑ estrogen
the 2nd and 3rd trimester ● Nipples enlarge, deeply pigmented, erectile
• Pregnancy is associated with an ↑ risk of vulvovaginal ● Areola broader, deeply pigmented
candidiasis, particularly during the 2nd and 3rd ● Glands of Montgomery – hypertrophic sebaceous
trimesters. glands

Pelvic Organ Prolapse

Obstitatips
Makinis, maputi siya pero ba’t ganun? – Nanay na si
● Associated with uncomplicated spontaneous vaginal MAUreen
delivery

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Hyperpigmentation
Chloasma or Melasma Gravidarum
• Irregular brownish patches
of varying size in the face

Figure 13: Chloasma

Figure 10: Gigantomasia

Linea Nigra
Changes During Pregnancy
• Pigmented linea alba
assuming brownish-black
Skin Changes color

Abdominal Wall

Striae Gravidarum (Stretch Mark)

• Reddish striae
• Silvery lines
Figure 14: Linea Nigra
• Depressed streaks
commonly develop in
the abdominal skin or • Hyperpigmentation is accentuated in women with darker
complexions
skin in the breast &
thigh • Elevated melanocyte stimulating hormone
• Estrogen and progesterone have melanocyte stimulating
effects à hyperpigmentation

Vascular Changes
Figure 11: Striae Gravidarum
Vascular Angioma/Spiders/Nevus/Telangiectasis
• Minute elevation on the skin particularly on the face,
Diastasis Recti
neck, upper chest and arms
• Muscles of the
abdominal wall
cannot withstand the
tension as a result
rectus muscle
separate in the
midline

Figure 12: Diastasis Recti

● Strongest association: weight gain, younger maternal
age, family Hx Figure 15: Vascular Angioma
● No definite treatment Palmar Erythema
• No clinical significance, consequence of
hyperestrogenemia

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Pitting Edema
• Due to:
o Partial vena cava occlusion
o Decreased interstitial colloid osmotic
Hair Changes pressure
• Increased water retention due to decreased plasma
• Anlagen (hair growth) – lengthen during pregnancy osmolality à reset threshold for thirst and vasopressin
• Telogen (resting preiod) – increases during postpartum
● Due to decreased plasma osmolality
• Telogen effluvium - excessive hair loss in the
● Hemodilution – increased water in interstitial space,
puerperium
leading to edema
● Seen particularly at the end of the day
Metabolic Changes
Protein Metabolism
• Basal Metabolic Rate: increase by 20% in the 3rd
trimester ● Products of conception, uterus, and maternal blood rich
Additional Total Pregnancy Energy Demands in protein rather than fat or carbohydrates
TRIMESTER Deman Fetus and Placenta 500 grams
1ST 85 KCAL/DAY Uterus, Breast, Maternal 500 grams
2ND 285 KCAL/DAY blood
3RD 475 KCAL/DAY
Estimated average requirements protein :
• Additional 10% with twin gestations • 1.22g/kg/d for early pregnancy
• 1.52g/kg/d late pregnancy
Additional Weight Gain
o 12.5 kgs/27.5 lbs Carbohydrate Metabolism
o Uterus and its contents
o Breast Normal Pregnancy:
o Blood volume and extravascular ECF o Mild fasting hypoglycemia
o Maternal reserve o Postprandial hyperglycemia
• Maternal Reserve: smaller fraction; increase accumulation o Hyperinsulinemia
in water, fat and protein • Post-prandial hyperglycemia is due to ­ peripheral
• Initial Maternal Weight & Weight gain highly associated insulin resistance to ensure sustained post-prandial
with fetal birth weight) glucose supply to the fetus
• Increased energy requirement
• increased adipose tissue (“500x greater” in 3rd trimester)

Water Metabolism

Increased Water Retention

Fetus, placenta, amniotic fluid 3.5 L
Increase in blood volume, 3.0 L
uterine & breast volume
Minimum extra water accrual 6.5 liters (corresponds to 14.3
lbs)

