Maternal Changes with Pregnancy

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Maternal Changes with Pregnancy
Dr. Ashraf fouda Ob/Gyn. Specialist Egypt
Domiatt General Hospital
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Pregnancy is a period of adaptation for

• The needs of the fetus
• Meeting the stress of pregnancy and labour

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THE GENITAL CHANGES
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(A) The whole uterus
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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
1 - Size
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increases from 50 gm in nonpregnant state to 1000
gm at term
2 - Weight
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pyriform in the nonpregnant state , becomes
globular at 8th week , then pyriform by 16th week
till term .
3 - Shape
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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.
4 - Position
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5 - Consistency

• becomes progressively softer due to
• i - Increased vascularity
• ii - Presence of amniotic fluid

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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 .
6 - Contractility
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7- Capacity

• increases from
• 4 ml in non-pregnant state to
• 4000 ml at term

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(B) Myometrial changes
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1 - Hypertrophy (estrogen effect) rather than
hyperplasia (progesterone effect) till 14th week,
then the fetus exerts a direct stretch
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2 - Formation of the lower uterine segment
(L.U.S.) from the isthmus and lower half inch of
the body
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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 term

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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

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Upper Uterine Segment

• Decidua Well-developed
• Membranes Firmly-attached
• Activity Active, contracts, retracts and becomes
  thicker during labour.

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Lower Uterine Segment

• Peritoneum Loosely-attached
• Myometrium 2 layers outer longitudinal and
  inner circular.

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Lower Uterine Segment

• Decidua Poorly-developed
• Membranes Loosely- attached.
• Activity Passive, dilates, stretches and becomes
  thinner during labour

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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)
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• (C) Uterine blood vessels

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• 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

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• Uterine blood flow increases progressively and
  reaches about 500 ml / minute at term

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(D) Changes in the cervix

• 1 - It becomes hypertrophied , soft and bluish in
  colour due to oedema and increased vascularity.

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• 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)

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

• Inactive , elongated , marked increase in
  vascularity
• There may be broad ligament varicose veins

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(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

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(G) Changes in the vulva

• It becomes soft, violet in colour
• Oedema and varicosities may develop

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(H) Changes in the ovaries

• 1 - Both ovaries are enlarged due to increased
  vascularity and oedema particularly the ovary
  which conatins the corpus luteum .

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(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)

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• Corpus luteum secretes
• 1.estrogen , 2.progesterone,
• 3.relaxin
• hormones

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(H) Changes in the ovaries

• 3 - Ovulation ceases during pregnancy due to
  pituitary inhibition by the high levels of
  oestrogen and progesterone

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• Relaxin is a protein hormone.
• Its exact role in pregnancy is unknown.
• It may induce softness and effacement of the
  cervix.

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• II - Haematological Changes

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(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 .

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- Plasma volume

• Increases from 2600 ml by 45 (1250 in the 1st
  pregnancy) and 1500 ml in subsequent pregnancies

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- 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 term.

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

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

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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 .

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• Increased blood volume more than the increase in
  red cell mass , leads to decreased blood
  viscosity which leads to decrease in peripheral
  resistance

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• (B) Blood indices

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• 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) .

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• Erythrocytes contents
• from 2,3- DPG increases which competes for 02
  binding sites in the Hb molecule , thus releasing
  more 02 to the fetus .

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• Hb concentrations falls
• from 14 gm / dl
• To
• 12 gm / dl.

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• 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 ?.

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• 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.

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• 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 .

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• 9 - Platelets ? or ?
• 10-Total plasma proteins slightly ?
• (mainly ? albumin) resulting in ? osmotic
  pressure.

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• (C) Coagulation system

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• Platelets ? or ?. (controversial).
• Fibrinogen doubled to 600 mg
• Factor VIII tripled .
• Factor VII factor X are doubled
• Factor XI factor XIII slight ?
• Fibrinolytic activity ?.

