Maternal Changes Maternal Changes with Pregnancywith Pregnancy

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

• The needs of the fetus The needs of the fetus

• Meeting the stress of pregnancy & laborMeeting the stress of pregnancy & labor

THE GENITAL THE GENITAL CHANGESCHANGES

(A)(A) The whole uterus The whole uterus

↑’↑’s from s from 7.5 x 5 x 2.5 cm 7.5 x 5 x 2.5 cm in non-pregnant in non-pregnant state to state to 35 x 25 x 20 cm35 x 25 x 20 cm at term, i.e. the at term, i.e. the volume volume 1000x1000x

11 - - SizeSize

↑ ↑ from from 50 gm50 gm in non-pregnant state in non-pregnant state

to to 1000 gm1000 gm at term at term

22 - - WeightWeight

pyriform – non pregnant state

globular - 8th week

pyriform - 16th week till

term

33- - ShapeShape

with ascent from the pelvis, the uterus usually undergoes rotation, with a tilt to the right (dextrorotation) due to presence of the recto-sigmoid colon on the left side.

44 - - PositionPosition

5 - Consistency:5 - Consistency:

Becomes progressively Becomes progressively softer softer due to:due to:

i - i - ↑↑ vascularity vascularity

ii - Presence of amniotic fluidii - Presence of amniotic fluid

From the 1From the 1stst trimester onward, the trimester onward, the uterus undergoes irregular painless uterus undergoes irregular painless contractions contractions (Braxton Hicks contractions)(Braxton Hicks contractions)..

They may cause some discomfort late They may cause some discomfort late in pregnancy & may a/c for in pregnancy & may a/c for false false labor painlabor pain..

66- - ContractilityContractility

7- Capacity7- Capacity

↑↑ from from 4 ml4 ml in non-pregnant state in non-pregnant state to to 4000 ml4000 ml at term at term

(B) Myometrial changes(B) Myometrial changes

1 - 1 - Hypertrophy Hypertrophy (estrogen effect)(estrogen effect) rather than rather than hyperplasia hyperplasia (progesterone effect)(progesterone effect) till 14till 14thth

weekweek, then the fetus exerts a direct stretch, then the fetus exerts a direct stretch 2 - 2 - Formation of the (L.U.S.) Formation of the (L.U.S.)

lower uterine segmentlower uterine segment from the from the

isthmus isthmus and lower half inch of the bodyand lower half inch of the body of uterusof uterus

Formation of lower uterine Formation of lower uterine segmentsegment

After 12 wks, After 12 wks, the isthmusthe isthmus (0.5cm)(0.5cm) starts to starts to expand gradually to form the expand gradually to form the lower uterine lower uterine segmentsegment, which measures , which measures 10 cm10 cm in length in length at termat term

Upper Uterine SegmentUpper Uterine Segment

• PeritoneumPeritoneum: : Firmly-attachedFirmly-attached

• MyometriumMyometrium:: 3 layers: 3 layers:

outer longitudinal, middle oblique & inner circular outer longitudinal, middle oblique & inner circular

• The The middle layermiddle layer forms forms 8-shaped fibers8-shaped fibers around around blood vessels to control postpartum hemorrhage blood vessels to control postpartum hemorrhage (living ligatures)(living ligatures)

Upper Uterine SegmentUpper Uterine Segment

• Decidua:Decidua: Well-developed Well-developed

• MembranesMembranes:: Firmly-attached Firmly-attached

• ActivityActivity:: Active, contracts, retracts Active, contracts, retracts and becomes thicker during labor.and becomes thicker during labor.

Lower Uterine SegmentLower Uterine Segment

• PeritoneumPeritoneum: : Loosely attachedLoosely attached

• MyometriumMyometrium: : 2 layers: 2 layers:

outer longitudinal outer longitudinal

inner circular.inner circular.

Lower Uterine SegmentLower Uterine Segment

• DeciduaDecidua: : Poorly developedPoorly developed

• MembranesMembranes: : Loosely attached.Loosely attached.

