Presentation on theme: "Maternal Changes with Pregnancy. Pregnancy is a period of adaptation for: The needs of the fetusThe needs of the fetus Meeting the stress of pregnancy."— Presentation transcript:
↑ from 50 gm in non-pregnant state to 1000 gm at term 2 - Weight
pyriform – non pregnant state globular - 8th week pyriform - 16th week till term 3 - Shape
with ascent from the pelvis, the uterus usually undergoes rotation, with a tilt to the right (dextrorotation) due to presence of the recto- sigmoid colon on the left side. 4 - Position
5 - Consistency: Becomes progressively softer due to: i - ↑ vascularity i - ↑ vascularity ii - Presence of amniotic fluid ii - Presence of amniotic fluid
From the 1 st trimester onward, the uterus undergoes irregular painless contractions (Braxton Hicks contractions). They may cause some discomfort late in pregnancy & may a/c for false labor pain. 6 - Contractility
7- Capacity ↑ from 4 ml in non-pregnant state to 4000 ml at term
(B) Myometrial changes 1 - Hypertrophy (estrogen effect) rather than hyperplasia (progesterone effect) till 14 th week, then the fetus exerts a direct stretch 2 - Formation of the (L.U.S.) lower uterine segment from the isthmus and lower half inch of the body of uterus
Formation of lower uterine segment After 12 wks, the isthmus (0.5cm) starts to expand gradually to form the lower uterine segment, which measures 10 cm in length at term
Upper Uterine Segment Peritoneum: Firmly-attachedPeritoneum: Firmly-attached Myometrium: 3 layers:Myometrium: 3 layers: outer longitudinal, middle oblique & inner circular The middle layer forms 8-shaped fibers around blood vessels to control postpartum hemorrhage (living ligatures)The middle layer forms 8-shaped fibers around blood vessels to control postpartum hemorrhage (living ligatures)
Upper Uterine Segment Decidua: Well-developedDecidua: Well-developed Membranes: Firmly-attachedMembranes: Firmly-attached Activity: Active, contracts, retracts and becomes thicker during labor.Activity: Active, contracts, retracts and becomes thicker during labor.
The junction b/w/ the upper uterine segment (U.U.S.) (thick) & the lower uterine segment (thin) is called the physiologic contraction ring at the level of the symphysis pubis (not seen/ felt)
1 - Uterine artery lumen: is doubled & its blood flow ↑ 5x 2 - Myometrial & decidual arteries (spiral arteries) undergo fibrinoid degeneration due to 2 waves of trophoblastic migration & become dilated to form the uteroplacental arteries (C) Uterine blood vessels Uterine blood flow ↑’s progressively & reaches about 500 ml / min at termUterine blood flow ↑’s progressively & reaches about 500 ml / min at term
(D) Changes in the cervix 1 - becomes hypertrophied, soft & bluish in color due to edema & ↑ vascularity. 2 - Soon after conception, a thick cervical secretion obstructs the cervical canal forming a mucous plug. 3 - The endocervical epithelium proliferates and/ or gets everted forming cervical ectopy (previously called erosion)
(E) Changes in fallopian tubes & ligaments (round & broad). Inactive, elongated, marked ↑ in vascularity.. There may be broad ligament varicose veins.
(F) Changes in the vagina The vagina becomes soft, warm, moist with ↑ secretion and violet in color (Chadwick's sign) due to ↑ vascularity
(G) Changes in the vulva It becomes soft, violet in colour Edema & varicosities may develop
(H) Changes in the ovaries 1 - Both ovaries are enlarged due to ↑ vascularity & oedema, particularly the ovary which contains the corpus luteum. 2 - Ovulation ceases during pregnancy due to pituitary inhibition by the ↑ levels of estrogen & progesterone
(H) Changes in the ovaries 3 - Corpus luteum continues to grow till 7 - 8 wks, then it stops growing. It becomes inactive & starts degeneration at 12 wks (degeneration is completed after labor)
Corpus luteum secretes 1.estrogen 1.estrogen2.progesterone 3.relaxin 3.relaxin
Relaxin is a protein hormone.Relaxin is a protein hormone. Its exact role in pregnancy is unknown.Its exact role in pregnancy is unknown. It may induce softness & effacement of the cervix.It may induce softness & effacement of the cervix.
