Definition of Preterm :

Pre-term labour is defined as the presence of true labour (Regular painful uterine contractions associated with cervical effacement and dilatation) before the 37^th week of pregnancy and after the age of viability of the fetus.

Eg 37 weeks and 1 day is not preterm while 36 weeks and 6 days is preterm.

In the UK the age of viability is considered to be 24 completed weeks of gestation -from the date of the last menstrual period-LMP or 22 completed weeks from the date of conception, assuming a 28 day menstrual cycle.

The correct term for the onset of labour before 24 weeks of gestation is miscarriage rather than preterm labour.

Predisposing factors/ causes of pre-term labour:

Obstetric and gynaecological causes:

i) Previous history of preterm/ premature rupture of membranes

ii) Cervical incompetence

iii) Multiple Pregnancy

iv) Polyhydramnios.

v) Antepartum Haemorrhage.

vi) History of previous intrauterine death of the fetus.

vii) Uterine abnormalities

viii) Idiopathic

ix) Previous history of elective delivery due to preterm or intrauterine growth retardation.

x) Vaginal infections

Medical causes:

i) Heart disease and other medical disorders

ii) Systemic infections

iii) Anaemia (Hb< 9.5g/dl) and high haemoglobin concentration (> 13.5 g/dl) is associated with a markedly increased risk of preterm.

Epidemiological Causes:

i)Women from the lower socioeconomic class of society

ii)Body mass index (BMI) <19

iii)Young and older age mothers.

iv)Smoking mothers.

v) Single mother (Unmarried/unsupported).

What is preterm pre-labour rupture of membranes?

This is the pre-labour rupture of the membranes with subsequent preterm labour. The important and well know complication of preterm pre-labour rupture of membranes is ascending infection.

Preterm Pre-labour rupture of membranes will be discussed separately on another post.

Incidence and epidemiology:

Approximately 7% of labours are preterm.

The incidence of preterm is much higher among women from the lower socioeconomic class of society. It is also much lower among more affluent areas.

The period called term (Between 37 and 42 completed weeks of gestation) is the period where 90% of births occur. This explains the fact that the length of a normal human pregnancy is much more variable than other mammals.

Diagnosis of preterm:

Although the only real proof of preterm labour is the progressive dilatation of the cervix, the diagnosis of preterm labour has to be made on the basis of uterine contractions. This is because it is too late to try any preventive measures once cervical dilatation is established.

Some of the problems associated with the diagnosis of preterm labour are:

i) Bouts of preterm uterine contractions experienced by numerous women and which are not associated with progressive dilatation of the cervix and preterm delivery.

ii) Preterm labour can be easily confused with acute presentations of abdominal pain such as in urinary tract infection (UTI) and pre-eclampsia.

A thorough history and examination should be undertaken in any woman suspected to have preterm labour as it is a leading cause of neonatal mortality.

If there is any evidence of ruptured membranes, digital examination should be avoided , as it increases the risk of ascending infection. The examination should be repeated 4 hours later if thee is any doubt doubt about the diagnosis.

Cardiotocography is  very useful in the diagnosis of preterm labour. It also helps to confirm fetal wellbeing by observing the fetal heart rate pattern. However one has to note that the absence of uterine contractions does not eliminate the diagnosis of preterm labour. A vaginal examination is still necessary.

A high vaginal swab at the time of the speculum examination for Gram stain, microscopy and culture (look for group B streptococcus- most dangerous). This will enable the use of appropriate antibiotics if infection develops.

The management of preterm labour will be covered in a subsequent post.

Feel free to ask any questions/comments below

References:

i) Chapter 24 pages 291-294 Preterm Labour by P.J Steer -Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates, Sixth Edition. Edited by D. Keith Edmonds.

ii) Chapter 18 pages 273-275 Preterm Labour -Obstetrics by Ten Teachers- Seventeenth Edition edited by Stuart Campball and Christoph Lees.

Epidemiology/Causes:

a) Age: Obesity can occur at all ages. The incidence of obesity increases with age. Obese infants are more likely to be obese in later life.

One-third of obesity in adults has been life long, ie since infancy.

