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Haemodynamics
Heart rate
Occurs as early as 4 weeks after conception
Increases by 17% by end of 1st trimester
Increases to 25% at the middle of 3rd trimester
Stroke volume
Increased by 20-30%
Most of the increase occurs in 1st trimester
Cardiac output
Increase progressively throughout pregnancy
40-45% above non-pregnant values at 12th to 28th week
Reach peak of 50% during 32-36th week
Then decrease slightly to 47% above non-pregnant level at term
NB:
According to [KB2:p248], cardiac output increases by 30% only
Blood pressure
Decreased in mean arterial blood pressure
Systolic BP and diastolic BP decrease by 10%
????Stable after 20weeks
Others
Central venous pressure and pulmonary capillary wedge pressure
--> Unchanged
Oncotic pressure falls by 14%
--> Predisposition to oedema
Labour
During labour, each uterine contraction squeezes about 300mL of blood into the
central maternal circulation
During labour, cardiac output:
Increase by 15% during latent phase of labour
Increase by 30% during the active phase
Increase by 45% during the expulsive stage
After delivery
Cardiac output and BP returns to non-pregnant level by 2 weeks after delivery
Changes to anatomy
Diaphragm
Diaphragm is displaced upwards by about 4cm
* Contraction is NOT marked restricted
Thoracic cage
Anteroposterior and transverse diameters increase by 2-3 cm
* Due to lower ribs flare out and increase in subcostal angle (from 68 to 103
degrees)
Circumference increase by 5-7cm
These changes are due to relaxin
* Secreted by corpus luteum
* Relaxes ligament attachments of the ribs
Other changes
Capillary engorgement throughout respiratory tract
--> Vocal cord may be swollen/oedematous
According to [AA4:p630]
* Difficult intubation in term pregnant women is 1 in 300, compared with 1
in 2200 in non-pregnant population
* Tonge and epiglottis also increase enlarged
Large airway dilated
--> Decreased airway resistance by 35%
ERV and RV
ERV and RV gradually decrease
20% less at term (than non-pregnancy level)
FRC
Decreases by 20% at term
In supine, FRC is about 70% of that in erect position
Tidal volume
Tidal volume begins to increase in the first trimester
--> 40% above non-pregnant level at term
NB:
In [PK1:p349], both 28% increase and 40% increase in tidal volume were
quoted
[JN5:p320, KB1:p249] tidal volume increase by 40%
Capacities
At term
Inspiratory capacity (IRV) increases 10%
Expiratory capacity (ERV) decreases 20%
Total lung capacity decrease by 5%
Vital capacity unchanged
NB:
According to [KB2:p248, AA5:p326]
* IRV is unchanged
Other changes
Compliance
Lung compliance unchanged
Chest wall compliance decreases
--> Total lung compliance decreases by 20%
NB:
Cause: elevation of the diaphragm
Minute ventilation
Minute ventilation starts to increase in early weeks
Maximal hyperventilation occurs as early as week 8-10
Minute ventilation increases to 50% above non-pregnant level at term
Component
40% increase in tidal volume
10% increase in respiratory rate
NB:
[KB2:p249] RR increase by 15%
[JN5:p320] RR unchanged
Cause
Stimulation of the respiratory centres by progesterone
[JN5:p320] Progesterone sensitise central chemoreceptors
--> Increase the slope of pCO2/ventilation response curve by 3 fold
[JN5:p320] Hypoxic ventilatory response is also increased by 2 fold
Result
At term, (with full renal compensation)
pCO2 = 32mmHg
pO2 increase very slightly due to hyperventilation
Lower bicarbonate level (18-21mmol/L)
pH normal
Increase in 2,3 DPG
Overall,
Oxygen dissociation curve stays unchanged
Other notes
[JN5:p320] Posture makes little difference in oxygenation
Oxygen flux
According to [KB2:p249],
Cardiac output increase by 30%
Blood oxygen content decrease due to fall in [Hb]
Overall,
Oxygen flux at term is about 10% above non-pregnant level
After delivery
FRC and RV returns to normal within 48 hours
Tidal volume declines to normal within 5 days
Anaesthetic implication
Decreased FRC and higher O2 consumption
--> Reduce the O2 reserve
Anatomical changes in upper airway
--> More difficult endotracheal intubation
Production
By syncytiotrophoblast cells
Structure
Made up of alpha and beta subunits
* Like pituitary glycoprotein hormones
Alpha subunit is the same as the alpha subunit of LH, FSH, and TSH
Function
Primarily luteinising and luteotropic
* Acts on same receptor as LH
Very little FSH activity
Thus,
Maintains corpus luteal oestrogen and progesterone production in 1st trimester
--> Maintains pregnancy until the placenta takes over
Levels
hCG level peaks at 10-12 weeks of pregnancy then declines to term
Other notes
Detection
Can be detected in blood as early as 6 days after conception
Can be detected in urine as early as 14 days after conception
Secretion in other situation
Small amounts of hCG are also secreted by some GIT and other tumours
Foetal liver and kidney also produce small amounts of hCG
Production
By syncytiotrophoblast cells
Amount produced is proportional to the size of the placenta
Structure
Very similar to human growth hormone
hPL, growth hormone and prolactin may come from a common progenitor
hormone [WG21:p453]
Function
Lipolysis
Antagonise actions of insulin
* i.e. Decrease glucose utilisation
K+, nitrogen, and Ca2+ retention
