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Maternal Changes with Pregnancy

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									Maternal Changes
 with Pregnancy
Pregnancy is a period of
    adaptation for :

• The needs of the fetus
• Meeting the stress of
  pregnancy and labour
(A) The whole
        Size - 1
increase from 7.5 x 5 x 2.5
cm in nonpregnant states
to 35 x 25 x 20 cm at term
 i.e. the volume increase
         1000 time
    Weight - 2

increases from 50 gm
 in nonpregnant state
  to 1000 gm at term
      Shape -3
     pyriform in the
   nonpregnant state ,
becomes globular at 8th
week , then pyriform by
  16th week till term .
     Position - 4
 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 :
becomes progressively
 softer due to :
 i - Increased vascularity
ii - Presence of amniotic fluid
    Contractility -6
  from the first trimester onwards ,
    the uterus undergoes irregular
         painless contractions
     (Braxton Hicks contractions) .
 They may cause some discomfort
late in pregnancy and may account
         for false labour pain .
    7- Capacity
   increases from
4 ml in non-pregnant
       state to
  4000 ml at term
(B) Myometrial
1 - Hypertrophy (estrogen
     effect) rather than
hyperplasia (progesterone
effect) till 14th week, then
 the fetus exerts a direct
2 - Formation of the
    lower uterine
 segment (L.U.S.)
 from the isthmus
and lower half inch
     of the body
 Formation of lower
  uterine segment
After 12 weeks, the isthmus
   (0.5cm) starts to expand
 gradually to form the lower
    uterine segment which
measures 10 cm in length at
 Upper Uterine Segment
• Peritoneum: Firmly-attached
• Myometrium: 3 layers; outer
  longitudinal, middle oblique and
  inner circular.
• The middle layer forms 8-shaped fibers
    around the blood vessels to control
         postpartum hemorrhage
 Upper Uterine Segment
• Decidua: Well-developed
• Membranes: Firmly-attached
• Activity: Active, contracts,
  retracts and becomes thicker
  during labour.
Lower Uterine Segment

• Peritoneum: Loosely-
• Myometrium : 2 layers;
  outer longitudinal and inner
Lower Uterine Segment
• Decidua: Poorly-developed
• Membranes: Loosely-
• Activity: Passive, dilates,
  stretches and becomes thinner
  during labour
   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
 at the level of the symphysis
     pubis (not seen or felt)
 (C) Uterine
blood vessels
1 - Uterine artery lumen:
    is doubled and its blood flow
          increases 5 times
2 - Myometrial and decidual
 arteries (spiral arteries) undergo
 fibrinoid degeneration due to 2
 waves of trophoblastic migration ,
 so they become dilated to be the
 uteroplacental arteries
• Uterine blood flow
  progressively and
 reaches about 500
ml / minute at term
(D) Changes in the cervix :

      1 - It becomes
 hypertrophied , soft and
  bluish in colour due to
  oedema and increased
2 - Soon after conception , a thick
 cervical secretion obstructs the
 cervical canal forming a
 mucous plug .
3 - The endocervical epithelium
 proliferates and or everted
 forming cervical ectopy
 (previously called erosion)
 (E) Changes in fallopian tubes
and ligaments (round and broad):

   Inactive , elongated ,
     marked increase in
    There may be broad
  ligament varicose veins
(F) Changes in the vagina :

The vagina becomes soft ,
    warm , moist with
 increased secretion and
     violet in colour
 (Chadwick's sign) due to
  increased vascularity
 (G) Changes in the vulva :

• It becomes soft, violet in
• Oedema and
  varicosities may develop
(H) Changes in the ovaries

  1 - Both ovaries are
enlarged due to increased
 vascularity and oedema
  particularly the ovary
which conatins the corpus
         luteum .
 (H) Changes in the ovaries

2 - Corpus luteum continues to
    grow till 7 - 8 weeks , then it
          stops growing
, It becomes inactive and starts
     degeneration at 12 weeks
    (degeneration is completed
            after labour)
Corpus luteum secretes
1.estrogen ,
(H) Changes in the ovaries