Most adipose cells are formed in early life, therefore infants who have more of these cells (hyperplastic obesity) are more likely to be obese in infancy and later life. It is very difficult to treat hyperplastic obesity in adult life.

b) Genetic Factors: There are genetic factors that could explain the aetiology of  obesity. There is a close relationship in the weight of identical twins, even if they are brought up in different environments.

c) Familial Tendency: It is well known that obesity runs in families. It is very difficult to determine if familial obesity is due to genetic factors, because members of the same family have similar eating habits.

d) Sex: Men are more likely to be obese at a relatively young age (between 29 and 35 years) while women gain most weight between 45 and 49 years of age.

e) Physical inactivity: There is an increased incidence of obesity among people who are physically inactive (Company executives) .This is a vicious cycle,ie the increase in obesity causes reduction in physical activity which in turn increases obesity.

f) Endocrine factors: This provides the explanation of obesity in Cushing’s syndrome and growth hormone deficiency. Endocrine factors are probably not involved in obesity in normal ndividuals.

g) Socio-economic status: There is an inverse relationship between obesity and socio-economic status.

h) Eating habits: This is very important. Eating in-between meals and preference to fats, refined foods and sweets can easily cause obesity.

Prevention of Obesity:

Prevention of obesity should begin in early childhood. Children should be taught about healthy eating habits.

Individuals at risk of obesity should be told to eat diets low in fat and high in fiber (like roots, cereals, legumes, fruits and vegetables). They should also avoid sedentary lifestyle and take regular exercise.

Control of Obesity:

i) Weight reduction by dietary changes: Dietary changes include an increase in high fiber foods (Please see above-as discussed in prevention of obesity). It is unfortunate that attempts in reduction in weight by dietary advice is usually unsuccessful.

ii) Increased physical activity: Regular physical activity can help reduce obesity, for effective reduction of weight this must be combined with dietary advice.

iii) Severe Obesity: In severe obesity surgery may be beneficial in some patients (eg Gastric bypass, gastroplasty etc).

References:

Short Textbook of Public Health Medicine for the Tropics- Adetokunbo O. Lucas and Herbert M. Gilles-4th edition.

Obesity and Pregnancy -Chapter 33 by Rani Akhil Bhat .Medical Disorders in Pregnancy- An Update .edited by Hiralal Konar and Pralhad Kushtagi. Federation of Obstetric and Gynaecological Societies of India.First Edition.

WHO 2000 No. 894

WHO 1995 No 854

FAO/WHO/UNU 1985 No. 724- Energy and protein requirements.

Chapter 6 Epidemiology of Non- Communicable diseases -Park’s Textbook of Preventive and Social Medicine by K Park.

Endometriosis is defined as the presence of actively funcitioning endometrium in any part of the body other than its normal position of lining the endometrial cavity( lining of the uterine cavity-inside the uterus).

The term endometriosis was first coined by Samson in 1921.

What is the difference between endometriosis and adenomyosis?

Adenomyosis refers to the presence of endometrial tissue within the myometrium (The uterine muscles -The muscles that make up the uterus), while endometriosis refers to the presence of functioning endometrial tissue outside the uterus.

What are the common sites/organs involved in endometriosis?

Endometriosis is most commonly found in the pelvis (surface of the ovary, broad ligaments, pelvic peritoneum and fallopian tubes).

Other sites where endometriosis may be found include: heart, lungs, pleura, eyes, upper limbs, skin, lymph nodes

Incidence of Endometriosis

The exact incidence and prevalence of endometriosis is not well known. 

Endometriosis has been found in 10 to 33 percent of gynaecological laporatomies.

90% of the women diagnosed with endometriosis are between the ages of 20 and 50 years.

With the use of advanced laporoscopic biopsy  it is now possible to identify endometriosis much earlier in life.

The increasing prevalence of endometriosis is probably due to advanced diagnostic techniques and increasing awareness of the disease rather than an increase in the disease itself.

There is a much higher incidence of endometriosis among Japanese women. 

It is more common among caucasian women compared to black women.

Endometriosis is common among the upper class of society (High socioeconomic group) . This is attributed to late marriage , which means the woman has had much more menstrual cycles and therefore higher chances of having endometriosis.

