Pregnancy is the condition of having developing embryo or fetus in the female. The duration of pregnancy is usually 10 lunar months or 9 calendar months. The woman in age of her reproductively active period (between menarche and menopause) can get pregnant.
Signs and symptom of pregnancy:
We’ll discuss the signs and symptoms according to the trimesters.
First trimester:
1. Amenorrhea:
Amenorrhea in woman having normal periods previously, who is reproductively period and sexually active, is most likely due to the pregnancy unless proven otherwise. Menstrual cycle vary among women in terms of lengths, cycles, amount of blood etc. So, amenorrhea is not reliable sign of pregnancy.
Other causes of amenorrhea:
- Stress
- Post-pill amenorrhea
- Psychotropic medications e.g. Phenothiazine
- Antihypertensive medications e.g. Reserpine
- Pituitary adenomas
- Sheehan’s Syndrome
- Polycystic ovary syndrome (PCOS)
- Premature ovarian failure
- Hypothyroid state
- Diabetes mellitus
Causes of bleeding per vagina other than menstruation (which may give false impression of menstruation)
- Placental sign / Implantation bleeding: Cyclic bleeding during first trimester until the decidual space is obliterated by fusion of decidua vera with decidua capsularis.
- Threatened abortion: It is the clinical entity where the process of miscarriage has started but not progressed to a state from which recovery is impossible
Miscarriages:
- Genital tract lesions: Vaginitis, trauma, polyps
- Ectopic pregnancy
- Hydatidiform mole
- Bleeding per vagina in second and third trimesters:
- Placental abruption
- Placenta previa / vasa previa
- Abnormal placentation (Placenta accreta)
- Ruptured uterus
2. Morning sickness:
It usually appears soon following missed period. It is characterized by nausea on rising from bed, loss of appetite and vomiting. Slight vomiting is common in early pregnancy (2-16 weeks). It usually does not affect the health of mother and not indicated to manage vomiting unless the vomiting is impairing the health status of mother (hyperemesis graviderum).
Other subjective symptoms include breast discomfort, fatigue, increased frequency of micturition, abdominal straie etc.
3. Breast changes:
It is more evident in primigravida. It is more evident between 6-8th week. Nipple and areola get more pigmented and thick yellow secretion can be expressed. Montgomery’s tubercles or areolar glands are more prominent which are sebaceous glands in areola surrounding nipple and make oily secretions to keep areola and nipples lubricated and protected.
4. Lower reproductive tract changes:
- Chadwick’s sign: The vaginal mucosa is dark, bluish red (dusky hue) and congested. It is visible from about 6th week of gestation.
- Vaginal sign: The vaginal walls become softened and non-irritating mucoid discharge may appear at 6th week of gestation.
- Osiander sign: Increased pulsations felt through the lateral fornices at 8th week.
5. Cervical sign:
- Bluish discoloration of cervix due to increased vascularity (Chadwick’s sign).
- Goodell sign: Cervix becomes soft at 6th week (even early in multipara). The cervical softening is increased as pregnancy advances.
6. Uterine signs:
The uterus is enlarged. During bimanual examination, it feels like doughy-elastic. Size of uterus is about
- Hen’s egg: 6th week
- Cricket ball: 8th week
- Fetal head: 12th week
The uterus becomes globular with average diameter of 8 cm.
- Hegar sign: It can be demonstrated at6-10th weeks of pregnancy. The firm cervix contrasts with the softer fundus and compressible interposed softened isthmus. Isthmic softening is so marked that cervix and uterine body seems to be separate organ.
- Palmar sign: During bimanual examination at 4-8th weeks, rhythmic uterine contractions can be elicited. During examination, the uterus becomes firm and well defined during contractions and soft and ill-defined during relaxation. The contraction lasts for 30 seconds and the relaxation phase increases with advance in pregnancy. Relaxation phases are so much increased that this test is difficult to perform after 10th week.
Second trimester
1. Quickening or fetal movements:
The perception of fetal movements by mother. It starts or usually felt in 16th -18th weeks of gestation.
2. Skin changes:
Chloasma /melasma:
It is also known as mask of pregnancy, it is pigmentation over forehead and cheeks at 22nd -26th week of gestation. These are symmetric blotchy, sharply marinated tan to dark brown hyperpigmentation of face. The pattern is:
- Malar (most common)
- Mandibular
- Centro facial
- Entire face (rare)
Linea nigra
It is dark vertical line that appears on abdomen, usually about a centimeter in width and runs vertically along the midline of abdomen from pubis to umbilicus usually and sometimes from pubis to top of abdomen.
Striae Gravidarum
These are the linear atrophic pink to violaceous bands most commonly appearing in areas such as thighs, breasts, abdomen (stretch areas).
3. Breasts changes:
Breasts become enlarged. Montgomery’s tubercles are also prominent. Prominent veins are visible with enlarged breasts. Striae, stretch marks can be seen.
4. Fundal Height:
It is increased with enlargement of uterus. Up to 12 weeks, uterus is pelvic organ and at 36th week fundal height is at xiphoid process of sternum.
- 12th week = uterus is pelvic organ.
- 16th week = midway between pubis and umbilicus.
- 20th week = at belly-button.
- 24th week = level of umbilicus.
- 28th week = junction of lower third and upper two thirds of distance between umbilicus and xiphoid process.
- 32nd week = about 4 cm below xiphoid process.
- 36th week = at xiphoid process.
- 40th week = same as 32nd week.
5. Palpation findings:
Uterus feels soft elastic and ovoid in shape. Fetal parts can be palpated distinctly by 20th week. Fetal movements can be felt by placing hand over the uterus.
6. Braxton Hicks contractions:
These are sporadic uterine contractions, which are often in infrequent, irregular, painless (mild cramps may felt) and without any effects on dilation of cervix.
7. Ballottement:
- External ballottement: It can be elicited when the fetus is relatively smaller the the volume of amniotic fluid. It can be elicited from 20th week.
- Internal ballottement: It can be elicited at 16th-28th week on per vaginal examination.
8. Fetal heart sounds:
These can be heard from 18th -20th weeks and is the most conclusive clinical sign of pregnancy. The range of fetal heart sounds is 110-160 beats per minute. In standard non-amplified stethoscope, fetal heart sounds may be audible from (as early as) 16th week. Instruments like Doppler ultrasound can detect heart sounds by 10 weeks. According to Herbert and coworkers (1987) fetal heart sounds are audible by 20 weeks in 80% of woman and by 22 weeks heart sounds are heard in all.
9. Uterine souffle:
These are soft blowing sound that is synchronous with maternal pulse, which is produced by the passage of blood thorough the uterine vessels. These sounds can be heard using stethoscope.
10. Funic souffle:
These are sharp, whistling sounds, synchronous with fetal pulse, which is caused due to passage of blood through umbilical arteries.
Third/ Last trimester:
Symptoms are amenorrhea, enlarged abdomen, lightening, increased frequency of micturition, increased fetal movements, increased pigmentations, striae etc.
- Increased fundal height.
- Palpation of fetal parts and fetal movements are easily perceived.
- Evident Braxton Hicks contractions.
- Fetal heart sounds are heard according to presentation and position of fetus.
