Diagnosis of Pregnancy

Pregnancy may be suspected in any sexually active woman, of childbearing age, whose menstrual period is delayed, particularly if combined with symptoms of early pregnancy, such as:

Nausea (1st trimester) Breast and nipple tenderness (1st trimester) Marked fatigue (1st and 3rd trimesters) Urinary frequency (1st and 3rd trimesters) The patient thinks she's pregnant

Early signs of pregnancy may include:

Blue discoloration of the cervix and vagina (Chadwick's sign) Softening of the cervix (Goodell's sign) Softening of the uterus (Ladin's sign and Hegar's sign) Darkening of the nipples Unexplained pelvic or abdominal mass

Pregnancy should be confirmed with a reliable pregnancy test. Urine or serum pregnancy tests can be used. Both are reliable and detect human chorionic gonadotropin (HCG). Pregnancy is considered present if 30-35 mIU of HCG are present in the urine or serum. Ultrasound may be used to confirm a pregnancy, if the gestational age is old enough for visualization of a recognizable fetus and fetal heartbeat. In that situation, a confirmatory HCG is not necessary. Among the military population of the United States Armed Forces, women represent almost 20% of the personnel.

Approximately 10% of them are pregnant at any given time. Half of those will be known to be pregnant, while the other half are not known to be pregnant. In some cases, it is too early in the pregnancy for anyone to know. In other cases, the woman knows, but has not brought it to the attention of her medical providers.

For these reasons, it is particularly important to aggressively test for pregnancy in women with clinically significant symptoms. http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Pregnancy/diagnos is_of_pregnancy.htm

Pregnancy
From Wikipedia, the free encyclopedia For pregnancy in non-human animals, see Pregnancy (mammals). Pregnancy is the fertilization and development of one or more offspring, known as an embryo or fetus, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Childbirth usually occurs about 38 weeks after conception; in women who have a menstrual cycle length of four weeks, this is approximately 40 weeks from the start of the last normal menstrual period (LNMP). Human pregnancy is the most studied of all mammalian pregnancies. The term embryo is used to describe the developing offspring during the first 8 weeks following conception, and subsequently the term fetus is used henceforth until birth.[1][2] 40% of pregnancies in the United States and United Kingdom are unplanned.[3][4] In many societies medical or legal definitions, human pregnancy is somewhat arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of prenatal development. The first trimester carries the highest risk of miscarriage (natural death of embryo or fetus). During the second trimester, the development of the fetus can be more easily monitored and diagnosed. The beginning of the third trimester often approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus.[5]

Etymology
One scientific term for the state of pregnancy is gravidity (adjective "gravid"), latin for heavy and a pregnant female is sometimes referred to as a gravida.[6] Similarly, the term parity (abbreviated as para) is used for the number of previous successful live births. Medically, a woman who has never been pregnant is referred to as a nulligravida, a woman who is (or has been only) pregnant for the first time as a primigravida,[7] and a woman in subsequent pregnancies as a multigravida or multiparous.[6][8][9] Hence, during a second pregnancy a woman would be described as gravida 2, para 1 and upon live delivery as gravida 2, para 2. An in-progress pregnancy, as well as abortions, miscarriages, or stillbirths account for parity values being less than the gravida number. In the case of twins, triplets etc., gravida number and parity value are increased by one only. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as nulliparous.[10]

[edit] Progression
Stages in prenatal development, with weeks and months numbered from last menstrual period.

Initiation

The initial stages of human embryogenesis. Although pregnancy begins with implantation, the process leading to pregnancy occurs earlier as the result of the female gamete, or oocyte, merging with the male gamete, spermatozoon. In medicine this process is referred to as fertilization; in lay terms, it is more commonly known as conception. After the point of fertilization, the fused product of the female and male gamete is referred to as a zygote or fertilized egg. The fusion of male and female gametes usually occurs following the act of sexual intercourse, resulting in spontaneous pregnancy. However, the advent of artificial insemination and in vitro fertilisation have made achieving pregnancy possible without engaging in sexual intercourse. This approach may be undertaken as a voluntary choice or due to infertility. The process of fertilization occurs in several steps, and the interruption of any of them can lead to failure. Through fertilization, the egg is activated to begin its developmental process, and the haploid nuclei of the two gametes come together to form the genome of a new diploid organism[11] At the beginning of the process, the sperm undergoes a series of changes, as freshly ejaculated sperm is unable or poorly able to fertilize, [12] The sperm must undergo capacitation in the female's reproductive tract over several hours, which increases its motility and destabilizes its membrane, preparing it for the acrosome reaction, the enzymatic penetration of the egg's tough membrane, the zona pellucida, which surrounds the oocyte. The sperm and the egg cell, which has been released from one of the female's two ovaries, unite in one of the two fallopian tubes. The fertilized egg, known as a zygote, then moves toward the uterus, a journey that can take up to a week to complete. Cell division begins approximately 24 to 36 hours after the male and female cells unite. Cell division continues at a rapid rate and the cells then develop into what is known as a blastocyst. The blastocyst is made up of three layers: the ectoderm (which will become the skin and nervous system), the endoderm (which will become the digestive and respiratory systems), and the mesoderm (which will become the muscle and skeletal systems). Finally, the blastocyst arrives at the uterus and attaches to the uterine wall, a process known as implantation. The mass of cells, now known as an embryo, begins the embryonic stage which continues until cell differentiation is almost complete at eight weeks. Structures important to the

support of the embryo develop, including the placenta and umbilical cord. During this time, cells begin to differentiate into the various body systems. The basic outlines of the organ, body, and nervous systems are established. By the end of the embryonic stage, the beginnings of features such as fingers, eyes, mouth, and ears become visible. Once cell differentiation is mostly complete, the embryo enters the final stage and becomes known as a fetus. The early body systems and structures that were established in the embryonic stage continue to develop. Sex organs begin to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the last weeks of pregnancy.

