Pregnancy (First, Second, Third Trimester)

Pregnancy occurs when an egg is fertilized by a sperm, grows inside a woman's uterus (womb), and develops into a baby. In humans, this process takes about 264 days from the date of fertilization of the egg, but the obstetrician will date the pregnancy from the first day of the last menstrual period (280 days 40 weeks).

The doctor will use certain terms when discussing a pregnancy. Some of the following definitions are useful:

• Intra-uterine pregnancy: A normal pregnancy occurs when a fertilized egg is implanted in the uterus (womb) and an embryo grows.
• Embryo: The term used for the developing fertilized egg during the first 9 weeks of pregnancy.
• Fetus: The term used for the developing embryo after 9 weeks of gestation.
• Beta human chorionic gonadotropin (also called beta-hCG): This hormone is secreted by the placenta and can be measured to determine the presence and progression of the pregnancy. Urine or blood can be tested for its presence, and it is the hormone involved in the performance of a home pregnancy test. A positive result means a woman is pregnant; however, this test result can stay positive for several weeks after delivering a baby or following a spontaneous miscarriage.
• Trimester: The duration of an individual pregnancy is divided into three periods called trimesters (approximately three months in duration). Each trimester is characterized by specific events and developmental markers. For instance, the first trimester includes the differentiation of the different organ systems.
• Estimated date of delivery (EDD): The delivery date is estimated by counting forward 280 days from the first day of the woman's last period. It is also called the estimated date of confinement (EDC).

A pregnant woman and her doctor will monitor the pregnancy to exclude or prevent certain pregnancy conditions. The physician will also treat non pregnancy-related medical conditions in such a way as to promote the appropriate physical and neurological development of the fetus. Conditions of particular importance include:

• High-risk pregnancy: If a woman is considered  prone to certain complications during pregnancy, she will be classified as high risk. Examples include pregnancies in women with diabetes and/or high blood pressure. Age-related complications can occur in women such as teenagers, women who are over the age of 35, or those who have been treated for infertility and have pregnancies resulting from the use of assisted reproductive technology.
• Ectopic pregnancy: This is a pregnancy in which the egg implants somewhere other than the uterus. This complication can be life-threatening. Ectopic pregnancy must be diagnosed early to avoid damage to the Fallopian tubes and to prevent serious maternal illness or death. It is also called tubal pregnancy (if the egg implants in the Fallopian tubes) or extra-uterine pregnancy.
• Cervical incompetence: This is a condition in which the cervix begins to open (widen) and/or efface (thin) without contractions before the pregnancy has reached term. Cervical incompetence can be a cause of mid-pregnancy miscarriage.
• Preterm Labor: In this condition, the uterus begins to contract before the baby has reached full-term.
• Preeclampsia/eclampsia: Preeclampsia is a systemic disease that can affect various organ systems. Vascular effects cause the blood pressure to rise in a pregnant woman. The condition may cause kidney damaged, generalized swelling, hyperactive reflexes, as well as deleterious abnormalities in blood chemistry and nerve reflexes. If left untreated, preeclampsia can proceed to eclampsia, a serious condition which may result in seizures, coma, and even death.
• Multiple Gestation (e.g. twins, triplets): Preterm births are twice as likely in twin pregnancies than in singleton pregnancies. The percentage of preterm birth is even greater for triplet pregnancies and higher order pregnancies. Preeclampsia is also seen three to five times more frequently with multiple gestation.

Pregnancy occurs with the fertilization of a woman's egg by a man's sperm. Fertility drugs may improve a woman's odds of achieving a pregnancy.

Symptoms of pregnancy include the following:

• Breast tenderness
• Nausea, vomiting, or both
• Missing a period or having an abnormal period
• Weight gain
• Breast enlargement, nipples darkening, or breast discharge
• Urinating more frequently than usual
• Fetal movement (may be perceived after 20 weeks for new mothers)

If a woman suspects that she may be pregnant or if she has a positive home pregnancy test, she should make an appointment with a health-care professional, which could be a doctor, an obstetrician (women's health specialist), a family physician, a midwife, or a nurse practitioner. Early prenatal care is essential to insure a favorable pregnancy outcome.