There is also a familial tendency to have endometriosis (Genetic basis basis of endometriosis?) .

Aetiology and Pathogenesis of Endometriosis (Causes)

Several theories have been suggested in the pathogenesis of endometriosis.

The lymphatic and haematological dissemination theory

This theory suggests that endometrial cells are carried by blood and lymphatics and implanted in other parts of the body. This could explain the occurrence of endometriosis in the lymph nodes, chest and axilla.

The coelomic metaplastic theory

This tries to explain the occurence of endometriosis as an early event during embryogenesis.

This theory suggests that there is abnormal differentation of coelomic epithelium ,which leads to the development of endometriosis anywhere in the coelomic epithelium .

This is the only theory that can explain the presence of endometriosis in males and in women who do not have uterus.

The Implantation Theory

Also known as the retrograde menstruation theory.

It tries to explain the occurence of endometriosis in the pelvis.

It was first postulated by Samson (1927).

He suggested that the endometrium could flow retrogradely through the fallopian tubes to  the pelvis during menstruation. It also explains the higher incidence of endometriosis in the pelvis compared to other sites.

This theory is supported by the fact that women without uterus do not develop pelvic endometriosis.

The occurence of endometriosis in abdominal surgical scars are due to the endometrial cells deposited in the skin during surgery.

Direct extension 

The direct growth of endometrium through the tissue space to the myometrium is thought to cause adenomyosis.

The clinical features and management will be discussed in a seperate topic.

References:

Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates. Sixth Edition by D Keith Edmonds.

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agboola et al 2 nd Edition .

Gynaecology by Ten Teachers .Edited by Stuart Campbell and Ash Monga, 17th edition.

Clinical Gynaecology for Undergraduates compiled by Dr WDN De Alwis, Dr R Gnanasekeram, Dr N. Gunawansa. Edited Prof. C Randeniya MBBS, MS, FRCOG. Senior Lecturer, Dept. of Obstetrics and Gynaecology, Faculty of Medicine ,Colombo. Consultant , De Soysa Hospital for Women and National Hospital of Sri Lanka.

Labour is divided into three stages

First Stage: This stage lasts from the onset of labour( When the woman begins to have regular painful uterine contractions) and a dilated cervix of 2-3 cm to a full cervical dilation of 10 cm.

The average duration of the first stage is about 12 to 14 hours for primigravida (woman who have not delivered before, ie first time delivery) . For women who have delivered before  (Multipara) this stage lasts about 8 to 10 hours.

Second Stage: The second stage starts at the time of full cervical dilatation and ends with the birth of the baby. The average duration of the second stage for a primigravida is about 25 minutes while for a multipara it lasts for about 15 minutes.

Third Stage: The third stage lasts from the time the baby is born to the time the placenta is delivered. The average duration of the third stage is about 5 minutes for the primigravida and 6 minutes for the multipara.

What is the average duration of labour?

In primigravida (woman who have not delivered before, ie first time delivery) the average total duration of labour is about 14 hours. While for a multipara (Women who have delivered before) the average total duration of labour is about 10 hours.

The components or essential factors of labour

The components or essential factors of labour are commonly referred to as the three P’s of  labour. These include:

i) The Passage: There are four types of pelvis, the gynecoid, android, anthropoid and platypelloid. The gynecoid pelvis is the normal female pelvis while the male type is referred to as the android. The pelvic inlet, the mid-cavity and the outlet should be carefully evaluated.

If the clinical pelvimetry is in doubt a lateral x-ray pelvimetry is very useful in assaying the bony pelvis. The soft tissue of the pelvis which includes the muscles, fascia and ligaments should also be assayed as excessive scarring can delay labour.

ii) The Powers: As labour progresses in normal labour the contractions become regular , stronger and well co-ordinated . They occur every 2 to 3 minutes (about 3 times per 10 minutes) . The intensity (force of contractions increases) from an average of 20 to 30 mmHg to 50 mmHg.

