Maternal Adaptations to

Pregnancy
Marella Barcelon
Norelle Infante

September 8, 2020
 Table of Contents
01 07
Reproductive Tract Respiratory Tract
02 08
Breasts Urinary System
03 09
Skin Gastrointestinal Tract
04 10
Metabolic Changes Endocrine System
05 11
Hematological Changes Musculoskeletal System
06 12
Cardiovascular System Central Nervous System
 01
Reproductive Tract
I. Uterus
● Non-pregnant woman:
○ weighs approx. 70g
○ almost solid, except for a cavity of 10 mL or less
○ usually 2.5 cm thick
● During pregnancy:
○ weighs 1100g at term
○ transformed into a thin-walled muscular organ
■ becomes 1-2 cm thin
○ total volume of contents at term = 5L but may be 20L or more
I. Uterus
● Marked stretching &
hypertrophy of cells
○ stimulated by the
action of estrogen
and progesterone
○ uterine enlargement
is most marked in the
fundus
● Increase in fibrous &
elastic tissues
Uterine shape and position
● Early pregnancy:
○ uterus maintains its original piriform or pear shape.
● By 12 weeks AOG:
○ corpus and fundus become globular and almost spherical
○ grows more rapidly in length than in width and becomes
ovoid
● By the end of 12th week:
○ enlarged uterus extends out of the pelvis
○ Dextrorotation caused by the rectosigmoid on the left side
of the pelvis
Uterine contractility
● Early pregnancy: uterus contracts irregularly
● Near term:
○ Infrequent contractions, but rises during the last week
or two
○ uterus may contract as often as every 10 to 20 minutes
and with some degree of rhythmicity
II. Uteroplacental Blood Flow
● Delivery of most substances essential for fetal and placental
growth, metabolism, and waste removal requires adequate
perfusion to the placental intervillous space
● Placental perfusion depends on total uterine blood flow
● Increase in:
○ Vascular dilation
○ Blood flow
○ Nitric oxide and eNOS
II. Uteroplacental Blood Flow
● The downstream fall in vascular resistance leads to an
acceleration of flow velocity and shear stress in upstream
vessels.
● Caused by:
○ Endothelial shear stress
○ PIGF (placental growth factor)
○ VEGF (vascular endothelial growth factor)
○ Relaxin
III. Ovaries
● Ovulation ceases during pregnancy, and maturation of new
follicles is suspended.
● At 6-7 weeks of pregnancy:
○ single corpus luteum functions maximally which initially
provides the progesterone to the product of conception
while placenta is not yet present
● Corpus luteum secretes relaxin:
○ remodels reproductive tract tissues in preparation for the
pregnancy
○ renal hemodynamics
○ decrease serum osmolality
○ uterine artery compliance
IV. Cervix
● One month after conception:
○ cervix begins to soften and gain bluish tones due to
increased vascularity and edema of the entire cervix
● Cervical glands undergo marked proliferation
○ by the end of pregnancy, glands occupy up to one half of
the entire cervical mass
○ prompts an extension, or eversion, of the proliferating
columnar endocervical glands onto the ectocervical portion
IV. Cervix
● Endocervical mucosal cells produce copious amounts of
tenacious mucus that obstruct the cervical canal soon after
conception
○ rich in immunoglobulins and cytokines
○ may act as an immunological barrier to protect the uterine
contents against infection
IV. Cervix
● Beading - poor crystallization of cervical mucus when spread
and dried on a glass slide
● Ferning- arborization of crystals; observed as a result of
amniotic fluid leakage
● Arias Stella Reaction - endocervical gland hyperplasia and
hypersecretory appearance
 Changes in cervix

Beading Ferning Arias Stella

Reaction
V. Vagina and Perineum
● Greater vascularity and
hyperemia develop in the skin and
muscles of the perineum and
vulva
○ Chadwick sign- consists of a
dark bluish or violet color of
the vagina or cervical mucosa
as a result of increased blood
supply to the area
V. Vagina and Perineum
● Vaginal walls also undergo these alterations:
○ epithelial thickening
○ connective tissue loosening
○ smooth muscle cell hypertrophy
● Elevated volume of cervical secretions during pregnancy forms a
somewhat thick, white discharge
○ pH is acidic, varying from 3.5 to 6
 02
Breasts
Breasts
● Early pregnancy: breast tenderness and paresthesias
● After second month:
○ increased breast size
○ delicate veins are visible just beneath the skin
○ nipples are larger, more deeply pigmented, and more erectile