A woman who is pregnant should call her health-care professional if any of the following conditions develop:

• Labor or rupture of membranes (leaking fluid)
• Serious abdominal or vaginal pain
• Bright red vaginal bleeding
• Vomiting more frequently than three times per day or vomiting blood
• Severely elevated blood pressure (above 140/90)
• Sudden and rapid weight gain
• Severe headache or visual changes
• Severe leg or chest pain

Seek care in a hospital's emergency department if pregnant and experiencing any of these conditions:

• Fainting
• Vaginal bleeding through more than one pad per hour
• Having severe pain in the abdomen or shoulder or severe dizziness
• Passing pink, gray, or white material from the vagina that does not look like a blood clot (The woman who is pregnant should take the material to the hospital.)
• Having a bloody discharge or gush of fluid from the vagina during late pregnancy (this may indicate that the onset of labor is imminent).
• Seizure activity but without a history of epilepsy (This may indicate eclampsia, a complication of pregnancy).
• Having an injury, such as a fall, a blow to the stomach or pelvis, or a car accident

Lower abdominal pain during late in pregnancy may indicate the onset of labor. Labor pains occur secondary to uterine contractions. A patient may attempt consumption of clear liquids or lying on her left side for a short time to determine if the contractions will resolve spontaneously. If the pain persists, her health care provider should be notified.

• Am I at risk for genetic diseases?
• How much weight should I gain during pregnancy?
• Am I gaining weight too fast?
• How should I alter my diet (especially if she is a vegetarian or a vegan)?
• What tests should I have and when should I schedule them?
• Am I a high-risk patient?
• What is my risk for cesarean birth?
• What exercises are safe?
• What vaccinations should I receive during pregnancy?
• What medications may I take?
• May we develop a birth plan?
• Should I hire a doula?
• Will I be allowed to have keepsake ultrasound pictures?

Several tests may be conducted while a woman is pregnant.

Pregnancy tests

The woman's urine or blood may be tested.

• Women may choose to perform a home pregnancy test. This is a urine test kit that can be purchased at a pharmacy or grocery store without a prescription. The test can indicate whether a woman is pregnant. This type of test is known as a qualitative test. It can only test for the presence of the pregnancy hormone, beta-hCG. If a doctor is considering prescribing a medication that might not be appropriate for consumption during pregnancy, one of these simple tests may be performed in the office to determine if a woman is pregnant or to make sure she is not pregnant. If the test is performed very early in a pregnancy, the hormone level may still be negative. Most current home pregnancy tests can show positive results immediately after the first missed menstrual period.
• If clinically indicated, more sophisticated tests are called quantitative hCG levels can be performed. These actually determine the the hCG levels in the bloodstream. This type of testing is completed by drawing blood for testing at a hospital or doctor's office. These levels indicate approximately how far along a woman is in her pregnancy. If levels of hCG do not rise as she progresses through her pregnancy, it could indicate a problem pregnancy such as an ectopic pregnancy with low levels or twins with high levels.

Ultrasound

A doctor may use sound waves to examine the pelvic structures such as the uterus, ovaries, and the embryo or fetus.