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• Therefore pregnancy is a hypercoagulative state .
• All these changes are reversed after labour with
  ? RBCs production (not ? destruction) the excess
  Fe is stored .

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• Ill - Cardiovascular system changes

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(A) Changes in the heart
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Position

• 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.

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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 .

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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.

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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
  phonocardiography.

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Murmurs

• 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

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ECG CHANGES

• The main features of ECG may be attributed to the
  changes in the position of the heart.
• The axis undergoes left shift by 15 - 28.
• The QRS complexes become of low voltage, and T
  wave becomes flattened.

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(B) Haemodynamic changes
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• 1 - Cardiac output (C.O.P.)

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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.

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Cardiac output

• Distribution
• 400 ml to the uterus ,
• 300 ml to the kidneys ,
• 300 ml to skin ,
• 300 ml to GIT , breast heart

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• 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

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• Postpartum
• the increased C.O.P. is maintained for up to 4
  days and then declines rapidly

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• 2 - Arterial blood pressure

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• Although C.O.P. incease , yet A.B.P. is decreased
  in midtrimester to increase again in 3rd
  trimester

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• This is due to
• i - Decreased Peripheral resistance
• (mainly affect diastolic B.P.) due to
  vasodilatation increase metabolism
  arteriovenous shunt at placenta .

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• 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 occur

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• iii - Decreased sensitivity of blood vessels to
  angiotensin II which is vasoconstrictor

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Vena Cava Syndrome
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• The posture of the pregnant woman affects
  arterial blood pressure.
• Typically, it is highest when she is sitting,
  lowest when lying in the lateral recumbent
  position and intermediate when supine.

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• Peripheral Vasodilatation

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Peripheral Vasodilatation

• ?blood flow to the skin, particularly in the
  hands and feet generally giving the pregnant
  women a feeling of warmth

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Peripheral Vasodilatation

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

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• 3 - Venous pressure

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• 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 --gt increase pressure in external iliac
  veins .

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Increased venous pressure in the lower limbs

• Predisposes to
• Oedema ,
• varicose veins
• and piles

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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).

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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.

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• 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.

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• IV - Respiratory system

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(A) Anatomically

• The enlarged uterus displaces the diaphragm up to
  4 cm .

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• 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.

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Respiratory functions

• The respiratory rate
• does not increase during pregnancy from its
  normal rate of 14 - 15 / minute.

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• Overbreathing
• (deep respiration)
• occurs due to the effect of excess progesterone

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• 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 capillaries .

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The vital capacity

• 1.The inspiratory capacity
• (Tidal volume inspiratory volume)
• is decreased in late pregnancy

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• 2.The expiratory reserve volume
• (maximum amount of air which can be expired after
  normal expiration) is reduced
• 3.The residual volume
• is reduced .

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• The reduction in
• 1.The inspiratory capacity
• 2.The expiratory reserve volume
• 3.The residual volume
• is not significant.

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• 4.The tidal volume
• (amount of gas inspired or expired in each
  respiration) rises throughout pregnancy by about
  40 .

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• Hyperventilation is due to increased tidal volume
  not respiratory rate

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• V - Urinary system

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(A) Kidney and kidney function tests

• Renal blood flow and glomerular filtration rate
  increases by 50 .
• This leads to increased excretion

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• Therefore
• 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 glucosuria

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• 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

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(B) Ureters

• Dilatation of the ureters and renal pelvis due to
  
• i - Relaxation of the ureters by the effect of
  progesterone .

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• 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

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(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 .

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• 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

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VI - Gastrointestinal tract liver
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1 - Gingivitis

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

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• 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.

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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.

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3 - Nausea and vomiting

• Nausea (morning sickness)
• and vomiting
• (emesis gravidarum)
• occur in early months

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• 4 - Appetite changes (longing or craving)

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• 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 .