• ActivityActivity:: Passive, dilates, stretches Passive, dilates, stretches & becomes thinner during labor& becomes thinner during labor

The junction b/w/ the upper uterine segment The junction b/w/ the upper uterine segment (U.U.S.) (thick) & the lower uterine segment (U.U.S.) (thick) & the lower uterine segment (thin) is called the (thin) is called the physiologic contraction ringphysiologic contraction ring at the level of the symphysis pubis at the level of the symphysis pubis (not seen/ (not seen/ felt)felt)

1 1 - - Uterine artery lumenUterine artery lumen::is doubled & its blood flow is doubled & its blood flow ↑↑ 5x 5x

2 - 2 - Myometrial & decidual arteriesMyometrial & decidual arteries (spiral (spiral arteries)arteries) undergo fibrinoid degeneration due undergo fibrinoid degeneration due to 2 waves of trophoblastic migration & to 2 waves of trophoblastic migration & become dilated to form the become dilated to form the uteroplacentaluteroplacental arteriesarteries

(C) Uterine blood vessels(C) Uterine blood vessels

• Uterine blood flow ↑’s progressively & Uterine blood flow ↑’s progressively &

reaches aboutreaches about 500 ml / min at term500 ml / min at term

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

1 - 1 - becomes becomes hypertrophied, soft & bluishhypertrophied, soft & bluish in color due to edema & in color due to edema & ↑ ↑ vascularity.vascularity.

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

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

(E) Changes in fallopian tubes (E) Changes in fallopian tubes & ligaments (round & broad)& ligaments (round & broad)

. . InactiveInactive, , elongatedelongated, marked ↑ in vascularity., marked ↑ in vascularity.

.. There may be broad ligament There may be broad ligament varicose veins.varicose veins.

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

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

secretion and secretion and violetviolet in color in color (Chadwick's sign)(Chadwick's sign)

due to ↑ vascularitydue to ↑ vascularity

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

• It becomes soft, violet in colour

• Edema & varicosities may develop

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

1 -1 - Both ovaries are Both ovaries are enlargedenlarged due to due to ↑↑ vascularity & oedemavascularity & oedema, particularly the ovary , particularly the ovary which contains the corpus luteum.which contains the corpus luteum.

2 - Ovulation ceases during pregnancy due to 2 - Ovulation ceases during pregnancy due to pituitary inhibition by the pituitary inhibition by the ↑ levels of estrogen ↑ levels of estrogen & progesterone& progesterone

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

33 - - Corpus luteum continues to grow till Corpus luteum continues to grow till 7 - 7 - 8 8 wkswks, then it stops growing. , then it stops growing.

It becomes It becomes inactive & starts inactive & starts degeneration degeneration at 12 wksat 12 wks (degeneration is (degeneration is completed completed after labor)after labor)

Corpus luteum secretesCorpus luteum secretes

1.estrogen 1.estrogen

2.progesterone2.progesterone

3.relaxin 3.relaxin

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

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

• It may induce It may induce softness & effacementsoftness & effacement of of the cervix.the cervix.

II - Haematological ChangesII - Haematological Changes

(A) Blood volume(A) Blood volume

The total blood volume The total blood volume ↑↑’s’s steadily from early steadily from early pregnancy to reach a maximum of pregnancy to reach a maximum of 35-45 %35-45 % above the non-pregnant level above the non-pregnant level at 32 wksat 32 wks

Plasma volumePlasma volume

↑↑’’ss fromfrom 26002600 ml by ± ml by ± 45 %45 %

((12501250 in the 1st pregnancy & in the 1st pregnancy & 1500 1500 ml in ml in subsequent pregnancies)subsequent pregnancies)

Red blood cell massRed blood cell mass

• ↑’↑’ss from from 1400 ml1400 ml (non pregnant) by (non pregnant) by 33 %33 % (± 450 ml) (± 450 ml)

due to ↑ production resulting from due to ↑ production resulting from erythropoeitin or action of hCG / HPLerythropoeitin or action of hCG / HPL

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

The ↑ in The ↑ in plasma volumeplasma volume is is >> ↑ in ↑ in red blood cell massred blood cell mass (Hb mass) (Hb mass)

resulting in haemodilution resulting in haemodilution

(physiologic anemia)(physiologic anemia)

However, the minimal Hb. However, the minimal Hb. accepted isaccepted is 10-11 gm%10-11 gm%

Value of ↑ blood volumeValue of ↑ blood volume

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

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

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

↑↑ in the blood volume in the blood volume >> the the ↑↑ in red cell in red cell mass --mass --

leads to: leads to: ↓ blood viscosity↓ blood viscosity which which ↓ in ↓ in

peripheral resistanceperipheral resistance

(B) Blood indices(B) Blood indices

1 - ↓ Hb% & RBC%:

• Erythrocytes ↓ from Erythrocytes ↓ from 4.5 million/ cb.mm to 3.7 4.5 million/ cb.mm to 3.7 million / cb.mmmillion / cb.mm (due to the relative ↑ in plasma volume > red (due to the relative ↑ in plasma volume > red cell mass) cell mass)

ErythrocyteErythrocyte contentscontents:: 2, 3 - DPG2, 3 - DPG ↑↑’s which ’s which competes for 0competes for 022 binding sites in the Hb binding sites in the Hb molecule, thus releasingmolecule, thus releasing more 0more 02 2 to the fetusto the fetus . .