• Transabdominal ultrasound: A conductive gel is placed on the abdomen, and a hand-held wand which emits sound waves is moved in a systematic pattern in an effort to examine the internal structures. This test requires a full bladder so that the organs in question are lifted out of the pelvis as the bladder fills. The patient may be asked to drink two to three glasses of water starting an hour prior to the test. This method works best for more advanced pregnancies when the fetus is well developed. The physician may have a vaginal scan performed during the first trimester to make sure the pregnancy is within the uterus and to rule out an ectopic pregnancy.It is also possible to visualize the fetal heartbeat and movement, and, thus, rule out a miscarriage. The vaginal scan can also determine if there is more than one pregnancy within the uterus.During the remainder of the pregnancy, scans may be used to look for problems, assess the age and development of the fetus, check out its position within the uterus, and, between 16 and 20 weeks, determine the fetal sex. There is no risk to the woman or her developing fetus with ultrasound, and it is not uncomfortable. Ultrasound examinations aid doctors in establishing an accurate due date. The estimated date of delivery can now be predicted within two to four days if the initial ultrasound is performed early in pregnancy.
• Endovaginal or transvaginal ultrasound: A long, thin, sound-wave wand is covered with a condom filled with conductive gel is placed inside the vagina. This type of ultrasound is usually performed early in pregnancy to confirm the intrauterine location of the fetus. This type of ultrasound also gives more detail regarding the structure of the woman's cervix and early embryonic anatomy.
• Targeted Ultrasound Tests: A targeted or level II ultrasound exam provides a detailed assessment of fetal anatomy. It is recommended if there are concerns for fetal problems based on other tests or history. It is usually performed by a Maternal-Fetal Medicine specialist (perinatologist).
• Nuchal Fold Translucency Tests: A non-invasive screening for genetic defects. A certified ultrasound technologist measures the fold at the back of the neck. Measurements are then used to calculate the risk factor for certain birth defects. It is usually done at 10 to 14 weeks gestation and offered with a blood test that also screens for birth defects.

Blood tests

• Complete blood count (CBC)
• Blood type, Rh status, and antibody test
• Thyroid test (optional)
• Urine culture
• Sickle cell screening if of African American heritage
• Syphilis tests, HIV test, and tests for hepatitis B
• Alpha fetoprotein tests or Quad Screen Test: A Quad Screen looks for four specific substances, Alpha fetoprotein, human chorionic gonadotropin, Estriol (an estrogen), and Inhibin-A (a protein produced by the placenta and ovaries).

Culture tests

• Gonorrhea culture (GC) and chlamydia testing
• Group B streptococcal test between 35 and 37 weeks of pregnancy
• Test for bacterial vaginosis (BV), candida, and trichomonas - these are performed as needed if the woman has vaginal discharge, burning with urination, or itching around the outside of the vagina.

Normal pregnancy is not an illness and needs no treatment other than standard prenatal care. After the initial visit and during the first six months of pregnancy, a patient should see her doctor approximately once per month. Visits should be scheduled every two weeks during the seventh and eighth month and weekly during the ninth month. Electronic fetal monitoring, sequential ultrasound examinations, or admission to the hospital may also be required depending on circumstances of the individual patient.

Influenza vaccinations are recommended for women during pregnancy..

• Eat small, frequent meals throughout the pregnancy. Eat a common-sense balanced diet. Expect to gain between 25 to 35 pounds if you are of normal weight. Expect to gain less wait if you are obese (approximately 10 to 15 pounds).
• Do not discontinue prescribed medications or initiate non-prescription medications without consulting a physician, but also consult with a doctor before taking any nonprescription medications.
• Ginger capsules (available as an over-the-counter option) may help with nausea in pregnancy, sometimes called morning sickness. Talk with a doctor about other options.
• Do not smoke, drink alcohol, or use illicit drugs.
• Continue to exercise with normal routines unless the doctor advises otherwise. Stay hydrated during exercise sessions.
• Sexual intercourse need not be prohibited during an uncomplicated pregnancy.

Electronic fetal monitoring: Sometimes late in pregnancy, a woman who is pregnant may be placed on a fetal monitor to verify the health of the fetus or to see if the woman is in early labor.

Biophysical Profile Test: This is a noninvasive test uses ultrasound to assess whether or not the baby is receiving an adequate supply of oxygen. It is typically performed during high risk pregnancies or if a woman has gone past her due date.

Because some medicines are not safe to take during pregnancy, it is important that a woman take only those that have been approved by her doctor. If anyone tries to prescribe a new medicine, the woman should explain that she is pregnant and ask if the drug is safe. The US Food and Drug Administration previously listed five categories of pharmaceutical labeling for drugs which might be used during pregnancy. A doctor or pharmacist can provide advice on the safety level (indicated by category) of medications before a pregnant patient begins their usage. Doctors will often use category B and C medications (see the following list) if it is felt that the potential benefit of the product outweighs any risks. Few conditions during pregnancy can be treated adequately with category A medications. The FDA categories were instituted in 2015. Thy are listed below.

