pregnancychanges-1 - Maternal Changes with Pregnancy with...

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Unformatted text preview: Maternal Changes with Pregnancy with Dr. Ashraf fouda Ob/Gyn. Specialist Egypt – Domiatt General Hospital Pregnancy is a period of adaptation for : adaptation • The needs of the fetus The • Meeting the stress of Meeting pregnancy and labour pregnancy THE ENITAL G ANGES CH (A) The whole uterus uterus Size - 1 Size increase from 7.5 x 5 x 2.5 cm in nonpregnant states cm to 35 x 25 x 20 cm at term 35 i.e. the volume increase 1000 time 1000 Weight - 2 Weight increases from 50 gm 50 in nonpregnant state to 1000 gm at term 1000 Shape -3 Shape pyriform in the nonpregnant state , becomes globular at 8th week , then pyriform by 16th week till term . Position - 4 Position 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. 5 - Consistency : Consistency becomes progressively softer due to : due i - Increased vascularity ii - Presence of amniotic fluid ii Contractility -6 Contractility from the first trimester onwards , the uterus undergoes irregular painless contractions (Braxton Hicks contractions) . (Braxton They may cause some discomfort late in pregnancy and may account for false labour pain . labour 7- Capacity 7increases from increases 4 ml in non-pregnant ml state to 4000 ml at term 4000 (B) Myometrial changes changes 1 - Hypertrophy (estrogen effect) rather than effect) hyperplasia (progesterone effect) till 14th week, then effect) till then the fetus exerts a direct stretch stretch 2 - Formation of the lower uterine segment lower (L.U.S.) from the isthmus and lower half inch of the body inch Formation of lower uterine segment uterine After 12 weeks, the isthmus After the (0.5cm) starts to expand (0.5cm) gradually to form the lower uterine segment which measures 10 cm in length at 10 term term Upper Uterine Segment Upper • Peritoneum: Firmly-attached Firmly-attached • Myometrium: 3 layers; outer longitudinal, middle oblique and inner circular. • The middle layer forms 8-shaped fibers The around the blood vessels to control postpartum hemorrhage postpartum Upper Uterine Segment Upper • Decidua: Well-developed Well-developed • Membranes: Firmly-attached Firmly-attached • Activity: Active, contracts, retracts and becomes thicker during labour. during Lower Uterine Segment Lower • Peritoneum: LooselyLooselyattached • Myometrium : 2 layers; Myometrium outer longitudinal and inner circular. circular. Lower Uterine Segment Lower • Decidua: Poorly-developed Poorly-developed • Membranes: Looselyattached. attached. • Activity: Passive, dilates, stretches and becomes thinner during labour during The junction between the upper uterine segment (U.U.S.) which is thick and the lower uterine segment which is thin is called the physiologic contraction ring physiologic at the level of the symphysis pubis (not seen or felt) (not (C) Uterine blood vessels blood 1 - Uterine artery lumen: Uterine is doubled and its blood flow is increases 5 times 2 - Myometrial and decidual arteries (spiral arteries) undergo arteries fibrinoid degeneration due to 2 waves of trophoblastic migration , so they become dilated to be the uteroplacental arteries uteroplacental arteries • Uterine blood flow Uterine increases progressively and reaches about 500 ml / minute at term ml (D) Changes in the cervix : (D) 1 - It becomes hypertrophied , soft and bluish in colour due to bluish oedema and increased vascularity. vascularity. 2 - Soon after conception , a thick cervical secretion obstructs the cervical canal forming a mucous plug . mucous 3 - The endocervical epithelium The proliferates and or everted forming cervical ectopy (previously called erosion) (previously (E) Changes in fallopian tubes and ligaments (round and broad): broad): Inactive , elongated , elongated marked increase in vascularity There may be broad ligament varicose veins varicose (F) Changes in the vagina : (F) The vagina becomes soft , The soft warm , moist with warm increased secretion and violet in colour violet (Chadwick's sign) due to (Chadwick's increased vascularity increased (G) Changes in the vulva : (G) • It becomes soft, violet in colour • Oedema and varicosities may develop (H) Changes in the ovaries (H) 1 - Both ovaries are enlarged due to increased vascularity and oedema particularly the ovary which conatins the corpus luteum . luteum (H) Changes in the ovaries (H) 2 - Corpus luteum continues to Corpus grow till 7 - 8 weeks , then it weeks stops growing , It becomes inactive and starts degeneration at 12 weeks degeneration (degeneration is completed after labour) Corpus luteum secretes Corpus 1.estrogen , 2.progesterone, 3.relaxin hormones hormones (H) Changes in the ovaries (H) 3 - Ovulation ceases during pregnancy due to pituitary inhibition by the high levels of oestrogen and progesterone and • Relaxin is a protein hormone. hormone. • Its exact role in pregnancy Its is unknown. • It may induce softness and It effacement of the cervix. effacement II - Haematological Changes Changes (A) Blood volume (A) The total blood volume The increases steadily from early pregnancy to reach a maximum of 35-45 % 35-45 above the non-pregnant level at 32 week . at - Plasma volume : Plasma Increases from 2600 ml by ± 45 % (1250 in the 1st 45 pregnancy) and 1500 ml in subsequent pregnancies pregnancies - Red blood cell mass : Red • Increases from 1400 ml Increases 1400 (nonpregnant) by 33 % (± 450 33 ml) due to increased production resulting from erythropoeitin or action of hCG or HPL . • The increase is steady till full The term. term. The increase in plasma volume is more than the increase in red blood cell mass (Hb mass) resulting in haemodilution (physiologic anemia) (physiologic However, the minimal Hb. accepted is accepted 10-11 gm% 10-11 Values of increased blood volume Values 1 - Meets increased demands for uterus , baby .... etc . for 2 - Protects against supine Protects hypotension syndrome . hypotension 3 - Protects against fluid loss Protects in labour . in Increased blood volume more than the increase in red cell mass , leads to decreased blood viscosity which leads viscosity to decrease in peripheral resistance peripheral (B) Blood indices indices 1 - Decreased Hb % and RBCs % : • Erythrocytes decrease from Erythrocytes 4.5 million / mm3 to 3.7 million / mm3 (due to the million relative increase in plasma volume more than red cell mass) . Erythrocytes contents Erythrocytes contents from 2,3- DPG increases 2,3which competes for 02 binding sites in the Hb molecule , thus releasing more 02 to the fetus . more Hb concentrations falls falls from 14 gm / dl 14 To To 12 gm / dl. 12 2 - M.C.H.C : no change M.C.H.C 3 - M.C.V. : , or no M.C.V. change (depending on the availability of Fe). the 4- Fragility of R.B.Cs: . 4- Fragility 5 - Reticulocytes : mild Reticulocytes 6 - E.S.R : from 12 to 50 mm / hour 50 7 – Fibrinogen: from Fibrinogen 200 - 400 mg / dl to 400 600 mg / dl. 600 8 - White blood cells: White (from 7.000 / mm3 to 10.500 / (from mm3 during pregnancy and up to 16.000 / mm3 during labour : to - PNL & its enzymes . - Lymphocytes : no change . 9 - Platelets: or 10-Total plasma proteins : slightly (mainly albumin) resulting in osmotic pressure. (C) Coagulation system • • • • Platelets or . (controversial). Platelets Fibrinogen doubled to 600 mg % Fibrinogen Factor VIII tripled . Factor Factor VII & factor X are Factor doubled • Factor XI & factor XIII slight Factor • Fibrinolytic activity . Fibrinolytic • Therefore pregnancy is a Therefore hypercoagulative state . hypercoagulative • All these changes are reversed after labour with RBCs production (not destruction)& the excess Fe is stored . is Ill - Cardiovascular system changes system (A) Changes in the heart (A) Position: As the diaphragm is elevated progressively during pregnancy the apex is displaced upwards and to the left so that it lies in the and 4th intercostal space outside the midclavicular line. midclavicular Pulse rate : Pulse - The resting pulse rate The increases by 8 beats / min. beats (8 weeks) and 16 beats / min. 16 (full term). (full -Some episodes of ectopic beats -Some - Water hummer pulse . Water Heart sounds Heart • The first heart sound become louder before midpregnancy and splitting of this sound may occur due to earlier closer of the mitral than the tricuspid valve mitral • The intensity of the second The heart sound may increase. heart Heart sounds Heart • The third sound becomes louder before mid­pregnancy and persists as such till one week post partum. • The fourth sound may be detectable by phonocardiography. Murmurs Murmurs Systolic functional murmurs develop in most of women, usually early systolic, but mid systolic early but murmurs may occur and heard over murmurs the left sternal edge, the they are thought to be due to functional tricuspid regurgitation functional ECG CHANGES ECG • The main features of ECG may be The attributed to the changes in the position of the heart. position • The axis undergoes left shift by 15 28°. • The QRS complexes become of low The QRS voltage, and T wave becomes voltage and wave flattened. flattened (B) Haemodynamic changes changes 1 - Cardiac output (C.O.P.) (C.O.P.) Cardiac output: Cardiac increases mainly by increased stroke volume rather than increased heart