Signs of Pregnancy

Presumptive Signs (Subjective Signs)

• findings in connection with the body system in which they occur and are experienced by the woman but cannot be documented by an examiner

1. Breast Changes - feelings of tenderness, fullness, tingling, enlargement and darkening of areola

2. Nausea and Vomiting - on arising or when fatigue

3. Amenorrhea - absence of menstruation

4. Fatigue - general feeling of tiredness

5. Frequent Urination - sense of having to void more often than usual (First Trimester: Due to hormonal changes; Second Trimester: Due to increasing size of utero)

6. Uterine Enlargement - uterus can be palpated over symphysis pubis

7. Quickening - Fetal movement felt by the woman (20 wks)

8. Linea Nigra - a dark vertical line that appears on the stomach during pregnancy

9. Melasma (Chloasma) - a darkened or reddened areas appear on face (Cheeks and Nose)

10. Striae Gravidarum - pink or reddish streaks forms on abdominal wall sometimes on the thigh

11. Palmar Erythema - redness and itchiness of the hands

Probable Signs (Objective Signs)

• Findings and can be verified by the examiner

1. Chadwick’s Sign - color change of the vagina from light pink to deep violet

2. Goodell’s Sign - softening of the cervix

3. Hegar’s Sign - softening of the lower uterine segment

4. Sonographic Evidence of Gestational Sac - characteristics ring is evident

5. Braxton Hick’s Contraction - periodic uterine tightening

6. Fetal outline felt by examiner through palpation

7. Ballottement – fetus can be felt to bounce against the top examining hand (16 –29 wks.) through bimanual examination

8. Laboratory Tests - blood serum and urine specimen to detect the presence of human chorionic gonadotrophin (hCG)

   • Maternal Serum Test - a venipuncture of blood serum reveal the presence of hCG

   • Urine Sample - concentrated such as a first urine in the morning

   • Early Prenatal Care - is the best safeguard to ensure successful pregnancy

Positive Signs

• Definitive Signs of Pregnancy

1. Sonographic evidence of fetal outline fetal outline can be seen and measure by sonogram

2. Fetal movement felt by examiner

3. Fetal heart audible – doppler ultrasound reveal heartbeat (10th – 12th week of gestation)

Physiologic Changes of Pregnancy

• They can categorize as local (confined to the reproductive organs) or systemic (affecting the entire body)

1. Reproductive System Changes

1. Uterine Changes -

   • increase the size of the uterus to accommodate the growing fetus.

     • Length – from 6.5 cm. to 32 cm;

     • Width – from 4cm to 24 cm;

     • Weight - increases from 50 g to 1000 g

     • Depth- increases from 2.5 cm to 22 cm

     • Uterine wall thickens from 1cm to 2cms

     • Volume – increases from 2 ml. to more than1,000 ml. can hold a total of 4000g at term ( 7-lb (3.175 g.) fetus, and 1,000 ml. amniotic fluid

   • Fundus height at various week of pregnancy

     • 20-22nd week – reaches the level of the umbilicus

     • 36th week – touches the xiphoid process

     • 38th week – fetal head settles into the pelvis

   • Hegar’s signs – extreme softening of the lower uterine segment

   • Ballottement – (ballotter meaning “to quake”) - the fetus can be felt to bounce or rise in the amniotic fluid up against a hand placed on the abdomen

   • Braxton Hick’s contraction – (practice contractions) serve as warm-up exercise for labor and play a role in ensuring the placenta receives adequate blood

   • Amenorrhea – absence of menstrual flow because of suppression of FSH by rising estrogen levels

2. Cervical Changes

   • becomes more vascular and edematous

   • Operculum – a mucus plug forms to seal out bacteria and help prevent infection in the fetus and membranes

   • Goodell’s sign - softening of the cervix

3. Vaginal Changes

   • increase vascularity of the vagina

   • Chadwick’s sign -changes in color from light pink to a deep violet

   • pH level falls to 4 or 5 (an acid pH) –helps the vagina resistant to bacterial invasion and occurs because of the action of Lactobacillus acidophilus

4. Ovarian Changes

   • ovulation stops due to active production of Estrogen and Progesterone produced in early pregnancy by the corpus luteum and late in pregnancy by the placenta

   • Corpus luteum created after ovulation continues to increase in size until 16th week of pregnancy, by which time the placenta takes over as the chief provider of estrogen and progesterone

5. Breast Changes

   • Feeling of fullness, tingling or tenderness because of increased estrogen level

   • Breast size increase - growth in mammary alveoli and in fat deposit

   • Areola of the nipple darkens and the diameter increases from about 1.5 inch to 2 or 3 inches)

   • Colostrum – thin, watery, high protein fluid expelled from 16th wk. of pregnancy

2. Endocrine System Changes

• Placenta - responsible for the production of Estrogen, progesterone, HCG and human placental lactogen (HPL), relaxin and prostaglandins during pregnancy

1. Estrogen

   • Breast and uterine enlargement

   • Palmar erythema – occur in early pregnancy as a response to high estrogen level

