Changing Contours Of The Primigravid Abdomen

As the skin stretches to accommodate the growth of the fetus, purplish striae may appear. The linea nigra, a brownish black pigmented line following the midline of the abdomen, may become evident. Muscle tone is diminished as pregnancy advances, and diastasis recti, or separation of the rectus muscles at the midline of the abdomen, may be noticeable in the later trimesters of pregnancy. If diastasis is severe, as it may be in multiparous women, only a layer of skin, fascia, and peritoneum covers most of the anterior uterine wall. The fetus is felt easily through this muscular gap.

Many anatomical changes take place in the pelvis through the course of pregnancy. The early diagnosis of pregnancy is based in part on changes in the vagina and the uterus. With the increased vascularity throughout the pelvic region, the vagina takes on a bluish or violet color. The vaginal walls appear thicker and deeply rugated because of increased thickness of the mucosa, loosening of the connective tissue, and hypertrophy of smooth muscle cells. Vaginal secretions are thick, white, and more profuse. Vaginal pH becomes more acidic due to the action of Lactobacillus acidophilus on the increased levels of glycogen stored in the vaginal epithelium. This change in pH helps protect the woman against some vaginal infections, but increased glycogen may contribute to higher rates of vaginal candidiasis (see p. 405).

The uterus is the organ most affected. Early in pregnancy, it loses the firmness and resistance of the nonpregnant organ. The palpable softening at the isthmus, called Hegar's sign, is an early diagnostic sign of pregnancy, and is illustrated on the right.

Hegar Sign
HEGAR'S SIGN

Over the course of 9 months, the uterus increases in both weight and size. Its weight grows from 2 ounces to 2 pounds, chiefly due to larger muscle cells, more extensive fibrous and elastic tissue, and the considerable increase in the size and number of blood vessels and lymphatics. The size of the uterus increases 500- to 1000-fold, with a capacity of approximately 10 liters by the end of the pregnancy.

As the uterus grows, it changes shape and position. The nongravid uterus may be anteverted, retroverted, or retroflexed. Up to 12 weeks of gestation, the gravid uterus is still a pelvic organ. Regardless of its initial positioning, the enlarging uterus becomes anteverted and quickly fills space usually occupied by the bladder, triggering frequent voiding. By 12 weeks' gestation, the uterus straightens and rises out of the pelvis and can be felt when palpating the abdomen.

The enlarging uterus pushes the intestinal contents laterally and superiorly and stretches its supporting ligaments, sometimes causing pain in the lower quadrants. It adapts to fetal growth and positions and tends to rotate to the right to accommodate to the rectosigmoid structures in the left side of the pelvis.

The cervix also looks and feels quite different. Pronounced softening and cyanosis appear very early after conception and continue throughout pregnancy (Chadwick's sign). The cervical canal is filled with a tenacious mucous plug that protects the developing fetus from infection. Red, velvety mucosa around the os is common on the cervix during pregnancy and is considered normal.

Common Concerns During Pregnancy and Their Explanations

Common Concerns

Time in Pregnancy

Explanation and Effects on Woman's Body

No menses

(amenorrhea)

Throughout

Continued high levels of estrogen, progesterone, and human chorionic gonadotropin following fertilization of the ovum build up the endometrium to support the developing pregnancy, averting menses and shedding of the endometrial lining.

Nausea with or without vomiting

1st trimester

Possible causes include hormonal changes of pregnancy leading to slowed peristalsis throughout the GI tract, changes in taste and smell, the growing uterus, or emotional factors. Women may have a modest (2-5 lb) weight loss in the first trimester.

Breast tenderness, tingling

1st trimester

The hormones of pregnancy stimulate the growth of breast tissue. As the breasts enlarge throughout pregnancy, women may experience upper backache from their increased weight. There is also increased blood flow throughout the breasts, increasing pressure on the tissue.

Weight loss

1st trimester

If a woman experiences nausea and vomiting, she may not be eating normally in early pregnancy (see nausea above).

Groin/lower abdominal pain

2nd trimester: 14-20 weeks

Rapid uterine growth early in second trimester causes tension and stretching of round ligaments, causing spasm with sudden movement or change of position.

Urinary frequency (nonpathologic)

1st/3rd trimesters

There is increased blood volume and increased filtration rate in the kidneys with increased urine production. Due to less space for the bladder from pressure from the growing uterus (first trimester) or from the descent of the fetal head (third trimester), the woman needs to empty her bladder more frequently.

Fatigue

1st/3rd trimesters

Rapid change in energy requirements; hormonal changes (progesterone has a sedative effect); in third trimester, weight gain, changes in mechanics of movement, and sleep disturbances contribute.

Edema

3rd trimester

There is increased venous pressure in the legs, obstruction of lymphatic flow, and reduced plasma colloid osmotic pressure.

Heartburn, constipation

Throughout

Relaxation of the lower esophageal sphincter allows stomach contents to back up into the lower esophagus. The decreased GI motility caused by pregnancy hormones slows peristalsis and causes constipation. Constipation may cause or aggravate existing hemorrhoids.

Backache (nonpathologic)

Throughout

Hormonally induced relaxation of joints and ligaments and the minor lordosis required to balance the growing uterus sometimes result in a lower backache. Pathologic causes must be ruled out.

Leukorrhea

Throughout

Increased secretions from the cervix and the vaginal epithelium, due to the hormones and vasocongestion of pregnancy, result in an asymptomatic milky white vaginal discharge.

The ovaries and fallopian tubes undergo changes as well, but few are noticeable during physical examination. Early in pregnancy, the corpus lu-teum, the ovarian follicle that has discharged its ovum, may be sufficiently prominent to be felt on the affected ovary as a small nodule, but it disappears by midpregnancy. It is important to examine the fallopian tubes to rule out a tubal pregnancy (see p. 408).

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