Hb concentrations fallsHb concentrations falls

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

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

5 -5 - ReticulocytesReticulocytes: mild : mild

6 - 6 - E.S.RE.S.R:: from 12 to 50 mm / hr from 12 to 50 mm / hr

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

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

(from 7,000 / mm3 to 10,500/ mm3 (from 7,000 / mm3 to 10,500/ mm3 during pregnancy & up to 16,000/ mm3 during pregnancy & up to 16,000/ mm3

during labor)during labor)

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

9 - 9 - Platelets: or

10-Total plasma proteins slightly (mainly albumin) resulting in

osmotic pressure.

(C) Coagulation system(C) Coagulation 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 doubled are doubled • Factor XI & factor XIIIFactor XI & factor XIII slight slight • Fibrinolytic activityFibrinolytic activity

(C) Coagulation system (C) Coagulation system

• Therefore pregnancy is a Therefore pregnancy is a hyper-coagulative hyper-coagulative statestate..

• All these changes are reversed after labor All these changes are reversed after labor with with RBC productionRBC production (not (not destruction) & destruction) &

the excess Fe is storedthe excess Fe is stored..

Ill - Cardiovascular system Ill - Cardiovascular system changeschanges

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

As the diaphragm is elevated progressively during As the diaphragm is elevated progressively during pregnancy the pregnancy the apexapex is is displaced upwards & to displaced upwards & to the leftthe left so that it lies in the so that it lies in the 4th intercostal4th intercostal spacespace outside the midclavicular line.outside the midclavicular line.

Position:Position:

Pulse ratePulse rate

- The resting pulse rate The resting pulse rate ↑↑ by by 8 beats/ min8 beats/ min (8 wks) & (8 wks) & 16 beats / min16 beats / min (full term). (full term).

-- Some episodes of Some episodes of ectopic beats ectopic beats

- - Water hammer pulse.Water hammer pulse.

Heart soundsHeart sounds

• The 1The 1stst heart sound heart sound becomes becomes louderlouder before mid before mid pregnancy & splitting of this sound may occur pregnancy & splitting of this sound may occur due to earlier closer of the mitral valve than the due to earlier closer of the mitral valve than the tricuspid valvetricuspid valve

• The intensity of the The intensity of the second heart soundsecond heart sound may ↑ may ↑

• The 3The 3rdrd sound sound becomes becomes louder louder before before mid-pregnancy & persists as such till 1 mid-pregnancy & persists as such till 1 wk post partum. wk post partum.

• The 4The 4thth sound sound may be detectable by may be detectable by phonocardiography.phonocardiography.

MurmursMurmurs

Systolic functional murmursSystolic functional murmurs

develop in most of women, usuallydevelop in most of women, usually early early systolicsystolic, ,

but but mid systolic murmursmid systolic murmurs may occur and may occur and heard over the left sternal edge, they are heard over the left sternal edge, they are thought to be due to thought to be due to functional tricuspid functional tricuspid regurgitationregurgitation

ECG CHANGESECG CHANGES

• The main features of ECG may be attributed The main features of ECG may be attributed to the changes in the position of the heart.to the changes in the position of the heart.

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

• The The QRSQRS complexes become of complexes become of low voltagelow voltage, , and and T wavesT waves become become flattenedflattened. .

(B) Haemodynamic (B) Haemodynamic changeschanges

Cardiac output:Cardiac output:

↑’↑’ss mainly bymainly by ↑↑ stroke volumestroke volume rather than rather than ↑↑ heart rate reaching aheart rate reaching a maximum of 40%maximum of 40% above the non-pregnant levelabove the non-pregnant level at 20 weeksat 20 weeks to be maintained till term.to be maintained till term.

