Signs and symptoms of early pregnancy.
Signs and symptoms of early pregnancy.
Signs and symptoms
of early pregnancy.
The state of having products of
conception implanted normally or
abnormally in the uterus or occasionally
elsewhere. Pregnancy is determinated
by spontaneous or elective abortion or
delivery. A myriad of physiologic
changes occur in a pregnant woman,
which affect every organ system.
Who has regular menstrual cycles and is
sexually active, a period delayed by more
than a few days to a week is suggestive of
Early antenatal care is important as soon as
possible after pregnancy has been confirmed
(after one or two missed periods)
1. To promote and maintain good health of the mother and
fetus during pregnancy.
2. To ensure that the pregnancy result in healthy infant and
3. To detect early and treat appropriately 'high risk'
conditions (medical or obstetrical).
4. To prepare the woman for labour, lactation and the
subsequent care of the baby.
Primigravida = a woman pregnant for the first time
Multigravida = a woman who has had two or more
Parity- refers to delivery
Nullipara = a woman who has not given birth to a
Multipara = a woman who has given birth to more
than one child
Grandmultipara = a woman who has given birth to
twoo or more children
The clinical criteria for the diagnosis of
pregnancy have been categorized into:
Possible (presumptive) signs
Early breast changes-increase in size, darkening of
areola, Montgomery’s tubercles
Amenorrhea-a women having regular cycle without the
use of hormonal contraceptives
Bladder irritability like frequency of micturation
Quickening -the date of the first fetal movement felt
by the mother provides an indicator of pregnancy.
A primigravidwomen feels it at 18-20 weeks,
the multigravida at 14-16 weeks
The presumptive indications of
Softening of the tip of the
cervix occasionally is noted
by the 4th–5th week of
Softening of the cervicouterine junction often occurs by 5–6
weeks. A soft spot may be noted anteriorly in the middle of
the uterus near its junction with the cervix.
A wider zone of softness and
compressibility in the lower
uterine segment is the most
valuable sign of early
pregnancy and can usually be
noted at 6 weeks.
If implantation is in the region
of a uterine cornu, a more pronounced
softening and suggestive
tumor like enlargement may occur.
Generalized enlargement and
diffuse softening of the uterine
corpus usually occur 8 weeks of
Presence of HCG ( human chorionic
gonadotropin) in blood, urine.
Visualization of fetus by ultrasound 6 weeks of
X-ray after 12 weeks of gestation
Fetal heart sounds by
- Fetal stethoscope or fetoscope (20th to 24th weeks of
Fetal movements by
Amenorrhea, nausea, vomiting, breast
tingling, mastalgia,urinary frequency,
urgency Quickening (fetal movement).
Changes in color, consistency, size, or shape of
cervix or uterus
Temperature elevation (usually by BBT)
Enlargement of abdomen
Breasts enlarged, engorged,
Pelvic souffle (bruit)
Uterine contractions (with enlarged corpus)
OF EARLY PREGNANCY
Active movements usually are palpable 18 weeks.
By the 16th–18th week, passive movements of the
fetus may be elucidated by abdominal and
After the 24th week, the fetal outline may be
palpated in many pregnant women.
No subjective evidence of
pregnancy is totally diagnostic.
Laboratory diagnosis is essential.
LABORATORY EVIDENCE OF
Many over-the-counter (OTC) urine pregnancy tests
have a high sensitivity and will be positive around the
time of the missed menstrual cycle. These urine tests
and the hospital laboratory serum assays test for the
beta subunit of human chorionic gonadotropin (βhCG).
This hormone produced by the placenta will rise to a
peak of 100.000mIU/ml by 10 weeks of gestation,
decrease throughout the second trimester, and then
level off at approximately 20.000 to 30.000 mIU/ml in
the third trimester.
LABORATORY EVIDENCE OF
Assays for beta-subunit hCG, commonly used to diagnose pregnancy,have an
admitted failure rate (1%).
They may be positive in nongestational ovarian choriocarcinoma or in uncommon
gastrointestinal or testicular tumors.
A positive beta-subunit hCG test may be considered reasonable proof of
Determinations of beta-subunit hCG in maternal serum compared
with a scale of predetermined quantitative values provide the most
accurate estimate of gestational age during the first 8–10 weeks.
After this, hCG levels slowly decrease, and the method becomes
Early first trimester ultrasound has four objectives:
● Locate, measure, and observe the configuration
of the gestational sac (mean sac diameter),
● Identify embryo(s), document fetal number, and
record presence or absence of life (usually
determined by heartbeat),
● Determine the extent of fetal development and
measure the crown-rump length (CRL),
● Evaluate the uterus, cervix and adnexa.
