Minor Complaints in Pregnancy

Minor Complaints in Pregnancy

Most pregnant women suffer at times from a number of very minor complaints. The majority of these are not significant but an occasional symptom may be of importance. This chapter sets out a list of these minor complaints or occasional complications, their appropriate treatment and when medical advice should be sought. It may appear unduly long, so that some people will assume there is a vast multitude of minor complications and complaints during pregnancy, but it is as well to state at the beginning that the majority of symptoms and complaints listed here are in fact of no real significance. Complaints such as headache, stuffy nose, constipation, tiredness or backache occur equally in the non-pregnant, but in pregnancy their very presence may cause worry and anxiety. It is hoped that after reading these pages the expectant mother will feel reassured about insignificant symptoms and will also appreciate warning complaints and seek medical advice for the necessary treatment.

Horror stories have no place in modern maternity care. Pregnant women are often assailed by stories, which are frequently grossly exaggerated, from their supposed friends, well-wishers and relations, about some of the complications, symptoms and complaints of pregnancy. Some of these conditions are mentioned in this chapter and it is hoped that by referring to them the pregnant woman will be reassured of their significance or lack of importance.

Minor Complaints in PregnancyIn this book importance has been given to a long list of minor complaints, whereas very little is said about such things as prolonged labour and difficult deliveries. This is because these latter complications are now comparative rarities and attention has been directed to, and will be increasingly focused upon, those minor complaints or ailments of pregnancy which make the life of the pregnant woman less comfortable and happy than it might otherwise be.

Inevitably there is some overlap between different sections (or even chapters), especially when discussing such common symptoms as headache and nausea. Repetition cannot be avoided if a reasonable explanation is to be given about symptoms that might occur at any stage during pregnancy or after delivery.

Nausea

Nausea in early pregnancy is an almost universal symptom. The degree of nausea varies not only from woman to woman but also from pregnancy to pregnancy in the same woman. It is most common in the morning, but may occur at any time of day and may even last throughout the day. Sickness may ensue if the nausea becomes severe.

Pregnant women are seldom worried by either nausea or sickness at night, although if they get out of bed suddenly they may suffer these symptoms.

The exact cause is not known and is probably a combination of several factors:

1. Hormone changes in early pregnancy undoubtedly exert an influence upon the metabolism of the body and probably predispose to both nausea’ and sickness.

2. The metabolic and chemical changes which take place in early pregnancy probably also predispose to nausea.

3. The hormones which exert their major effect during the early part of pregnancy are formed mainly from the corpus luteum in the ovary and at about the 12th to the 14th week of pregnancy the production of these hormones is taken over by the placenta. There may be a slight difference in the exact nature of the hormones so produced, but this has not yet been detected.

4. During early pregnancy progesterone causes relaxation of involuntary muscle and thus dilatation of the blood vessels resulting in a fall in blood pressure. It is common for a fall in blood pressure to make people feel faint and occasionally nauseated, and this may be an additional factor.

Psychological factors. It has long been considered that psychological factors are a very potent cause of both nausea and vomiting in pregnancy but it is extremely difficult to pinpoint the exact part they play. Some of the most well balanced and stable women complain of extreme nausea and almost continuous vomiting, while in others the psychological element plays a large part. Anxiety, fear, worry, apprehension, all have an important effect, and one only has to consider the plight of the unmarried girl with an unwanted pregnancy, afraid to discuss it with her parents or friends, to appreciate the psychological problems which may exert themselves during the early stages of pregnancy.

Nausea is one of the earliest symptoms of pregnancy. The sensation of nausea or feeling of sickness takes many slightly different forms not only in different women but also in the same woman during different times of the day or different stages of pregnancy. It may be a simple sensation of fullness in the upper abdomen, or so severe as to come in repeated waves, each one associated with the desire to vomit.

Nausea results in several other minor side effects. There is usually a reduction or loss of appetite accompanied by some weight loss during the first three months of pregnancy. The amount lost depends upon the severity of the nausea.

Some types of nausea are associated with the desire to eat whereas others are associated with a marked objection to food. Even when hungry, a woman who is nauseated will usually find that a comparatively small amount of food will satisfy her hunger and she will sit down to quite a large plate of food and find she can only manage to eat a small amount because of the fairly rapid onset of a sensation of fullness. Some women find that eating a small amount of food actually relieves nausea, whereas others are relieved only by self-induced vomiting, such as by tickling their throat.

Nausea is often aggravated by fatty foods or the smell of fat, especially cooking fat, and these should be avoided.

Other factors that specifically create nausea vary from person to person as well as from pregnancy to pregnancy, but smoking and tobacco smoke are classic examples. Strangely enough, coffee is frequently accused and many women will ‘go off’ all types of alcohol in early pregnancy.

The symptoms, therefore, of ‘nausea’ vary from a vague sensation of loss of appetite to an almost paralysing feeling of abdominal discomfort and desire to vomit. The more severe the nausea, the more likely is vomiting to occur. There are no hard and fast rules for the onset of nausea or its progress but one simple consolation is the old adage ‘the more the nausea, the better the pregnancy’ and it is true that the more nausea you have the less likely are you to miscarry. The converse that a person with no nausea is likely to miscarry is certainly not true, but most obstetricians nevertheless like their patients to have some nausea and sickness during the first three months as it does indicate a more stable pregnancy.

Most pregnant women require no specific treatment for nausea other than simple reassurance that it is normal in early pregnancy and will disappear at the end of the 14th week. With these assurances they are quite happy to put up with the minor discomforts involved, and find that simple regulation of their diet and daily activities reduces its severity.

The effects of nausea and vomiting upon different women vary. Some accept nausea without complaint, while others complain bitterly. Similarly, vomiting elicits a very different response from different people. Some state that vomiting relieves their symptoms, while others complain bitterly of the discomforts of being sick. There is no simple remedy or cure, but minor changes in routine and diet help different women. Remember:

1. It is a normal phenomenon in early pregnancy.
2. The symptoms will go at about the 14th week.
3. Get up slowly and only after a small amount of tea and dry toast or tea and biscuit has been taken.
4. Take frequent small meals, with a small quantity of liquid and drink between meals.
5. Avoid fats and fatty foods.
6. Avoid those things which cause nausea.
7. Avoid wearing very tight clothing.

If the nausea and vomiting persist beyond the 14th week, become excessive or recur later in pregnancy, you must inform your medical adviser.

Drugs of all types are avoided if possible during the first three months of pregnancy, but if nausea becomes severe then it can usually be controlled by an antihistamine drug. Most of these are perfectly safe and Avomine is the one that is most frequently used, but you should not take any of these unless they are specifically prescribed by your doctor. If you are given pills for your nausea, remember that the action of most of them lasts for up to about 12 hours, so that you should take a tablet at bed-time to control morning nausea, and a tablet in the morning to ease nausea in the evening. Some antihistamines make people feel sleepy so you should ask your doctor if you may drive while taking them.

Morning Sickness

Morning sickness or vomiting is a classic symptom of early pregnancy and the majority of women probably vomit at least once at some stage during this time. Vomiting does not usually disturb every morning of early pregnancy. The term ‘morning sickness’ usually refers to the nausea that is common in early morning rather than to actual vomiting. Vomiting is not always confined to the early morning. It may occur at any time of the day or even throughout the day. Some women suffer from vomiting only in the evening.

Vomiting in early morning takes the form of retching because the stomach is empty and only a small quantity of mucus can be produced. Morning sickness may also be brought on by coughing or by the smell of cooking, especially cooking fatty foods, or by eating, especially food containing fat.

The action of vomiting is most uncomfortable and anyone who vomits several times in rapid succession may afterwards suffer from some residual soreness in the abdominal muscles. This will go after a few hours and is of no significance. Vomiting does not harm the baby or the pregnancy, although a person who vomits severely may feel as though she is pressing the whole pregnancy down and out of the pelvis. This never happens; vomiting itself is never a cause of prolapse.

Some women induce vomiting to relieve nausea, especially when it becomes severe.

There are no golden rules for the treatment of morning sickness as each woman is different and her symptoms will vary from day to day and week to week. The intelligent use of the basic principles for the treatment of nausea usually control most, if not all, of the actual sickness.

Occasionally, however, it may be necessary to give drugs, of which the antihistamines are the most useful and most frequently used. Some have been especially developed for use in early pregnancy, whereas others are not advised. Before taking any drugs you should consult your doctor and only take what he prescribes.

One of the secrets in the control of nausea in early pregnancy, and therefore the control of vomiting, is small frequent meals avoiding anything containing fat and any particular foods which cause nausea to the individual concerned. Two or three plain biscuits should be taken to the bedroom at night and placed in a tin beside the bed. These may be eaten at any time on waking during the night and in the morning before any attempt is made to get up, together with a cup of warm sweetened tea. Getting out of bed should be delayed for 15 or 20 minutes after this. About an hour after rising a light breakfast may be eaten consisting of a small quantity of cereal with sugar and a little milk, followed by boiled or poached egg with toast and marmalade, marmite or honey, but no butter. Tea or coffee should not contain much milk. If severe nausea and vomiting persist a light meal or small snack should be taken approximately every two hours throughout the day consisting of unbuttered toast or biscuits, together with whatever fluid is considered least likely to provoke vomiting. Clear soups and Bovril may be drunk as beverages. Butter and fatty foods should be avoided if possible. Milk, while being an extremely good food, is particularly liable to cause nausea and vomiting at this stage of pregnancy and should be avoided if it does. It is important to drink as much fluid as possible without causing vomiting and also to eat a reasonable quantity of sugar, or to add glucose or sugar to the fluids.

Most pregnant women lose weight in the first three months of pregnancy. This weight loss may be as much as 4 kg. or even 7 kg. A 4 kg. loss in a woman of average weight is of little importance (or 7 kg. in a woman who is overweight). Weight loss in excess of this is usually associated with persistent vomiting and medical advice should be sought. The nausea and vomiting should diminish between the 12th and 14th week of pregnancy and disappear after the end of the 14th week, after which weight will be regained rapidly. If the essential fluid intake and glucose or sugar intake are satisfactorily maintained in early pregnancy, the small weight loss is of no importance.

An example of a daily diet for a patient who is suffering from severe nausea, with or without some vomiting, is given below:

Before rising. Two dry biscuits or one slice of unbuttered toast together with a cup of warm tea containing sugar but little milk.
Breakfast (one hour after rising). Breakfast cereal with a small amount of milk and sugar. Unbuttered toast, biscuits or boiled or poached egg. Tea or coffee with sugar and a small amount of milk.
Mid-morning. Milk or Bovril together with toast or biscuits.
Lunch. Soup. Boiled chicken or steamed fish. Puree vegetables. Fresh fruit or stewed fruit with a little sugar. Orange juice, lemon juice or water.
Mid-afternoon. Tea, coffee or orange juice, together with sweet biscuit or sponge cake.
Tea-time. Unbuttered toast, sweet biscuits, sponge cake, tea or coffee with little sugar, or any other form of beverage which does not contain much milk.
Supper. Meat, fish or eggs which have not been fried, together with boiled vegetables or fresh salad. This may be followed by fresh or stewed fruit and the meal may be finished by biscuit and tea or coffee.
Late evening. Biscuit with unbuttered toast together with a glass of fluid, preferably plain water.