DistributionDistribution:: • 400 ml400 ml - the - the uterusuterus, , • 300300 ml -ml - the the kidneyskidneys,,• 300 ml300 ml - - skinskin• 300 ml300 ml - - GITGIT, , breast breast & & heartheart

• Importance:

Distributes extra 02

• During labor:

C.O. C.O. ↑’↑’s more particularly during the 2nd stage s more particularly during the 2nd stage due to due to pain, uterine contractions, and expulsive pain, uterine contractions, and expulsive effortsefforts pushing the blood into the general pushing the blood into the general circulationcirculation

• Postpartum:

the ↑the ↑’d’d C.O. is maintained for up to C.O. is maintained for up to 4 days4 days & & then declines rapidlythen declines rapidly

2 - Arterial blood pressure2 - Arterial blood pressure

Although C.O. Although C.O. ↑↑’s’s, yet A.B.P. is , yet A.B.P. is ↓↓’d’d in in mid-trimestermid-trimester to to ↑↑ again in 3rd trimesteragain in 3rd trimester

This is due to:

i - - ↓ Peripheral resistance↓ Peripheral resistance::

(mainly affects diastolic B.P.)(mainly affects diastolic B.P.) due due to:to:

vasodilatation + vasodilatation + increase metabolism + increase metabolism + arteriovenous shunt at placentaarteriovenous shunt at placenta

ii - ii - Supine hypotensionSupine hypotension : :

may develop in some women in late may develop in some women in late pregnancy while lying supine due to pregnancy while lying supine due to compression on the I.V.C. by the large compression on the I.V.C. by the large pregnant uterus, resulting in pregnant uterus, resulting in venous venous return return C.O. and low B.P. to the C.O. and low B.P. to the

extentextent that that fainting fainting may occurmay occur

iii -iii - ↓ sensitivity of blood vessels↓ sensitivity of blood vessels to to

angiotensin II angiotensin II (which is a vasoconstrictor)(which is a vasoconstrictor)

Vena Cava SyndromeVena Cava Syndrome

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

• Typically, it is Typically, it is highest highest when she iswhen she is sittingsitting, , lowest lowest when lying in thewhen lying in the lateral lateral recumbent positionrecumbent position and intermediate and intermediate when supine.when supine.

Peripheral Peripheral VasodilatationVasodilatation

blood flow to the blood flow to the skinskin, particularly in , particularly in the hands and feet generally giving the hands and feet generally giving

the pregnant women the pregnant women a feeling of a feeling of warmthwarmth

Peripheral VasodilatationPeripheral Vasodilatation

Peripheral VasodilatationPeripheral Vasodilatation

↑↑’’ss the congestion of the congestion of nasal mucosanasal mucosa leading to a common complaint leading to a common complaint

of nasal obstruction and of nasal obstruction and bleeding bleeding (epistaxis).(epistaxis).

3 - Venous pressure3 - Venous pressure

↑↑’’dd venous pressure in the venous pressure in the lower limbs due tolower 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 on 2. Mechanical pressure of the uterus on pelvic veins.pelvic veins.

3. ↑3. ↑’d’d venous return from internal iliac veins venous return from internal iliac veins →→ ↑ pressure in external iliac veins ↑ pressure in external iliac veins

↑↑’’dd venous pressure in venous pressure in the lower limbsthe lower limbs

Predisposes toPredisposes to

Oedema,Oedema,

varicose veinsvaricose veins

& piles& piles

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

i - i - Venous pressureVenous pressure. .

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

progesteroneprogesterone

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

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

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

Varicose Veins treatmentVaricose Veins treatment

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

2. avoid 2. avoid constricting clothesconstricting clothes..

3. keep the 3. keep the legs elevatedlegs elevated while sitting while sitting and during sleep.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 uterus displaces the The enlarged uterus displaces the diaphragmdiaphragm up to ± 4 cm. up to ± 4 cm.

This results inThis results in::

1.1. The diaphragmatic mobility is ↓ The diaphragmatic mobility is ↓ and and respiration becomes respiration becomes mainly thoracicmainly thoracic..

2. Widen the sub-costal angle2. Widen the sub-costal angle and and ↑ the transverse diameter of the ↑ the transverse diameter of the chest.chest.

Respiratory functionsRespiratory functions

The respiratory rateThe respiratory rate does not ↑does not ↑ during pregnancy from its during pregnancy from its

normal rate of normal rate of 14 - 15/ min14 - 15/ min

Over-breathing

(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)

dyspneadyspnea is ais a common complaint of common complaint of the pregnant women which may be the pregnant women which may be

due to unfamiliarity with low C0due to unfamiliarity with low C02 2

tension in the alveolar capillariestension in the alveolar capillaries . .