Figure 16: Comparison of Glucose and Insulin in pregnant and

non pregnant women

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Leptin
• Peptide hormone primarily secreted by the adipose
tissue in non-pregnant woman
Peripheral Insulin Resistance • Plays a key role in body fat and energy expenditure
regulation and reproduction
• Insulin sensitivity normally lowers by 30-70%
• Important for implantation, cell proliferation, and
○ Progesterone
angiogenesis
○ hPL & cortisol • Deficiency leads to anovulation and infertility
○ Tumor necrosis factor • Leptin functions as a proinflammatory cytokine in
○ Leptin white adipose tissue, which may dysregulate the
● Function: inflammatory cascade and lead to placental dysfunction
○ Inhibit Insulin in obese women.
• It is also associated with preeclampsia and gestational
○ Blood glucose level is increased
diabetes
● Purpose is to ensure sustained postprandial supply of
• Leptin levels fall after delivery
glucose to the fetus
• HPL increases lipolysis with liberation of free fatty acids Other Adipocytokines
which in turn increases tissue resistance to insulin ● Adiponectin – act as a potent insulin sensitizer
● Ghrelin- secreted in the stomach in response to hunger,
Accelerated Starvation
cooperates with leptin in energy homeostasis modulation
● Visfatin – elevated levels together with leptin impairs
• Postprandial hyperglycemia à Fasting hypoglycemia à
uterine contractility
­ free fatty acids, triglycerides, cholesterol à Ketonuria
• Switch fuels from glucose to lipids
Electrolyte and Mineral Metabolism
• Pregnant woman changes rapidly from a postprandial
state char by elevated & sustained glucose to a fasting Normal Pregnancy
state – decreased plasma glucose and amino acid ● 1000 mEq of Na retained
• Simultaneously, plasma concentrations of free fatty acid, ● 300 mEq of K retained
TG & cholesterol
• Pregnancy is a diabetogenic state characterized by Increase Decrease Unchanged
hyperinsulinemia and insulin resistance. This progressive
change in the maternal metabolism is due to the body's GFR of Na, K Serum Na, K Excretion of Na, K
effort to provide adequate nutrition for the growing fetus. Iodine Total serum Ca Serum ionized Ca
requirement Serum Mg Phosphate
Fat Metabolism Iron requirement

Maternal Hyperlipidemia
● Serum Na & K slightly decrease because of expanded
• The most consistent change in pregnancy plasma volume
• Due to: ○ However, very near non pregnant range
o Increased Insulin resistance ● Iodine:
o Estrogen stimulation ○ Maternal T4 production increases to maintain
• Favors maternal use of lipids as an energy source, spares euthyroid state and to transfer T hormone to
glucose for fetus fetus
• Increase: lipids, lipoproteins, apolipoproteins ○ Fetal thyroid hormone production increases
• Fat is deposited mostly in the central rather than during 2nd half of pregnancy
peripheral sites ○ Greater renal clearance
Augmented lipid synthesis
Calcium
1st to 2nd trimester and food intake contribute
to maternal fat accumulation ● Fetus imposes a significant demand on maternal
calcium
3rd trimester ­lipolytic activity à fat ● Fetus accumulates 30 grams of Calcium at term met by:
storage declines or ceases 1. Doubling of maternal calcium intestinal
absorption

