Skin Changes During Pregnancy

• The body undergoes physiologic and anatomical changes influenced by estrogen and progesterone during pregnancy.

Skin, Hair, and Nails

• Striae gravidarum, also known as stretch marks, appear as pinkish-red streaks with slight depressions usually fade to a white or silvery color, but may not completely resolve postpartum on the abdomen, breasts, thighs and buttocks.
• Hormonal influences cause hyperpigmentation:
  • Linea nigra is a dark line extending from the umbilicus to the mons pubis.
  • Chloasma darkens facial skin, known as the "mask of pregnancy".
  • Women taking oral contraceptives may experience chloasma due to medication hormones, even when not pregnant.
• Darkening appears on the areolae and nipples, axillae, umbilicus, and perineum.
• Scars and moles may also darken due to melanocyte-stimulating hormone influence.
• Vascular changes like spider nevi (tiny red angiomas) on the face, neck, chest, arms, and legs stem from elevated estrogen levels.
• Palmar erythema (pinkish color) may be observed on the palms.
• Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a skin disorder in the third trimester, marked by erythematous papules, plaques, and urticarial lesions, starting on the abdomen and spreading to the thighs, buttocks, and arms.
• Acne vulgaris is common.
• Hair and nail growth tends to increase.
• The scalp may become excessively oily or dry, and nails soften and thin around the sixth week of gestation.
• Hirsutism on the face, abdomen, and back may occur during the second and third trimesters.

Ears and Hearing

• Hearing may decrease, fullness in the ears, or earaches may occur due to increased vascularity in the tympanic membrane and blockage of the eustachian tubes.

Mouth, Throat, Nose, and Sinuses

• Gingival bleeding during brushing and hypertrophy are common.
• Epulis, small, irritating gum nodules.
• Edema of the larynx may cause vocal changes.
• Nasal "stuffiness" is common.
• Estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses commonly cause Epistaxis during pregnancy.

Thorax and Lungs

• Progesterone influences relaxation of the ligaments and joints, leading to shortness of breath as the pregnancy progresses. This relaxation allows the rib cage to flare, increasing anteroposterior and transverse diameters, as the enlarging uterus pushes up on the diaphragm. Respiratory pattern changes from abdominal to costal.

Breasts

• Tingling sensations and tenderness are common.
• Breasts and nipples enlarge.
• The areola and nipple become hyperpigmented.
• Montgomery tubercles and superficial veins enlarge.
• Striae develop.
• Colostrum may be expressed in the second and third trimesters.

Heart

• Heart rate may increase by 10 to 15 beats/min, and systolic murmurs may be audible.
• Cardiac output and maternal blood volume increase by 40% to 50%. The heart enlarges and rotates up and to the left approximately 1 to 1.5 cm.

Peripheral Vascular System

• Pseudoanemia: Hematocrit decreases during pregnancy as plasma volume increases by 40-50%, while red blood cell count increases by 18-30%.
• Feeling dizzy and lightheadedness can occur in the second trimester.
• Dependent edema and varicosities are common.
  • Two-thirds of pregnant women experience lower extremity swelling in the third trimester, especially late in the day after prolonged standing, which is caused by pregnancy hormones, increased hydrophilicity of intracellular connective tissue, and increased venous pressure.
  • Varicose veins are common in the lower extremities, vulva, and rectum.
• Thrombophlebitis: Thrombophlebitis causes swelling (inflammation) of a vein due to a blood clot from the hypercoagulable state of pregnancy. Women on bed rest during pregnancy face a high thrombophlebitis risk.

Abdomen

• Abdominal muscles stretch as the uterus enlarges; rectus abdominis muscles may separate, causing diastasis recti abdominis.
• Four paired ligaments (broad, uterosacral, cardinal, and round) support the uterus and keep it in the pelvic cavity.
• Hydronephrosis and hydroureter results from Urinary frequency, a common issue in the first and third trimesters is from pressure on the kidneys and ureters causing flow decrease and urine stagnation.
• Heartburn is a common complaint.
• GERD is experienced by many.
• Ptyalism: Some experience excessive salivation.
• Some experience Pica, craving or ingesting non-nutritional substances.
• Maternal hypoglycemia leads to hypoinsulinemia and increased ketosis rates.
• Maternal hyperglycemia leads to hyperinsulinemia.

Genitalia

• Before conception, the uterus is a small, pear-shaped organ weighing about 44 g, holding about 10 mL of fluid.
• During pregnancy the uterus grows to weigh about 1,000 g, holding approximately 5 L of amniotic fluid, mainly from hypertrophy of preexisting myometrial cells and hyperplasia of new cells.
• McDonald's rule is the measurement of fundal height from the symphysis pubis.
• At 16 weeks' gestation, the fundus reaches halfway between the symphysis pubis and the umbilicus.
• The fundus is at the level of the umbilicus around 20 weeks' gestation. After 20 weeks, the uterus grows about 1 cm/week, and the fundal height should match the number of weeks pregnant.
• In a full-term pregnancy, the fundus should reach the xiphoid process. In the final weeks, the fundal height measurement may drop if the fetal head engages and descends.
• Cervical softening (Goodell sign).
• Bluish discoloration (Chadwick sign).
• Glands in the cervical canal hypertrophy occur.
  • Increased mucus secretion leads to increased vaginal discharge, which is acidic. The mucus collects in the cervix, forming a plug that seals the endocervical canal to prevent bacteria from ascending into the uterus, preventing infection. Vaginal smooth muscle and connective tissue soften and expand to prepare the passage for the fetus through the birth canal.