Currently, endovaginal ultrasonic detection
of the implanted products of conception
is possible when the MSD is 2–3 mm. This
occurs at 4 wk 3 d menstrual age (MA)
and the β-hCG is 500–1500 IU/mL.
Transabdominal ultrasound will detect the
gestational sac at 5 mm MSD (5 wk MA).
In a normal early pregnancy, the mean
gestational sac diameter increases by 1.2
The embryo may be ultrasonically visualized at a
CRL of 2–3.9 mm (34–40 d MA).
There is generally cardiac activity by 22–36 d
when the embryo is 1.5–3 mm.
An important correlation is that fetuses destined
to progress will have cardiac activity by CRL of
5 mm. At this time, the MSD is 15–18 mm and
the MA is 6.5 wk.
Generally, the early fetal heartbeat is more rapid
(160 bpm) and slows with gestation. Near term,
the rate is 120–140 bpm.
DURATION OF PREGNANCY
AND EXPECTED DATE
After a positive diagnosis, the duration of
pregnancy and the estimated date of
confinement (EDC) must be determined.
These calculations start from the first day of the last
menstrual period (LMP).
DURATION OF PREGNANCY
Pregnancy in women lasts about 10 lunar
months (9 calendar months).
The average length of pregnancy is 266 days.
The median duration of pregnancy is 269 days.
However, only 6% of patients will deliver
spontaneously on their EDC.
Most (60%) will deliver within 2 weeks of the
Add 7 days to the first day of the LMP,
subtract 3 months, and add 1 year.
EDC - LMP 7 days 3 months 1 year
DURATION OF PREGNANCY
Not all women have a 28-day cycle.
Hence, the physician also must consider the length of her
A patient with a regular 40-day cycle obviously will not
ovulate on day 14 but closer to or on day 26.
Therefore, her EDC cannot be estimated accurately by
Nagele’s rule alone.
Moreover, some women tend to have long or short
gestations as a familial predisposition.
1st TRIMESTER PREGNANCY’S
There are physiological, biochemical and anatomical
changes that occur during pregnancy.
These changes may be systemic or local.
• Most of the systemic changes return to pre pregnancy
status 6 weeks after delivery.
• These changes occur during pregnancy to maintain a
healthy environment for the fetus without
compromising the mother’s health.
And prepare for the process of delivery and care of the
Phisiologic adaptations in the mother occur in the
response to demands created by pregnancy.
Support of the fetus( volume, nutritional and oxygen
support, clearance of fetal waste).
Protection of the fetus ( from starvation, drugs, toxins).
Preparation of the uterus for labor.
Protection of the mother from potential cardiovascular
injury at delivery.
All maternal organ systems are required to adapt
to the demands of pregnancy.
The quality, degree and timing of the adaptation
varies from one individual to another and from
one organ system to another
Maternal systems changed by
MATERNAL CARDIOVASCULAR CHANGES
Blood volume (composed of the plasma volume +
the cellular volume) increases 45%–50% during
The plasma volume increases more and earlier in
gestation than does the cellular volume, although
the latter increases about 33% (450 mL).
This creates a declining hematocrit (HCT) until near
the 30th week of pregnancy, when the plasma
volume plateaus, and is termed the dilutional or
physiologic anemia of pregnancy.
Blood volume changes during
pregnancy and the postpartum
Dilutional or physiologic anemia of pregnancy.
The red blood cell mass begins to increase at the start of
the 2nd trimester and continues to rise.
Leukocytes (primarily polymorphonuclear leukocytes)
increase from nonpregnant levels (4300–4500/mL) to
5000–12000/mL at term.
During labor, leukocytes may rise even higher
There is a marked increase (50%) in fibrinogen over the
course of gestation. This increase is accompanied by a
general enhancement of clotting activity, which causes a
significant rise in the erythrocyte sedimentation rate
Small decreases in platelet count may occur.
Increased plasma volume may be due to augmented
plasma renin, secondary to elevated estrogen and
progesterone. This encourages
sodium retention by stimulating aldosterone secretion.
Thus, total body water is increased, and there is a gradual
cumulative retention of sodium over the course of an
This results in a total body water increase of 6–8 liters,
of which 4–6 liters is extracellular.
This results in a total body water increase of 6–8
liters, of which 4–6 liters is extracellular.