3 - Ovulation ceases during
      pregnancy due to
 pituitary inhibition by the
  high levels of oestrogen
     and progesterone
• Relaxin is a protein
• Its exact role in pregnancy
  is unknown.
• It may induce softness and
  effacement of the cervix.
II - Haematological
 (A) Blood volume
The total blood volume
 increases steadily from
early pregnancy to reach
 a maximum of 35-45 %
 above the non-pregnant
    level at 32 week .
  - Plasma volume :
Increases from 2600 ml by
   ± 45 % (1250 in the 1st
  pregnancy) and 1500 ml
 in subsequent pregnancies
- Red blood cell mass :
   • Increases from 1400 ml
 (nonpregnant) by 33 % (± 450
ml) due to increased production
resulting from erythropoeitin or
    action of hCG or HPL .
• The increase is steady till full
 The increase in plasma
 volume is more than the
increase in red blood cell
mass (Hb mass) resulting
    in haemodilution
(physiologic anemia)
However, the
 minimal Hb.
 accepted is
 10-11 gm%
Values of increased blood volume

1 - Meets increased demands
 for uterus , baby .... etc .
2 - Protects against supine
 hypotension syndrome .
3 - Protects against fluid loss
 in labour .
Increased blood volume
 more than the increase
 in red cell mass , leads
   to decreased blood
  viscosity which leads
      to decrease in
  peripheral resistance
(B) Blood
  1 - Decreased Hb % and
           RBCs % :
• Erythrocytes decrease from
    4.5 million / mm3 to 3.7
   million / mm3 (due to the
  relative increase in plasma
   volume more than red cell
             mass) .
 Erythrocytes contents
from 2,3- DPG increases
  which competes for 02
 binding sites in the Hb
molecule , thus releasing
  more 02 to the fetus .
Hb concentrations
  from 14 gm / dl
     12 gm / dl.
2 - M.C.H.C : no change
3 - M.C.V. :  ,  or no
 change (depending on
 the availability of Fe).
4- Fragility of R.B.Cs: .
5 - Reticulocytes : mild 
6 - E.S.R : from 12 to
 50 mm / hour
7 – Fibrinogen:  from
 200 - 400 mg / dl to 400 -
 600 mg / dl.
8 - White blood cells:
(from 7.000 / mm3 to 10.500 /
 mm3 during pregnancy and up
 to 16.000 / mm3 during labour :
-  PNL & its enzymes .
- Lymphocytes : no change .
9 - Platelets:  or 
10-Total plasma proteins
 : slightly 
(mainly  albumin)
 resulting in  osmotic
(C) Coagulation
• Platelets  or . (controversial).
• Fibrinogen doubled to 600 mg %
• Factor VIII tripled .
• Factor VII & factor X are
• Factor XI & factor XIII slight 
• Fibrinolytic activity .
• Therefore pregnancy is a
 hypercoagulative state .
  • All these changes are
reversed after labour with 
   RBCs production (not 
destruction)& the excess Fe
           is stored .
Ill - Cardiovascular
  system changes
(A) Changes in the heart
  As the diaphragm is elevated
 progressively during pregnancy
  the apex is displaced upwards
and to the left so that it lies in the
 4th intercostal space outside the
        midclavicular line.
       Pulse rate :
     - The resting pulse rate
    increases by 8 beats / min.
  (8 weeks) and 16 beats / min.
            (full term).
-Some episodes of ectopic beats
     - Water hummer pulse .
      Heart sounds
• 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
• The intensity of the second
  heart sound may increase.
      Heart sounds
• The third sound becomes
  louder before mid-pregnancy
  and persists as such till one
  week post partum.
• The fourth sound may be
  detectable by
Systolic functional murmurs
develop in most of women, usually
   early systolic, but mid systolic
murmurs may occur and heard over
         the left sternal edge,
    they are thought to be due to
  functional tricuspid regurgitation
• The main features of ECG may be
  attributed to the changes in the
  position of the heart.
• The axis undergoes left shift by 15 -
• The QRS complexes become of low
  voltage, and T wave becomes
(B) Haemodynamic
1 - Cardiac output
  Cardiac output:
increases mainly by increased
   stroke volume rather than
increased heart rate reaching a
  maximum of 40% above the
 non-pregnant level at 20 weeks
   to be maintained till term.
      Cardiac output
        Distribution :
•   400 ml to the uterus ,
•   300 ml to the kidneys ,
•   300 ml to skin ,
•   300 ml to GIT , breast &
            • 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. is
 maintained for up
to 4 days and then
  declines rapidly
2 - Arterial blood
  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 :
(mainly affect diastolic B.P.)
    due to : vasodilatation +
     increase metabolism +
     arteriovenous shunt at
            placenta .
  ii - Supine hypotension :
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.
  to the extent that fainting may
   iii - Decreased
  sensitivity of blood
vessels to angiotensin II
which is vasoconstrictor
Vena Cava Syndrome
• The posture of the pregnant
  woman affects arterial blood
• Typically, it is highest when she
  is sitting, lowest when lying in
  the lateral recumbent position
  and intermediate when supine.
Peripheral Vasodilatation