The vital capacityThe vital capacity

1. The inspiratory capacity1. The inspiratory capacity

(Tidal volume + inspiratory volume) (Tidal volume + inspiratory volume) is is ↓↓ in late pregnancy in late pregnancy

2. The expiratory reserve volume2. The expiratory reserve volume (maximum amount of air which can (maximum amount of air which can

be be expired after normal expiration) is ↓expired after normal expiration) is ↓

3. The residual volume 3. The residual volume is ↓is ↓

The reduction in:The reduction in:1.The inspiratory capacity1.The inspiratory capacity

2.The expiratory reserve volume2.The expiratory reserve volume

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

4.4.The tidal volumeThe tidal volume: :

(amount of gas inspired or (amount of gas inspired or expired in each respiration) expired in each respiration) risesrises through out pregnancy by about through out pregnancy by about 40 %40 %

Hyperventilation Hyperventilation is due tois due to increased tidal volume increased tidal volume not not

respiratory raterespiratory 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 ↑ excretion

ThereforeTherefore::1.1. There is There is serum creatinine serum creatinine (due to (due to

creatinine clearance), creatinine clearance),

the same for the same for uric aciduric acid..

2. 2. blood urea blood urea..

3. 3. kidney excretion of glucose kidney excretion of glucose due to due to filtration load and filtration load and renal threshold renal threshold leading to leading to renal glucosuria renal glucosuria

Therefore, in interpreting the Therefore, in interpreting the results of RFT one should take results of RFT one should take

into consideration that into consideration that

the highest normal value in the highest normal value in pregnancy = the lowest pregnancy = the lowest

normal value in thenormal value in the

non-pregnant statenon-pregnant state

(B) Ureter(B) Ureter

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

i - Relaxation of the ureter by the effect of i - Relaxation of the ureter by the effect of progesterone.progesterone.

ii - ii - Pressure against the pelvic brimPressure against the pelvic brim by the by the uterusuterus, particularly on the , particularly on the right sideright side, , due to dextro-posed uterus and due to dextro-posed uterus and dilatation of the right ovarian vesselsdilatation of the right ovarian vessels

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

Frequency of micturitionFrequency of micturition in early in early pregnancy due to:pregnancy due to:

i - i - PressurePressure on the bladder by the on the bladder by the enlarged uterus .enlarged uterus .

ii - ii - CongestionCongestion of the bladder mucosa of the bladder mucosa

Urinary stress incontinence may develop for the first time during pregnancy

(due to ↓ intra-urethral pressure and ↓ length of the urethra)

and spontaneously relieved later on

VI - Gastrointestinal tract VI - Gastrointestinal tract & liver& liver

1 - Gingivitis:1 - Gingivitis:

There is ↑ vascularity and tendency for bleeding as well as hypertrophy of the interdental papillae

• The gums may become hyperemic and The gums may become hyperemic and soft and may soft and may bleedbleed when mildly when mildly traumatized, as with a tooth brush. traumatized, as with a tooth brush.

• Epulis of pregnancyEpulis of pregnancy may develop. may develop. Treated by dental hygiene and cryosurgery Treated by dental hygiene and cryosurgery

for severe casesfor severe cases.

2 - Ptyalism:2 - Ptyalism:

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

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

• Smoking is stopped; anticholinergic Smoking is stopped; anticholinergic drugs may helpdrugs may help..

3 - Nausea and vomiting3 - Nausea and vomiting

Nausea (morning sickness) Nausea (morning sickness)

and vomiting and vomiting

(emesis gravidarum) (emesis gravidarum)

occur occur in early monthsin early months

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

• The pregnant woman The pregnant woman dislikes some dislikes some food and odourfood and odour while desires others. while desires others.

• ↓ ↓ sensitivitysensitivity of the of the taste budstaste buds during during pregnancy creates the desire for pregnancy creates the desire for markedly sweet, sour, or salty foods.markedly sweet, sour, or salty foods.

(pica)(pica)

Deviation may be so extreme Deviation may be so extreme to the extent of eating to the extent of eating

blackboard chalk, coal or mud.blackboard chalk, coal or mud.

5 - Indigestion 5 - Indigestion and flatulenceand flatulence

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

i - i - ↓ ↓ gastricgastric acidity acidity caused by caused by regurgitation of alkaline secretion regurgitation of alkaline secretion from from the intestine to the stomach. the intestine to the stomach.

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

6 - Heart burn6 - Heart burn

Due to Due to refluxreflux of acidic gastric of acidic gastric

contents to the oesophaguscontents to the oesophagus

The treatment includesThe treatment includes::

(a)(a) small frequent mealssmall frequent meals to prevent to prevent overdistension of the stomach.overdistension of the stomach.

The evening meal should be The evening meal should be taken taken at least 3 hours before at least 3 hours before

going to going to bed.bed.

