Electrolyte and Mineral Metabolism

During normal pregnancy, nearly 1000 mEq of sodium and 300 mEq of potassium are retained
(Lindheimer and colleagues, 1987). Although the glomerular filtration of sodium and potassium
is increased, the excretion of these electrolytes is unchanged during pregnancy as a result of
enhanced tubular resorption (Brown and colleagues, 1986, 1988). And although there are
increased total accumulations of sodium and potassium, their serum concentrations are decreased
slightly because of expanded plasma volume (see Appendix). Still, they remain very near the
range of normal for nonpregnant women (Kametas and colleagues, 2003b).
Total serum calcium levels decline during pregnancy, the reduction reflecting lowered plasma
albumin concentration and, in turn, the consequent decrease in the amount bound to protein.
Levels of serum ionized calcium, however, remain unchanged (Power and associates, 1999). The
developing fetus imposes a significant demand on maternal calcium homeostasis. For example,
the fetal skeleton accretes approximately 30 g of calcium by term, 80 percent of which is
deposited during the third trimester. This demand is largely met by a doubling of maternal
intestinal calcium absorption mediated, in part, by 1,25-dihydroxyvitamin D3 (Kovacs and
Fuleihan, 2006). In addition, dietary intake of sufficient calcium is necessary to prevent excess
depletion from the mother (see Table 8-7). This is especially important in pregnant adolescents,
in whom bones are still developing (Repke, 1994).
Serum magnesium levels also decline during pregnancy. Bardicef and colleagues (1995)
concluded that pregnancy is actually a state of extracellular magnesium depletion. Compared
with nonpregnant women, they found that both total and ionized magnesium were significantly
lower during normal pregnancy. Serum phosphate levels are within the nonpregnant range
(Kametas and colleagues, 2003b). The renal threshold for inorganic phosphate excretion is
elevated in pregnancy due to increased calcitonin (Weiss and colleagues, 1998).
With respect to most other minerals, pregnancy induces little change in their metabolism other
than their retention in amounts equivalent to those needed for growth (see Chap. 4, Ions and
Trace Metals, and Chap. 8, Minerals). An important exception is the considerably increased
requirement for iron, which is discussed subsequently.
Hematological Changes
Blood Volume
The well-known hypervolemia associated with normal pregnancy averages 40 to 45 percent
above the nonpregnant blood volume after 32 to 34 weeks (Pritchard, 1965; Whittaker and
associates, 1996). In individual women, expansion varies considerably. In some there is only a
modest increase, whereas in others the blood volume nearly doubles. A fetus is not essential for
this because increased blood volume develops in some women with hydatidiform mole
(Pritchard, 1965).

Pregnancy-induced hypervolemia has important functions:

1. To meet the metabolic demands of the enlarged uterus with its greatly hypertrophied
vascular system.
2. To provide an abundance of nutrients and elements to support the rapidly growing
placenta and fetus.
3. To protect the mother and in turn the fetus, against the deleterious effects of impaired
venous return in the supine and erect positions.
4. To safeguard the mother against the adverse effects of blood loss associated with
parturition.
Maternal blood volume begins to increase during the first trimester. By 12 menstrual weeks,
plasma volume expands by approximately 15 percent compared with that of prepregnancy
(Bernstein and co-workers, 2001). As shown in Figure 5-5, maternal blood volume expands most
rapidly during the second trimester. It then rises at a much slower rate during the third trimester
to plateau during the last several weeks of pregnancy.