● After first few months:
○ areolae are broader and more deeply pigmented
■ Glands of Montgomery: hypertrophic sebaceous glands
which are located around the areola
03
Skin
I. Abdominal wall
● Striae gravidarum (stretch
marks)
○ Beginning after mid
pregnancy, reddish,
slightly depressed streaks
commonly develop in the
abdominal skin and some-
times in the skin over the
breasts and thigh
I. Abdominal wall
● Diastasis recti
○ When muscles of the
abdominal walls do not
withstand the tension of
the expanding pregnancy,
rectus muscles separate
in the midline
II. Hyperpigmentation
● Linea nigra
○ midline of the anterior
abdominal wall skin linea
alba—takes on dark
brown-black
pigmentation to form the
linea nigra
II. Hyperpigmentation
● Chloasma or melasma
gravidarum
○ mask of pregnancy
○ irregular brownish
patches of varying size
appear on the face and
neck
III. Vascular changes
● Angiomas (vascular spiders)
○ minute, red skin papules with radicles branching out from a
central lesion
○ common on the face, neck, upper chest, and arms
III. Vascular changes
● Palmar erythema
 04
Metabolic changes
I. Weight gain
II. Water metabolism
● Greater water retention is normal
● At term:
○ water content of fetus, placenta, and amniotic fluid =
approx. 3.5 L
○ another 3.0 L accumulates from expanded maternal blood
volume and from uterus and breast growth
● Edema in legs is caused by increased venous pressure below
the level of uterus caused by partial vena cava occlusion &
decreased interstitial colloid oncotic pressure
III. Protein metabolism
● Products of conception, the uterus, and maternal blood are
relatively rich in protein than fat or carbohydrate
● At term:
○ the normally grown fetus and placenta together weigh
about 4 kg and contain approximately 500 g of protein, or
about half of the total pregnancy increase, while the rest go
to uterus, breast and maternal blood as hemoglobin &
plasma proteins
● Amino acid concentrations are higher in the fetal than in the
maternal compartment
IV. Carbohydrate metabolism
● Normal pregnancy is characterized by mild fasting hypogly-
cemia, postprandial hyperglycemia, and hyperinsulinemia
○ pregnancy is a state of peripheral insulin resistance
○ ensures a sustained postprandial supply of glucose to the
fetus
● Pregnant women can change rapidly from a postprandial state
to a fasting state called accelerated starvation
V. Fat metabolism
● Lipids, lipoproteins & apolipoproteins are increased due to
increased insulin resistance & estrogen stimulation
● During late pregnancy, maternal hyperlipidemia is one of the
most consistent and striking changes of lipid metabolism
● Increased levels of VLDLs, LDLs and HDLs
VI. Electrolyte and Mineral Metabolism
● During normal pregnancy, nearly 1000 mEq of sodium and 300
mEq of potassium are retained
● Total serum calcium levels decrease during pregnancy
● Both total and ionized magnesium concentrations are
significantly lower during normal pregnancy (compared with
nonpregnant women)
● Iodine requirements increase during normal pregnancy
 05
Hematological changes
I. Blood volume
● Hypervolemia associated with normal pregnancy averages 40-45%
above the nonpregnant blood volume after 32-34 weeks' gestation
○ meets the metabolic demands of the enlarged uterus and its
greatly hypertrophied vascular system
○ provides abundant nutrients and elements to support the rapidly
growing placenta and fetus
○ protects the mother and fetus against the deleterious effects of
impaired venous return in the supine and erect positions
○ safeguards the mother against the adverse effects of parturition-
associated blood loss
Hemoglobin Concentration and Hematocrit
● Hemoglobin concentration and hematocrit decline slightly during
pregnancy
○ whole blood viscosity decreases
● At term: hemoglobin = 12.5 g/dL
II. Iron metabolism
● Iron requirement in pregnancy - 1000 mg
○ >300 mg go to fetus, placenta
○ >200 mg are obligatory losses
○ average increase in the total circulating erythrocyte volume (about
450 mL) requires another 500 mg
● Most iron is used during the latter half of pregnancy, the iron requirement
becomes large after midpregnancy and averages 6-7 mg/day
● half of iron stores is lost during puerperium
○ 500 mL is lost for single vaginal delivery
○ 1000 mL is lost for twin delivery or cesarean section