It is often found that iced foods and particularly drinks are less nauseating than warm ones.

Many women are fortunate enough not to experience any nausea or vomiting in early pregnancy, while others feel only occasional nausea. It is only the unfortunate few who experience severe nausea or recurrent vomiting. Even those with severe nausea find that the nausea is worse at different times of the day and that some days are particularly worse than others. It is noticeable that any stress, strain or difficulties will tend to make the nausea or vomiting worse, and it is characteristic of some pregnancies that the symptoms become more severe in the evening while rarely present in the morning. The reason for this is unknown and it is untrue to suggest that it is to impress the husband when he returns home from the day’s work! There was always stated to be quite a marked psychological factor in the causation of nausea and vomiting. This is probably not true. The most sensible people can suffer from severe nausea and vomiting which will not respond to psychiatric treatment or to psychiatric drugs.

There is very longstanding and extremely good advice that the more a woman has to do in pregnancy the less will she be aware of her nausea and vomiting. It is true that women with the most severe nausea and vomiting are frequently those who have the least to keep them occupied and it is, therefore, most important to keep busy either at work or in the house, encouraged by the knowledge that these symptoms will disappear at the end of the third month of pregnancy.

Do not indulge in self-pity. Do not upset yourself by cooking fatty meals or fried food for the rest of the family, who for a while will have to live on a simple and plain diet and put up with it. A limited amount of exercise, especially outside, is extremely good, but violent exercise usually provokes a further bout of nausea and possibly vomiting.

Excess Vomiting (Hyperemesis)

Occasionally a woman vomits with extreme severity, and any person who vomits several times a day should notify her doctor. Severe vomiting in early pregnancy may require hospital treatment for a few days because the body cannot obtain enough sugar for its daily needs and it then starts to make special adds known as ketones. Their presence in urine is usually an indication that the vomiting is particularly severe and is sufficient indication for admission to hospital. Immediately on admission to hospital most women are given only fluids by mouth, usually sweetened with sugar or glucose. If they continues to vomit on this strict regime, glucose and other fluids will be fed directly into the circulation via a vein in the arm and they will be given nothing by mouth until all vomiting and nausea cease. With this very strict regime the symptoms will rapidly disappear. The patient who is placed on an intravenous infusion is usually given only sips of water by mouth until such time as she feels hungry. She is then allowed very small quantities (30 to 60 gm.) of fluid each hour by mouth. If vomiting does not recur the amount of fluid is gradually increased until eventually she can take a light diet. The intravenous infusion is then discontinued.

Only a small and ever decreasing number of pregnant women suffer in this way and are admitted to hospital for treatment. Severe vomiting is not an indication for medical termination of pregnancy except in very rare instances. It used to be a common means whereby a woman with an unwanted pregnancy tried to obtain an abortion, and as soon as she was convinced that the pregnancy would not be medically terminated the sickness would cease quite quickly. With modern drugs and intravenous drip therapy there is no reason to terminate any pregnancy for severe nausea and vomiting in the absence of any other disease.

While there may occasionally be a large psychological factor in the causation of hyperemesis in early pregnancy, the assistance of a psychiatrist in the treatment of this condition has not been as helpful as anticipated, and their help is usually sought only for the treatment of previously existing psychiatric disorders. The family doctor is often far better able to understand the stresses and strains which may accentuate ordinary nausea and sickness into excessive vomiting.

You should inform your doctor if vomiting does not cease soon after the 14th week or if it recurs later in pregnancy.

Heartburn

Heartburn is not to be confused with simple indigestion. It is a searing, burning sensation felt in the lower part of the chest just beneath the breast bone, and is frequently associated with bringing up or regurgitating small quantities of very sour acid fluid.

This symptom may occur normally in many women, especially those suffering from gastric or duodenal ulcer, but it is common during pregnancy and does not indicate, any ulceration of either the stomach or the duodenum, or anything to do with the heart or the lungs. During pregnancy the effect of progesterone relaxes the valve at the upper end of the stomach which allows regurgitation of the normal , acid contents of the stomach into the lower end of the oesophagus or food pipe which leads from the mouth to the stomach. This tube is not normally resistant to acid and constant regurgitations of acid causes severe inflammation in its lower end, and further regurgitation of acid upon this inflamed area results in the sensation of heartburn.

The enlarging uterus also tends to push against the stomach, which tends to cause further regurgitation. In addition, it pushes out the lower ribs, to which the diaphragm is attached, and this has the effect of slightly opening the aperture through which the oesophagus passes into the stomach, enabling regurgitation to occur more easily. In order to try and relieve this burning sensation some people swallow air (aerophagy) and then belch it up again. This only makes the symptoms worse, because the air brings up still more acid with it which further irritates the oesophagus.

In the non-pregnant state the contents of the stomach are not allowed to enter the lower end of the oesophagus, except when there is a defect at the place at which the oesophagus passes through the diaphragm into the stomach. This defect is know as hiatus hernia. During pregnancy any woman who suffers from a hiatus hernia is likely to have an exacerbation of symptoms, particularly heartburn.

Towards the end of pregnancy, if there is excessive pressure applied to the lower ribs, heartburn may become particularly severe. This may be noticeable in women who suffer from hydramnios, which is an excessive quantity of fluid, or have a multiple pregnancy. It is also particularly noticeable in women who have breech presentation and will often be relieved when the presentation is corrected.

If heartburn becomes a constant or serious problem you should notify your doctor. Since most of the causes of heartburn are dependent on the pregnancy itself it is difficult to treat. Part of the cause is the acidity of the stomach contents, so if this can be neutralized by an alkali the pain should be partially or totally relieved, while the other cause is the regurgitation of stomach contents into the oesophagus. Both aspects should be treated.

Swallowing large quantities of strong alkaline mixture to correct the gastric acidity will, however, only relieve the symptoms for a short time and in the end succeeds in making them worse because the stomach reacts to the administration of alkali by producing even more acid. The correct treatment is to take a small quantity of alkali to neutralize the stomach contents and then to suck an alkali tablet so that there is a constant stream of dilute alkali passing down the oesophagus. This will immediately neutralize any regurgitation of gastric contents and thus give the oesophagus time to heal. Once the inflammation has subsided the heartburn will cease. Any of the well-known alkali tablets are satisfactory for this purpose. A quarter of the tablet should be bitten off, chewed and swallowed, and the rest pushed between the cheek and gum where it can dissolve slowly over the next three to four hours.

Milk of Magnesia is also very effective in relieving heartburn. Another very effective method is to give a mixture of aluminium hydroxide gel and magnesium hydroxide (Mucaine). These sub-stances form a film over the lower part of the oesophagus which is impenetrable by the gastric acid, thus allowing time for the inflammation to subside.

Spicy foods should be avoided and small meals should be taken. Large meals just before returning to bed should be especially avoided. Heartburn is also associated with extra weight gain or an excess intake of carbohydrate and these factors should be checked.

At night when relaxed and lying flat in bed, heartburn may be particularly severe. A simple remedy is to raise the head of the bed, or to sleep with three or four pillows instead of the usual one or two. This prevents slow regurgitation of gastric fluids during the night and will frequently relieve the nocturnal heartburn. Any activity or position that tends to allow regurgitation of stomach contents up into the oesophagus must be avoided, such as lying flat, or especially lying with the head down or bending with the head below the chest (playing with a young child on the floor).

Ptyalism or Excess Salivation

Ptyalism is a rare complication of pregnancy and is caused by an apparently excessive amount of secretion of the salivary glands into the mouth. It is often accompanied by an offensive taste. This is a most annoying complication of pregnancy and is extremely distressing for those women who suffer from it. The excess salivation floods the mouth and becomes so profuse that the woman is unable to swallow it and is forced to spit out a large quantity, usually into a handkerchief which she carries and which may become absolutely sodden with saliva within twenty to thirty minutes.

The amount of saliva produced during 24 hours by a normal person (and a normal pregnant woman) is about 1-5 litres. Swallowing such a large quantity of saliva is done unconsciously like breathing or blinking. Ptyalism varies in its severity but it is easy to imagine the distress of someone who is constantly dribbling anything up to 1 or even 1.5 litres of saliva in 24 hours.

It is now accepted that this condition is not, in feet, caused by any excess production of saliva but is the result of a hysterical inability to swallow the normal amount of saliva being produced. Ptyalism is very difficult to treat and almost impossible to cure. The only real chance of cure is to discover why the woman has developed this psychosomatic symptom. Attempts to reduce the amount of saliva produced, by the administration of atropine and similar agents, will most certainly fail to relieve the symptom, because even a slight reduction in the amount of saliva produced will not affect the apparent inability to swallow fluid within the mouth. The condition may improve as pregnancy advances, but usually persists until delivery when it is spontaneously relieved. Fortunately ptyalism is becoming less common and is now a rare complication of pregnancy.

Frequency of Micturition

Increased frequency of micturition is one of the earlier symptoms of pregnancy and may, in certain circumstances, persist quite normally until delivery. Most pregnant women will become aware of this when they have to get up at night to pass urine and on reflection will also be aware of an increase in urinary frequency during the day. The frequency may be the vascular congestion around the bladder neck which is being compressed by the uterus enlarging in the pelvis. There is no recognizable way of improving or reducing the day frequency. The night frequency may occasionally be helped by reducing the amount of fluid drunk after 8.0 p.m. Most women, however, only get up once during the night and do not consider this one disturbance justifies reducing their fluid intake.

Later in pregnancy a urinary tract infection may cause increased frequency and some urgency to pass urine, or actual pain before, during or after the act of passing water. If frequency of micturition is associated with pain, burning, or the passage of blood then an infection of the bladder or urinary tract is likely and medical advice should be sought.

As pregnancy advances beyond the 30th week the baby’s head is either becoming engaged in the pelvis or sitting in the pelvic brim. In either of these positions it irritates the bladder and may result in a marked increase in urinary frequency which is not associated with any pain, discomfort, or burning. The frequency may reach disturbing proportions such as once every two hours, or even once every hour, but providing there is no pain it is unlikely that any infection is present. There is no specific treatment for frequency when it is caused by the pressure of the head upon the bladder.

Right at the end of pregnancy, when the foetal head is engaged in the pelvis, frequency of micturition may recur. At this stage there is no room in the pelvis for the bladder as well as the baby’s head, and the bladder is pushed up into the abdomen where, as it fills, a swelling is seen in the lower abdomen. Again there is no treatment for frequency at this stage of pregnancy. However, if a urinary tract infection is suspected medical advice should be sought, as its treatment at this stage of pregnancy is of paramount importance.