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

● Iron requirement is not available from maternal storage

in most women
2. Dietary intake of sufficient calcium to avoid ● If the nonanemic pregnant woman is not given
deficiency in mother supplemental iron, then serum iron and ferritin
concentrations decline after midpregnancy
Iodine
Iron Metabolism
● Requirement increases during pregnancy because:
○ Maternal thyroxine production rises to maintain ● Iron Requirement: 1000mg
maternal euthyroidism ○ 300 mg to fetus & placenta
○ Fetal thyroid hormone production increases ○ 200 mg lost thru excretion
during the second half of pregnancy ○ 500 mg to 450 ml of circulating erythrocytes
○ Primary route of iodine excretion is through the ○ Most Fe used during the latter half of pregnancy
kidneys
Hepcidine
● Wolff-Chaikoff effect – autoregulation of the thyroid
● Peptide hormone that functions as a hemeostatic
gland – to curb thyroxine production in response to
regulator of systemic iron metabolism
iodide overconsumption
● Rises during inflammation and drops with iron deficiency
● In summary, because of greater thyroid hormone anemia, estrogen, vitamin D and prolactin
production, fetal iodine requirements and augmented
renal clearance, dietary iodine needs are higher during
normal gestation Summary:
Increased Decreased No Change
- Clotting Factors - Clotting Factors - Clotting time
Hematological Changes
(except XI and XIII) (XI and XIII) - Anti-thrombin
- Fibrinogen - Platelets levels
Hypervolemia
- Thromboxane A2 - Activated C
● To meet metabolic demands of the enlarging uterus - Protein Z protein resistance
● To provide abundant nutrients and elements to support - Protein S
the growing placenta & fetus
• Coagulation and Fibrinolysis are both are augmented but
● To protect the mother and fetus against the deleterious
remain balanced to maintain hemostasis
effects of impaired venous return in the supine & erect
position
● To safeguard the mother against the adverse effects of
blood loss associated with parturition
Obstitatips
● Increase in RBC (450ml) & plasma (15% compared to Increased: “Fibrin Thrombo ProZ at CFac (except 11
prior pregnancy) and 13)”
No change: ang ClotT AnTi “Ang kalat Auntie”
● Begins in the 1st trimester
Everything else is decreased
● Expands rapidly in the 2nd trimester
● Averages 40-45% above nonpregnant blood volume after
32-34wks BV expansion or hypervolemia varies.
● Postpartum Hemorrhage - The average amount of
blood loss after the birth of a single baby in vaginal
delivery is about 500 ml. The average amount of blood
loss for a cesarean birth is approximately 1,000 ml.

Hemoglobin Concentration and Hematocrit

● ­ plasma augmentation à Hgb and HC decline slightly

during pregnancy
● 12.5g/dl- average Hgb concentration at term
● Below 11g/dl late in pregnancy is considered abnormal
– Iron deficiency anemia
● HGB will average 12.5 at term

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Spleen

• By the end of normal pregnancy the spleen enlarges by

up to 50%
Immunological Changes • Cause of splenomegaly is unknown but might follow the
increase blood volume and hemodynamic changes of
pregnancy
Increased Decreased
• T-helper 1 cells • T-helper 2 cells
suppression suppression Cardiovascular Changes
• T-cytotoxic 1 cells • CD4 T Lymphocytes • Heart is displaced to the left and upward rotated to its
• IL 4, 6, 13 • Monocytes long axis à larger cardia silhouette (++mild pericardial
• IgA and IgG effusion)
• Leukocyte Count • ECG findings show left axis deviation
(14,000-16,000/μl) • Cardiac heart sounds show:
• CD8 T Lymphocytes o Systolic murmur 90%
• Inflammatory o Soft Diastolic Murmur 20%
markers (CRP, ESR,
C3, C4, Leukocyte Summary of Cardiovascular Changes
alkaline INCREASED DECREASED NO CHANGE
phosphatase)
-CO(1.2L/min), - Systemic Vascular - ECG (except for
HR, SV Resistance left axis deviation)
• Decreased T-helper cells for non-rejection of fetus -Plasma volume - Pulmonary Vascular - Aortic and
-Preload Resistance pulmonic
Obstitatips -S1 splitting - Mean arterial components of S2
Decreased: “Th2 CD4 Mono” -S3 sound pressure - Pulmonary
T-helper 2 cells suppression, CD4 T lymphocytes and - BP on sitting capillary wedge
-Basal metabolic
monocytes are decreased. Everything else is increased pressure
rate
- Central venous
pressure
- Antecubital
Leukocytes and Lymphocytes venous pressure

