1. Signs and symptoms of early pregnancy.
Anita Kazdepka-Ziemińska

2. 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.

3. Diagnosis
Who has regular menstrual cycles and is sexually active, a period delayed by more than a few days to a week is suggestive of pregnancy.

4. Diagnosis
Early antenatal care is important as soon as possible after pregnancy has been confirmed (after one or two missed periods)

5. Objectives 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
healthy mother.
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.

6. Defintions Gravidity: Pregnancy
Primigravida = a woman pregnant for the first time
Multigravida = a woman who has had two or more pregnancice
Parity- refers to delivery
Nullipara = a woman who has not given birth to a child birth
Multipara = a woman who has given birth to more than one child
Grandmultipara = a woman who has given birth to twoo or more children

7. The clinical criteria for the diagnosis of pregnancy have been categorized into:
-presumptive,
-probable,
-and positive.

8. 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
Morning sickness
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 weeks,
the multigravida at weeks

9. The presumptive indications of pregnancy.
Softening of the tip of the cervix occasionally is noted
by the 4th–5th week of pregnancy.

10. Ladin’s sign.
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.

11. Hegar’s sign.
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.

12. Piskacek’s sign. If implantation is in the region
of a uterine cornu, a more pronounced softening and suggestive
tumor like enlargement may occur.

13. Generalized enlargement and diffuse softening of the uterine corpus usually occur 8 weeks of pregnancy

14. Probable signs
Presence of HCG ( human chorionic gonadotropin) in blood, urine.
Uterine growth.
Braxtonhiks contraction.
Ballottement.

15. Positive signs
Visualization of fetus by ultrasound 6 weeks of gestation
X-ray after 12 weeks of gestation
Fetal heart sounds by
- Ultrasound
- Fetal stethoscope or fetoscope (20th to 24th weeks of
gestation)
Fetal movements by
- Palpation
- Visible

17. Symptoms
Amenorrhea, nausea, vomiting, breast tingling, mastalgia,urinary frequency, urgency Quickening (fetal movement).

18. Signs
Leukorrhea
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)

19. ABDOMINAL FINDINGS 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 vaginal palpation.
After the 24th week, the fetal outline may be palpated in many pregnant women.

20. Laboratory diagnosis is essential.
No subjective evidence of pregnancy is totally diagnostic.
Laboratory diagnosis is essential.

21. LABORATORY EVIDENCE OF PREGNANCY
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 (β-hCG).
This hormone produced by the placenta will rise to a peak of mIU/ml by 10 weeks of gestation, decrease throughout the second trimester, and then level off at approximately to mIU/ml in the third trimester.

22. LABORATORY EVIDENCE OF PREGNANCY
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 pregnancy.
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
inaccurate.

23. ULTRASONOGRAPHY 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.

24. ULTRASONOGRAPHY
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 mm/day.

25. ULTRASONOGRAPHY
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.

26. DURATION OF PREGNANCY AND EXPECTED DATE OF CONFINEMENT
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).

27. 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 EDC.

28. NAGELE’S RULE 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

29. DURATION OF PREGNANCY Not all women have a 28-day cycle.
Hence, the physician also must consider the length of her cycle.
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.

30. 1st TRIMESTER PREGNANCY’S PHYSIOLOGY.
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 newborn.

31. PREGNANCY’S PHYSIOLOGY
Phisiologic adaptations in the mother occur in the response to demands created by pregnancy.
These include:
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.

32. PREGNANCY’S PHYSIOLOGY
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

33. Maternal systems changed by pregnancy.

34. MATERNAL CARDIOVASCULAR CHANGES DURING PREGNANCY
Blood volume (composed of the plasma volume + the cellular volume) increases 45%–50% during pregnancy.
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.
Hemodilution !

35. Blood volume changes during pregnancy and the postpartum period.

36. 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.

37. HEMATOLOGIC SYSTEM
Leukocytes (primarily polymorphonuclear leukocytes) increase from nonpregnant levels (4300–4500/mL) to 5000–12000/mL at term.
During labor, leukocytes may rise even higher
(to 25,000/mL).
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 (ESR).
Small decreases in platelet count may occur.

38. HEMATOLOGIC SYSTEM
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 average pregnancy.
This results in a total body water increase of 6–8 liters, of which 4–6 liters is extracellular.

39. HEMATOLOGIC SYSTEM
This results in a total body water increase of 6–8 liters, of which 4–6 liters is extracellular.

40. HEMATOLOGIC SYSTEM
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.

41. Hypotensive syndrome The uterus compresses the inferior vena cava
( and probably also the aorta) – reduced blood flow to the heart.

42. HYPOTENSIVE SYNDRPME
The position of the gravida makes a significant difference —
the best being the left lateral decubitus.

