• Principles of physiological adaptation of pregnancy
• Physiological changes in different systems of a pregnant woman
• Symptoms and signs of minor disorders in pregnancy and their treatment

• Corpus luteum: normally regress 8 days after ovulation
• If pregnancy occurs, secretion of hCG by developing embryo stops the regression
• Corpus luteum enlarges rapidly
• After 14 weeks of pregnancy when the peak of hCG is passed corpus luteum begins to regress

• Ovarian cyst in early pregnancy
• Can do dating scans to determine size/age of foetus, delivery date
• If you think you see a cyst, there is a possible that it could be the corpus luteum
• Therefore, wait until after the 14th week and see if cyst is still there - if it is, you can be certain that this is a cyst (genuine pathology). If it has regressed, it was probably the corpus luteum

• Increase in size
• Corpus and cervix
• Corpus is composed of muscle and undergoes growth and hypertrophy
• Cervix mainly composed of connective tissue and remains firm and closed

• During pregnancy, oxygen consumption rises by 45 ml/min i.e. increase by 18%
• Increase for metabolism of foetus and placenta
• Also for extra metabolism for the mother
• Tidal volume of mother: increases from 500 to 700 ml
• No increase in respiratory rate
• Ventilation is increased by 40%

• Normal first pregnancy plasma volume increases from 2600 ml by 1250 ml
• Haemoglobin, haemotocrit and red cell count fall during pregnancy
• Expansion of plasma volume greater than that of the red cell mass
• Therefore decrease of some of the substances in some of the substance in the blood
• Eg. [Hb] drops during pregnancy due to increased plasma volume (physiological anaemia)

• To know whether she is anaemic due to pregnancy or anaemic due to other reasons (pre-existing anaemia), need to know:

1. Hb level at booking
2. Hb level in 2nd trimester

• MCV: low MCV woman may have iron deficiency anaemia, thalassaemia trait (make sure that mother and father are not both thalassaemia trait - or else baby may be thalassaemia major)
• Blood parameters needed in pregnancy

1. Hb
2. MCV
3. Platelet count

• Therefore, promote early antenatal care to know all blood parameters

• Rise in cardiac output by 40% (3.5 l/min to 6 l/min)
• Rise due to rise in heart rate and increase in stroke volume
• Fall in peripheral resistance (due to oestrogens and prostaglandins)

• Arterial BP begins to fall in the first trimester and continues to reach its lowest level by mid-pregnancy
• During the third trimester, both systolic and diastolic readings slowly rise to about the pre-pregnant level
• Usually BP in 2nd trimester is lower than pre-pregnancy BP. If it is not, may develop preeclampsia or HT

• Kidney size increases 1 cm during normal pregnancy
• GFR and effective renal plasma flow increase to levels 50% above non-pregnant level
• Plasma levels of creatinine and urea decease
• All the increments are present by the second trimester
• Reduction in GFR of 15 % during the third trimester
• Preeclampsia: only occurs in pregnancy. Multi-organ disease. Can make kidneys leaky - therefore, protein in urine

• Gastro-oesophageal reflux up to 70%
• Due to increases pressure, reduced pyloric sphincter with back-wash of bile secondary to hormonal changes
• Simple measures: avoidance of fat and alcohol, upright posture, antacids

• Amenorrhoea: no menstrual period [O&G always ask date of last period - LMP]
• Morning sickness
• As early as the first missed period
• 6 to 12 weeks
• Stops after 14 weeks
• Coincides with the peak levels of hCG: in 1st trimester
• Increased hCG in

1. Multiple birth
2. Molar pregnancy - abnormal, acts like malignancy (can spread to brain if left untreated), uterus filled with molar tissue, aka trophoblastic disease, more common in SEA & HK; Tx with D&C, continue to monitor hCG, should fall)

Determining date of delivery

• LMP: used when regular periods
• Dating scan: if periods are irregular by about 2 wk

• Tenderness and fullness
• Areolar colour darkens (oestrogen) - irreversible

• Frequency: uterus presses on UB (pressure effect)

• Primigravida (first birth): first foetal movement between 18 and 20 weeks
• Multiparae : 22 weeks (later)

• Diet
• Calcium: non-pregnant state is 0.5 gm; Pregnancy 1.5 gm
• Iron: absorption from ordinary diet 1.2 mg; Requirement during pregnancy 3.5 mg daily [high iron content before and during pregnancy helps mother cope with blood loss during birth - eg. C-section loses 300ml]
• Gentle exercise
• AN classes: preferably with partner ; learn about labour: environmental, options (epidural, gas)
• Lactation preparation: promote breast feeding: clean, cheap, Ab for baby; if you promote breast-feeding before the birth, mothers are more like to do it (rate in HK very low - 15%)
• Coitus: no harm to baby if mother has sexual intercourse while pregnant ® Contraindications: bleeding in pregnancy (eg. Placenta previa: placenta is low lying); rupture of membranes (membranes act as protective mechanism, therefore chance of ascending infection into uterus) ® Encourage other positions - eg. Lying on side

• Hyperemesis gravidaum

1. If vomiting so excessive that it causes a health risk
2. Dehydrated
3. Urine shows lots of ketones (Pt not eating and drinking)
4. Related to hCG but actual reason unknown
5. Related to psychosocial background (eg. Lots of housework, arguing with spouse)
6. Talking to psychiatrist may help (sick role)
7. Thyroid dysfunction: as thyroid hormone and hCG have similarities
8. Give Pt's a drink, some TLC, Pt's almost always get better

• Varicose veins; Vulval varices; Haemorrhoids

1. Very common
2. Pressure effect
3. Hormones also play a role
4. Always disappear after pregnancy - therefore no need to operate

• Pruritus vulvae

1. Change of pH, Candida therefore more common in pregnancy
2. General advice: don't use Dettol/soap (destroys vaginal commensals, Candida grows even more), use warm water to wash, wear cotton underwear, no tight pants

• Legs cramps

1. Can be due to decreased calcium - therefore increase intake
2. Some Europeans drink tonic water

• Acroparaesthesia: numbness (fingers)

1. Related to oedema of pregnancy pressing on median nerve (carpal tunnel)
2. Improves after pregnancy