blood flow to the skin,
particularly in the hands
and feet generally giving
 the pregnant women a
   feeling of warmth
Peripheral Vasodilatation

Increases the congestion of
  nasal mucosa leading to
  a common complaint of
   nasal obstruction and
    bleeding (epistaxis).
3 - Venous pressure
 Increased venous pressure
  in the lower limbs due to :
1. Back pressure from the compressed
   I.V.C. by the pregnant uterus .
2.Mechanical pressure of the uterus
   on pelvic veins .
3.Increased venous return from
   internal iliac veins --> increase
   pressure in external iliac veins .
Increased venous pressure
    in the lower limbs
     Predisposes to :
        Oedema ,
      varicose veins
        and piles
   Oedema and varicose veins in the
    lower limbs & vulva are due to
 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).
v -  Interstitial pressure (Na retention).
 Varicose Veins treatments
1. avoid long periods of
 standing and encourage
 active exercise.
2. avoid constricting clothes.
3. keep the legs elevated while
 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
5. stretch panties may be
 necessary for vulval varicosities.
IV - Respiratory
(A) Anatomically:
  The enlarged
 uterus displaces
the diaphragm up
    to ± 4 cm .
     This result in :
1. The diaphragmatic mobility
 is reduced and respiration
 becomes mainly thoracic .
2. Widen the subcostal angle
 and increases the transverse
 diameter of the chest.
Respiratory functions
 The respiratory rate
does not increase during
   pregnancy from its
 normal rate of 14 - 15 /
(deep respiration)
 occurs due to the
  effect of excess
  Shortness of breath
(the need to breath becomes a
        conscious one)
 and dyspnea are common
 complaint of the pregnant
women which may be due to
unfamiliarity with low C02
   tension in the alveolar
The vital capacity
1.The inspiratory capacity
     (Tidal volume +
   inspiratory volume)
   is decreased in late
2.The expiratory reserve
(maximum amount of air
which can be expired after
  normal expiration) is
 3.The residual volume
      is reduced .
   The reduction in:
1.The inspiratory capacity
2.The expiratory reserve
3.The residual volume
   is not significant    .
  4.The tidal volume :
(amount of gas inspired
    or expired in each
    respiration) rises
 through­out pregnancy
     by about 40 % .
    is due to
 increased tidal
   volume not
respiratory rate
V - Urinary system
 (A) Kidney and kidney
     function tests