[edit] Duration
Healthcare professionals name three different dates as the start of pregnancy:

the first day of the woman's last normal menstrual period, the date of conception (about two weeks before her next expected menstrual period), and the date of implantation (about one week after conception).

Since these are spread over a significant period of time, the duration of pregnancy necessarily depends on the date selected as the starting point chosen. The most common system used among healthcare professionals is Naegele's rule, which was developed in the early 19th century. This calculates the expected due date from the first day of the last normal menstrual period (LMP or LNMP) regardless of factors known to make this inaccurate, such as a shorter or longer menstrual cycle length. Pregnancy most commonly lasts for 40 weeks according to this LNMP-based method, assuming that the woman has a predictable menstrual cycle length of close to 28 days and conceives on the 14th day of that cycle, and a birth between 37 and 42 weeks LNMP is considered fullterm.[13] Other, more accurate algorithms take into account a variety of other variables, such as whether this is the first or subsequent child (i.e., pregnant woman is a primipara or a multipara, respectively), ethnicity, parental age, length of menstrual cycle, and menstrual regularity), but these are rarely used by healthcare professionals. There is a standard deviation of 89 days surrounding due dates calculated with even the most accurate methods. This means that fewer than 5 percent of births occur at exactly 40 weeks; 50 percent of births are within a week of this duration, and about 80 percent are within 2 weeks.[14] It is much more useful and accurate, therefore, to consider a range of due dates, rather than one specific day, with some online due date calculators providing this information.[15] Pregnancy is considered "at term" when gestation attains 37 complete weeks but is less than 42 (between 259 and 294 days since LMP). Events before completion of 37 weeks (259 days) are considered preterm; from week 42 (294 days) events are considered postterm.[16] When a pregnancy exceeds 42 weeks (294 days), the risk of complications

for both the woman and the fetus increases significantly. [13][17] Therefore, in an otherwise uncomplicated pregnancy, obstetricians usually prefer to induce labour at some stage between 41 and 42 weeks.[18][19] Birth before 39 weeks, even if considered "at term", increases the risk of complications and premature death, from factors including under-developed lungs, infection due to under-developed immune system, problems feeding due to under-developed brain, and jaundice from under-developed liver. Some hospitals in the United States have noted a significant increase in neonatal intensive care unit patients when women schedule deliveries for convenience and are taking steps to reduce induction for non-medical reasons.[20] Complications from Caesarean section are more common than for live births. Recent medical literature prefers the terminology preterm and postterm to premature and postmature. Preterm and postterm are unambiguously defined as above, whereas premature and postmature have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy.[21][22] Accurate dating of pregnancy is important, because it is used in calculating the results of various prenatal tests, (for example, in the triple test). A decision may be made to induce labour if a fetus is perceived to be overdue. Furthermore, if LMP and ultrasound dating predict different respective due dates, with the latter being later, this might signify slowed fetal growth and therefore require closer review. The age of fetal viability has been receding because of continued medical progress. Whereas it used to be 28 weeks, it has been brought back to as early as 23, or even 22 weeks in some countries.[citation needed]

[edit] Childbirth
Main article: Childbirth Childbirth is the process whereby an infant is born. It is considered to be the beginning of the infant's life, and age is defined relative to this event in most cultures. A woman is considered to be in labour when she begins experiencing regular uterine contractions, accompanied by changes of her cervix primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours, while others find that concentrating on the birth helps to quicken labour and lessen the sensations. Most births are successful vaginal births, but sometimes complications arise and a woman may undergo a cesarean section. During the time immediately after birth, both the mother and the baby are hormonally cued to bond, the mother through the release of oxytocin, a hormone also released during breastfeeding. Studies show that skin-to-skin contact between a mother and her newborn immediately after birth is beneficial for both mother and baby. A review done by the World Health Organization found that skin-to-skin contact between mothers and babies after birth reduces crying, improves mother-infant interaction, and helps mothers to

breastfeed successfully. They recommend that neonates be allowed to bond with the mother during their first two hours after birth, the period that they tend to be more alert than in the following hours of early life.[23]

[edit] Postnatal period

Main article: Postnatal The postnatal period begins immediately after the birth of a child and then extends for about six weeks. During this period, the mother's body begins the return to prepregnancy conditions that includes changes in hormone levels and uterus size.

[edit] Diagnosis

Linea nigra in a woman at 22 weeks pregnant. The beginning of pregnancy may be detected in a number of different ways, either by a pregnant woman without medical testing, or by using medical tests with or without the assistance of a medical professional. Most pregnant women experience a number of symptoms,[24] which can signify pregnancy. The symptoms can include nausea and vomiting, excessive tiredness and fatigue, cravings for certain foods that are not normally sought out, and frequent urination particularly during the night. A number of early medical signs are associated with pregnancy.[25][26] These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body