rate reaching a maximum of 40% above the maximum non-pregnant level at 20 weeks at to be maintained till term. to Cardiac output Cardiac Distribution : • • • • 400 ml to the uterus , 400 uterus 300 ml to the kidneys , 300 kidneys 300 ml to skin , 300 300 ml to GIT , breast & 300 heart heart • Values : Distributes extra 02 • During labour : C.O.P. increases more particularly during the second stage due to pain , uterine contractions , and expulsive efforts pushing the blood into the general circulation • Postpartum : the increased C.O.P. the increased C.O.P. is maintained for up to 4 days and then declines rapidly 2 - Arterial blood pressure pressure Although C.O.P. Although C.O.P. incease , yet A.B.P. is decreased in midtrimester to increase again in 3rd trimester This is due to: i - Decreased Peripheral resistance : resistance (mainly affect diastolic B.P.) (mainly due to : vasodilatation + due increase metabolism + arteriovenous shunt at placenta . placenta ii - Supine hypotension : Supine may develop in some women in late pregnancy while lying supine due to compression on the I.V.C. by the large pregnant uterus , resulting in decreased venous return C.O.P. and low B.P. return to the extent that fainting may occur occur iii - Decreased iii sensitivity of blood vessels to angiotensin II vessels which is vasoconstrictor which Vena Cava Syndrome Vena • The posture of the pregnant The woman affects arterial blood pressure. • Typically, it is highest when she Typically, is sitting, lowest when lying in is the lateral recumbent position the and intermediate when supine. and Peripheral Vasodilatation Vasodilatation Peripheral Vasodilatation Peripheral blood flow to the skin, blood particularly in the hands and feet generally giving the pregnant women a feeling of warmth feeling Peripheral Vasodilatation Peripheral Increases the congestion of Increases nasal mucosa leading to a common complaint of nasal obstruction and bleeding (epistaxis). (epistaxis). 3 - Venous pressure Venous Increased venous pressure in the lower limbs due to : in 1. Back pressure from the compressed 1. I.V.C. by the pregnant uterus . I.V.C. 2.Mechanical pressure of the uterus 2.Mechanical on pelvic veins . on 3.Increased venous return from 3.Increased internal iliac veins --> increase pressure in external iliac veins . pressure Increased venous pressure in the lower limbs in Predisposes to : Oedema , varicose veins varicose and piles and Oedema and varicose veins in the lower limbs & vulva are due to lower i - Venous pressure . ii - Relaxation of the smooth muscles in the wall of the veins by progesterone iii - Osmotic pressure in blood . iv - Capillary permeability (due to progesterone and aldosterone). progesterone v - Interstitial pressure (Na retention). Varicose Veins treatments Varicose 1. avoid long periods of 1. avoid standing and encourage standing active exercise. active 2. avoid constricting clothes. 2. constricting 3. keep the legs elevated while 3. legs sitting and during sleep. sitting 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 system system (A) Anatomically: (A) The enlarged The uterus displaces the diaphragm up the to ± 4 cm . to This result in : This 1. The diaphragmatic mobility 1. is reduced and respiration becomes mainly thoracic . becomes 2. Widen the subcostal angle 2. Widen and increases the transverse diameter of the chest. diameter Respiratory functions Respiratory The respiratory rate The does not increase during pregnancy from its normal rate of 14 - 15 / minute. minute. Overbreathing (deep respiration) occurs due to the effect of excess progesterone Shortness of breath Shortness (the need to breath becomes a conscious one) conscious and dyspnea are common dyspnea complaint of the pregnant women which may be due to unfamiliarity with low C02 tension in the alveolar capillaries capillaries . The vital capacity The 1.The inspiratory capacity (Tidal volume + inspiratory volume) is decreased in late decreased pregnancy 2.The expiratory reserve volume volume (maximum amount of air which can be expired after normal expiration) is reduced reduced 3.The residual volume is reduced . is The reduction in: The 1.The inspiratory capacity 2.The expiratory reserve volume volume 3.The residual volume 3.The is not significant is . 4.The tidal volume : 4. (amount of gas inspired or expired in each respiration) rises rises through-out pregnancy by about 40 % . by Hyperventilation is due to increased tidal volume not respiratory rate V - Urinary system Urinary (A) Kidney and kidney function tests function • Renal blood flow and glomerular filtration rate increases by 50 % . This leads to increased excretion • Therefore: 1. There is serum creatinine (due to There creatinine cleareance) ,the same for uric acid. uric 2. blood urea . 