The distribution of blood volume varies with
changes in body position.
Sitting and supine recumbency during the third
trimester traps blood in the legs.
This also occurs during the supine hypotensive
syndrome (i.e., bradycardia and hypotension due
to reducedblood flow to the heart), when the
uterus compresses the inferiorvena cava.
The uterus compresses the inferior vena cava
( and probably also the aorta) – reduced blood
flow to the heart.
The position of the gravida makes a significant
the best being the left lateral decubitus.
Cardiac output (CO) - the product of the heart rate (HR) and stroke volume (SV) increases 40% (1.5 liters/min) during gestation. It reaches the maximum at 20–
24 weeks, then - stable until term.
SV – 1st and 2nd trimesters - the increase (peak of 25%–30% at 12–24
weeks), then - stable until term.
The HR increases by 15 beats/min at 1st, 2nd, 3rd trimesters.
In the supine position, this increases venous return and transiently augments
CO by about 25%; whereas in the lateral recumbent position,there is only a
Similarly, SV rises more in the supine vs. lateral recumbent (33% v. 7.7%), and
the pulse rate falls less (15% v. 0.7%).
The magnitude of these changes is modified also by the strength of the
The enhanced CO is distributed primarily to certain sites. Uterine blood flow rises
steadily, reaching 500 mL/min at term.
Increase in cardiac output during
Elevated cardiac output
and reduced peripheral
resistance – characterize
Early in pregnancy, the renal blood flow is increased
about 30% above the average for nonpregnant
women, and the glomerular filtration rate (GFR)
increases to some 50% above nonpregnant levels. This
augmentation persists to term.
Mammary blood flow increases considerably
There is no change in CNS or hepatic blood
flow during pregnancy.
At term the distribution of the raised cardiac
« Uterus 400 ml/min extra
« Kidneys 300 ml/min extra
« Skin 500 ml/min extra
« Elsewhere 300 ml/min extra.
The uterine blood flow increases from about
100ml/min in the nonpregnant state ( 2% of
CO) to about 1200ml/min (17% of CO) at
Progesterone causes relaxation of smooth muscle. This
is apparent in the venous system and results in
dilated pelvic veins,increased vasculature of the
uterus, and marked dilatation of the veins in the
However, this effect also is noted in the arteries.
BP – systolic pressure falls slightly, whereas diastolicdecreases more markedly.
Mean BP gradually falls during pregnancy, with
the largest decrease in BP typically occurring at
16 to 20 weeks. BP then begins to rise during
the mid-third trimester to levels approaching
prepregnancy BP values.
No change in the upper body.
Increase in the lower extermities enlarged
Decrease venous return to the heart increases
pressure and results in edema.
Chest Wall / Lung Mechanics
Chest wall compliance - Decreased
Thoracic diameter - Increased
Diaphragm - Elevated
Lung compliance - Unchanged
Total Lung Capacity - Unchanged or slightly decreased
Vital capacity - Unchanged or slightly increased
Inspiratory capacity - Slightly increased
Functional residual capacity - Decreased
Residual volume - Slightly decreased
Expiratory reserve volume - Decreased
( less air in the lungs in the end of EX)
Minute ventilation - Increased
Tidal volume - Increased
Respiratory rate - Unchanged
pH Normal (7.39–7.42)
PaO2 - Slightly elevated (100–105 mmHg) ( Partial pressure of oxygen in arterial blood)
PaCO2 - Slightly decreased (32–34 mmHg) (Partial pressure of carbon dioxide in arterial blood)
Bicarbonate Slightly - decreased (15–20 meq/L)
From the middle of the second trimester,
expiratory reserve volume, residual volume and
functional residual volume are progressively
decreased, by approximately 20% at term.
Airway resistance is reduced due to the
progesterone-mediated bronchial and tracheal
smooth muscle relaxation. Progesteronemediated hypersensitivity to CO2 increases the
respiratory rate by 15% and the tidal volume by
40%. Since dead space remains unchanged,
alveolar ventilation is about 70% higher at the
end of gestation.
Pregnancyrepresents a state
The diaphragm is progressively displaced
cranially by the gravid uterus causing 4 cm
decreases total lung
capacity by 4%–5%.
(respiration is more diaphragmatic)
The respiratory rate rises to 18 to 20 to
compensate for increased maternal oxygen
consumption, which is needed for demands of
the uterus, the placenta, and the fetus.
Capillary dilatation throughout the respiratory tract
causes voice changes and makes nose breathing difficult
from early pregnancy.