(A) Blood volume The total blood volume ↑ ’s steadily from early pregnancy to reach a maximum of 35-45 % above the non-pregnant level at 32 wks
Plasma volume ↑ ’s from 2600 ml by ± 45 % (1250 in the 1st pregnancy & 1500 ml in subsequent pregnancies)
Red blood cell mass ↑’s from 1400 ml (non pregnant) by 33 % (± 450 ml)↑’s from 1400 ml (non pregnant) by 33 % (± 450 ml) due to ↑ production resulting from erythropoeitin or action of hCG / HPL The ↑ is steady till full term.The ↑ is steady till full term.
The ↑ in plasma volume is > ↑ in red blood cell mass (Hb mass) resulting in haemodilution (physiologic anemia) (physiologic anemia) However, the minimal Hb. accepted is 10-11 gm%
Value of ↑ blood volume 1 - Meets ↑ demands for uterus, baby, etc. 2 - Protects against supine hypotension syndrome. 3 - Protects against fluid loss in labor.
↑ in the blood volume > the ↑ in red cell mass -- leads to: ↓ blood viscosity which ↓ in peripheral resistance leads to: ↓ blood viscosity which ↓ in peripheral resistance
1 - ↓ Hb% & RBC%: Erythrocytes ↓ from 4.5 million/ cb.mm to 3.7 million / cb.mmErythrocytes ↓ from 4.5 million/ cb.mm to 3.7 million / cb.mm (due to the relative ↑ in plasma volume > red cell mass) Erythrocyte contents: 2, 3 - DPG ↑ ’s which competes for 0 2 binding sites in the Hb molecule, thus releasing more 0 2 to the fetus.
2 - M.C.H.C: no change 3 - M.C.V: , or no change (depending on the availability of Fe). 4 - Fragility of R.B.Cs: 5 - Reticulocytes: mild 6 - E.S.R: from 12 to 50 mm / hr 7 – Fibrinogen: from 200 - 400 mg / dl to 400 - 600 mg / dl
8 - White blood cells: 8 - White blood cells: (from 7,000 / mm3 to 10,500/ mm3 during pregnancy & up to 16,000/ mm3 during labor) - Lymphocytes: no change. 9 - 9 - Platelets: or 10-Total plasma proteins slightly (mainly albumin) resulting in osmotic pressure.
Platelets or (controversial) Fibrinogen doubled to 600 mg% Fibrinogen doubled to 600 mg% Factor VIII tripled Factor VIII tripled Factor VII & factor X are doubled Factor VII & factor X are doubled Factor XI & factor XIII slight Factor XI & factor XIII slight Fibrinolytic activity Fibrinolytic activity (C) Coagulation system
Therefore pregnancy is a hyper-coagulative state.Therefore pregnancy is a hyper-coagulative state. All these changes are reversed after labor with RBC production (not destruction) & the excess Fe is stored.All these changes are reversed after labor with RBC production (not destruction) & the excess Fe is stored.
As the diaphragm is elevated progressively during pregnancy the apex is displaced upwards & to the left so that it lies in the 4th intercostal space outside the midclavicular line. Position:
Pulse rate -The resting pulse rate ↑ by 8 beats/ min (8 wks) & 16 beats / min (full term). -Some episodes of ectopic beats - Water hammer pulse.
Heart sounds The 1 st heart sound becomes louder before mid pregnancy & splitting of this sound may occur due to earlier closer of the mitral valve than the tricuspid valveThe 1 st heart sound becomes louder before mid pregnancy & splitting of this sound may occur due to earlier closer of the mitral valve than the tricuspid valve The intensity of the second heart sound may ↑The intensity of the second heart sound may ↑ The 3 rd sound becomes louder before mid- pregnancy & persists as such till 1 wk post partum.The 3 rd sound becomes louder before mid- pregnancy & persists as such till 1 wk post partum. The 4 th sound may be detectable by phonocardiography.The 4 th sound may be detectable by phonocardiography.
Murmurs Systolic functional murmurs develop in most of women, usually early systolic, but mid systolic murmurs may occur and heard over the left sternal edge, they are thought to be due to functional tricuspid regurgitation
ECG CHANGES The main features of ECG may be attributed to the changes in the position of the heart.The main features of ECG may be attributed to the changes in the position of the heart. The axis undergoes left shift by 15 - 28°.The axis undergoes left shift by 15 - 28°. The QRS complexes become of low voltage, and T waves become flattened.The QRS complexes become of low voltage, and T waves become flattened.
