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Physiologic Changes in Pregnancy PowerPoint Presentation

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Slide 1 - Physiologic Changes in Pregnancy Thomas S. Ivester, MD, MPH Maternal-Fetal Medicine
Slide 2 - Why should this matter to me???
Slide 3 - Relevance of OB physiology 5-10 % of women in ER are pregnant Many don’t know or show Any female of reproductive age could be pregnant Should be assumed so! Virtually every organ system affected Can touch almost any specialty
Slide 4 - Case history
Slide 5 - Case 1 36 y.o. female presents to ER CC: Fatigue, dyspnea, chest pain HPI: Progressive SOB and dyspnea over several weeks. Poor exercise tolerance and easy fatigability ‘get winded after 1 flight of stairs’ Substernal chest pain, peaks in morning and night Nocturnal cough, semi-productive – clear Leg swelling polyuria
Slide 6 - Case 1 PMH Mild obesity Ob/gyn – menses at age 12; irregular menses; no pregnancies Meds Oral contraceptives multivitamins Social Married for 2 years. No exposures
Slide 7 - Case 1: PE Skin warm, clammy. Mild facial acne and increased hair – medium coarseness HEENT NC/AT. Nasal mucosa slightly hyperemic. Mild non-nodular thyromegaly CV Tachycardia (HR 107) + JVD 2/6 systolic murmurs over pulmonic and aortic v.
Slide 8 - PE cont’d Chest Clear bilaterally. Diaphragm elevated with decreased excursion Ext 1+ pretibial pitting edema Abd Skin – spider angiomata and striae. Medium course hair, infraumbilical. Distended, firm, non-tender.
Slide 9 - Studies / labs EKG: Sinus rhythm; tachy; Left axis deviation CXR: Lungs clear. Cardiomegaly. Increased vascular markings Labs: Hct 32% (low); WBC 12 (high) Cholesterol 300 mg/dl D-dimer elevated Potassium and creatinine low
Slide 10 - What does she have???
Slide 11 - General Principles Most changes begin early Even before pregnancy recognized Most are hormonally driven Progesterone, estrogen, renin / aldosterone, cortisol, insulin Some ‘mechanically’ driven Designed to optimize conditions for fetus & prepare for delivery Delivery of oxygen & nutrients
Slide 12 - Cardiovascular & Hematologic Vascular Decreased tone / vaso-relaxation SVR decreased 20% Positional effects Placenta – low resistance shunt Hematologic Blood volume increases 50-100% RBC increases 25-40% Relative anemia (“physiologic”)
Slide 13 - ppt slide no 13 content not found
Slide 14 - Hematologic Hypercoagulable Estrogen & Vascular stasis Increased risk for thromboembolic disease Increase in fibrinogen, all coag factors except II, V, XII Fall in protein S and sensitivity to APC Fall in platelets and factor XI and XIII Increase in WBC
Slide 15 - Changes in the Pump Cardiac axis displaced cephalad and left PMI lateral & elevated (not just due to baby!) Altered thoracic dimensions Left axis deviation Murmurs > 96% Virtually all valves Esp. Aortic and Pulmonary Mammary Souffle Rate – increased (80’s typical) Ventricular distention – 25% increase
Slide 16 - More changes in the Pump Rhythm Non-specific ST & T changes Increase in dysrhythmias Physiologic hypokalemia Anatomy LVH & Pericardial effusion Function Increased & markedly fluctuating output
Slide 17 - ppt slide no 17 content not found
Slide 18 - Blood Pressure 50 55 60 65 70 75 8 to 16 20 to 25 28 to 35 36 to 40 Normal Normal Weeks (Benedetto et al, Obstet Gynecol, 1996)
Slide 19 - Pregnancy Adaptations
Slide 20 - Anatomical considerations
Slide 21 - Uterine Position over Time
Slide 22 - ppt slide no 22 content not found
Slide 23 - Cardiac Output – Positional Effects Aorto-caval Compression <23 wks - No change 24-28 wks - Decrease by 8% 29-32 wks - Decrease by 14% 33-term - Decrease by 25%
Slide 24 - Labor Changes SVR – Increased 10-25% with CTX Volume – autotransfusion 300-500cc Cardiac output - <3cm Increased 17% 4-7cm Increased 23% >8cm Increased 34% Changes over pregnancy baseline CO.
