Maternal Changes Maternal Changes with Pregnancywith Pregnancy

Pregnancy is a period of Pregnancy is a period of adaptation for :adaptation for :

• The needs of the fetus The needs of the fetus

• Meeting the stress of Meeting the stress of pregnancy and labourpregnancy and labour

THE THE GENITAL GENITAL

CHANGESCHANGES

(A) The whole (A) The whole uterusuterus

increase from increase from 7.5 x 5 x 2.5 7.5 x 5 x 2.5 cmcm in nonpregnant states in nonpregnant states to to 35 x 25 x 20 cm35 x 25 x 20 cm at term at term i.e. the volume increase i.e. the volume increase

1000 time1000 time

11 - - SizeSize

increases from increases from 50 gm50 gm in nonpregnant state in nonpregnant state to to 1000 gm1000 gm at term at term

22 - - WeightWeight

pyriform in the nonpregnant state ,

becomes globular at 8th week , then pyriform by

16th week till term .

33- - ShapeShape

with ascent from the pelvis , the uterus usually undergoes rotation

with tilting to the right (dextrorotation) due to the

presence of the rectosegmoid colon on the left side.

44 - - PositionPosition

5 - Consistency :5 - Consistency :

becomes progressively becomes progressively softer softer due to :due to :

i - Increased vascularity i - Increased vascularity ii - Presence of amniotic fluidii - Presence of amniotic fluid

from the first trimester from the first trimester onwards , the uterus onwards , the uterus

undergoes irregular painless undergoes irregular painless contractions contractions

(Braxton Hicks contractions)(Braxton Hicks contractions) . . They may cause some They may cause some

discomfort late in pregnancy discomfort late in pregnancy and may account for false and may account for false

labour pain .labour pain .

66- - ContractilityContractility

7- Capacity7- Capacity

increases from increases from 4 ml4 ml in non-pregnant in non-pregnant

state to state to 4000 ml4000 ml at term at term

(B) Myometrial (B) Myometrial changeschanges

1 - 1 - Hypertrophy Hypertrophy (estrogen (estrogen effect)effect) rather than rather than

hyperplasia hyperplasia (progesterone (progesterone effect)effect) till 14th weektill 14th week, then , then the fetus exerts a direct the fetus exerts a direct

stretchstretch

2 - Formation of 2 - Formation of the the lower uterine lower uterine segmentsegment (L.U.S.) (L.U.S.) from the isthmus from the isthmus

and lower half and lower half inch of the bodyinch of the body

Formation of lower Formation of lower uterine segmentuterine segment

After 12 weeks, After 12 weeks, the isthmusthe isthmus (0.5cm)(0.5cm) starts to expand starts to expand

gradually to form the lower gradually to form the lower uterine segment which uterine segment which

measures measures 10 cm10 cm in length at in length at termterm

Upper Uterine SegmentUpper Uterine Segment

• PeritoneumPeritoneum: : Firmly-attachedFirmly-attached

• Myometrium:Myometrium: 3 layers; outer 3 layers; outer longitudinal, middle oblique and longitudinal, middle oblique and inner circular. inner circular.

• The middle layer forms 8-shaped fibers The middle layer forms 8-shaped fibers around the blood vessels to control around the blood vessels to control

postpartum hemorrhagepostpartum hemorrhage

Upper Uterine SegmentUpper Uterine Segment

• Decidua:Decidua: Well-developedWell-developed

• Membranes:Membranes: Firmly-attachedFirmly-attached

• Activity:Activity: Active, contracts, Active, contracts, retracts and becomes thicker retracts and becomes thicker during labour.during labour.

Lower Uterine SegmentLower Uterine Segment

• PeritoneumPeritoneum: : Loosely-Loosely-attachedattached

• Myometrium Myometrium : : 2 layers; 2 layers; outer longitudinal and inner outer longitudinal and inner circular.circular.

Lower Uterine SegmentLower Uterine Segment

• DeciduaDecidua: : Poorly-developedPoorly-developed

• MembranesMembranes: : Loosely- Loosely- attached.attached.

• ActivityActivity:: Passive, dilates, Passive, dilates, stretches and becomes thinner stretches and becomes thinner during labourduring labour

The junction between the The junction between the upper uterine segment upper uterine segment

(U.U.S.) which is thick and the (U.U.S.) which is thick and the lower uterine segment which lower uterine segment which

is thin is called the is thin is called the physiologic contraction ringphysiologic contraction ring at the level of the symphysis at the level of the symphysis

pubis pubis (not seen or felt)(not seen or felt)

(C) Uterine (C) Uterine blood vesselsblood vessels

1 1 - - Uterine artery lumen:Uterine artery lumen:is doubled and its blood flow is doubled and its blood flow

increases 5 times increases 5 times 2 - 2 - Myometrial and decidual Myometrial and decidual

arteriesarteries (spiral arteries) undergo (spiral arteries) undergo fibrinoid degeneration due to 2 fibrinoid degeneration due to 2 waves of trophoblastic migration , waves of trophoblastic migration , so they become dilated to be the so they become dilated to be the uteroplacentaluteroplacental arteriesarteries

• Uterine blood flow Uterine blood flow increases increases

progressively and progressively and reaches about reaches about 500 500

ml / minute at termml / minute at term

(D) Changes in the cervix :(D) Changes in the cervix :

1 - 1 - It becomes It becomes hypertrophied , soft and hypertrophied , soft and bluishbluish in colour due to in colour due to oedema and increased oedema and increased

vascularity.vascularity.

2 - Soon after conception , a thick 2 - Soon after conception , a thick cervical secretion obstructs the cervical secretion obstructs the cervical canal forming a cervical canal forming a mucous plugmucous plug . .

