NORMAL PREGNANCY

Table of Contents

Normal Pregnancy refers to growth and development of a fertilized ovum and begins from when the ovum is fertilized until the fetus is expelled from the uterus.

Normally the fetus is expelled at term or 9 months or 40 weeks or 280 days.
If the fetus is expelled before 28 weeks, it is called an abortion and if fetus is expelled after 28 weeks but before 37weeks it’s called premature labour and if born after 42 weeks, the post- mature is used.

Pregnancy is said to be normal when;

The fertilized ovum is growing in the cavity of the uterus.
One fetus is forming, one placenta and two membranes.
There is about 1000-1500ml of liquor amnii.
There is vertex presentation.
There is no bleeding until show in first stage of labour.
The mother should remain healthy with no serious disorders of pregnancy.

SIGNS AND SYMPTOMS OF PREGNANCY

When a woman misses one or two menstrual periods, she may begin to suspect that she is pregnant, and in most cases, her intuition is correct with an accuracy of about 98%, especially if she has been experiencing regular menstruation.

The signs of pregnancy can be classified into three groups:

Presumptive
Probable
Positive.

Presumptive signs:

Amenorrhea: This refers to the absence of menstruation. A woman may report missing one or two periods, which can be a strong indicator of pregnancy. However, amenorrhea can also be caused by factors such as contraceptive use, changes in environment, prolonged illness, or emotional disturbances.
Breast changes: Many women experience tingling and prickling sensations, as well as breast enlargement and tenderness. These changes are commonly associated with pregnancy.
Morning sickness (nausea and vomiting): Approximately 30-50% of pregnant women experience morning sickness, which typically occurs between the 4th and 14th weeks of pregnancy. While other conditions can also cause nausea and vomiting, the combination of these symptoms with amenorrhea strongly suggests pregnancy. Morning sickness often subsides by the end of the first trimester.
Increased frequency of urination: The growing uterus puts pressure on the bladder, leading to more frequent trips to the bathroom. This symptom is usually experienced before 12 weeks of pregnancy and tends to decrease once the uterus rises out of the pelvis at around 12 weeks.
Skin changes:
- Striae gravidarum: These stretch marks appear around the 16th week of pregnancy on the abdomen, thighs, and breasts.
- Chloasma (mask of pregnancy): Some women develop patches of darkened skin on the face.
- Linea nigra: A dark line may darken and appear both above and below the umbilicus.
- Darkening of areolas: The primary areolas become darker, and secondary areolas may form. The hormone responsible for these pigmentation changes is called melanin hormone and is produced by the anterior pituitary gland.
Quickening: This refers to the first fetal movements felt by the mother, usually occurring around 18-20 weeks of pregnancy for primigravida (first-time pregnancies) and 16-18 weeks for multigravida (women who have been pregnant before). Quickening can assist a midwife or healthcare provider in estimating the gestational age of a mother who is unsure of her dates.
Fatigue: Pregnant women often experience fatigue due to increased blood production, lower blood sugar levels, and decreased blood pressure influenced by progesterone. Sleep disturbances and nausea can also contribute to feelings of tiredness.
Mood changes: Physical stress, metabolic changes, fatigue, and hormonal fluctuations, particularly progesterone and estrogen, can lead to mood swings in pregnant women.

Probable signs:

Hagar’s sign: This sign can be detected between the 6th and 12th week of pregnancy. It involves performing a vaginal examination where two fingers are inserted into the anterior fornix of the vagina while the other hand presses the uterus abdominally. When the fingers from both hands meet, a softening of the isthmus can be felt, indicating pregnancy.
Jacquemier’s sign: This sign refers to the bluish discoloration of the vaginal walls, which becomes noticeable from the 8th week onwards. It is caused by pelvic congestion, a common indication of pregnancy.
Osiander’s sign: Increased pulsation felt on the lateral vaginal fornices is known as Osiander’s sign. This sign can be detected from the 8th week onwards and is a result of increased vascularity in the area.
Softening of the cervix (Goodell’s sign): Starting from the 8th week of pregnancy, the cervix of a pregnant woman becomes noticeably softer. It can be compared to the texture of the lower lip, whereas in a non-pregnant state, it is as firm as the tip of the nose.
Uterine soufflé: This refers to a soft blowing sound heard on auscultation of the abdomen. It typically occurs from the 16th week of pregnancy due to increased vascularity in the uterus.
Abdominal enlargement: The uterus undergoes rapid and progressive enlargement from the 16th week onwards. This enlargement can be observed and felt during abdominal palpation, helping to differentiate it from other causes such as gaseous distension, a full bladder, fibroids, or ascites.
Braxton Hicks contractions: These are painless contractions that usually begin from the 16th week of pregnancy. They can be felt during abdominal palpation and occur approximately every 15 minutes.
Internal ballottement: This technique involves giving the uterus a sharp tap just above the cervix, causing the fetus to float upward in the amniotic fluid. When the fetus sinks back down, the movement can be felt by fixed fingers within the vagina. Internal ballottement can be detected between the 16th and 28th weeks of pregnancy.
Presence of hCG (Human chorionic gonadotropin): The hormone hCG can be detected in the blood as early as 9 days after conception and in urine approximately 14 days after conception. The presence of hCG is a reliable indicator of pregnancy and can also be detected in conditions like hydatidiform mole.

Positive signs:

Positive signs are those that definitively confirm the presence of pregnancy. These signs include:

Fetal heart sounds: The fetal heart begins beating around the 24th week after conception. It can be heard using a Doppler device as early as 10 weeks and with a fetoscope by 24 weeks. It is important to distinguish the fetal heart sounds from the uterine soufflé caused by pulsating maternal arteries. The normal fetal heart rate ranges between 120 and 160 beats per minute.
Ultrasound scanning of the fetus: Using ultrasound technology, the gestation sac can be visualized and photographed. As early as the 4th week, an embryo can be identified, and by the 10th week of gestation, fetal body parts begin to appear on the ultrasound images.
Palpation of the entire fetus: A trained examiner can palpate and feel the various parts of the fetus, including the head, back, and upper and lower body parts. This allows for a comprehensive assessment of the baby’s position and size.
Palpation of fetal movement: Skilled healthcare providers can feel and detect fetal movements through palpation after the 24th week of gestation. This involves perceiving the baby’s kicks, rolls, and other movements by gently applying pressure on the mother’s abdomen.
X-ray: While an X-ray can identify the complete fetal skeleton as early as the 12th week, it is not a recommended method for confirming pregnancy due to the potential risks associated with radiation exposure. Total body radiation from X-rays in utero can have harmful effects on the developing fetus, leading to genetic or gonadal alterations. Therefore, other non-invasive methods, such as ultrasound, are preferred for assessing pregnancy.
Actual delivery of the baby: The ultimate confirmation of pregnancy occurs when the woman delivers the baby. The delivery of a live newborn is the conclusive evidence of pregnancy.

Differential Diagnosis:

Abdominal enlargement can be caused by conditions other than pregnancy, and it is important to consider these possibilities. Some of the potential differential diagnoses include:

Ovarian cysts: Enlargement of the abdomen can occur due to the presence of ovarian cysts. When palpated, the swelling caused by ovarian cysts can be distinguished from the uterus, and pregnancy tests will yield negative results.
Fibroids: Fibroids are noncancerous growths that can develop in the uterus. They can sometimes be mistaken for pregnancy, as they can cause a hard mass to be felt in the abdomen. However, pregnancy tests will be negative in the case of fibroids.
Distended urinary bladder: Abdominal enlargement can also result from a distended urinary bladder due to urine retention. In such cases, a catheter can be inserted to relieve the urine retention, and there will be no other signs indicating pregnancy.
Pseudocyesis: Pseudocyesis, also known as false pregnancy or phantom pregnancy, is a condition in which a woman experiences symptoms that mimic pregnancy, including amenorrhea (absence of menstruation) and other signs suggestive of pregnancy. However, upon examination, the typical signs of pregnancy are absent, and pregnancy tests will be negative. Pseudocyesis often occurs in women who have a strong desire to conceive or who experience high levels of anxiety related to pregnancy.