Slide 25 - The Fetus and Placenta Fetus (aka – “the parasite”) A sensitive survivor A window Placenta A veritable hormone factory Receives 20-25% of cardiac output* 750-1000 ml/min Refractory to vasoactive meds Uses as much O2 as fetus
Slide 26 - Normal physiology or disease?
Slide 27 - Signs & Symptoms of Normal Pregnancy that may Mimic Heart Disease Signs Peripheral edema JVD Symptoms Reduced exercise tolerance Dyspnea Auscultation S3 gallop Systolic ejection murmur Chest x-ray Change in heart position & size Increased vascular markings EKG Nonspecific ST-T wave changes Axis deviation LVH
Slide 28 - Other systems
Slide 29 - Changes in the Filter Renin – stimulated by progesterone Also made by placenta Angiotensinogen Angiotensin I Angiotensin II Aldosterone Distal tubule Net absorption of Na+ Excretion of K+ Water retention: 6-8 liters Increased renal blood flow 50-75% increase GFR – 50% increase Decreased Albumin = lower colloid oncotic pressure
Slide 30 - Other urinary tract changes Ureteral dilation / hydroureter Smooth muscle relaxation Later exacerbation by uterine obstruction Urinary stasis* Dilation of pelves and calyces Increased kidney size
Slide 31 - Lungs and respiration
Slide 32 - Respiratory Adaptations No change in rate or IRV Thorax Tr. Diameter 2cm; circumference 5-7cm Increased minute ventilation Reduced FRC – 20% Increased Tidal Volume – 30-40% Compensated respiratory alkalosis pH 7.4+ PaO2; PaCO2 (40 – 30) Drives gradient b/w mom and fetus
Slide 33 - Respiratory Changes
Slide 34 - Gastrointestinal Slowed GI motility Constipation, early satiety Relaxation of LES GERD Nausea / vomiting Often proportional to HCG level Liver / gallbladder Biliary stasis, cholesterol saturation More stones Coagulation factors Increased binding proteins (thyroid, steroid, vitamin D)
Slide 35 - Other “Adaptations” “I can’t see my feet!!!” Altered center of gravity Altered gait Greater joint laxity Widening of symphysis pubis Affects other joints Thorax; widened costovertebral angle Fatigue / somnolence
Slide 36 - Integumentary Changes Spider angiomata and palmar erythema Hair growth (abdomen and face) Mucosal hyperemia Striae gravidarum Hyperpigmentation (esp. linea nigra) Rashes and acne relatively common
Slide 37 - Other Endocrine Pancreas Carbohydrate metabolism -Insulin resistance Human placental lactogen, cortisol Thyroid Function Increased TIBG (via liver) Increased total T4 and T3 free levels unchanged HCG suppresses TSH Adrenal function Free plasma cortisol is elevated CRH from placenta stimulates ACTH
Slide 38 - Immunology Must adapt to accept ‘allograft’ Immune response altered, but not deficient Modulates away from cell-mediated cytotoxic effects Progesterone effect NK cells decrease by 30% Enhanced humoral / innate immunity Immunoglobulins still active IgG crosses placenta More susceptible to CMV, HSV, Varicella, Malaria Decrease in symptoms of some autoimmune disorders
Slide 39 - Pregnancy – not a disease Profound changes in physiology and anatomy Affects most organ systems Can dramatically impact disease states, susceptibility, and treatment Almost all will encounter and treat pregnant women Even if you don’t know it Under-appreciation of changes will lead to suboptimal treatment or outright mistakes
 

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