SINGAPORE – When she became pregnant in her mid-30s, former nurse Ellie was prepared for morning sickness. But she was not ready for swollen feet and pimples during her first trimester.

“I didn’t have a problem with acne my entire life and then, suddenly, during the pregnancy, I got a lot of pimples,” says the 36-year-old housewife, who wanted to be known only by her nickname.

Her feet swelled early in pregnancy, which meant she could no longer wear size 39 shoes and had to buy size 41.

“I thought my feet looked like pig’s legs – they were so big and chunky. I couldn’t deal. I was really struggling with all the body changes,” says Ms Ellie, whose first child, a daughter, was born in August 2022.

Her feet have since gone back to their pre-pregnancy size.

Acne, going up in shoe size and even developing carpal tunnel syndrome are some of the lesser-known side effects of pregnancy that women might experience.

Expectant mums may struggle with these and other physical changes, say gynaecologists and other specialists who spoke to The Straits Times.

They may also feel pressure to look good during pregnancy and return to the pre-pregnancy state after childbirth, thanks to unrealistic expectations set by celebrities and social media influencers.

Experts break down the changes women may experience during pregnancy and after childbirth, and how to deal with some of these physical and emotional conditions.

Pimples or pregnancy glow?

Many women do indeed have a “glow” about them during pregnancy.

Dr Sarah Li, a consultant at the National University Hospital’s (NUH) division of maternal fetal medicine at the department of obstetrics and gynaecology, says that higher hormone levels in the body during pregnancy cause extra blood flow to the skin. “As a result, most women find that their skin looks healthier with a ‘glow’,” she says.

However, a number of women might find themselves developing skin conditions as a result of hormonal and immunological changes to their bodies.

Dr Coni Liu, founding dermatologist of private clinic DermAlly Specialist Skin Clinic & Surgery, sees pregnant women with itchy rashes that may or may not be benign.

The most common type of itchy rash is atopic eruption of pregnancy or AEP, which can account for 50 per cent of cases in a pregnancy clinic, she says.

Another type, polymorphic eruption of pregnancy or PEP, occurs in one out of every 160 pregnancies worldwide and manifests as itchy rashes over the stomach, breasts, arms and legs. It usually spares the face and is seen in first pregnancies during the third trimester.

AEP and PEP are benign conditions that resolve after childbirth, says Dr Liu.

Two rarer rashes – pemphigoid gestationis and intrahepatic cholestasis of pregnancy – require careful monitoring, however, as these can affect the baby, she says.

Pemphigoid gestationis shows up around the navel as itchy red patches with blisters and can also appear on the baby in up to 10 per cent of cases. It is treated with oral corticosteroids. Some studies have also observed that the condition is associated with premature delivery and low birth weight.

Intrahepatic cholestasis of pregnancy occurs in the third trimester, and the skin may sometimes be yellow. It is associated with high bile acid levels in the blood and can mean that the baby’s health will also be affected.

“Early diagnosis, prompt treatment and close monitoring are important,” says Dr Liu.

Stretch marks and carpal tunnel syndrome

All the body’s organs swell during pregnancy, according to Dr Christopher Chong, an obstetrician, gynaecologist and urogynaecologist at Gleneagles Hospital.

As the womb swells, deep blood vessels may be compressed, causing blood to flow to superficial veins that lie nearer the skin. This can cause varicose veins in the limbs and haemorrhoids in the anal region.

Water retention is common and nerves in the wrist may be compressed as a result, causing carpal tunnel syndrome, he adds.

The body gains fat during pregnancy, notably around the gluteal area and the upper arms. The breasts enlarge and the areolae darken.

A darkened line known as linea nigra develops from the belly button to the pubic area. The skin tears as the womb swells, leading to stretch marks.

Nine out of 10 women develop stretch marks, notes Dr Li, and these marks on the abdomen, thighs, hips and upper arms can be itchy. “Most skin changes that occur during pregnancy will gradually improve or go away after birth,” she adds.

Bigger shoes and floppy tummy

Some changes, however, last longer.

It is common to have swollen feet because of water retention during pregnancy. However, some women should be prepared for a permanent change in shoe size.

Dr Partana Pamela Sandriany, an associate consultant at Singapore General Hospital’s department of obstetrics and gynaecology, says this is because the arch of the foot falls, elongating the foot.