Urgency of Micturition

During the last 6 or 8 weeks of pregnancy the baby’s head or feet may bounce against the bladder causing a sensation of the utmost urgency to pass urine. This is only an occasional problem but can be most disturbing and disconcerting.

Stress Incontinence

This is the term used for the lack of control, or weakness, of the bladder. Very often during the later weeks of pregnancy the control of the bladder becomes increasingly difficult and occasionally small amounts of urine may escape when they are not intended to do so. This may sometimes happen if the baby gives the bladder a powerful kick, or as a result of the mother coughing, sneezing, straining, lifting or carrying—in other words when anything raises the pressure in the abdomen.

Difficulty in Control of Micturition

Some difficulty in control of micturition may occasionally be noticed after delivery and especially if the labour has been long or the delivery difficult. Postnatal exercises, especially pelvic floor exercises, will soon overcome this and the bladder will rapidly return to normal.

Constipation

The woman who goes to the lavatory every day does not necessarily empty her bowel completely or satisfactorily. A normal stool is soft and well formed and is passed easily without straining or undue discomfort. A tendency to constipation develops very early during pregnancy because the hormone progesterone causes relaxation of the intestine, therefore reducing its power to propel its contents towards the rectum and the anus. Hence, the intestine tends to dilate and constipation ensues. The onset of constipation is usually the result of habit. Women who for years have foiled to obey the call to defaecate when the rectum is loaded and ready to be emptied have gradually ceased to appreciate the sensation of the desire to defaecate. In due time, therefore, the rectum becomes distended with faeces but the owner receives no signal that the rectum requires emptying. Faeces which are kept in the lower part of the intestinal tract for an indefinite period become hard and inspissated, so that great strain and energy are required to pass them. This vicious cycle must be broken, and it can be broken relatively easily by obeying a few simple rules and regulations.

Firstly, the bowels must be opened every day. Secondly, every call to defaecate must be obeyed, no matter how inconvenient it may be. Thirdly, an adequate fluid intake is essential. At least 2 litres of fluid should be drunk each day. The majority of pregnant women fail to drink a sufficient quantity of fluid. Fourthly, a reasonable amount of roughage, fresh vegetables and raw, fresh fruit, should be eaten each day. If these simple rules are obeyed, most pregnant women will be relieved of their constipation.

If aperients are required they should be prescribed by the doctor. The correct amount of any aperient is that amount which will enable the bowels to be opened normally each day. Never take too large a dose which will result in attacks of diarrhoea, inevitably followed by two or three days of constipation whilst the intestine refills, and this is again inevitably followed by the administration of a violent purgative and a further bout of diarrhoea. Strong purgation also predisposes to abortion.

Some iron tablets may cause constipation and if this happens it should be discussed with your doctor with a view to changing to another variety which does not disturb the bowel.

Flatulence

Flatulence is a common complaint especially in early pregnancy and is usually caused by the swallowing of air (aerophagy) to relieve the nausea so common in the first three months of pregnancy. Flatulence and gas distension of the intestine may result in a feeling of distension and also a frequent desire to pass flatus. It is also possible that the constipation so often present during pregnancy is a further factor in producing flatulence. A very mild purgative, such as Milk of Magnesia, which encourages intestinal movement may help, not only in the dispersal of the wind but also in discouraging its further formation within the intestine. Women who suffer from flatulence should avoid gas-producing foods such as onions, beans, peas, carbohydrate and heavily fried foods. By learning not to swallow air the gaseous distension of the abdomen will frequently be alleviated.

In later pregnancy flatulence may be associated with heartburn, where aerophagy is a common reaction to the pain.

Vaginal Discharge

Vaginal discharge may occur throughout pregnancy as a result of increased blood supply to the vagina and cervix. The term discharge is intended to mean the passage from the vagina of a simple clear mucoid or white discharge without any soreness, pain or irritation. This occurs normally during pregnancy and may also occur at puberty, at the time of ovulation, for a few days before or immediately after a period, as a result of sexual excitement, and in some women while taking contraceptive pills. Apart from these circumstances it should always be examined, in particular during pregnancy, especially if it becomes offensive, causes irritation or soreness. At some stage of pregnancy more than 50 per cent of women develop an erosion or ulcer on the cervix. This is a result of the rapid rise in hormone levels during the early stages of pregnancy and such an erosion increases the amount of vaginal discharge that may already be present, but it should be clear and mucoid causing no other symptoms.

Occasionally the discharge becomes yellowish and smelly and this is nearly always because the cervical erosion has become infected, although it may mean the vagina is infected while the cervix is quite healthy. The discharge will almost certainly then become more profuse and cause soreness in the vulva. If this happens you should report it when you next visit the clinic so that it can be treated.

A cervical erosion usually, heals spontaneously within a few weeks of delivery; if it does not, the discharge will continue and special treatment will be required to cure it.

Vaginal Irritation

Vaginal irritation is nearly always associated with irritation of the vulva. A very mild discomfort may occur in the early stages of pregnancy as a result of pelvic congestion, but this is barely noticeable and always transient. It is otherwise caused by a vaginal infection or an infection of a cervical erosion. Such infections are caused by ordinary bacteria that may similarly infect the skin or throat. They are not dangerous and will not cause any damage to your baby or harm to yourself. They are just very annoying. The irritation is caused by inflammation set up by the infection; the discharge will be yellow and offensive.

An offensive and infected discharge should be reported when you next visit the clinic. The exact diagnosis may be doubtful and a small amount of the discharge will then be taken for culture in the laboratory. Inserting antibiotic pessaries or chemical cream into the vagina at night will cure the infection and relieve the symptoms.

Thrush Infection (Monilia)

Pregnant women are very susceptible to this particular type of infection which frequently produces a distressing amount of irritation and soreness. It is easily and simply treated by using a fungicidal cream or pessaries. If you have had a thrush infection during pregnancy, keep a reserve of fungicidal cream or pessaries since the infection has a habit of recurring later in the pregnancy for no apparent reason.

Trichomonas Vaginitis

Trichomonas vaginalis infection may also produce very severe irritation and soreness, but can be cured quite easily with appropriate treatment.

Tiredness in Pregnancy

Tiredness, weakness and lassitude are normal symptoms in early pregnancy and are nature’s way of slowing down the pregnant woman to help preserve the pregnancy. From a purely biological point of view it seems obvious that the more a pregnant woman can rest in early pregnancy the better chance does the pregnancy have of surviving, and a sensation of tiredness or lassitude can be accepted as a natural phenomenon. It is quite wrong to fight against it. You do much better to give in gracefully and to take more rest. It will nearly always be found that one or two hours’ rest in the afternoon and an extra hour or two’s rest at night will suffice.

Women who are having their third child frequently complain of feeling more tired and lethargic than they did with their first one or two. This is not surprising since they now have one or two children to look after, whereas with their first pregnancy they did not have this demanding task to face as well as a pregnancy itself.

It really is most important that your husband and other members of the family should realize that tiredness, weakness and lassitude are a normal part of pregnancy. They are usually more severe in the first three months and your husband must understand that this, together with a certain amount of nausea, may stop you from being the energetic individual that he is accustomed to. He may have to cancel appointments or social engagements, but this is immaterial. Rest is essential. If you do not rest then you will become depressed and bad tempered, and quite honestly it just is not worth it.

Extra rest does not necessarily mean sleep. If you are working and are unable to rest in the afternoon, you should try to get at least 10 hours in bed at night, even though this does not mean 10 hours’ sleep.

Most of the tiredness and lassitude will go at the end of the 14th week and, with the return of some of your former energy, you will feel much happier. Tiredness may again return towards the end of pregnancy, when it is only natural.

Shortness of Breath

Many pregnant women complain of intermittent shortness of breath at all stages of pregnancy, but it is more common towards the end when the enlarging uterus pushes the abdominal contents upwards underneath the ribs. The diaphragm is thus forced up into the chest. This incursion upon what is really the thoracic cage means that the diaphragm cannot descend as far as usual and, therefore, the respiratory movement of the chest becomes less efficient. This causes inefficient breathing and shortness of breath on the slightest exertion may easily occur. It should not be sufficient to incapacitate a person during normal day to day living and if it becomes noticeable while walking gently on the flat or after climbing one flight of stairs, you should tell the physician or midwife when you next visit the antenatal clinic.

Shortness of breath may occur at night while lying fairly flat in bed and can usually be relieved by propping the head and shoulders up on two or three pillows which reduces the pressure of the enlarging uterus on the diaphragm.

Women having their first baby usually notice ‘lightening’ at, or about, the 36th week and this is the result of the baby’s head descending into the bony pelvis, causing the upper part, or fundus, of the uterus to descend anything up to 5 or even 7-5 cm. The consequent reduction of pressure on the diaphragm allows it to descend further and thus increase its efficiency. Shortness of breath which is present before the head engages may easily be relieved when this happens.

If shortness of breath is sudden, or associated with any upper respiratory tract infection, cold, fever or bronchitis (or even with a severe cough) you should notify your doctor as soon as possible.

Fainting

Most women feel faint on some occasion during early pregnancy and a few may actually faint. The feeling of faintness results from the lowering of the blood pressure which is due to two main factors. Firstly, the effect of progesterone which dilates the smooth muscle of the blood vessels and therefore predisposes to pooling of blood in the lower parts of the body, and, secondly, the sudden and rapid demands of the uterus for an increased blood supply. If the blood pressure falls below a certain level the blood supply to the brain is reduced, causing faintness. When people faint they fall to the ground, so that their brain is once more on a level with their heart instead of being several inches above it and the blood supply is automatically restored.

Faintness or fainting are particularly noticeable during the first three months of pregnancy when the blood pressure is lowered beneath its normal level and is likely to fall even further if blood is allowed to ‘pool’ in the legs during prolonged standing such as in bus or shopping queues. It can be prevented by not standing still for any length of time or, if it is necessary, by moving and exercising the feet and legs to ensure the return of blood from the legs to the heart.

Fainting is especially likely to occur when suddenly standing from a sitting position because the automatic reflexes of the body which adjust the blood pressure to the sudden changes of posture are rather slow to react, and the brain has a temporary lack of blood.

The actual feeling of faintness is not harmful and recovery is rapid, nor does fainting itself harm either the baby or the mother, although she may injure herself when she falls to the ground. Injuries, however, are rarely serious, unless a woman falls on some sharp or hard object. A pregnant woman should practise her immediate reaction to a sensation of faintness. Immediately she begins to feel light-headed she should sit down if she has been standing, or lie down if she has been sitting. She should immediately take several deep breaths as rapidly as possible. This movement of the chest will help the return of blood to the heart and the blood pressure will rapidly return to normal. The old-fashioned precaution that a pregnant woman should carry a bottle of smelling salts in her handbag is extremely good, but taking several deep breaths has the same effect as inhaling smelling salts.