3 - The endocervical epithelium 3 - The endocervical epithelium proliferates and or everted proliferates and or everted forming cervical ectopy forming cervical ectopy (previously called erosion)(previously called erosion)

(E) Changes in fallopian tubes (E) Changes in fallopian tubes and ligaments (round and broad):and ligaments (round and broad):

InactiveInactive , , elongatedelongated , , marked increase in marked increase in

vascularity vascularity There may be broad There may be broad

ligament ligament varicose veinsvaricose veins

(F) Changes in the vagina :(F) Changes in the vagina :

The vagina becomes The vagina becomes softsoft , , warmwarm , , moist moist with with

increased secretion and increased secretion and violetviolet in colour in colour

(Chadwick's sign)(Chadwick's sign) due to due to increased vascularityincreased vascularity

(G) Changes in the vulva :(G) Changes in the vulva :

•It becomes soft, violet in colour

• Oedema and varicosities may develop

(H) Changes in the ovaries(H) Changes in the ovaries

1 - Both ovaries are 1 - Both ovaries are enlarged due to increased enlarged due to increased vascularity and oedema vascularity and oedema particularly the ovary particularly the ovary

which conatins the corpus which conatins the corpus luteum .luteum .

(H) Changes in the ovaries(H) Changes in the ovaries

2 - Corpus luteum continues to 2 - Corpus luteum continues to grow till grow till 7 - 8 weeks7 - 8 weeks , then it , then it

stops growing stops growing

, It becomes , It becomes inactive and starts inactive and starts degeneration at 12 weeksdegeneration at 12 weeks

(degeneration is completed (degeneration is completed after labour) after labour)

Corpus luteum secretesCorpus luteum secretes

1.estrogen , 1.estrogen , 2.progesterone, 2.progesterone,

3.relaxin 3.relaxin

hormoneshormones

(H) Changes in the ovaries(H) Changes in the ovaries

3 - 3 - Ovulation ceases during Ovulation ceases during pregnancy due to pregnancy due to

pituitary inhibition by the pituitary inhibition by the high levels of oestrogen high levels of oestrogen

and progesteroneand progesterone

• RelaxinRelaxin is a protein is a protein hormone.hormone.

• Its exact role in pregnancy Its exact role in pregnancy is unknown. is unknown.

• It may induce It may induce softness and softness and effacementeffacement of the cervix. of the cervix.

II - Haematological II - Haematological ChangesChanges

(A) Blood volume(A) Blood volume

The total blood volume The total blood volume increases steadily from increases steadily from

early pregnancy to reach early pregnancy to reach a maximum of a maximum of 35-45 %35-45 % above the non-pregnant above the non-pregnant

level level at 32 weekat 32 week . .

- Plasma volume :Plasma volume :

Increases fromIncreases from 2600 2600 ml by ml by ± ± 45 %45 % ( (12501250 in the 1st in the 1st

pregnancy) and pregnancy) and 1500 1500 ml ml in subsequent pregnanciesin subsequent pregnancies

- Red blood cell massRed blood cell mass :

• Increases from Increases from 1400 ml1400 ml (nonpregnant) by (nonpregnant) by 33 %33 % (± 450 (± 450

ml) due to increased production ml) due to increased production resulting from resulting from erythropoeitin erythropoeitin

or action of hCG or HPL . or action of hCG or HPL .

• The increase is steady till full The increase is steady till full term.term.

The increase in plasma The increase in plasma volume is more than the volume is more than the increase in red blood cell increase in red blood cell mass (Hb mass) resulting mass (Hb mass) resulting

in haemodilution in haemodilution

(physiologic (physiologic anemia)anemia)

However, the However, the minimal Hb. minimal Hb. accepted isaccepted is

10-11 gm%10-11 gm%

Values of increased blood volumeValues of increased blood volume

1 - Meets increased demands 1 - Meets increased demands for uterus , baby .... etc .for uterus , baby .... etc .

2 - Protects against supine 2 - Protects against supine hypotension syndrome .hypotension syndrome .

3 - Protects against fluid loss 3 - Protects against fluid loss in labour .in labour .

Increased blood volume Increased blood volume more than the increase more than the increase in red cell mass , leads in red cell mass , leads

to to decreased blood decreased blood viscosityviscosity which leads which leads

to to decrease in decrease in peripheral resistanceperipheral resistance

(B) Blood (B) Blood indicesindices

1 - Decreased Hb % and RBCs % :

• Erythrocytes decrease from Erythrocytes decrease from 4.5 million / mm3 to 3.7 4.5 million / mm3 to 3.7

million / mm3million / mm3 (due to the (due to the relative increase in plasma relative increase in plasma volume more than red cell volume more than red cell

mass) . mass) .

ErythrocytesErythrocytes contentscontents

from from 2,3- DPG2,3- DPG increases increases which competes for 02 which competes for 02 binding sites in the Hb binding sites in the Hb

molecule , thus releasing molecule , thus releasing more 02 to the fetusmore 02 to the fetus . .

Hb concentrations Hb concentrations fallsfalls

from from 14 gm / dl14 gm / dl

ToTo

12 gm / dl.12 gm / dl.

2 -2 - M.C.H.CM.C.H.C : no change : no change

3 - 3 - M.C.V.M.C.V. : : , , or or no no change change (depending on (depending on the availability of Fe).the availability of Fe).

4- 4- FragilityFragility of R.B.Cs: of R.B.Cs: ..

5 - 5 - ReticulocytesReticulocytes : mild : mild

6 - 6 - E.S.R E.S.R :: from 12 to from 12 to 50 mm / hour50 mm / hour

7 – 7 – FibrinogenFibrinogen: : from from 200 - 400 mg / dl to 400 - 200 - 400 mg / dl to 400 - 600 mg / dl.600 mg / dl.