As the labour progresses the upper segment becomes thicker while the lower segment becomes thinner.

iii) The Passenger: The passenger refers to the baby. The average size babies tend to have the best prognosis (assuming that the baby does not have any congenital malformations/diseases) in terms of neonatal well being . 

The average size of the fetus at term(Birth weight) varies from country to country .eg in Sri Lanka the average birth weight is 2.8 Kg while in Nigeria it is 3.4 Kg.

References:

Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates (Sixth Edition)-Edited by Keith Edmonds FRCOG , FRACOG

Oxford Handbook of Clinical Specialties-6 th edition

Obstetrics by Ten Teachers- edited by Stuart Campbell and Ash Monga- 17th edition

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agboola et al-2nd edition

What is false labour (Braxton Hicks contractions)?

This refers to irregular weak uterine contractions which may occur before term or at term. They are usually not painful. Braxton Hicks contractions can cause a lot of anxiety and may even lead to premature admission to the labour ward.

How can I differentiate a false labour from a true labour?

The only definitive way to differentiate a false labour from a true labour is to get a vaginal examination (V/E) done by a midwife or a doctor. The vaginal examination will reveal  a dilated cervix and or effaced cervix.

In true labour there must be more than one contraction in 10 minutes. Contractions can either be recorded by modern instruments or by feeling the abdomen with the palm of the hand.False labour is usually not very painful and not forceful.

It must be emphasized that labour does not begin at a point, it is a gradual physiological transition from late pregnancy to labour.

What causes the onset of labour?

The mechanism responsible for the onset of labour is still not properly understood.

What is known is that prostaglandin hormones are primarily responsible for stimulating uterine contractions of labour . It is believed that prostaglandin action on the uterus is mainly due to cervical ripening rather than stimulating uterine contractions. Cytokines, oxytocin ,steroid hormones, endothelin-1 and platelet activating factor (PAF) may stimulate prostaglandin synthesis ,while progesterone and phospholipase A2 inhibitors may inhibit prostaglandin synthesis.

A fall in plasma progesterone has also been observed prior to the onset of labour. Even though oxytocin stimulates uterine contractions , its concentration in the blood does not rise near term. Relaxin, is another hormone that is thought to help cervical ripening.

Prostaglandins and oxytocin may increase intracellular free calcium ions which in turn causes contractions by formation of the contractile entity of  actin-phosphorylated myosin.

Uterine contractions are involuntary in nature . There is little or no neuronal control over uterine contractions.

The duration of pregnancy is also affected by the fetal genotype.

There is progressive shortening of the uterine smooth muscles as labour progresses .This is called retraction . Retraction mainly takes place in the upper segment of the uterus. After contractions they do not return to their original size. This enables the lower segment to become thinner and more stretched, eventually the cervix also becomes stretched and taken up into the lower segment of the uterus.

References:

Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates (Sixth Edition)-Edited by Keith Edmonds FRCOG , FRACOG

Oxford Handbook of Clinical Specialties-6 th edition

Obstetrics by Ten Teachers- edited by Stuart Campbell and Ash Monga- 17th edition

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agboola et al-2nd edition

Hypertensive diseases of pregnancy accounts for 15% of maternal deaths.

Hypertensive disorders complicate 5-7 % of all pregnancies.

The complex aetiology (Cause) of hypertension in pregnancy has led to confusion in both its definition and management.

Approximately 70% of women diagnosed with hypertension during pregnancy have gestational hypertension and pre-eclampsia.

Chronic (Pre- existing) hypertension complicates 1 to 3% of all pregnancies. Hypertensive disorders in pregnancy have a wide range of presentation ranging from mild elevation of blood pressure to severe organ failure.

Definition

Hypertension is defined as changes of blood pressure recorded on at least two occasions at least six hours apart, either:

i) Diastolic blood pressure greater than 90mm Hg or

ii) Systolic blood pressure greater than 140mm Hg or

iii)A rise in diastolic pressure of at least 15mm Hg or

iv)A rise in systolic blood pressure of at least 30mm Hg

Classification of Hypertensive Disorders in Pregnancy

a) Gestational hypertension (Previously known as pregnancy induced hypertension).

b) Pre eclampsia

c) Chronic hypertension

d) Chronic hypertension with superimposed pre-eclampsia.