Anus and Rectum

• Constipation is a common issue; progesterone decreases intestinal motility for nutrient absorption for the mother and fetus, increases water absorption, hardening the stool, and decreasing bowel movements. Iron supplements may exacerbate constipation.
• Hemorrhoids (varicose veins in the rectum) may develop due to venous pressure when straining during bowel movements. Vascular congestion of the pelvis also contributes.

Musculoskeletal System

• Gradual Lordosis: The growing uterus pulls the pelvis forward, curving the spine, and shoe size may increase, especially in width.

Neurologic System

• Most neurologic changes during pregnancy are discomforting
  • Pain or tingling in the thigh: Caused by pressure on the lateral femoral cutaneous nerve.
• Carpal tunnel syndrome:
  • Tinel and Phalen tests help determine it.
• Leg cramps: Usually caused by inadequate calcium intake.
• Dizziness and lightheadedness: Usually occurs in early pregnancy may result from decreased BP due to vasodilation and decreased vascular resistance.
• Supine hypotensive syndrome (SHS): Occurs in women in the second half of pregnancy due to compression of the aorta and inferior vena cava by the gravid uterus, decrease in cardiac output can results in effects ranging from transient asymptomatic hypotension to cardiovascular collapse. Left lateral tilt positioning can easily avoid this.

Health Assessment: Collecting Subjective Data: The Nursing Health History

Biographical Data

• Biographical data included in the health history includes the client's name, birth date, address, and phone number, education level, occupation, and work status enables effective communication. The data the client's significant other with phone number and contact information in case of emergency should be collected.

History of Present Health Concern

• Optimal weight gain during pregnancy depends on your height and weight as a client. You are an underweight client if you gain 28-40 lb during pregnancy; if your weight is normal you should aim to gain 25-35 lb; overweight client, 15-25 lb; obese client 11-20 lb. Low pregnant weight and inadequate weight gain can contribute to intrauterine growth retardation and low birth weight.
• Exposure to cytomegalovirus can cause intrauterine growth retardation, developmental delay, hearing impairment, and mental retardation. Latest research indicates that Zika virus is likely associated with microcephaly in the fetus.
• Increased nasal "stuffiness" and nosebleeds (epistaxis) are common due to estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses.
• Persistent cough and frequent chest infections may indicate pneumonia or tuberculosis.
• If Nausea or vomiting is prolonged, the client may be at risk for hyperemesis gravidarum, cholecystitis, or cholelithiasis.
• Changes in stool appearance and bowel habits may indicate constipation or hemorrhoids.
• Pregnant women may have asymptomatic bacteriuria, therefore if you experience a burning sensation with urination this suggests UTIs diagnosed and treated with antibiotics can predispose the client to complications such as preterm labor, pyelonephritis, and sepsis.
• Vaginal bleeding indicates placenta previa. Leakage of fluid may indicate membrane rupture. Vaginal discharge indicates vaginal infections, so untreated infections predispose the client to preterm labor or fetal infections.
• Loss of interest in eating or sleeping and/or feeling depressed could indicate in psychological disorders. So be aware of these and continually monitor her, if the client has a history of psychological disorders. Make sure to collaborate with a psychologist or psychiatrist if needed, if the client is on medications prescribed for psychological problems, evaluate the medications in light of their possible teratogenic effects on the fetus.
• Breast pain, lumps, or fluid leakage may indicate breast disease. Colostrum secretion, however, is normal so Erythematous, painful breasts may indicate a bacterial infection.
• Supply educational resources for the client, to discuss the advantages of breastfeeding for the client and infant. Be supportive of the feeding method chosen by the client.
• Offering one last opportunity to discuss any other concerns she may have allows any new issues to be discussed.

Personal Health History

• Genetic counseling and testing should be offered if you will be 35 years or older at the time of delivery. Obtain genetic information so you can assess risk of abnormal karyotype or genetic disorders.
• The following information will determine the client's gravida/para status:

  • Gravida is the total number of pregnancies.

  • Para is the number of pregnancies that delivered over 20 weeks

  • Term gestation includes the delivery of pregnancies 38 to 42 weeks

  • Preterm gestation includes the delivery of pregnancies after 20 weeks before the 38 weeks gestation

  • Abortion refers to any termination of pregnancy that is induced or spontaneous

  • Living refers to the number of living children

  • History of previous pregnancies is important to know as it help identify risks for complications during current pregnancy e.g.(preterm labor, gestational diabetes).

  • Knowing the history of neonatal complications will help discover abnormalities and may be hereditary in a future birth.

  • Death of a child in the first year of life may indicate a risk for fetal cardiac disease or other diseases, as assessment is important as assessing fetal risk for birth defects

  • Discuss previous abortions because is history helps to identify women who have had habitual abortions and who may need medical treatment to maintain the pregnancy. medical complications that put the client at risk for habitual abortions include incompetent cervix and systemic lupus erythematosus

  • Previous Molar pregnancies occur in 1 of every 700 to 1,000 pregnancies; with Asian origin; or with late-onset menarche after 12 years of age, light menstruation, or use of oral contraceptive pills.

• Ectopic pregnancy occurs in 1 in every 50, caused by infection, inflammation of fallopian tubes or scar tissue from previous infection, abnormal formation in the fallopian tube.
  • Menstrual history is important to determine the expected date of confinement
• IUDs in place at the time of conception place the client at risk for an ectopic pregnancy. Birth control pills should be discontinued when pregnancy is confirmed.
• Inability to conceive after trying for more than 1 year may signal reproductive complications such as infertility.
• Reproductive surgery and instrumentation to the cervix place the client at risk for complications during pregnancy. Conization of the cervix places the client at risk for an incompetent cervix during pregnancy.