8 - 8 - White blood cells:White blood cells:

(from 7.000 / mm3 to 10.500 / (from 7.000 / mm3 to 10.500 / mm3 during pregnancy and up mm3 during pregnancy and up to 16.000 / mm3 during labour :to 16.000 / mm3 during labour :

- - PNL & its enzymes . PNL & its enzymes .

- Lymphocytes : no change .- Lymphocytes : no change .

9 - 9 - Platelets: or

10-Total plasma proteins : slightly

(mainly albumin) resulting in osmotic pressure.

(C) Coagulation (C) Coagulation system system

• PlateletsPlatelets or or . (controversial).. (controversial).

• FibrinogenFibrinogen doubled to 600 mg % doubled to 600 mg %

• Factor VIIIFactor VIII tripled . tripled .

• Factor VII & factor XFactor VII & factor X are are doubled doubled

• Factor XI & factor XIIIFactor XI & factor XIII slight slight

• Fibrinolytic activityFibrinolytic activity ..

• Therefore pregnancy is a Therefore pregnancy is a hypercoagulative statehypercoagulative state . .

• All these changes are All these changes are reversed after labour with reversed after labour with

RBCs production (not RBCs production (not destruction)& the excess Fe destruction)& the excess Fe

is stored .is stored .

Ill - Cardiovascular Ill - Cardiovascular system changessystem changes

(A) Changes in the heart(A) Changes in the heart

As the diaphragm is elevated As the diaphragm is elevated progressively during pregnancy progressively during pregnancy the apex is the apex is displaced upwards displaced upwards

and to the leftand to the left so that it lies in the so that it lies in the 4th intercostal space outside the 4th intercostal space outside the

midclavicular line.midclavicular line.

Position:Position:

Pulse rate :Pulse rate :

- The resting pulse rate The resting pulse rate increases by increases by 8 beats / min.8 beats / min.

(8 weeks) and (8 weeks) and 16 beats / min16 beats / min. . (full term).(full term).

-Some episodes of -Some episodes of ectopic beats ectopic beats - Water hummer pulse .- Water hummer pulse .

Heart soundsHeart sounds• The first heart soundThe first heart sound become become

louder before midpregnancy louder before midpregnancy and splitting of this sound may and splitting of this sound may occur due to earlier closer of the occur due to earlier closer of the mitral than the tricuspid valvemitral than the tricuspid valve

• The intensity of the The intensity of the second second heart soundheart sound may increase. may increase.

Heart soundsHeart sounds•The third soundThe third sound becomes louder before becomes louder before mid-pregnancy and mid-pregnancy and persists as such till one persists as such till one week post partum. week post partum.

•The fourth soundThe fourth sound may may be detectable by be detectable by phonocardiography.phonocardiography.

MurmursMurmursSystolic functional murmursSystolic functional murmurs

develop in most of women, usually develop in most of women, usually early systolicearly systolic, but , but mid systolic mid systolic

murmursmurmurs may occur and heard over may occur and heard over the left sternal edge,the left sternal edge,

they are thought to be due to they are thought to be due to functional tricuspid regurgitationfunctional tricuspid regurgitation

ECG CHANGESECG CHANGES• The main features of ECG may be The main features of ECG may be

attributed to the changes in the attributed to the changes in the position of the heart.position of the heart.

• The axisThe axis undergoes undergoes left shift by 15 - left shift by 15 - 28°. 28°.

• The The QRSQRS complexes become of complexes become of low low voltagevoltage, and , and T waveT wave becomes becomes flattenedflattened. .

(B) Haemodynamic (B) Haemodynamic changeschanges

1 - Cardiac output 1 - Cardiac output (C.O.P.)(C.O.P.)

Cardiac output:Cardiac output:

increases mainly by increased increases mainly by increased stroke volume rather than stroke volume rather than

increased heart rate reaching a increased heart rate reaching a maximum of 40%maximum of 40% above the above the

non-pregnant level non-pregnant level at 20 weeksat 20 weeks to be maintained till termto be maintained till term. .

Cardiac outputCardiac outputDistribution :Distribution :

• 400 ml400 ml to the to the uterusuterus , , • 300300 ml ml to the to the kidneyskidneys , ,• 300 ml300 ml to to skin skin ,,• 300 ml300 ml to to GIT GIT , , breast breast & &

heartheart

•Values : Distributes extra 02 •During labour :

C.O.P. increases more C.O.P. increases more particularly during the particularly during the

second stage due to second stage due to pain , pain , uterine contractions , and uterine contractions , and expulsive effortsexpulsive efforts pushing pushing the blood into the general the blood into the general

circulationcirculation

• Postpartum :

the increased the increased C.O.P. is C.O.P. is

maintained for up maintained for up to to 4 days4 days and then and then

declines rapidlydeclines rapidly

2 - Arterial blood 2 - Arterial blood pressurepressure

Although C.O.P. Although C.O.P. incease , yet incease , yet

A.B.P. is A.B.P. is decreaseddecreased in midtrimesterin midtrimester to to increase again in increase again in

3rd trimester3rd trimester

This is due to:i - - Decreased Peripheral Decreased Peripheral

resistanceresistance : :

(mainly affect diastolic B.P.) (mainly affect diastolic B.P.) due to :due to : vasodilatation + vasodilatation + increase metabolism + increase metabolism + arteriovenous shunt at arteriovenous shunt at

placenta .placenta .

ii - ii - Supine hypotensionSupine hypotension : :

may develop in some women in may develop in some women in late pregnancy while lying supine late pregnancy while lying supine due to compression on the I.V.C. due to compression on the I.V.C.

by the large pregnant uterus , by the large pregnant uterus , resulting in decreased venous resulting in decreased venous

returnreturn C.O.P. and low B.P. C.O.P. and low B.P. to the extent that to the extent that fainting fainting may may

occuroccur

iii -iii - Decreased Decreased sensitivity of blood sensitivity of blood

vesselsvessels to to angiotensin II angiotensin II which is vasoconstrictorwhich is vasoconstrictor

Vena Cava SyndromeVena Cava Syndrome

• The posture of the pregnant The posture of the pregnant woman affects arterial blood woman affects arterial blood pressure. pressure.

