Normal Physiology of Pregnancy
In pregnancy almost all of the mother’s organ systems need to adapt, and several factors, such as age, ethnicity, and genetic factors all affect how well she adapts to being pregnant. There are four reasons why the mother’s body needs to adapt.
1- To SUPPORT the fetus in the womb ≫ Volume (space) ≫ Oxygen
≫Nutrition ≫ Waste removal
2- To PROTECT the fetus ≫ Starvations ≫ Drugs ≫ Toxins
3- To PROTECT the mother from harm during the delivery
4- To PREPARE the mother for the delivery
- The maternal respiratory system needs to adapt to optimise maternal and fetal oxygenation and to facilitate the removal and clearance of CO2 from the fetus.
- Many women complain of shortness-of-breath (SOB) during pregnancy. As the abdomen grows, the diaphragm elevates 4cm and the ribs are pushed up and out. This creates a decreased expiratory reserve volume , and although this is physiologically balanced out by an increased tidal volume this still gives the sensation of being SOB. Normally good explanation and reassurance is all that is needed.
- Box 1 shows how lung function tests change in pregnancy, note that the respiratory rate remains unchanged, but the tidal volume increases, thaught to be a result of increased progesterone levels.
- Box 2 shows how blood gasses change in pregnancy. If we remember how diffusion works, substances move from an area of high concentration to an area of low concentration. The reason why the CO2 falls in the mother is so that CO2 is drawn out of the fetal blood into the mothers, where it can be breathed out in the lungs. You would have thaught that the opposite would apply and that there would be an equally large rise in the oxygen levels in the maternal blood, however this is not necessary as the haemoglobin in the fetus (fetal haemoglobin) has a higher oxygen carrying capacity than adult haemoglobin. Remember because the bicarbonate levels also decrease, pregnancy gives a state of COMPENSATED RESPIRATORY ALKOLOSIS.
- There are some changes in the lungs during pregnancy that can be observed on a chest x-ray (although extreme care must be taken during the x-ray and it is very rare that one is performed on a pregnant lady). Firstly there may be an increase in the amont of vascular soft tissues visible. Secondly small pleural effusions may be visible, especially soon after delivery of the baby.
There are several reasons why the cardiovascular system in particular needs to adapt.
- The fetus grows rapdly and has a huge oxygen consumption
- Many maternal tissues hypertrophy and again need more oxygen
- The muscular work of the mother increases to support and move the additional weight.
- Progesterone decreases vascular resistance, which lowers blood pressure. Therefore Cardiac output increases by 30-50%. Blood pressure does, however return to normal later in pregnancy, cardiac output does not, and in fact increases by another third during labour!
- As a result of the drop in blood pressure, the renin-angiotensin system is activated, which causes Na+ and H2O retention. This increases blood volume by 40%. However most of the increased blood volume is plasma, and as such many pregnant women are described as having a physiological anaemia.
- As well as this there is constriction of the peripheral circulation. This could explain why some pregnant ladies complain of symptoms of Raynaud’s Syndrome.
- In pregnant ladies there may often be a systolic ejection murmur, as well as a third heart sound which is the ventricles filling with blood.
- As the diaphragm raises, the heart rotates up and out, which gives changes not only in x-rays but in ECGs. It is important to note that these changes can be seen in completley healthy pregnant ladies, and before ordering any test you should make sure the person doing/interpreting the test knows that the patient is pregnant.
- Pregnancy also increases the chance of varicose veins forming.
- The kidneys increase in size by 1cm
- In early pregnancy, renal blood flow increases by 40%. The raised glomerular filtration rate (GFR) leads to increased readsorption and as such plasma urea and creatinine levels are reduced. The increased GFR also leads to increased levels of aldosterone being secreted to maintain adequate fluid balance. One substance that is not fully readsorbed however is glucose, and as such 15% of normal pregnant women have some degree of glycosuria.
- Increased progesterone levels relax the smooth muscle in the bladder and ureteric walls. As a result of this the ureters elongate and become both dilated and tortuous. Unfortunately this can lead to urine stasis, increasing the risk of urine tract infections (UTIs).
- One of the noticible features of pregnancy is the increased frequency of urination. In the first part of pregnancy this is all down to increased urine production, however as pregnancy progresses and the uterus gets larger, mechanical pressure on the bladder plays a larger and larger part.
- Increased oestrogens may lead to Palmar erythema and Spider Angioma formation.