Most pregnant women rapidly appreciate the conditions which make them feel faint and avoid such situations. The classical example is a young woman, eight weeks pregnant, who, not having eaten any breakfast, leaves home to stand for five minutes in a bus queue.

Backache

Backache is a very common symptom throughout pregnancy. It is explained very easily on theoretical grounds. The placenta produces the hormone progesterone which causes softening and eventual stretching of the tendons and ligaments in the body. This is most important in the pelvic joints, but the hormone also acts upon the spine, causing relaxation of the ligaments supporting the spinal column. The characteristic posture adopted by most women in pregnancy places a considerable strain on the lower joints of the spine, especially the one between the spine and the pelvis. The relaxation of the ligaments results in excessive mobility of this joint and strain upon the surrounding structures with the resulting aching discomfort. This is made worse by bad posture or by excessive exercise, either of which alone may cause backache. Backache may also be increased by an excessive gain in weight, repeated changing from high to low heels, or previous injury or damage to the back.

The most, important aspect of the treatment for backache is preventive. Correct posture is essential; this may be attained by pressing the whole length of the spine against a flat wall and trying to maintain that posture. Adequate rest, especially during the last three months of pregnancy, is of immense importance. Some people prescribe supporting corsets for the back, but unless there is any underlying disease of the spine it is unlikely that they are of any-thing but temporary value. Massage and application of heat in the form of an electric pad, or radiant heat may also give some relief. The application of liniments is no more beneficial than the massage used to rub them in.

Very occasionally backache is associated with damage to an intervertebral disc. Prolapse of an intervertebral disc is an organic disease of the back and can cause backache, sciatica or lumbago in the non-pregnant state. When this occurs in pregnancy the symptoms may become very severe. Any woman who has a predisposition to lumbago or has had a slipped intervertebral disc must be extremely careful during her pregnancy to avoid excessive weight gain or back strain. In the event of true lumbago she should go to bed and rest there until medical advice has been sought. Occasionally the pain involves the sciatic nerve and travels through the centre of the buttock, down the back of the leg behind the knee and even as far as the ankle. This sort of irritation of the sciatic nerve nearly always indicates some pressure is present and that the nerve is being distorted or inflamed and medical advice should be sought. The usual treatment of this is complete bed rest, lying flat upon a hard, rigid bed or on an ordinary mattress with fracture boards underneath. If boards are not available the top mattress can be placed on the floor.

Sacro-iliac Pain

Sacro-iliac pain is a classical low backache of pregnancy. The pain occurs in the sacro-iliac joint which is at the top of the buttocks about 3 in. from the mid-line and extends downwards into the buttock itself. The pain of sacro-iliac strain is usually located exactly over the joint and is quite distinctive, whereas that of low backache or a slipped intervertebral disc is generally in the mid-line. In sacro-iliac strain there is usually a single area of maximum pain and pressure upon this area can be extremely painful whereas sciatic pain is usually along the distribution of the sciatic nerve. Generally, sacroiliac strain produces an intense local pain which may become worse on rotatory movements of the spine upon the pelvis, as turning over sideways in bed, which tend to open and close the joint. This condition can be quite crippling and may easily prevent satisfactory walking. It may cause a very pronounced limp and may be so severe as to make life absolutely miserable.

The usual treatment is manipulation. It is usually accompanied by many creaks and cracks which are caused by the breaking down of tiny adhesions within the joint, thus resulting in a much more mobile joint which by virtue of its mobility is no longer painful, although complete relief may not be felt for two or three days. The results can be quite dramatic, and the gratitude of someone who has been relieved of severe sacro-iliac pain has to be seen to be believed.

Everyone agrees that bad posture causes backache, but good posture is very difficult to achieve and almost impossible to maintain all the time. The main problem of posture in pregnancy is the obvious effort in maintaining a good upright posture in early pregnancy if you are feeling nauseated, tired and somewhat miserable, and in late pregnancy when you have a large abdomen sticking out in front. It is so much easier just to relax and let it stick out. However, good posture must be maintained both in early and in late pregnancy. The great secret is to stand as upright as possible holding the abdomen and buttocks in and pushing the chest out. Lounging or slouching in chairs is just as bad for your back as standing badly.

Excess Weight Gain

Excess weight gain obviously places undue strain on the back and will eventually result not only in bad posture but also in backache. The importance of control of weight gain in pregnancy cannot be too forcefully repeated.

Varicose Veins

Varicose veins may develop in the legs at any stage of pregnancy. The veins in the leg, as elsewhere in the body, carry the blood back from the tissues to the heart, whence it is sent to the lungs to be oxygenated and then sent once again to the body through the arteries. Veins are fairly thin tubes with muscular walls which are normally capable of controlling the pressure of blood within their lumen. When a person is standing the heart is approximately 4 ft. above the lower part of the leg and a head of pressure may build up in the veins of the legs. A constant pressure of a column of 4 ft. of blood on the veins in the lower part of the leg would after a time cause them to dilate, distend and become distorted. The veins, therefore, contain a number of valves which are situated at approximately 6 in. intervals throughout their length, and effectively divide the column of blood, preventing the veins in the lower part of the leg from being subjected to a pressure equal to the column of blood rising to the heart. These valves are small, elliptical shaped pieces of tissue which close if any back pressure is applied from above. They are in pairs, one on each side of the vessel and they meet in the middle. If the veins dilate at the site of the valve, the valve cusps will fail to meet and blood will be allowed to pass back. When this happens the valve is said to be incompetent and pressure from above will be transmitted through the valve to the area of vein beneath. This will increase the pressure in this particular area and will place an undue strain upon its muscular wall. If this strain becomes too great the muscle in the wall of the vein becomes tired and allows the vein wall to dilate and stretch. The vessel will, therefore, become not only wider but also longer than normal and this distended tortuous vein is known as a varicose vein.

So long, therefore, as the valves in the vein remain satisfactory and competent it is unlikely that a vein will become varicose. The hormone progesterone causes smooth muscle to relax and this includes the muscle of the vein walls which will then dilate. If this occurs at the site of a valve it will become incompetent and lead, to varicosity. Standing for long periods also predisposes to varicose veins in the legs.

As pregnancy advances and the uterus increases in size it presses on the veins in the pelvis, tending to create an obstruction to the flow of blood from the legs to the heart and thus increasing the pressure within the veins of the legs. The last factor frequently causes eventual breakdown of the valvular system in the superficial veins of the legs and to the formation of varicosities.

Excess weight gain is an important factor in causing veins to dilate.

There is also a hereditary factor in the formation of varicose veins which may be transmitted by either the mother or the father. Any woman with a predisposition to varicose veins is more likely to suffer from them during pregnancy. Once varicosity has commenced in the veins of the lower limbs it becomes a progressive condition which deteriorates gradually during pregnancy.

Varicose veins are unlikely to form during the first pregnancy, or if they do they only appear in the pregnancy to a mild extent. They improve after delivery since the obstruction due to the enlarged uterus is removed, the progesterone level is no longer high and the weight is reduced; the improvement will usually continue for up to six months. They become gradually more severe with each successive pregnancy and, as their severity increases, so does their perseverence between pregnancies. While mild varicose veins may regress completely after the end of pregnancy, severe varicose veins will only partially regress so that their treatment by either injection or surgery becomes necessary. The first veins to be involved are usually those on the inside and back of the calf, and frequently the right leg is affected earlier and more extensively than the left. They may also start above the knee on the inside of the thigh. Severe varicose veins in the legs are unusual before the end of a third pregnancy and many women manage to get through four or even six pregnancies without any varicose veins appearing.

Occasionally varicose veins first appear as very small spidery networks in the skin itself. These are the superficial skin blood vessels known as capillaries. The affected veins themselves are distended, soft, turgid cords lying just beneath the skin. The bluish discoloration may show through the skin, but later this may be superseded by brown staining of the skin over the veins.

Varicose veins may be prevented or their development kept to a minimum by (1) avoiding excessive weight gain, (2) avoiding standing still, (3) avoiding crossing the legs, and (4) gentle exercise. Even when standing still the muscles of the legs should be gently contracted intermittently by rocking backwards and forwards on the feet, consciously pressing the knees backwards to extend the legs fully, flexing and contracting the toes, or by gentle movements of the feet. Any movement of the feet or toes which will contract the muscles both in front and behind the leg below the knee will assist the circulation of blood through the lower limbs.

It is essential to avoid wearing underwear with any form of elastic round the upper part of the legs, since this constricts the legs and slows down the venous return from the leg. Similarly tight abdominal underwear will restrict the blood flow from the lower limbs.

When sitting down it is always advisable to raise the feet on a stool, since this will assist the return of blood. The legs should not be crossed because this obstructs the main flow of blood behind the knee.

The symptoms of varicose veins are variable. A mild irritation of the skin overlying the varicosity may be the first indication that a vein is dilating. Many women complain about the unsightly blue or brown colour of the veins. In very severe instances the skin over the lower and inner part of the shin becomes thin and shiny and tends to lose its vitality. It subsequently becomes smooth and red and may eventually ulcerate to form a varicose ulcer. Such ulcers are rare and are usually a manifestation of very severe varicose veins which should have received treatment many years previously.

Dilated veins may cause swelling of the ankles and feet during pregnancy, even in the absence of any other factor. This is not usually severe but may cause some discomfort, especially towards the end of the day, and may also cause shoes to become tight after standing for any length of time.

A dull aching pain in the calf or shin may be caused by varicose veins. This pain is not usually severe but its very persistence may cause considerable annoyance. The discomfort is worse at the end of the day, although it may occur at any time, especially after prolonged standing or exercise.

Severe cramp in the calf of the leg may happen at night. This is thought to be due to calcium deficiency but it has not been proved. Day cramps may be associated with varicose veins.

Varicose veins cannot be cured nor can they be prevented completely during pregnancy. The advice given above will reduce their severity.

If varicose veins have already developed then extra care should be taken to ensure that they do not progress further. Elastic nylon stockings or tights provide support for the outer side of the superficial veins. They assist the venous return from the leg and go a long way towards preventing the veins becoming worse. Such elastic support must be worn all day and should preferably be put on before getting up in the morning or immediately after bathing. It is useless to wear them for just a few hours each day, or to wear them for all but one hour during the day, because during that hour the pressure upon the veins can cause further damage. Elastic support cannot cure varicose veins—all it may do is prevent their further deterioration.

Stockings or tights may be bought in various sizes and only the correct size should be worn. Elastic bandages may also be used to support the legs. These may be 7 or 10 cm. wide and when applied should be wrapped once or twice round the foot in order to anchor the bandage before it is wrapped in a spiral fashion up the leg extending to at least 10 or 15 cm. above the knee. The difficulty with applying elastic bandages is obtaining an even application so that the edges do not bite into the skin to form localized constrictions. These tight rings cause even worse varicosities below them instead of helping to prevent further dilatation. Special supporting elastic nylon stockings or tights are socially as well as medically acceptable. They should be washed each night. All they require is simple rinsing in a hand basin and they will hang dry overnight.

