Physiologic changes in pregnancy: surgical implications.

Pregnancy has measurable effects on essentially every organ system in a woman's body. An understanding of these changes is vital for determining what is normal or abnormal in a pregnant woman. These changes frequently alter symptoms and signs of surgical diseases during pregnancy. In addition, many surgical diseases, as well as their therapies, have multisystemic effects. It therefore is mandatory to appreciate the physiologic changes that occur in a normal pregnancy to avoid incorrect diagnoses and treatment. These physiologic changes are complex and not always well understood. This article will review these changes, concentrating on an organ-system format, with particular emphasis on manifestations that might be confuses with surgical diseases or that have implication for treatment.

CLINICAL OBSTETRICS AND GYNECOLOGY Volume 37. Number 2, pp 241-255 & 1994. J. B. Lippincotl Co. Physiologic Changes in Pregnancy: Surgical Implications CAROLYN MARTIN, MD, and MICHAEL W. VARNER, MD University of Utah School of Medicine Sail Lake City, Utah Pregnancy has measurable effects on essen­tially every organ system in a woman's body. An understanding of these changes is vital for determining what is normal or ab­normal in a pregnant woman. These changes frequently alter symptoms and signs of surgical diseases during pregnancy. In addition, many surgical diseases, as well as their therapies, have multisystemic ef­fects. It therefore is mandatory to appre­ciate the physiologic changes that occur in a normal pregnancy to avoid incorrect di­agnoses and treatments. The mechanisms behind these physio­logic changes are complex and not always well understood. However, many are me­diated via progressive increases in preg­nancy- associated hormones, such as pro­gesterone, estrogens, and human placental lactogen, or by progressive increases in ma­ternal cardiac output and blood volume. Correspondence: Michael IV. Varner. MD, Department of Obstetrics and Gynecology. University of Utah School of Medicine. 50 North Medical Drive. Salt Lake City. UT 84132. This article will review these physiologic changes, concentrating on an organ-system format, with particular emphasis on man­ifestations that might be confused with sur­gical diseases or that have implications for treatment. Optimum Weight Gain Optimum weight gain during pregnancy is dependent upon the patient's preconceptual nutritional status. In thin women, optimum pregnancy outcome occurs with weight gains of25-35 pounds. The enlarging uterus and its contents contribute to the woman's weight 11-14 pounds at term, but the ma­jority of the remaining weight gain is caused by progressive expansion of maternal blood volume (3-4 pounds) and involuntary ca­loric retention in the forms of fat and pro­tein (4-6 pounds). The latter occur princi­pally in the second trimester. Maternal ca­loric retention is caused by the body's anticipation of the progressive late preg­nancy caloric requirements of the fetus as CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 37 / NUMBER 2 / JUNE 1994 241 TABLE 1. Recommended Daily Allowances for Pregnancy and Lactation 242 MARTIN AND VARNER Nutrient Additional Requirements for Additional Requirements for For Nonpregnant Women Pregnant Women Lactating Women Calories (kcal) Protein (gm) Vitamin A (RE) Vitamin D (pg) Vitamin E (mg) Ascorbic acid (rag) Folic acid (mg) Niacin (mg) Riboflavin (mg) Thiamin (mg) Vitamin B6 (mg) Vitamin B12 (pg) Calcium (mg) Phosphorus (rag) Iodine 0/g) Iron (mg) Magnesium (mg) Zinc (mg) 2,100 44 800 7.5 10 60 0.4 14 1.3 1.1 2 3 800 800 150 18 300 15 300 30 200 0-5 2 20 0.3 2 0.3 0.4 0.6 1 400 400 25 Supplement 50 5 500 20 400 0-5 3 40 0.1 5 0.5 0.5 0.5 1 400 400 50 0 150 10 well as the increased caloric requirements of lactation. Other contributions to mater­nal weight gain include extracellular fluid (2-3 pounds) and breast enlargement (1-2 pounds). Obese women have optimum pregnancy outcomes with weight gains of 15-20 pounds and characteristically have less weight gain in the second trimester than do thin women. Obese women already have a substantially expanded vascular volume as well as an adequate caloric reserve. In surgical patients, nutrition may be compromised by prolonged periods without oral intake. Although 5%-dextrose solution supplies minimal energy substrate, it is usually sufficient to maintain the patient and fetus for several days.1 However, those patients who require longer periods of par­enteral nutrition without enteral nutrition may require nutritional supplementation with total parenteral nutrition (TPN). The indications for starting TPN in a pregnant patient include situations in which the bowel is not functional, such as biliary dis­ease, pancreatitis, or complex bowel sur­gery, and diseases requiring prolonged bowel rest. If prolonged bowel rest is antic­ipated, TPN should be started before the patient's own nutritional stores are de­pleted. Whenever the bowel is functional, but the patient is unable to eat, for example with hyperemesis gravidarum or oral sur­gery, enteral nutrition via feeding tube is appropriate. Firm guidelines for the pregnant patient do not exist for TPN or enteral nutrition. Therefore, a team approach between the obstetrician and nutritionist is desirable. This should include routine laboratory studies as well as periodic ultrasonography to verify fetal growth. Persistent ketonuria should be avoided, and indicates insuffi­cient nutritional supplementation. Most importantly, malnutrition is best avoided rather than corrected, especially in the pregnant woman. Over the years, a substantial effort has gone into the definition of recommended dietary allowances during pregnancy and lactation. These recommendations are listed in Table l.2 Female Reproductive Tract The increase in uterine size during preg­nancy is due primarily to cellular hypertro­ Surgical Implications of Physiologic Changes 243 phy but is also the result of modest hyper­plasia. There is a 20-fold increase in