• Typically, it is Typically, it is highest when she highest when she is sittingis sitting, , lowest when lying in lowest when lying in the lateral recumbent positionthe lateral recumbent position and intermediate when supine.and intermediate when supine.

Peripheral Peripheral VasodilatationVasodilatation

blood flow to the skin, blood flow to the skin, particularly in the hands particularly in the hands and feet generally giving and feet generally giving the pregnant women a the pregnant women a

feeling of warmthfeeling of warmth

Peripheral VasodilatationPeripheral Vasodilatation

Peripheral VasodilatationPeripheral Vasodilatation

Increases the congestion of Increases the congestion of nasal mucosa leading to nasal mucosa leading to a common complaint of a common complaint of nasal obstruction and nasal obstruction and bleeding bleeding (epistaxis).(epistaxis).

3 - Venous pressure3 - Venous pressure

Increased venous pressure Increased venous pressure in the lower limbs due to :in the lower limbs due to :

1. 1. Back pressure from the compressed Back pressure from the compressed I.V.C. by the pregnant uterus .I.V.C. by the pregnant uterus .

2.Mechanical pressure of the uterus 2.Mechanical pressure of the uterus on pelvic veins .on pelvic veins .

3.Increased venous return from 3.Increased venous return from internal iliac veins --> increase internal iliac veins --> increase pressure in external iliac veins .pressure in external iliac veins .

Increased venous pressure Increased venous pressure in the lower limbsin the lower limbs

Predisposes to :Predisposes to :

Oedema ,Oedema ,

varicose veinsvaricose veins

and pilesand piles

Oedema and varicose veins in the Oedema and varicose veins in the lower limbs & vulva are due tolower limbs & vulva are due to

i - i - Venous pressure . Venous pressure .

ii - Relaxation of the smooth muscles in ii - Relaxation of the smooth muscles in the wall of the veins by progesterone the wall of the veins by progesterone

iii - iii - Osmotic pressure in blood . Osmotic pressure in blood .

iv - iv - Capillary permeability (due to Capillary permeability (due to progesterone and aldosterone).progesterone and aldosterone).

v - v - Interstitial pressure (Na retention). Interstitial pressure (Na retention).

Varicose Veins treatmentsVaricose Veins treatments

1. 1. avoid longavoid long periods of periods of standingstanding and encourage and encourage active exercise.active exercise.

2. avoid 2. avoid constricting clothesconstricting clothes..3. keep the 3. keep the legs elevatedlegs elevated while while

sitting and during sleep.sitting and during sleep.

4. use of elastic stockings. These should be removed at

night and applied with leg elevated before getting out of bed in the morning (empty veins).

5. stretch panties may be necessary for vulval varicosities.

IV - Respiratory IV - Respiratory systemsystem

(A) Anatomically:(A) Anatomically:

The enlarged The enlarged uterus displaces uterus displaces the diaphragmthe diaphragm up up

to ± 4 cm .to ± 4 cm .

This result in :This result in :1. 1. The diaphragmatic mobility The diaphragmatic mobility

is reduced and is reduced and respiration respiration becomes mainly thoracicbecomes mainly thoracic . .

2. 2. Widen the subcostal angleWiden the subcostal angle and increases the transverse and increases the transverse diameter of the chest.diameter of the chest.

Respiratory functionsRespiratory functions

The respiratory rateThe respiratory rate

does not increase during does not increase during pregnancy from its pregnancy from its

normal rate of normal rate of 14 - 15 / 14 - 15 / minute.minute.

Overbreathing

(deep respiration)

occurs due to the effect of excess progesterone

Shortness of breathShortness of breath (the need to breath becomes a (the need to breath becomes a

conscious one)conscious one) and and dyspneadyspnea are common are common complaint of the pregnant complaint of the pregnant

women which may be due to women which may be due to unfamiliarity with low C02 unfamiliarity with low C02

tension in the alveolar tension in the alveolar capillariescapillaries . .

The vital capacityThe vital capacity

1.The inspiratory capacity1.The inspiratory capacity (Tidal volume + (Tidal volume +

inspiratory volume) inspiratory volume) is is decreaseddecreased in late in late

pregnancy pregnancy

2.The expiratory reserve 2.The expiratory reserve volumevolume

(maximum amount of air (maximum amount of air which can be expired after which can be expired after

normal expiration) is normal expiration) is reducedreduced

3.The residual volume3.The residual volume is reduced .is reduced .

The reduction in:The reduction in:1.The inspiratory capacity1.The inspiratory capacity 2.The expiratory reserve 2.The expiratory reserve

volumevolume

3.The residual volume3.The residual volume is not significantis not significant ..

4.4.The tidal volumeThe tidal volume : :

(amount of gas inspired (amount of gas inspired or expired in each or expired in each respiration) respiration) risesrises

through out pregnancy through out pregnancy by about 40 % .by about 40 % .