Varicose veins that persist after pregnancy can be completely removed by surgical operation.

Vulval Varicose Veins

Varicose veins occasionally form in the vulva during pregnancy, where they are usually to be found in the labia majora. They may cause quite severe aching and irritation during the later stages of pregnancy. Support for veins in the vulva is difficult and probably the easiest method is to wear tights or a pair of tight elastic pants (not constricting the top of the legs, however). The wearing of sanitary pads may also provide support, but is not recommended. Women with varicose veins of the vulva are often very afraid that these may burst and cause profuse haemorrhage, but this is almost impossible except occasionally during delivery. If one does happen to rupture, however, the bleeding can be easily controlled by pressing with the finger on the area of the rupture until medical aid is obtained. Vulval varicose veins usually disappear spontaneously after delivery but if they persist the treatment is by a simple surgical operation.

Piles

Piles, or haemorrhoids, are varicose veins in and around the rectum and anal canal. They are formed in much the same way as varicose veins in the legs, except that whereas in the legs there is pressure by virtue of the distance from the legs to the heart, in the rectum and anal canal pressure may be caused by constipation and straining. They frequently cause bleeding, especially when the bowels are opened.

Piles are caused by:

1. straining to empty the bowel, which may be the result of either constipation or uncontrolled diarrhoea;

2. progesterone, the hormone which relaxes the smooth muscle of all the blood vessels and to which the veins of the anal canal are no exception;

3. a previous history of constipation and straining which may have caused some varicose deformation of the veins prior to the onset of pregnancy and which during pregnancy will become much more marked and obvious;

4. the pressure of the baby’s head in the pelvis during late pregnancy which may obstruct the veins and impair the return of blood from the pelvic organs;

5. a hereditary predisposition to the formation of haemorrhoids, although this might basically be a predisposition to constipation.

Pregnancy causes increased pressure within all the veins below the umbilicus and as the uterus enlarges this pressure on the large vein in the back of the abdomen which carries the blood back towards the heart is increased. The lining of the anal canal contains many veins which can enlarge and become varicose in the same way as the veins in the leg. The presence of hard and often bulky faeces, together with straining to pass them helps to cause enlargement of the varicose veins in the anal canal.

If haemorrhoids become sufficiently large they will spread to include those veins at the margin of the entrance of the anus and if they become larger still they will actually protrude outside the anus. Protrusion occurs at first only momentarily with the passage of a motion, but later they may remain prolapsed after the bowels have been opened.

Bleeding from haemorrhoids may occur at any time during their formation but is more likely the larger they become. It may be slight and only noticeable immediately after the passage of a motion or occasionally become more severe and continue for several minutes. Rarely does bleeding continue for any length of time.

Local irritation around the anus is one of the commonest symptoms of early haemorrhoids. This becomes worse in the presence of constipation. Local soreness and even pain may be present especially when the bowels are open, but frequently occur during constipation as the result of pressure from a large mass of faeces upon the anal canal. When haemorrhoids protrude through the anus and become prolapsed they become intensely sore and very painful.

Occasionally a small thrombosis may occur in one of the piles protruding through the anal margin and this is known as a thrombosed prolapsed pile. The pile becomes swollen and extremely tender. It can be felt as a comparatively small, hard, rounded area just at the margin of the anus and is one of the most painful conditions that can happen during pregnancy. It is a self-limiting condition taking three days for the pain and tenderness to increase, followed by three days in which the symptoms remain fairly constant and then three days during which they disappear. A thrombosed prolapsed haemorrhoid can be sufficiently painful to prevent a person walking and is certainly very painful on sitting down.

Chronic constipation is the biggest factor in the formation of this uncomfortable, and sometimes painful, complication, and it is probably the constipation rather than any inherent hereditary factor which causes the formation of the piles. The best treatment of piles is the routine prevention of constipation, before, during and after pregnancy. Slight rectal bleeding should be treated by diligent care of the bowels and avoidance of constipation. If rectal bleeding becomes more severe your doctor should be notified, for although it is difficult to treat piles satisfactorily during pregnancy, he should be aware of the condition and may prescribe some suppositories. Irritation and soreness, which are usually more noticeable at night, are best treated by the application of an ointment to the anal area after defaecation and before going to bed.

If the piles actually prolapse and remain prolapsed after defaecation they should be replaced as soon as possible. The haemorrhoids can be gently pushed back with the finger, although care must be taken that they are not damaged by the finger nail, and once they have been found to prolapse even more vigorous measures must be taken to ensure that constipation does not recur. If the piles cannot be replaced immediately they may be replaced after lying for a few minutes in a warm bath. If they prolapse again as soon as they have been replaced then the woman should go to bed and rest with the feet up for 30 to 60 minutes after the piles have been replaced. If piles need to be replaced after defaecation your doctor should be notified.

The treatment of thrombosed prolapsed piles varies greatly. This intensely painful condition usually occurs during the last 6 or 8 weeks of pregnancy. The local application of Anusol or Proctosedyl ointment will help to alleviate the symptoms. It is often suggested that the local application of cold lead lotion or witch hazel, or some other compress, will help. They do certainly soothe the pain though they do not really help the natural history of the condition. Any further straining and constipation must be rigorously avoided. Your doctor may consider that it is necessary to remove the clot from the pile and this is done quite easily and painlessly after injecting a small amount of local anaesthetic. This results in a dramatic relief of symptoms, but is usually considered only worth performing if it can be done during the first two days that the pile has become thrombosed. The use of an anaesthetic ointment applied three or four times a day will often relieve some of the pain.

It is not usually considered wise to inject haemorrhoids during pregnancy, although some doctors do treat the more severely affected without any ill effect. Operative treatment is usually reserved for persistently prolapsed piles. Most doctors prefer to reserve both injection and operation until some time after the end of pregnancy and will usually persevere with conservative treatment if possible.

Minor degrees of haemorrhoids usually regress spontaneously after the end of pregnancy and require no treatment. It is wise, however, for any patient who has suffered from haemorrhoids in pregnancy to discuss this with her doctor afterwards because any residual haemorrhoids will become rapidly worse during a subsequent pregnancy and it is to her advantage to have them treated before her next pregnancy.

Intertrigo

Intertrigo is a red irritating skin rash where folds of skin are in close contact. It is seen most frequently underneath heavy and pendulous breasts and also in the groins. Intertrigo is more common in women who are overweight and especially in those who either do not wash sufficiently frequently or perspire excessively. It is caused by an excessive quantity of sweat which cannot evaporate because of the close contact of the skin surfaces. The skin first becomes soggy then sore and inflamed, giving rise to a reddened, scaly irritating rash.

The easiest way to prevent this condition is to avoid putting on an excess amount of weight and to prevent the skin becoming wet and continuously soggy by excessive perspiration. If intertrigo develops it is treated by frequent bathing and washing of the affected areas and gently powdering with ordinary talcum powder. Care must be taken not to apply so much talcum powder that it becomes caked. If the irritation is annoying either calamine lotion or hydrocortisone ointment (on a doctor’s prescription) can be applied twice daily.

Pigmentation

Breasts

Pigmentation of the nipples and the areola commences at about the 14th week of pregnancy. The amount and area of pigmentation varies from person to person, but is generally more obvious in women who have dark hair and less marked in women who have fair hair and skin. Women with red hair, who so frequently have very delicate skin, usually have very little pigmentation of both the nipple and the areola. In very dark people this pigmentation may spread beyond the areola onto the breast itself. This secondary areola usually appears about the 18th or 20th week of pregnancy. It may occasionally involve most of the skin over the breast. Pigmentation of the secondary areola will disappear very rapidly after 208 delivery except in those women who have very dark colouring when it may remain for several weeks or even months.

Pigmentation on the primary areola tends to be of a more permanent nature. The nipple and the areola may become lighter very shortly after delivery but some brown pigmentation may become permanent in women who have had more than one child. Breast-feeding does not affect the permanence of this nipple and areola coloration.

The Linea Nigra

The linea nigra is the dark line which develops down the centre of the abdomen commencing at the 14th week of pregnancy. Similar to other areas of pigmentation in pregnancy, it is most noticeable in brunettes, less noticeable in fair-haired women and frequently absent in red-headed women. Except in those of the very fairest complexion, the linea nigra always accompanies pregnancy, and extends as a pigmented dark line of varying width up to 1 cm. from the pubic hair to the umbilicus. The umbilicus itself flattens and pigments as pregnancy advances. The linea nigra may extend above the umbilicus to the lower part of the rib cage.

The linea nigra has no special significance to either the mother or the unborn child. It cannot be washed or scrubbed away because it is caused by dark, or pigmented, cells within the substance of the skin itself. It begins to fade soon after delivery but may take several months to disappear completely. Occasionally the pigmentation in and around the umbilicus remains for several years.

Other Areas of Pigmentation

Any pigmented birthmark, mole or scar is likely to become darker during pregnancy. This applies particularly to freckles, which may also enlarge. This effect becomes even more obvious if they are exposed to the tanning effect of the sun. Any scar, particularly on the abdomen, which has been present for less than one year at the onset of pregnancy may undergo quite severe pigmentation.

The increase in the pigmentation and the number of freckles both on the face and the body will begin to disappear shortly after delivery, and the condition of the skin will return to normal within a few weeks. Occasionally larger moles or darker areas of pigmentation may persist for longer.

The Butterfly Mask of Pregnancy

There is a characteristic area of pigmentation that occurs on the face in late pregnancy, especially if it has been exposed to the sun. It has a butterfly-shaped distribution where the pigmentation spreads from the nose over the cheeks like the wings of a butterfly. An area of pigmentation may also occur on the forehead. While the mask of pregnancy may sometimes be attractive, its characteristic blotchy and irregular colouring is more likely to annoy its owner.

It has no special significance. There are many old-fashioned stories concerning either its value or its disadvantage to its owner, but none of these have any medical or scientific basis.

Women should not bleach the mask of pregnancy. Such attempts usually result in more blotchiness, and as the surrounding skin is also bleached so the mask itself becomes even more obvious. The mask will begin to fade a few days after delivery and may disappear completely in three or four weeks. Occasionally, however, it persists for several months.

Stretch Marks

Why do stretch marks occur? There are many erroneous theories about their origin but there are only two main reasons. The first is the amount of progesterone produced by the pregnant woman and the second, the amount of weight gain.

A large number of old-fashioned remedies are advised to prevent stretch marks, none of which are guaranteed to work. They range from eating certain special vegetables and herbs to massaging the abdomen with liniments and oils.

It is commonly thought that some women have a particular type of skin which possesses great elasticity and will therefore not form stretch marks, whilst others have skin which contains little or no elasticity and will develop stretch marks regardless of what they do to avoid them. This is erroneous.