 • Renal blood flow and
glomerular filtration rate
   increases by 50 % .
 This leads to increased
          • Therefore:
1. There is  serum creatinine (due to
    creatinine cleareance) ,the same
   for uric acid.
2.  blood urea .
3.  kidney excretion of glucose due
  to  filtration load and  renal
  threshold leading to renal
Therefore , in interpretating
      the results of kidney
 function test you should take
    into consideration that
the highest normal values in
   pregnancy = the lowest
     normal values in non-
        pregnant state
     (B) Ureters
Dilatation of the ureters
and renal pelvis due to :
 i - Relaxation of the
ureters by the effect of
     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
(C) Bladder and urethra
• Frequency of micturition
 in early pregnancy due to :
 i - Pressure on the bladder
 by the enlarged uterus .
ii - Congestion of the
 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
       & liver
  1 - Gingivitis :
   There is increased
vascularity and tendency
 for bleeding as well as
   hypertrophy of the
  interdental papillae
   • The gums may become
  hyperemic and soft and may
bleed when mildly traumatized,
     as with a tooth brush.
   • Epulis of pregnancy
        may develop.
Treated by dental hygiene and
 cryosurgery for severe cases.
        2 - Ptyalism:
• It is excessive salivation which is
  more common in association with
  oral sepsis .
• It is due to failure to swallow saliva
  and not due to increase in amount.
• Smoking is stopped and
  anticholinergic drugs may help.
3 - Nausea and vomiting

Nausea (morning sickness)
      and vomiting
  (emesis gravidarum)
  occur in early months
4 - Appetite changes
 (longing or craving)
• The pregnant woman dislikes
  some foods and odours while
  desires others
• Reduced sensitivity of the
  taste buds during pregnancy
  creates the desire for
  markedly sweet, sour , or salt
  foods .
Deviation may be so
extreme to the extent
of eating blackboard
 chalk , coal or mud
5 - Indigestion
and flatulence
    This is probably due to :
i - Decreased gastric acidity
  caused by regurgitation of
  alkaline secretion from the
  intestine to the stomach .
ii - Decreased gastric motility
  (progesterone effect).
  6 - Heart burn
Due to reflux of acidic
gastric contents to the
The treatment includes :
(a) small frequent meals to
 prevent overdistension of
 the stomach ,The evening
  meal should be taken at
 least 3 hours before going
            to bed
    (b) avoid fatty foods,
 chocolate, and smoking, as
     these relax the lower
    esophageal sphincter.
(c) the bed should be raised
 at the head (15-20 cm), and
   an extra pillow is used.
    (d) Antacid
containing aluminium
    hydroxide are
      7 - Constipation
           due to :
i - Reduced motility of large
  intestine (progesterone effect).
ii - Increased water reabsorption
  from large intestine
  (aldosterone effect).
     7 - Constipation
iii - Pressure on the pelvic
  colon by the pregnant
iv - Sedentary life during
  pregnancy .
It is treated by
(a) evacuation of the
  bowel at the same
    time each day
   (bowel training)
(b) diet rich in fiber in
 the form of vegetables,
 fruits, and bran
(c) milk and avoid
 dehydration by
 increasing fluid intake.
(d) minimize coffee and
 tea as they are diuretics
 and cause dehydration.
(e) increase physical
 activity and avoid
 sedentary life.
(f) a mild laxative may
    be needed. Liquid
    paraffin is better
 avoided as it prevents
    absorption of fat
    soluble vitamins.
In some women
may be the cause
  8 - Gall stones

More tendency to stone
formation due to atony
 and delayed emptying
  of the gall bladder
9 - Haemorroids
           due to :
i - Mechanical pressure on
  the pelvic veins.
ii - Laxity of the walls of
  the veins by progesterone
iii - Constipation.
   10 - Appendix
Is displaced upwards and
     laterally (pain and
      tenderness due to
appendicitis is higher than
   in nonpregnant state)
i - Decreased albumin and
  increased globulin resulting
  in decreased A/G ratio
ii - Increased heat labile serum
  alkaline phosphatase .
 Therefore both A/G
 ratio and heat labile
 alkaline phosphatase
are not reliable as liver
 function tests during
VII - Metabolic
(A) Weight gain
The average
weight gain in
pregnancy is
 10 - 12 kg
   The increase
 occurs mainly in
  the second and
third trimester at a
 rate of 350 - 400
     gm/ week
Out of the 11 kg weight gain
    6 kg is composed of
   maternal tissues (breast,
    fat, blood and uterine
          tissues), and
5 kg of fetal tissue , placenta
      and amniotic fluid
              Maternal Tissues
     Increases during weeks of Pregnancy
                                                  Mammary Gland
  600                                             Plasma Volume
          10 wk       20 wk       30 wk   40 wk

