Question 18

Describe the respiratory changes that occur throughout pregnancy.

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College Answer

The question asked for a description of the respiratory changes throughout pregnancy, which includes labour. Simple lists of changes did not score highly. A straightforward structure including; first, second and third trimester delineation would have elevated many answers from below par to a pass. Many good answers gave succinct detail on both mechanical respiratory changes and the hormonal mechanisms behind them. Higher scoring answers also described the overall effect of individual changes to spirometry, geometry or respiratory control.

Discussion

Respiratory Changes that Occur in Pregnancy

Pregnancy-related changes Effect of these changes
Airway function and structure
Mucosal oedema in the upper airway
  • Greater resistance to flow
  • Bag-valme-mask ventilation becomes more difficult
  • Greater risk of airway obstruction with sedation
Structural properties of the chest wall and lung volumes
Anatomical changes
  • The diaphragm is pushed up by 4cm
  • Diaphragmatic excusion increases by about 2cm
  • Rib cage expands: subcostal angle of the ribs at the xiphoidal level
    increases from 68.5° at the beginning of pregnancy to 103.5° at term
  • Anatomical dead space increases by about 445% due to increased airway diameter late in pregnancy
Lung volumes
  • Tidal volume increases  by ~ 30-50%
  • Respiratory rate increases  to 15-17
  • Minute volume increases by 20-50%.
  • TLC is reduced by about 5%
  • IC is increased by about 10%
  • FRC is decreased by about 20%
Compliance
  • Chest wall compliance decreases due to increased fat and abdominal content
  • Lung compliance remains the same

Resistance

  • Resistance to air flow in the lower airways increases in early pregnancy, and decreases in late pregnancy
  • FEV1/FVC is stable over the course of pregnancy
Gas exchange and gas transport
Blood gas tension
  • PaCO2 decreases
  • PaO2 increases
Oxygen-carrying capacity
  • Maternal erythrocytes produce higher levels of 2,3-DPG
  • p50 remains normal (by the combined effects of 2,3-DPG increase and alkalosis)
Control of ventilation

Central respiratory control

  • Progesterone-associated chronic respiratory alkalosis develops (due to increased sensitivity to CO2)
Respiratory workload and demand

Demands on the respiratory system

  • Increased body mass (increased weight plus one extra organism on board) = increased total body oxygen demand (by about 21%)  and increased ventilatory requirements for the clearance of the excess CO2
  • During labour, the oxygen consumption increases by about 60%.


 

References

Yeomans, Edward R., and Larry C. Gilstrap III. "Physiologic changes in pregnancy and their impact on critical care." Critical care medicine 33.10 (2005): S256-S258.

Hegewald, Matthew J., and Robert O. Crapo. "Respiratory physiology in pregnancy." Clinics in chest medicine 32.1 (2011): 1-13.

LoMauro, Antonella, and Andrea Aliverti. "Respiratory physiology of pregnancy: physiology masterclass." Breathe 11.4 (2015): 297-301.