temperature sustained for over 2 weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the uterus isthmus), and pigmentation of linea alba Linea nigra, (darkening of the skin in a midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy).[25] [26] Breast tenderness is common during the first trimester, and is more common in women who are pregnant at a young age.[27] Pregnancy detection can be accomplished using one or more various pregnancy tests,[28] which detect hormones generated by the newly formed placenta. Clinical blood and urine tests can detect pregnancy 12 days after implantation. [29] Blood pregnancy tests are more accurate than urine tests.[30] Home pregnancy tests are urine tests, and normally cannot detect a pregnancy until at least 12 to 15 days after fertilization. A quantitative blood test can determine approximately the date the embryo was conceived. In the post-implantation phase, the blastocyst secretes a hormone named human chorionic gonadotropin, which in turn stimulates the corpus luteum in the woman's ovary to continue producing progesterone. This acts to maintain the lining of the uterus so that the embryo will continue to be nourished. The glands in the lining of the uterus will swell in response to the blastocyst, and capillaries will be stimulated to grow in that region. This allows the blastocyst to receive vital nutrients from the woman. Despite all the signs, some women may not realize they are pregnant until they are quite far along in their pregnancy. In some cases, a few women have not been aware of their pregnancy until they begin labour. This can be caused by many factors, including irregular periods (quite common in teenagers), certain medications (not related to conceiving children), and obese women who disregard their weight gain. Others may be in denial of their situation. An early obstetric ultrasonography can determine the age of the pregnancy fairly accurately. In practice, medical professionals typically express the age of a pregnancy (i.e., an "age" for an embryo) in terms of "menstrual date" based on the first day of a woman's last menstrual period, as the woman reports it. Unless a woman's recent sexual activity has been limited, she has been charting her cycles, or the conception is the result of some types of fertility treatment (such as IUI or IVF), the exact date of fertilization is unknown. Without symptoms such as morning sickness, often the only visible sign of a pregnancy is an interruption of the woman's normal monthly menstruation cycle, (i.e., a "late period"). Hence, the "menstrual date" is simply a common educated estimate for the age of a fetus, which is an average of 2 weeks later than the first day of the woman's last menstrual period. The term "conception date" may sometimes be used when that date is more certain, though even medical professionals can be imprecise with their use of the two distinct terms. The due date can be calculated by using Naegele's rule. The expected date of delivery may also be calculated from sonogram measurement of the fetus. This method is slightly more accurate than methods based on LMP.[31] Additional obstetric diagnostic techniques can estimate the health and presence or absence of congenital diseases at an early stage.

[edit] Physiology

Breast changes as seen during pregnancy. Note the increase in size and darkening of the areola. Pregnancy is typically broken into three periods, or trimesters, each of about three months.[32] While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.

[edit] First trimester

Traditionally, medical professionals have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implantation and chemical detection. In medicine, pregnancy is often defined as beginning when the developing embryo becomes implanted in the endometrial lining of a woman's uterus. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding. After implantation, the uterine endometrium is called the decidua. The placenta, which is formed partly from the decidua and partly from outer layers of the embryo, connects the developing embryo to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. The umbilical cord is the connecting cord from the embryo or fetus to the placenta. The developing embryo undergoes tremendous growth and changes during the process of fetal development. Morning sickness occurs in about seventy percent of all pregnant women, and typically improves after the first trimester.[33] Although described as "morning sickness", women can experience this nausea during afternoon, evening, and throughout the entire day. Shortly after conception, the nipples and areolas begin to darken due to a temporary increase in hormones.[34] This process continues throughout the pregnancy. The first 12 weeks of pregnancy are considered to make up the first trimester. The first two weeks from the first trimester are calculated as the first two weeks of pregnancy even though the pregnancy does not actually exist. These two weeks are the two weeks before conception and include the woman's last period. The third week is the week in which fertilization occurs and the 4th week is the period when implantation takes place. In the 4th week, the fecundated egg reaches the uterus and burrows into its wall which provides it with the nutrients it needs. At this point, the

zygote becomes a blastocyst and the placenta starts to form. Moreover, most of the pregnancy tests may detect a pregnancy beginning with this week. The 5th week marks the start of the embryonic period. This is when the embryo's brain, spinal cord, heart and other organs begin to form.[35] At this point the embryo is made up of three layers, of which the top one (called the ectoderm) will give rise to the embryo's outermost layer of skin, central and peripheral nervous systems, eyes, inner ear, and many connective tissues.[35] The heart and the beginning of the circulatory system as well as the bones, muscles and kidneys are made up from the mesoderm (the middle layer). The inner layer of the embryo will serve as the starting point for the development of the lungs, intestine and bladder. This layer is referred to as the endoderm. An embryo at 5 weeks is normally between 116 and 18 inch (1.6 and 3.2 mm) in length. In the 6th week, the embryo will be developing basic facial features and its arms and legs start to grow. At this point, the embryo is usually no longer than 16 to 14 inch (4.2 to 6.3 mm). In the following week, the brain, face and arms and legs quickly develop. In the 8th week, the embryo starts moving and in the next 3 weeks, the embryo's toes, neck and genitals develop as well. According to the American Pregnancy Association, by the end of the first trimester, the fetus will be about 3 inches (76 mm) long and will weigh approximately 1 ounce (28 g).[36] Once pregnancy moves into the second trimester, all the risks of miscarriage and birth defects occurring drop drastically.

[edit] Second trimester

By the end of the second trimester, the expanding uterus has created a visible "baby bump". Although the breasts have been developing internally since the beginning of the pregnancy, most of the visible changes appear after this point. Weeks 13 to 28 of the pregnancy are called the second trimester. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away.

The uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy. Although the fetus begins to move and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as "quickening", can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. However, it is not uncommon for some women not to feel the fetus move until much later. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproductive organs distinguish the fetus as male or female. During the second trimester, most women begin to wear maternity clothes.