III. Immunological functions
● Pregnancy is associated with suppression of various humoral and
cell-mediated immunological functions to accommodate the “foreign”
fetus
○ suppression of T helper 1 & T cytotoxic cell
○ upregulation of T helper 2 cells
● Normal leukocyte counts during pregnancy can be higher than
nonpregnant values, and upper values approach 15,000/μL
IV. Coagulation and FIbrinolysis
● During normal pregnancy, coagulation and fibrinolysis are
augmented but remain balanced to maintain hemostasis
○ increased concentrations of all clotting factors except factors I
and III
● Resistance to activated protein C grows progressively
○ related to a concomitant drop in free protein S levels and greater
factor VIII concentrations
● Decrease in platelet concentrations - < 2.5th percentile
 06
Cardiovascular System
● First 8 weeks of pregnancy - changes in cardiac function
● 5th week - increase in cardiac output which reflects a reduced
systemic vascular resistance and an increased heart rate
● 6 to 7 weeks from LNMP - significantly lower brachial systolic blood
pressure, diastolic blood pressure, and central systolic blood pressure
● Increase in resting pulse rate to 10 bpm
● Plasma volume expansion (between 10 and 20 weeks) → increase in
preload → large left atrial volumes and ejection fractions
● Decrease in systemic vascular resistance and changes in pulsatile
arterial flow
 Heart
● Displaced to the left and upward and is rotated on its long
axis
● Apex is moved laterally from its usual position and produces a
larger cardiac silhouette in CXR
● Some degree of benign pericardial effusion which may
enlarge the cardiac silhouette
● ECG changes:
○ Slight left axis deviation due to altered heart position
○ Q waves in leads II, III, and avF
○ Flat or inverted T waves in leads III, V1-V3
 Heart
● Cardiac sounds:
○ Exaggerated splitting of S1 and increased loudness of
both components
○ No definite changes in the aortic and pulmonary
elements of the second sound
○ Loud, easily heard third sound
● 90% - systolic murmur intensified during inspiration or
expiration that disappeared shortly
● 20% - transient soft diastolic murmur
● 10% - continuous murmurs arising from the breast
vasculature
 Heart
● Expanding plasma volume is reflected by enlarging cardiac
end-systolic and end-diastolic dimensions
● Septal thickness or ejection fraction does not change
because of ventricular remodeling by left ventricular mass
expansion of 30-35% near term
● Stewart and colleagues, 2016:
○ Left ventricular mass increased significantly beginning at
26 to 30 weeks’ gestation continuing until delivery
○ Concentric and proportional to maternal size for both
normal and overweight women
○ Resolves within 3 months of delivery
Heart
 Cardiac Output
● Lateral recumbent position at rest
○ Cardiac output increases significantly beginning in early
pregnancy
○ Continues to rise and remains elevated during the remainder
of pregnancy
● Supine position
○ Large uterus compresses veins and diminishes venous
return from the lower body
○ May also compress the aorta
○ Cardiac filling is reduced and cardiac output lessened
● Standing
○ Cardiac output falls to the same degree as in the
nonpregnant woman
 Cardiac Output
● Multifetal pregnancies
○ Maternal cardiac output is augmented further by almost 20%
○ Left atrial and left ventricular end-diastolic diameters were also
longer due to augmented preload
○ Greater heart rate and inotropic contractility imply that
cardiovascular reserve is reduced
● First stage of labor
○ Cardiac output rises moderately
● Second stage
○ Appreciably greater with vigorous expulsive efforts
● After delivery
○ Pregnancy-induced increase is lost, at times dependent on
blood loss
Hemodynamic Function in Late Pregnancy
● Late pregnancy
○ Increases in heart rate, stroke volume, and cardiac output
○ Systemic vascular resistance, pulmonary vascular
resistance, and colloid osmotic pressure dropped
significantly
○ No change in pulmonary capillary wedge pressure and
central venous pressure
○ Although cardiac output rises, left ventricular function
remains similar to nonpregnant normal range
 Circulation and Blood Pressure
● Brachial artery pressure: sitting < lateral recumbent position
● Systolic blood pressure: lateral positions < either flexed sitting or supine positions