Hyperventilation Hyperventilation is due to is due to

increased tidal increased tidal volume not volume not

respiratory rate respiratory rate

V - Urinary systemV - Urinary system

(A) Kidney and kidney (A) Kidney and kidney function testsfunction tests

• Renal blood flow and glomerular filtration rate

increases by 50 % . This leads to increased

excretion

• Therefore:Therefore:1.1. There is There is serum creatinine serum creatinine (due to (due to

creatinine cleareance) ,the same creatinine cleareance) ,the same for for uric aciduric acid..

2. 2. blood urea blood urea . .

3. 3. kidney excretion of glucose due to kidney excretion of glucose due to

filtration load and filtration load and renal renal threshold leading to threshold leading to renal renal glucosuria glucosuria

Therefore , in interpretating Therefore , in interpretating the results of kidney the results of kidney

function test you should function test you should take into consideration that take into consideration that

the highest normal values the highest normal values in pregnancy = the in pregnancy = the

lowest normal values in lowest normal values in non-pregnant statenon-pregnant state

(B) Ureters(B) Ureters

Dilatation of the ureters Dilatation of the ureters and renal pelvis due to :and renal pelvis due to :

i - Relaxation of the i - Relaxation of the ureters by the effect of ureters by the effect of

progesterone .progesterone .

ii - Pressure against the ii - Pressure against the pelvic brim by the uterus pelvic brim by the uterus particularly on the right particularly on the right side due to dextroposed side due to dextroposed uterus and dilatation of uterus and dilatation of

the right ovarian vesselsthe right ovarian vessels

(C) Bladder and urethra(C) Bladder and urethra

• Frequency of micturitionFrequency of micturition

in early pregnancy due to :in early pregnancy due to : i - Pressure on the bladder i - Pressure on the bladder

by the enlarged uterus .by the enlarged uterus . ii - Congestion of the ii - Congestion of the

bladder muscosa .bladder muscosa .

• Urinary stress incontinence

may develop for the first time during pregnancy (due to decreased intraurethral pressure and decreased length of the urethra)

and spontaneously relieved later on

VI - Gastrointestinal VI - Gastrointestinal tract tract

& liver& liver

1 - Gingivitis :1 - Gingivitis :

There is increased vascularity and tendency

for bleeding as well as hypertrophy of the

interdental papillae

• The gums may become The gums may become hyperemic and soft and may hyperemic and soft and may

bleedbleed when mildly traumatized, when mildly traumatized, as with a tooth brush. as with a tooth brush.

• Epulis of pregnancyEpulis of pregnancy

may develop.may develop.

Treated by dental hygiene and Treated by dental hygiene and cryosurgery for severe casescryosurgery for severe cases.

2 - Ptyalism:2 - Ptyalism:

• It is excessive salivation which is It is excessive salivation which is more common in association with more common in association with oral sepsis . oral sepsis .

• It is due to It is due to failure to swallowfailure to swallow saliva saliva and not due to increase in amount. and not due to increase in amount.

• Smoking is stopped and Smoking is stopped and anticholinergic drugs may helpanticholinergic drugs may help..

3 - Nausea and vomiting3 - Nausea and vomiting

Nausea (morning sickness) Nausea (morning sickness) and vomiting and vomiting

(emesis gravidarum) (emesis gravidarum) occur in early monthsoccur in early months

4 - Appetite changes4 - Appetite changes (longing or craving) (longing or craving)

• The pregnant woman dislikes The pregnant woman dislikes some foods and odours while some foods and odours while desires others desires others

• Reduced sensitivity of the Reduced sensitivity of the taste budstaste buds during pregnancy during pregnancy creates the desire for creates the desire for markedly sweet, sour , or salt markedly sweet, sour , or salt foods .foods .

(pica)(pica)Deviation may be so Deviation may be so

extreme to the extreme to the extent of eating extent of eating

blackboard chalk , blackboard chalk , coal or mudcoal or mud

5 - Indigestion 5 - Indigestion and flatulenceand flatulence

This is probably due to :This is probably due to :

i - Decreased gastric acidity i - Decreased gastric acidity caused by regurgitation of caused by regurgitation of alkaline secretion from the alkaline secretion from the intestine to the stomach . intestine to the stomach .

ii - Decreased gastric motility ii - Decreased gastric motility (progesterone effect).(progesterone effect).

6 - Heart burn6 - Heart burn

Due to reflux of acidic Due to reflux of acidic gastric contents to the gastric contents to the

oesophagus oesophagus

The treatment includes :The treatment includes :

(a) (a) small frequent mealssmall frequent meals to to prevent overdistension of prevent overdistension of the stomach ,The evening the stomach ,The evening meal should be taken at meal should be taken at

least 3 hours before going least 3 hours before going to bed to bed

(b) (b) avoidavoid fatty foods, fatty foods, chocolate, and smoking, as chocolate, and smoking, as

these relax the lower these relax the lower esophageal sphincter. esophageal sphincter.

(c) the (c) the bed should be raisedbed should be raised at the head (15-20 cm), and at the head (15-20 cm), and

an extra pillow is used. an extra pillow is used.

(d) (d) Antacid Antacid PreparationsPreparations

containing aluminium containing aluminium hydroxide are hydroxide are

favoured.favoured.

7 - Constipation7 - Constipation

due to :i - Reduced motility of large i - Reduced motility of large

intestine intestine (progesterone effect).(progesterone effect).

ii - Increased water reabsorption ii - Increased water reabsorption from large intestine from large intestine (aldosterone effect).(aldosterone effect).

7 - Constipation7 - Constipation

iii - Pressure on the pelvic colon by the pregnant uterus.

iv - Sedentary life during pregnancy .