[edit] Third trimester

Comparison of growth of the abdomen between 26 weeks and 40 weeks gestation. Final weight gain takes place, which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28 g per day. The woman's belly will transform in shape as the belly drops due to the fetus turning in a downward position ready for birth. During the second trimester, the woman's belly would have been very upright, whereas in the third trimester it will drop down quite low, and the woman will be able to lift her belly up and down. The fetus begins to move regularly, and is felt by the woman. Fetal movement can become quite strong and be disruptive to the woman. The woman's navel will sometimes become convex, "popping" out, due to her expanding abdomen. This period of her pregnancy can be uncomfortable, causing symptoms like weak bladder control and backache. Movement of the fetus becomes stronger and more frequent and via improved brain, eye, and muscle function the fetus is prepared for ex utero viability. The woman can feel the fetus "rolling" and it may cause pain or discomfort when it is near the woman's ribs and spine. There is head engagement in the third trimester, that is, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perenium and cervix are further flattened and the head may be felt vaginally. [37] Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic

floor and the rectum, and the mother may experience the perpetual sensation that the fetus will "fall out" at any moment.[38] It is during this time that a baby born prematurely may survive. The use of modern medical intensive care technology has greatly increased the probability of premature babies surviving, and has pushed back the boundary of viability to much earlier dates than would be possible without assistance.[39] In spite of these developments, premature birth remains a major threat to the fetus, and may result in ill health in later life, even if the baby survives.

[edit] Embryonic and fetal development and ultrasound imaging

See also: Prenatal development and Obstetric ultrasonography Prenatal development is divided into two primary biological stages. The first is the embryonic stage, which lasts for about two months. At this point, the fetal stage begins. At the beginning of the fetal stage, the risk of miscarriage decreases sharply, [40] and all major structures including the head, brain, hands, feet, and other organs are present, and they continue to grow and develop. When the fetal stage commences, a fetus is typically about 30 mm (1.2 inches) in length, and the heart can be seen beating via ultrasound; the fetus can be seen making various involuntary motions at this stage.[41] Electrical brain activity is first detected between the 5th and 6th week of gestation, though this is still considered primitive neural activity rather than the beginning of conscious thought, something that develops much later in fetation. Synapses begin forming at 17 weeks, and at about week 28 begin to multiply at a rapid pace which continues until 3 to 4 months after birth.[42]

Embryo at 4 weeks after fertilization[43]

Fetus at 8 weeks after fertilization[44]

Fetus at 18 weeks after fertilization[45]

Fetus at 38 weeks after fertilization[46]

Relative size in 1st month (simplified illustration)

Relative size in 3rd month (simplified illustration)

Relative size in 5th month (simplified illustration)

Relative size in 9th month (simplified illustration) One way to observe prenatal development is via ultrasound images. Modern 3D ultrasound images provide greater detail for prenatal diagnosis than the older 2D ultrasound technology.[47] While 3D is popular with parents desiring a prenatal photograph as a keepsake,[48] both 2D and 3D are discouraged by the FDA for nonmedical use,[49][dead link] but there are no definitive studies linking ultrasound to any adverse medical effects.[50] The following 3D ultrasound images were taken at different stages of pregnancy:

75-mm fetus (about 14 weeks gestational age)

Fetus at 17 weeks

Fetus at 20 weeks

[edit] Physiological changes

Main article: Maternal physiological changes in pregnancy

Melasma pigment changes to the face due to pregnancy During pregnancy, the woman undergoes many physiological changes, which are entirely normal, including cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle.

[edit] Management
Main article: Prenatal care Prenatal medical care is the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to appropriate specialists, hospitals, etc. if necessary.

[edit] Nutrition
Main article: Nutrition and pregnancy A balanced, nutritious diet is an important aspect of a healthy pregnancy. Eating a healthy diet, balancing carbohydrates, fat, and proteins, and eating a variety of fruits and vegetables, usually ensures good nutrition. Those whose diets are affected by health

issues, religious requirements, or ethical beliefs may choose to consult a health professional for specific advice. Adequate periconceptional folic acid (also called folate or Vitamin B9) intake has been proven to limit fetal neural tube defects, preventing spina bifida, a very serious birth defect. The neural tube develops during the first 28 days of pregnancy, explaining the necessity to guarantee adequate periconceptional folate intake.[51][52] Folates (from folia, leaf) are abundant in spinach (fresh, frozen, or canned), and are found in green leafy vegetables e.g. salads, beets, broccoli, asparagus, citrus fruits and melons, chickpeas (i.e. in the form of hummus or falafel), and eggs. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.[53] DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for the woman to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the woman through the placenta during pregnancy and in breast milk after birth.[54] Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is prevalent. [55] In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may require supplementation. [56][57][58] A 2011 study examined cord blood of healthy neonates and found that low levels of vitamin D are associated with increased risk of lower respiratory tract infection the first year of life.[59] Dangerous bacteria or parasites may contaminate foods, particularly Listeria and toxoplasma, toxoplasmosis agent. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Soft cheeses may contain Listeria; if milk is raw, the risk may increase. Cat feces pose a particular risk of toxoplasmosis. Pregnant women are also more prone to Salmonella infections from eggs and poultry, which should be thoroughly cooked. Practicing good hygiene in the kitchen can reduce these risks.[60]

[edit] Weight gain

Caloric intake must be increased to ensure proper development of the fetus. The amount of weight gained during a single pregnancy varies among women. The Institute of Medicine recommends an overall pregnancy weight gain for women starting pregnancy at a normal weight, with a body mass index of 18.524.9, of 2535 pounds (11.415.9 kg). [61] Women who are underweight, with a BMI of less than 18.5, may need to gain between 2840 lbs. Overweight women are advised to gain between 1525 lbs, whereas an obese woman may expect to gain between 1120 lbs. Doctors and dietitians may make different, or more individualized, recommendations for specific patients, based on factors including low maternal age, nutritional status, fetal development, and morbid obesity.