May also inhibit maternal growth hormone secretion
NB:
Lipolysis and glucose-sparing divert glucose to the foetus
Levels
hPL level rises throughout the pregnancy and peaks near term
Steroid hormone
i.e. Oestrogen and progesterone
Placenta produces enough oestrogen and progesterone from maternal and foetal
precursors to take over the function of corpus luteum after the 6th week of
pregnancy
Decrease in
Growth hormone
* Possibly by hPL (which also has growth hormone activity)
Gonadotrophin
* By increased level of oestrogen and progesterone
Other changes
Adrenal hormones
All increase
* ???? By oestrogen and progesterone [PK1:p346]
Cortisol (both free and total)
Aldosterone
* Due to natriuretic effect of progesterone
Renin and angiotensin
Thyroid hormones
Both T3 and T4 synthesis increase
However,
Thyroid binding globulin also increase
--> Free plasma level of T3 and T4 are unchanged
Parathyroid hormone
PTH increase due to increased utilisation of free Ca2+
Increase in PTH
--> Increase GIT absorption of Ca2+
Prostaglandins
Prostaglandin A increase 300% during 1st trimester
--> Systemic vasodilation
Prostaglanding E only increases during 3rd trimester
Corpus luteum
Fails to regress when fertilisation occurs
Enlarges due to hCG
Enlarged corpus luteum of pregnancy secretes oestrogen, progesterone, and
relaxin
Corpus luteum starts to decline after 8 weeks of pregnancy, but persists
throughout pregnancy
Oxygen consumption
Oxygen consumption increase by 20% at term
NB:
[JN5:p320] Oxygen consumption increase by 15-30% at term
Carbohydrate metabolism
Insulin secretion increase from end of first trimester to 32 weeks, then declines
to non-pregnant level at term
Fat metablism
Net storage of fat in the first half of pregnancy
--> Decreased FFA and glycerol in plasma
Mobilisation during second half
--> Increased FFA and glycerol in plasma
Haematology
Plasma volume increases (45%) relatively more than RBC volume increase (20%)
Thus,
[Hb] falls to 12-13g/L
Haematocrit falls to 33-35%
Also,
WBC count increases to 8 to 9 x 10^6/L
* Due to increase in neutrophil and monocytes
NB:
According to [KB2:p6],
Without iron supplementation
--> RBC volume increase by 250mLs (18%)
With iron supplementation
--> RBC volume increase by 450mLs (30%)
Coagulation
Significant increase in plasma concentration of
Factor 7,8,9,10
Fibrinogen
Platelet concentration is unchanged or slightly decreased due to haemodilution
NB:
According to [AA4:p328],
Factor II, V slightly increased
Factor VII increase 10-fold
Factor VIII increase 2-fold
Factor IX and X increased
Factor XII increase 30-40%
Factor XI and XIII decreased
Plasminogen inhibitor increased
Plasminogen activator reduced
Antithrombin IIIa decreased slightly
Plasma proteins
Total circulating protein increase during pregnancy
But,
Concentration of total protein and albumin decrease due to haemodilution
Other proteins
Increase in total globulin
* Increase in alpha and beta-globulin
* Slight decrease in gamma-globulin
Fibrinogen increases
* From 300mg/dL to 450mg/dL at term
Serum pseudocholinesterase activity
* Reduced by 20-30% by the end of 1st trimester
* Constant until term
Stomach
Gastric motility is reduced
Delayed gastric emptying at 12-14 weeks of gestation
Further gastric emptying delay during labour due to pain and anxiety
Acid production
Gastrin production increases progressively throughout pregnancy
* Produced by the placenta
Gastric acid production increased during the 3rd trimester
Intestine
Reduced plasma concentration of motilin
--> Reduced motility of small and large intestines
Gallbladder
Reduced release of CCK (due to progesterone)
--> Reduced contractility of the gallbladder
Liver
Histological changes in liver
* Mild fatty changes
* Mild glycogen depletion
* Lymphocytic infiltration
Others
Increase in serum alkaline phosphatase and serum cholesterol
Anatomical changes
Obstruction of urine flow by gravid uterus or dilated ovarian plexuses
--> Progressive dilatation of the renal pelvis, calyces, and ureters from the 2nd or
3rd months of pregnancy
Glycosuria
Glycosuria is common
Due to
Increased GFR
Slightly reduced proximal tubular reabsorption
Proteinuria
Proteinuria is present in 20%
May be due to increased renal venous pressure
Endorphin
The placenta produces endorphins and enkephalins
* May be analgesic during pregnancy
Endorphin production increases significantly in proportion to the frequency and
duration of uterine contractions during labour and delivery
* Role unclear
Progesterone
Progesterone has sedative actions
* Increase 10-20 fold in 3rd trimester
Implication
MAC of volatile agents is reduced by 30-40% during pregnancy
* Partly because of endorphins and progesterone
Before birth
Umbilical vessels
Umbilical vein x 1
Umbilical arteries x 2
Foetal capillaries
Umbilical flow = 300mL/min
Foetal [Hb] = 170g/L
p50 = 18-20mmHg
Umbilical artery
pO2 = 18mmHg
Umbilical vein
pO2 = 28mmHg
=====
[KB2:p251]
Respiratory parameters: Neonate vs adult
Neonate vs adult
Neonat
Adult units
e
10- breath/mi
RR 30-40
15 n
I:E 1 1.5
FRC 30 30 mL/kg
Specific
0.05 0.05 /cmH2O
compliance
Oxygen
6-7 3-3.5 mL/kg/min
consumption
Foetal
Umbilical artery
pO2 = 18 mmHg (SatO2 = 45%)
pCO2 = 55 mmHg
Umbilical vein
pO2 = 28 mmHg (SatO2 = 70%)
pCO2 = 40 mmHg