PHYSIOLOGICAL

CHANGES IN
PREGNANCY AND ITS
IMPLICATIONS
Presenter – Dr. Neha Yadav

Moderator -Dr. jyoti

Dr. Tanvi
There are five important physiologic changes that have implications on the clinical
anesthetic management of obstetric patients.
(1) Airway changes posing intubation difficulties;
(2) Metabolic and respiratory changes resulting in profound hypoxemia during apnea;
(3) Gastrointestinal changes predisposing the partient to regurgitation and aspiration;

(4) Pressure effects of the gravid uterus on the aorta and inferior vena cava resulting in the supine

hypotensive syndrome of pregnancy;

(5) Mechanical, Hormonal, and Biochemical factors that can result in an increased spread of intrathecal

and epidural drugs.

Cardiovascular changes

 Maternal intravascular fluid volume increase in the first trimester secondary to changes in
the renin angiotensin-aldosterone system promoting sodium absorption and water retention
induced by rising progesterone

 The elevation of the diaphragm by the growing uterus shifts the heart anteriorly and to the left.
Left axis deviation as well as left ventricular hypertrophy

 At term, the plasma volume is 50% to 55% above the nonpregnant level. It is thought that the
increase in blood volume prepares the parturient for delivery blood loss. Blood volume returns
to prepregnancy values approximately 6 to 9 weeks postpartum.
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 First trimester, maternal cardiac output increases 35%

to 40% above prepregnancy values

 second trimester. increase 40% to 50% I
 Stroke volume Increase (25%-30%)
 Heart rate Increase (15%-25%).
 Systemic vascular resistace Decreases 20%
 CVP. Unchanged
 Labor further increases cardiac output,
which fluctuates with each uterine
contraction.

 The largest increase in cardiac output

occurs immediately after delivery, when
cardiac output can increase by 80% to
100% more than prelabor values.

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IMPLICATIONS
Aortocaval Compression

 Aortocaval compression by the gravid uterus as a result of supine positioning is associated

with a decrease in systemic blood pressure And causes a decrease in both stroke volume and
cardiac output of 10% to 20%

 may exacerbate venous stasis in the legs and thereby result in ankle edema, varices, and
increased risk for lower extremity deep venous thrombosis.

 SUPINE HYPOTENSION SYNDROME

Fall in MAP more than 15mmHg

Increased HR more than 20 beats/min

Diaphoresis, nausea, altered mentation.

Caption
 Degree of hypotension is reduced by elevating the right hip 10 to 15 cm ( 15 degree left-tilt)
with a blanket, wedge, or table tilt.

 blood loss of 300 to 500 mL typically associated with vaginal delivery and the estimated blood
loss of 800 to 1000 mL that accompanies a standard cesarean delivery.
RESPIRATORY CHANGES

 Pregnancy results in significant alterations in

 (1) the upper airway,
 (2) lung volumes and ventilation, and
 (3) O 2 consumption and metabolic rate
 The Upper Airway Capillary engorgement with increased tissue friability and edema
of the mucosal lining of the oropharynx, larynx, and trachea begins early in the first
trimester.
 The expanding uterus forces the diaphragm cephalad and creates a 20% decrease in functional
residual capacity (FRC) by term

 This reduction is comprised of nearly equal reductions in both the expiratory reserve volume
(ERV)
Pulmonary ParameterValue Near Term
 Minute ventilation. Increased
 Respiratory rate Increased
 Tidal volume Increased

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 LUNG VOLUMES
 Inspiratory reserve volume. Increased
 Tidal volume. Increased
 Expiratory reserve volume. Decreased
 Residual volume. Decreased
LUNG CAPACITIES
 Vital capacity. No change
 Functional residual capacity. Decreased
 Total lung capacity. Decreased

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 RESPIRATORY MEASURES
 FEV1 No change
 FEV1 /FVC. No change
 Closing capacity. No change

 Maternal PaCO 2decreases from 40 mm Hg to approximately 30 mm Hg as a reflection of the

increased minute ventilation.

 Arterial pH, however, remains only mildly alkalotic (typically 7.42 to 7.44) because of
metabolic compensation with increased renal excretion of bicarbonate ions

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IMPLICATION

 Patient’s position should always be optimized and back-up airway instrumentation available
before attempts are made at intubation of the trachea.

 During induction of general anesthesia, desaturation and subsequent hypoxemia occur more
rapidly because of decreased O 2 reserve (secondary to decreased FRC) combined with
increased O 2 uptake (resulting from increased metabolic rate).

 Preoxygenation before general anesthesia is critical for patient safety to mitigate these
physiologic changes and increase apnea time. Preoxygenation with inhalation of 100% O
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 Increased risk for bleeding exists during manipulation of the upper airway, in addition

 Increased risk of difficult mask ventilation and intubation of the trachea.

 Nasal instrumentation should be avoided.

 After extubation, the airway may be compromised as a result of edema, with subsequent risk for
airway obstruction in the immediate recovery period.Consequently,

 Attempts at laryngoscopy should be minimized and cuffed endotracheal tube with a smaller
diameter (should be placed to minimize the chances of difficult placement secondary to airway
edema.

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GI TRACT CHANGES

 The stomach and pylorus are moved cephalad by the gravid uterus, which repositions the
intraabdominal portion of the esophagus intrathoracically and decreases the competence of the lower
esophageal sphincter muscle.

 Higher progesterone and estrogen levels of pregnancy further reduce lower esophageal sphincter
tone.

 Gastrin, secreted by the placenta, increases gastric hydrogen ion secretion and lowers the gastric pH
in pregnant women.