(b) (b) avoidavoid fatty foods, chocolate, and fatty foods, chocolate, and smoking, as these relax the smoking, as these relax the

lower lower esophageal sphincter. esophageal sphincter.

(c) the (c) the bed should be raisedbed should be raised at the at the head end (15-20 cm), and an head end (15-20 cm), and an extra pillow is used. extra pillow is used.

(d)(d) Antacid PreparationsAntacid Preparations containing aluminium containing aluminium

hydroxide hydroxide are favoured.are 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 ii - Increased water reabsorption reabsorption from large from large intestine intestine (aldosterone (aldosterone effect)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)(a) evacuation of the bowel at the same evacuation of the bowel at the same time each day time each day (bowel training)(bowel training)

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

(c) (c) milkmilk. Also, avoid dehydration by . Also, avoid dehydration by increasing fluid intakeincreasing fluid intake..

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

(e) (e) ↑ physical activity↑ physical activity and avoid sedentary and avoid sedentary

life.life. (f) (f) a a mild laxativemild laxative may be needed. may be needed. Liquid Liquid

paraffin is better avoidedparaffin is better avoided as it prevents as it prevents

absorption of fat soluble vitamins.absorption of fat soluble vitamins.

In some women In some women iron iron supplementationsupplementation may be the cause may be the cause

8 - Gall stones8 - Gall stones

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

the gall bladderthe gall bladder

9 - Haemorroids9 - Haemorroids

due todue 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 non pregnant state)

AppendixAppendix

LiverLiveri - ↓ albumin and ↑globulin resulting ↓ albumin and ↑globulin resulting

in in ↓ A/G ratio ↓ A/G ratio

ii - ii - ↑↑ heat labile serum heat labile serum alkaline alkaline phosphatasephosphatase..

Therefore both Therefore both A/G ratioA/G ratio and and heat labile heat labile alkaline phosphatasealkaline phosphatase are are not not reliable as reliable as

liver function tests during pregnancyliver function tests during pregnancy

VII - Metabolic changesVII - Metabolic changes

(A) Weight gain

The average weight gain in The average weight gain in pregnancy is pregnancy is 10 - 12 kg10 - 12 kg

The increase occurs The increase occurs

mainly in the mainly in the

second second and and third trimesterthird trimester

at a rate of at a rate of 350 - 400 gm/ wk350 - 400 gm/ wk

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

6 kg is 6 kg is composed ofcomposed of maternal tissues maternal tissues (breast, (breast, fat, blood and uterine tissues) fat, blood and uterine tissues)

&&

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

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

77 kg are waterkg are water 33 kg fatkg fat

11 kg proteinkg protein

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.

)B) Water metabolismB) Water metabolism

There is tendency to There is tendency to water water retentionretention secondary to secondary to

sodium retentionsodium retention

(C) Protein metabolism(C) Protein metabolism

There is tendency for There is tendency for nitrogen nitrogen retentionretention (+ ve nitrogen balance)(+ ve nitrogen balance) for for

fetal and maternal tissue formationfetal and maternal tissue formation

(D) Carbohydrate metabolism(D) Carbohydrate metabolism

Pregnancy is potentially diabetogenicPregnancy is potentially diabetogenic

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

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

(E) Fat metabolism(E) Fat metabolism

There is increase of plasma lipids with tendency to acidosis (HPL action)

(F) Mineral metabolism

There is There is increased demandincreased demand for for ironiron, , calciumcalcium, ,

phosphate phosphate and and magnesiummagnesium

VIII - Musculoskeletal changesVIII - Musculoskeletal changes

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

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

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

(d) (d) Pendulous abdomenPendulous abdomen in multigravida in multigravida

BackacheBackache

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

• It is due to It is due to increased lumbar lordosisincreased lumbar lordosis to to counter-balance the forward growth of counter-balance the forward growth of the uterusthe 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 local creams. creams. ParacetamolParacetamol is the drug of is the drug of choice, Non-steroidal anti-inflammatory choice, Non-steroidal anti-inflammatory drugs as indomethacin may be given.drugs as indomethacin may be given.

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

Orthopaedic consultationOrthopaedic consultation is is indicated if pain is indicated if pain is severesevere, , or or radiates to the legsradiates to the legs, and , and

in the presence of in the presence of

neurological signsneurological signs

Leg crampsLeg cramps

• These are common in the These are common in the second halfsecond half of pregnancy of pregnancy particularly particularly at nightat night..

• The exact The exact cause cause is is unknownunknown..

