Chapter 4 Maternal Physiology
Chapter 4 Maternal Physiology
These remarkable changes begin soon after fertilization and continue Intensity varies between approximately 5 -25 mm Hg
throughout gestation Last several weeks of pregnancy, these Braxton contractions are infrequent
Most occur in response to physiological stimuli provided by the fetus and Number increases during the last week or two.
placenta Uterus may contract as often as every 10-20 minutes and with some
Woman who was pregnant is returned almost completely to her prepregnancy degree of rhythmicity.
state after delivery and lactation Low and uncoordinated patterns early in gestation, which become progressively
Cardiovascular changes during pregnancy normally include substantive more intense and synchronized by term
increases in blood volume and cardiac output, which may mimic thyrotoxicosis Late in pregnancy, contractions may cause some discomfort and account for so-
Same adaptations may lead to ventricular failure during pregnancy if there is called False Labor
underlying heart disease.
Uteroplacental Blood Flow
REPRODUCTIVE TRACT Delivery of most substances essential for fetal and placental growth,
Uterus metabolism, and waste removal is dependent on adequate perfusion of the
Nonpregnant woman: placental intervillous space
Uterus weighs 70 g Placental perfusion is dependent on total uterine blood flow
Almost solid, except for a cavity of 10 ml or less Uteroplacental blood flow increase progressively during pregnancy
During pregnancy: 450-650 ml/min near term
Uterus is thin-walled muscular organ sufficient to accommodate the fetus, Blood flow in the entire circulation of a nonpregnant woman is
placenta, and amnionic fluid. approximately 5000 ml/min.
Total volume of the contents at term averages approximately 5 L but may Uterine veins also significantly adapt during pregnancy
be > 20 L. Reduced elastin content and adrenergic nerve density.
End of pregnancy: uterus is 500-1000 times greater than in the nonpregnant Increased venous caliber and distensibility.
state Necessary to accommodate the massively increased uteroplacental blood
Increase in uterine weight by term, organ weighs nearly 1100 g. flow.
Uterine enlargement involves stretching and hypertrophy of muscle cells, Uterine contractions, either spontaneous or induced, caused a decrease in
whereas the production of new myocytes is limited. uterine blood flow that was approximately proportional to the contraction
Increase in myocyte size intensity.
Accumulation of fibrous tissue (external muscle layer) Tetanic contraction caused a precipitous fall in uterine blood flow.
Increase in elastic tissue content adds strength to the uterine wall. Uterine contractions appear to affect fetal circulation much less
Walls of the corpus become thicker during the first few months of pregnancy; Uteroplacental blood flow regulation
they then begin to thin gradually. Maternal-placental blood flow progressively increases during gestation by
By term, myometrium is only 1-2 cm thick. means of vasodilation
Later months, the uterus is changed into a muscular sac with thin, soft, readily Uterine artery diameter doubled by 20 weeks and concomitant mean
indentable walls through which the fetus usually can be palpated. Doppler velocimetry was increased eightfold.
Uterine hypertrophy early in pregnancy is stimulated by estrogen and Slight diameter increases in the uterine artery produces a
progesterone. tremendous blood flow capacity increase
Hypertrophy of early pregnancy does not occur entirely in response to Vessels that supply the uterine corpus widen and elongate while
mechanical distention by the products of conception, because similar preserving contractile function.
uterine changes are observed with ectopic pregnancy Spiral arteries, which directly supply the placenta, widen but completely
After 12 weeks, uterine size increase is related to pressure exerted by the lose contractility.
expanding products of conception. Results from endovascular trophoblast invasion that destroys the
Uterine enlargement is most marked in the fundus. intramural muscular elements
Early pregnancy months, the fallopian tubes and the ovarian and round Vasodilation during pregnancy is the consequence of estrogen stimulation
ligaments attach only slightly below the apex of the fundus. 17-estradiol promote uterine artery vasodilation and reduce uterine
Later months, they located slightly above the middle of the uterus. vascular resistance
Position of the placenta influences the extent of uterine hypertrophy. Contribute to the downstream fall in vascular resistance in women with
Portion of the uterus surrounding the placental site enlarges more rapidly advancing gestational age
than does the rest. Estradiol
Progesterone
Myocyte Arrangement Relaxin
Uterine musculature during pregnancy is arranged in three strata. Downstream fall in vascular resistance leads to an acceleration of flow velocity
a) Outer Hoodlike Layer and shear stress in upstream vessels.
Arches over the fundus and extends into the ligaments. Shear stress leads to circumferential vessel growth
b) Middle layer Nitric Oxide play a key role regulating this process
Composed of a dense network of muscle fibers perforated in all Potent vasodilator
directions by blood vessels. All augment Endothelial Nitric Oxide Synthase (ENOS)
c) Internal layer Nitric Oxide production
Sphincter-like fibers around the fallopian tube orifices and internal Endothelial Shear Stress
cervical os. Estrogen
Most of the uterine wall is formed by the middle layer. Placental Growth Factor (PlGF)
Each cell has a double curve that the interlacing of any two gives approximately Vascular Endothelial Growth Factor (VEGF)
the form of a figure eight. Promoter of angiogenesis
Arrangement is crucial because when the cells contract after delivery, they VEGF and PlGF signaling is attenuated in response to excess placental
constrict penetrating blood vessels and thus act as ligatures secretion of their soluble receptor (soluble FMS-like tyrosine kinase 1 (sFlt-1))
Increased maternal sFlt-1 levels inactivate and decrease circulating PlGF
Uterine Size, Shape, and Position and VEGF concentrations
First few weeks, uterus maintains its original piriform or pear shape. Important factor in preeclampsia pathogenesis.