During pregnancy, insufficient or excessive weight gain can compromise the health of the mother and fetus. All women are encouraged to choose a healthy diet regardless of prepregnancy weight. Exercise during pregnancy, such as walking and swimming, is recommended for healthy pregnancies. Exercise has notable health benefits for both mother and baby, including preventing excessive weight gain.[62]

[edit] Immune tolerance

Main article: Immune tolerance in pregnancy The fetus inside a pregnant woman may be viewed as an unusually successful allograft, since it genetically differs from the woman.[63] In the same way, many cases of spontaneous abortion may be described in the same way as maternal transplant rejection.
[63]

[edit] Medication use

Main article: Drugs in pregnancy Drugs used during pregnancy can have temporary or permanent effects on the fetus. Therefore many physicians would prefer not to prescribe for pregnant women, the major concern being over teratogenicity of the drugs. Drugs have been classified into categories A,B,C,D and X based on the Food and Drug Administration (FDA) rating system to provide therapeutic guidance based on potential benefits and fetal risks. Drugs, including some multivitamins, that have demonstrated no fetal risks after controlled studies in humans are classified as Category A. On the other hand drugs like thalidomide with proven fetal risks that outweigh all benefits are classified as Category X.[64]

[edit] Exposure to toxins

Various toxins pose a significant hazard to fetuses during development. A 2011 study found that virtually all U.S. pregnant women carry multiple chemicals, including some banned since the 1970s, in their bodies. Researchers detected polychlorinated biphenyls, organochlorine pesticides, perfluorinated compounds, phenols, polybrominated diphenyl ethers, phthalates, polycyclic aromatic hydrocarbons, perchlorate PBDEs, compounds used as flame retardants, and dichlorodiphenyltrichloroethane (DDT), a pesticide banned in the United States in 1972, in the bodies of 99 to 100 percent of the pregnant women they tested. Bisphenol A (BPA) was identified in 96 percent of the women surveyed. Several of the chemicals were at the same concentrations that have been associated with negative effects in children from other studies and it is thought that exposure to multiple chemicals can have a greater impact than exposure to only one substance.[65]

Alcohol ingestion during pregnancy may cause fetal alcohol syndrome, a permanent and often devastating birth-defect syndrome. A number of studies have shown that light to moderate drinking during pregnancy might not pose a risk to

the fetus, although no amount of alcohol during pregnancy can be guaranteed to be absolutely safe.[66][67][68] Numerous studies show that children exposed to prenatal cigarette smoke may experience a wide range of behavioral, neurological, and physical difficulties.[69] Elemental mercury and methylmercury are two forms of mercury that may pose risks in pregnancy. Methylmercury, a worldwide contaminant of seafood and freshwater fish, is known to produce adverse nervous system effects, especially during brain development.[70] Eating fish is the main source of mercury exposure in humans and some fish may contain enough mercury to harm the developing nervous system of an embryo or fetus, sometimes leading to learning disabilities. Mercury is present in many types of fish, but it is mostly found in certain large fish. The United States Food and Drug Administration and the Environmental Protection Agency advise pregnant women not to eat swordfish, shark, king mackerel and tilefish and limit consumption of albacore tuna to 6 ounces or less a week.[71] The Center for Children's Environmental Health reports studies that demonstrate that exposure to air pollution during pregnancy is related to adverse birth outcomes including low birth weight, premature delivery, and heart malformations. Cord blood of exposed babies shows DNA damage that has been linked to cancer. Follow-up studies show a higher level of developmental delays at age three, lower scores on IQ tests and increased behavioral problems at ages six and eight.[72][73] According to the U.S. Centers for Disease Control, the developing nervous system of the fetus is particularly vulnerable to lead toxicity. Neurological toxicity is observed in children of exposed women as a result of the ability of lead to cross the placental barrier and to cause neurological impairment in the fetus. A special concern for pregnant women is that some of the bone lead accumulation is released into the blood during pregnancy. Several studies have provided evidence that even low maternal exposures to lead produce intellectual and behavioral deficits in children1.[74] A 2006 study found that children who were exposed prenatally to the insecticide chlorpyrifos had significantly poorer mental and motor development by three years of age and increased risk for behavior problems.[75] A 2007 study using a mouse model suggested that exposure to polycyclic aromatic hydrocarbons prior to conceiving and when lactating reduces the number of eggs in the ovaries of female offspring by two-thirds.[76] A 2009 study of pregnant women exposed to tetrachloroethylene in drinking water found an increased risk of oral clefts and neural tube defects in their children.[77] A 2009 study found that prenatal exposure to phthalates, the chemical compounds used as plasticizers in a wide variety of personal care products, children's toys, and medical devices, may be an environmental risk factor for low birth weight in infants."[78] A 2010 study found that prenatal exposure to flame retardant compounds called polybrominated diphenyl ethers is associated with adverse neurodevelopmental effects in young children.[79]

[edit] Sexual activity during pregnancy

Main article: Sexual activity during pregnancy Most women can continue to engage in sexual activity throughout pregnancy.[80] Most research suggests that during pregnancy both sexual desire and frequency of sexual relations decrease.[81][82] In context of this overall decrease in desire, some studies indicate a second-trimester increase, preceding a decrease during the third trimester.[83][84] Some individuals are sexually attracted to pregnant women (pregnancy fetishism, also known as maiesiophilia). Sex during pregnancy is a low-risk behavior except when the healthcare provider advises that sexual intercourse be avoided for particular medical reasons. Otherwise, for a healthy pregnant woman who is not ill or weak, there is no safe or right way to have sex during pregnancy: it is enough to apply the common sense rule that both partners avoid putting pressure on the uterus, or a partners full weight on a pregnant belly.[85]