● Arterial pressure declines to a nadir at 24-26 weeks’ gestation and rises thereafter
● Diastolic pressure decreases more than systolic
 Circulation and Blood Pressure
● Significant decline in mean arterial pressure and arterial stiffness
○ Suggests that pregnancy confers a favorable effect on maternal
cardiovascular remodeling
■ Reduced risk of preeclampsia in subsequent pregnancies
● Antecubital venous pressure remains unchanged during pregnancy
● Venous blood flow in the legs is retarded during pregnancy
○ Due to occlusion of the pelvic veins and inferior vena cava by the
enlarged uterus
○ Returns to normal in lateral recumbent position and after delivery
○ Causes dependent edema and varicose veins in the legs and vulva,
as well as hemorrhoids
○ Deep vein thrombosis
 Circulation and Blood Pressure
● Supine Hypotension
○ 10% of women
○ Supine compression of the great vessels by the uterus
causes significant arterial hypotension (Supine Hypotensive
Syndrome)
○ Uterine arterial pressure and uterine blood flow are
significantly lower than that in the brachial artery
 Renin, Angiotensin II, and Plasma Volume
● All components of renin-angiotensin-aldosterone axis are increased in
normal pregnancy
● Renin - increased and is produced by both maternal kidney and placenta
● Angiotensinogen (renin substrate) - greater amounts are produced by both
maternal and fetal liver
○ Results from augmented estrogen production during normal
pregnancy
○ Important in first trimester blood pressure maintenance
● Pregnant women lose their acquired vascular refractoriness to angiotensin
II within 15-30 minutes after delivery of placenta
○ Progesterone related
○ Large amounts of IM progesterone given during late labor delay this
diminishing refractoriness
 Cardiac Natriuretic Peptides
● 2 species:
○ Atrial Natriuretic Peptides (ANP)
○ Brain Natriuretic Peptides (BNP)
■ Secreted by cardiomyocytes in response to chamber-wall
stretching
■ They regulate blood volume by provoking natriuresis, diuresis,
and vascular smooth muscle relaxation
■ Plasma levels maintained in the nonpregnant range
■ In severe preeclampsia, BNP levels are increased and is
caused by cardiac strain from increased afterload
 Prostaglandins
● Role in control of vascular tone, blood pressure, and sodium
balance
● Renal medullary prostaglandin E2 synthesis is markedly
elevated during late pregnancy and is presumed to be
natriuretic
● Prostacyclin (PGI2) levels increase during late pregnancy
○ Regulates blood pressure and platelet function
○ Helps maintain vasodilation during pregnancy
○ Deficiency is associated with pathological vasoconstriction
● Ratio of PGI2 to thromboxane in maternal urine and blood is
important in preeclampsia pathogenesis
 Endothelin
● Endothelin-1
○ Potent vasoconstrictor produced in endothelial and
vascular smooth muscle cells and regulates local vasomotor
tone
○ Production is stimulated by angiotensin II, arginine
vasopressin, and thrombin
○ Elevated levels play a role in preeclampsia
● Stimulate secretion of ANP, aldosterone, and catecholamines
 Nitric Oxide
● Potent vasodilator released by endothelial cells
● May modify vascular resistance
● Important mediator of placental vascular tone and
development
● Abnormal synthesis has been linked to preeclampsia
development
 07
Respiratory tract
● Diaphragm rises approximately 4 cm during pregnancy
● Subcostal angle widens as the transverse diameter of the thoracic
cage lengthens approximately 2 cm
● Thoracic circumference increases about 6 cm but not sufficiently to
prevent reduced residual lung volumes created by the elevated
diaphragm
● Diaphragmatic excursion is greater in pregnant than in nonpregnant
women
 Pulmonary function
● Functional Residual Capacity (FRC)
○ Decreases by 20-30% or 400-700 mL
■ Expiratory reserve volume : decreases 15-20% or 200-300mL
■ Residual Volume: decreases 20-25% or 200-400 mL
● FRC and residual volume decline progressively due to diaphragm
elevation
● Inspiratory Capacity - maximum volume that can be inhaled from FRC
○ Rises by 5-10% or 200-350mL
● Total Lung Capacity
○ Combination of FRC and inspiratory capacity
○ Unchanged or decreases by <5% at term
● Respiratory Rate
○ Unchanged
 Pulmonary function
● Tidal volume and resting minute ventilation
○ Increases significantly as pregnancy advances
