Attenuation of anterior vaginal wall suppOrt can lead to prolapse of the bladder, that is, a cystocele. Urinary stasis with a cystocele predisposes to infection. Pregnancy may also worsen coexistent stress urinary incontinmce (SUi), likely because urerhral closing pressures do nor risc suiciently to compensate for altered bladder neck support. Urinary incontinence afects nearly 20 percent of women during the first trimester and nearly 40 percent during the third trimester. Most cases stem from SUI rather than urgency urinary incontinence (Abdullah, 2016a; Franco, 2014; Iosif, 1980). In primigravidas, maternal age greater than 30 years, obesity, smoking, constipation, and gestational diabetes mellitus are all risk factors associated with SUI development during pregnancy (Sangsawang, 2014).
Attenuation of posterior vaginal wall support can result in a rectocele. A large defect may fill with feces that occasionally can be evacuated only digitally. During labor, a cystocele or rectocele can block fetal descent unless they are emptied and pushed out of the way. Rarely, an enterocele of considerable size may bulge into the vagina. If the mass interferes with delivery, the hernia sac and its abdominal contents are gently reduced to permit fetal descent.
In early pregnancy, women often experience breast tenderness and paresthesias. Mter the second month, the breasts grow in size, and delicate veins are visible just beneath the skin. he nipples become considerably larger, more deeply pigmented, and more erectile. Mter the first few months, a thick, yellowish luid-colosrum-can often be expressed from the nipples by gentle massage. During the same months, the areolae become broader and more deeply pigmented. Scattered through each areola are several small elevations, the glands of Montgomey, which are hypertrophic sebaceous glands. If breasts gain extensive size, skin striae similar to those observed in the abdomen may develop. Rarely, breasts can become pathologically enlarged-referred to as gigantomastia-which may require postpartum surgical reduction (Fig. 4-2) (Eler Dos Reis, 2014; Rezai,i2015).
For most normal pregnancies, prepregnancy breast size and ultimate volume of breast milk do not correlate, as multiple factors influence milk production (Hartmann, 2007). These
FIGURE 4-2 Gigantomastia in a woman near term. (Used with permission from Dr. Patricia Santiago-Munoz.) factors and gestation breast changes are further discussed in Chapter 36 (p. 656).
Skin changes are common, and Fernandes and Amaral (2015) described dermatological changes in more than 900 pregnant women. They found at least one physiological cutaneous change in 89 percent of the women examined. Dermatologic pathologies during pregnancy are found in Chapter 62.
Beginning after midpregnancy, reddish, slightly depressed streaks commonly develop in the abdominal skin and some times in the skin over the breasts and thighs. These are called striae gravidarum or stretch marks. In multiparas, glistening, silvery lines that represent the cicatrices of previous striae fre quently coexist. In one study of 800 primiparas, 70 percent their breasts; and 41 percent on their hips and thighs (Picard, 2015). The strongest associated risk factors included younger maternal age, family history, and prepregnancy weight and weight gain during pregnancy. The etiology of striae gravi darum is unknown, and there are no preventive steps or defini tive treatments (Korgavkar, 2015).