The signs and symptoms of pregnancy vary with different periods and may be classified under three trimesters, the first, second and third trimesters.
FIRST TRIMESTER
Subjective Symptoms
AMENORRHEA Amenorrhea in a normally menstruating healthy woman exposed to the risk of pregnancy is highly suggestive of pregnancy. However amenorrhea may be caused by a number of conditions other than pregnancy like anovulation, severe illness or emotional disturbances. Moreover, cyclical bleeding can occur in the first 8-12 weeks of pregnancy either from a bicornuate uterus or uterus didelphys and even from a normal uterus prior to the fusion of the deciduas vera and capsularis. Pathological lesions in the genital tract can also give rise to bleeding during pregnancy.
MORNING SICKNESS In the early weeks, nausea and vomiting are common. 'Morning sickness' generally starts around 4-6 weeks of pregnancy and may continue till about week 16. Usually, it is present in the early hours of the morning and reduces as the day progresses. In some cases, however, sickness may continue throughout the day. The cause of this disorder is unknown but may be due to high levels of hCG, Fortunately, the discomfort can be Sminimised by eating small feeds at more frequent intervals and avoiding foods that precipitate the symptoms. Occasionally vomiting may be severe enough to cause weight loss, dehydration, acidosis and hypokalemia. This condition is termed as hyperemesis gravidarum. [Intravenous crystalloid solutions and anti-emetics are required to correct the acid-base imbalances.
SALIVATION AND CHANGES IN DISPOSITION Salivation is an early symptom and is pronounced in certain cases. The changes in disposition may be shown by a change in the temperament, resulting in the patient becoming irritable and capricious. She may evince a desire for articles of food quite at variance with her preferences. These have been termed the 'longings' or pica of pregnancy; they are not of diagnostic value, as they purely subjective and are may occur in various neurotic conditions as well.
IRRITABILITY OF THE BLADDER Frequency of micturition is a common complaint and is due to the pressure exerted on the bladder by the growing uterus. As the uterus increases in size and becomes an abdominal organ, this pressure is relieved and the symptom gradually disappears.
FATIGUE Easy fatigability is very frequent in early pregnancy.
Objective Signs
CHANGES IN THE BREASTS Changes in the breasts are marked, particularly in primigravidas. There is a general enlargement with prominence of the veins and increased pigmentation, forming the characteristic primary and secondary areolae. The nipples also become more prominent, erectile, and turgescent. Montgomery's follicles appear first on the primary areolae and later on the secondary areolae. The secondary areolae develop from the 20th week onward, while the other changes generally take place during the first trimester - from the 4th to the 12th week of pregnancy. The presence of a little fluid in the breast can usually be detected from week 12 onward by gently squeezing the breast in the direction of the nipple. The fluid is clear and contains some colostrum corpuscles. Occasionally, changes in the breast similar to those caused by pregnancy are found in women with prolactin secreting pituitary tumours or in women on some drugs. In multiparas, the changes in the breasts are not of much diagnostic value because pregnancy may take place in a lactating woman, while pigmentation of the areola and the milky secretion in the breasts may persist after a previous pregnancy..
BLUISH DISCOLORATION OF THE VAGINA This sign is generally detected between the 4th and 8th weeks of pregnancy. The discoloration increases in intensity upto the 16th week, when it has perhaps reached its maximum. It persists throughout pregnancy. The vulva and the vaginal mucous membranes, consequent upon the congestion of the blood vessels, present a violet or light blue tint, and later a purplish or deep blue tint. This sign was first described by Jacquemier, and later emphasised by Chadwick, and is therefore known as Jacquemier's sign or Chadwick's sign. Besides the discoloration, there may be a sensation of increased warmth in the genitalia resulting from the augmented blood supply to these parts. At a later stage, increased vaginal pulsations may be noticed; this is sometimes called Osiander's sign. This may, however, be produced by any condition that causes congestion of the pelvic organs.
UTERINE CHANGES The uterus is perhaps the most important organ to undergo remarkable changes due to pregnancy. In the early weeks of pregnancy, changes in size, shape and position occur. These can be detected by bimanual examination either by the abdominovaginal or the abdominorectal method of palpation.