● Causes of increased minute ventilation:
○ Enhanced respiratory drive due to stimulatory action of progesterone
○ Low expiratory reserve volume
○ Compensated respiratory alkalosis
○ Decreased plasma osmolality - not dependent on progesterone
● Pulmonary Function
○ Increased
■ Peak expiratory flow rate and airway conductance
○ Decreased
■ Total Pulmonary Resistance
○ Unchanged
■ Lung compliance, maximum breathing capacity, and forced/timed vital
capacity
Pulmonary function
 Oxygen Delivery
● Increased
○ Amount of oxygen delivered into the lungs by the increased
tidal volume exceeds oxygen requirements imposed by
pregnancy
○ Total hemoglobin mass
○ Total oxygen-carrying capacity
○ Cardiac output
○ Oxygen consumption - 20% during pregnancy (10% higher
in multifetal gestations); 40-60% during labor
● Decreased
○ Maternal arteriovenous oxygen
 Acid-Base Equilibrium
● Physiological dyspnea
○ Result from greater tidal volume that lowers the blood PCO2 slightly
and paradoxically causes dyspnea
○ Progesterone acts centrally where it lowers the threshold and raises
sensitivity of the chemoreflex response to CO2
● Plasma bicarbonate levels decrease from 26 to 22 mmol/L
● Minimal increase in blood pH→shift of oxygen dissociation curve to the
LEFT → increases affinity of maternal hemoglobin for oxygen (Bohr
effect) → lowering the oxygen-releasing capacity of maternal blood
● Minimal increase in blood pH→ increase 2,3-diphosphoglycerate in
maternal erythrocytes →shifts the curve back to the RIGHT
● Reduced PCO2 from maternal hyperventilation aids CO2 transfer from the
fetus to the mother while also aiding oxygen release to the fetus
 08
Urinary System
 Kidney
● Kidney size increase 1 cm
● Glomerular filtration rate (GFR) increases as much as 25% by the 2nd
week after conception and 50% by the beginning of the 2nd trimester
● Renal plasma flow increases early in pregnancy
● 2 Factors for Hyperfiltration:
○ Hypervolemia-induced hemodilution
■ Lowers protein concentration and oncotic pressure of plasma
entering the glomerular microcirculation
○ Renal plasma flow increases by 80% before the end of the first
trimester
● As a consequence of elevated GFR, 60% of nulliparas experience urinary
frequency during the 3rd trimester and 80% experience nocturia
Kidney
 Kidney
● Relaxin
○ Boosts nitric oxide production → renal vasodilation and lowered
renal afferent and efferent arteriolar resistance → increases renal
blood flow and GFR
○ Increase vascular gelatinase activity → renal vasodilation,
glomerular hyperfiltration, and reduced myogenic reactivity of small
renal arteries
● Maternal posture
○ Na+ excretion rate in the supine position averages less than half that
in the lateral recumbent position
● Increased amounts of some nutrients lost in the urine
○ Amino acids and water-soluble vitamins
 Kidney
● Renal Function Tests
○ Serum creatinine levels decline from a mean of 0.7 to 0.5 mg/dL
■ ≥0.9 mg/dL suggests underlying renal disease
○ Creatinine clearance
■ 30% higher than the 100-115 mL/min in nonpregnant women
● Urinalysis
○ Glucosuria - may not be abnormal but once identified, search for DM is
pursued
■ Increased GFR
■ Impaired tubular reabsorptive capacity for filtered glucose
○ Hematuria
■ Frequently results from contamination during collection
■ Urinary tract disease or infection
■ Common after difficult labor
 Kidney
● Proteinuria
■ Nonpregnant women: protein excretion rate of >150 mg/d
■ Pregnant women: protein excretion rate of at least 300 mg/d
■ Increases with gestational age which corresponds with the peak in GFR
■ Measuring Urine Protein
● Qualitative classic dipstick
○ Fails to account for renal concentration or dilution of urine
● Quantitative 24-hour collection
○ Affected by urinary tract dilatation leading to errors related to
retention and timing
● Albumin/Creatinine or Protein/Creatinine ratio
○ Data obtained quickly and collection errors are avoided
○ Amount of protein per unit of creatinine excreted during a 24-
hour period is not constant
Kidney
 Ureters
● Displaced laterally and compressed at the pelvic brim by the enlarging
uterus causing elevated intraureteral tonus and ureteral dilatation
○ Right sided in 86% of women
○ Unequal dilatation may result from:
■ Cushioning provided the left ureter by the sigmoid colon
