This is actually physiological amenorrhoea. It lasts throughout pregnancy. It is due to high levels of oestrogen, progesterone and human chorionic gonadotrophin. There is continued build up of the endometrium to support the developing pregnancy. This build up also averts menses.

2) Breast Tenderness and/or Tingling

This usually occurs during the first trimester of pregnancy. The hormones of pregnancy stimulates the growth of the breast tissue. Women may also experience upper backache from the increased weight of the breasts.During pregnancy there is also increased blood flow throughout the breasts and delicate veins become visible beneath the skin.

3)Weight Loss

This may occur in the first trimester of pregnancy if the woman experiences morning sickness (nausea and vomiting). She may not be eating normally in early pregnancy due to the nausea and vomiting.

4) Nausea with or without vomiting

This is common in the first trimester. This is probably due to hormonal changes of pregnancy leading to slowed peristalsis throughout the gastrointestinal tract and changes in taste and smell. The growing uterus and emotional factors may also contribute to the nausea and vomiting. Women may have a moderate (2-5 lb) weight loss in the first trimester.

5) Groin/Lower Abdominal Pain

This is common in the 2nd trimester (14-20 weeks). This is due to rapid uterine growth in the early part of the second trimester which causes tension and stretching of the round ligaments. This causes spasm with sudden movement or change of position.

6) Increased Frequency of Passing Urine:

This occurs in the 1st and 3rd trimesters. This is probably due to the increased blood volume and increased filtration rate in pregnancy.This is compounded by less space for the bladder from pressure of the growing uterus (first trimester) or from the descent of the fetal head (third trimester).

7)Tiredness (Fatigue)

Common in the 1st and 3rd trimesters. This is due to changes in energy requirement.

Contributory factors include sedative effect of progesterone, weight gain,changes in mechanics of movement and sleep disturbances.

Edema (swelling of the legs-due to fluids)

This usually occurs in the third trimester. Factors that contribute to edema in pregnancy include obstruction of lymphatic flow, increased venous pressure in the legs and reduced plasma colloid osmotic pressure.

9) Backache

This may occur anytime during pregnancy. The minor lordosis required to balance the growing uterus and the hormonally induced relaxation of joints and ligaments may result in lower backache

10)Leukorrhea (increased milky white discharge from the vagina)

This may occur throughout pregnancy. This asymptomatic milky white vaginal discharge results from increased secretions from the cervix and vaginal epithelium due to the hormones and vasocongestion of pregnancy.

11) Heartburn and Constipation

This may also occur anytime during pregnancy and is due to the relaxation of the lower oesophageal sphincter which allows the contents of the stomach to reach the lower oesophagus. There is also decreased gastrointestinal motility due to the hormones of pregnancy which may cause constipation. Existing haemorrhoids may also be aggravated by the constipation.

References:

Pages 817 to 823. Chapter 19. The Pregnant Woman. Bates Guide to Physical Examination and History Taking.

i) Weight

ii) Blood Pressure

iii) Fundal height

iv) Fetal heart rate

v) Urine for protein and glucose

Review any other problems/concerns the patient may have related to pregnancy or general well being, including nutrition.

6-12 Weeks

i) Confirmation of the uterine size and growth by pelvic examination.

ii) Doppler scan for fetal heart rate and tone, which is usually audible by doppler at 10-12 weeks of gestation.

iii) Transvaginal Chorionic Villus Sampling. The ideal time to do a transvaginal chorionic villus sampling (Only if indicated) is 10- 12 weeks.

Transvaginal chorionic villus sampling is used for screening of trisomy 18, 21 and cardiac defects.

The parameters used for screening include nuchal translucency via sonography, hcg and PAPP-A.

12- 18 Weeks

i) Genetic counseling: of women aged 35 years or older at delivery or for those with a family history of congenital anomalies.

Women who have had a previous child with a chromosomal abnormality , metabolic disease or neural tube defect should also be counseled.

ii) Amniocentesis: Can be performed as indicated (Usually after counseling for genetic abnormalities-see above) and requested by the patient.

12- 24 Weeks

i) Fetal ultrasound scan: The best time for a dating fetal ultrasound scan (To confirm the correct age of the fetus) is 18-20 weeksof gestation.

Ultrasound scan done around this time is also useful to evaluate fetal anatomy.

16-20 Weeks

i) Maternal serum alpha-fetoprotein test: This should be offered to all women to screen for neural tube defects. In some states of the USA this test is compulsory.

The serum alpha-fetoprotein measurement can be combined with the measurement of hcg and estriol (Called the triple screening test for fetal Down’s syndrome) or inhibin A (Quad screen test for Down’s) for the detection of fetal Down’s syndrome.

20-24 Weeks

i) Cervical length measurement by ultrasound: This is very important in women with a previous history of preterm labour .It should be measured from 18 weeks in women with a history of preterm labour (>2.5 cm is normal).