It is treated byIt is treated by

(a) evacuation of the (a) evacuation of the bowel at the same bowel at the same

time each day time each day (bowel training)(bowel training)

(b) (b) diet rich in fiberdiet rich in fiber in in the form of vegetables, the form of vegetables, fruits, and bran fruits, and bran

(c) (c) milkmilk and avoid and avoid dehydration by dehydration by increasing fluid intake.increasing fluid intake.

(d) (d) minimize coffee and minimize coffee and teatea as they are diuretics as they are diuretics and cause dehydration.and cause dehydration.

(e) (e) increase physical increase physical activityactivity and avoid and avoid sedentary life. sedentary life.

(f) a (f) a mild laxativemild laxative may may be needed. Liquid be needed. Liquid paraffin is better paraffin is better

avoided as it prevents avoided as it prevents absorption of fat absorption of fat soluble vitamins. soluble vitamins.

In some women In some women iron iron

supplementationsupplementation may be the causemay be the cause

8 - Gall stones8 - Gall stones

More tendency to stone More tendency to stone formation due to atony formation due to atony and delayed emptying and delayed emptying

of the gall bladderof the gall bladder

9 - Haemorroids9 - Haemorroids

due to :due to :

i - Mechanical pressure on the pelvic veins.

ii - Laxity of the walls of the veins by progesterone

iii - Constipation.

10 - Appendix10 - Appendix

Is displaced upwards and laterally (pain and tenderness due to

appendicitis is higher than in nonpregnant state)

AppendixAppendix

LiverLiveri - Decreased albumin and Decreased albumin and

increased globulin resulting increased globulin resulting in in decreased A/G ratio decreased A/G ratio

ii - Increased heat labile serum ii - Increased heat labile serum alkaline phosphatase .alkaline phosphatase .

Therefore both Therefore both A/G A/G ratioratio and and heat labile heat labile alkaline phosphatasealkaline phosphatase

are not reliable as liver are not reliable as liver function tests during function tests during

pregnancy pregnancy

VII - Metabolic VII - Metabolic changeschanges

(A) Weight gain

The average The average weight gain in weight gain in pregnancy is pregnancy is

10 - 12 kg10 - 12 kg

The increase The increase occurs mainly in occurs mainly in the second and the second and

third trimester at a third trimester at a rate of rate of 350 - 400 350 - 400

gm/ weekgm/ week

Out of the 11 kg weight gainOut of the 11 kg weight gain

6 kg is 6 kg is composed ofcomposed of maternal tissuesmaternal tissues (breast, (breast,

fat, blood and uterine fat, blood and uterine tissues), and tissues), and

5 kg of fetal tissue , placenta 5 kg of fetal tissue , placenta and amniotic fluid and amniotic fluid

Maternal TissuesMaternal TissuesIncreases during weeks of Pregnancy

0

200

400

600

800

1000

1200

1400

1600

10 wk 20 wk 30 wk 40 wk

UterusMammary GlandPlasma Volume

King JC. Am J Clin Nutr 71 (5(S));2000.

Products of ConceptionProducts of ConceptionIncreases during weeks of PregnancyIncreases during weeks of Pregnancy

0

500

1000

1500

2000

2500

3000

3500

10 wk 20 wk 30 wk 40 wk

FetusPlacentaAmniotic Fluid

King JC. Am J Clin Nutr 71 (5(S));2000.

Out of the 11 kg Out of the 11 kg weight gainweight gain::

77 kg are waterkg are water, , 33 kg fat andkg fat and11 kg proteinkg protein

)B) Water metabolismB) Water metabolism

There is tendency to There is tendency to water retention water retention secondary to secondary to

sodium retentionsodium retention

(C) Protein metabolism(C) Protein metabolism

There is tendency for There is tendency for nitrogen retention nitrogen retention

(+ ve nitrogen balance)(+ ve nitrogen balance) for fetal and maternal for fetal and maternal

tissue formation tissue formation

(D) Carbohydrate metabolism(D) Carbohydrate metabolism

Pregnancy is potentially Pregnancy is potentially diabetogenicdiabetogenic

- - Alimentary glucosuriaAlimentary glucosuria may may occur in occur in earlyearly pregnancy . pregnancy .

- - Renal glucosuriaRenal glucosuria may occur in may occur in the the middlemiddle of pregnancy . of pregnancy .

(E) Fat metabolism(E) Fat metabolism

There is increase of plasma lipids with

tendency to acidosis (HPL action)

(F) Mineral metabolism

There is increased There is increased demand for iron , demand for iron ,

calcium , phosphate calcium , phosphate and magnesium and magnesium

VIII - Musculoskeletal VIII - Musculoskeletal changeschanges

(a) (a) Increased mobility of Increased mobility of pelvic jointspelvic joints due to due to softening of the joints and softening of the joints and ligaments caused byligaments caused by progesteroneprogesterone and and relaxinrelaxin

(b) (b) Flattening of feetsFlattening of feets . .

(c) (c) Progressive lordosisProgressive lordosis leading to lordotic gait & leading to lordotic gait & backache (backache ( by high by high heals).heals).

(d) (d) Pendulous abdomenPendulous abdomen in in multigravida resulting in multigravida resulting in many complicationsmany complications

BackacheBackache

• The majority of pregnant The majority of pregnant women complain of low women complain of low backache which increases backache which increases as pregnancy advances. as pregnancy advances.

• It is due to It is due to increased increased lumbar lordosislumbar lordosis to counter- to counter-balance the forward balance the forward growth of the uterusgrowth of the uterus

• This puts strain on ligaments and muscles leading to pain.

• Strain of sacroiliac joint is relatively common.

• Progesterone causes softening and relaxation of ligaments.

Backache is treated by:

(a) more periods of rest.

(b) use of maternity corset.