cellular mass and a thousandfold increase in intra­uterine volume. Uterine blood flow also increases enor­mously. Uterine artery blood flow increases from approximately 50 ml/min in the non­pregnant woman to 600 ml/min at the end of pregnancy. These increases are primarily estrogen-mediated and are critical for ad­equate delivery of oxygen and nutrients to the developing fetus. Uterine blood flow also may be affected by many drugs and maternal conditions (Table 2). There is also a 60-fold increase in pelvic venous capacity by the end of pregnancy. These dilated pelvic veins are a frequent site of thromboembolisms. Although preg­nancy is associated with a modest increased incidence in thromboembolic disease, there is a substantial additional increase in such complications in the first few weeks post­partum. Women with reproductive tract infections and/or operative deliveries are at a particularly increased risk. Pregnant women requiring surgery are also at an in­creased risk over the general population for thromboembolic disease. This necessitates appropriate prophylactic measures during surgery, usually with pneumatic compres­sion devices. Increases in blood volume within the uterus and pelvic vasculature represent ap­proximately 1,000 ml at any moment late in pregnancy. This increased volume is not the result of shunting from elsewhere in the maternal circulation but rather represents an increase of maternal blood volume and cardiac output during pregnancy. The breasts increase in size from early in pregnancy in anticipation of lactation. The enlargement of the ductal system is due primarily to estrogen, and the enlargement of the alveolar system is due to progester­one. A complex interaction of estrogen, progesterone, prolactin, human placental lactogen, insulin, and cortisol is required for lactation. TABLE 2. Drugs and/or Maternal Conditions That May Affect Uterine Blood Flow Increased uterine blood flow Correction of acute factors (vide infra) responsible for decreased uterine blood flow Estrogens (specifically estradiol) Prostaglandins (especially PGI2, PGE2) Decreased uterine blood flow Uterine contractions Labor Oxytocin administration Hypertonus (e.g., abruption) Hypertension Toxemia Essential Hypotension Sympathetic blockade Hypovolemia Vacoconstrictors Alpha-adrenergic drugs Excess sympathetic discharge PGIj = prostacyclin; PGEj = prostaglandin E2. Cardiovascular System Cardiac output increases by 30-50% during pregnancy, from a level of 4.0-4.51/min in nonpregnant women to a maximum during pregnancy of approximately 6.01/min.3 The increase in output is directed primarily to the maternal uterus, kidneys, and skin, and does not represent shunting from other or­gans. Cardiac output is the product of heart rate and stroke volume, which both increase during normal pregnancy. Stroke volume increases early in pregnancy, then decreases somewhat near term, and the maternal pulse gradually increases through the course of pregnancy to 15-20 beats/min over rates in nonpregnant women. As previously stated, maternal blood volume also is increased by 30-50% during pregnancy. However, maternal red blood cell volume is only increased by 20-30%. This results in a decrease in hematocrit throughout the course of pregnancy, even though total maternal oxygen-carrying ca­pacity is increased. In fact, failure of the maternal hematocrit to decrease during pregnancy (i.e., the failure of the maternal blood volume to expand) is associated with244 MARTIN AND VARNER a distinct increased risk of suboptimum pregnancy outcome. This mechanism is probably in a large part under genetic con­trol. 4 Certainly, it is not necessary to impose large quantities of iron and vitamin sup­plements on pregnant women to overcome this physiologic hemodilution; however, the maternal hematocrit should be maintained above 30% to facilitate optimum oxygen supply to the fetus. This may require a lower threshold for transfusion in the pregnant woman after acute surgical blood loss. Circulatory volume expansion may in­terfere with the diagnosis of surgical disease during pregnancy. This is seen mainly in situations of hypovolemia, because tachy­cardia and hypotension may not develop in pregnant patients until they lose 30-35% of their expanded circulating blood volume.1 This maternal blood volume expansion is also partly responsible for the altered med­ication requirements frequently seen during pregnancy. There is a progressive increase in lower extremity venous pressure during preg­nancy. This is the result of several factors, including the expanded blood volume and compressive effects of the enlarged uterus. The ovarian artery and venous plexus com­press the right common iliac vein. This lat­ter effect explains why many of the signs and symptoms of increased lower extremity venous pressure, such as varicosities, are more frequent and more severe on the ma­ternal right side. Upper extremity venous pressure and central venous pressure re­main unchanged during pregnancy. There is a decrease in systemic vascular resistance during pregnancy. When com­bined with the increase in cardiac output and blood volume, several characteristic changes can be expected on physical ex­amination. Because the uteroplacental bed functions as a low-pressure, left-to-right shunt, the maternal blood pressure char­acteristically drops during the midportion of normal pregnancy. In the second trimes­ter, this usually represents a systolic de­crease of 5-10 mmHg and a diastolic de­crease of 10-20 mmHg. These changes gradually return toward, or perhaps slightly above, the prepregnant levels by the end of pregnancy. Thus, what is normal pressure in the nonpregnant state may be considered abnormal in the middle portion of preg­nancy. For example, a blood pressure of 140/90 mmHg would be a considered bor­derline level in the nonpregnant state. However, it should be considered distinctly abnormal at 20 weeks' gestation, reflecting either a prepregnant pressure of approxi­mately 145-150/100-110 mmHg or a fail­ure of the maternal vascular