Cardiovascular and lymphatic systems

During pregnancy the increasing needs of the growing fetus and of her own tissues throw an added burden on the mother’s heart. The work that the heart does is measured by the amount of blood it expels per minute (the cardiac output). Rapid increase in the cardiac output occurs between the 9th and the 14th week of gestation. During the period from the 28th to the 30th week, when the load is heaviest, the heart of a pregnant woman is doing 25 to 30 percent more work than it was doing before pregnancy. As the time of delivery approaches, the heart’s workload diminishes to some extent; when the baby is born, the load is approximately equal to what it was when the mother was in the nonpregnant state. This decrease in cardiac output and cardiac work, which occurs in spite of the continued needs of the fetus and of the maternal tissues for blood-borne oxygen and nutriments, is explained by the more efficient way that the tissues draw on the mother’s blood for oxygen and nourishment during the terminal weeks of pregnancy.

The position of the heart is changed to a greater or lesser degree during pregnancy. As the uterus enlarges, it elevates the diaphragm. This in turn pushes the heart upward, to the left, and somewhat forward, so that it is nearer the chest wall beneath the breast. Near the end of gestation the large uterus may raise the heart until the latter lies almost at a right angle to the long axis of the woman’s body. These changes, which also bring some rotation of the heart, vary considerably in different individuals. When present to a marked degree, they may give an examining physician the erroneous impression that a normal heart is considerably enlarged. Actually, in spite of its greater workload, a healthy heart enlarges little or not at all even during the midportion of pregnancy, when the load is greatest.

Changes in the position of the heart, the greater workload, the increased volume of blood that the heart expels per beat, the decreased viscosity of the blood, and the larger amount of blood in the woman’s blood vessels (discussed below) will, in many women, cause some distortion of the sounds that the physician hears when listening to a patient’s heart with a stethoscope. Such distorted sounds, called “functional” murmurs (as distinguished from “organic” murmurs, which may be present when the heart is diseased), do not indicate that anything is amiss, although they may be sufficiently atypical to cause the obstetrician to refer the patient to a cardiologist for evaluation. Pregnancy sometimes produces minor changes in the electrocardiogram, but these changes are within normal limits.

Such is the ability of the heart to respond to an increased workload that even the pregnant woman with serious heart disease, given proper care and without an unexpected complication, will usually go through her pregnancy and delivery without a catastrophe. She may, however, encounter difficulty when she tries to cope with the stress of caring for her family after the baby is born.

Normal pregnancy does not increase the mother’s blood pressure. Indeed, a slight lowering of the blood pressure is commonly noted during the course of the pregnancy. Any notable rise in a pregnant woman’s blood pressure is reason for alertness on the part of her physician, and, if it continues to rise, for concern; it usually foretells the onset of preeclampsia (see below).

The pulse rate is a trifle more rapid during pregnancy, reflecting the more rapid heartbeat that is necessary in order to move the larger volume of blood present. The rate at which blood flows through the myriad of small blood vessels in the skin (the peripheral circulation) is accelerated during pregnancy, leading to the elevated skin temperature, the tendency to perspire, and, in part, to the redness of the palms and the tiny dilated blood vessels in some women as their pregnancies progress.

The most notable change in the circulatory system during pregnancy, other than those described in the heart, is a slowing of the blood flow in the lower extremities. With this decrease in the rate of flow there is an increase in the pressure within the veins and some stasis—stagnation—of the blood in the legs. These changes, which are believed to be caused primarily by the pressure of the uterus on the large blood vessels in the pelvis, are progressive during pregnancy and disappear after delivery. They also are thought to be caused in part by the marked increase in the amounts of the hormones estrogen and progesterone in the circulating blood. Increased venous pressure, slowing of the rate of venous flow, and partial stasis of the blood in the veins are major factors in causing the swelling of the legs and the varicose (abnormally dilated) veins of the lower legs that are commonly present near the end of pregnancy.

The lymphatic vessels of the pregnant woman’s pelvis become enlarged in response to the increased amount of tissue fluid in the engorged pelvic organs. As the uterus grows in size, it presses on these channels, causing impairment of the lymphatic drainage from the woman’s legs, with resultant swelling and distention of her feet and legs.

Although some fluid almost invariably collects in the feet, ankles, and legs near the time of delivery, sudden swelling of the feet and legs or a notable increase in swelling may be an early signal of impending preeclampsia, a serious disorder of pregnancy that is discussed below. Generalized swelling—i.e., swelling of the hands, face, and other parts of the body—is a cause for serious concern.

Respiratory tract

One would expect that, as the uterus grows larger and pushes the diaphragm up, it would interfere with breathing, but the lungs actually work as efficiently as they do in the nonpregnant state. This is due to a change in the shape of the chest cavity during pregnancy; the chest diameter increases as its height decreases, so that there is actually a slight increase in the space that the lungs occupy.

The amount of air drawn in and expelled per minute by the lungs increases progressively during pregnancy. Immediately before delivery the number of breaths per minute is approximately twice what it is after the baby is born. This, like so many of the other changes in the mother’s body, is an adaptation of one of her vital functions that is necessary to supply her tissues and those of the growing fetus with increasing amounts of oxygen.