Physiologic Changes, Discomforts and Hormones in Pregnancy

1
Physiologic Changes, Discomforts and Hormones in
Pregnancy

• Randy S. Heninger
• CNM/WHNP Student
• N6101
• September 21st 2004

2
Digestive System Discomforts

• Nausea and Vomiting (Morning Sickness)
• Info
• 70of all pregnancies
• Lasting from 6-8 weeks until 13-16 weeks
• Changes in smell and taste contribute
• More common in primigravidas, young, lt12years
  education, nonsmokers, gt170 lbs.
• More severe in women with higher hCG levels
  (multiple gestation and hydatidiform mole)
• Education
• Smaller more frequent meals
• Avoid greasy spicy foods, eat protein snack at
  HS
• 250 mg of ginger 4X per day, 25mg B6 3X per day
• Self-limiting
• Contact provider if symptoms not relieved for
  pharmacological interventions
• Hormones
• Estrogen
• hCG

3
Digestive System Discomforts

• Heart Burn
• Info
• Reduced smooth muscle motility-related relaxation
  of the lower esophageal sphincter and cardiac
  sphincter
• Expanding uterus displaces the stomach up ward
  decreasing stomach size and increasing pressures
  inside the organ
• Experienced by 85 of pregnant women
• Education
• Avoid, overeating, spicy foods, gas producing
  foods, fried foods
• Avoid lying recumbent soon after eating
• Eat small frequent meals
• Sleep on stacked pillows or raise head of bed
  with blocks
• Antacids containing magnesium hydroxide or
  magnesium trisalicylate
• Hormone
• Progesterone
• Estrogen

4
Digestive System Discomforts

• Constipation
• Info
• Decreased bowel transit time (first trimester
• Displacement and compression of intestine by
  growing uterus (third trimester)
• Iron supplementation
• Education
• Consuming at least 2 quarts of fluid daily
• Include bulk fiber in diet (fresh fruits,
  vegetables grains)
• Regular exercise
• Mild laxatives (MoM, and stool softeners)
• Cathartic laxatives and enemas are needed rarely
  use only provider consultation
• Firm abdominal massage in a clockwise direction
  to stimulate peristalsis
• Acupressure for 10 seconds midway between the
  pubic and umbilicus over 10 minutes may stimulate
  bowel activity
• Hormone
• Progesterone

5
Digestive System Discomforts

• Hemorrhoids
• Info
• Relaxation of smooth muscle contributes to vessel
  wall weakening
• Increases in venous pressure
• Usually mildly irritating that can be compounded
  by untreated constipation
• Often regress after delivery
• They can worsen after delivery especially if
  prolong second stage and/or excessive pushing
• Education
• Alert provider if they become hard and tender
  (possible thrombosis) or cause bleeding
• Avoid constipation prolonged sitting
• Kegel exercise to improve rectal tone
• Proctofoam, Anusol, and preparation H are safe
  and effective
• Thrombosed external hemorrhoids may require
  incision and evacuation under local anesthesia
• Hormone
• Progesterone

6
Digestive System Discomforts

• Flatulence
• Info
• Relaxation of smooth muscles leading to decreased
  motility resulting in gas pockets
• Causing bloating
• Gas pain
• Flatulence
• Education
• Avoid foods like
• Onions
• Beans
• Lentils
• Collard greens
• Cauliflower
• Brussels sprouts
• Cabbage
• Turnips
• Eat foods like
• Yogurt
• Drinking buttermilk

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Respiratory System Discomforts

• Shortness of Breath
• Info
• Pregnancy-Induced Hyperventilation
• Reduced residual volume and functional residual
  capacity due the mechanical limitation of a
  growing uterus
• These changes can cause dyspnea
• Education
• Measures to alleviate dyspnea
• Standing
• Sit erect
• While lying use one or more pillows to prop up
  head and shoulders
• Breathe slowly and deeply
• Pace herself to accomi8date the added demand that
  pregnancy places on pulmonary function
• Hormone
• Progesterone

8
Respiratory System Discomforts

• Nasal Congestion
• Info
• Increased preivascular edema
• Enlargement of nasal turbinates
• Exacerbate preexisting allergy or sinus problems
• Nosebleeds
• Education
• Petroleum jelly to nasal mucosa
• Room humidifier
• Saline nose drops
• Topical nasal decongestants limited to 2 to 3
  days to prevent rebound rhinitis medicamentosus
• Nasal steroids use with patients with chronic
  symptoms
• Hormones
• Estrogen
• Progesterone

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Urinary System Discomforts

• Frequency
• Info
• First trimester due to increased pressure on the
  bladder from the uterus until it rises out of the
  pelvis in second trimester
• Third trimester due to fetal engagement of
  presenting part
• Increased circulation volume
• Increased glomerular filtration rate
• Education
• Burning or pain needs to be ruled out for UTI and
  vaginal infections which can lead to preterm
  labor or acute and chronic pyelonephritis
• Decrease fluids close to bed time BUT do not
  decrease fluid intake overall