volume to ex­pand. In either case, such a pregnancy is at increased risk for superimposed pre­eclampsia, abruption, stillbirth, a small-for- gestational age fetus, and various neonatal complications. Many of the normal cardiovascular changes in pregnancy could be miscon­strued as representing primary cardiovas­cular disease. Cruikshank and Hays5 note that a number of physiologic changes of normal pregnancy might be misdiagnosed as heart disease (Table 3). TABLE 3. Signs and Symptoms of Normal Pregnancy That May Mimic Heart Disease Symptoms Reduced exercise tolerance Dyspnea Signs Peripheral edema Distended neck veins Point of maximal impulse displaced laterally Auscultation Increased splitting of first and second heart sounds Third heart sound (S3 gallop) Systolic ejection murmur along left sternal border Chest radiography Straightening ofleft heart border Heart position more horizontal Increased cardiothoracic ratio Increased pulmonary vascular markings Electrocardiogram Left axis deviation (without hypertrophy) Nonspecific ST-T wave changes From Cruikshank DP, Hays PM.5 By permission.Surgical Implications of Physiologic Changes 245 Labor and delivery, as well as the im­mediate puerperium, are periods of in­creased cardiovascular stress. During labor, cardiac output may increase further by as much as 40%. Although some of this is un­doubtedly the result of response to pain,6 some is also due to the cardiovascular ef­fects of labor contractions. Each contraction squeezes 300-500 ml of blood out of the uterus and into the maternal vasculature. This leads to increased venous return and subsequent increased cardiac output. The immediate puerperium also is associated with changes in cardiac output as a result of immediate "auto transfusion" of500-800 ml of volume previously contained within the vasculature of the term uterus. There is also a substantial mobilization of intracel­lular fluid in the first 48 hours postpartum. Both result in a 10-20% increase in cardiac output, reflex bradycardia, and increased stroke volume. Histologic changes in the peripheral vas­culature also occur during pregnancy. These include hyperplasia of the arterial and ve­nous intima and changes in the organization and content of the arterial media. These conditions may predispose the pregnant woman to the formation or rupture of ar­terial aneurysms. Because of the multiple changes in the cardiovascular system during pregnancy, the hemodynamic status of the pregnant woman is often confusing. Therefore, acutely ill, pregnant surgical patients may benefit more often from invasive hemody­namic monitoring to facilitate appropriate fluid resuscitation and care. Respiratory System Maternal respiratory adaptations during pregnancy can be understood best if one considers that the pregnant woman must get oxygen in and carbon dioxide out for two individuals. Fetal oxygen requirements increase exponentially during pregnancy. This is reflected clinically as a progressive increase in minute volume during preg­nancy. Although the diaphragm is elevated during pregnancy, actual diaphragmatic excursion is not impeded. This physiologic "hyperventilation" requires greater use of the accessory breathing muscles. The pro­gressive circumferential expansion of the chest cage during pregnancy, averaging 5-7 cm, frequently results in disruption of chest wall proprioceptors. The combined reduction in maternal Pec* a°d increase in tidal volume accounts for the sensation of dyspnea and breathlessness reported by two thirds of pregnant women. Changes in pulmonary-function testing associated with pregnancy also reflect the need for increased maternal gas exchange. The progressive increase in tidal volume and minute respiration reach 30-40% by term. Because vital capacity and respiratory rate remain unchanged, the increase in tidal volume occurs in association with a de­crease in expiratory reserve volume. Neither forced vital capacity nor forced expiratory volume are altered by pregnancy, consistent with the observation that large airway function is unaltered by pregnancy.7 Likewise, there is no evidence of impaired small airway function in pregnancy.8 Analysis of arterial blood gases during pregnancy reflects this physiologic hyper­ventilation. Maternal Pec* is decreased, and maternal pH is increased. Because oxygen consumption increases less (15-20%) dur­ing pregnancy than does minute ventilation, a modest increase in maternal arterial P02 levels occurs. These changes in maternal Pee* and Pc* are important because they enhance the exchange gradients between other and fetus for carbon dioxide and oxygen. The partially compensated respi­ratory alkalosis is apparent within the first few months of pregnancy. Women with sig­nificant pulmonary disease, especially of an obstructive nature, are affected adversely by the physiologic changes of pregnancy. By far, the most common respiratory disease seen in association with pregnancy is246 MARTIN AND VARNER asthma. Because of its intermittent nature, the predictability of its course during preg­nancy is often difficult. Ophthalmic Changes Many of the ophthalmic changes in normal pregnancy are the result of the modest in­crease in extracellular fluid. Other physio­logic changes that have ophthalmic impli­cations include progressive increases in melanocyte-stimulating hormone and en­largement of the pituitary gland. Progressive hyperpigmentation of the eyelids is the result of increased melanocyte- stimulating hormone. Pregnancy does not affect extraocular eye movements but is as­sociated with a modest increase in corneal edema. As a result, contact lenses may not fit as well during pregnancy. In addition, there appears to be a decrease in comeal sensitivity during the third trimester. There is also a modest increase in extracellular fluid in the lens during pregnancy, resulting in a tendency toward myopia. Intraocular pressure tends to decrease during the second half of pregnancy, sug­gesting that glaucoma and its sequelae might be less common in pregnant women. Because there