Body Water During Pregnancy: Physiology, Clinical Significance and Assessment Methods: A Narrative Review

Total body water (TBW) undergoes substantial physiological expansion during pregnancy, reflecting coordinated cardiovascular, renal, and endocrine adaptations required to support maternal metabolism, uteroplacental perfusion, and fetal growth. These changes involve not only an overall increase in body water but also shifts in the distribution of extracellular water (ECW) and intracellular water (ICW), which influence maternal body composition, the interpretation of biochemical biomarkers affected by hemodilution, and pregnancy-related clinical outcomes. Despite its physiological and clinical relevance, the regulation and assessment of body-water compartments during pregnancy remain insufficiently integrated within nutritional and clinical research. This narrative review synthesizes current knowledge on the physiological regulation of TBW and its compartments across gestation and provides a critical analysis of the methodological approaches used to assess body-water distribution in pregnant populations. We review the mechanisms underlying plasma volume expansion, interstitial fluid accumulation, and tissue hydration, and discuss their implications for fetal growth, hypertensive disorders of pregnancy, and gestational diabetes mellitus. We also examine the principles, strengths, and limitations of the main techniques used to assess TBW and body-water compartments during pregnancy. Isotope dilution using stable isotopes (²H₂O and H₂¹⁸O) remains the reference method for TBW assessment, whereas bioelectrical impedance-based approaches, including bioelectrical impedance analysis (BIA), bioelectrical impedance spectroscopy (BIS), and bioelectrical impedance vector analysis (BIVA), offer practical alternatives for longitudinal monitoring of fluid redistribution during gestation. By integrating physiological and methodological perspectives, this review provides a framework for understanding body-water dynamics during pregnancy and for selecting appropriate approaches to assess maternal body composition and hydration.