Physiological Changes During Pregnancy

Physiological changes during pregnancy
During pregnancy and lactation, a number of changes occur throughout a
woman’s body, primarily to support the fetus during different stages of
development. Some of these changes may directly affect the manner and extent to
which a woman may be exposed to environmental agents, whereas other changes
may impact the distribution and metabolism of the agent once it enters the body
Maternal blood volume, plasma volume, red cell mass, white cell count, and
platelet production are all increased during pregnancy. The increase in blood
volume begins at about 6–8 weeks gestation and then continues to increase until
reaching a plateau at 30–34 weeks, with an overall typical blood volume increase
of 40–50% (although individual increases may range from 20 to 100%) (Simpson,
et al., 2007). Cardiac output (CO), which is a product of stroke volume (SV) and
heart rate (HR) (i.e., CO=SV × HR), increases significantly during pregnancy, with
the uterus, placenta, and breasts being the main target for most of the increase in
CO. Data show that the mean±SD (coefficient of variation) CO in l/h increases
from the pre-pregnancy value of 301±65 (22%) to 354±76 (22%), 386±75 (20%),
400±79 (20%), and 391±79 (20%) at 10, 20, 36, and 38 weeks of gestation,
respectively (Abduljalil, et al., 2012). Greater increases in blood and plasma

volume and CO are observed in twin and other multiple pregnancies (Roland, et
al., 2020).
Total body water increases gradually during pregnancy. Abduljalil et al.
(2012) conducted a meta-analysis of available total body water data. The analysis
shows that the mean±SD (coefficient of variation) of total body water in liters
increases from 31.67±4.6 (15%) before pregnancy to 35.22±1.65 (5%), 40.14±7.55
(19%), and 46.0±5.5 (13%) at 12, 25, and 40 weeks of gestation,
respectively. Approximately 3.5 l of the total body water is accounted for by the
water content of the fetus, placenta, and amniotic fluid at term. The expansions of
the maternal blood volume by 1500–1600 ml, plasma volume by 1200–1300 ml,
and red blood cells by 300–400 ml account for additional water. The remainder is
attributed to extravascular fluid, intracellular fluid in the uterus and breasts, and
expanded adipose tissue.
During pregnancy, several changes occur in the renal system. The kidneys
enlarge in size and weight increases due to increased renal vasculature, interstitial
volume, and urinary dead space, Changes are also observed as the maternal
anatomy changes to accommodate the growing fetus. This includes decreases in
the capacity of the bladder and increases in the frequency of urinary incontinence.
Renal blood flow increases 50–80% in the first trimester, then decreases by full
term (Roland, et al., 2020). The increase in renal blood flow results in increased
glomerular filtration rates in the range of 40–60% (Roland, et al., 2020). Creatinine
clearance also increases by 30–50%.
Both anatomical and physiological changes occur in the maternal respiratory
system during pregnancy to ensure adequate supply of oxygen to the developing
fetus. These include: increase in tidal volume (30–40%), increase in inspiratory
capacity (5–10%), increase in minute ventilation (30–50%), decrease in functional
residual capacity (20%), decrease in expiratory reserve volume (20–30%), decrease
in residual volume (20%), and a slight decrease in total lung capacity (5%), all of
which may potentially affect airborne exposures (Roland, et al., 2020).
The increase in progesterone levels during pregnancy results in a decrease in
intestinal tone and motility. The decrease in intestinal motility leads to an increase
in the absorption of nutrients such as calcium and iron, as well as other substances.
Calcium metabolism during pregnancy and lactation is a highly studied area.
Maternal calcium metabolism is adjusted during pregnancy and lactation to
enhance the transport of this mineral to the fetus without a long-term alteration in
the mother’s bones (Roland, et al., 2020). Pregnant women can be at risk years
after lead exposure due to mobilization of lead from the bone when calcium needs
increase in pregnancy. Two studies found limited evidence supporting the

hypothesis of lead mobilization from the bone during lactation , whereas others
found that breastfeeding practices and maternal bone lead were good predictors of
blood lead levels. Bone turnover is higher during the postpartum period. Therefore,
the blood lead concentration is shown to be highest 3–6 months after parturition.
This potential risk of lead exposure to the woman and the breastfeeding
infant is associated with very low (one half to two thirds the daily recommended
requirements) calcium intakes. It has also been shown that foods high in calcium
may have a protective effect against the accumulation of lead in bone (Fernández-
Buhigas, et al., 2020).
Dietary energy requirements increase during pregnancy, on average, by an
additional 200 kcal/day. Energy expenditure and preferential use of carbohydrates
is increased to support fetal growth and milk synthesis (Rooney et al., 2020). Butte
et al (1999) conducted a study of energy expenditures in 76 women (40 lactating
and 36 non-lactating) at 37 weeks gestation, and 3 and 6 months postpartum. Total
energy expenditure and its components (basal metabolic rate, sleeping metabolic
rate, and minimal sleeping metabolic rate) were observed to be 15–26% higher
during pregnancy than postpartum. During the postpartum period, total energy
expenditure and sleeping metabolic rate were higher in lactating than in non-
lactating women.
Maternal fat stores increase to a peak in the late second trimester and then
decline towards the end of gestation as a result of mobilization to support the
rapidly growing fetus (Rooney et al., 2020). The mean±SD (coefficient of
variation) total fat mass in kilograms increases from a pre-pregnancy mass of
17.14±6.6 (39%) to 19.07±6.7 (35%), 19.80±7.5 (38%), and 22.6±7.0 (31%) at
gestational weeks 13, 27, and 37, respectively. Blood plasma levels of lipids
(fats/triglycerides, fatty acids, and cholesterol) and lipoproteins also increase in
pregnancy, but by 8 weeks postpartum triglyceride levels return to pre-pregnancy
levels (including during lactation). During pregnancy, the combined effect of
endocrine, metabolic, mechanical, and blood flow alterations in the body cause a
woman’s skin to undergo substantial changes. Most of the changes are cosmetic in
nature and are therefore not harmful or associated with risks to the mother or
developing fetus. However, the blood flow changes during pregnancy can alter the
absorption of drugs through the skin (Rooney et al., 2020).