are no normal pregnancy-as­sociated changes in the retina, any observed retinal changes must be explored further. The pituitary gland increases in size during pregnancy, and a modest bitemporal hemi­anopsia can occur in some women. There are no other normal pregnancy- associated changes in the optic nerve, chiasm, or retrochiasmatic structures. Spe­cifically, normal pregnancy is not associated with increased intracranial pressure or papilledema. Otorhinolaryngologic Changes Most otorhinolaryngologic changes asso­ciated with pregnancy are the result of pro­gesterone- mediated mucosal hyperemia. This hyperemia is most apparent in the oropharynx. Hyperemia of the nasal mu­cosa increases the frequency and severity of epistaxies and may cause symptomatic na­sal congestion. In pronounced cases, this occurrence may be misinterpreted as a chronic upper respiratory infection, and only modest improvement is achieved with medications. However, these symptoms dramatically resolve 2-3 days postpartum, in conjunction with the postpartum de­crease in mucosal hyperemia. In addition, pregnant women with preexisting periodontal disease can antici­pate exacerbation. There are changes in the oral cavity microbial flora that approximate those seen in the reproductive tract. Mucosal edema in the oropharynx has significant anesthetic implications. As mu­cosal edema increases, especially in the third trimester or with preeclampsia, intu­bation and general anesthesia become more difficult. The visibility necessary for intu­bation may be compromised, requiring fi­beroptic procedures, awake intubations, or, possibly, a significant delay of surgical pro­cedures. In extreme emergencies, the sur­geon must be prepared always to perform a tracheostomy to restore the maternal air­way. Mucosal hyperemia may predispose a woman to functional occlusion of the eu­stachian canal. This occlusion frequently becomes symptomatic when pregnant women experience sudden changes in alti­tude (e.g., during travel by airplane). The modest increase in extracellular fluid in the semicircular canals also may explain in part why pregnant women are likely to experi­ence transient dizziness with sudden changes in position. Pregnant women are also relatively more likely to experience symptomatic accumulation of cerumen in the external auditory canal. Endocrine System The endocrine system undergoes profound alterations during pregnancy. Many of theseSurgical Implications of Physiologic Changes 247 changes reflect progressive estrogen-me­diated increases in hormone binding pro­teins. Although hypothalamic function appears unaltered during pregnancy, there is a pro­gressive increase in pituitary size and blood flow during pregnancy- This increase in pi­tuitary blood flow is responsible partly for the increased susceptibility of the gland to ischemic necrosis during pregnancy and the immediate puerperium (Sheehan's syn­drome). Prolactin levels progressively increase from early in pregnancy. This change has obvious clinical importance, because it ne­gates the usefulness of this blood test for diagnosing or following prolactinomas. Pregnancy is associated with a progres­sive increase in thyroid-binding globulin. This increase results in a characteristic al­teration in thyroid-function tests with an increase in total T4, a decrease in Trresin uptake, and an unchanged thyroid function index (reported by most laboratories as a T7 or free-thyroid index) (Table 4). Al­though recent laboratory analysis suggests that there may be a modest increase in free T4 during pregnancy, this increase in free T4 is controversial and is not of major clin­ical significance. Pregnancy is also associated with a pro­gressive increase in corticosteroid-binding globulin, resulting in an elevated plasma cortisol concentration. By the end of preg­nancy, this increase in total cortisol may be as much as a threefold. Because the pro­portion of bound and free cortisol does not change during pregnancy, there is a relative increase in free cortisol during pregnancy. Although these increased levels may overlap with levels seen in Cushing's syndrome, diurnal variability is preserved and serves as a potentially valuable clinical discrimi­nator. There is no consistent increase in total weight of the normal adrenal gland, al­though there is a relative increase in the zona fasciculata. The zona fasciculata is re- TABLE 4. Pregnancy-Associated Changes in Thyroid Function Tests Nonpregnant Pregnant TBG (ng/dl) 19-30 40-60 T4 (ng/dl) 5-10 8-16 Tj (ng/dl) 65-14 140-180 RT3U (%) 30-40 <30 FTI ("T7) 1.5-4.0 1.5-4.0 sponsible for glucocorticoid production. Its increase is compatible with laboratory ob­servations that the increase in circulating glucocorticoids is the result not only of in­creased corticosteroid-binding globulin and decreased clearance, but of increased pro­duction as well. Those changes return to, or below, prepregnant values within the first 2 weeks postpartum and may explain in part the pregnancy-associated improvement of some autoimmune diseases (notably rheu­matoid arthritis) as well as the puerperal exacerbation of others (e.g., systemic lupus erythematosus). Other alterations occur in maternal cor­ticosteroid concentrations that are not the exclusive result of altered maternal physi­ology. Pregnancy is associated with pro­gressive increases in deoxycorticosterone, but this reflects increased production by the fetoplacental unit. Maternal levels are not affected either by adrenocorticotrophic hormone administration or by dexameth- asone suppression. The adrenal medulla also is affected by pregnancy. Normal pregnancy is associated with a substantial and progressive increase in aldosterone levels. This increase pro­motes sodium reabsorption in the renal tu­bules. Although estrogens and deoxycorti­costerone also function in this way, the ma­jor increase in circulating aldosterone levels is the predominant mechanism by which the net sodium requirements of pregnancy (900-1,000 mEq Na+ in the fetus, placenta, and maternal intra- and extra-vascular