• Category A - Safety established using human studies
• Category B - Presumed safety based upon animal studies
• Category C - Uncertain safety with animal studies showing an adverse effect
• Category D - Unsafe with evidence of risk that may, in certain clinical circumstances, be justifiable
• Category X - Highly unsafe with risk or use outweighing any possible benefit

During the first six months of pregnancy, monthly doctor's visits are standard. After that, visits are biweekly until the last month of pregnancy when they should be at least once per week. Usually, blood testing and anemia checks are performed at the first doctor's visit and at the 16- and 28-week visits.

The doctor will probably provide the woman who is pregnant with information to read regarding her pregnancy. She should ask questions if she needs help understanding the written information or what is happening during the pregnancy.

Contraception refers to methods used to prevent pregnancy. There are many ways to prevent pregnancy, but none of them is 100% effective with the exception of abstinence. The following currently used methods of contraception can vary widely in their effectiveness:

• Permanent birth control methods: male (vasectomy) or female (tubal ligation, tubal implant, Essure sterilization)
• Hormonal contraceptives: birth control pills , birth control patches, birth control vaginal ring
• Intra-uterine device (IUD) or intra-uterine system (Mirena)
• Implanon or Nexplanon implants
• Diaphragm
• Cervical caps
• Condoms
• Spermicides
• Coitus interruptus: withdrawal by the male before ejaculation
• Rhythm method: Not having sex during the time when is woman is most likely to be fertile
• Emergency contraception

Many events determine the outcome of a pregnancy.

• Maternal weight gain: The amount of weight a woman gains when pregnant can be important in predicting the outcome of pregnancy.
• • Excess weight gain places a pregnan patient at risk for diabetes and hypertension, and it may increase the chance for needing a cesarean birth (C-section).
  • Too little weight gain places the infant at risk for interuterine growth restriction and the mother at risk for anemia, nutritional deficiencies, and osteoporosis.
• Nausea and vomiting: Even if a pregnant patient experiences what seems like an abnormal amount of nausea and vomiting (morning sickness), it probably will not affect the baby's health, particularly if the woman is still gaining weight at the anticipated rate.
• Low or high red blood cell counts: The normal red blood cell count range varies slightly between laboratories, but is generally 4.2 - 5.9 million red cells per microliter. The risk of delivering prematurely is increased if the woman's blood count is low (anemia). Low blood counts also put her at risk of requiring a transfusion following a delivery. If the woman's blood count is too high (polycythemia), her baby may be larger than expected.
• Maternal obesity: A person with a body mass index (BMI) over 30 is considered obese. If a woman who is pregnant is obese and has diabetes, her baby is three times more likely to have a birth defect. If she is obese but does not have diabetes, the risk of birth defects is not increased.
• Maternal age: If the pregnant patient is older than 35 years, her infant is at a higher risk of birth defects and complications. The focus of genetic screening is to enable the woman to understand any problems her newborn may have. There is a 2% to 3% rate of major birth defects in this population.
• Folic Acid Deficiency: A pregnancy which is deficient in the nutrient folic acid, also known as folate, can lead to neural tube defects such as spina bifida in the fetus. Neural tube defects are malformations of the brain and spinal cord which typically occur with in the first few weeks of pregnancy; therefore, folic acid supplementation should be taken prior to conception and throughout the course of the pregnancy. It is recommended all non-pregnant women take a daily supplement containing 400mg of folate and pregnant women should take a supplement with 1000mg of folate.
• DHA Deficiency: During pregnancy, a diet which is deficient in the omega-3 fatty acid docosahexaenoic acid (DHA) can lead to inadequate development of the eyes, brain, and central nervous system of a fetus. It is recommended that pregnant and lactating women consume 300mg DHA per day. DHA is found in animal meats, fish, eggs, and vegetable oils.
• Omega-3 Fatty Acid Deficiency: Having an Omega-3 deficiency during pregnancy can be harmful to both the mother and the baby. Omega-3's are polyunsaturated fats that support the growth and development of a fetus and help reduce the risks of pregnancy complications. It is recommended women consume 300mg of Omega-3's daily during the course of pregnancy. This nutrient can be found in cold water fish, eggs, walnuts, and dark green leafy vegetables.