Maternal Changes

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MATERNAL PHYSIOLOGICAL CHANGES

A. Changes in Blood Volume

Parturients undergo remarkable changes during pregnancy, labor, and the immediate postpartum period that can directly affect anesthetic techniques; hence a broad knowledge of these changes is essential for proper management of these women. Maternal blood volume increases during pregnancy, and this involves an increase in plasma volume as well as in red cell and white cell volumes. The plasma volume increases by 40% to 50%, whereas the red cell volume goes up by only 15% to 20%, which causes a situation that is described as “physiological anemia of pregnancy” (normal hemoglobin,
12 g/dL; hematocrit, 35). Because of this apparent hemodilution, blood viscosity decreases by approximately 20%. The exact mechanism of this increase in plasma volume is unknown. However, several hormones such as reninangiotensin-aldosterone, atrial natriuretic peptide, estrogen, and progesterone may be involved in this interesting phenomenon. Two current hypothesis attribute the increase to (1) an underfill state caused by initial vasodilation, which stimulates hormones such as renin, angiotensin, and aldosterone or (2) an overfill state characterized by an early increase in sodium retention (due to an increase in mineralcorticoids) that retains fluid, causing an increase in blood volume. Levels of clotting factors I, VII, VIII, IX, X, and XII, and the fibrinogen count are elevated during pregnancy as well. At present the majority of observers report a statistically significant fall in platelet count as pregnancy progresses.3 A recent study that observed an increase in thrombopoietin with the advancement of the gestational age also confirmed this finding. Systemic fibrinolysis also may increase slightly.

Clinical Implications

The increased blood volume serves several important functions: (1) it takes care of the…...

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