■ Greater right ureteral compression excreted by the dextrorotated
uterus
■ Right ovarian vein complex lies obliquely over the right ureter
● Ureteral elongation
● Ureter thrown into curves of varying size
○ Smaller = sharply angulated
○ Usually single or double curves that may appear as acute angulations
Ureters
 Bladder
● Shows few significant anatomical changes before 12 weeks’ gestation
● Increase in size and hyperplasia of bladder muscle and connective tissues elevate
the trigone and thicken its intraureteric margin marked deepening and widening of
the trigone
● Bladder mucosa: increase in the size and tortuosity of its blood vessels
● Bladder pressure in primigravidas increases from 8 cm H2O early in pregnancy to
20 cm H2O at term
● Absolute and functional urethral lengths increased by 6.7 and 4.8 mm, respectively
● Maximal urethral pressure increases from 70 to 93 cm H2O ⟶ continence is
maintained
● Near term, the entire base of the bladder is pushed ventral and cephalad ⟶
converts convex surface into a concavity
● Pressure impairs blood and lymph drainage from bladder base rendering the area
edematous, easily traumatized, and more susceptible to infection
 09
Gastrointestinal tract
● Stomach and intestines are displaced cephalad by the enlarging uterus
● Appendix usually displaced upward and laterally. At times may reach
the right flank
● Pyrosis (heartburn)
○ Most likely caused by reflux of acidic secretion into the lower
esophagus
○ Altered stomach position contribute to its frequency
○ Lower esophageal sphincter tone decreased
○ Intraesophageal pressures are lower and intragastric pressures
higher
○ Esophageal peristalsis has lower wave speed and lower amplitude
● Gastric emptying time
○ Unchanged during each trimester
○ Prolonged during labor especially after administration of
analgesics
● Hemorrhoids
○ Caused by constipation and elevated pressure in rectal veins
below the level of the enlarged uterus
 Liver
● Liver size unchanged
● Hepatic arterial and portal venous blood flow increase
● Hepatic Function
○ Total alkaline phosphatase activity doubles
■ Attributable to heat-stable placental alkaline phosphatase isoenzymes
○ Serum aspartate transaminase (AST), alanine transaminase (ALT), γ-glutamyl
transpeptidase (GGT), and bilirubin levels are slightly lower
● Serum albumin concentration declines
○ Late pregnancy: 3.0 g/dL
● Total body albumin levels rise
○ Pregnancy-associated increased plasma volume
● Serum globulin levels are slightly higher
● Leucine aminopeptidase is markedly elevated
○ Pregnancy-specific enzyme(s) with distinct substrate specificities
○ Oxytocinase and vasopressinase activity causing transient diabetes insipidus
 Gallbladder
● Gallbladder contractility is reduced ⟶ greater residual volume
○ Progesterone inhibits cholecystokinin-mediated smooth muscle
stimulation
● Increased prevalence of cholesterol gallstones in multiparas
○ Caused by impaired emptying, subsequent stasis, and increased
cholesterol saturation of bile
 10
Endocrine System
 Pituitary Gland
● Pituitary gland enlarges by 135%
○ May compress optic chiasma reducing visual fields
○ Caused by estrogen-stimulated hypertrophy and hyperplasia of the
lactotrophs
○ Parallel the maternal serum prolactin levels
● Gonadotrophs decline in number
● Corticotrophs and thyrotrophs remain constant
● Somatotrophs suppressed due to negative feedback by placental
production of growth hormone
● Peak pituitary size of 12 mm in the first days postpartum and the
involutes rapidly and reaches normal size by 6 months postpartum
● Maternal pituitary gland is not essential for pregnancy maintenance
 Pituitary Gland
● Growth Hormone
○ First trimester: secreted predominantly from maternal pituitary gland
(0.5-7.5 ng/mL)
○ 6 weeks’ gestation: secreted from the placenta becomes detectable
○ 20 weeks: placenta is the principal source
■ Placental GH differ from pituitary GH by 13 amino acid residues
and is secreted by syncytiotrophoblast in a nonpulsatile fashion
■ Influences fetal growth via upregulation of insulin-like growth
factor 1
■ Higher levels ⟶ preeclampsia
■ Placental expression correlates positively with birthweight but
negatively with fetal growth restriction
 Pituitary Gland
● Growth Hormone
○ Rise slowly from 3.5 ng/mL: at 10 weeks to plateau at 14 ng/mL after
28 weeks