Cardiac output: ↑’ s mainly by ↑ stroke volume rather than ↑ heart rate reaching a maximum of 40% above the non-pregnant level at 20 weeks to be maintained till term. Distribution: 400 ml - the uterus, 400 ml - the uterus, 300 ml - the kidneys, 300 ml - the kidneys, 300 ml - skin 300 ml - skin 300 ml - GIT, breast & heart 300 ml - GIT, breast & heart
Importance: Distributes extra 0 2 During labor : C.O. ↑’ s more particularly during the 2nd stage due to pain, uterine contractions, and expulsive efforts pushing the blood into the general circulation Postpartum: the ↑ ’d C.O. is maintained for up to 4 days & then declines rapidly
2 - Arterial blood pressure Although C.O. ↑ ’s, yet A.B.P. is ↓ ’ d in mid-trimester to ↑ again in 3rd trimester
This is due to: - ↓ Peripheral resistance : i - ↓ Peripheral resistance : (mainly affects diastolic B.P.) due to: vasodilatation + increase metabolism + arteriovenous shunt at placenta
ii - Supine hypotension : may develop in some women in late pregnancy while lying supine due to compression on the I.V.C. by the large pregnant uterus, resulting in venous return C.O. and low B.P. to the extent that fainting may occur
iii - ↓ sensitivity of blood vessels to angiotensin II (which is a vasoconstrictor)
The posture of the pregnant woman affects arterial blood pressure.The posture of the pregnant woman affects arterial blood pressure. Typically, it is highest when she is sitting, lowest when lying in the lateral recumbent position and intermediate when supine.Typically, it is highest when she is sitting, lowest when lying in the lateral recumbent position and intermediate when supine.
↑ ’d venous pressure in the lower limbs due to: 1.Back pressure from the compressed I.V.C. by the pregnant uterus. 2. Mechanical pressure of the uterus on pelvic veins. 3. ↑ ’d venous return from internal iliac veins → ↑ pressure in external iliac veins
↑ ’d venous pressure in the lower limbs Predisposes to Oedema, varicose veins varicose veins & piles
Oedema and varicose veins in the lower limbs & vulva are due to: i - Venous pressure. ii - Relaxation of the smooth muscles in the wall of the veins by progesterone iii - Osmotic pressure in blood. iv - Capillary permeability (due to progesterone and aldosterone). v - Interstitial pressure (Na retention).
Varicose Veins treatment 1. avoid long periods of standing and encourage active exercise. 2. avoid constricting clothes. 3. keep the legs elevated while sitting and during sleep.
4. use of elastic stockings. These should be removed at night and applied with leg elevated before getting out of bed in the morning (empty veins). 5. stretch panties may be necessary for vulval varicosities.
(A) Anatomically The enlarged uterus displaces the diaphragm up to ± 4 cm.
This results in: 1.The diaphragmatic mobility is ↓ and respiration becomes mainly thoracic. 2. Widen the sub-costal angle and ↑ the transverse diameter of the chest.
Respiratory functions The respiratory rate does not ↑ during pregnancy from its normal rate of 14 - 15/ min
Over-breathing (deep respiration) occurs due to the effect of excess progesterone
Shortness of breath (the need to breath becomes a conscious one) dyspnea is a common complaint of the pregnant women which may be due to unfamiliarity with low C0 2 tension in the alveolar capillaries.
The vital capacity 1. The inspiratory capacity (Tidal volume + inspiratory volume) is ↓ in late pregnancy 2. The expiratory reserve volume (maximum amount of air which can be expired after normal expiration) is ↓ 3. The residual volume is ↓
The reduction in: 1.The inspiratory capacity 2.The expiratory reserve volume 3.The residual volume is not significant. is not significant.