The virgin uterus is pyriform or pear-shaped, and is usually anteflexed. During the first 8-10 weeks of gestation, the organ gradually becomes rounded or globular and more anteflexed The uterus in the carly weeks of pregnancy lies within the pelvic cavity. By the 12th week it rises gradually upward towards the abdomen
Many changes take place in the uterus; it becomes much softer. The softening is particularly noticeable in the cervix and the lower uterine segment. This softening of the cervix is an important sign and can be recognised from the 4th week onwards Softening and compressibility of the isthmus or lower uterine segment constitute Hegar's sign. This is of great value and has been observed from about the 6th or 8th week to the 12th week of pregnancy. This sign is more difficult to recognise in multiparas than in primiparas. But when definitely present, it constitutes one of the most valuable of physical signs in the recognition of pregnancy at this period. It is, however, not positively diagnostic of pregnancy since softening can sometimes occur for other reasons.
Hegar's sign can be elicited in several ways:
a) In women with a lax abdominal wall and a roomy vagina, two fingers are introduced into the vagina behind the cervix while the fingers of the other hand are pressed down into the abdomen from above the symphysis pubis. The fingers of the two hands will almost meer as if there was no fresisting tissue between, and the cervix and body of the uterus will appear as two Lindependent masses.
b)In other cases, two fingers can be passed into the anterior fornix, The fingers of the other hand are placed above the symphysis behind the body of the anteflexed uterus and pressed downward to meet the vaginal fingers. Because of the danger of causing an interruption of pregnancy, these manipulations must be gentle, and pressure over the body of the uterus must be avoided. No attempt should be made to elicit Hegar's sign after the 12th week of pregnancy
CHANGES IN THE CERVIX In a nulliparous woman, the external os is circular, the mucous membrane smooth and intact and the orifice closed. In a parous woman on the other hand, the orifice is a transverse patulous slit and may admit the tip of the finger. Where a premature labour or abortion has occurred, the cervix may not show the characteristic signs; on the other hand, as a result of operative manipulations, the cervix of a nullipara may be torn and resemble a multiparous cervix.
The cervix softens by 6 to 8 weeks of pregnancy, The cervix in the non-pregnant state resembles the nasal cartilage - but during pregnancy it becomes soft. However estrogen-progesterone contraceptives may also cause such a softening of the cervix.
SECOND TRIMESTER
Subjective Symptoms Quickening.
During this period, some of the signs and symptoms that were present in the earlier periods of pregnancy gradually disappear and other signs and symptoms become apparent. Morning sickness, increased salivation and frequency of micturition generally disappear by this time. An important symptom that may be felt during the second trimester is quickening. The mother generally feels the active fetal movements first at the end of week 16, as a slight flutter, and the term 'quickening' is applied to the first recognition. The movements become more vigorous and may sometimes be painful. They may cease entirely in some cases although the fetus continues to be alive. Their sudden and complete cessation, however, is suggestive of death of the fetus in utero. Peristaltic movements of the intestines may sometimes be mistaken for fetal movements.
The date of 'quickening', if it is definitely ascertained by the patient, is helpful in reckoning the period of pregnancy and calculating the probable date of delivery.
Objective Signs
CHANGES IN THE SKIN Pigmentation is one of the characteristic changes that take place in pregnancy. This is more marked on the forehead and cheeks in the form of dark brown patches,more noticeable in those who are fair.Pigmentation and striae may also be seen on the breasts and over the abdominal wall. A linear pigmented area stretching from the umbilicus to the symphysis pubis is of deeper colour and is known as the linea nigra, On either side over the abdominal wall are other striae, whitish appearance and spoken of as linea albicantes. These may sometimes be absent during gestation and may be associated conversely with the use of steroidal contraceptives.
CHANGES IN THE SHAPE AND SIZE OF THE UTERUS The uterus, being a progressively growing organ in pregnancy, gradually increases in size and becomes ovoid in shape. It can be felt at different levels in the abdomen in successive periods of pregnancy.