[edit] Exercise
The Clinical Practice Obstetrics Committee of Canada recommends that "All women without contraindications should be encouraged to participate in aerobic and strengthconditioning exercises as part of a healthy lifestyle during their pregnancy". Although an upper level of safe exercise intensity has not been established, women who were regular exercisers before pregnancy and who have uncomplicated, healthy pregnancies should be able to engage in high intensity exercise programs, such as jogging and aerobics for less than 45 minutes, with no adverse effects if they are mindful of the possibility that they may need to increase their energy intake and are careful to not become overheated. In the absence of either medical or obstetric complications,they advise an accumulation of 30 minutes a day of exercise on most if not all days of the week. In general, participation in a wide range of recreational activities appears to be safe, with the avoidance of those with a high risk of falling such as horseback riding or sking or those that carry a risk of abdominal trauma, such as soccer or hockey.[86] The American College of Obstetricians and Gynecologists reports that in the past, the main concerns of exercise in pregnancy were focused on the fetus and any potential maternal benefit was thought to be offset by potential risks to the fetus. However, they write that more recent information suggests that in the uncomplicated pregnancy, fetal injuries are highly unlikely. They do, however, list several circumstances when a woman should contact her health care provider before continuing with an exercise program. Contraindications include: Vaginal bleeding, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness, preterm labor, decreased fetal movement, amniotic fluid leakage, and calf pain or swelling (to rule out thrombophlebitis. [87] The Journal for Nurse Practitioners (2007) reports that many pregnant women do not exercise and they recommend that moderate exercise should be advised for pregnant

women as part of prenatal care. They advise that exercise has benefits for both mother and fetus as well. [88] A 2006 Cochrane review of prenatal exercise-related studies assessed the effects of regular aerobic exercise (at least two to three times per week) on physical fitness, the course of labor and delivery, and the outcome of pregnancy in healthy women. They concluded that regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness, however the authors noted that the trials were small and not of high methodologic quality and the data was insufficient to infer important risks or benefits for the mother or infant. The authors suggested that larger and better trials are needed before confident recommendations can be made about the benefits and risk of aerobic exercise in pregnancy.[89]

[edit] Complications
Main article: Complications of pregnancy Each year, according to the WHO, ill-health as a result of pregnancy is experienced (sometimes permanently) by more than 20 million women around the world. Furthermore, the "lives of eight million women are threatened, and more than 500,000 women are estimated to have died in 1995 as a result of causes related to pregnancy and childbirth."[90] Pregnancy poses varying levels of health risk for women, depending on their medical profile before pregnancy. The following are some of the complaints that may occur during and/or after pregnancy due to the many changes which pregnancy causes in a woman's body:

Pregnancy induced hypertension Anemia[91] Back pain. A particularly common complaint in the third trimester when the patient's center of gravity has shifted. Carpal tunnel syndrome in between an estimated 21% to 62% of cases, possibly due to edema.[92] Constipation. A complaint that is caused by decreased bowel mobility secondary to elevated progesterone (normal in pregnancy), which can lead to greater absorption of water. Braxton Hicks contractions. Occasional, irregular, and often painless contractions that occur several times per day. Edema (swelling). Common complaint in advancing pregnancy. Caused by compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities. Regurgitation, heartburn, and nausea. Common complaints that may be caused by Gastroesophageal Reflux Disease (GERD); this is determined by relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach

(normal in pregnancy), as well as by increased intraabdominal pressure, caused by the enlarging uterus. Haemorrhoids. Complaint that is often noted in advancing pregnancy. Caused by increased venous stasis and IVC compression leading to congestion in venous system, along with increased abdominal pressure secondary to the pregnant spaceoccupying uterus and constipation. Pelvic girdle pain. PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system,[93] altered laxity/stiffness of muscles,[94] laxity to injury of tendinous/ligamentous structures[95] to mal-adaptive body mechanics.[96] Musculo-Skeletal Mechanics involved in gait and weightbearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. There is pain, instability or dysfunction in the symphysis pubis and/or sacroiliac joints. Postpartum depression Postpartum psychosis Round Ligament Pain. Pain experienced when the ligaments positioned under the uterus stretch and expand to support the woman's growing uterus Thromboembolic disorders. The leading cause of death in pregnant women in the USA.[97] Increased urinary frequency. A common complaint referred by the gravida, caused by increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus. Urinary tract infection[98] Varicose veins. Common complaint caused by relaxation of the venous smooth muscle and increased intravascular pressure. PUPPP skin disease that develop around the 32nd week. (Pruritic Urticarial Papules and Plaques of Pregnancy), red plaques, papules, itchiness around the belly button that spread all over the body except for the inside of hands and face.