4.The tidal volume: (amount of gas inspired or expired in each respiration) rises throughout pregnancy by about 40 %
Hyperventilation is due to increased tidal volume not respiratory rate
(A) Kidney and kidney function tests Renal blood flow and glomerular filtration rate increases by 50 %. This leads to ↑ excretion
Therefore: 1.There is serum creatinine (due to creatinine clearance), the same for uric acid. 2. blood urea. 3. kidney excretion of glucose due to filtration load and renal threshold leading to renal glucosuria
Therefore, in interpreting the results of RFT one should take into consideration that the highest normal value in pregnancy = the lowest normal value in the non-pregnant state
(B) Ureter Dilatation of the ureter and renal pelvis due to: i - Relaxation of the ureter by the effect of progesterone. ii - Pressure against the pelvic brim by the uterus, particularly on the right side, due to dextro-posed uterus and dilatation of the right ovarian vessels
(C) Bladder and urethra Frequency of micturition in early pregnancy due to: i - Pressure on the bladder by the enlarged uterus. i - Pressure on the bladder by the enlarged uterus. ii - Congestion of the bladder mucosa ii - Congestion of the bladder mucosa
Urinary stress incontinence may develop for the first time during pregnancy (due to ↓ intra-urethral pressure and ↓ length of the urethra) and spontaneously relieved later on
1 - Gingivitis: There is ↑ vascularity and tendency for bleeding as well as hypertrophy of the interdental papillae
The gums may become hyperemic and soft and may bleed when mildly traumatized, as with a tooth brush.The gums may become hyperemic and soft and may bleed when mildly traumatized, as with a tooth brush. Epulis of pregnancy may develop.Epulis of pregnancy may develop. Treated by dental hygiene and cryosurgery for severe cases Treated by dental hygiene and cryosurgery for severe cases.
2 - Ptyalism: It is excessive salivation which is more common in association with oral sepsis.It is excessive salivation which is more common in association with oral sepsis. It is due to failure to swallow saliva (not due to increase in amount).It is due to failure to swallow saliva (not due to increase in amount). Smoking is stopped; anticholinergic drugs may help.Smoking is stopped; anticholinergic drugs may help.
3 - Nausea and vomiting Nausea (morning sickness) and vomiting (emesis gravidarum) occur in early months
The pregnant woman dislikes some food and odour while desires others.The pregnant woman dislikes some food and odour while desires others. ↓ sensitivity of the taste buds during pregnancy creates the desire for markedly sweet, sour, or salty foods.↓ sensitivity of the taste buds during pregnancy creates the desire for markedly sweet, sour, or salty foods.
(pica) Deviation may be so extreme to the extent of eating blackboard chalk, coal or mud.
This is probably due to: i - ↓ gastric acidity caused by regurgitation of alkaline secretion from the intestine to the stomach. ii - ↓ gastric motility (progesterone effect).
6 - Heart burn Due to reflux of acidic gastric contents to the oesophagus
The treatment includes: (a)small frequent meals to prevent overdistension of the stomach. The evening meal should be taken at least 3 hours before going to bed.
(b) avoid fatty foods, chocolate, and smoking, as these relax the lower esophageal sphincter. (c) the bed should be raised at the head end (15-20 cm), and an extra pillow is used.
(d) Antacid Preparations containing aluminium hydroxide are favoured.
7 - Constipation due to: i - Reduced motility of large intestine (progesterone effect) ii - Increased water reabsorption from large intestine (aldosterone effect)
7 - Constipation iii - Pressure on the pelvic colon by the pregnant uterus. iv - Sedentary life during pregnancy.
It is treated by (a)evacuation of the bowel at the same time each day (bowel training) (b) diet rich in fiber in the form of vegetables, fruits, and bran (c) milk. Also, avoid dehydration by increasing fluid intake.
(d) minimize coffee and tea as they are diuretics and cause dehydration. (e) ↑ physical activity and avoid sedentary life. (f) a mild laxative may be needed. Liquid paraffin is better avoided as it prevents absorption of fat soluble vitamins.
In some women iron supplementation may be the cause
8 - Gall stones More tendency to stone formation due to atony and delayed emptying of the gall bladder
9 - Haemorroids due to: i - Mechanical pressure on the pelvic veins. ii - Laxity of the walls of the veins by progesterone iii - Constipation.