• Elevated during pregnancy upper values approach

15,000/ul
o normally >10,000/ul means viral infection
• During labor and early puerperium it may reach 25,000/ul • Increase in CO as a function of a decrease in SVR and
or greater increase in HR)

Inflammatory Markers Supine Hypotension Syndrome

• Cannot be used reliably during pregnancy because all • 10% of women
inflammatory markers are usually elevated. • Due to supine compression of great vessels
o Leukocyte alkaline phosphatase
• May directly affect fetal heart rate patterns
o C- reactive protein
o Erythrocyte sedimentation rate
Renin, Angiotensin, Plasma Volume
o Procalcitonin
o Complement factors C3 and C4 levels rise • Renin angiotensin-aldosterone axis is intimately
during the second and third trimesters involved in blood pressure control via sodium and water
balance
• All components of this system are increased

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

• PGI2 – regulates blood pressure and platelet function

• Renin is produced by both the maternal kidney and the o Helps maintain vasodilatation during pregnancy
placenta ○ Deficiency is associated with pathological
• Angiotensinogen is produced by both maternal and vasoconstriction
fetal liver ○ Ratio of PGI2 to thromboxane is important in
preeclampsia pathogenesis
Cardiac Natriuretic Peptide
Respiratory Tract Changes
• Secreted by cardiomyocytes in response to chamber wall
stretching
• These peptides regulate blood volume by provoking
natriuresis, diuresis, and vascular smooth-muscle
relaxation
• Atrial Natriuretic peptide – participate in extracellular
fluid volume expansion & elevated plasma aldosterone
concentration
• Brain natriuretic peptide – increased in severe
preeclampsia and this may cause cardiac strain from
increase cardiac afterload

Endothelin

• Endothelin 1 – potent vasoconstrictor produced in

endothelial and vascular smooth muscle cells and
regulates vasomotor tone
• Pathologically elevated levels may play a role in
preeclampsia
• Its production is stimulated by angiotensin II, arginine
vasopressin, and thrombin. Endothelins, in turn, Figure 16: Respiratory anatomical changes
stimulate secretion of ANP, aldosterone, and • Diaphragm rises about 4 cm
catecholamines • Subcostal angle widens as the transverse diameter of the
• With RAAS, ­ BP thoracic cage increases about 2 cm
• Thoracic circumference increases about 6 cm
Nitric Oxide • Diaphragmatic excursion is actually greater during
pregnancy than when nonpregnant
● Potent vasodilator, released by endothelial cells and may • ↓ Respiratory Volume = due to ↑ Progesterone
modify vascular resistance during pregnancy
● It is also an important mediator of placental vascular
tone and development
● Abnormal nitric oxide synthesis has been linked to
preeclampsia development

Prostaglandin

• Elevated levels of prostaglandin production during

pregnancy is thought to have a central role in the control
of vascular tone, blood pressure and sodium balance.
• Evening primrose - prostaglandin precursor, used
therapeutically to reduce risk of pre-eclampsia
• PGE2 – presumed to be natriuretic

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Mechanism of Physiological Dyspnea:

Pulmonary Function Increased TV à decrease PCO2 à DYSPNEA à respiratory

alkalosis à plasma bicarbonate levels decrease (pH) à shift O2
dissociation to the LEFT à increased affinity for oxygen
Bohr Effect

