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Physiological changes in pregnancy

Article  in  Drug Invention Today · August 2018

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 Review Article

Physiological changes in pregnancy

J. A. Shagana1, M. Dhanraj1, Ashish R. Jain1, T. Nirosa2

ABSTRACT

Physiological changes occur in pregnancy to upbringing the developing fetus and prepare the mother for labor and delivery.
Early changes result in metabolic demands, increasing levels of pregnancy hormones, particularly those of progesterone
and estrogen. Later changes starting in midpregnancy are caused from the expanding uterus by mechanical pressure. During
pregnancy, some changes in maternal physiology can occur including increased maternal fat, blood volume, cardiac output,
and blood flow to the kidneys and uteroplacental unit, decreased blood pressure, delayed gastrointestinal motility, and gastric
emptying. These alterations are essential to optimize fetus and mother health.

KEY WORDS: Body weight, Fetal growth, Physiological changes, Pregnancy and uterus

INTRODUCTION CHANGES IN UTERUS

Pregnancy is a unique period during a women’s life Uterus provides a nutritive and protective environment
which is characterized by complex physiological and in which the fetus will grow and develop after
hormonal changes. Pregnancy is a normal condition conception. It increases from the size of a small pear in
and simultaneously the most common altered its non-pregnant state to accommodate a full-term baby
physiologic state to which human beings are subject at 40 weeks of gestation. The tissues from which the
to changes. The physiological changes are begin after uterus is made continue to grow for the first 20 weeks,
conception and affect every organ system in the body and it increases in weight from about 50–1000 grams.
and also help the women to adapt the pregnant state After this time, it does not get any heavier, but it
and to aid fetal growth. Many of these alterations stretches to accommodate the growing baby, placenta,
and amniotic fluid. By the time, the pregnancy has
significantly affect the pharmacokinetics (absorption,
reached full term, the uterus will have increased to
distribution, metabolism, and elimination) and
about 5  times its normal size in height from 7.5 to
pharmacodynamics properties of different therapeutic
30 cm, in width from 5 to 23 cm, and in depth from
agents.[1] These changes resolve after pregnancy with
2.5 to 20 cm. Softening and compressibility of lower
minimal residual effects in uncomplicated pregnancy. uterine segment occurs at approximately 6  weeks
Such anatomical and physiological changes may cause of gestation which is called Hegar sign. As uterus
confusion during clinical examination of pregnant increase in size, blood flow also increases. The weight
woman. During pregnancy, some changes in blood of the fetus, the enlarged uterus, the placenta, and the
biochemistry may create difficulties in interpretation amniotic fluid, together with the increasing curvature
of results. To improve maternal and fetal outcome, of her back, put a large strain on the woman’s bones
the pathological deviations in these anatomical and and muscles. As a result, many pregnant women get
physiological changes should be recognized.[2] back pain.[3]

CHANGES IN THE BODY WEIGHT

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Continuing weight increase in pregnancy is considered
to be one favorable indication of maternal adaptation

1
Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Chennai, Tamil Nadu,
India, 2Department of Public Health Dentistry, Saveetha Dental College and Hospital, Saveetha, University, Chennai,
Tamil Nadu, India

*Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha
University, Ponamalle High Road, Chennai - 600 127, Tamil Nadu, India. Phone: +91-9884233423. E-mail: dr.ashishjain_r@
yahoo.com