Gestational Hypertension

Hypertension which develops as a direct result of the gravid state  is referred to as gestational hypertension (previously known as pregnancy induced hypertension).

Gestational hypertension is defined as systolic blood pressure of at least 140mm Hg and a diastolic B.P of at least 90mm Hg on at least two occasions at least 6 hours apart after the 20 th week of gestation in women known to be normotensive before pregnancy and before 20 weeks of gestation.The B. P recordings should not be greater than 7 days apart.

Sever gestational hypertension is defined as sustained elevation is systolic B.P. of at least 160mm Hg and/or in diastolic B.P to at least 110mm Hg for at least 6 hours. Approximately 25% of women with gestational hypertension will develop proteinuria (Means proteins in the urine, a feature of pre- eclampsia).

Features of Gestational Hypertension

i) Confined to pregnancy

ii) Blood pressure becomes normal usually 24 to 48 hours after delivery or following death in utero.

iii)Occurs usually after the 20th week of pregnancy .

iv)More common in primigravida (Mothers who are pregnant for the first time).

v) Common in situations where there is an increase in placental mass eg. Multiple pregnancies  and  trophoblastic disease. There is also a higher incidence of hydrops fetalis due to Rh incompatibility or non-immune hydrops fetalis.

vi) Associated with diseases affecting the vascular system eg Diabetes Mellitus.

vii) Non- dependent oedema and proteinuria are accompaning features.

Pre- Eclampsia

Pre -Eclampsia is a triad of oedema, hypertension and proteinuria (Presence of proteins in the urine) , which usually occurs in a nulliparous female after the 20th week of gestation, other common signs and symptoms in pre- eclampsia include oedema, visual disturbances, headache and epigastric pain.

Lab tests may show increased liver enzymes, haemolysis and low platelet counts.

The proteinuria in pre-eclampsia is defined as the presense of 0.3 gram (300mg) or more of protein in a 24 hour urine collection.

Eclampsia

Eclampsia is defined as the presense of new onset grand mal seizures( also known as fit,ie like epilepsy) in a woman with pre-eclampsia.

Gestational hypertension ,pre- eclampsia and eclampsia will be dealt with in more detailed in subsequent posts dedicated to each. I do not want to overwhealm our readers who are mostly non-medical people.

As usual if you have any questions/comments you may either post it below or discuss it in my forums.

References

Obstetrics by Ten Teachers, edited by Stuart Campbell and Christoph Lees, 17th Edition.

Medical Disorders in Pregnancy-an update edited by Hiralal Konar and Pralhad Kushtagi 1st edition- Federation of Obstetric and Gynaecological Societies of India.

]]> http://www.askdrshihaan.org/pregnancy/2008/10/hypertensive-disorders-in-pregnancy-an-introduction/feed/ 0 http://www.askdrshihaan.org/pregnancy/2008/10/what-will-the-doctormidwife-ask-me-during-my-first-booking-antenatal-visit/ http://www.askdrshihaan.org/pregnancy/2008/10/what-will-the-doctormidwife-ask-me-during-my-first-booking-antenatal-visit/#comments Mon, 06 Oct 2008 02:37:18 +0000 Dr Shihaan http://www.askdrshihaan.org/pregnancy/?p=19 The booking visit, which is the first antenatal visit to your hospital/clinic is very important because it allows health care workers to identify any risk factors that may adversely effect your pregnancy.

Feel free to disclose confidential issues such as previous abortions, stillbirths, contraceptives etc.

A detailed history and a comprehensive examination will be done by the medical doctor or midwife.

The booking history briefly comprises of the following:

a) History of the Current Pregnancy:

It is important that a careful menstrual history be taken from a pregnant woman.

Are her menstrual cycles regular or irregular? If it is regular, what is the length of the normal cycle? The date of her last known menstrual period (LMP) should be ascertained. It should be stressed that we are always talking about the 1st day of the last menstrual period.

If the duration of the menstrual period or the quantity of the blood loss has been abnormal , effort should be made to identify the last normal period.It is also important to find out weather her last menstrual period was similar to a normal period. Sometimes women can mistaken a decidual bleeding for a normal menstruation.