space) are met These changes are necessary because there otherwise exists during preg­ 248 MARTIN AND VARNER nancy the possibility of a significant natri- uresis as a result of the increased glomerular filtration rate and increasing progesterone concentrations. Normal pregnancy is characterized by accelerated starvation in the fasting state. Fasting blood sugars are normally 10-15 mg% below those seen in the nonpregnant state. This is the result primarily of the con­tinuous transplacental metabolic drain of glucose to the fetus and is not due to a per­sistent hyperinsulinemia. In fact, the unfed state generally is thought to be associated with hypoinsulinemia. During pregnancy, starvation predisposes the woman to ketosis because of rapid transplacental shunting of glucose and a decrease in serum buffering capacity. On the other hand, the fed state during pregnancy is characterized by hy­perglycemia and hyperinsulinemia. This apparently paradoxical situation is ex­plained by the progressive increase of hor­mones that are functional insulin antago­nists. These include estrogens, progestins, adrenal corticosteroids, and human pla­cental lactogen. These result in a 60-80% increase in insulin resistance during preg­nancy. While most pregnant women respond to these changes by producing sufficient extra insulin, 44-6% of pregnant women will be unable to increase their insulin production adequately and will develop gestational di­abetes. Women particularly prone to this complication include those who have a family history of type II diabetes or are obese, and those who have a past obstetric history of delivering large or anomalous babies or having unexplained stillbirths. Together, the fetus and placenta produce the majority of biologically active hormones in the maternal compartment. Human cho­rionic gonadotropin, synthesized by the syncytiotrophoblast in the placenta, is a lu- teotrophic agent that maintains the corpus luteum during early pregnancy. It also en­hances steroidogenesis in the placenta and the fetal adrenal gland and also is of value as a tumor marker for various trophoblastic and nontrophoblastic malignancies. Certain systemic diseases (e.g., urinary tract infec­tion, proteinuria, hematuria, and systemic lupus erythematosus) can cause false-posi­tive human chorionic gonadotropin assays, as can certain drugs (i.e., phenothiazines, barbiturates, methadone, and penicillin). As previously mentioned, progesterone causes numerous physiologic effects in pregnancy. In the first few weeks after con­ception, it is produced primarily by the cor­pus luteum. After the first 8-10 weeks, the majority of progesterone is produced by the fetoplacental unit. Human placental lactogen production by the syncytiotrophoblast is directly propor­tional to the functional placental size. It is secreted primarily into the maternal com­partment, where it facilitates adequate nu­trient delivery to the fetus (lipolysis, ma­ternal insulin antagonism).9 Orthopedic Changes Pregnancy is characterized by progressive ligamentous laxity, especially of the weight­bearing joints. This is caused by the effects of progesterone and relaxin. Mobility of the pelvic synchondroses and the pubic sym­physis can be demonstrated radiographi- cally and undoubtedly facilitates normal vaginal delivery. Unfortunately, these changes also may lead to pelvic discomfort late in pregnancy. In an attempt to maintain the center of balance over the legs, the preg­nant woman experiences progressive out­ward rotation of the femurs as well as lum­bar lordosis with thoracic kyphosis and cer­vical lordosis. Consequently, there is a greatly increased incidence of low back dis­comfort and exacerbation of preexisting lumbosacral disc disease. These changes predispose the pregnant woman to an un­steady gait, and pregnancy is a period of increased risk for falls and other trauma. However, pregnancy also is associated with increased rates of domestic violence, andSurgical Implications of Physiologic Changes 249 this possibility always should be considered in the differential diagnosis of orthopedic and soft tissue injury. The increase in extracellular fluid accu­mulation during pregnancy predisposes the pregnant woman to entrapment syndromes, particularly carpal tunnel syndrome. Total maternal serum calcium concentrations gradually decrease during pregnancy, pri­marily because of the progressive decrease in serum albumin that occurs during preg­nancy. 10 The ionized calcium concentration remains unchanged during gestation, in spite of several changes that might be ex­pected to cause a decrease. These changes include transplacental calcium transfer, in­creased extracellular fluid volume, and the increased glomerular filtration rate. The ionized calcium concentration is main­tained at a normal nonpregnant level as a result of a progressive increase in the para­thyroid hormone concentration, which reaches over 100% above nonpregnant val­ues by term. In spite of this increase in parathyroid hormone concentration, no significant calcium is lost from bone, per­haps because of a secondary increase in cal­citonin concentration during pregnancy. Neurologic Changes There is no evidence that central nervous system blood flow is altered by pregnancy, although pregnancy does seem to increase the frequency of cerebrovascular disease. The majority of physiologic changes in the nervous system reflect peripheral nerve en­trapment syndromes due to increased ex­tracellular fluid retention or hormonally mediated ligamentous relaxation. Muscle cramps are distinctly more com­mon during pregnancy. It is estimated that as many as 30% of pregnant women expe­rience painful muscle cramps,1 ,J2 almost always involving the leg muscles and fre­quently occurring at night. The cause of leg cramps during pregnancy remains un­known. It clearly is not related to precon- ceptual conditioning, although vigorous exercise may aggravate the tendency. Like­wise, women who experience leg cramps before conception may find them to occur more frequently and be more severe