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(pica)

• Deviation may be so extreme to the extent of
  eating blackboard chalk , coal or mud

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• 5 - Indigestion and flatulence

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• 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).

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6 - Heart burn

• Due to reflux of acidic gastric contents to the
  oesophagus

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• 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

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• (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.

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• (d) Antacid Preparations containing aluminium
  hydroxide are favoured.

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7 - Constipation

• due to
• i - Reduced motility of large intestine
  (progesterone effect).
• ii - Increased water reabsorption from large
  intestine (aldosterone effect).

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7 - Constipation

• iii - Pressure on the pelvic colon by the
  pregnant uterus.
• iv - Sedentary life during pregnancy .

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• It is treated by
• (a) evacuation of the bowel at the same time each
  day (bowel training)

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• (b) diet rich in fiber in the form of vegetables,
  fruits, and bran
• (c) milk and avoid dehydration by increasing
  fluid intake.

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• (d) minimize coffee and tea as they are diuretics
  and cause dehydration.
• (e) increase physical activity and avoid
  sedentary life.

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• (f) a mild laxative may be needed. Liquid
  paraffin is better avoided as it prevents
  absorption of fat soluble vitamins.

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• In some women iron supplementation may be the
  cause

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8 - Gall stones

• More tendency to stone formation due to atony and
  delayed emptying of the gall bladder

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• 9 - Haemorroids

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• due to
• i - Mechanical pressure on the pelvic veins.
• ii - Laxity of the walls of the veins by
  progesterone
• iii - Constipation.

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10 - Appendix

• Is displaced upwards and laterally (pain and
  tenderness due to appendicitis is higher than in
  nonpregnant state)

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Appendix
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Liver

• i - Decreased albumin and increased globulin
  resulting in decreased A/G ratio
• ii - Increased heat labile serum alkaline
  phosphatase .

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• Therefore both A/G ratio and heat labile alkaline
  phosphatase are not reliable as liver function
  tests during pregnancy

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• VII - Metabolic changes

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(A) Weight gain

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

133

• The increase occurs mainly in the second and
  third trimester at a rate of 350 - 400 gm/ week

134

• 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

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Maternal TissuesIncreases during weeks of
Pregnancy
King JC. Am J Clin Nutr 71 (5(S))2000.
136
Products of ConceptionIncreases during weeks of
Pregnancy
King JC. Am J Clin Nutr 71 (5(S))2000.
137

• Out of the 11 kg weight gain
• 7 kg are water ,
• 3 kg fat and
• 1 kg protein

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)B) Water metabolism

• There is tendency to water retention secondary to
  sodium retention

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(C) Protein metabolism

• There is tendency for nitrogen retention
• ( ve nitrogen balance) for fetal and maternal
  tissue formation

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(D) Carbohydrate metabolism

• Pregnancy is potentially diabetogenic
• - Alimentary glucosuria may occur in early
  pregnancy .
• - Renal glucosuria may occur in the middle of
  pregnancy .

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(E) Fat metabolism

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

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(F) Mineral metabolism

• There is increased demand for iron , calcium ,
  phosphate and magnesium

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• VIII - Musculoskeletal changes

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• (a) Increased mobility of pelvic joints due to
  softening of the joints and ligaments caused by
  progesterone and relaxin
• (b) Flattening of feets .

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• (c) Progressive lordosis leading to lordotic gait
  backache (? by high heals).
• (d) Pendulous abdomen in multigravida resulting
  in many complications

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• Backache

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• 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

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• This puts strain on ligaments and muscles leading
  to pain.
• Strain of sacroiliac joint is relatively common.
  
• Progesterone causes softening and relaxation of
  ligaments.

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• 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

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• (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 needed.

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• Orthopaedic consultation is indicated if pain is
  severe, or radiates to the legs, and in the
  presence of neurological signs

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Leg cramps

• These are common in the second half of pregnancy
  particularly at night.
• The exact cause is unknown.