24 Weeks to Delivery

i) Perform ultrasound scan as indicated for fetal size and growth-usually evaluated when fundal height is 3cm less than or greater than expected for gestational age.

In diagnosed cases of multiple pregnancy ultrasound scanning should be performed every 4 weeks.

26- 28 Weeks:

i) Screening for gestational diabetes by a 50g glucose load (Glucola) followed by a 1-hour post-Glucola blood glucose determination.

If values of the 1-hour test ate abnormal, it should be followed up by 3-hour glucose tolerance test.

28 Weeks:

Repeat antibody testing for Rh-negative patients if the initial antibody screen is negative.

Please note that the result is not necessary before Rh (D) immune globulin is administered.

28-32 Weeks:

Repeat the complete blood count to evaluate for anemia of pregnancy.

28 Weeks to Delivery:

Determination of the fetal position and presentation. The patient should be questioned at each visit for the symptoms and signs of preterm labour or rupture of membranes.

Maternal perception of fetal movements should be assessed at each visit.

Other investigations such as CTG can be performed if indicated.

36 Weeks to Delivery:

i) Repeat syphilis test, HIV test, cervical cultures for N gonorrhoea and Chlamydia trachomatis in at-risk patients.

ii) Discuss with the patient the signs and symptoms of the onset of labour, pain management during labour and the management of labour and delivery.

iii) Fetal lung maturity tests for all elective cesarean sections.

iv) The CDC (Atlanta) has recommended universal prenatal culture based screening for group B streptococcal colonization in pregnancy.

a single standard culture of the vagina and anorectum should be collected at 35 to 37 weeks of gestation.

Prophylaxis should be given only if the cultures are positive.

In patients who have not done the screening, the risk factors for ascending infection are intrapartum temperatures greater than 38 degrees celsius or membrane rupture greater than 18 hours.

Recommended prophylaxis :

penicillin G, 5 million units intravenously as a loading dose followed by 2.5 million units intravenously every 4 hours until delivery.

Alternatively 2g of Cefazolin intravenously followed by 1g intravenously every 8 hours until delivery.

41 Weeks and Beyond:

Examination of the cervix to determine the probability of successful induction of labour. If the cervix is favourable (> or =50% effaced, cervix> or = 2cm,vertex at -1 station, soft cervix and midposition) ,induction of labour can be undertaken.

If unfavourable antepartum fetal testing is begun while preparing for a cesarean section delivery

This article sumarizes the changes felt by a woman who is pregnant. Please note that diagnosis(Which means conformation of pregnancy) will be covered in another article.

The Stages (Trimesters of Pregnancy)

We can divide pregnancy into three stages by time.

These stages are known as the trimesters, because it divides the duration of pregnancy which is approximately 9 months into three (Tri).

i)The first trimester corresponds to the first twelve weeks of pregnancy, ie week1 to week 12 completed weeks (This is roughly the first three months).

ii)The second trimester corresponds to the second 12 weeks of pregnancy, ie from week 13 to 24 completed weeks( This is roughly the second three months).

iii)The third trimester is from the 25th week to delivery (This is roughly the last three months).

To make things easier for laymen to understand the symptoms of pregnancy I will cover this topic under three subheadings. Each trimester will have its own section.

Symptoms of Pregnancy in the First Trimester

Most of the new symptoms are obviously noticed by the pregnant lady in the first trimester.

There are a few troublesome symptoms that need  explanation in detail because they are very common and can be very distressful to the mother.

1)Nausea and Vomiting (Morning Sickness)

This is a very common symptom, present in about 80% of pregnant women.

Starts during 6-8 week

Peaks during the 10th week

Settles down by 12-14 week.

The symptoms are nausea, vomiting ,dizziness and fatigue.

It is thought that these symptoms are caused by Human Chorionic Gonadotrophin (HCG) . This is a hormone secreted by the placenta. HCG being the causative agent is suggested by the fact that the symptoms follow the HCG concentration curve.

There are certain gynaecological , medical and surgical diseases that could mimic morning sickness and if these diseases occur during pregnancy it would be difficult to diagnose, therefore if the symptoms of morning sickness are severe enough to affect day-to-day activities of the woman these conditions should be excluded. eg. Viral hepatitis, cholicystitis, pyelonephritis(Infection of the kidney) and intestinal obstruction.

Hydatidiform mole (Molar Pregnancy)twin pregnancy can both cause excessive morning sickness-Topics for discussion in another article.

Managemen of Morning Sickness: It is important to reassure mothers that this is a normal occurring in the first 12 weeks of pregnancy.

Women should be encouraged to maintain adequate fluid intake. Dehydration and ketosis can be harmful to the fetus.

in mild to moderate vomiting, oral rehydration fluids are adequate, this could be in the form of soups etc.

In severe cases intravenous fluids and anti-emetics should be given eg. Meclozine 25mg or Cyclizine 50mg 8 hourly in severe cases.

Women with severe vomiting should have an ultrasound scan to exclude hydatidiform mole and multiple pregnancy.