Received on: 06-02-2018; Revised on: 09-04-2018; Accepted on: 18-05-2018

1594 Drug Invention Today | Vol 10 • Issue 8 • 2018

 J. A. Shagana, et al.

and fetal growth. There can be a slight loss of weight resistance and peripheral resistance. Heart rate is
during early pregnancy if the woman experiences increased maximally by the second trimester, but
much nausea and vomiting (often called “morning there is no further change in the third trimester.[12]
sickness”). The expected increase in weight of a Stroke volume is increased at 8 weeks gestation and
healthy woman in an average pregnancy, where there increased much higher by the end of the second
is a single baby is about 2.0  kg in total in the first trimester, then remains level until term. Systolic blood
20  weeks, then approximately 0.5  kg per week until pressure does not drop or slightly changed. However,
full term at 40 weeks and a total of 9–12 kg during the there is a marked drop in diastolic blood pressure and
pregnancy. A woman who is pregnant with more than also decreases in venous return.[13]
one baby will have a higher weight gain than a woman
with only one fetus. She will also require a higher RESPIRATORY CHANGES
calorie diet. A lack of significant weight gain may not
be a cause for concern in some women, but it could be Changes in respiratory system in pregnancy start as early
an indication that the fetus is not growing properly.[4] as the 4th week of gestation. There is slight increase in
respiratory rate. Minute ventilation is increased which
HEMATOLOGICAL CHANGES is mainly due to increased tidal volume.[14] Dead
volume of lungs increases due to relaxation of muscles
In pregnancy, maternal physiological adjustments in conducting passageways. Total capacity decreases
support the requirements of fetal hemostasis. During due to encroachment by diaphragm. Also there is
pregnancy, the normal values for many hematologic, Increased alveolar ventilation without any change in
biochemical, and physiologic indices differ from anatomical dead space.[15] Increased progesterone can
those in non-pregnant range.[5] Throughout normal decrease threshold of medullary respiratory center to
pregnancy, plasma volume increases progressively. carbon dioxide. Functional residual capacity, residual
The increase starts at around 6 weeks’ gestation and volume, and expiratory reserve volume are decreased
reaches a maximal volume by 32  weeks gestation. at term. Inspiratory capacity and inspiratory reserve
A rapid increases in blood volume until midpregnancy, volume are increased.[16] There is no change in vital
with a slower increases thereafter.[6] Plasma volume capacity. Due to increased chest circumference, the
increases significantly much higher, which leads total lung capacity is reduced slightly even with the
to “physiologic anemia” of pregnancy. There is a presence of elevation of diaphragm.[17]
fall in hematologic concentration, increased white
and red blood cell counts, and no change in mean RENAL CHANGES
corpuscular volume or mean corpuscular hemoglobin
concentration.[7] The platelet count itself is relatively Renal pelvis and uterus are dilated which lead to
unchanged, although the platelet volume may be increase in urinary stasis and increase the chance
increased. Iron demands increase in later gestation of infection.[18] During pregnancy, the glomerular
and supplementation of iron is needed to avoid iron filtration rate is increased due to increased renal
depletion.[8] Nearly, all the procoagulants are increased plasma flow. Due to increased filtration rate, there is
in pregnancy so that patient is hypercoagulable as the decreased plasma blood urea nitrogen and creatinine
gestation progresses. There is increase in fibrinogen concentration.[19] Serum concentrations of certain
and factor VIII and slower increases in factors VII, drugs are lower during pregnancy because of both
IX,  X, and XII. Fibrinolytic activity is diminished expanded blood volume and increased glomerular
during pregnancy by unknown mechanism. In filtration rate.[20] There are no changes in urinal output
proportion to fibrinogen, plasminogen level increased. during pregnancy but require increase efficiency in the
Clotting and lysing activities are balanced. It take urinary system. Glucose and amino acids might not
about 8 weeks after delivery for the blood volume to be absorbed; hence, glucose Rica and aminoaciduria
return back to normal.[9] may develop in normal gestation.[21] Glucosuria is
not abnormal with no change increases in capacity to
CARDIOVASCULAR CHANGES resorb sugar due to increased filtration rate. There is
increased renin secretion and prostaglandin synthesis
There are numerous changes in the cardiovascular in pregnancy. These changes are return to normal by
system during pregnancy. The heart is displaced the 6th week of delivery.[22]
upward, slightly to the left due to increased size of
the uterus in pregnancy so that there is an increased GASTROINTESTINAL CHANGES
capacity of the heart.[10] Cardiac output is increased
in pregnancy and attained maximal increase around During Pregnancy there is Increased nutritional
24  weeks gestation. It is one of the most important requirements, increased maternal appetite and morning
maternal changes.[11] There are increased heart rate sickness. Gastrointestinal motility, lower esophageal
and stroke volume and decreased systemic vascular pressure, and food absorption are decreased during