○ In amniotic fluid, peaks at 14-15 weeks and slowly declines to reach
baseline values after 36 weeks
○ Complete absence of this hormone still progresses fetal growth
○ May act in concert with placental lactogen to regulate fetal growth
● Prolactin
○ Maternal plasma prolactin levels increase markedly
○ Tenfold greater at term - about 150 ng/mL
○ After delivery, plasma concentrations drop
○ During lactation, pulsatile bursts of prolactin secretion in response to
suckling
 Pituitary Gland
● Prolactin
○ Ensure lactation
○ Acts to initiate DNA synthesis and mitosis of glandular epithelial cells
and presecretory alveolar cells of the breast
○ Augments the number of estrogen and prolactin receptors in these
cells
○ Promotes mammary alveolar cell RNA synthesis, galactopoiesis, and
production of casein, lactalbumin, lactose, and lipids
○ Present in amniotic fluid in high concentrations
■ Synthesized by uterine decidua
■ Prevent fetal dehydration
■ Up to 10,000 ng/mL at 20 to 26 weeks’ gestation
■ Decline thereafter and reach nadir after 34 weeks
 Pituitary Gland
● Oxytocin
○ Secreted from the posterior pituitary gland
○ Complex mechanisms promote quiescence of oxytocin systems
● ADH/Vasopressin
○ Secreted from the posterior pituitary gland
○ Unchanged
 Thyroid Gland
● Thyrotropin-releasing hormone (TRH)
○ Secreted by the hypothalamus
○ Stimulates thyrotrope cells of the anterior pituitary to release TSH
○ Does not increase
○ Cross the placenta and stimulate the fetal pituitary to secrete TSH
● Serum TSH and hCG
○ Vary with gestational age
○ ∝-subunits are identical; β-subunits differ in their amino acid
sequence
■ This structural similarity results to an intrinsic thyrotropic activity
of hCG, and thus, high serum hCG levels cause thyroid
stimulation
○ TSH in the first trimester decline but still remain in the normal range
 Thyroid Gland
● Boosts production of thyroid hormones by 40-100% to meet maternal
and fetal needs
○ Thyroid gland undergoes moderate enlargement caused by glandular
hyperplasia and greater vascularity
■ Mean thyroid volume increases from 12 mL in the first trimester
to 15 mL at term
● Thyroid-binding globulin (TBG) - principal carrier protein
○ Increases, reach their zenith at 20 weeks and stabilize at double
baseline values for the remainder of pregnancy
○ Results from:
■ Higher hepatic synthesis rates - due to estrogen stimulation
■ Lower metabolism rates die to greater TBG sialylation and
glycosylation
 Thyroid Gland
● ↑TBG levels ⟶ ↑ total serum T4 and T3 concentrations but do not affect
serum free T4 and free T3 levels
○ Total serum T4 - beginning between 6 and 9 weeks’ gestation and
reach plateau at 18 weeks; only rise slightly and peak along hCG
levels and then return to normal
● Fetus relies on maternal T4, which crosses the placenta in small quantities
to maintain normal fetal thyroid function
○ Fetal thyroid does not begin to concentrate iodine until 10-12 weeks’
gestation
○ Synthesis and secretion of thyroid hormone by fetal pituitary TSH
ensues at 20 weeks
○ At birth, 30% of T4 in the umbilical cord blood is of maternal origin
 Thyroid Gland
● Iodine Status
○ Iodine requirements increase
○ Low or marginal intake: deficiency may manifest as low T4 and higher
TSH levels
○ Early exposure to thyroid hormone of the fetus is essential for the
nervous system
 Parathyroid Glands
● Pregnancy is a vulnerable period of osteoporosis
○ Calcium needed for fetal growth and lactation may be drawn from
the maternal skeleton
○ Factors affecting bone turnover yield a net result favoring fetal
skeleton formation at the expense of the mother
● Parathyroid Hormone
○ Action on bone resorption, intestinal absorption, and kidney
reabsorption to raise extracellular fluid calcium concentration and
lower phosphate levels
○ Fetal skeleton mineralization requires 30g of calcium, primarily during
3rd trimester
 Parathyroid Glands
● Calcitonin
○ C cells secrete calcitonin and are located in the perifollicular areas of
the thyroid gland
○ Opposes actions of PTH and vitamin D and protects the maternal
skeleton during times of calcium stress
○ Rise postpartum
○ Calcium and magnesium promote biosynthesis and secretion of
calcitonin
○ Gastric hormones (gastrin, pentagastrin, glucagon, and
pancreozymin) and food ingestion increase calcitonin plasma levels
 Adrenal Glands