2)Amenorrhoea

Amenorrhoea means the absense of menstruation (Periods).

A period of amenorrhoea is one of the first symptoms to occur in pregnancy. This loss of menstrual periods continues throughout pregnancy. However there could be blood spotting on the days corresponding to the menstrual days for the first three months in some patients. This is also known as decidual bleeding and is much less than the normal menstrual bleeding and is not a risk to the pregnancy.When taking a history of the first date of the last menstrual period, it is more appropriate to ask when was the first date of the last regular menstrual period.Was it similar to previous menstrual periods?Women on hormonal contraceptives can also have irregular menstrual periods.

When a female in the reproductive age presents with missed periods she should be regarded as pregnant until proven otherwise.

Please not that the period of amenorrhoea after delivery of pregnancy (Lactational amenorrhoea ) can provide diagnostic difficulty in the early stages of pregnancy( Assuming the woman gets pregnant within a few months after delivery of a baby).

3)Increased frequency of Micturition (Urination)

Many pregnant women complain of increased frequency of passing urine. This is normal in the first trimester of pregnancy. The reason for this is the enlargement and anterved  (Forward bent) uterus, this presses the bladder and results in a decreased capacity of the bladder which in turn result in frequent urination. Other factors which may contribute to the increased frequency of urination include increased vascularity of the bladder and enlarging cervix.

After the 12th week of pregnancy (ie in the 2nd trimester) the uterus rises up from the pelvis(ie it becomes an abdominal organ) and the increased frequency of urination settles.

4)Breast Discomfort

Many women also complain of breast discomfort during the first trimester .Breast discomfort ranges from feeling of fullness, tingling sensation and pain. Breast discomfort usually starts in the 6-7th week of pregnancy and is attributed to the increased levels of oestrogen which causes fluid retention and distention of the breasts.

These breast symptoms will diminish if the baby dies inside the womb during the first three months (Missed Abortion).

5)Increased Pigmentation of the Breast

There is increased pigmentation of the breast skin around the nipple which leads to the formation of primary areola(Dark skin around the Nipple) around the 6th to 8th week of pregnancy (In primi mothers-First time pregnancy). This increase in pigmentation persist’s throughout life. There is also formation of small elevations around the nipple which are due to enlarged sebaceous glands (Montgomery Tubercles).

6)Abdominal Enlargement

The abdominal enlargement during pregnancy is usually mild during the first trimester, because the uterus is still within the pelvis.

Enlargement of the abdomen during the first trimester, which is usually slight is due to the relaxation of the abdominal smooth muscles attributed to the hormone progesterone.

Symptoms of Pregnancy in the Second Trimester

1)Perception of fetal movement(Quickening)

Quickening refers to the first perception of active fetal movements by the mother.Women who are pregnant for the first time (Primigravida) perceive fetal movements around the 18th to 20th week of pregnancy and in multigravidas (Women who have already been pregnant at least once) feel the first fetal movement earlier- around the 17th week.

The exact date of quickening is also very helpful in calculating the expected date of delivery.

2)Enlargement of the Abdomen

During the second trimester the uterus slowly becomes an abdominal organ (Moves upwards from the pelvis to the abdomen). It is important to note that if by now pregnancy is not confirmed, one has to exclude other lumps that could arise from the pelvis, such as uterine fibroids, ovarian cyst, and distended bladder.

3)Colostrum

The clear secretion from the breast after the 16th week of pregnancy is known as colostrum. This is normal and therefore the mother should be reassured.

4)Mask of Pregnancy (Chloasma)

This refers to the increase in pigmentation over the forehead and cheeks, which appear around the 20th to 24th week of gestation. Chloasma may persist until the pregnancy is over and obviously cannot be seen in dark women.

5) Appearance of Linea Niagra

Linea Niagra refers to the darkly pigmented line in the mid line of the abdomen. It extends from the Xiphisternum (Just below the sternum) to the pubic symphysis (This is the joint in the front part of the pelvic bones in the midline).Linea niagra appears around the 20th week due to the increased concentration of MSH (Melanocyte Stimulating Hormone).

6)Striae Gravidarum

This refers to the fat like lines that appear commonly in the abdomen of pregnant women. It is due to the rupture of the elastic fibers under the skin caused by high levels of corticosteroids. This is normal and nothing to worry about.

Symptoms of Pregnancy in the Third Trimester

In the third trimester, there are no new symptoms. There is further enlargement of the abdomen. There could also be increased frequency of micturition due to the pressure effects of the presenting part on the bladder.

References

1) Clinical Obstetrics for undergraduates- Compiled by WDN De Alwis, Dr R Gunasekeram, Dr N Gunawansa. Edited by Dr C Randeniya MBBS, MS, FRCOG.

2)Essential Antenatal Care- A guide for the trainee by Deepal S. Weerasekera MS (O$G), MRCOG (UK), FRCS( Ed).

3)Obstetrics by ten teachers (Seveenth Ed) edited by Stuart Campbell and Christoph Lees.