154

• 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

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• Treated by taking calcium tablets, and reducing
  the intake of phosphorous-containing substances
  as milk, meat, and cheese.
• Vitamin B complex may be tried.
• Leg massage and hyperextension of foot help
  during the attack.

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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 ligaments.

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• IX - Endocrine system

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• 1 - Anterior pituitary

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• i - Increase in size more than increase in
  vascularity
• This renders anterior pituitary liable for
  ischaemia

160

• ii - Pregnancy cell (modified chromophobe)
  appears due to increased hCG .
• iii - Prolactin level increases up to 150 ng /ml
  at term to ensure lactation .

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2 - Posterior pituitary

• Does not hypertrophy , but increase its oxytocin
  secretion near term

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3 - Thyroid gland

• There is diffuse slight enlargement of the gland

163

• 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 ?TSH

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4 - Parathyroid gland

• Hypertrophy due to increased demand for Calcium

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5 - Suprarenal gland

• Hypertrophy particularly the cortex resulting in
  increased glucocorticoids (cortisone) and
  increased mineralocorticoids (aldosterone)

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6 - Insulin

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

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7 -Ovaries

• corpus luteum of pregnancy
• functions till 8-12 wks. when its function is
  taken by the placenta

168

• XI - Skin changes

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• 1 - Persistance of basal body temperature (BBT)
  elevation beyond the expected day of menstruation
  
• (due to increased progesterone).

170

• 2 - Spider telangiectasis palmar erythema
• due to
• increased estrogen
• or
• cutaneous vasodilatation

171

• 3 - Cutaneous vasodilatation (hyperaemia)

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• leads to
• i - Masks pallor due to anaemia with or without
  palmar erythema .
• ii - ? Glandular activities (sweat sebaceous
  glands).
• iii - Sensation of heat and nasal congestion

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• 4 - Pigmentation

due to increased estrogen or melanocyte
stimulating hormone or ACTH
174

• In the face chloasma graviderom mask of
  pregnancy
• a butterfly pigmentation on the cheeks and nose
  .
• It usually disappears few months after labour .

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• In abdomen
• Linea Nigra pigmentation in midline below the
  umbilicus

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Linea nigra
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Stria gravidarum

• pigmentation in the lower abdomen ,
• flanks , inner thighs , buttocks breast and
  increase as pregnancy advances

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• 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)

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• 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

181
5 - Secretions

• increase in sweat and sebaceous glands activity

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• (B) Breast signs

183

• 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

184

• 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

185

• ii - Second month
• increased pigmentation of the nipple areola and
  prominence of Montgomery tubercles (nonpigmented
  nodules around the primary areola (12 - 20)

186
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

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Breast changes
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• iii - Third month
• secretion of colostrum (thick yellowish fluid)
  which can be expressed from the nipple

189

• iv - Fourth month
• a pigmented area appears around the primary
  areola called the secondary areola

190
Lower limbs signs

• i - Edema
• bilateral and pitting ii - Varicose veins

191

• XII. Neurologic System

192

• Sensory changes from compression of nerves
• Tension headaches
• Carpal tunnel syndrome due to edema
• Numbness and tingling related to postural changes

193
1. Headache

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

194
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.

195
2. Fainting

• It results from lowering of blood pressure due to
  vasodilatation which occur in pregnancy

196
3. Insomnia

• During pregnancy some women are sleepy and
  depressed, others may be irritable and suffer
  insomnia

197
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

198

• There is tingling, numbness and burning sensation
  affecting the radial side of the hand

199

• 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 (retinaculum)

200

• Operation is rarely needed during pregnancy by
  incising the retinaculum to relieve compression

201

• Other compression neuropathies affect the lateral
  cutaneous nerve of the thigh , obturator and
  peroneal nerves

202
LEUCORRHOEA

• The normal vaginal discharge increases during
  pregnancy because of excess oestrogen and may
  form a complaint

203

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

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• THANK YOU