Decidual bleeding or implantation bleeding is slight bleeding that takes place during implantation, which is actually 2-3 weeks after the LMP.

Calculation of the EDD (Expected Date of Delivery):

On average the pregnancy lasts for 40 weeks from the date of the last menstrual period.

The expected date of delivery(EDD) can easily be found by adding 9 months and 7 days to the last menstrual period( LMP).

b) History of Past Deliverie (Past Obstetric History)

This is an extremely important  aspect of the history taking during the booking visit. A summary should be made of all previous pregnancies (including stillbirths and abortions).

Pregnancies should be noted in chronological order from the first to the last.

The details of the pregnancy such as the year , place of confinement, antenatal history, duration of pregnancy, weather labour was induced or spontaneous, duration of labour, method of delivery, problems during delivery and in the puerperium. Other important details include the weight, sex, condition at birth and subsequent health and the method of feeding of the baby should be recorded.

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.

This means that you have to let your doctor know that you are planning to conceive. Many developed countries provide pre-pregnancy services in the form of clinics.

Why is it important to attend pre-pregnancy clinic or meet a doctor for pre-pregnancy advice?

The aim is to ensure that prospective parents are counseled about a woman being in a good state of health which will in turn ensure a well-grown healthy baby.

The most crucial time in the development of the fetus(Baby in the womb) is the first 8 weeks of pregnancy. During this time many pregnant women are not even aware that they are pregnant (after conception it can take anywhere between 2 to 5 weeks for the woman to realize that she has missed her period).

It is during the first four weeks that organogenesis (Formation of the various organs such as the heart, brain etc) takes place.It is important to realize that by the end of the eighth week of gestation(Pregnancy) most anomalies (Abnormalities in the baby) that are going to affect the fetus and newborn are already present.

Therefore it is the responsibility of the governments and health care workers (Nurses, Doctors, Midwives etc) to embark on a well planned health education campaign on the importance of pre-pregnancy counseling.Health education on pre-pregnancy counseling can be done via posters, printed media, health talk and can be introduced to secondary school curriculum.

Areas covered under pre-pregnancy counseling include:

1)Diet

A woman who is planning to conceive should have optimal nutritional status.

Some women may have deficiencies of vitamins, minerals and proteins calorie-malnutrition which has to be corrected in the pre-pregnancy clinic.Both obesity and malnutrition can have detrimental effects on pregnancy,therefore the bodyweight should be kept at average for height during the pre-pregnancy period.

Another important reason why women should have adequate nutrition in the pre-pregnancy state is the appearance of nausea and vomiting in the first three months( First trimester of pregnancy). This is also known as morning sickness and it can further deteriorate her nutritional status. Blood tests should be done during this period and treatment should be started if it is less than 12g/dl.

2)Folic Acid Supplementation

It is a well established fact that folic acid can prevent neural tube defects. All women should have folate rich foods and 0.4mg of folic acid daily( eg Preconceive).If there is a previous history of deliver of a baby with neural tube defects or if the pregnant woman is on anti-epileptic drugs she should take 5mg of folic acid per day.

There has been recent reports that folic acid supplementation can cause certain types of cancers. Please note that this risk is very small and can be reduced further if it is taken only up to 13 weeks of pregnancy.Patients who are at higher risk are those who already have a personal history  or family history of gastrointestinal tract malignancies such as colon cancer etc.The risk of the baby having neural tube defects can be almost eliminated by taking folate supplements.

The neural plate of the developing embryo closes to form the neural tube 24 to 48 days after conception. Incomplete closure in this process can cause Neural Tube Defects (eg Spina Bifida, Anencephaly).

The following are folate rich foods, but please bear in mind that taking folate rich foods alone is not enough to prevent neural tube defects. eg: Brussels sprouts,aspragus, spinach, blackeye beans, fortified break-fast cereals.

3)Medical Problems

Women who are diabetic must have their diabetes under best possible control before she enbarks on a pregnancy.

This is due to the fact that women who are diabetic have a much higher chance of having abnormal babies( Teratogenic effect).