King JC. Am J Clin Nutr 71 (5(S));2000.
        Products of Conception
     Increases during weeks of Pregnancy


 2000                                               Fetus
 1500                                               Placenta
                                                    Amniotic Fluid

          10 wk        20 wk        30 wk   40 wk

King JC. Am J Clin Nutr 71 (5(S));2000.
 Out of the 11 kg
  :weight gain
,kg are water 7
kg fat and 3
kg protein 1
)B) Water metabolism
  There is tendency to
     water retention
  secondary to sodium
(C) Protein metabolism

There is tendency for
   nitrogen retention
(+ ve nitrogen balance)
 for fetal and maternal
    tissue formation
(D) Carbohydrate metabolism

  Pregnancy is potentially
- Alimentary glucosuria may
  occur in early pregnancy .
- Renal glucosuria may occur in
  the middle of pregnancy .
(E) Fat metabolism

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
(a) Increased mobility of
 pelvic joints due to
 softening of the joints and
 ligaments caused by
 progesterone and relaxin
(b) Flattening of feets .
(c) Progressive lordosis
 leading to lordotic gait &
 backache ( by high
(d) Pendulous abdomen in
 multigravida resulting in
 many complications
• The majority of pregnant
  women complain of low
  backache which increases
  as pregnancy advances.
• It is due to increased
  lumbar lordosis to counter-
  balance the forward
  growth 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
(d) analgesics given systemically
  or as local creams,
  Paracetamol is the drug of
  choice, Non-steroidal anti-
  inflammatory drugs as
  indomethacin may be given
(e) physiotherapy may be
Orthopaedic consultation
   is indicated if pain is
 severe, or radiates to the
 legs, and in the presence
   of neurological signs
   Leg cramps
• These are common in
    the second half of
pregnancy particularly
         at night.
  • The exact cause is
It may be related to shift of
     blood away from the
    muscle, i.e., ischaemic
 cramp, or it may be tetanic
   cramp caused by lack of
    calcium, or increased
    phosphorous, or both
   • Treated by taking calcium
  tablets, and reducing the intake
     of phosphorous-containing
   substances as milk, meat, and
• Vitamin B complex may be tried.
      • Leg massage and
   hyperextension of foot help
       during the attack.
    Round ligament strain
• Pain is felt along the round
  ligament and in the groin.
• Pain unilateral and left-sided,
  (dextroflexion ).
• It is due to stretching of the
  nerve fibres in the round
IX - Endocrine
1 - Anterior pituitary
 i - Increase in size
more than increase in
 This renders anterior
  pituitary liable for
ii - Pregnancy cell (modified
  chromophobe) appears due
  to increased hCG .
iii - Prolactin level increases
  up to 150 ng /ml at term to
  ensure lactation .
2 - Posterior pituitary

Does not hypertrophy ,
   but increase its
  oxytocin secretion
      near term
3 - Thyroid gland

 There is diffuse
slight enlargement
    of the gland
 Gland activity is  as
evidenced by normal free T4
(although total T4 ) due to
  thyroid binding globulin
          (TBG) ,
BMR 20 % ,  total T3 ,
 protein bound iodine and
4 - Parathyroid gland