(c) local heat in the form of hot water bag or infrared lamp

(d) analgesics given systemically or as local creams, local creams, Paracetamol is the drug of Paracetamol is the drug of choice, Non-steroidal anti-choice, Non-steroidal anti-inflammatory drugs as inflammatory drugs as indomethacin may be given indomethacin may be given

(e) (e) physiotherapy physiotherapy may be may be needed.needed.

Orthopaedic Orthopaedic consultationconsultation is is

indicated if pain is indicated if pain is severe, or radiates severe, or radiates to the legs, and in to the legs, and in

the presence of the presence of neurological signsneurological signs

Leg crampsLeg cramps

• These are common in These are common in the the second halfsecond half of of

pregnancy particularly pregnancy particularly at nightat night..

• The exact cause is The exact cause is unknown.unknown.

It may be related to shift of It may be related to shift of blood away from the blood away from the

muscle, i.e., muscle, i.e., ischaemicischaemic cramp, or it may be cramp, or it may be tetanictetanic

cramp caused by lack of cramp caused by lack of calcium, or increased calcium, or increased phosphorous, or bothphosphorous, or both

• Treated byTreated by taking taking calcium calcium tabletstablets, and , and reducing the intake reducing the intake

of phosphorous-containing of phosphorous-containing substancessubstances as milk, meat, and as milk, meat, and

cheese.cheese.• Vitamin B complexVitamin B complex may be tried. may be tried.

• Leg massageLeg massage and and hyperextension of foot help hyperextension of foot help

during the attackduring the attack.

Round ligament strainRound ligament strain

• Pain is felt along the round Pain is felt along the round ligament and in the groin. ligament and in the groin.

• Pain unilateral and left-sided, Pain unilateral and left-sided, (dextroflexion ).(dextroflexion ).

• It is due to stretching of the It is due to stretching of the nerve fibres in the round nerve fibres in the round ligaments. ligaments.

IX - Endocrine IX - Endocrine systemsystem

1 - Anterior pituitary1 - Anterior pituitary

i - Increase in size i - Increase in size more than increase in more than increase in

vascularity vascularity This renders anterior This renders anterior

pituitary liable for pituitary liable for ischaemiaischaemia

ii - ii - Pregnancy cellPregnancy cell (modified (modified chromophobe) appears due chromophobe) appears due to increased hCG . to increased hCG .

iii - iii - Prolactin levelProlactin level increases increases up to 150 ng /ml at term to up to 150 ng /ml at term to ensure lactation . ensure lactation .

2 - Posterior pituitary2 - Posterior pituitary

Does not Does not hypertrophy , but hypertrophy , but

increase its increase its oxytocin secretion oxytocin secretion

near termnear term

3 - Thyroid gland3 - Thyroid gland

There is diffuse There is diffuse slight slight enlargement enlargement

of the glandof the gland

Gland activity is Gland activity is as as evidenced by normal free T4 evidenced by normal free T4 (although total T4 (although total T4 ) due to ) due to thyroid binding globulin thyroid binding globulin

(TBG) , (TBG) ,

BMR 20 % ,BMR 20 % , total T3 total T3 , , protein bound iodine andprotein bound iodine and

TSHTSH

4 - Parathyroid gland4 - Parathyroid gland

Hypertrophy due to Hypertrophy due to increased demand increased demand

for Calciumfor Calcium

5 - Suprarenal gland5 - Suprarenal gland

HypertrophyHypertrophy particularly the particularly the cortex cortex resulting in increased resulting in increased glucocorticoids glucocorticoids (cortisone)(cortisone)

and increased and increased mineralocorticoids mineralocorticoids

(aldosterone)(aldosterone)

6 - Insulin6 - Insulin

increased mainly increased mainly due to HPL due to HPL (anti - (anti - insulin hormone)insulin hormone)

7 -Ovaries7 -Ovaries

corpus luteum of corpus luteum of pregnancypregnancy

functions till 8-12 wks. functions till 8-12 wks. when its function is taken when its function is taken

by the placentaby the placenta

XI - Skin changesXI - Skin changes

1 - Persistance of basal Persistance of basal body temperature body temperature

(BBT) elevation(BBT) elevation beyond beyond the expected day of the expected day of

menstruation menstruation (due to increased (due to increased

progesterone).progesterone).

2 - Spider telangiectasis Spider telangiectasis & palmar erythema& palmar erythema

due to due to increased estrogenincreased estrogen

oror cutaneous vasodilatationcutaneous vasodilatation

3 - 3 - Cutaneous Cutaneous vasodilatation vasodilatation (hyperaemia)(hyperaemia)

leads to :leads to :ii - - Masks pallorMasks pallor due to due to anaemia with or without anaemia with or without palmar erythema . palmar erythema .

ii - ii - Glandular activities Glandular activities (sweat & sebaceous (sweat & sebaceous glands).glands).

iii - iii - Sensation of heat Sensation of heat and nasal congestionand nasal congestion

4 4 - Pigmentation- Pigmentationdue to increased estrogen due to increased estrogen

or or

melanocyte stimulating hormone melanocyte stimulating hormone

or or ACTHACTH

• In the faceIn the face = = chloasma chloasma graviderom = mask of graviderom = mask of

pregnancypregnancy a butterfly pigmentation a butterfly pigmentation on the cheeks and nose . on the cheeks and nose . It usually disappears few It usually disappears few

months after labourmonths after labour . .