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 Aminotransferase (AST), (ALT). increase

 Bilirubin increase

 Alkaline phosphatase Increase. Secondary to placental production.

 Plasma protein reduced

 Decreased serum albumin levels can result in elevated free blood levels of highly protein-
bound drugs.


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IMPLICATIONS

 These changes in combination with the increased gastric pressure from the enlarged uterus increase the
risk for acid reflux in pregnancy.

 Conversely, gastric emptying is decreased with the onset of labor, pain, anxiety, or administration of
opioids. Increased gastric contents can further increase the risk for aspiration

 To reduce this risk, a nonparticulate antacid, a rapid sequence induction of anesthesia technique
including cricoid pressure, and endotracheal intubation are considered routine parts of general
anesthesia in a pregnant woman.

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 Metoclopramide, a dopamine antagonist, increases lower esophageal sphincter (LES) tone, is a
prokinetic, and has central antiemetic effects. It can have significant effects on gastric volume
as early as 15 min after administration.“

 Anticholinergics, such as atropine 7 microg/kg i.m. or glycopyrrolate 4 microg/kg, used in

combination with oral antacid are more efficacious in reducing risk of acid aspiration .

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RENAL CHANGES

 Glomerular filtration rate (GFR) Increase

 renal plasma flow increase

 renal vascular resistance. Decrease

 The renal blood flow is 75% greater and the GFR is 50% greater than baseline, and this rate is
maintained until the end of pregnancy. The GFR does not return to prepregnancy levels until 3
months postpartum.

 Creatinine clearance is increased to 150 to 200 mL/min from the normal baseline values of 120
mL/min.

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HEMATOLOGICAL CHANGES
Changes in Coagulation System at Term
PRO-COAGULANT FACTORS.
 Increased. I, VII, VIII, IX, X, XII von Willebrand factor
 Decreased. XI, XIII
 Unchanged. II, V
ANTI-COAGULANT FACTORS
 Increased. None
 Decreased. Antithrombin III, Protein S
 Unchanged. Protein C
PLATELETS . Decreased
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 Plasma volume increases approximately 50% above pre pregnancy values

 Increased sodium retention(RAAS)

 Decresed thirst threshold

 Decreased plasma oncotic pressure ( reduced serum albumin)

 red cell volume increases only approximately 25%.

 The greater increase in plasma volume creates a physiologic anaemia of pregnancy with a
hemoglobin value 11.6 mg/dl. Hb below this are concerning.

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 IMPLICATION

 Leukocytosis is common in pregnancy and is unrelated to infection.

 Blood vlume returns to normal state after 2 weeks postpartum.

 Gestational thrombocytopenia is due to a combination of hemodilution and more rapid platelet

turnover and is a diagnosis of exclusion.

 Other more consequential diagnoses such as idiopathic thrombocytopenic purpura and

hemolysis, elevated liver enzyme, and low platelet count (HELLP) syndrome must be
excluded.

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CNS CHANGES AND IMPLICATION
 Reduced minimum alveolar concentration (MAC) for inhaled anesthetics due to progesterone and beta
endorphins.

 The MAC of a volatile anesthetic is reduced by 28% in humans during the first trimester of
pregnancy.

 At term, the epidural veins are distended, the volume of epidural fat increases, which decreases the
size of the epidural space and volume of cerebrospinal fluid (CSF) in the subarachnoid space.

 the local anesthetic dose requirement is decreased for neuraxial block as early as the first trimester,

 Increased nerve sensitivity and decrease in local anesthetic dose requirements.

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 Epidural veins are engorged so epidural catheter may canulate epdural veins leading to bloody
tap to be common

 Avoid advancing spinal/ epidural needle during contraction as incresed CSF pressue increase
risk of dural puncture and CSF expulsion at high pressures.

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METABOLIC CHANGES

 Pregnancy is DIABETOGENIC
 Human Placental Lactoge (HPL).
 Relative insulin resistance

Blood glucose , amino acids—— reduced

Free fatty acids , ketones and triglycerides —. Increase
Promote hypertrophy of thyroid gland
Increase T3, T4 and normal TSH

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 Maternal-fetal exchange
 Maternal-fetal exchange across the placenta occurs by one of four mechanisms:

 Passive diffusion, facilitated diffusion, transporter-mediated mechanisms, and vesicular transport.

Placental transfer of drugs depends on

Molecular weight (<500 Da)

Protein binding – inversely proportional

Lipid solubility

Maternal and fetal pH

Maternal drug concentration

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 Nondepolarizing neuromuscular blocking drugs are ionized, have a high molecular weight, and
poor lipid solubility resulting in minimal placental transfer. Succinylcholine has a low
molecular weight but is highly ionized .

 drugs that readily cross the blood-brain barrier also readily cross the placenta. Therefore most
centrally acting general anesthetics cross the placenta and affect the fetus.

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Ion Trapping

 Fetal blood is more acidic than maternal blood,

 lower pH creates an environment in which weakly basic drugs, such as local anesthetics and
opioids, cross the placenta as nonionized molecules and become ionized in the fetal circulation.

 Because this newly ionized molecule has more resistance to diffusion back across the placenta,
the drug may accumulate in the fetal circulation and reach levels higher than the maternal
blood. This process is referred to as “ion trapping.”

 During fetal distress (fetal acidemia), resulting in fetal bradycardia, ventricular

arrhythmias, acidosis, and severe cardiac depression.

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 Fentanyl is a synthetic opioid that is highly lipidsoluble and has a short duration and no active
metabolites.

 When given in small IV doses of 50 to 100 μg/h, no significant differences are seen in neonatal
Apgar scores and respiratory effort compared with those in newborns of mothers not receiving
fentanyl.

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 THANK YOU

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