● Undergo little, if any, morphologic change
● Cortisol
○ Serum levels rise but much of it is bound by transcortin
○ Adrenal secretion rate is not elevated and probably lower than in
nonpregnant state
○ Metabolic clearance rate is diminished because its half-life is nearly
doubled
○ Early pregnancy: levels of circulating ACTH are dramatically reduced
○ As pregnancy progresses, ACTH and free cortisol levels rise equally
and strikingly
○ May modulate trophoblast growth and placental size
 Adrenal Glands
● Aldosterone
○ 15 weeks’ gestation: maternal adrenal glands secrete increased
amounts of aldosterone
○ By 3rd trimester, ~1 mg/d is released
○ Levels of renin and angiotensin II rise → increasing aldosterone
secretion
○ Protects against the natriuretic effect of progesterone and atrial
natriuretic peptide
○ May modulate trophoblast growth and placental size
 Adrenal Glands
● Deoxycorticosterone
○ Progressively increase to near 1500 pg/mL by term
■ Augmented kidney production resulting from estrogen
stimulation
■ Higher in fetal blood suggesting transfer of fetal
deoxycorticosterone into the maternal compartment
● Androgens
○ Androgenic activity rises
○ Both maternal plasma levels of androstenedione and testosterone are
increased
■ Both are converted to estradiol in the placenta increasing their
clearance rates, however, greater plasma sex hormone-binding
globulin levels retard testosterone clearance
 Adrenal Glands
● Androgens
○ Source of this higher C19-steroid production likely originates in the
ovary
○ Little or no testosterone in maternal plasma enters the fetal
circulation as testosterone because of the near complete
trophoblastic conversion of testosterone to 17β-estradiol
○ Maternal serum and urine levels of dehydroepiandrosterone sulfate
are lower
■ Stems from the greater metabolic clearance though extensive
maternal hepatic 16α-hydroxylation and placental conversion to
estrogen
 11
Musculoskeletal System
● Progressive lordosis - characteristic feature
○ Compensating for the anterior position of the enlarging uterus
○ Shifts the center of gravity back over the lower extremities
● Increased mobility of the sacroiliac, sacrococcygeal, and pubic joints
○ Mostly during the first half of pregnancy
○ May contribute to maternal posture alterations and create lower
back discomfort
○ >1 cm symphyseal separation may cause significant pain
● Aching, numbness, and weakness of the upper extremities
○ Result from marked lordosis and associated anterior neck flexion
and shoulder girdle slumping producing traction on the ulnar and
median nerves
● Joint strengthening begins immediately after delivery and completed
within 305 months
 12
Central Nervous System
 Memory
● CNS changes are few and mostly subtle
● Problems with attention, concentration, and memory
● Pregnancy-related memory decline - third trimester
○ Transient and quickly resolved following delivery
○ Poorer verbal recall and processing speed
○ Worse spatial recognition memory
● Cerebral blood flow in the middle and posterior cerebral arteries declined
progressively
○ Mechanisms and significance unknown
● Pregnancy does not affect cerebrovascular autoregulation
 Eyes
● Intraocular pressure drops
○ Partly due to greater vitreous outflow
● Corneal sensitivity is decreased
● Slight increase in corneal thickness due to edema
● Krukenberg spindles
○ Brownish-red opacities on the posterior surface of the cornea
○ Due to hormonal effects causing increased pigmentation
● Visual function is unaffected other than the transient loss of
accommodation
 Sleep
● 12 weeks’ gestation through the first 2 months postpartum
○ difficulty falling asleep
○ frequent awakenings
○ fewer hours of night sleep
○ reduced sleep efficiency
● Sleep apnea is more common in pregnancy, especially in obese patients
● Postpartum
○ Greatest disruption of sleep which may contribute to postpartum
blues or to frank depression
 References:
● Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S.,
Hoffman, B. L., Sheffield, J. S. (2018). Williams obstetrics (25th edition.).
New York: McGraw-Hill Education.
● Chatterjee, P., Chiasson, V. L., Bounds, K. R., & Mitchell, B. M. (2014).
Regulation of the Anti-Inflammatory Cytokines Interleukin-4 and
Interleukin-10 during Pregnancy. Frontiers in immunology, 5, 253.
https://doi.org/10.3389/fimmu.2014.00253
Thank you!