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Urinary System Discomforts

• Incontinence
• Info
• Stress type is usually caused by
• Coughing
• Sneezing
• Laughing
• Can be confused with premature rupture of
  membranes
• Multigravidas experience more due to poor muscle
  tone in the perineal muscles
• Education
• Encourage Kegel exercises
• May not resolve until after delivery

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Cardiovascular Discomforts

• Dizziness and Syncope
• Info
• Growing uterus causes compression of lower
  extremities and pelvic veins causing venous
  pooling
• Potentiated in warmer weather when body heat is
  dissipated by peripheral vasodilatation
• Symptoms occur later in pregnancy while lying
  recumbent secondary to uterine pressure on the
  vena cava causing hypotension
• Hypoglycemia secondary to nausea and vomiting
  later in pregnancy, fetal demand may lower
  maternal glucose levels
• Education
• Calf exercises and long support stockings to
  combat venous pooling
• Use of left lateral tilt position for correcting
  hypotension

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Cardiovascular Discomforts

• Edema
• Info
• Slowed venous return caused by uterine pressure
  on vena cava in the third trimester
• Increased circulating volume
• Education
• Avoid sitting and standing for long periods of
  time
• Daily leg exercises
• Support stockings
• Loose fitting waistbands
• Leg elevation and rest
• Be alert for edema rapidly progressing or not
  lessening overnight particularly in the third
  trimester (may be a sign of preeclampsia)

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Cardiovascular Discomforts

• Varicose Veins
• Info
• Relaxation of vessel smooth muscle
• Increased venous pressure in pelvis and lower
  extremities
• Can be found in legs and vulva
• Leads to leg fatigue and painful night time leg
  cramps
• Education
• Rest and elevation
• Elastic stockings
• Vulvar varicosities respond to added pressure by
  wearing several perineal pads
• If varicosities become warm, hard or painful see
  provider as phlebitis may be present
• Hormone
• Progesterone

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Hematological

• Physilolgic anemia of pregnancy
• Info
• Because plasma volume increases more than the RBC
  mass, maternal hematocrit falls
• Anemia reaches a nadir at 30 to 34 weeks
• Hematocrit may rise at 30 weeks when volume
  expansion has plateaued
• Education
• Need to absorb 3.5 mg/day during first two
  trimesters
• 6 to 7 mg per day in third trimester
• Increasing iron rich foods is usually not enough
• 30mg elemental iron /day
• 325 ferrous gluconate
• Taking iron prior to 20 weeks and increase nausea
  and vomiting
• Take with stool softener to decrease constipative
  effects

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Breast Discomforts

• Breast Changes
• Info
• Breast tenderness ranging mild to severe and
  transient in nature abating by end of first
  trimester
• Increase in size
• Become more nodular
• Nipples become darker and more erectile
• Colostrum may be produced and seen in third
  trimester
• Education
• Wear good support bra one size larger than
  pregnancy size no underwires or seams with wide
  enough shoulder straps and back to prevent
  tension over shoulders and under arms
• Acetaminophen or cold compresses with severe pain
• Hormones
• Estrogen
• Human placental lactogen
• hCG
• Prolactin
• Progesterone

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Skin Discomforts

• Skin Changes
• Info
• Skin changes are a result of stimulation of
  melanocytes
• Areola of breast become darker
• Linea nigra develops from xiphoid to pubic
  symphysis
• Mask of pregnancy (reddish brown color over
  bridge of nose and under eyes)
• Striae (stretch marks) on abdomen, breasts and
  hips which occurs in 65 of all pregnancies and
  usually fade to a pink or silver after delivery
• Education
• No proven prevention for stretch marks
• Cocoa butter, vitamin E and lotions may help with
  itching that can accompany striae formation
• Hormones
• Estrogen
• Progesterone

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Skin Discomforts

• Rashes of Pregnancy
• Info
• Papular dermatitis
• 3 to 5 mm erythematous papules anywhere on the
  body
• Prurigo gestationis
• Small excoriated Pruritic papules on abdomen,
  trunk, or extensor surface of extremities
• Pruritic urticarial papules and plaques pf
  pregnancy syndrome (PUPPPS)
• Discrete erythematous papules and urticarial
  plaques over the abdomen, thighs, buttocks, legs
  and arms
• Pruritus gravidarum
• Abdominal pruritus without distinct lesions
• Education
• Oatmeal baths
• Loose-fitting clothing
• Calamine lotion
• Severe cases
• Topical corticosteroids
• Antihistamines

