Physiological aspects of normal pregnancy

geekymedics.com /physiological-changes-pregnancy/

Anna 7/9/2015
Birtles

Definitions for dating pregnancy

Conception: 2 weeks after 1st day of last menstrual period (LMP) with a regular 28 day cycle

Estimated due date (EDD): Naegeles rule add 9 months + 7 days to 1st day of LMP. Pregnancy lasts 38wks
from conception/40wks from 1st day of LMP

Trimesters:

1st trimester = 1-12wks

2nd trimester = 13-27wks
3rd trimester = 28-40wks

Puerperium:

Delivery > 6wks.

Reversal of the physiological changes of pregnancy

Maternal physiological changes during pregnancy

Cardiovascular and respiratory changes

40% increase in plasma volume by 32wks. [RBC] increases by 20%.

40% rise in cardiac output. CO and BP fall if supine due to vena cava compression.
Reduced peripheral venous return causes BP drop in early pregnancy. Return to pre-pregnancy level later.
40% increase in tidal volume.
Haemodilution: overall amount of Hb rises, but concentration falls.
O2 demand increases by 15%.
Increased clotting risk: increased factor VII, VIII, X, and rise in fibrinogen.
Increased RBC mass: protects against the ~0.5L delivery blood loss (1L if twins or CS)

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Renal changes

Renal pelvis + ureters dilate (pressure/progesterone): risk of acute pylonephritis.

GFR increases by 50%: reduces plasma urea, creatinine and osmolality.
Increased urinary protein loss. >500mg in 24hrs is abnormal however.

Endocrine changes

Insulin secretion doubles. Physiological glycosuria may occur.

Thyroid binding globulin doubles. T3 + T4 fall slightly. Goitre more common.
Anterior pituitary doubles in size risk of ischaemia in PPH (Sheehans syndrome)
Rise in total and free serum cortisol and urinary free cortisol

Musculoskeletal and skin changes

Joints of the lower back and pelvis soften.

Increased incidence of rashes/epistaxis/hyperpigmentation/spider naevi/erythema

Calcium and phosphate

Increased demand of Ca (especially in 3rd trimester and puerperium) leads to increased gut absorption.
Calcium is actively transported across placenta.
Serum Ca + phosphate levels fall (bound to albumin). Ionised Ca remains stable

Liver

Hepatic blood flow unchanged

ALP levels rise by 50% and albumin falls by 10g/L (causes a fall in total protein)

Uterine physiology
Morula becomes blastocyst at the 32 cell stage
Implantation 7-14 days post conception: blastocyst attaches and trophoblast cells invade the
endometrium.
Organogenesis: 2-8 wks post conception.
Inner cell mass becomes embryo. Trophectoderm becomes placental trophoblast.
Foetus develops in amniotic cavity, attached to placenta by umbilical cord.
Amnion: membrane lining of cavity, expands as placenta progresses. 2nd layer (chorion) in apposition to the
amnion.
Placenta is anchored to maternal decidua.
Intervillous space supplied by maternal spiral arteries.
Cord has 2 arteries (deoxygenated blood from fetus to placenta) + 1 vein (oxygenated blood from placenta
to foetus).
Uterus holds 5L at term (500x pre-pregnancy): muscle hypertrophy.

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 Blood supply from uterine + ovarian arteries.
Cervical mucous plug protects during pregnancy.

Multiple pregnancy
10X higher risk of stillbirth
50% pre-term
Increased risk of IUGR

Dizygotic = non-identical, duplication of normal processes, dichorionic, diamniotic.

Monozygotic = earlier split, more independent. DCDA <3 days, 4-7days MCDA, >8d MCMA. Requires tertiary
centre care if monozygotic!

Risks to mother:

Anaemia
Pre-eclampsia
Hyperemesis
Polyhydramnios
Complicated labour

Risks to developing foetuses:

Congenital abnormalities
Twin-to-twin transfusion
Pre-term delivery
Twin entrapment

More regular antenatal checks are required.

Foetal growth
Growth governed by intrinsic (maternal height/weight/ethnicity, fetal sex/genes/conditions) and extrinsic
(environmental social class, nutrition, maternal disease) factors.

Small for Gestational Age a foetus that has failed to achieve a specific biometric or estimated weight threshold
by a specific gestational age may be constitutional or due to intra-uterine growth restriction (IUGR).

Assessments of foetal growth: Biparietal distance, head circumference, abdominal circumference, femur length
serial measurements more useful to gauge velocity. Plotted on centiles can show if any dropping
off/lag/acceleration.

Assessment of babys coping: kick charts, CTG, biophysical profile (fetal breathing movements, fetal movements,
fetal tone, amniotic fluid volume).

Assessment of babys nutrition: placental assessment appearance, blood flow characteristics via Doppler
(umbilical fetus to placenta, uterine mother to placenta). Progressively greater resistance leads to absent or
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reversed End Diastolic Flow. (read up on this if youre interested, I wont go into it further! )

Foetal development

Early pregnancy

Day 14 = ovulation
Fertilisation occurs commonly in the fallopian tube
Cell division occurs: zygote morula blastocyst as moving to uterine cavity
Day 23 = implantation beginning of fetal-maternal dialogue
When the blastocyst implants production of hCG by the decidua stimulates the ovary to produce
progesterone (causes modification of maternal physiology).
hCG levels rapidly rise <10wks. Can be detected in serum/urine 4 weeks after LMP (urine PT +ve when
concentration of hCG is 25IU/ml)

Ultrasound

4-5 weeks gestation sac ~6mm

5-6 weeks yolk sac
6 weeks foetal pole ~5mm
7 weeks foetal heart activity
8 weeks limb buds, fetal movements
Foetus should double in size every week until 12 weeks gestation

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