• To compensate for the resulting respiratory alkalosis ,

plasma bicarbonate levels normally drop from 26-22
mmol/L. although blood pH is increased only minimally it
does shift the oxygen dissociation curve to the left and
this shift increases the affinity of maternal hemoglobin for
oxygen
• The hyperventilation that results in a reduced maternal
Figure 17: Lung volume changes in pregnancy PCO2 facilitates transport of carbon dioxide from the
fetus to the mother and facilitates the release of oxygen
from maternal blood to the fetus.
INCREASE DECREASE NO CHANGE
Tidal Functional residual Maximum
Volume Capacity breathing Renal Changes
Inspiratory Capacity
Capacity Kidneys

Minute Ventilatory Residual Volume Timed Vital • Both glomerular filtration rate and renal plasma flow
Volume Capacity increases during pregnancy
• Urinary frequency is due to ↑ GFR and bladder
compression
Minute oxygen Total Pulmonary Lung compliance
uptake Resistance
PARAMETER ALTERATION RELEVANCE
Kidney size 1cm longer in Xray Returns to normal
Airway Peak expiratory
conductance flow Dilatation Hydronephrosis in Confused with
UTZ/IVP Obstructive
Ureteral dilation > uropathy; retained
Critical Closing urine leads to
R
Volume collection errors;
renal infections
Total Oxygen more virulent;
Carrying capacity Renal Function GFR & renal Serum creatitine
plasma flow decreases;
increase 50% >0.8 mg/dl
• Highlighted in Purple: most significant changes Borderline
• Increased in minute ventilation: Maintenance of Decreased PCO2 of 40mHg
o Enhance respiratory drive by progesterone Acid-Base Bicarbonate represents CO2
o Low expiratory reserve volume threshold retention
o Compensated respiratory alkalosis stimulates
Respiratory Center
Acid-Base Equilibrium Plasma Osmoregulation Serum Osmolality
Osmolality altered decreases
• Increased awareness of a desire to breathe that maybe
interpreted as dyspnea

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

• Pyrosis (heartburn) caused by reflux of acidic secretions

into the lower esophagus
• Serum creatinine of 0.9 mg/dl suggest underlying renal
Reason why pyrosis is common during pregnancy:
disease and should prompt further evaluation
1. Altered position of the stomach
• Nocturia during pregnancy is due to mobilization of
2. Lower esophageal sphincter tone is decreased
fluid accumulated during the day, at night while pregnant
3. Intraesophageal pressures are lower, intragastric
woman is recumbent
pressures higher in pregnant women.
Relaxin 4. Esophageal peristalsis has lower wave speed and lower
• Boosts renal nitric oxide production, which leads to renal amplitude.
vasodilation and lowered renal afferent and efferent 5. Gums may become hyperemic and softened during
arteriolar resistance. This augments renal blood flow and pregnancy.
GFR

Ureters

• Hydronephrosis - more pronounced on the right side

o may result from cushioning provided the left
ureter by the sigmoid colon and perhaps from
greater compression of the right ureter as a
consequence of dextrorotation
Figure 18: Hemorrhoids
• Hemorrhoids are secondary to constipation and
Urinalysis in Pregnancy increased venous pressure below the level of the
enlarged uterus
• Glucosuria may not be abnormal, and is common.
• Proteinuria is abnormal.
INCREASED DECREASED
• Hematuria is usually a result of contamination.
Alkaline phosphatase Serum aspartate transaminase
Leucine aminopeptidase Alanine transaminase
Proteinuria Glutamyl transferase
bilirubin
• Non-pregnant: < 150 mg/day
Serum albumin
• Pregnancy significant proteinuria:
o =/> 300mg/day Gallbladder contractility
• Measuring Significant Proteinuria
o Dipstick • Some laboratory test results of hepatic function are
o 24 hours collection altered during normal pregnancy
o Albumin/Creatinine or Protein/Creatinine Ratio