10 - Appendix Is displaced upwards and laterally (pain and tenderness due to appendicitis is higher than in non pregnant state)
Liver ↓ albumin and ↑globulin resulting in ↓ A/G ratio i - ↓ albumin and ↑globulin resulting in ↓ A/G ratio ii - ↑ heat labile serum alkaline phosphatase. Therefore both A/G ratio and heat labile alkaline phosphatase are not reliable as liver function tests during pregnancy
(A) Weight gain The average weight gain in pregnancy is 10 - 12 kg
The increase occurs mainly in the second and third trimester at a rate of 350 - 400 gm/ wk
Out of the 11 kg weight gain 6 kg is composed of maternal tissues (breast, fat, blood and uterine tissues) & 5 kg of fetal tissue, placenta and amniotic fluid Out of the 11 kg weight gain 7 kg are water 7 kg are water 3 kg fat 3 kg fat 1 kg protein 1 kg protein
Maternal Tissues Maternal Tissues Increases during weeks of Pregnancy King JC. Am J Clin Nutr 71 (5(S));2000.
Products of Conception Increases during weeks of Pregnancy King JC. Am J Clin Nutr 71 (5(S));2000.
B) Water metabolism )B) Water metabolism There is tendency to water retention secondary to sodium retention
(C) Protein metabolism There is tendency for nitrogen retention (+ ve nitrogen balance) for fetal and maternal tissue formation
(D) Carbohydrate metabolism Pregnancy is potentially diabetogenic Pregnancy is potentially diabetogenic -Alimentary glucosuria may occur in early pregnancy. - Renal glucosuria may occur in the middle of pregnancy.
(E) Fat metabolism There is increase of plasma lipids with tendency to acidosis (HPL action)
(F) Mineral metabolism There is increased demand for iron, calcium, phosphate and magnesium
(a)Increased mobility of pelvic joints due to softening of the joints and ligaments caused by progesterone and relaxin (b)Flattening of feets. ( c) Progressive lordosis leading to lordotic gait & backache ( by high heals). (d) Pendulous abdomen in multigravida
Majority of pregnant women complain of low backache which increases as pregnancy advances.Majority of pregnant women complain of low backache which increases as pregnancy advances. It is due to increased lumbar lordosis to counter-balance the forward growth of the uterusIt is due to increased lumbar lordosis to counter-balance the forward growth of the uterus
This puts strain on ligaments and muscles leading to pain. Strain of sacroiliac joint is relatively common. Progesterone causes softening and relaxation of ligaments.
Backache is treated by: (a) more periods of rest. (b) use of maternity corset. (c) local heat in the form of hot water bag or infrared lamp local creams. Paracetamol is the drug of choice, Non-steroidal anti-inflammatory drugs as indomethacin may be given. (d) analgesics given systemically or as local creams. Paracetamol is the drug of choice, Non-steroidal anti-inflammatory drugs as indomethacin may be given. (e) physiotherapy may be needed.
Orthopaedic consultation is indicated if pain is severe, or radiates to the legs, and in the presence of neurological signs
Leg cramps These are common in the second half of pregnancy particularly at night.These are common in the second half of pregnancy particularly at night. The exact cause is unknown.The exact cause is unknown.
It may be related to shift of blood away from the muscle, i.e., ischaemic cramp, or it may be tetanic cramp caused by lack of calcium, or increased phosphorous, or both
Treated by taking Ca tablets, and reducing the intake of phosphorous-containing substances as milk, meat, and cheese.Treated by taking Ca tablets, and reducing the intake of phosphorous-containing substances as milk, meat, and cheese. Vitamin B complex may be tried.Vitamin B complex may be tried. Leg massage and hyperextension of foot help during the attackLeg massage and hyperextension of foot help during the attack.
Round ligament strain Pain is felt along the round ligament and in the groin.Pain is felt along the round ligament and in the groin. Pain unilateral and left-sided, (dextroflexion).Pain unilateral and left-sided, (dextroflexion). It is due to stretching of the nerve fibres in the round ligaments. It is due to stretching of the nerve fibres in the round ligaments.
i - ↑ in size > ↑ in vascularity. This renders the anterior pituitary liable for ischaemia ii - Pregnancy cell (modified chromophobe) appears due to ↑ hCG. iii - Prolactin level ↑ up to 150 ng/ml at term to ensure lactation.