2. 3. kidney excretion of glucose due 3. to filtration load and renal threshold leading to renal glucosuria Therefore , in interpretating the results Therefore , in interpretating the results of kidney function test you should take into consideration that the highest normal values in the pregnancy = the lowest normal values in nonnormal pregnant state (B) Ureters (B) Dilatation of the ureters and renal pelvis due to : and i - Relaxation of the Relaxation ureters by the effect of progesterone . progesterone ii - Pressure against the pelvic brim by the uterus particularly on the right side due to dextroposed uterus and dilatation of the right ovarian vessels the (C) Bladder and urethra (C) • Frequency of micturition in early pregnancy due to : in i - Pressure on the bladder by the enlarged uterus . by ii - Congestion of the bladder muscosa . bladder • 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 tract & liver liver 1 - Gingivitis : Gingivitis There is increased vascularity and tendency for bleeding as well as hypertrophy of the interdental papillae • The gums may become The hyperemic and soft and may bleed when mildly traumatized, bleed as with a tooth brush. • Epulis of pregnancy may develop. may Treated by dental hygiene and cryosurgery for severe cases. cryosurgery 2 - Ptyalism: Ptyalism: • It is excessive salivation which is It more common in association with oral sepsis . • It is due to failure to swallow saliva It failure and not due to increase in amount. • Smoking is stopped and Smoking anticholinergic drugs may help. anticholinergic 3 - Nausea and vomiting Nausea Nausea (morning sickness) and vomiting (emesis gravidarum) occur in early months occur 4 - Appetite changes Appetite (longing or craving) • The pregnant woman dislikes The some foods and odours while desires others • Reduced sensitivity of the Reduced taste buds during pregnancy taste creates the desire for markedly sweet, sour , or salt foods . foods (pica) (pica) Deviation may be so Deviation extreme to the extent of eating blackboard chalk , coal or mud coal 5 - Indigestion and flatulence and This is probably due to : This i - Decreased gastric acidity Decreased caused by regurgitation of alkaline secretion from the intestine to the stomach . ii - Decreased gastric motility (progesterone effect). (progesterone 6 - Heart burn Heart Due to reflux of acidic gastric contents to the oesophagus The treatment includes : The (a) small frequent meals to (a) small prevent overdistension of the stomach ,The evening meal should be taken at least 3 hours before going to bed (b) avoid fatty foods, avoid chocolate, and smoking, as these relax the lower esophageal sphincter. (c) the bed should be raised bed at the head (15-20 cm), and an extra pillow is used. (d) Antacid Preparations Preparations containing aluminium hydroxide are favoured. favoured. 7 - Constipation Constipation due to : i - Reduced motility of large Reduced intestine (progesterone effect). (progesterone ii - Increased water reabsorption ii from large intestine (aldosterone effect). (aldosterone 7 - Constipation Constipation iii - Pressure on the pelvic colon by the pregnant uterus. iv - Sedentary life during pregnancy . It is treated by It (a) evacuation of the bowel at the same time each day (bowel training) (bowel (b) diet rich in fiber in diet the form of vegetables, fruits, and bran (c) milk and avoid milk dehydration by increasing fluid intake. increasing (d) minimize coffee and tea as they are diuretics tea and cause dehydration. and (e) increase physical (e) activity and avoid activity sedentary life. (f) a mild laxative may mild be needed. Liquid paraffin is better avoided as it prevents absorption of fat soluble vitamins. In some women iron supplementation supplementation may be the cause may 8 - Gall stones Gall More tendency to stone formation due to atony and delayed emptying of the gall bladder of 9 - Haemorroids Haemorroids due to : due i - Mechanical pressure on the pelvic veins. ii - Laxity of the walls of the veins by progesterone iii - Constipation. 