Obstitatips
GI Changes Decrease: BAGSAG (Sounds like the Tagalog word for
• Physical examination of certain diseases are altered due falling, it’s activity “Goes down”)
to displacement of GIT (by the enlarging uterus) Bilirubin, Alanine Transferase, Glutamyl transferase, Serum
o Appendix may be displaced up to the right Albumin, Gallbladder contractility
flank
• Gastric emptying time unchanged, but may be prolonged Increase: ALa (It means wing, so you know it’s activity
during labor rises)
o ↑ Gastric emptying time about 6-8 hours Alkaline phosphatase, Leucine Aminopeptidase
(normal is 3-4 hours)

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2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

Androstenedione Increased
Testosterone Increased
• Alkaline phosphatase • Androsterone and testosterone both converted to
o Increase is caused by Heat-stable placental estradiol in the placenta
alkaline phosphatase isozymes.
• Leucine Aminopeptidase
o Liver Disease can also increase LeuAP Obstitatips
o Pregnancy-Induced LeuAP: oxytocinase &
“Down with DHEA!”
vasopressinase activity
The only endocrine activity that decreases during
o Occasionally causes Transient Diabetes
pregnancy the rest are increased and one doesn't
Insipidus.
change (GH)
• Serum Albumin
o Pregnant: 3.0 g/dL Thyroid Gland
o Normal: 4.3 g/dL
• Moderate enlargement by hyperplasia & increased
Gallbladder vascularity
o Increased hormonal production
o Increased TBG, T4, T3
• Decreased contractility
o No change in FT3/T4
o leads to increased residual volume
• No significant thyromegaly
o Progesterone induced
• TRH unchanged but crosses the placenta
• Progesterone potentially impairs gallbladder contraction
by inhibiting cholecystokinin – mediated smooth muscle • Suppression of TSH
stimulation which is the primary regulator of gallbladder o Normal suppression of TSH during pregnancy
contraction. may lead to a misdiagnosis of subclinical
hyperthyroidism.

Endocrine System
CHANGES Musculoskeletal Changes
Pituitary gland Enlarges by approximately
135% Lordosis
Growth hormone Levels unchanged
• Compensate for the anterior position of the enlarging
prolactin Increased 10 fold uterus, lordosis shifts the center of gravity back over the
Thyroid gland •glandular hyperplasia and extremities
increased vascularity • Sacroiliac, sacrococcygeal and pubic joint have increased
•Thyroxine-binding globulin in mobility.
increases; (T4) increases • Associated Neck flexion and Shoulder Girdle Slumping
•TRH unchanged o Traction on the Ulnar and Median Nerves
Parathyroid hormone physiological
hyperparathyroidism in
pregnancy to supply the fetus
with adequate calcium
calcitonin Increased
Vitamin D3 (1,25- Increased
dihydroxyvitamin)
cortisol Increased
Aldosterone secretion Increased
deoxycorticosterone Increased
Dehydroepiandrosterone Decreased
Sulfate (DHEA-S)

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 C E U OBSTETRICS 2nd Shifting

2022
Maternal Physiology A.Y. ‘19 - ‘20
Dr. Santos Section A / B
Medicine
Sept. 13, 2019

References
• Dr. Santos’ lecture on maternal physiology
• William’s Obstetrics 25th ed

Figure 19: Lordosis during pregnancy

Eye Changes
• Intraocular pressure decreases during pregnancy,
attributed in part to increased vitreous outflow
• Corneal sensitivity also is decreased
• Krukenberg spindles - brownish-red opacities on the
posterior surface of the cornea
• Corneal Thickness increased
• Transient loss of accommodation
o Pregnancy
o Lactation
• Visual function is mostly unaffected by pregnancy

CNS Changes
• Reports of problems with attention, concentration &
memory
• Difficulty going to sleep, frequent awakenings, fewer
hours of night sleep, and reduced sleep efficiency
• During normal pregnancy, the frequency and duration of
sleep apnea episodes were decreased significantly
compared with those postpartum
• Greatest disruption of sleep is encountered postpartum
and may contribute to postpartum blues.
• Mean Blood Flow decreases
o Middle Cerebral a.
o Posterior Cerebral a.

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