Many girls at the time of puberty develop stretch marks on the breasts, buttocks and thighs, and occasionally on the upper arms. These are associated with the rapid production of hormones and a rapid weight gain at that time. The production of oestrogen and progesterone at puberty is usually associated with an increase of appetite, but they also cause better utilization, of the food, so that it is more readily deposited as fat in the breasts and in the subcutaneous tissues of the buttocks and thighs. Stretch marks form if the skin is stretched beyond its normal elasticity. They are originally brightish red or livid and while they may lose their colour over several years, the scars never completely disappear. A similar process works during pregnancy when stretch marks occur on the breasts, especially in women who normally have small breasts that enlarge rapidly and dramatically with the onset of pregnancy. Nothing can be done to prevent these. They also appear later on the anterior abdominal wall. Stretch marks over the buttocks, legs and upper arms during pregnancy are always associated with gross increase in weight.

During what doctors might call a ‘good pregnancy’ a great deal of hormone may be produced which predisposes to fluid retention and a very rapid increase in weight. A woman does not know if she has a large amount of circulating hormone, but she does know that anything she eats ‘turns to fat’ and she must be particularly careful with her diet if she is to avoid excessive weight gain. A woman who gains only 9 kg. throughout a pregnancy will almost certainly not develop stretch marks whereas a woman who gains 18 kg. almost certainly will.

Oiling the skin of the abdomen will not prevent stretch marks although many people swear that it will. The woman who religiously oils her abdomen to prevent stretch marks is usually one who is most careful with her diet and her weight and, though she may attribute her lack of marks to oiling her skin, it is in fact due to her lack of obesity. However, the skin does tend to become dry and scaly during pregnancy and the daily application of oil over the whole body will do a great deal to preserve its normal texture.

If over-distension of the abdomen occurs as the result of a twin pregnancy or polyhydramnios then stretch marks are extremely difficult to avoid. Some women do avoid them by rigid control of their weight gain, which during twin pregnancy should be restricted to 13 kg.

The first stretch marks appear literally overnight and are rapidly followed by others if weight gain is not carefully controlled. Once stretch marks have appeared they will remain for ever. It takes several months following delivery for the marks to lose their livid coloration and eventually they have a light silvery colour, but, probably even more important, the skin that has been stretched will never properly return to its former elasticity and texture.

Taste

A change or alteration in taste is not really a minor ailment of pregnancy but, like so many things that happen in pregnancy, it is difficult to know under what particular heading this should be described.

Even before the suppression of the first period some women can diagnose their pregnancy because they notice a strange taste in their mouth, or a different taste appreciation for certain foods. The classic taste is metallic, persistent, quite definite and unfortunately usually lasts throughout pregnancy.

Other women notice that their tastes change and that, whereas they had previously liked coffee, it now tastes horrible; similarly, some women may show dislike of spicy foods and alcohol. Unfortunately, most of the changes result in a liking for sugar and sweet things, which makes dieting even more difficult.

Changes of taste are not the same as cravings or ‘pica’, although some alterations of taste are quite out of character and occasionally quite bizarre. Gingivitis or other infections in the mouth will not only alter taste but may also create an unpleasant taste in the mouth and cause the breath to become offensive. When they are treated the symptoms will go.

Bleeding from the Gums (Gingivitis)

The gums respond to hormones in pregnancy as do most of the other organs in the body. A certain amount of congestion is the result of an increased blood supply. This causes thickening of the gums, especially where they lie immediately against the teeth, so that tiny little depressions are formed between the gum and the tooth. Food particles, other debris and stale saliva will collect in these hollows as well as in the spaces between the teeth. Bacteria inevitably grow and multiply in these conditions and very shortly begin to cause infection. Infection of the gum immediately adjacent to the tooth is known as gingivitis. It further increases the blood supply to the mouth, makes the gum sore, tender and liable to bleed very easily. Infection between the gum and the tooth is the whole basis for dental caries in pregnancy. It is true that the baby may take calcium from the mother’s bones but he cannot remove any calcium from the teeth and thereby predispose them to dental caries. The dental caries result from gingivitis due to poor mouth hygiene.

Treatment of bleeding from the gums should ideally be preventive by regularly consulting your dentist and being most meticulous about oral hygiene. Proper brushing of the teeth with a not too hard brush in an upwards movement from the gums to the crown, and not vigorous sideways abrasion, is essential. If bleeding does occur, you should see your dentist as soon as possible so that treatment can be started before any permanent damage has been done.

Nasal Congestion

Nasal congestion or stuffiness in the nose is a common complaint during pregnancy. Congestion is due to the increased blood supply to the mucous membrane and an increase in the secretions of the nasal passages, and does not require any specific treatment unless it becomes intolerable to the patient. She should then consult her doctor who may advise her to insert drops or to use a nasal spray for a short time. These should not be used without first consulting a doctor, because these drops or sprays contain decongestants which cause a constriction of the vessels in the nose and which, although very good for the nose, may adversely affect other parts of the body if they are absorbed into the blood stream. Their excessive use may make the whole condition much worse.

Nasal congestion is a direct result of pregnancy and will, therefore, be relieved when the pregnancy ends. If it persists you should seek expert advice.

Nose Bleeds in Pregnancy

Bleeding from the nose is more common in pregnancy and is particularly noticeable during autumn and winter. Nose bleeds are usually transient with the loss of only a small amount of blood and they cease spontaneously after a few minutes.

In pregnancy they are not an indication of a rise of blood pressure and all the old wives’ tales associated with recurrent nose bleeds and injury to the foetus in utero are absolutely groundless.

The mucous membrane lining the nasal passages has a greatly increased blood supply during pregnancy which makes it become thicker, congested and more easily damaged. It may be injured by trauma, of which the classical example is picking the nose with the finger, or result indirectly from living in a dry centrally heated atmosphere when the secretions in the nasal passages become hard and encrusted on them, and their removal may damage the mucous membrane.

Nose bleeds should be treated by applying pressure with a hand-kerchief to the affected nostril or by gently pinching the nose. If the nasal passages are dry and cracked, a small amount of white vaseline or lanoline should be inserted into each nostril on a finger-tip and gradually massaged into the nose by gently rubbing the nostril. This should be repeated each night. If this does not stop the bleeding, or if the bleeding recurs, you should consult your doctor.

Headache

Headaches may occur at any time during pregnancy, just as they occur in the non-pregnant woman. They are not more likely to occur than at any other time, although occasionally the worry and concern that a woman may have during pregnancy makes them more frequent. Some women complain of quite severe headache with the nausea of early pregnancy. Headaches may be treated by simple remedies such as rest or taking aspirin or paracetamol. Codeine is not usually recommended because it tends to increase constipation.

Migraine sufferers are usually slightly better when they are pregnant, but there is no hard and fast rule.

Headaches associated with common causes, such as ’flu or too much alcohol, are the same as in the non-pregnant and the normal remedy of aspirin with a pint of water is all the treatment usually required.

Headaches which occur in the front of the head, usually situated above the eyes, must always be treated carefully, partly because they may be associated with migraine or eyestrain, but also because they may be particularly difficult to relieve by simple aspirin treatment. If the pain is not relieved after about an hour then you should rest in bed.

The serious, but extremely rare, condition of eclampsia is also associated with a very severe frontal type of headache, which is not relieved by aspirin or any other type of drug. It is a very severe pain and is associated with flashes of light, changes of vision, irritability and vomiting.

Pressure headaches, where there is a sensation of a heavy weight pressing on the top of the head, are usually caused by nervousness or emotional problems and nearly always respond to tranquillizers or similar treatment. These should only be taken on advice of a doctor.

Muscle Cramps

Cramp in the muscles of the thigh, calf and foot, more especially in the calf, become fairly frequent during the last quarter of pregnancy and usually occur at night. They can be intensely painful and suddenly wake a woman from sleep with a sensation of severe cramping pain in the calf extending down to the foot. The muscles of the calf are felt tightened into a hard knot and the pain may be sufficient to make the woman cry out immediately she wakes. The treatment is rapid, firm and almost violent massage of the affected muscles as well as movement of the foot both upwards and downwards helping it with one hand. During a cramp the foot is nearly always extended and pressed downwards, and one of the secrets of relieving the pain is to bend the foot and toes upwards. The combination of movement of the foot and massage of the calf usually relieves the pain although it may take a few minutes. After the acute pain has ceased a fairly severe ache remains. Tenderness persists in the calf for several hours and frequently lasts for two or three days, making walking difficult. Such muscle cramps do not damage the leg or its muscles, but they can be extremely painful and their demoralizing effect quite considerable.

It was generally thought that cramps were due to a low level of usable calcium in the blood. The standard treatment for frequent cramps was to take calcium tablets two or three times a day. However there is no definite evidence that such treatment is useful. On rare occasions muscle cramps are the result of a persistent low salt diet. If a woman has been on such a diet and her cramps are not relieved by taking calcium, she may be given more ordinary salt to eat. Generally speaking, the intake of salt during pregnancy should be diminished or reduced and pregnant women are warned against taking large quantities of salt. Taking extra salt for the treatment of cramps must, therefore, only be under the direction of a physician.

Pelvic Discomfort

Pelvic discomfort is nearly always present towards the end of pregnancy and may take one of a variety of forms. In a woman having her first baby it usually begins at about the 30th or 32nd week with the softening of the ligaments which hold together the bones of the pelvic girdle. This results in some relaxation of the joints and the resulting extra unaccustomed movements may cause severe aching which is most noticeable after exercise or at the end of the day. It is best treated by rest; lying down for half and hour or so usually relieves the discomfort. At the 36th week of pregnancy in a woman having her first baby the baby’s head usually engages in the pelvis causing aching or generalized heaviness in the pelvis. The head may press upon nerves, causing pains in the groins that sometimes radiate down the front or inner side of the thigh as far as the knee and which are most noticeable when walking or after exercise. Occasionally pain may occur in the back of the pelvis and radiate down the back of the leg. These pains, being due to pressure on nerves, are intermittent and there is no need to be concerned, but if they become severe or continuous you should report them to the antenatal clinic when you next attend.

The bones in the front of the pelvis are joined together at the symphysis pubis and this joint, like the others in the pelvis, is softened and tends to separate towards the end of pregnancy. Pressure upon it may cause some tenderness and on rare occasions it becomes painful. This will be noticed particularly after exercise or when moving the weight from one leg to the other. Although occasionally pain in the symphysis pubis may be quite severe, it causes no harm. It used to be treated by very tight binding of the pelvis to try and prevent movement in the joint; it is now accepted that this does not relieve the pain and that there is no specific treatment for its relief other than rest, avoiding violent exercise, re-assurance and the administration of aspirin or similar analgesic if required.

Abdominal Pain

Abdominal pain may occur during pregnancy from any condition which might cause abdominal pain in the non-pregnant state. It is impossible to consider all the causes of abdominal pain that might occur throughout pregnancy. Generally speaking, however, pain is a frightening symptom. It can be considered under three different headings:

Well-known pain. This type of pain or discomfort has been noticed before the onset of pregnancy. It may be, for instance, associated with constipation. Such a pain need not worry you but should be mentioned to your doctor or at the clinic at your next appointment.

