Ch 14 physiological adaptation part II Dr. Areefa Albahri Midwifery department

GI System  Ptyalism (excessive salivation) It may be associated with gastro-oesophageal reflux  Nausea and vomiting (popularly known as ‘morning sickness’) is experienced by more than half of all pregnant women, usually resolve by 16–20 weeks. Women need to know that it is not usually associated with a poor pregnancy outcome and should be advised that ginger, P6 (wrist) acupressure and antihistamines appear to be effective in reducing symptoms

 Pica is the persistent craving and compulsive consumption of substances such as ice, clay, soap, coal or starch.  Several theories have been proposed to explain the condition, such as nutritional deficiencies of zinc or iron, or the sensory enjoyment of the taste, texture or smell of the substance.  Pica can cause a number of medical problems, such as nutritional deficiencies, constipation, electrolyte imbalance, gastrointestinal and metabolic disturbances, lead poisoning, dental complications and weight gain

 Abdominal distension and a ‘bloated’ feeling occur when nutrients and fluids remain in the intestinal tract for longer, particularly in the third trimester due to the prolonged transit time. Increased flatulence may also occur due to decreased motility and pressure of the uterus on the bowel (Blackburn 2007).  Heartburn or acid reflux into the lower oesophagus during pregnancy occurs in 30– 80% of women, particularly during the third trimester (Rayner & Micell 2005). Frequent or more severe heartburn can interfere with sleep and deter the woman from eating adequately.

Changes in metabolism  The major changes in the utilization of carbohydrate, fat and protein during pregnancy are closely linked with the functions of the various endocrine glands. The placenta is already secreting hormones that affect metabolism within a few weeks of conception (see Ch. 11). Metabolic changes are essential for the continuous supply of glucose and amino acids for fetal growth as well as for meeting the increased physiological demands of the woman during pregnancy, labour and lactation

 Weight gain averages between 11 and 16kg but variations are large. A birth weight of 3.1–3.6kg has been associated with optimal maternal and fetal outcomes. Maternal nutritional status at the time of conception is very important for fetal growth and development. It is important to attain a healthy body weight prior to conception

Skeletal changes  Back pain occurs in approximately 70% of pregnant women. The weight of the pregnant uterus and altered posture (compensatory lordosis) increase susceptibility which is exacerbated by progesterone and relaxin causing softening and relaxation of the ligaments of the pelvis.

measures to reduce pain  limiting physical activity, alteration of posture, wearing low-heeled shoes and adequate rest. Supportive pillows beneath the knees and abdomen and local application of heat may relieve pain. exercises and acupuncture can reduce back pain (Pennick & Young 2007). While not substantiated by research, reports suggest a range of alternatives may be beneficial including massage, yoga, relaxation therapy, water exercises and osteopathy (Wang et al 2005).

Skin changes  Almost all women note some degree of skin darkening as one of the earliest signs of pregnancy. While the exact pathogenesis remains unclear, it is generally attributed to an increase in melanocyte stimulating hormone, progesterone and oestrogen serum levels. Hyperpigmentation is more in areola, genitalia and umbilicus, in areas prone to friction, such as the axillae and inner thighs and in recent scars.

 Hair growth Stimulated by oestrogen, the growing period for hairs is increased in pregnancy so the woman reaches the end of pregnancy with many overaged hairs. Normal hair growth is usually restored by 6–12 months. Mild hirsutism is common during pregnancy, particularly on the face (Muallem & Rubeiz 2006). Actions that may help include reducing damage to the hair by not combing when it is wet, and avoiding hairstyles that pull and stress hair, using shampoos and conditioners that contain biotin and silica. Diet that is high in fruits and vegetables containing flavonoids and antioxidants may provide protection for the hair follicles and encourage growth.

 The linea nigra is a line that lies over the midline of the from the umbilicus to the symphysis pubis.  Pigmentation of the face affects up to 75% of pregnant women (Muallem & Rubeiz 2006). Known as chloasma or melasma, or ‘mask of pregnancy’ it is caused by melanin deposition into epidermal or dermal macrophages, further exacerbated by sun exposure. The chloasma usually regresses postpartum but may persist in approx 10% of women. Oral contraceptives may aggravate melasma and should be avoided in susceptible women (Cunningham et al 1997). If chloasma persists postpartum it can be treated with a variety of topical agents, including hydroquinone, tretinoin, kojic acid and vitamin C (Katsambas & Stratigos 2001).

 striae gravidarum (stretch marks) caused by thin tears occurring in the dermal collagen.  Pruritus in pregnancy (not due to liver disease) can be distressing. In the absence of a rash, aspirin is recommended. If there is a rash chlorphenindione (chlorpheniramine) may be more effective (Young & Jewell 2002).  A rise in temperature by 0.2–0.4 °C occurs as a result of the effects of progesterone and the increased basal metabolic rate (BMR). As a result, pregnant women ‘feel the heat’ and often sweat profusely, particularly in hot, humid climates. Peripheral vasodilation and acceleration of sweat gland activity help to dissipate the excess heat produced by maternal, placental and fetal metabolism (Lowdermilk & Perry 2004).

 Quickening  The first fluttering movements of the fetus are felt around 20 weeks in a first pregnancy and 18. Fetal movements can begin to be detected by the examiner around 20 weeks.

Sign of pregnancy Presumptive Breast changes (including feelings of tenderness, fullness, or tingling, and enlargement or darkening of areola)  Hyperprolactinemia induced by tranquilizers  Infection  Prolactin-secreting pituitary tumor  Premenstrual syndrome Nausea or vomiting upon arising  Gastric disorders  Infections  Psychological disorders, such as anorexia nervosa Amenorrhea  Anovulation  Blocked endometrial cavity  Endocrine changes  Medications (phenothiazines)  Metabolic changes

Frequent urination  Emotional stress  Pelvic tumor  Renal disease  Urinary tract infection Uterine enlargement (in which the uterus can be palpated over the symphysis pubis)  Ascites  Obesity  Uterine or pelvic tumor  Excessive flatus Quickening (fetal movement felt by the woman) Increased peristalsis Cardiopulmonary disorders

Probable Sign Serum laboratory tests (revealing the presence of human chorionic gonadotropin [hCG] hormone) Possible cross-reaction of luteinizing hormone (similar to hCG) in some pregnancy tests Chadwick's sign (vagina changes color from pink to violet) Hyperemia of cervix, vagina, or vulva Goodell's sign (cervix softens)Estrogen-progestin hormonal contraceptives Ballottement (fetus can be felt to rise against abdominal wall when lower uterine segment is tapped during bimanual examination) Ascites Uterine tumor or polyps

Probable Sign Braxton Hicks contractions (periodic uterine tightening)  Hematometra  Uterine tumor Palpation of fetal outline (through abdomen)  Subserous uterine myoma

Positive Sign Sonographic evidence of fetal outlineNone Fetal heart audible by Doppler ultrasoundNone Palpation of fetal movement (through abdomen) None

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