•In abdomenIn abdomen::

Linea Nigra=Linea Nigra= pigmentation in pigmentation in

midline below the midline below the umbilicus umbilicus

Linea nigraLinea nigra

Stria gravidarumStria gravidarum

pigmentation in the lower pigmentation in the lower abdomen ,abdomen ,

flanks , inner thighs , flanks , inner thighs , buttocks & breast and buttocks & breast and increase as pregnancy increase as pregnancy

advancesadvances

It starts bluish It starts bluish (stria rubra)(stria rubra) , , then becomes pale to become then becomes pale to become

white white (stria albicans)(stria albicans) after after delivery , which persists delivery , which persists

(primigravida has stria rubra (primigravida has stria rubra only ,while multigravida has only ,while multigravida has

both both S.RS.R and S.A) and S.A)

It It may be due to It It may be due to mechanical mechanical stretching or increased stretching or increased

glucocorticoidsglucocorticoids which results which results in rupture of the elastic in rupture of the elastic fibres in the dermis and fibres in the dermis and exposure of the vascular exposure of the vascular

subcutaneous tissuessubcutaneous tissues

5 - Secretions5 - Secretions

increase in sweat increase in sweat and sebaceous and sebaceous glands activityglands activity

(B) Breast signs(B) Breast signs

•Diagnostic in primigravidaDiagnostic in primigravida and and may persist after delivery .may persist after delivery .

• In multigravida it may be due In multigravida it may be due to the previous pregnancies . to the previous pregnancies .

•They They may occur with any may occur with any hyperestrogenhyperestrogen , so they are , so they are not diagnostic for pregnancynot diagnostic for pregnancy

i - First month :i - First month :

increased size & vascularity increased size & vascularity (dilated veins)(dilated veins) , mastodynia , mastodynia

may be present which ranges may be present which ranges from tingling to frank pain from tingling to frank pain

due to hormonal responses of due to hormonal responses of the mammary ducts and the mammary ducts and

alveolar systemalveolar system

ii - Second month :ii - Second month :

increased pigmentation of increased pigmentation of the nipple & areola and the nipple & areola and

prominence of prominence of Montgomery tuberclesMontgomery tubercles (nonpigmented nodules (nonpigmented nodules

around the around the primary primary areola (12 - 20)areola (12 - 20)

Montgomery tuberclesMontgomery tubercles

They were thought to be They were thought to be enlarged sebaceous enlarged sebaceous

glands, but recently they glands, but recently they are found to be the lips of are found to be the lips of

orifices of peripheral orifices of peripheral active lacteal ductsactive lacteal ducts

Breast changesBreast changes

iii - iii - Third month :Third month : secretion of secretion of colostrumcolostrum

(thick yellowish (thick yellowish fluid) which can be fluid) which can be expressed from the expressed from the

nipplenipple

iv - iv - Fourth month :Fourth month :

a pigmented area a pigmented area appears around the appears around the

primary areola called primary areola called the the secondary areolasecondary areola

Lower limbs signsLower limbs signs

i - i - EdemaEdema ::

bilateral and pitting bilateral and pitting ii - ii - Varicose veinsVaricose veins

XII. Neurologic XII. Neurologic SystemSystem

• Sensory changes from Sensory changes from compression of nervescompression of nerves

• Tension headachesTension headaches

• Carpal tunnel syndrome due Carpal tunnel syndrome due to edemato edema

• Numbness and tingling Numbness and tingling related to postural changesrelated to postural changes

1. 1. HeadacheHeadache

It is relatively common, and It is relatively common, and attributed to intracranial attributed to intracranial vasodilatation caused by vasodilatation caused by

oestrogen and oestrogen and progesteroneprogesterone

1. 1. HeadacheHeadache• It is most troublesome in the It is most troublesome in the

second trimester, but may second trimester, but may persist throughout pregnancy.persist throughout pregnancy.

• However, headache may be due However, headache may be due to lack of sleep, or overwork.to lack of sleep, or overwork.

• An analgesic is prescribedAn analgesic is prescribed.

2. 2. FaintingFainting

It results from lowering It results from lowering of blood pressure due to of blood pressure due to

vasodilatation which vasodilatation which occur in pregnancyoccur in pregnancy

3. 3. InsomniaInsomnia

During pregnancy some During pregnancy some women are sleepy and women are sleepy and

depressed, others may be depressed, others may be irritable and suffer irritable and suffer

insomniainsomnia

4.Carpal tunnel syndrome4.Carpal tunnel syndrome

Caused by Caused by compressioncompression of of the the median nervemedian nerve as it as it

passes through its fibrous passes through its fibrous tunnel at the wrist, as a tunnel at the wrist, as a result of fluid retention result of fluid retention

and oedema in pregnancyand oedema in pregnancy

There is tingling, There is tingling, numbness and numbness and

burning sensation burning sensation affecting the radial affecting the radial side of the handside of the hand

• Treatment: Treatment: includes reassurance, use of a includes reassurance, use of a

wrist splint, diuretics, non wrist splint, diuretics, non steroidal anti-inflammatory steroidal anti-inflammatory drugs, and local injection of drugs, and local injection of hydrocortisone in the tunnel hydrocortisone in the tunnel

below the fibrous roofbelow the fibrous roof (retinaculum)(retinaculum)

Operation is rarely Operation is rarely needed during needed during

pregnancy by incising pregnancy by incising the retinaculum to the retinaculum to

relieve compressionrelieve compression

Other compression Other compression neuropathies affect neuropathies affect

the lateral cutaneous the lateral cutaneous nerve of the thigh , nerve of the thigh ,

obturator and obturator and peroneal nervesperoneal nerves

LEUCORRHOEALEUCORRHOEA

The normal vaginal The normal vaginal discharge increases discharge increases

during pregnancy because during pregnancy because of excess oestrogen and of excess oestrogen and may form a complaint may form a complaint

However, a pathological However, a pathological discharge, e.g., discharge, e.g.,

monilial infectionsmonilial infections which is common in which is common in pregnancy must be pregnancy must be

excluded.excluded.

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