It may be related to shift of blood away It may be related to shift of blood away from the muscle, i.e., from the muscle, i.e., ischaemicischaemic cramp, cramp,

or or it may be it may be tetanictetanic cramp caused by cramp caused by lack of lack of

calciumcalcium, or , or increased phosphorousincreased phosphorous, or , or bothboth

• Treated byTreated by taking taking Ca tabletsCa tablets, and , and reducing the intake of reducing the intake of phosphorous-containing 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 hyperextension and hyperextension

of foot help during the attackof foot help during the attack.

Round ligament strainRound ligament strain

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

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

• It is It is due to stretching of the nerve due to stretching of the nerve

fibresfibres in the round ligaments. in the round ligaments.

IX - Endocrine systemIX - Endocrine system

1 - Anterior pituitary1 - Anterior pituitary

i i -- ↑ in size↑ in size > ↑ in vascularity. > ↑ in vascularity.

This renders the anterior pituitary This renders the anterior pituitary liable for ischaemialiable for ischaemia

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

iii - iii - Prolactin levelProlactin level ↑ up to ↑ up to 150 ng/ml at term150 ng/ml at term to ensure lactation. to ensure lactation.

2 - Posterior pituitary2 - Posterior pituitary

Does not hypertrophy, but Does not hypertrophy, but ↑↑ its its oxytocin secretion near oxytocin secretion near

termterm

3 - Thyroid gland3 - Thyroid gland

There is diffuse slight There is diffuse slight enlargement enlargement of the glandof the gland

Gland activity is Gland activity is

as evidenced by: as evidenced by:

normal free T4normal free T4 (although total T4 (although total T4 ) due to: ) due to: thyroid binding globulin (TBG), thyroid binding globulin (TBG), BMR 20 %,BMR 20 %, total T3total T3, , protein bound iodine protein bound iodine

TSHTSH

4 - Parathyroid gland4 - Parathyroid gland

Hypertrophy Hypertrophy due to due to ↑↑ demand for Calciumdemand for Calcium

5 - Suprarenal gland5 - Suprarenal gland

HypertrophyHypertrophy particularly the particularly the cortex cortex resulting in:resulting in:

↑ ↑ glucocorticoids glucocorticoids (cortisone)(cortisone)

↑ ↑ mineralocorticoids mineralocorticoids (aldosterone)(aldosterone)

6 - Insulin6 - Insulin

↑↑ mainly due to HPL mainly due to HPL

(anti-insulin hormone)(anti-insulin hormone)

7 -Ovaries7 -Ovaries

corpus luteum of pregnancycorpus luteum of pregnancy

functions till 8-12 wks, when its functions till 8-12 wks, when its function is taken by the placentafunction is taken by the placenta

XI - Skin changesXI - Skin changes

1 - Persistence of basal body Persistence of basal body temperature (BBT) elevationtemperature (BBT) elevation beyond the expected day of beyond the expected day of menstruation (due to menstruation (due to ↑ progesterone↑ progesterone).).

2 - Spider telangiectasis & palmar erythemaSpider telangiectasis & palmar erythema

due to ↑estrogen or cutaneous due to ↑estrogen or cutaneous vasodilatationvasodilatation

3 - 3 - Cutaneous vasodilatation Cutaneous vasodilatation (hyperemia)(hyperemia)

leads toleads to::i - i - Masks pallorMasks pallor due to anaemia with or without due to anaemia with or without

palmar erythema. palmar erythema.

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

iii - iii - Sensation of heatSensation of heat and and nasal congestionnasal congestion

4 4 - Pigmentation- Pigmentation

due to due to ↑↑ estrogen estrogen

or or

melanocyte stimulating melanocyte stimulating hormonehormone

or or

ACTH ACTH

In the faceIn the face::

chloasma gravidarum = mask of pregnancychloasma gravidarum = mask of pregnancy

a butterfly pigmentation on the cheeks a butterfly pigmentation on the cheeks and nose. and nose.

It usually disappears few months after It usually disappears few months after

labor.labor.

In abdomenIn abdomen::

Linea Nigra =Linea Nigra = pigmentation pigmentation in midline below the in midline below the

umbilicusumbilicus

Linea nigraLinea nigra

Stria gravidarumStria gravidarum

pigmentation in the pigmentation in the lower lower abdomen, flanks, inner abdomen, flanks, inner thighs,thighs, buttocksbuttocks & & breastbreast and and ↑↑ as pregnancy as pregnancy

advancesadvances

It starts reddish It starts reddish (stria rubra)(stria rubra), then , then becomes becomes palepale to become to become whitewhite (stria (stria

albicans)albicans) after delivery, which persists after delivery, which persists

(primigravida has stria rubra only, while (primigravida has stria rubra only, while multigravida has both S.R and S.A) multigravida has both S.R and S.A)