As pregnancy advances, corpus and fundus become more globular and Refractoriness to the pressor effects of infused angiotensin ii and
almost spherical by 12 weeks gestation. norepinephrine
Organ increases more rapidly in length than in width and assumes an Insensitivity serves to increase uteroplacental blood flow
ovoid shape. Relaxin may help mediate uterine artery compliance
End of 12 weeks, the uterus has become too large to remain entirely within the Large-conductance potassium channels expressed in uterine vascular smooth
pelvis. muscle also contribute to uteroplacental blood flow regulation through several
As the uterus enlarges, it contacts the anterior abdominal wall, displaces the mediators, including estrogen and nitric oxide
intestines laterally and superiorly, and ultimately reaches almost to the liver. Placental perfusion decrease likely results from greater uteroplacental vascular
With uterine ascent from the pelvis, it usually rotates to the right (dextrorotation) bed sensitivity to epinephrine and norepinephrine compared with that of the
Caused by the rectosigmoid on the left side of the pelvis. systemic vasculature.
As the uterus rises, tension is exerted on the broad and round ligaments.
With the pregnant woman standing, longitudinal axis of the uterus Cervix
corresponds to an extension of the pelvic inlet axis. As early as 1 month after conception, the cervix begins to undergo pronounced
Abdominal wall supports the uterus and maintains relation between softening and cyanosis.
the long axis of the uterus and the axis of the pelvic inlet. These changes result from increased vascularity and edema of the entire
When the pregnant woman is supine, uterus falls back to rest on the cervix, together with hypertrophy and hyperplasia of the cervical glands
vertebral column and adjacent great vessels. Although the cervix contains a small amount of smooth muscle, its major
component is connective tissue.
Uterine Contractility Rearrangement of this collagen-rich connective tissue is necessary to
Early pregnancy, uterus undergoes irregular contractions that are normally permit functions as
painless (Braxton Hicks Contraction) Maintenance of a pregnancy to term
During the second trimester, contractions may be detected by bimanual Dilatation to aid delivery
examination. Repair following parturition so that a successful pregnancy can be
Contractions appear unpredictably and sporadically repeated
Carbohydrate metabolism
Normal pregnancy is
characterized by
Mild fasting
hypoglycemia
METABOLIC CHANGES Postprandial
In response to the increased demands of the rapidly growing fetus and placenta, hyperglycemia
the pregnant woman undergoes metabolic changes Hyperinsulinemia
By the third trimester, maternal basal metabolic rate is increased by 10-20% Increased basal level of plasma insulin in normal pregnancy is associated with
compared with that of the nonpregnant state. several unique responses to glucose ingestion
This is increased by an additional 10% in women with a twin gestation After an oral glucose meal, gravid women demonstrate prolonged
Additional total pregnancy energy demands associated with normal pregnancy hyperglycemia and hyperinsulinemia as well as a greater suppression of
are approximately 77,000 kcal or 85 kcal/day, 285 kcal/day, and 475 kcal/day glucagon
during the first, second, and third trimester, respectively Cannot be explained by an increased metabolism of insulin because its
Increased caloric requirements and increased energy demands were also half-life during pregnancy is not changed
compensated for by normal pregnant women gravitating to less physically This response is consistent with a pregnancy-induced state of peripheral
demanding activities. insulin resistance
To ensure a sustained postprandial supply of glucose to the fetus.
Insulin sensitivity in late normal pregnancy is 45-70% lower than that of
nonpregnant women
Insulin resistance
Progesterone and estrogen may act, directly or indirectly, to
mediate this insensitivity.
RESPIRATORY TRACT
Abnormally increased sensitivity was an alteration in vessel wall refractoriness Diaphragm rises about 4 cm during pregnancy
rather than the consequence of altered blood volume or renin-angiotensin Subcostal angle widens appreciably as the transverse diameter of the thoracic
secretion. cage lengthens approximately 2 cm.
Vascular responsiveness to angiotensin II may be progesterone related. Thoracic circumference increases about 6 cm, but not sufficiently to prevent
Normally, pregnant women lose their acquired vascular refractoriness to reduced residual lung volumes created by the elevated diaphragm.
angiotensin II within 15- 30 minutes after the placenta is delivered. Diaphragmatic excursion is greater in pregnant than in nonpregnant women.
Large amounts of intramuscular progesterone given during late labor
delay this diminishing refractoriness.
Eyes
Intraocular pressure decreases during pregnancy
Attributed in part to increased vitreous outflow
Corneal sensitivity is decreased
Greatest changes are late in gestation.
Most pregnant women demonstrate a measurable but slight increase in corneal
thickness, thought to be due to edema.
Difficulty with previously comfortable contact lenses
Brownish-red opacities on the posterior surface of the cornea (Krukenberg
spindles)
Have been observed with a higher than expected frequency during
pregnancy.
Hormonal effects similar to those observed for skin lesions are postulated
to cause this increased pigmentation.
Transient loss of accommodation reported with both pregnancy and lactation,
visual function is unaffected by pregnancy.
Sleep
Beginning as early as approximately 12 weeks gestation and extending through
the first 2 months postpartum, women have difficulty with going to sleep,
frequent awakenings, fewer hours of night sleep, and reduced sleep efficiency
Frequency and duration of sleep apnea episodes were reported to be decreased
significantly in pregnant women compared with those postpartum
In the supine position, however, average Pao2 levels were lower.
Greatest disruption of sleep is encountered postpartum and may
contribute to postpartum blues or to frank depression