INTERMITTENT UTERINE CONTRACTIONS This is known as Braxton Hicks sign, and it is found irrespective of whether the fetus is alive or dead. It may be detected by palpation as early as in week 16. These contractions, as a rule, occur throughout pregnancy at fairly long intervals and last for a few seconds. They may be easily elicited by keeping the hand in full contact with the abdominal wall over the uterus, when the gradual relaxation and contraction of the uterine musculature will be felt. Similar contractions are sometimes noticed in cases of hematometra and occasionally with soft myomas, especially the pedunculated submucous variety.
ACTIVE FETAL MOVEMENTS When felt or seen, these signs show positive evidence of continuing pregnancy and of a live child. They may be noticed after the 16th or 18th week of pregnancy, but generally during the last trimester.
PALPATION OF THE FETAL PARTS About the middle of pregnancy, the fetus is generally increased to a size when it can be recognised by abdominal palpation. As pregnancy progresses, this sign is of great value, not only in detecting pregnancy but also in ascertaining the various positions of the fetus in utero.
AUSCULTATORY SIGNS Auscultation over the abdomen during pregnancy is useful for eliciting various sounds, some of which are of great importance in the positive diagnosis of pregnancy.
The fetal heart:The fetal heart can be heard from the 17th to 20th week of pregnancy using Pinard's, fetoscope, This is the only sign of pregnancy, which, by itself and in the absence of all others. is perfectly reliable for the diagnosis of pregnancy. The point of greatest intensity of the fetal heart sounds will vary with the position of the child in utero . Ordinarily, the fetal heart beats 120-160 times a minute.
It is possible to hear fetal heart sounds using the ultrasound Doppler technique. The ultrasound wave, reflected by the moving blood flow, fundergoes a shift in pregnancy, the echo of which 615 detected by the receiving crystal, adjacent to the transmitting crystal. This method to detect feral heart sounds becomes useful by the 10th week.
Echocardiography can be used to detect the fetal heart movement as early as 48 days after the last menstrual period. Visualisation of heart motion by vaginal ultrasonography is possible from the 5th week of pregnancy
The funic souffle: This is a sharp, whizzing sound synchronous with the fetal heart beat, heard rarely and said to be due to the rush of blood through the umbilical arteries.
Other sounds that may be heard are due to the movements of the fetus, intestinal movements and maternal aortic pulsation PERCEPTION OF FETAL MOVEMENTS These may be elicited by internal or external manipulations producing a passive movement of the ferus in utero
Internal ballottement: This sign may be elicited by placing the left hand over the abdomen . The fingers of the other hand are passed through the vagina to give a sharp tap upwards. This impulse is obtained from the 18th week onward. To elicit this sign, the patient is placed in the dorsal posture the index and middle fingers are introduced into the vagina and steadied are introduced into the vagina and steadied- Cagainst the lower pole of the fetus, which is pressed down by the other hand over the abdomen. The fingers in the vagina give a sharp tap upwards. The impulse thus generated is transmitted to the fetus, which bounds upward and then after a moment falls back upon the examining fingers. If clearly elicited, it is considered as one of the most valuable signs of pregnancy at this period. Rarely, some pathological conditions may give rise to a very similar sensation, for example, a calcufus in the bladder, a fibroid or an ovarian tumour complicated with ascites. In such cases, however, no other signs of pregnancy will be present.
Before the 18th week, the fetus is too small to respond to the digital impulse, and after the 28th week, the fetus is relatively too large, filling so much of the uterine cavity that it cannot be moved about as freely as before. This sign may not be elicited in conditions associated with a deficiency of the liquor amnii where the fetus is not presenting by the cephalic pole .
External ballottement: This sign is elicited with the patient in recumbent position, by steadying the uterus with one hand applied to the side and gently tapping with the other hand from the opposite side, when the impact of the fetal parts will be felt. It depends upon the amount of liquor amnii present in the uterine cavity. It is difficult to elicit this sign in cases where the abdominal wall is thick and fatty, and when the liquor amnii is very much diminished in quantity.
THIRD TRIMESTER
During this period of pregnancy, the painless uterine contractions persist, the fetal movements are more easily felt and seen, ballottement is generally not obtainable, the fetal parts are easily palpable, and the fetal heart is heard clearly if the fetus is alive. The uterus enlarges progressively till, at term, it fills almost the entire abdomen.