10 - Appendix 10 Is displaced upwards and laterally (pain and tenderness due to appendicitis is higher than in nonpregnant state) Appendix Appendix Liver Liver i - Decreased albumin and increased globulin resulting in decreased A/G ratio ii - Increased heat labile serum alkaline phosphatase . alkaline Therefore both A/G ratio and heat labile ratio alkaline phosphatase alkaline are not reliable as liver function tests during pregnancy VII - Metabolic changes changes (A) Weight gain The average weight gain in pregnancy is 10 - 12 kg 10 The increase occurs mainly in the second and third trimester at a rate of 350 - 400 gm/ week gm/ Out of the 11 kg weight gain Out 6 kg is composed of composed maternal tissues (breast, maternal fat, blood and uterine tissues), and 5 kg of fetal tissue , placenta and amniotic fluid Maternal Tissues Maternal Increases during weeks of Pregnancy 1600 1400 1200 1000 Uterus Mammary Gland Plasma Volume 800 600 400 200 0 10 wk 20 wk 30 wk King JC. Am J Clin Nutr 71 (5(S));2000. 40 wk Products of Conception Products Increases during weeks of Pregnancy 3500 3000 2500 2000 Fetus Placenta Amniotic Fluid 1500 1000 500 0 10 wk 20 wk 30 wk King JC. Am J Clin Nutr 71 (5(S));2000. 40 wk Out of the 11 kg :weight gain weight ,kg are water 7 kg kg fat and 3 kg kg protein 1 kg )B) Water metabolism There is tendency to There is tendency to water retention secondary to sodium retention (C) Protein metabolism (C) There is tendency for nitrogen There is tendency for nitrogen retention (+ ve nitrogen balance) for fetal and maternal tissue formation (D) Carbohydrate metabolism (D) Pregnancy is potentially diabetogenic diabetogenic - Alimentary glucosuria may Alimentary occur in early pregnancy . early - Renal glucosuria may occur in Renal the middle of pregnancy . middle (E) Fat metabolism (E) There is increase of plasma lipids with tendency to acidosis (HPL action) (F) Mineral metabolism There is increased demand for iron , calcium , phosphate and magnesium VIII - Musculoskeletal changes changes (a) Increased mobility of pelvic joints due to pelvic softening of the joints and ligaments caused by ligaments progesterone and relaxin progesterone relaxin (b) Flattening of feets . (b) Flattening (c) Progressive lordosis Progressive leading to lordotic gait & backache ( by high backache heals). heals). (d) Pendulous abdomen in (d) Pendulous multigravida resulting in many complications many Backache Backache • The majority of pregnant The women complain of low backache which increases as pregnancy advances. • It is due to increased It lumbar lordosis to counterlumbar balance the forward balance growth of the uterus growth • 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, Paracetamol is the drug of choice, Non-steroidal antichoice, inflammatory drugs as inflammatory indomethacin may be given (e) physiotherapy may be needed. needed. Orthopaedic consultation Orthopaedic consultation is indicated if pain is severe, or radiates to the legs, and in the presence of neurological signs Leg cramps Leg • These are common in These the second half of second pregnancy particularly at night. at • The exact cause is The unknown. unknown. It may be related to shift of blood away from the muscle, i.e., ischaemic ischaemic cramp, or it may be tetanic tetanic cramp caused by lack of calcium, or increased phosphorous, or both phosphorous, • Treated by taking calcium tablets, and reducing the intake tablets and of phosphorous-containing substances as milk, meat, and substances cheese. cheese. • Vitamin B complex may be tried. • Leg massage and hyperextension of foot help during the attack. during Round ligament strain Round • Pain is felt along the round Pain ligament and in the groin. • Pain unilateral and left-sided, Pain (dextroflexion ). (dextroflexion • It is due to stretching of the nerve fibres in the round ligaments. IX - Endocrine system system 1 - Anterior pituitary Anterior i - Increase in size more than increase in vascularity This renders anterior pituitary liable for ischaemia ischaemia ii - Pregnancy cell (modified Pregnancy chromophobe) appears due to increased hCG . iii - Prolactin level increases Prolactin up to 150 ng /ml at term to ensure lactation . 2 - Posterior pituitary Posterior Does not hypertrophy , Does not hypertrophy , but increase its oxytocin secretion near term 3 - Thyroid gland Thyroid There is diffuse slight enlargement of the gland of Gland activity is as evidenced by normal free T4 (although total T4 ) due to due thyroid binding globulin (TBG) , BMR 20 % , total T3 , protein bound iodine and TSH 4 - Parathyroid gland Parathyroid Hypertrophy due to increased demand for Calcium for 5 - Suprarenal gland Suprarenal Hypertrophy particularly the Hypertrophy cortex resulting in increased glucocorticoids (cortisone) (cortisone) and increased mineralocorticoids (aldosterone) (aldosterone) 6 - Insulin Insulin increased mainly due to HPL (anti insulin hormone) insulin 7 -Ovaries -Ovaries corpus luteum of pregnancy pregnancy functions till 8-12 wks. when its function is taken by the placenta by XI - Skin changes XI 1 - Persistance of basal body temperature (BBT) elevation beyond (BBT) the expected day of menstruation (due to increased progesterone). progesterone). 