Radiologically, pulmonary vascular markings are enhanced.
Uterine enlargement is accompanied by as much as 4
cm diaphragm elevation, but this altered position does
not impede diaphragmatic function. Indeed, the
abdominal muscles relax during pregnancy, and, thus,
respiration is more diaphragmatic.
The lower ribcage is flared outward, enhancing the
subxiphoid angle and increasing the thoracic
circumference by up to 6 cm.
Dead space volume increases because of conducting airway
Gradual increase in tidal volume (35%–50%) occurs with lengthening
Diaphragm elevation decreases total lung capacity by 4%–5%.
Tidal volume increases 40%.
Functional residual capacity, residual volume, and expiratory reserve volume
are reduced by 20%.
Alveolar ventilation is increased by 65% by the combination of larger tidal
volume and smaller residual volume. Inspiratory capacity is increased 5%–
10% by the maximum at 22–24 weeks.
There is a slight increase in respiratory rate, minute ventilation increases
50%, and by term, oxygen consumption is increased 15%–20% above the
Respiratory minute volume is increased 26%
The urinary and reproductive systems are closely
related and conditions affecting one system
influence the other.
Chage occur due to increased maternal and placental
hormones (ACTH, ADH, cortisole, etc.) and increase
in plamsma volume.
Glomerular Filtration Rate increase by 50% (begins
early and last up to term).
Renal blood flow rate increase by 20-25% (early to
midtrimester) after the end of 2nd trimester remain
Urine volume dose not increase although glomerular
filitration rate increase because of reabsorption.
Each kidney increase in length and weight. (can
increase up to 2cm in length, increased
The renal pelvis and ureter dilate and lengthen
(these changes are evident by the 3rd
gestational month and persist until the
12th week post partum).
The kidneys must work extra hard excreting the
mother's own waste products plus those of the fetus.
There is an increase in urinary output and a decrease in
the specific gravity.
Frequent urination is a complaint during the first
through third trimester. As the uterus rises out of the
pelvic cavity in early pregnancy, pressure on the bladder
decreases and frequency diminishes. When lightening
occurs during the final weeks of pregnancy, pressure on
the bladder returns to cause frequency.
Increased oestrogen and progesterone production
causes muscular and hypertrophic changes in the
urinary tract resulting in hypomotility of the urinary
Mechanical obstruction by the enlarged uterus can
contribute to ureteral distension as well as changes to
The patient may develop urine stasis and pyelonephritis
in the right kidney. This is due to pressure on the right
ureter resulting from displacement of the uterus slightly
to the right by the sigmoid colon.
Thus there is an increase urinary stasis increase
risk of infection and stone formation.
Creatinine and BUN decrease because of
increased clearance rate.
Glycosuria is not necessarily as normal.
Proteinuria changes little during pregnancy.
As the pregnancy progresses, the uterus
enlarges. It rises up and out of the pelvic cavity.
This action displaces the stomach, intestines,
and other adjacent organs.
Peristalsis is slowed because of the production of the
hormone progesterone, which decreases tone and
mobility of smooth muscles. This slowing enhances the
absorption of nutrients and slows the rate of secretion
of hydrochloric acid and pepsin. Flare-up of peptic
ulcers is uncommon in pregnancy. Slow emptying may
increase nausea and heartburn (pyrosis). Relaxation of
the cardiac sphincter may increase regurgitation and
chance for heartburn. Movement through the large
intestines is also slowed due to an increase in water
consumption from this area. This increases the chance
(1) If the mother has difficulty with nausea and/or
heartburn, advise her to eat small, frequent meals.
(2) The patient should eat a well- balanced diet high
in protein, iron, and calcium for fetal growth; high
fiber and fluids to prevent constipation.
(3) The mother should not lie flat for 1 to 2 hours
after eating because this may cause heartburn
The appendix is displaced superiorly and into the right
flank, and the bowel is displaced upward and
laterally. This knowledge is most important
when appendectomy must be performed in
Diagnosis of acute surgical problems
(appendicitis) can prove difficult due to the
altered site of intra-abdominal contents with the
enlarged uterus displacing organs upwards and
Many patients may have enlargement of their
thyroid during pregnancy as a result of changes
in the renal handling of plasma inorganic iodide.
Raised filtration of this causes a fall in plasma
levels and the thyroid hypertrophies in an
attempt to maintain normal iodide
oncentrations. Development of a goitre in
pregnancy may indicate mild relative iodine
Thanks for attention!