“To prepare for this change, expecting mothers should be aware that their feet might permanently elongate. Investing in shoes with excellent arch support and being open to sizing up can help ensure ongoing comfort,” she says.

She adds that pregnancy and childbirth can weaken the abdominal muscles and lead to a condition known as rectus diastasis, which is a separation of the abdominal wall muscles.

“This separation typically closes on its own within weeks of birth. However, if it doesn’t, it can result in a softer and floppier-looking tummy.

“Incorporating core-strengthening exercises in post-pregnancy workouts, with a focus on torso muscles, can help bring the abdominal muscles back together,” she says.

Headaches and hair loss

Hormonal changes may cause mild headaches in the first few months of pregnancy, but can later be a sign of more serious health issues. PHOTO: ISTOCKPHOTO

Dr Li says that hormonal changes mean that women commonly experience mild headaches in the early months of pregnancy.

Those who already suffer from migraines might find no change or experience some relief. Others find their headaches worsen.

Headaches can signal other underlying health issues such as poor sleep, stress, dehydration, low blood sugar or eye strain. “A headache after 20 weeks can be a sign of pre-eclampsia (a high blood pressure disorder), which is a serious pregnancy condition that needs urgent medical attention,” she says.

Changes in oestrogen levels after pregnancy commonly cause hair loss, according to Dr Li. The hair falls out more than normal until around four months after birth.

Hormonal changes can also lead to diminishing sex drive in pregnant women, though some experience an upsurge in libido, according to Dr Chong.

After childbirth, breastfeeding induces a hormonal state similar to menopause, which also reduces the sex drive, he adds.

Pregnancy and childbirth also cause stretching of the pelvic floor and loss of vaginal muscle tone. The first can lead to incontinence and the latter to reduced pleasure during intercourse.

Dr Pamela says: “Mothers can prepare by engaging in pelvic floor muscle therapy. This helps strengthen the pelvic floor muscles, facilitating quicker recovery of bladder control. Some women may also benefit from a physiotherapy review to guide them along.”

Focus on health, not appearance

Dr Cornelia Chee, head and senior consultant at NUH’s department of psychological medicine, says women often face pressure to return to the pre-pregnancy body, including from social media celebrities who are apparently able to do so.

However, this is an unrealistic expectation, she says. “There are usually permanent changes to one’s body after childbirth, such as having a higher waist-to-hip ratio or looser belly skin.”

She adds: “I think if women could be guided by health rather than just appearances, it would be much better for their mental health too. Losing weight to within a healthy body mass index (BMI), strengthening one’s pelvic floor muscles again, eating a balanced diet, and catching sleep whenever one can would benefit a woman holistically.”

Her department offers the specialised Women’s Emotional Health Service, which provides personalised care for women in emotional distress, including during pregnancy and the first postnatal year.

It can be helpful to reframe the physical changes to one’s body, Dr Chee says. “One patient told me that she viewed her stretch marks as the equivalent of ‘battle scars’ – a mark of honour even. Another used humour and wryly remarked that her enlarged feet were ‘yet another perk of mummyhood’.”

Do not forget about mental health

Ms Ellie has battled the eating disorder anorexia, and depression, for many years, which made it harder for her to cope with the weight gain and physical changes her body went through while she was pregnant.

She credits her current health and that of her daughter to the interventions of her doctors at SGH. A psychiatric team looked after her during pregnancy, and she saw a psychologist and dietitian alongside the gynaecologist.

Dr Pamela of SGH says that the hospital routinely screens patients for antenatal and postnatal depression.

The team asks about the patient’s emotional well-being at each antenatal visit, as well as after childbirth – before her discharge from the hospital and at the sixth-week postnatal check.

A specialised psychiatric clinic, the perinatal mental health clinic, serves patients at the Obstetrics and Gynaecology Centre.

Ms Ellie currently has a BMI of 21, which is considered healthy, and breastfeeds.

She says: “Society usually portrays images of happy, healthy women who have the time of their lives during pregnancy. Sometimes, the reality is very different.

“Not everyone will enjoy pregnancy because of how it affects the body and makes them feel. There’s no point comparing yourself with others. Everyone is different.”