2 - Spider telangiectasis & palmar erythema palmar due to increased estrogen increased or or cutaneous vasodilatation cutaneous 3 - Cutaneous vasodilatation (hyperaemia) (hyperaemia) leads to : leads i - Masks pallor due to anaemia Masks pallor with or without palmar erythema . ii ­ Glandular activities (sweat & sebaceous glands). iii ­ Sensation of heat and nasal congestion 4 - Pigmentation Pigmentation due to increased estrogen due or melanocyte stimulating hormone or ACTH ACTH • In the face = chloasma graviderom = mask of pregnancy pregnancy a butterfly pigmentation on the cheeks and nose . It usually disappears few months after labour . months •In abdomen: Linea Nigra= Linea pigmentation in midline below the umbilicus Linea nigra Linea Stria gravidarum Stria pigmentation in the lower abdomen , abdomen flanks , inner thighs , flanks buttocks & breast and increase as pregnancy advances advances It starts bluish (stria rubra) , (stria then becomes pale to become white (stria albicans) after (stria delivery , which persists (primigravida has stria rubra only ,while multigravida has both S.R and S.A) S.R It It may be due to mechanical stretching or increased glucocorticoids which results glucocorticoids in rupture of the elastic fibres in the dermis and exposure of the vascular subcutaneous tissues subcutaneous 5 - Secretions Secretions increase in sweat increase in sweat and sebaceous glands activity (B) Breast signs (B) •Diagnostic in primigravida and may persist after delivery . • In multigravida it may be due to the previous pregnancies . •They may occur with any hyperestrogen , so they are not diagnostic for pregnancy i - First month : First increased size & vascularity (dilated veins) , mastodynia (dilated may be present which ranges from tingling to frank pain due to hormonal responses of the mammary ducts and alveolar system alveolar ii - Second month : ii increased pigmentation of the nipple & areola and prominence of Montgomery tubercles Montgomery (nonpigmented nodules around the primary areola (12 - 20) areola Montgomery tubercles Montgomery They were thought to be They enlarged sebaceous glands, but recently they are found to be the lips of orifices of peripheral active lacteal ducts active Breast changes Breast iii - Third month : Third secretion of colostrum colostrum (thick yellowish fluid) which can be expressed from the nipple nipple iv - Fourth month : Fourth a pigmented area appears around the primary areola called the secondary areola secondary Lower limbs signs Lower i - Edema : Edema bilateral and pitting ii - Varicose veins Varicose XII. Neurologic System System • Sensory changes from Sensory compression of nerves compression • Tension headaches • Carpal tunnel syndrome due Carpal to edema to • Numbness and tingling Numbness related to postural changes related 1. Headache Headache It is relatively common, and attributed to intracranial vasodilatation caused by oestrogen and progesterone progesterone 1. Headache Headache • It is most troublesome in the It second trimester, but may persist throughout pregnancy. persist • However, headache may be due to lack of sleep, or overwork. to • An analgesic is prescribed. An 2. Fainting Fainting It results from lowering of blood pressure due to vasodilatation which occur in pregnancy occur 3. Insomnia Insomnia During pregnancy some women are sleepy and depressed, others may be irritable and suffer insomnia insomnia 4.Carpal tunnel syndrome 4.Carpal Caused by compression of compression the median nerve as it median passes through its fibrous tunnel at the wrist, as a result of fluid retention and oedema in pregnancy and There is tingling, numbness and burning sensation affecting the radial side of the hand side • Treatment: Treatment: includes reassurance, use of a wrist splint, diuretics, non steroidal anti-inflammatory drugs, and local injection of hydrocortisone in the tunnel below the fibrous roof below (retinaculum) (retinaculum) Operation is rarely needed during pregnancy by incising the retinaculum to relieve compression relieve Other compression neuropathies affect the lateral cutaneous nerve of the thigh , obturator and peroneal nerves peroneal LEUCORRHOEA LEUCORRHOEA The normal vaginal The discharge increases during pregnancy because of excess oestrogen and may form a complaint However, a pathological discharge, e.g., monilial infections monilial which is common in pregnancy must be excluded. excluded. 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