Drug Invention Today | Vol 10 • Issue 8 • 2018 1595

 J. A. Shagana, et al.

pregnancy due to an increased level of plasma and follicular-stimulating hormone (FSH). Plasma
progesterone.[23] On the other hand, intragastric FSH levels recover within 2  weeks of delivery, but
pressure is increased during the third trimester of pulsatile luteinizing hormone release is only resumed
pregnancy. Gastric emptying time of solid and liquid in women who do not breastfeed. In suckling mothers,
material is not changed during pregnancy but slower prolactin inhibits gonadotropin-releasing hormone
during labor and hence gastric volume us increased. and hence LH.[25]
Due to decreased plasma gastric concentration, there
is reduction in the total acid content of the stomach and Metabolic Changes
increased serum alkaline phosphatase. Gallbladder Fluid balance
function and emptying during pregnancy, hence, An underfilled state stimulates the renin-angiotensin-
pregnant woman may prone to gallstone problems.[23] aldosterone system which is created by arterial
dilatation. As a result, sodium and water retention
ENDOCRINE CHANGES throughout pregnancy leads to a 6–8 l rise in total
extracellular fluid volume. Plasma volume increases
Thyroid Function
steadily until week 32 when it is 40% above non-
The thyroid faces three challenges during pregnancy. pregnant levels. This is partly mediated by a fall in the
First, increased renal clearance of iodide and losses to osmotic threshold for thirst, with a concomitant fall
the fetus create a state of relative iodine deficiency, such in the threshold for secretion of antidiuretic hormone
that pregnancy stimulates growth of thyroid goiters in (AVP) preventing a water diuresis and sustaining a low
geographical areas where dietary iodine intake is low. plasma osmolality until term. During the second half
of
Second, high estrogen levels induce hepatic synthesis pregnancy, placental production of vasopressinase
of thyroid binding globulin, but free thyroxine (T4) and increases maternal Arginine Vasopressin (AVP)
triiodothyronine (T3) levels still fall during pregnancy, degradation, but plasma AVP levels remain stable as
occasionally below the normal range for non-pregnant pituitary secretion of AVP normally increases 4-fold.
women. Thyroid-stimulating hormone (TSH) levels A failure of increased AVP secretion leads to transient
rise as pregnancy progresses but generally remain diabetes insipidus of pregnancy. Plasma atrial
within the normal range for non-pregnancy. Third, natriuretic peptide levels are normal until the second
placental human chorionic gonadotropin (hCG) shares trimester, when they rise by approximately 40%.[25]
structural similarities with TSH and has weak TSH-
like activity. Although hCG rarely stimulates free T4 Carbohydrate metabolism
levels into the thyrotoxic range, trophoblastic disease Glucose is the primary energy source of fetoplacental
and hyperemesis gravidarum are often associated with tissues. During early pregnancy, basal plasma
high hCG levels and can lead to hypothyroxinemia glucose and hepatic glucogenesis are unchanged.
and suppression of TSH. In these circumstances, the However, during late pregnancy, the mother develops
mother remains clinically euthyroid.[24] hypoglycemic (specifically under fasting). The
development of maternal hypoglycemia despite the
Pituitary Function enhanced glucogenesis and reduced consumption of
The maternal pituitary makes only a small contribution glucose by maternal tissues due to insulin resistant is
to a successful pregnancy once ovulation has occurred the result of high rate of placental transfer of glucose.
and the uterus is prepared for implantation. The The fetus does not synthesize glucose but uses it as
only pituitary hormone to increase significantly its oxidative substrate which causes fetal glycemia to
during pregnancy is prolactin, which is responsible be normally lower than its mother, allowing a positive
for breast development and subsequent milk maternal-fetal glucose gradient that facilitates its
production. Pituitary secretion of growth hormone placental glucose transfer.[24]
(GH) is mildly suppressed during the second half of
pregnancy by placental production of a GH variant, Protein metabolism
the role of which is unclear, but it may contribute to Protein is essential for fetal growth and must be
gestational insulin resistance. Placental production sustained by the active transfer of amino acids
of adrenocorticotropin hormone (ACTH) leads to an from maternal circulation. Protein metabolism
increase in maternal ACTH levels but not beyond the changes occur gradually throughout gestation so
normal range for non-pregnant subjects. Free cortisol that nitrogen conservation of fetal growth achieves
levels double and in the second half of pregnancy full potential during the last quarter of pregnancy.
may contribute to insulin resistance and striae Due to reduction in urinary nitrogen excretion as
gravidarum. High estrogen levels during pregnancy a consequence of decreased urea synthesis, there
stimulate lactotroph hyperplasia and result in pituitary is increased nitrogen retention in late pregnancy.
enlargement. These high levels, together with those Nitrogen balance is improved in late pregnancy which
of progesterone, suppress luteinizing hormone (LH) allowing a more efficient use of dietary proteins.

1596 Drug Invention Today | Vol 10 • Issue 8 • 2018

 J. A. Shagana, et al.

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favor nitrogen conservation, pregnancy is associated pregnancy. Clin Obstet Gynecol 1979;22:785-98.
8. Murphy JF, Newcombe RG, O’riordan J, Coles EC, Pearson JF.
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