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Skin Discomforts

• Increased perspiration
• Info
• Increases in eccrine glands all over the skin
  surface
• Possibly caused by increased thyroid activity
• Increased dilation of the blood vessels in the
  skin enhances the bodys ability to eliminate
  waste and dissipate excess heat
• Education
• Reassure that this is a normal occurrence
• Bathing
• Loose fitting clothing of absorbent material
• Control room temp

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Skin Discomforts

• Uncomfortable warmth
• Info
• Vasodilatation that increases skin temperature
• Maternal fatty stores
• In latter stages, placenta may contribute to
  increased body temperature
• Education
• Reassurance normalcy in absence of infection
• Wear light layered clothing
• Keep thermostat at a lower setting
• Hormone
• Progesterone

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Skeletalmuscular Discomforts

• Lower Backache
• Info
• Altered center of gravity (increased abd wt and
  breast wt)
• Stretched abdominal muscles
• Compensatory lumbar lordosis causing
  predisposition to lower back pain
• Latter half of pregnancy joints and ligaments in
  the body become more lax
• Women with poor abdominal muscle tone are more
  susceptible
• Education
• Avoid excessive weight gain
• Improve posture
• Proper bending with back straight
• Proper lifting techniques
• Sleeping on a firm mattress
• Local heat application
• Massage
• Report unilateral leg pain or weakness to
  provider (possible lumbar disk disease)
• Hormones
• Progesterone
• Relaxin

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Skeletalmuscular Discomforts

• Abdominal Pain
• Info
• Sharp pain caused by spasm of the round ligaments
  are the most common
• Enlarged uterus makes these ligaments more
  susceptible to strain
• Pain is associated with abrupt movements and felt
  mostly on the right side
• Contractions, gastroenteritis, appendicitis and
  renal or biliary colic should be considered as
  well
• Education
• Increase physical exercise and abdominal muscle
  tone
• Rise and sit gradually
• Avoid sudden movements
• Rest with local heat application
• Analgesia is necessary occasionally with
  acetaminophen

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Miscellaneous Discomforts

• Leukorrhea
• Info
• Vaginal flow is increased
• Whitish in color and variable consistency
• Non-problematic unless accompanied with itching,
  burning, foul odor or labial swelling
• Change in quantity or quality should be
  differentiated form leaking or ruptured membranes
• Education
• Bathe daily
• Wear cotton underwear
• Dushing is not indicated unless advised by
  provider
• Hormone
• Estrogen

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Miscellaneous Discomforts

• Headaches
• Info
• Can be related to
• Sinus congestion
• Increased vascular blood flow
• Nasal edema
• Fatigue
• Tension eyestrain
• Migraines
• Education
• Relaxation and warm compresses
• Acetaminophen may be necessary
• Be alert for HAs that are accompanied by
  dizziness, blurred vision, scotomata, and or
  unrelieved by acetaminophen (possible sign of
  preeclampsia
• Hormones
• Estrogen
• Progesterone

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Miscellaneous Discomforts

• Fatigue
• Info
• Can be related to
• Increased basal metabolism rate
• Increased demand on cardiovascular and renal
  systems
• Loss of sleep due to urinary frequency
• Emotional factors
• Stress
• Anxiety
• Depression
• Lessens in second trimester then increases in
  late pregnancy due to
• Increased wt
• Difficulty finding a comfortable position
• Fetal factors
• Urinary frequency
• Education
• Proper nutrition and exercise
• Treat possible anemia with diet and exercise

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Miscellaneous Discomforts

• Sleep Difficulty
• Info
• Early in pregnancy
• Psychologic stressors
• Frequency of urination
• Later in pregnancy
• Difficulty finding position of comfort
• Fetal movements
• Feeling short of breath
• Education
• Plan quiet time before going to bed
• Limit fluid intake prior to sleeping
• Pillows to support back, abdomen and legs
• Warm bath or shower and massage
• Meditation and visualization
• Warm milk
• Raspberry leaf tea
• Skullcap tincture (30 drops of commercial
  tincture ½ hour before bedtime)

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Miscellaneous Discomforts

• Dental Problems
• Info
• Gum hypertrophy
• Gum bleeding
• Tooth decay progresses more rapidly
• Education
• Soft toothbrush
• Mild toothpaste
• Daily flossing
• Dental work can be done during pregnancy with
  local anesthesia (General anesthesia should be
  avoided)
• Hormone
• Estrogen

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References

• Gabe, S. G., Niebyl, J. R., Simpsom, J. L.
  (2002) Obstetrics Normal and problem
  pregnancies. (4th ed.). Philadelphia Churchill
  Livingstone.
• Ratcliffe, S. D., Baxley, E. G., Byrd, J. E.,
  Sakronbut, E. L. (2001) Family Practice
  Obstetrics (2nd ed.). Philadelphia Hanley
  Belfus Inc.
• Walsh, L. V. (2001) Midwifery Community-based
  care during the childbearing years. Philadelphia
  W. B. Saunders Company.