The references
Simpson, J. L., & Otano, L. (2007). Prenatal genetic diagnosis. Gabbe SG, Niebly JR, Simpson JL (Eds).
Obstetrics: Normal and Problem Pregnancy Churchill Livingstone. Elsevier, 5, 152-183.
Abduljalil, K., Furness, P., Johnson, T. N., Rostami-Hodjegan, A., & Soltani, H. (2012). Anatomical,
physiological and metabolic changes with gestational age during normal pregnancy. Clinical
pharmacokinetics, 51(6), 365-396.
Roland, M. C. P., Lekva, T., Godang, K., Bollerslev, J., & Henriksen, T. (2020). Changes in maternal
blood glucose and lipid concentrations during pregnancy differ by maternal body mass index and are
related to birthweight: A prospective, longitudinal study of healthy pregnancies. Plos one, 15(6),
e0232749.
Fernández-Buhigas, I., Brik, M., Martin-Arias, A., Vargas-Terrones, M., Varillas, D., Barakat, R., &
Santacruz, B. (2020). Maternal physiological changes at rest induced by exercise during pregnancy: A
randomized controlled trial. Physiology & behavior, 220, 112863.
Rooney, H. B., O’driscoll, K., O’doherty, J. V., & Lawlor, P. G. (2020). Effect of increasing dietary energy
density during late gestation and lactation on sow performance, piglet vitality, and lifetime growth of
offspring. Journal of animal science, 98(1), skz379.
Butte, N. F., Hopkinson, J. M., Mehta, N., Moon, J. K., & Smith, E. O. B. (1999). Adjustments in energy
expenditure and substrate utilization during late pregnancy and lactation. The American journal of clinical
nutrition, 69(2), 299-307.

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Physiological changes during pregnancy

During pregnancy and lactation, a number of changes occur throughout a

woman’s body, primarily to support the fetus during different stages of

which a woman may be exposed to environmental agents, whereas other changes

of 40–50% (although individual increases may range from 20 to 100%) (Simpson,

CO. Data show that the mean±SD (coefficient of variation) CO in l/h increases

respectively (Abduljalil, et al., 2012). Greater increases in blood and plasma

Total body water increases gradually during pregnancy. Abduljalil et al.

increases from 31.67±4.6 (15%) before pregnancy to 35.22±1.65 (5%), 40.14±7.55

(19%), and 46.0±5.5 (13%) at 12, 25, and 40 weeks of gestation,

respectively. Approximately 3.5 l of the total body water is accounted for by the

the maternal blood volume by 1500–1600 ml, plasma volume by 1200–1300 ml,

expanded adipose tissue.

anatomy changes to accommodate the growing fetus. This includes decreases in

clearance also increases by 30–50%.

Both anatomical and physiological changes occur in the maternal respiratory

system during pregnancy to ensure adequate supply of oxygen to the developing

fetus. These include: increase in tidal volume (30–40%), increase in inspiratory

capacity (5–10%), increase in minute ventilation (30–50%), decrease in functional

residual capacity (20%), decrease in expiratory reserve volume (20–30%), decrease

which may potentially affect airborne exposures (Roland, et al., 2020).

The increase in progesterone levels during pregnancy results in a decrease in

Calcium metabolism during pregnancy and lactation is a highly studied area.

Maternal calcium metabolism is adjusted during pregnancy and lactation to

increase in pregnancy. Two studies found limited evidence supporting the

Buhigas, et al., 2020).

Dietary energy requirements increase during pregnancy, on average, by an

additional 200 kcal/day. Energy expenditure and preferential use of carbohydrates

et al (1999) conducted a study of energy expenditures in 76 women (40 lactating

and 36 non-lactating) at 37 weeks gestation, and 3 and 6 months postpartum. Total

during pregnancy than postpartum. During the postpartum period, total energy

decline towards the end of gestation as a result of mobilization to support the

rapidly growing fetus (Rooney et al., 2020). The mean±SD (coefficient of

variation) total fat mass in kilograms increases from a pre-pregnancy mass of

17.14±6.6 (39%) to 19.07±6.7 (35%), 19.80±7.5 (38%), and 22.6±7.0 (31%) at

(fats/triglycerides, fatty acids, and cholesterol) and lipoproteins also increase in

pregnancy, but by 8 weeks postpartum triglyceride levels return to pre-pregnancy

levels (including during lactation). During pregnancy, the combined effect of

absorption of drugs through the skin (Rooney et al., 2020).

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