- Increased oestrogens combined with increased levels of melanocyte stimulating hormone often leads to hyperpigmentation of the umbilicus, nipples, face and linea nigra.
- Shifts in posture and gait are often observed as additional weight of pregnancy goes on.
- Another consequence of the additional abdominal weight is that lower back strains are common.
- The increased progesterone levels soften critical ligaments, so that bones may seperate a bit during labour. The best example of this is the pubic symphsis.
- Nausea (morning sickness) occurs in more than 7/10 pregnancies. It normally resolves after 16-18 weeks.
- It has already been mentioned that progesterone relaxes smooth muscles, and the smooth muscle in the GI tract is no exception. This leads to decreased gastric motility (therefore constipation) and reflux.
- The decreased smooth muscle activity in the gallbladder increases the risk of gallstone formation. Cholesterol stones are most likely to form.
- Because the mothers body is trying to provide the fetus with a constant supply of glucose, pregnancy also increases the chance of a diabetic state developing.
- Before pregnancy, the uterus weighs 100g, and at term it weighs 1100g. The huge increase in weight is achieved by hypertrophy, not hyperplasia of the myometrial cells. The hypertrophy occurs up to 20 weeks after conception, after that the increase in uterus size is purely stretching from the fetus and surrounding fluid.
- To go with the increase in weight, there is an increase in blood flow to the uterus, the vast majorite (85%) goes to the placenta.
- In later pregnancy oestrogens cause the cervix to become softer and erosions begin to form in it. The uterine ligaments lengthen and thicken and there is a marked increase in vaginal secretions.
The immune system is depressed in pregnancy, giving an increased risk of viral infections.
ENDOCRINOLOGY IN PREGNANCY
Almost all endocrine gland is altered by pregnancy, below is a summary, only a few are discussed in some depth.
Anterior Pituitary = 1. ↑Prolactin 2. ↓FSH 3. ↓LH 4. ↓GH
Posterior Pituitary = 1. ↓Oxytocin (storage and release)
Adrenals = 1. ↑Cortisol 2. ↑Renin 3. ↔/↑adrenaline/noradrenaline (elevates in labour)
Thyroid= 1. ↑Thyroid Hormones
Placenta= 1. ↑hCG 2. ↑hPL 3.↑Oestrogens 4.↑Progesterones
PROLACTIN is produced in the anterior pituitary gland. It increases within a few days of conception, and during pregnancy it affects water transport across the placenta, and therefore the fluid balance of the fetus. After pregnancy it controls the production and secretion of milk.
OXYTOCIN is produced in the hypothalamus and stored in the posterior pituitary. During labour it is released in pulses.
THE THYROID GLAND is stimulated (it is thaught) by hCG in early pregnancy, and there are increased amounts of thyroid hormones in the blood of pregnant ladies. Pregnancy is described as a hyperdynamic state and the basal metabolic rate is raised, leading to symptoms of hyperthyroidism.
THE ADRENALS are split into an outer cortex, and an inner medulla. In pregnancy the cortex secretes increased amounts of rennin and cortisol, however the medulla does not increase production/secretion of adrenaline and noradrenaline. Only In labour do the adrenals secrete more adrenaline/noradrenaline.
HUMAN CORIONIC GONADOTROPIN (hCG) is produced in huge amounts by syncytiotrophoblasic cells within days of conception and can be detected within 8-10 days. They form the basis of all pregnancy tests. The function of hCG appears to be to maintain the corpus luteum until the placenta is developed enough to take over hormone production, which happens at 8 weeks. This theory is supported by the fact that levels of hCG peak at 8-10 weeks then decrease. hCG also has a thyrotropic effect, however this is not normally significant unless there are huge amounts of hCG, for example in molar pregnancies.
HUMAN PLACENTAL LACTOGEN (hPL) is produced by the placenta in proportion to placental mass. It is similar in structure to growth hormone and prolactin, and although its true function is not yet known, it is known to have insulin resistant properties.
STEROID HORMONES are produced in large amounts by the placenta during pregnancy. Their effects are widespread and have been covered above however below is a brief overview
OESTROGENS – are produced from androgen precursors and in pregnancy are mainly involved in preparing the uterus for labour.
PROGESTERONES – Are produced mainly from cholesterol, and relax smooth muscle, maintain uterine quiescence (cells grow not divide), and softens ligaments in order to make delivery of the baby easier.