2 - Posterior pituitary Does not hypertrophy, but ↑ its oxytocin secretion near term
3 - Thyroid gland There is diffuse slight enlargement of the gland
Gland activity is as evidenced by: normal free T4 (although total T4 ) due to: thyroid binding globulin (TBG), BMR 20 %, total T3, protein bound iodine TSH
4 - Parathyroid gland Hypertrophy due to ↑ demand for Calcium
Persistence of basal body temperature (BBT) elevation beyond the expected day of menstruation (due to ↑ progesterone). 1 - Persistence of basal body temperature (BBT) elevation beyond the expected day of menstruation (due to ↑ progesterone). Spider telangiectasis & palmar erythema 2 - Spider telangiectasis & palmar erythema due to ↑estrogen or cutaneous vasodilatation
3 - Cutaneous vasodilatation (hyperemia) leads to: i - Masks pallor due to anaemia with or without palmar erythema. ii - Glandular activities (sweat & sebaceous glands). iii - Sensation of heat and nasal congestion
4 - Pigmentation due to ↑ estrogen or melanocyte stimulating hormone orACTH
In the face: chloasma gravidarum = mask of pregnancy a butterfly pigmentation on the cheeks and nose. It usually disappears few months after labor.
In abdomen: Linea Nigra = pigmentation in midline below the umbilicus Linea Nigra = pigmentation in midline below the umbilicus
Stria gravidarum pigmentation in the lower abdomen, flanks, inner thighs, buttocks & breast and ↑ as pregnancy advances
It starts reddish (stria rubra), then becomes pale to become white (stria albicans) after delivery, which persists (primigravida has stria rubra only, while multigravida has both S.R and S.A) (primigravida has stria rubra only, while multigravida has both S.R and S.A)
Diagnostic in primigravida and may persist after delivery.Diagnostic in primigravida and may persist after delivery. In multigravida it may be due to the previous pregnancies. In multigravida it may be due to the previous pregnancies. They may occur with any hyper- estrogen, so they are not diagnostic for pregnancyThey may occur with any hyper- estrogen, so they are not diagnostic for pregnancy
i - First month: ↑ size & vascularity (dilated veins), mastodynia may be present which ranges from tingling to frank pain due to hormonal responses of the mammary ducts and alveolar system ii - Second month: ↑ pigmentation of the nipple & areola and prominence of Montgomery tubercles (non pigmented nodules around the primary areola (12 - 20)
Montgomery tubercles They were thought to be enlarged sebaceous glands, but recently they are found to be the lips of orifices of peripheral active lacteal ducts
iii - Third month: secretion of colostrum (thick yellowish fluid) which can be expressed from the nipple secretion of colostrum (thick yellowish fluid) which can be expressed from the nipple iv - Fourth month: a pigmented area appears around the primary areola called the secondary areola a pigmented area appears around the primary areola called the secondary areola
Lower limbs signs i - Edema: bilateral and pitting ii - Varicose veins i - Edema: bilateral and pitting ii - Varicose veins
XII. Neurologic System Sensory changes from compression of nervesSensory changes from compression of nerves Tension headachesTension headaches Carpal tunnel syndrome due to edemaCarpal tunnel syndrome due to edema Numbness and tingling related to postural changesNumbness and tingling related to postural changes
1. Headache It is relatively common, and attributed to intracranial vasodilatation caused by oestrogen and progesterone
1. Headache It is most troublesome in the second trimester, but may persist throughout pregnancy.It is most troublesome in the second trimester, but may persist throughout pregnancy. However, headache may be due to lack of sleep, or overwork. However, headache may be due to lack of sleep, or overwork. An analgesic is prescribed An analgesic is prescribed.
2. Fainting It results from lowering of blood pressure due to vasodilatation which occur in pregnancy
3. Insomnia During pregnancy some women are sleepy and depressed, others may be irritable and suffer insomnia
4. Carpal tunnel syndrome Caused by compression of the median nerve as it passes through its fibrous tunnel at the wrist, as a result of fluid retention and edema in pregnancy There is tingling, numbness and burning sensation affecting the radial side of the hand
Treatment: reassurancereassurance wrist splintwrist splint DiureticsDiuretics NSAIDSNSAIDS local injection of hydrocortisone in the tunnel below the fibrous roof (retinaculum)local injection of hydrocortisone in the tunnel below the fibrous roof (retinaculum) Operation is rarely needed during pregnancy (incising the retinaculum to relieve compression)
Other compression neuropathies affect: the lateral cutaneous nerve of the thigh obturator nerve peroneal nerves
LEUCORRHOEA The normal vaginal discharge ↑ during pregnancy because of excess oestrogen and may form a complaint However, a pathological discharge, e.g., monilial infection which is common in pregnancy, must be excluded.