during pregnancy, particularly if other predispos­ing factors, such as salt depletion, dehydra­tion, uremia, or hypothyroidism also are present. Likewise, certain rare medical complications may be associated with mus­cle cramps plus generalized weakness in­cluding extrapyramidal or pyramidal dis orders, amyotrophic lateral sclerosis, tetanus, or myophosphorylase deficiency (McArdle's Disease). Renal System The major renal adaptations to pregnancy result from pregnant woman's efforts to clear not only her own fixed metabolic wastes but those of the fetus as well. This is accomplished via increased renal blood flow and glomerular filtration. Increased renal blood flow is associated with an in­crease in renal vascular and interstitial vol­ume, resulting in increased renal size during pregnancy. Whether measured by renal plasma flow or glomerular filtration rate, renal blood flow increases within a few weeks after conception. This increase is as­sociated with many alterations in normal laboratory values. There is an increase in creatinine clearance during pregnancy to an average of 110-160 ml/min, as well as a de­crease in serum creatinine concentration (normal value in pregnancy, < 0.9 mg%), serum blood urea nitrogen concentration (normal value in pregnancy, <15 mg%), and serum uric acid concentration (normal value in pregnancy, < 6 mg%). These changes are prominent by the end of the first trimester and are outlined in Table 5. It is important to remember these changes, because a patient with moderate renal disease may have falsely normal-ap­pearing laboratory parameters beyond the end of the first trimester. There is no sig-250 MARTIN AND VARNER TABLE 5. Changes during Pregnancy of Renal Function Parameters Relative Change Nonpregnant Late Pregnancy Renal plasma flow (ml/min) ^ Glomerular filtration rate (ml/min) Creatinine clearance Blood urea (BUN) (mg%) Creatinine (mg%) Uric acid (mg%) Plasma osmolality (mOsm/kg H20) Aldosterone (ng/I) Plasma renin activity Proteinuria (mg/24 hr) nificant increase in urinary protein excre­tion during pregnancy, although specimen contamination with vaginal secretions nor­mally may increase total urinary protein concentration to as much as 300 mg per 24 hours. Pregnancy is associated with progressive ureteral and renal pelvic dilation, resulting in a doubling of collecting-system volume due to the effects of progesterone on ureteral smooth muscle as well as compression by the enlarging uterus and infundibulopelvic ligaments. These changes, more prominent on the maternal right side than on the left, result in characteristic changes on intrave­nous pyelography, including ureteral dila­tion (greater on the right than the left), blunting of the renal calyces, and an in­crease in renal size. As a result of these changes, pregnant women with bacteriuria are at an increased risk for developing symptomatic upper urinary tract infection. Pregnancy per se does not increase the risk of asymptomatic bacteriuria. Plasma osmolality begins to decrease within the first month after conception, and by the end of the first trimester decreases by 10 mOsm/kg. This decrease is due pri­marily to a decrease in the serum sodium concentration. In spite of this change, so­dium metabolism is altered during preg­nancy to allow the accumulation of ap­proximately 1,000 mEq of sodium. Al­though the increases in glomerular filtration 428 695 100 -*• 18 150 ±30 80-120 120-180 10-20 ^ 15 0.7-1.4 £0.9 3.0-5.4 2.0-4.7 285-*- 5 275 ± 5 100-200 200-700 0.45-1.28 3.33-4.09 100-300 100-300 rate and serum progesterone might be ex­pected to cause an increase in urinary so­dium excretion, these changes are more than offset by increased renal tubular reab­sorption. Renal tubular absorption is me­diated by increased concentrations of al­dosterone, desoxycorticosterone, and es­trogen during pregnancy. There are also significant changes in the renin-angiotensin system during preg­nancy, and these, in turn, are responsible for the observed increase in aldosterone. Plasma renin activity is increased by ap­proximately five times, as are concentra­tions of angiotensin and angiotensinogen. The normal pregnant woman has a sub­stantially reduced sensitivity to these va­sopressors, but their increase leads to the aforementioned increase in aldosterone production. Women who subsequently de­velop preeclampsia show evidence of in­creased sensitivity to these vasopressors many weeks before their disease becomes clinically evident. Recent evidence suggests that this altered sensitivity has a strong ge­netic component. Urinary glucose excretion is increased in most pregnant women, primarily because of the increased glomerular filtration rate. As a result, as much as 25% of all pregnant women have glycosuria during pregnancy. Clinicians appropriately manage diabetes via blood glucose determinations, because these physiologic alterations make urineSurgical Implications of Physiologic Changes 251 TABLE 6. Changes during Pregnancy in Serum Chemistries Reflecting Hepatic Function Parameter Change Normal Nonpregnant Value Late Pregnancy Value Total protein (g/dl) 1 6.5-7.5 5.7-6.5 Albumin (g/di) 1 3.2-3.8 2.4-3.1 Alkaline phosphatase (IU/1) t 30-115 100-210 Aspartate transaminase (IU/1) - 0-31 Unchanged Lactate dehydrogenase (IU/1) - 100-210 Unchanged Total bilirubin (mg/dl) - 0.26-1.00 Unchanged Prothrombin time (seconds) - 10-13 Unchanged Partial thromboplastin time (seconds) - 22-33 Unchanged Bleeding time - <;8 Unchanged Cholesterol (mg/dl) t 120-190 190-330 Triglycerides (mg/dl) t 76-92 205-247 glucose values unreliable. Likewise, there is a progressive urinary excretion of many, but not all, amino acids.13 Gastrointestinal System Most physiologic alterations of the gas­trointestinal tract during pregnancy are the result of progesterone-mediated smooth muscle relaxation or mechanical displace­ment of the abdominal viscera by the en­larging uterus. This displacement occurs in superior, lateral, and posterior directions. Progesterone causes a decrease in the tone of the functional gastroesophageal sphincter, resulting clinically in increased heartburn. Likewise, there is an increase in small bowel transit time, allowing more complete absorption of nutrients. The in­creased transit time in the colon promotes more complete water absorption and con­stipation. Although appendicitis is no more com­mon in pregnant women than it is in non­pregnant women, it is more serious in preg­nancy for the following reasons: the appen­dix is displaced upward and outward from McBumey's point (and therefore often misdiagnosed as cholecystitis) late in preg­nancy; there is a general reticence among physicians to perform exploratory laparot­omies on pregnant women; and, if the ap­pendix ruptures, the omentum is less ca­pable of preventing a generalized perito­nitis. 