43. CARDIAC OUTPUT
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 7%–8% increase.
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 uterine contractions.
The enhanced CO is distributed primarily to certain sites. Uterine blood flow rises steadily, reaching 500 mL/min at term.

44. CARDIAC OUTPUT

45. Increase in cardiac output during pregnancy.

46. CARDIAC OUTPUT Elevated cardiac output and reduced peripheral
resistance – characterize
pregnancy.

47. CARDIAC OUTPUT
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
by term.
There is no change in CNS or hepatic blood flow during pregnancy.

48. CARDIAC OUTPUT
At term the distribution of the raised cardiac output is:
« Uterus 400 ml/min extra
« Kidneys 300 ml/min extra
« Skin 500 ml/min extra
« Elsewhere 300 ml/min extra.

49. CARDIAC OUTPUT
The uterine blood flow increases from about 100ml/min in the nonpregnant state ( 2% of CO) to about 1200ml/min (17% of CO) at term.

50. ARTERIAL BLOOD PRESSURE (BP)
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 lower extremities.
However, this effect also is noted in the arteries.
BP – systolic pressure falls slightly, whereas diastolic- decreases more markedly.

51. ARTERIAL BLOOD PRESSURE (BP)
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.

52. ARTERIAL BLOOD PRESSURE
sphygmomanometer

53. VENOUS PRESSURE No change in the upper body.
Increase in the lower extermities enlarged
Decrease venous return to the heart increases pressure and results in edema.

54. RESPIRATORY SYSTEM

55. RESPIRATORY PHYSIOLOGIC CHANGES.
Chest Wall / Lung Mechanics
Chest wall compliance - Decreased
Thoracic diameter - Increased
Diaphragm - Elevated
Lung compliance - Unchanged
Lung Volumes
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)
Ventilation
Minute ventilation - Increased
Tidal volume - Increased
Respiratory rate - Unchanged
Blood gas
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)

56. RESPIRATORY PHYSIOLOGIC CHANGES.
From the middle of the second trimester, expiratory reserve volume, residual volume and functional residual volume are progressively decreased, by approximately 20% at term.

57. RESPIRATORY PHYSIOLOGIC CHANGES.
Airway resistance is reduced due to the progesterone-mediated bronchial and tracheal smooth muscle relaxation. Progesterone-mediated 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. 

58. RESPIRATORY PHYSIOLOGIC CHANGES.
Pregnancy-
represents a state
of compensated
respiratory
alkalosis.
Hyperventilation!

59. RESPIRATORY PHYSIOLOGIC CHANGES.
The diaphragm is progressively displaced cranially by the gravid uterus causing 4 cm elevation. 
Diaphragm elevation
decreases total lung
capacity by 4%–5%.
(respiration is more diaphragmatic)

60. RESPIRATORY PHYSIOLOGIC CHANGES.

61. RESPIRATORY PHYSIOLOGIC CHANGES.
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.

62. RESPIRATORY PHYSIOLOGIC CHANGES.
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.

63. RESPIRATORY PHYSIOLOGIC CHANGES.
Dead space volume increases because of conducting airway musculature relaxation.
Gradual increase in tidal volume (35%–50%) occurs with lengthening pregnancy.
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 nonpregnant.
Respiratory minute volume is increased 26%

64. RENAL FUNCTION
The urinary and reproductive systems are closely related and conditions affecting one system
influence the other.

65. RENAL FUNCTION
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 constant.
Urine volume dose not increase although glomerular filitration rate increase because of reabsorption.

66. RENAL FUNCTION
Each kidney increase in length and weight. (can increase up to 2cm in length, increased glomerular size).
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).

67. RENAL FUNCTION
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.

68. RENAL FUNCTION
Increased oestrogen and progesterone production causes muscular and hypertrophic changes in the urinary tract resulting in hypomotility of the urinary tract.
Mechanical obstruction by the enlarged uterus can contribute to ureteral distension as well as changes to
surrounding structures.
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.

69. RENAL FUNCTION
Thus there is an increase urinary stasis increase risk of infection and stone formation.

70. RENAL FUNCTION
Creatinine and BUN decrease because of increased clearance rate.
Glycosuria is not necessarily as normal.
Proteinuria changes little during pregnancy.

72. GASTROINTESTINAL ALTERATIONS
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.

73. GASTROINTESTINAL ALTERATIONS
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 for constipation.

74. GASTROINTESTINAL ALTERATIONS
Nursing implications.
(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 and/or regurgitation.

75. GASTROINTESTINAL ALTERATIONS
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 advanced pregnancy.

76. GASTROINTESTINAL ALTERATIONS
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 outwards.

77. THE THYROID
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 deficiency.

78. Thanks for attention!