2. Progesterone

   • Major role in maintaining the endometrium

   • Inhibiting uterine contractility

   • Aiding in the development of the breast for lactation

3. Human Chorionic Gonadotropin

   • secreted by the trophoblast cells beginning early in pregnancy

   • it stimulates progesterone and estrogen synthesis in the ovaries until the placenta can assume this role

4. Human Chorionic Somatomammotropin (HPL)

   • serves as an antagonist to insulin, making insulin less effective, so allow more glucose to become available for fetal growth

   • Causes gestational diabetes

5. Relaxin

   • secreted by the corpus luteum of the ovary

   • responsible for helping to inhibit uterine activity

   • soften the cervix allowing for dilatation at birth

   • softening of collagen allows for laxness in the lower spine which helps enlarge the birth canal

6. Prostaglandins

   • affect smooth muscle contractility to such an extend they may be the trigger that initiates labor at term

• Pituitary Gland – halt in production of FSH and LH because of high estrogen and progesterone levels produced by the placenta

• increased production of growth hormones and melanocyte stimulating hormone which causes skin pigment changes

• Prolactin production begin late in pregnancy and helps breast prepare for lactation

• Posterior pituitary gland begins to produce oxytocin needed to aid labor during late pregnancy

PANCREAS

• Pancreas increases the production of insulin in response to the higher level of glucocorticoid produced by the adrenal glands

• Insulin is less effective because estrogen, progesterone, and hPL are all antagonist of insulin

• Glucose level of fetus - 30 mg./100 ml. lower than the maternal serum glucose level

3. Immune System Changes

• Immunologic competency during pregnancy decreases to prevent a woman’s body from rejecting the fetus as if it were transplanted organ.

• Immunoglobulin G (IgG) production is decreased which can make a woman more prone to infection during pregnancy

  • IgG is the main type of antibody found in blood and allowing it to control infection of body tissues.

  • IgG protects the body from infection

4. Integumentary System Changes

1. Linea Nigra

   • a narrow brown line running from the umbilicus to the symphysis pubis

2. Melasma (Chloasma)

   • a darkened or reddened areas appear on face (Cheeks and Nose)

   • “Mask of Pregnancy”

3. Striae Gravidarum

   • pink or reddish streaks forms on abdominal wall sometimes on the thigh

   • weeks after birth it lighten to a silvery color, although permanent they become barely noticeable

   • Causes:

     • Abdominal wall stretch to accommodate the increasing size of uterus.

     • Stretching can cause rupture and atrophy of small connective layer of the skin.

4. Palmar erythema

   • redness and itchiness of the hands

   • results from increased level of estrogen

5. Respiratory System Changes

• congestion, or “stuffiness” of the nasopharynx due to increased estrogen levels

• Two major changes occur during pregnancy:

  1. Rapid than usual breathing rate (18 -20 bpm)

  2. feeling of shortness of breath

• The lungs receive an increasing amount of pressure toward the end of pregnancy and displace the diaphragm by as much as 4 cm upward

• Physiologic reasons for those changes:

  • Residual volume – amount of air remaining in the lungs after expiration is decreased up to 20% because of the pressure of the diaphragm.

  • Tidal volume – volume of air inspired is increased up to 40% in deeper breaths to increase the effectiveness of air exchange

TEMPERATURE

• Body temperature increases slightly due to secretion of progesterone from corpus luteum and decreases to normal on the 16 wks. (4th months)

6. Cardiovascular System Changes

1. Blood volume increases by 30% - 50%

   • To provide for an adequate exchange of nutrients across the placenta and for adequate blood to compensate for maternal blood loss at birth

2. Blood Loss at Birth:

   • Normal vaginal birth – blood loss is 300-400 ml.

   • Cesarean birth – blood loss can be a high as 800-1,000 ml.

• increase in blood volume occurs gradually beginning at the end of the first semester

• 28th – 32nd week – its peak and continues at this high level throughout the third trimester

• The concentration of hemoglobin and erythrocytes declines in early pregnancy and giving the woman Pseudoanemia

• Hemoglobin level back to near normal by the 2nd trimester

• Iron, Folic acid, and Vitamins Needs Management:

  1. Encourage to eat foods high in folic acid (Spinach, asparagus, legumes)

  2. Prenatal vitamins - contains iron, folic acid.

     • 350-400 mg. iron/day – fetus requirement

     • 400 mg. iron/day – maternal requirement

     • Folic acid – demand increases beginning early in pregnancy to prevent the risk of fetal neural tube defect and abdominal wall disorders

1. Heart rate increases by 10 beats/min. causing cardiac output to increase as 25%- 50%

   • Heart murmur develop during pregnancy due to increase blood volume and pressure from the diaphragm

   • Palpitation of the heart - caused by circulatory adjustment to increased blood volume

   • Later months - result from increased thoracic pressure of the diaphragm.

2. Blood Pressure

   • Slightly decreases during the second trimester because the expanding placenta causes peripheral resistance to circulation to lower

   • BP during the 3rd trimester rises again to firsttrimester levels.