Pain of gradual onset. There are several specific discomforts or pains which occur during pregnancy commencing very gradually, so that it is several days or weeks before a pain of noticeable severity has developed. This type of pain does not indicate any serious condition and should be discussed at your next visit to the clinic.

Pain of sudden onset. This type of pain has never occurred previously and is, therefore, likely to be associated with the pregnancy. Such severe pains are associated with miscarriage, ectopic pregnancy, fibroids and ovarian cysts, although it is surprising how much pain constipation or foetal movements can sometimes cause. Severe pains of sudden onset should be reported as soon as possible.

Round Ligament Pain

This is a specific pain or discomfort that occurs during pregnancy caused by the stretching of the round ligaments supporting the uterus. These ligaments pass from the upper and outer part of the uterus down the lower side of the abdomen into the groin. Round ligament pain usually begins about the 16th or 20th week of pregnancy, although it may not begin until the 28th week, and usually continues until about the 32nd week when it disappears spontaneously. It is recognized as being an aching, dragging, nagging pain, usually more severe on the right side than the left, just to one side of the uterus. Occasionally sharp stabs of pain may be felt and the pain may be particularly annoying when a woman stands up after sitting for any length of time. It can be confused with an acute or chronic appendicitis and should be mentioned when you next visit the clinic.

There is no specific treatment for round ligament pain. Reassurance is all that can be given. The pain will not do the patient or her baby any harm. It does not usually become sufficiently severe for pain-killing drugs to be given.

Costal Margin Pain

The costal margin is the lower border of the chest wall. Towards the end of pregnancy pain may be felt here, at the junction of the lower edge of the ribs and the abdominal wall, just below the breasts or occasionally to the side. This is caused by compression of the lower ribs by the enlarging uterus and usually begins at the 30th, 32nd or even 34th week of pregnancy. It is more common on the right than the left side because the uterus usually enlarges more to the right and presses more on the right ribs. It can, however, occur on the left or may sometimes be present on both sides and can be sufficiently severe to cause a great deal of discomfort. The pain tends to be more severe when sitting than when standing or lying fiat, because in the sitting position the ribs are compressed even more by the enlarging uterus. There is little that can be done to relieve it other than to avoid sitting in a slumped or slouched position.

Occasionally the ribs become very sore and the pain becomes quite severe. There is no definite cure other than delivery. The pain disappears spontaneously as soon as the uterine fundus stops pressing on the lower ribs. If it is the first baby this happens when the head engages in the pelvis and lightening occurs at about the 36th week—otherwise the discomfort may continue until labour begins.

Reassurance and a promise that the pain will go at delivery do not seem to offer very much in the way of treatment, but most women learn to live with it after they realize that it will not harm either them or their baby.

Oedema (Swelling of the Ankles and Feet)

Part of the natural weight gain of pregnancy is due to the retention of water within the body. The amount of water retained varies from woman to woman and also between different pregnancies in any one person. It is impossible to give any reliable figure for the exact amount of water retained at any stage during pregnancy. Salt is one of the main factors which allow the body to hold extra fluid within the tissues and the majority of obstetricians therefore limit the amount of salt taken by their patients. An excessive amount of fluid retained in the body tends to gravitate into the feet and ankles during the day, or onto the skin overlying the lower part of the back when a person is lying in bed.

A minute amount of swelling of the ankles is common in most people, pregnant and non-pregnant, towards the end of the day but hardly noticeable. Obvious, unnatural swelling of the ankles, generally known as oedema, can be easily recognized because of its ‘pitting’ nature. If pressure is applied to an area of oedema with a finger or thumb for 20 or 30 seconds, the fluid in the tissues being compressed will spread into the surrounding area, and when the pressure is removed a depression will remain which can be both seen and felt easily. It is one of the classical signs of pre-eclampsia. In fact, the majority of women develop pitting oedema at some stage during their pregnancy.

Oedema of the ankles results not only from the retention of large amounts of fluid in the body but also during hot weather and by prolonged standing which allows pooling of fluid in the lower parts of the legs. The oedema or swelling usually disappears during the night, when the feet are raised, but reappears during the following day. It is a gravitational problem and rest during the day with the feet raised will tend to reduce swelling.

Severe oedema or swelling may be associated with considerable discomfort in the lower leg and ankle. It also causes pain and discomfort when wearing shoes, because they constrict the feet which not only become hot and swollen but also tend to swell to a greater extent at the edge of the shoe, or in the region of the straps, thus causing them to cut into the skin.

Any pregnant woman who develops recognizable oedema of the ankles or feet should consult her medical adviser or midwife when she next visits the antenatal clinic. Oedema is not dangerous but it constitutes an abnormality of pregnancy and merits serious consideration by those looking after her. Also their advice upon diet or any other factors related in the management of the pregnancy may be necessary.

The management of oedema of the ankles varies according to its severity. A very mild amount occurring only at the end of the day, especially in warm weather, requires no treatment. Slightly more oedema occurring at the end of the day in cold weather may require only extra rest during the afternoon. As the amount of oedema increases it can be controlled by a more rigid diet and careful supervision of the woman’s weight gain, and sometimes by eliminating spices and pickles from the diet. Even more severe oedema demands strict rest at home and the doctor may proscribe diuretic drugs which squeeze extra water out of the body. The prolonged use of diuretics or salt intake restriction are inappropriate forms of treatment.

If oedema of the feet remains severe or there is an accompanying rise in blood pressure, the woman will be admitted to hospital for further observation and treatment.

Swelling of the Face

A certain amount of swelling of the face is natural during pregnancy. One of the earliest methods of diagnosing pregnancy in social circles is to notice a fullness of the face especially in the region of the cheek bones and around and beneath the jaw bones. A certain amount of generalized enlargement of the face results from the deposition of subcutaneous fat and fluid that occurs as pregnancy advances. This is normal and may sometimes be very pronounced. Occasionally, however, there is true oedema of the face when the wrinkles of the forehead are eliminated, the eyelids become heavy and rather baggy, the skin on the cheeks becomes distended and shiny, and jowl forms in the skin under the jaw bone. Such marked facial alterations usually accompany excessive weight gain or fluid retention. While not being one of the diagnostic signs of pre-eclampsia, they are usually associated with it.

The treatment of this condition is by strict and rigid dietary control, or the administration of diuretics, to remove the extra fluid. The increases or alterations of the facial contour will always return to normal after delivery, providing of course that the woman’s weight returns to normal. Any permanent increase in her weight will also result in permanent alteration in her facial contour.

Swelling of the Fingers

A certain amount of swelling of the fingers seems to occur during most pregnancies, for which the reason is unknown. The knuckle joints of the fingers tend to become much larger so that rings which could easily be removed can only be removed with difficulty towards the end of pregnancy or after delivery. There is rarely any pain or discomfort with such swelling. Oedema of the fingers, however, may also occur during the latter stages of pregnancy causing rings to become excessively tight, and is usually associated with fluid retention. This type of oedema is not due to gravity because the hands are not always hanging down. Oedema of the hands becomes more marked during the night and is therefore most noticeable early in the morning, when the fingers are stiff and may have a tingling sensation. It may be necessary to work the fingers before they are sufficiently supple to handle ordinary kitchen utensils. Stiffness or swelling of the fingers should be reported to the doctor or midwife at the next visit to the antenatal clinic. Rings which have become uncomfortably tight may be removed after soaking the hands in cold water and wiping the ring and its finger with soap. There is also a very ancient but effective method of doing this by winding a piece of string gently round the finger starting at the tip and gradually working the way up towards the ring. This squeezes the fluid out of the finger and towards the hand, and when the string is removed the ring can be slipped over the now normal finger.

Severe swelling of the fingers may occur as a symptom of pre-eclampsia, but should generally be regarded by pregnant women as a warning and not as a symptom of serious disease. Oedema of the fingers may be treated in the same way as oedema of the ankles, mainly by diet, but sometimes by diuretics.

Carpal Tunnel Syndrome

Pain in the wrist and pins and needles extending from the wrist down into the hand is a condition known as carpal tunnel syndrome. The carpal tunnel is in the front of the wrist and carries the tendons and nerves to the palm of the hand and fingers. When the hand and fingers swell the area of the carpal tunnel also swells but, as it is bounded by bone on one side and a fibrous ligament on the other, any swelling results in pressure on the tendons and nerves within the tunnel. The pressure causes irritation of the median nerve as it traverses the tunnel, resulting in the sensation of pins and needles extending downwards into the thumb and fingers, but never affects the little finger. This is most frequently noticed in the early morning before movement of the wrist has dispersed any fluid, and is usually accompanied by stiffness of the fingers and joints of the hand. As the hands are moved, the joints become more supple and the numbness and tingling pass. If it continues throughout the day it should be reported to the doctor.

Carpal tunnel syndrome is the classic reason why a pregnant woman drops things in the early morning.

It is a warning rather than a dangerous symptom, although the discomfort may make the woman seek medical advice. The management is exactly the same as that for oedema of the ankles and fingers, namely dietary control and sometimes diuretic treatment. It always disappears a few days after delivery.

Occasionally, if there is no swelling of the fingers or of the ankles, the symptoms may be due to a deficiency of vitamin B and not pressure on the nerve. The symptoms may respond to the administration of vitamin B, so all vitamin pills given by the doctor or clinic should be taken regularly.

Discomfort in Bed

Towards the end of pregnancy it may be extremely difficult to find a comfortable position in bed, especially if you normally sleep on your back or abdomen. The growing uterus will obviously prevent you from sleeping on your abdomen and will also make sleeping on you back rather uncomfortable. If you turn on one side then your enlarged uterus will tend to drag you over into an uncomfortable position. You may find that sitting up with two or three extra pillows is the most comfortable position and the one in which you will sleep longest, or lying on your side with a pillow under the abdomen may be sufficiently comfortable for a good night’s sleep.

One of the main prescriptions for a good sleep is a firm bed. There is nothing worse than a mattress that sags into a hollow in the middle and, if it is not practical to buy a new mattress or bed, the hollow can be counteracted by putting some 15 cm. wide wooden boards across the bed under the mattress.

Heartburn is often worse at night and discomfort can be eased, or even cured, by raising your head on two or three extra pillows or by lifting the head of the bed about 15 cm. with bricks or similar objects under the legs at the head end. Make sure it is secure!

Insomnia

Insomnia is the inability to sleep. Many pregnant women find that mild insomnia may affect them in different ways, mostly during the last third of their pregnancy. Firstly, they have difficulty in getting to sleep. Secondly, they wake after two or three hours of sleep and find that they cannot sleep again. Thirdly, they have problems with their temperature control. Fourthly, they may suffer from frequency of micturition.