[edit] Ectopic pregnancy

Main article: Ectopic pregnancy An ectopic pregnancy is a complication of pregnancy in which the embryo implants outside the uterine cavity.[99] With rare exceptions, ectopic pregnancies are not viable. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. It should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in a location other than the uterine cavity is clear evidence of an ectopic pregnancy. Tubal ectopic pregnancy is the most common cause of maternal death in the first trimester of pregnancy.[100] About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.[100] In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades blood vessels which causes bleeding resulting

in the expulsion of the implantation from the tube. Termed "tubal abortions", about half of ectopic pregnancies will resolve without treatment. The use of methotrexate treatment for ectopic pregnancy has reduced the need for surgery, but surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. The surgical intervention may be laparoscopic or through a larger incision, known as a laparotomy.[101] A woman who has had a previous ectopic pregnancy is more likely to have another. The majority of women with ectopic pregnancies have had pelvic inflammatory disease or salpingitis, an inflammation of the fallopian tube. A history of gonorrhea or chlamydia can also cause tubal problems that increase the risk. Endometriosis, a condition that causes the tissue that normally lines the uterus to develop outside the uterus may slightly increase the incidence of an ectopic. The risk is increased in women who have unusually shaped fallopian tubes or tubes which has been damaged, possibly during surgery. Taking medication to stimulate ovulation increases the risk of ectopic pregnancy. When used properly, pregnancy is rare when using birth control pills or an intrauterine device (IUD) however, if it does occur, it's more likely to be ectopic. Although pregnancy is rare after tubal ligation, if it does occur, it's more likely to be ectopic. [102] A recent meta-analysis of clinical outcomes has shown that cigarette smoking significantly increases the risk of tubal ectopic pregnancy.[100] http://en.wikipedia.org/wiki/Pregnancy

Pregnancy Weight Gain

Nowadays all we seem to be concerned with is how much anyone weighs. Is so and so fat? Or are they skinny? We really don't seem to care much about health. These attitudes linger into pregnancy, when weight really does matter, but maybe not in the ways you think. Go back to when my husband was born and my mother-in-law will tell you the delightful story of how she went in to her doctor for the first visit weighing 99 pounds (after two

previous children). He gives her several prescription medications. She had water pills, she had diet pills, she had it all. The message was loud and clear, don't gain weight. Many practitioners don't do this any more, although a good majority still don't send the right messages about weight gain in pregnancy. Society is also largely to blame for our fear of fat, even during pregnancy. Anyone here have night mares about chubby thighs, expanding waists and a body that is never quite the same? One woman told me recently that when she's done having children her husband is going to pay good money to have her body put back together "the way he found it." Let's look at what needs to happen to stay healthy during pregnancy. First of all, no matter what you weigh prior to pregnancy you must gain weight. Women who are clinically obese still need to gain at the minimum 11 pounds, and women who are underweight need to gain more than the average statement of 25-35 pounds, usually at least 10-15 pounds more depending on the severity of the weight problem. These figures are for the healthy woman carrying a single baby. Moms who are expecting multiples will need to gain more weight, although no standards have been devised for these special needs as a whole. Why gain weight? Weight gain does things for you and your baby. First of all remember you are growing a new human being. We know that women who deprive themselves of good nutrition during pregnancy tend to have smaller, sickly babies who require more hospital time and have a higher incidence of problems including neonatal death. How should I gain weight? Good thing you asked! Because I'd tell you anyway! Remember that eating for two doesn't mean eating twice as much. In general you do not need to add any more than 200300 calories a day to your present diet. However, it's what you eat that really counts. Making sure that your diet is nutrient dense, that is full of good things for you and your baby as opposed to junk food that is full of fat and sugar. This means at snack time reach for fresh fruit instead of a candy bar. Add some cheese to your crackers. Most women will notice a slight weight gain in the beginning of pregnancy, usually about four pounds during the first trimester. Some of this is water weight, some of this is materials needed to help your baby grow. Your baby is still very tiny at the end of this trimester. Occasionally you will see women who gain a bit more weight up to about ten pounds during the first trimester from lowered activity levels and water weight gain. If you are overweight you need to gain about three pounds and if you are underweight you should gain about five pounds.

The majority of the weight will be fairly evenly spread over the last two trimesters, about a pound a week, with a little more at the end. Again, if you are underweight it should be increased by about 25% (or a quarter pound per week) and if you are overweight it should be decreased by the same amount. It is also quite common to notice a cessation of weight gain, perhaps even a slight weight loss at the very end of pregnancy. If you notice that you've put on several pounds one week, look back at your diet. Did you changes your dietary habits? Your practitioner will also use your weight gain as an indicator of baby's growth and in looking for potential problems. Remember slow and steady wins the race! http://pregnancy.about.com/od/weightgain/a/Pregnancy-Weight-Gain.htm

Pregnancy Nutrition
Without a doubt, a nutritious, well-balanced eating plan can be one of the greatest gifts you give to your soon-to-be-born baby. Adopting a healthy eating plan before pregnancy is ideal, but no matter how many weeks are left on your countdown calendar, its never too late to start! Supplying your own body with a tasty blend of nutritious foods can not only improve your fertility, keep you feeling healthy during pregnancy, and pave the way for an easier labor, but it can also help to establish essential building blocks of growth and overall health for your child.

The food we eat on a daily basis affects how our bodies work, how we heal and grow, and how we maintain energy and strength for years to come. It also determines the basic nutritional health that our children are born with, and provides a model for their eating habits during childhood and beyond. Pregnancy is the one time in your life when your eating habits directly affect another person. Your decision to incorporate delicious vegetables, whole grains and legumes, lean protein, and other wise food choices into your eating plan before and during pregnancy will give your baby a strong start in life.