Multiple Choice Questions:

Which of the following is a presumptive sign of pregnancy?
a) Fetal heart sounds
b) Softening of the cervix
c) Palpation of fetal movement
d) Morning sickness
Hagar’s sign is detected by:
a) Auscultation of fetal heart sounds
b) Palpation of fetal movement
c) Vaginal examination
d) Ultrasound scanning
Which sign is a probable sign of pregnancy?
a) Fetal heart sounds
b) Ovarian cysts
c) Presence of HCG
d) Pseudocyesis
What is the normal fetal heart rate?
a) 60-80 beats per minute
b) 90-120 beats per minute
c) 120-160 beats per minute
d) 180-200 beats per minute
Which sign can help in determining the gestational age if the mother is unsure of her dates?
a) Quickening
b) Internal ballottement
c) Jacquemier’s sign
d) Amenorrhea
Which diagnostic tool can visualize the gestation sac and fetal parts?
a) X-ray
b) Ultrasound scanning
c) Fetal palpation
d) HCG test
What is the most accurate method to confirm pregnancy?
a) Palpation of fetal movement
b) X-ray
c) Actual delivery of the baby
d) Ultrasonography
Which condition can cause abdominal enlargement and yield negative pregnancy test results?
a) Fibroids
b) Ovarian cysts
c) Pseudocyesis
d) Morning sickness
Osiander’s sign is characterized by:
a) Softening of the cervix
b) Increased pulsation in the vaginal fornices
c) Bluish discoloration of the vaginal walls
d) Enlargement of the breasts
Which sign can be detected by both Doppler and fetoscope?
a) Fetal heart sounds
b) Uterine soufflé
c) Internal ballottement
d) Quickening
What differentiates fibroids from pregnancy?
a) Positive pregnancy test results
b) Palpable fetal movements
c) Presence of uterine soufflé
d) Hard mass felt on palpation
What is the purpose of X-ray in pregnancy?
a) To visualize the fetal heart rate
b) To determine the gestational age
c) To confirm pregnancy definitively
d) It is not recommended due to radiation risks
What differentiates pseudocyesis from a true pregnancy?
a) Amenorrhea
b) Fetal heart sounds
c) Palpation of fetal movement
d) Negative pregnancy test results
What is the primary cause of morning sickness during pregnancy?
a) Increased blood production
b) Hormonal changes
c) Bladder pressure
d) Emotional upsets
Which sign is considered a positive sign of pregnancy?
a) Morning sickness
b) Softening of the cervix
c) Distended urinary bladder
d) Palpation of fetal movement

Fill in the Blanks:

________ is the absence of menstruation and a presumptive sign of pregnancy.
________ can be detected by performing a vaginal examination and palpating the isthmus.
Increased pulsation in the lateral vaginal fornices is known as ________.
________ is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
Fetal heart sounds can be detected by a ________ or a fetoscope.
The normal fetal heart rate ranges between ________ beats per minute.
Ultrasound scanning can visualize the ________ and identify the fetal parts.
Palpation of ________ is necessary to assess the position and size of the fetus.
X-ray is not recommended for pregnancy confirmation due to potential ________ risks.
The delivery of a live newborn is the ________ evidence of pregnancy.

Multiple Choice Questions:

Answer: d) Morning sickness
Answer: c) Vaginal examination
Answer: b) Ovarian cysts
Answer: c) 120-160 beats per minute
Answer: b) Internal ballottement
Answer: b) Ultrasound scanning
Answer: c) Actual delivery of the baby
Answer: a) Fibroids
Answer: b) Increased pulsation in the vaginal fornices
Answer: a) Fetal heart sounds
Answer: d) Hard mass felt on palpation
Answer: d) It is not recommended due to radiation risks
Answer: d) Negative pregnancy test results
Answer: b) Hormonal changes
Answer: d) Palpation of fetal movement

Fill in the Blanks:

Amenorrhea is the absence of menstruation and a presumptive sign of pregnancy.
Hagar’s sign can be detected by performing a vaginal examination and palpating the isthmus.
Increased pulsation in the lateral vaginal fornices is known as Osiander’s sign.
Pseudocyesis is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
Fetal heart sounds can be detected by a Doppler or a fetoscope.
The normal fetal heart rate ranges between ________ beats per minute.
Ultrasound scanning can visualize the gestation sac and identify the fetal parts.
Palpation of the entire fetus is necessary to assess the position and size of the fetus.
X-ray is not recommended for pregnancy confirmation due to potential radiation risks.
The delivery of a live newborn is the ultimate evidence of pregnancy.