The movements of the baby sometimes become more vigorous at night than during the day. This may be actual fact or simple imagination, but in either event they become more noticeable and may be sufficiently violent to wake the mother from comparatively deep sleep. Once she has been awakened her baby is often sufficiently active to prevent her getting to sleep again. The movements of the baby vary as pregnancy progresses and are often most violent at about the 32nd week when the baby is sufficiently strong and still has sufficient room actually to punch and kick. As pregnancy advances beyond the 32nd week the amount of water surrounding the baby gradually diminishes in relation to the size of the baby so that its movements have more of a squirming nature. One type of movement is not more likely to wake, or keep awake, a woman than another, but if the kicks of the 32nd week cause wakening then the squirming movements later on may not do so.

The variation in the metabolic rate of the pregnant woman often causes confusion in her temperature regulation. The body temperature is accurately controlled by a delicate temperature regulation centre in the lower part of the brain which may occasionally fail to function satisfactorily during pregnancy, making a woman feel alternately hot and sweaty, then cold and clammy. This is most commonly experienced during the height of summer or the depths of winter, particularly at night, and more especially in the last 10 weeks of pregnancy.

The treatment of insomnia is basically comfort and peace of mind. Someone who is either uncomfortable or worried will obviously have difficulty in sleeping. If discomfort is due to any actual aches and pains you should mention these when you next visit the antenatal clinic. If there are any worries concerning the pregnancy or its outcome these should also be discussed, and it will usually be found that these fears are groundless. Comfort together with a warm drink when going to bed are the usual household recipes for sound sleep and are just as applicable in pregnancy.

Increased frequency of micturition occasionally results in an inability to sleep through the night. A woman may be wakened by the desire to empty her bladder after which it is difficult for her to return to sleep. In these circumstances she should not drink for one or two hours before going to sleep.

It is difficult to advise any realistic method of enabling a return to sleep having once woken during the night. When people do wake at this time they usually become very ‘wide awake’. Their mind becomes active and the harder they try to return to sleep the more difficult it becomes. Perhaps getting up, walking around, malting a warm drink or reading a book is the ideal method of trying to reduce the mental activity. When apparent temperature changes such as heat and sweating cause wakefulness it is no use throwing off some of the bed clothes, because in a short while you will feel cold. If the feeling of warmth causes persistent waking or insomnia then the number of blankets ought to be gradually reduced. The amount of bed clothing used by most married couples is a habit arrived at by mutual agreement. If a pregnant wife wakes in the night feeling hot and sweaty and wishes to reduce the number of bed clothes, her husband, who does not feel any of the other inconveniences of pregnancy, should graciously give way even at the expense of feeling cold in the middle of the night. He can always wear a vest! If this is his only discomfort in pregnancy he can hardly grumble.

There is a whole range of sleep inducing tablets available. Some are mild and some are extremely powerful. There is also a large range of tranquillizers. None of these should be taken without the permission of your doctor, and the stated dose should never be exceeded. While some drugs may be harmful to the pregnant patient, there is a large range of tranquillizers and hypnotic drugs which are safe to take during pregnancy so long as they are taken in the recommended dose.

It is most important that you should get a good night’s sleep, otherwise you will become tired and irritable during the day and your pregnancy will become rather a bore. Simple sleeping tablets are perfectly safe for you to take during the later weeks of your pregnancy. You need not be afraid you will become addicted to them since your normal sleeping pattern will return after delivery.

Cystitis

Cystitis, or urinary tract infection is one of the most common infections during pregnancy and probably affects about 20 per cent of all women at some stage.

The classical symptoms are an increase in the frequency of micturition with discomfort or pain before, during or after passing urine. There may also be a sense or urgency to pass urine which may occasionally contain blood. The infection is usually long-standing or recurrent, and the symptoms may appear gradually over several weeks or even months. However, cystitis may occasionally be sudden in onset when the symptoms of pain and frequency of micturition will appear in just a few hours. An acute cystitis is nearly always associated with a rise of temperature and perhaps also an attack of shivering. There may be pain in one of the loins in the region of the kidney. If an acute cystitis is suspected you should go to bed, send for the doctor and drink as much water as possible while awaiting his arrival.

A special specimen of urine is usually taken for investigation and culture of the organism. Most of these infections are treated by a course of antibiotics and the majority are quickly cured. A urinary tract infection even of the most severe nature will not affect the baby and will not have any permanent effect on the mother provided it is treated properly and cured fairly quickly.

Overstretching of the Abdominal Muscles

During a normal pregnancy the abdominal muscles become distended and stretched but are always able to return to their former condition after the conclusion of the pregnancy, especially with the help of gentle exercises. Abdominal distension does not start until about the 20th week of the first pregnancy, or about the 16th week of a subsequent pregnancy. The abdominal girth, should increase to a maximum of approximately 100 cm. at term in a normal pregnancy and the muscles are perfectly capable of returning to their normal tone providing this girth is not exceeded.

There are three main factors which contribute towards over-distension of the uterus or abdomen during pregnancy and, therefore, to overstretching of the abdominal muscles. They are obesity, multiple pregnancy and polyhydramnios—an excessive amount of water around the baby. During normal pregnancy the muscles may begin to ache, especially just above the pubic bone, at about the 20th week. This is due to normal stretching and usually lasts for three or four weeks. It is especially noticeable after exercise or towards the end of the day and indicates that the muscles are being placed under a certain amount of stress and that more rest should be taken.

Some people believe that support of the abdomen and abdominal muscles is beneficial at this stage. This is doubtful since the muscles themselves are perfectly capable of maintaining their tone and will not become overstretched during a normal pregnancy. An abdominal support allows the muscles to become slack so that they are in fact more likely to lose their tone later in pregnancy or after delivery. Bad posture undoubtedly causes some overstretching of the abdominal muscles. During pregnancy the weight of the body is thrown forward by the pregnant abdomen which leads to an arching of the back and a prominence of the buttocks and a compensatory leaning back of the upper part of the chest. Later in pregnancy this characteristic posture becomes more marked and the tilting forward of the pelvis leads to the classical pregnant walk or wobble. High-heeled shoes cause the pelvis to tilt further forwards and the back to arch even more. This places an increased strain on the muscles of the abdomen and leads to their overstretching. The correct posture is to keep the bottom tucked in as much as possible, which in turn will flatten out the curve in the small of the back and level the pelvis. This means a woman is standing much straighter and more erect and there is less, protuberance of the abdomen.

There is no reason to suppose that wearing a maternity girdle or maternity corset will in any way assist posture during pregnancy. If one is worn it should only support the lower part of the abdomen so as to relieve the sense of weight or heaviness and should not constrict the abdomen above the umbilicus.

Injuries during Pregnancy

Most pregnant women fall down at some stage during their pregnancy especially during the last month when their balance is upset by the protuberant abdomen and by the awkward clumsiness generally accompanying the end of pregnancy. Simple falls or accidents usually result in a few bruises, but frequently the falls are in a forward direction, resulting in the abdomen (and uterus) receiving most of the force of the fall. Such a fall may cause great anxiety to a woman in late pregnancy, because of the possibility of injury to her baby and because of the possibility of injury to herself or the onset of premature labour. It is almost impossible to cause physical injury to a baby when it is inside the uterus. This applies at any stage of pregnancy. The only way in which a foetus can be injured by direct violence is by striking the uterus very hard with an extremely sharp object. Ordinary falls, no matter how severe, almost never cause damage or injury to the baby. Occasionally, women in late pregnancy fall downstairs and this may result in multiple injuries both to the back and the abdomen. Even so, it is extremely difficult to damage the contents of the uterus even if the anterior abdominal wall strikes the leading edge of the stairs while falling. In such an accident the first reaction is to see if any bones have been broken and if all limbs and joints move freely it is unlikely that severe damage has been done. Bruising is bound to occur but is not harmful. The pregnant woman should rest quietly for a few minutes in a comfortable chair or in bed. The only indication in early pregnancy that the uterus has been damaged is bleeding from the vagina and if this occurs she should go to bed and tell the doctor immediately. Bleeding resulting from ordinary injuries is rare.

Later in pregnancy a pregnant woman can feel if foetal movements are continuing after an accident. Sometimes after a violent fall foetal movements cease for one or even two hours and then recommence again with their former vigour. If they cease for more than three or four hours the doctor should be notified. The doctor or the hospital should be notified immediately if there is any loss of blood or water from the vagina. If her head has been struck during the fall and the woman knows that she lost consciousness, even for the shortest time, she should notify her doctor as soon as possible.

Virus Disease

Obviously all infections should be avoided if possible during pregnancy. The majority of contagious diseases are caused by viruses, most of which can cross the placenta and enter the foetal circulation, so that in early pregnancy (before the 12th week) there is a possibility that they may affect the development of the baby. After the 12th week they cannot harm the foetus but are better avoided even in late pregnancy because they produce unpleasant symptoms.

Visual Disturbances

Some women complain that their eyesight changes during pregnancy. There is nothing in pregnancy itself that causes or results in any damage to the eyes.

During pregnancy, however, extra fluid is retained within the body and if this becomes excessive, as in pre-eclampsia, or there is a large gain in weight, some very minor changes may occur in the eyes. A woman with particularly good eyesight will not notice these changes, but if a woman’s eyesight is not very good at the onset of pregnancy, then the small changes may be noticeable. Her vision will return to normal after the end of pregnancy.

Contact Lenses

If an abnormal amount of fluid is retained in the body during pregnancy some inevitably finds its way into the eyes and produces a very slight change in the shape of the eyeball itself. This may be quite critical to those women who wear contact lenses which may become uncomfortable. The eyes will return to their previous contour after the end of the pregnancy and the lenses will again be comfortable. It is especially important for those women who wear contact lenses not to gain too much weight.

Warning to those who wear contact lenses. Those of you who wear contact lenses must always tell your doctor, your midwife and the staff at the booking clinic in the hospital when you first see them. Doctors have a habit of gently pulling down the lower eyelid to see the colour of the mucous membrane on its inner side which gives them a good indication of the condition of your blood. Unless the doctor realizes that you are wearing contact lenses, he may inadvertently press on the upper eyelid and, although he is unlikely to dislodge the lens, it may cause discomfort.

It is particularly important to remove contact lenses when labour begins, preferably before you go to hospital—but do not forget to take them with you.

Spots before the Eyes

Most people occasionally notice a few spots before the eyes which disappear quite rapidly when they blink or move their head. In pregnancy fairly large spots occasionally appear in the field of vision. These may disappear quickly, or may persist and be associated with a severe frontal headache when they are usually caused by a sudden rise in blood pressure. If spots before the eyes persist with a frontal headache it should be reported immediately.

Flashes of Light

Women who develop severe pre-eclampsia with a very high blood pressure may notice bright flashes of light before their eyes. Such a symptom usually heralds the onset of eclampsia and is now extremely rare in Great Britain.

Personality Changes

There are many different changes that may occur in a woman’s personality during her pregnancy. Some personality changes together with variations in emotional response are to be expected and anyone who is interested in pregnancy should make some attempt to understand what these involve and try to appreciate their extent and influence on a pregnant woman.