Weight Change and Calories

It is a wonderful fact --your body will gain weight during your pregnancy! As you watch your weight begin to increase, take it as proof that your body is nurturing your growing baby. By the time you are ready to give birth, your total blood volume will have increased by as much as 60%. Your breasts will have filled with milk. Your uterus will have grown to accommodate your baby and has filled with amniotic fluid; your baby has grown to weigh 6 to 10 pounds (on average). To accomplish all of these productive changes, your body needs approximately 300 extra calories per day during your 2nd and 3rd trimester of pregnancy. Every woman should discuss her individual nutrient needs with her health care provider. Do not neglect your babys health by neglecting your own! http://www.americanpregnancy.org/pregnancyhealth/pregnancynutrition.html

Pregnancy What is pregnancy? Pregnancy is the term used to describe when a woman has a growing fetus inside of her. In most cases, the fetus grows in the uterus. Human pregnancy lasts about 40 weeks, or just more than 9 months, from the start of the last menstrual period to childbirth What are the signs of pregnancy? The primary sign of pregnancy is missing one or more consecutive menstrual periods.

However, because many women experience menstrual irregularities that may cause missed periods, women who miss a period should see their health care provider to find out whether they are pregnant or whether there is another health problem. Others signs and symptoms of pregnancy may include:

Nausea or vomiting, morning sickness Sore breasts or nipples Fatigue Headaches Food cravings or aversions Mood swings Frequent urination

How do I know Im pregnant? A pregnancy test is the best way to determine if you are pregnant. Home pregnancy test kits are available over-the-counter and are considered highly accurate. A health care provider can also do a pregnancy test. NICHD research in the 1970s found that high levels of the hormone human chorionic gonadatropin (HCG) in the urine were associated with pregnancy. This research led to the development of the home pregnancy test that is commercially available today. If you think you may be pregnant, or have a positive home pregnancy test, see a health care provider. What is prenatal care and why is it important? Prenatal care is the care woman gets during a pregnancy. Getting early and regular prenatal care is important for the health of both mother and the developing baby. In addition, health care providers are now recommending a woman see a health care provider for preconception care, before she is even trying to get pregnant. Health care providers recommend women take the following steps to ensure the best health outcome for mother and baby:

Getting at least 400 micrograms of folic acid every day to help prevent many types of neural tube defects. Health care providers recommend taking folic acid both before and during pregnancy. Being properly vaccinated for certain diseases (such as chicken pox and rubella) that could harm a developing fetusit is important to have the vaccinations before becoming pregnant Maintaining a healthy weight and diet and getting regular physical activity before,

during, and after pregnancy Avoiding smoking, alcohol, or drug use before, during, and after pregnancy

What is a high-risk pregnancy? All pregnancies involve a certain degree of risk to both mother and baby. But, factors present before pregnancy or that develop during pregnancy can place the mother and baby at higher risk for problems. Women with high-risk pregnancies may need care from specialists or a team of health care providers to help promote healthy pregnancy and birth. Factors present before pregnancy that can increase risk may include:

Young or old maternal age Being overweight or underweight Having had problems in previous pregnancies, such as miscarriage, stillbirth, or preterm labor or birth Pre-existing health conditions, such as high blood pressure, diabetes, or HIV/AIDS

During pregnancy, problems may also develop even in a woman who was previously healthy. These may include (but are not limited to) gestational diabetes or preeclampsia/eclampsia. Getting good prenatal care and seeing a health care provider regularly during pregnancy are important ways to promote a healthy pregnancy. Where can I get more information about pregnancy?

Am I at risk for gestational diabetes? Managing gestational diabetes: A patients guide to a healthy pregnancy

NIH State-of-the-Science Conference on Cesarean Delivery on Maternal Request Final Statement http://www.nichd.nih.gov/health/topics/pregnancy.cfm

Signs of Pregnancy
Thinking you might be pregnant and wondering what the most common signs of pregnancy are. Well, we got them for you. We've included all the common symptoms as well as some the less common ones. Examine the symptoms to your heart's content, but remember your doctor is the only one who can confirm pregnancy.

Common Signs of Pregnancy

No menstrual period Although this is not proof positive, absence of your menstrual cycle is a good indicator of pregnancy. Fatigue and sleepiness For many women, fatigue is the first symptom of pregnancy. If you suddenly find yourself needing an afternoon nap, you could be pregnant. Breast changes Along with fatigue, breast changes are possibly the earliest sign of pregnancy. Breast changes include fullness, tenderness, sensitivity to touch, change in size, and darkening of the areola. Nausea and vomiting Nausea and vomiting, also known as morning sickness, is another symptom of pregnancy. Not all women experience morning sickness and morning sickness may not occur until two to four weeks after a missed period. Generally, morning sickness resolves or improves in the second trimester. Frequent urination Once you become pregnant, your blood volume increases and your kidneys increase in size. These factors can lead to an increase in urination. Fullness, bloating, achiness in the abdominal area Believe it or not for many women the symptoms of pregnancy mimic the symptoms of PMS. If you are experiencing PMS symptoms, don't rule out the possibility of pregnancy. Some women will also complain of diarrhea or constipation in pregnancy Mood swings and irritability Hormonal changes combined with fatigue may cause mood swings and irritability. If you find yourself incredibly crabby this could be a sign of pregnancy. Keep in mind, however, that crabbiness is also a sign of PMS. Other common signs of pregnancy include an increase in vaginal secretions, aversion to certain foods or smells, weight gain, and constipation.

Less common signs of pregnancy

Implantation bleeding An estimated twenty percent of women will experience bleeding when the fertilized egg implants into the uterus. Implantation bleeding is typically light in color and amount and generally occurs six to ten days past ovulation. Headaches For women that suffer from headaches, pregnancy usually decreases the frequency of headaches. For some, however, there will be a marked increase in the amount of headaches during pregnancy.

http://www.justmommies.com/articles/signs_and_symptoms.shtml