PERIPHERAL BLOOD FLOW

• 3rd trimester - blood flow to the lower extremities impaired

1. Edema and Varicosities (vulva, rectum, and legs)

   • Management

     1. Wear elastic support stockings for relief of varicosities

     2. Rest in a Sim’s position or on the back with the legs raised against the wall for 15-20 mins.

     3. Avoid use of constricting garters.

     4. Vitamin C, A, and B - helps in reducing the size of varicosities.

     5. Have a “ walk break” at least twice a day.

2. Supine Hypotension Syndrome

   • lies in supine and the weight of the growing uterus presses the vena cava obstructing blood flow from the lower extremities

   • decrease in blood return to the heart and decreased cardiac output and hypotension

   • S/Sx

     • Lightheadedness

     • Faintness

     • Palpitations

   • Management:

     • Teach the woman to always rest on the left side rather than their back so blood flow through the vena cava increases and prevent hypotension

3. Blood Constitutions

   • Fibrinogen – blood necessary for clotting increases by 50% stimulated by the increased level of estrogen

   • Clotting factors and platelet count increase as safeguard against bleeding

   • WBC count rises both as a protective mechanism against infection

   • Total protein level of blood decreases, indicating the amount of protein being used by the fetus

   • Blood lipids increase by one third, cholesterol serum level increases by 90% to 100% to provide a ready supply of energy for the fetus

Gastrointestinal System Changes

• 50% of woman experience Morning sickness early in the morning on rising, or if fatigued during the day

1. Nausea and vomiting

   • begins at the time level of hCG and progesterone begins to rise that may contribute to its cause.

   • Causes

     1. hCG and progesterone rise

     2. Sensitivity to the high level of hCG hormone

     3. High progesterone and estrogen level.

     4. Lowered maternal blood sugar caused by the needs of the developing embryo.

     5. Diminished gastric motility

   • Management:

     1. Eat dry crackers before rising in the morning.

     2. Eat a light breakfast or delay breakfast.

     3. Eat small but frequent meals.

   • Hyperemesis Gravidarum

     • severe nausea and vomiting that is prolonged, occur within 12 wks. of pregnancy

     • Management:

       1. All oral food and fluids are withheld.

       2. IV fluids (3000 ml. of Ringer’s lactate)

       3. Measure intake and output.

2. Constipation and Flatulence

   • peristalsis are slows and the weight of growing uterus presses against the bowel

   • Management:

     1. Increase the amount of fiber in the diet

     2. Encourage to evacuate her bowels regularly

     3. Drink at least 8 glasses of water daily

3. Hemorrhoids

   • are varicosities of the rectal veins due the pressure on these veins from the growing uterus

   • Management:

     1. Daily bowel evacuation to prevent constipation

     2. Drinking adequate fluid, eating adequate fibers

     3. Resting in modified sims position to prevent and relieve pain

     4. At day’s end assuming a knee-chest position for 10- 15 mins to reduce the pressure on rectal veins

     5. A stool softener may be recommended. f.

     6. Applying cold compress to external hemorrhoids.

     7. Replacing hemorrhoids with gentle finger pressure.

4. Heart Burn (Pyrosis)

   • a burning sensation along the esophagus caused by regurgitation of gastric contents into the lower esophagus

   • Causes:

     • Decreased gastric motility which slow gastric emptying.

     • Pressure of the expanding uterus pushing up against the stomach

   • Management:

     1. Eat small meals frequently.

     2. Sleep on the left side with pillows to elevate the upper torso.

     3. Avoid fatty and fried foods. (coffee, carbonated beverages, tomato products, and citrus juices)

     4. Drugs - may be prescribed for relief.

        • Aluminum hydroxide ( Amphojel, Alternagel)

        • Aluminum and Magnesium Hydroxide (Maalox)

        • Cimetidine (Tagamet)

        • Ranitidine (Zantac)

Urinary System Changes

• Urinary system undergoes physiologic changes during pregnancy (alterations in fluid retention, renal, ureters, and bladder function)

• Causes:

  1. Compression of the bladder and ureters by growing fetus.

  2. Effect of high estrogen and progesterone level.

  3. Increased blood volume.

  4. Postural influences

1. Urinary frequency – urge to void more often than usual.

2. First 3 months of pregnancy – due to increased blood supply in the kidneys.

3. Third trimester – pressure of enlarged uterus.

4. Poor bladder emptying and bladder infection due to pressure on the urethra.

Musculoskeletal System

• Excessive mobility of the joints can cause discomfort

• S/Sx

  • Backache – strain from the extra uterine weight puts on lower vertebra.

  • Leg cramps – due to increased pressure on the lower extremities

  • Fatigue and muscles tenseness

• Management

  1. Limit the use of high heels – they add to the natural lordosis of pregnancy

     • Lordosis - excessive inward curvature of the spine.

  2. Rest daily with feet elevated.

  3. Walk with head high, pelvis straight.

  4. Increased calcium and phosphorous intake.

  5. Lie on the back and extend legs keeping the knee straight while dorsiflexion the foot.