Presentation on theme: "Physiological changes of pregnancy"— Presentation transcript:
1Physiological changes of pregnancy Tom Archer, MD, MBAUCSD Anesthesia
2Outline Normal changes Implications for pathological conditions. CVRespiratoryHematologicEndocrineUrinaryGIImplications for pathological conditions.Pregnancy as a “stress test for life”Unveils problems that will appear later.
3Outline Cardiovascular changes: To meet increased metabolic demand. Increased blood volume / RBC massDecreased Hct and viscosityIncreased cardiac output deterioration in symptoms from stenotic heart lesions or pulmonary hypertension.
4Outline Cardiovascular changes: Reversible cardiac hypertrophy (50%) Valvular incompetency / conduction changesAll murmurs are not “flow murmurs”! But most are innocent.
6Outline Respiratory changes: Increased O2 consumption / CO2 production Decreased PaCO2 and venous HCO3-Lots of normal saline will cause hyperchloremic metabolic acidosis.Increased work of breathingDecreased FRC (“airtank” reserve)Decreased tolerance for apnea or hypoventilation.Airway swelling.
7Outline Endocrine (insulin) changes: Pregnancy is diabetogenic due to placental hormones (Placental lactogen, HGH, cortisol, progesterone).Insulin requirement increases during pregnancy.Insulin requirement falls abruptly after delivery.RAAS probably influences cardiac hypertrophy and increased RBC mass.
8Type II DM in 2008 Obesity Hyperglycemia Inflammation Genetic predispositionInsulin resistanceHyperglycemiaAtherosclerosisNephropathyRetinopathyNeuropathyImmune dysfunctionPoor wound healingDecreased insulin outputPancreatic beta cell damage
9Outline Urinary changes: GFR increases, normal creatinine falls. “Normal” creatinine may show disease!Ureteral obstruction with hydropnephrosis and pyelonephritis is common.1/200 pregnancies will have urolithiasis
10Outline GI changes: GERD is common Gastric emptying is impaired during labor assume full stomachRoutine “triple Rx” before C/S? Bicitra, metoclopramide, famotidine.
11Mom4 ml O2 / kg / minFeto-placental unit12 ml O2 / kg / minMother is consuming and deliveringoxygen for two!
12CV in pregnancy– Big Picture Increase O2 demand Increased CO.Stable BP with increased CO means decreased SVR.Slight increase in HR, Increase in SV.
13Cardiac output increases 35% by 12 weeks50% for rest of pregnancy60%-100% during laborCO highest right after delivery (release of aorto-caval compression) and uterine contraction (autotransfusion).
14Both delivery and oxytocin cause increase in cardiac output. Delivery of babyOxytocin 5U IV pushPhenylephrine bolus for hypotensionC/S under epidural in pt with previous peripartum cardiomyopathy (May 30, 2007)
15Increased CO in pregnancy increases symptoms from stenotic heart lesions or pulmonary hypertension May need interventional procedure (balloon mitral valvuloplasty, AVR) or termination of pregnancy.Case at UTHSCSA of AS, decompensation with balloon valvuloplasty, emergency AVR, fetal death, maternal improvement in AS.
17Eccentric cardiac hypertrophy in pregnancy Due to increased activity of RAAS?
18Non-pregnant vs late pregnant mouse hearts Non-pregnant vs late pregnant mouse hearts. Note hypertrophy and conduction disturbance (QRS prolongation) in LP mouse heart.Eghbali M (Trends Cardiovasc Med 2006;16:285–291)
19Pressure overload eg AS Volume overload eg pregnancy or athletics
20Hematologic changes at term: Blood volume increased by 45%.RBC volume increased by 15%.Hct falls blood viscosity fallsPregnant woman may tolerate hemorrhage better than non-pregnant woman, before showing fall in BP.
21Average blood loss at delivery: 600 ml with vaginal delivery.1000ml with C/S.
22Hematologic changes at term: Fibrinogen increased.PT, PTT shortened 20%.Increased platelet turnover.Increase in coagulation factors,immobilization and aorto-caval compression all increase risk of DVT.
23Physiological changes of pregnancy at term: Maternal-fetal O2 consumption increases 40-50% over non-pregnant state.Cardiac output increases by 50%.Functional residual capacity (apneic reserve of O2) decreases by 20%Pregnant patient has diminished capacity to tolerate apnea!Chestnut chap. 53
24Functional residual capacity (FRC) is our “air tank” for apnea. from Google images
25Pregnant Mom has a smaller “air tank”. Non-pregnant woman
26Pregnant woman: a respiratory disaster waiting to happen Lung Volumes and implications:FRC is reduced to 80% of non-pregnant value by term.FRC of pregnant woman in supine position is 70% of that in sitting position.Regional anesthesia further decreases the FRC!HENCE: SUPINE, PREGNANT PATIENT WITH A REGIONAL BLOCK HAS A TRIPLY DIMINISHED FRC!!!OBESITY IS A FOURTH FACTOR DECREASING FRC!Anesthetic implication: VERY rapid desaturation in pregnant patients after apnea due to rapid sequence induction or seizure.YOU MUST DO A GOOD PRE-OXYGENATION PRIOR TO INDUCTION OF GA!YOU MUST HAVE ALL OF YOUR AIRWAY SUPPLIES IMMEDIATELY AVAILABLE!
27At term, mother has respiratory alkalosis with metabolic compensation (less HCO3- buffer). ABGsNon-pregnantAt termPaCO24030PaO2100103pH7.407.44HCO3-2418Chestnut
28Compared to non-pregnant state, pregnant woman has less tolerance for: ApneaAcidosis
29Vascular congestionSwelling of respiratory mucosa (nose, rest of airway).Don’t put anything through the nose if you can avoid it prevent bad nose bleed.
30Pregnancy is “diabetogenic”. Why? Placental hormones plus obesity may overwhelm adaptive capacity of pancreatic insulin output.
31Obesity Two vicious cycles of type II DM in pregnancy: #1 Inflammation“Glucotoxicity”GeneticpredispositionInsulin resistance#1PlacentalhormonesHyperglycemiaPlacental vascular damageAtherosclerosisNephropathyRetinopathyNeuropathyImmune dysfunctionPoor wound healingDecreased insulin output#2Pancreatic beta cell damage
32Gestational DM:Appears in 4% of pregnancies. Possibly due to inability to make enough insulin to counteract the “counteregulatory hormones” which increase in pregnancy—placental lactogen, placental GH, cortisol and progesterone.Gestational DM tends to recur in subsequent pregnancies. Gestational DM increases risk for type 2 DM later in life.
33Pregestational DM:Insulin requirements increase rapidly after the 26th week of gestation. Insulin requirement at term is about 50% more than pre-pregnant requirements.Insulin requirements fall during first stage of labor, but rise during second stage of labor.Insulin requirement falls up to 40% the day after delivery. Placental hormones are “diabetogenic”.
34Urinary system Renal infections increase in incidence. Progesterone relaxes uretersCompression of ureters at pelvic brim obstruction infection
35GI tract Decreased gastric emptying Increase GERD Full stomach precautions
36Avoid aorto-caval compression: use left uterine displacement (LUD) LUD helps venous return. C/S as part of resuscitation?LUD decreases chance of DVTLUD increases O2 delivery to fetus:Increases uterine artery pressure and decreases uterine venous pressure.Why we don’t do it: It doesn’t look right!