It is also very important that women who are on oral hypoglycemic drugs (Oral drugs used in controlling diabetes) should change over to insulin before the pregnancy so that exposure of the fetus to these drugs within the first few weeks can be avoided.

All women who have a family history of diabetes mellitus and women who had gestational diabetes in a previous pregnancy should have her fasting blood sugar level checked.

Women who are already on drugs for other medical disorders such as epilepsy, hypertension, chronic asthma etc, should change over th the least teratogenic drugs.

4 Genetic Counseling

This is the provision of information to those at risk of having abnormal conception.

This is also the right time to screen women for thalassaemia and sickel cell disease in certain ethnic groups such as Asians and Blacks.

The patient can also be adviced to meet the clinical genetist if they had a previous history of a loss of baby due to congenital abnormality.

In women who are planning to have children after the age of 35years, the increased risk of having Down’s syndrome should be discussed.The risk of Down’s syndrome at the age of 35 years is about 1 in 350, at 40 years 1 in 100 and at the age of 45 years 1 in 30.The chance of recurrence of Down’s syndrome in a woman with a previous baby affected with downs is about 1.5%.

5)Vaccination

This is the ideal time to ensure that a pregnant woman is immune to Rubella and Chicken Pox prior to pregnancy.

The relationship between maternal rubella with congenital rubella syndrome is now well established. The risk to the fetus depends on the period of gestation at the time of infection . The greatest risk is in the first twelve weeks of pregnancy,where congenital rubella syndrome occurs in about 80% of the cases of maternal rubella and severe congenital abnormalities such as cardiac, cataract, deafness and cerebral palsy occur in upto 80% of those infected. The incidence of fetal infection decreases gradually thereafter.

Congenital rubella syndrome can be eradicated if protective levels of rubella antibodies are maintained among women of reproductive age.

Those with suceptible immunity levels and women who are non-immune should be vaccinated promptly. Since the vaccine used is a live vaccine, the patient should be properly adviced to refrain from getting pregnant for three months after vaccination and a proper contraceptive advice should be given.

6)Risk of radiation exposure

Any investigation requiring exposure to radiation in women of reproductive age should be done during the first half of the menstrual cycle to ensure that the woman is not pregnant at the time of the investigation.Common investigations which involves radiation include intra-venous urography or Ba enema.

Advice on contraception is very important till her medical problems are sorted out.

7)Cigarette Smoking

It is very important to ask for a history of smoking from a pregnant woman and her partner. Smoking can effect the pregnant woman , her partner. and even the unborn child.In men smoking can result in abnormal sperm production and reduction in sperm penetrating capacity.

Children born to smokers have shown reduced learning ability.

In pregnant women smoking is associated with a two fold increased rate of miscarriages, preterm labour and small for gestational age babies(Mean is 3376g in Non-smoker, Smoker: 3200g)

Both the pregnant lady and her partner should be encouraged to quit smoking.

However only 17% of smoking mothers stop before or during pregnancy, this should not discourage you to stop advising them to quit smoking.

8)Alcohol Consumption

Alcohol consumption is also associated with an increased risk of miscarriages.High levels of consumption can cause the fetal alcohol syndrome.Although mild to moderate alcohol consumption has not shown to adversely affect the fetus, alcohol should still be avoided because it does cross the placenta and reach the fetal blood where it can affect the development of the fetal brain.

Pre-Conception counseling becomes extremely important in the following groups of women:

If you had any of the following please make sure that you see a doctor several months before conceiving.

1)Previous history of abnormal baby.

2)Women with a family history of genetically transmitted diseases.

3)Women who are on regular medication for medical problems.

4)Women who marry late(Greater than 30 years).

5)History of previous still birth, miscarriage or neonatal death.

6) Pre existing medical condition such as diabetes mellitus, epilepsy and heart disease.

References

1) Essential Antenatal Care-A Guide for the Trainee-Deepal S. Weerasekera

2) Oxford Handbook of Clinical Specialties Judith Collier, Murray Longmore, Peter Scally- 6th Edition

3) Medical Disorders in Pregnancy- An Update-2006, Federation of Obstetric and Gynaecological Societies of India