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during pregnancy
Bernhard H Heidemann FRCA
John H McClure FRCA
Maternal physiology undergoes many changes g litre1 during the third trimester (Fig. 1). This
during pregnancy. These are largely secondary is termed the physiological anaemia of preg- Key points
to the effects of progesterone and oestrogen nancy. At two weeks post partum, the blood Difficult intubation is
which are produced predominantly by the ovary volume has returned to pre-pregnancy levels. more common in preg-
in the first 12 weeks of pregnancy and there- nancy.
The increased circulating volume offers protec-
after are produced by the placenta. These Desaturation is more
tion for mother and fetus from the effects of
rapid in pregnant women.
changes both enable the fetus and placenta to haemorrhage at delivery but it can delay the
Mendelsons syndrome
EH16 9SA
30 ing aorta also leads to a reduction in uterine Tel: 0131 242 3136
20 blood flow. This may cause fetal distress. Fax: 0131 242 3138
E-mail: b.heidemann@ed.ac.uk
10
RBC volume Aortocaval compression typically occurs after
Plasma volume John H McClure FRCA
Total blood volume 20 weeks gestation but must be considered as a
0 Honorary Clinical Senior Lecturer,
Cardiac output cause of maternal hypotension from the end of University Department of
-10 Anaesthesia, Critical Care and Pain
0 10 20 30 40 the first trimester onwards. To compensate for
Medicine,The Royal Infirmary, Little
Weeks' gestation the effects of aortocaval compression, there is France, Edinburgh EH16 9SA
firstly an increase in sympathetic tone causing Tel: 0131 242 3159
Fax: 0131 242 3138
Fig. 1 Haematological changes. vasoconstriction and tachycardia. Secondly, E-mail: john.mcclure@ed.ac.uk
DOI 10.1093/bjacepd/mkg065 British Journal of Anaesthesia | CEPD Reviews | Volume 3 Number 3 2003
The Board of Management and Trustees of the British Journal of Anaesthesia 2003 65
Changes in maternal physiology during pregnancy
blood from the lower limbs may flow through the vertebral
plexus and the azygos veins to reach the right heart. In 10% of 70
parturients, these mechanisms are inadequate to maintain blood
60
pressure in the supine position. The fall in blood pressure may
50
Change (%)
be severe enough for the mother to loose consciousness.
However, fetal hypoxia may occur in the asymptomatic mother. 40
Respiratory rate
Induction of general anaesthesia and neuraxial blockade abolish 30 Tidal volume
Minute ventilation
this sympathetic response and increase the risk of supine
20 Alveolar ventilation
hypotension. Therefore, all pregnant patients should either be
10
tilted to the left or have a wedge inserted under their right hip
when being positioned supine and the full lateral position 0
0 10 20 30 40
adopted whenever possible.
Weeks' gestation
Many of the physiological changes in the respiratory system Table 2 Renal function
are mediated by increased progesterone levels, such as Plasma concentration Non-pregnant Pregnant
bronchial and tracheal smooth muscle relaxation. Creatinine (mol litre1) 73 5073
Progesterone-mediated hypersensitivity to CO2 increases the Urea (mmol litre1) 4.3 2.34.3
Urate (mmol litre1) 0.20.35 0.150.35
respiratory rate by 10%. The increases in respiratory rate and Bicarbonate (mmol litre1) 2226 1826
tidal volumes result in increases in both alveolar and minute
ventilation. Consequently, there is a fall in PaCO2 that plateaus
at 4.1 kPa by the end of the first trimester. PaO2 rises to 14 kPa oxygen and consequently oxygen delivery to the fetus
during the third trimester but then falls to < 13.5 kPa at term decreases. If labour is particularly painful and prolonged, the
because increased oxygen consumption is no longer fully increase in oxygen consumption and basic metabolic rate can
compensated for by the rise in cardiac output. Thus, the alve- result in lactic acidosis, a right shift of the oxyhaemoglobin
olar arterial oxygen gradient increases. In some parturients, dissociation curve and a decrease in maternal oxygen uptake.
by the gravid uterus and displacement of the gastric axis. on its own production of insulin. Poorly controlled maternal
Additionally, there is a progesterone-mediated reduction in diabetes is associated with fetal macrosomia. Maternal hyper-
lower oesophageal sphincter tone. Upper oesophageal sphinc- glycaemia causes increases in fetal insulin and this can result
ter pressure is not affected by progesterone as it is formed in neonatal hypoglycaemia as the carbohydrate load falls
from striated muscle. There is no evidence that pregnancy immediately after birth.
itself is associated with delayed gastric emptying. However,
labour causes both delayed gastric emptying and an increase Acknowledgement
in gastric volume. If opioids are administered these changes The figures and tables are taken and modified by permission
are made worse. Induction of anaesthesia reduces upper from The Simpson Handbook of Obstetric Anaesthesia by Dr
oesophageal sphincter pressure and, combined with an incom- A S Buchan and Dr G H Sharwood-Smith.
petent lower oesophageal sphincter, predisposes pregnant
women to aspiration. Pneumonitis may result (Mendelsons
Key references
Insulin production rises during pregnancy but is accompanied Ganong WF. Review of Medical Physiology. New York: McGraw Hill, 2001
Sharma SK, Philip J,Whitten CW, Padakandla UB, Landers DF.Assessment
by increased insulin resistance caused by placental hormones
of changes in parturients with preeclampsia using thromboelastogra-
(mainly human placental lactogen). Therefore, any carbohy- phy. Anesthesiology 1999; 90: 38590
drate load will cause a greater than normal increase in plasma Whittaker M. Plasma cholinesterase variants and the anaesthetist.
glucose concentrations. This facilitates placental glucose Anaesthesia 1980; 35: 17497
transfer. As insulin does not cross the placenta, the fetus relies See multiple choice questions 4549.