It may be due to It may be due to

mechanical stretching or mechanical stretching or increased glucocorticoidsincreased glucocorticoids

which results in which results in

rupture of the elastic fibres rupture of the elastic fibres

in the dermis and in the dermis and

exposure of the vascular exposure of the vascular subcutaneous tissuessubcutaneous tissues

5 - Secretions5 - Secretions

↑↑ in sweat and sebaceous in sweat and sebaceous glands glands activityactivity

(B) Breast signs(B) Breast signs

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

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

• They They may occur with any hyper-may occur with any hyper-estrogenestrogen, so they are not diagnostic , so they are not diagnostic

for pregnancyfor pregnancy

i -i - First month First month::

↑ ↑ size & vascularity (dilated veins), size & vascularity (dilated veins), mastodyniamastodynia may be present which ranges from may be present which ranges from tingling to frank pain due to hormonal responses tingling to frank pain due to hormonal responses

of theof the mammary ducts and alveolar systemmammary ducts and alveolar system

ii -ii - Second month Second month::

↑ ↑ pigmentation of the nipple & areola and pigmentation of the nipple & areola and prominence of prominence of Montgomery tuberclesMontgomery tubercles (non (non pigmented nodules around the pigmented nodules around the primary areola (12 primary areola (12 - 20)- 20)

Montgomery tuberclesMontgomery tubercles

They were thought to be enlarged They were thought to be enlarged sebaceous glands, but recently they are sebaceous glands, but recently they are found to be the found to be the lips of orifices of peripheral lips of orifices of peripheral

active lacteal ductsactive lacteal ducts

Breast changesBreast changes

iii -iii - Third monthThird month::

secretion of secretion of colostrumcolostrum (thick yellowish fluid) (thick yellowish fluid)

which can be expressed from the nipplewhich can be expressed from the nipple

iv -iv - Fourth month Fourth month::

a pigmented area appears around the a pigmented area appears around the primary areola called the primary areola called 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 SystemXII. Neurologic System

• Sensory changesSensory changes from compression of from compression of nervesnerves

• Tension headachesTension headaches

• Carpal tunnel syndromeCarpal tunnel syndrome due to edema due to edema

• Numbness and tinglingNumbness and tingling related to postural related to postural changeschanges

1. Headache1. Headache

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

1. Headache1. Headache

• It is most troublesome in the second trimester, It is most troublesome in the second trimester, but may persist throughout pregnancy.but may persist throughout pregnancy.

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

• An analgesic is prescribedAn analgesic is prescribed.

2. Fainting2. Fainting

It results from It results from lowering of blood lowering of blood pressurepressure due to vasodilatation due to vasodilatation which occur in pregnancywhich occur in pregnancy

3. Insomnia3. Insomnia

During pregnancy some women are During pregnancy some women are sleepy and depressed, others may sleepy and depressed, others may

be irritable and suffer insomniabe irritable and suffer insomnia

4. Carpal tunnel syndrome4. Carpal tunnel syndrome

Caused by Caused by compressioncompression of the of the median median nervenerve as it passes through its fibrous as it passes through its fibrous tunnel at the wrist, as a result of fluid tunnel at the wrist, as a result of fluid

retention and edema in pregnancyretention and edema in pregnancy

There is There is tingling,tingling, numbnessnumbness and and burningburning sensation affecting the sensation affecting the radialradial sideside of the of the

handhand

TreatmentTreatment:: • reassurance reassurance • wrist splint wrist splint • DiureticsDiuretics• NSAIDS NSAIDS • local injection of hydrocortisone in the tunnel local injection of hydrocortisone in the tunnel

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

Operation is rarely needed during pregnancyOperation is rarely needed during pregnancy (incising the retinaculum to relieve compression)(incising the retinaculum to relieve compression)

Other compression neuropathies affect:Other compression neuropathies affect:the lateral cutaneous nerve of the thighthe lateral cutaneous nerve of the thighobturator nerveobturator nerveperoneal nervesperoneal nerves

LEUCORRHOEALEUCORRHOEA

The normal vaginal discharge The normal vaginal discharge ↑↑ during pregnancy because of during pregnancy because of excess oestrogenexcess oestrogen and may form a and may form a complaintcomplaint

However, a pathological discharge, However, a pathological discharge, e.g., e.g., monilial infectionmonilial infection which is which is common in pregnancy, must be common in pregnancy, must be excluded.excluded.

THANK YOUTHANK YOU