14 Cholecystitis may be another source of acute abdominal pain in a pregnant woman. While 95% of nonpregnant women have gallstone cholecystitis, gallstones are found in only 50-90% of pregnant woman with symptomatic cholecystitis. Murphy's sign is positive in only about 5% of pregnant women with cholecystitis, and laboratory tests of liver function are less likely to be abnormal during pregnancy. Although con­servative management is the initial treat­ment of choice, delaying appropriate sur­gical therapy is not warranted. Both open and laparoscopic techniques have been de­scribed during pregnancy with low compli­cation rates.15-17 There is no change in hepatic blood flow during pregnancy, but several serum chem­istries reflective of liver dysfunction may be altered by normal pregnancy (Table 6). There is a decrease in total protein and al­bumin concentrations. Serum alkaline phosphatase concentrations progressively increase during pregnancy and reflect pla­cental production (heat-stable) rather than obstructive liver disease or bone disease. Serum cholesterol levels increase through­out pregnancy and are approximately dou­ble the nonpregnant levels by term. There are no changes normally asso­ciated with pregnancy in the serum levels of transaminases, lactate dehydrogenase, and bilirubin. Alternative explanations for abnormalities in these values always must be sought.252 MARTIN AND VARNER Although concentrations of fibrinogen and factors VII-X increase during preg­nancy, concentrations of factors V and XII, as well as factor II (prothrombin), remain unchanged, and concentrations of factors XI and XIII decrease. There are no changes in the standard coagulation function tests, and the bleeding time is normal during pregnancy. Nonetheless, pregnancy gener­ally is considered a hypercoagulable state. Although pregnancy is associated with a 1.5-2.0-fold increase in thromboembolic disorders, the first few weeks of the puer- perium is actually the period of greatest risk, with relative risks generally noted to be be­tween four- and sixfold greater than in the nonpregnant state. This certainly demon­strates the importance of small vessel in­jury and stasis for the development of thromboembolic disorders. Acute abdominal pain, regardless of cause, is a great source of confusion for the physician and surgeon. Almost 50% of pre­operative diagnoses in pregnant women with acute abdominal pain are incorrect19; therefore, a firm preoperative diagnosis is not always essential. Although perinatal outcome depends on the severity of the un­derlying disease process, delay in the di­agnosis and therapy is the major cause of excessive maternal and fetal morbidity and mortality.1'1819 By far, the most common complication reported from surgical dis­eases and procedures is preterm labor. In addition to appendicitis and chole­cystitis, other potential surgical diseases in pregnancy include gallstone pancreatitis, adnexal masses or torsion, and acute trauma.2**22 Hematologic Changes Not only does maternal blood volume ex­pand by 30-50% during normal pregnancy, but circulating red blood cell mass also in­creases by 20-30%. The net result is that pregnant women have an apparent decrease in their hematocrit, even though their total oxygen carrying capacity is increased. This makes teleologic sense: If a pregnant woman must pump 30-50% more blood through her vascular system 30-50% faster than she does in the nonpregnant state, it would be easier to do if that blood were less viscous. Certainly, the once-held opinion that preg­nancy represented a "physiologic anemia" should be discarded. Normal pregnancy is associated with a 10-20% relative decrease in hematocrit, which is maximal at about 34 weeks' gestation. In fact, hematocrit lev­els that do not decrease are associated with failure of maternal volume expansion. This, in turn, places the pregnancy at risk for complications, including small-for-gesta- tional age fetus, premature labor, and still­birth. The increase in maternal blood vol­ume also protects the mother from hem­orrhage at the time of delivery, dissipates fetal metabolic heat, and provides adequate renal and placental perfusion. Although iron and folate supplementa­tion is appropriate to optimize maternal hematopoiesis, it need not be prescribed in quantities sufficient to maintain maternal hematocrits at nonpregnant levels. The purpose of iron supplementation during pregnancy is to prevent iron deficiency in the mother, not to maintain the maternal hematocrit or supplement the fetus. Iron is transported actively across the placenta, even with clinical and laboratory evidence of iron deficiency in the mother. In this re­gard, red blood cell indices do not change during a normal pregnancy. Peripheral white blood cell counts pro­gressively increase during pregnancy. By the end of the first trimester, the average white blood cell count is between 9,000 cells/mm and 10,000 cells/mm,3 with a modest fur­ther increase through the second and third trimesters. Labor and the immediate puer- perium may be associated with a substantial leukocytosis, to as high as 20,000-30,000 cells/mm3 and do not necessarily reflect other underlying pathology. These increases are primarily in leukocytes. Although theSurgical Implications of Physiologic