Hypertrophy due to
 increased demand
    for Calcium
5 - Suprarenal gland
Hypertrophy particularly the
 cortex resulting in increased
  glucocorticoids (cortisone)
        and increased
   6 - Insulin
increased mainly
due to HPL (anti -
 insulin hormone)
    7 -Ovaries
    corpus luteum of
 functions till 8-12 wks.
when its function is taken
     by the placenta
XI - Skin changes
1 - Persistance of basal
  body temperature
(BBT) elevation beyond
  the expected day of
   (due to increased
2 - Spider telangiectasis
  & palmar erythema
          due to
    increased estrogen
 cutaneous vasodilatation
3 - Cutaneous
         leads to :
i - Masks pallor due to
  anaemia with or without
  palmar erythema .
ii -  Glandular activities
  (sweat & sebaceous
 iii - Sensation of heat and
  nasal congestion
4 - Pigmentation
   due to increased estrogen
melanocyte stimulating hormone
• In the face = chloasma
  graviderom = mask of
 a butterfly pigmentation
 on the cheeks and nose .
 It usually disappears few
    months after labour .
 •In abdomen:
 Linea Nigra=
pigmentation in
midline below the
Linea nigra
   Stria gravidarum
pigmentation in the lower
        abdomen ,
  flanks , inner thighs ,
   buttocks & breast and
  increase as pregnancy
It starts bluish (stria rubra) ,
 then becomes pale to become
  white (stria albicans) after
    delivery , which persists
(primigravida has stria rubra
 only ,while multigravida has
       both S.R and S.A)
It It may be due to mechanical
       stretching or increased
  glucocorticoids which results
      in rupture of the elastic
     fibres in the dermis and
     exposure of the vascular
        subcutaneous tissues
5 - Secretions
increase in sweat
  and sebaceous
  glands activity
(B) Breast signs
• 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 :
increased size & vascularity
 (dilated veins) , mastodynia
may be present which ranges
 from tingling to frank pain
due to hormonal responses of
   the mammary ducts and
       alveolar system
   ii - Second month :
increased pigmentation of
  the nipple & areola and
       prominence of
   Montgomery tubercles
  (nonpigmented nodules
    around the primary
      areola (12 - 20)
 Montgomery tubercles
They were thought to be
   enlarged sebaceous
glands, but recently they
are found to be the lips of
  orifices of peripheral
   active lacteal ducts
Breast changes
iii - Third month :
secretion of colostrum
    (thick yellowish
  fluid) which can be
  expressed from the
iv - Fourth month :
    a pigmented area
  appears around the
 primary areola called
 the secondary areola
Lower limbs signs

      i - Edema :
bilateral and pitting
ii - Varicose veins
XII. Neurologic
• Sensory changes from
  compression of nerves
• Tension headaches
• Carpal tunnel syndrome due
  to edema
• Numbness and tingling
  related to postural changes
     1. Headache
It is relatively common, and
  attributed to intracranial
   vasodilatation caused by
         oestrogen and
      1. Headache
• It is most troublesome in the
  second trimester, but may
  persist throughout pregnancy.
• However, headache may be due
  to lack of sleep, or overwork.
• An analgesic is prescribed.
     2. Fainting

It results from lowering
of blood pressure due to
   vasodilatation which
   occur in pregnancy
    3. Insomnia
During pregnancy some
  women are sleepy and
depressed, others may be
   irritable and suffer
4.Carpal tunnel syndrome

Caused by compression of
  the median nerve as it
passes through its fibrous
 tunnel at the wrist, as a
 result of fluid retention
and oedema in pregnancy
There is tingling,
  numbness and
burning sensation
affecting the radial
 side of the hand
      • 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
 Operation is rarely
    needed during
pregnancy by incising
  the retinaculum to
 relieve compression
 Other compression
 neuropathies affect
the lateral cutaneous
 nerve of the thigh ,
   obturator and
  peroneal nerves
  The normal vaginal
   discharge increases
during pregnancy because
 of excess oestrogen and
 may form a complaint
However, a pathological
    discharge, e.g.,
  monilial infections
  which is common in
  pregnancy must be

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