Changes 253 number of lymphocytes remains un­changed, the number of helper T3-cells de­creases through the course of pregnancy. This suggests that the acquired immune de­ficiency syndrome may be unmasked or ex­acerbated by pregnancy, although there is no clinical evidence for this hypothesis. Platelet counts decrease modestly during pregnancy, although the platelet count in a normal pregnancy should remain within the normal range for a nonpregnant woman. There is evidence to suggest that the average platelet lifespan is somewhat shorter during pregnancy. This is manifested by a modest increase in platelet size during pregnancy, reflecting the presence of younger, and therefore larger, platelets in the peripheral circulation. Platelets also are likely to ag­gregate in late pregnancy and the puerper- ium. This may explain in part the increased incidence of cerebrovascular disease during this time. The relative increase in circulating coag­ulation factors during pregnancy is associated with an increased incidence of cerebrovas­cular disease. This increase is particularly prominent in the first few weeks postpartum, especially if the pregnancy has been compli­cated by preeclampsia, chronic hypertension, or a significant hypotensive episode. Dermatologic Changes Pregnancy is associated with progressive, in­creased pigmentation in areas of high mela­nocyte concentration, particularly the eyelids, areola, linea nigra, and external genitalia. This is the combined effect of progressive increases of melanocyte-stimulating hormone, estro­gen, and progesterone. Estrogen and proges­terone also seem to be responsible for the oc­casional development of chloasma in preg­nant women. This frequently is referred to as the "mask of pregnancy" and represents a photosensitive hyperpigmentation. It also may be seen in women taking oral contra­ceptives. Although this condition may fade after delivery, little can be done to treat it, and it is best prevented with sunscreen prep­arations. Palmar erythema and/or spider nevi are seen commonly in pregnant women, with two thirds of women having one or both. The spider nevi are most common over the area of superior vena cava distribution. These changes reflect the progressive in­crease in circulating estrogen levels during pregnancy and do not represent hepatocel­lular dysfunction. Pregnant women frequently report that their hair is coarser and/or straighter than normal. Alopecia is seen occasionally in as­sociation with pregnancy but is very com­mon at 2-4 months postpartum. This is a transient phenomenon and should be ex­pected to be resolved by 6-12 months post­partum. Pregnancy also may be associated with a more masculine hair distribution pattern. This reflects a modest but progressive in­crease in circulating androgen levels during pregnancy, and patients can be reassured that these changes will be resolved post­partum. Significant masculinization is not normal and requires further investigation. Women are more diaphoretic during pregnancy. In a large part, this represents their need to dissipate not only their own metabolic heat but that of the fetus as well. Stretch marks, or striae, are common in pregnancy, being somewhat more common in women who are tall, obese, or blonde. They are seen most commonly on the breasts, lower abdomen, buttocks, and an­terior thigh. Their cause remains unclear but is probably a combination of collagen- fibril weakening and mechanical disruption by expanding underlying tissue in geneti­cally predisposed individuals. There as yet is no effective prophylaxis. Psychiatric/Psychologic Changes Most pregnant women have some degree of anxiety or apprehension about their preg­ 254 MARTIN AND VARNER nancy. This often is evident as the fear of delivering an abnormal infant, concern about injury or pain during labor and de­livery, or ambivalence toward the preg­nancy or parenthood. Appreciation that these apprehensions are common allows the health care provider to resolve them with explanations and/or counselling. Pregnancy, labor and delivery, and par­enthood are stressful events. Therefore, they might be expected to unmask latent psy­chiatric disease or psychologic dysfunction. This issue is confused further by the pro­found hormonal changes that occur during pregnancy and the puerperium, which may have psychologic implications. Postpartum depression is a very common occurrence, with over half of all puerperal women having some degree of transient depression. This occurs most commonly around 3-7 days postpartum. As long as it is short lived (a few days) and is not asso­ciated with suicidal thoughts or attempts or delusional ideation, patients may be reas­sured. If any of the above psychiatric signs are seen, however, prompt psychiatric con­sultation is mandatory. Conclusion Almost every system is affected in some manner by pregnancy and the postpartum period. This may have profound effects on the course of surgical diseases in these women, the choice of diagnosis, and the treatment protocols used to treat them. It therefore is important for physicians deal­ing with women in the reproductive age group, especially during pregnancy, to ob­tain a working knowledge of the physiologic state of pregnancy and the puerperium. It also is important to remember that the most severe complications from surgical diseases in pregnant women result fr^m delayed di­agnosis and subsequently delayed treat­ment. Some of these complications can be avoided, given adequate understanding of the changes occurring during pregnancy and the puerperium along with the knowledge of the surgical disease processes. References 1. Dudley D, Cruikshank D. Trauma and acute surgical emergencies in pregnancy. Semin Perinatol. 1990;14:42-51. 2. Institute of Medicine, Subcommittee for a Clinical Application Guide, Committee on Nutritional Status During Pregnancy and Lactation, National Academy of Sciences. Nutrition during Pregnancy: An Implemen­tation Guide. Washington, DC: National Academy; 1992. 3. 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