NORMAL PREGNANCY

Definitions:

 Pregnancy (gestation) is the maternal condition of having a developing

fetus in the body.
 The human conceptus from fertilization through the eighth week of
pregnancy is termed an embryo; from the eighth week until delivery, it
is a fetus.
 For obstetric purposes, the duration of pregnancy is based on gestational
age: the estimated age of the fetus calculated from the first day of the last
(normal) menstrual period (LMP), assuming a 28-day cycle.
 Gestational age is expressed in completed weeks.
 This is in contrast to developmental age (fetal age), which is the age of
the offspring calculated from the time of implantation.
 The term gravid means pregnant, and gravidity is the total number of
pregnancies (normal or abnormal).
 Parity is the state of having given birth to an infant or infants weighing
500 g or more, alive or dead.
 In the absence of known weight, an estimated duration of gestation of 20
completed weeks or more (calculated from the first day of the LMP) may
be used.
 From a practical clinical viewpoint, a fetus is considered viable when it
has reached a gestational age of 23-24 weeks and a weight of 600 g or
more.
 However, only very rarely will a fetus of 20-23 weeks weighing 500-600
g or less survive, even with optimal care.
 With regard to parity, a multiple birth is a single parous experience.

Live Birth

 Live birth is the complete expulsion or extraction of a product of

conception from the mother, regardless of the duration of pregnancy,
which, after such separation, breathes or shows other evidence of life
(e.g. beating of the heart, pulsation of the umbilical cord, or definite
movements of the involuntary muscles) whether or not the cord has been
cut or the placenta detached
 An infant is a live-born individual from the moment of birth until the
completion of 1 year of life.
 In the most recent nomenclature, a preterm infant is defined as one born
prior to the 37th week of gestation (259 days).
 An abortion is the expulsion or extraction of all (complete) or any part
(incomplete) of the placenta or membranes, without an identifiable fetus
or with a fetus (alive or dead) weighing less than 500 g.
 In the absence of known weight, an estimated duration of gestation of
under 20 completed weeks (139 days) calculated from the first day of the
LMP may be used.
 An immature infant weighs 500-1000 g and has completed 20 to less
than 28 weeks of gestation.
 A premature infant is one with a birthweight of 1000-2500 g and
duration of gestation of 28 to less than 37 weeks.
 A low-birthweight infant is any live-born infant weighing 2500 g or less
at birth.
 An undergrown or small-for-date infant is one who is significantly
undersized (< 2 SD) for the period of gestation.
 A mature infant is a live-born infant who has completed 37 weeks of
gestation (and usually weighs over 2500 g).
 A postmature infant is one who has completed 42 weeks or more of
gestation.
 The postmature syndrome is characterized by prolonged gestation,
sometimes an excessive-size fetus, and diminished placental capacity for
sufficient exchange, associated with cutaneous and nutritional changes in
the newborn infant.
 A fetus or infant of excessive size (macrosomic) is one who is larger than
the gestation would indicate or who at the time of birth weighs over 4500
g.
 Significantly increased morbidity and mortality rates may be associated
with the relative dystocia created by the large fetus
 About 10% of newborn infants are oversized (> 4000 g), and 2% are of
"excessive" size (> 4500 g).
 Excessive fetal size should be suspected in large multiparous or obese
mothers, those with diabetes mellitus, or those whose weight gain during
pregnancy has been greater than anticipated.
 A prolonged pregnancy is a gestation that has advanced beyond 2 SD
from the mean and with duration of 421/2 weeks or longer (297 days).
 The perinatal mortality rate at 43 weeks is twice that at 39-42 weeks.
 The fetus probably develops a relatively restricted placental exchange
capability, leading to an increased intrauterine death rate.
Birth Rate & Fertility Rate

 Birth rate is commonly expressed in terms of the number of live births

per 1000 population.
 The fertility rate is expressed as the number of live births per 1000
women aged 15-44 years and is thus a more sensitive measure of the
reproductive activity of a given population.

Neonatal Interval

 The neonatal interval is from birth until 28 days of life.

 During this interval, the infant is referred to as a newborn infant.
 The interval may be divided into 3 periods:
1. Neonatal period I: birth through 23 hours, 59 minutes.
2. Neonatal period II: 24 hours of life through 6 days, 23 hours, 59
minutes.
3. Neonatal period III: seventh day of life through 27 days, 23 hours, 59
minutes.

Perinatal Interval

 The perinatal interval is the span of fetal and neonatal life.

 The perinatal interval of life may be divided into 2 periods:
1. Perinatal period I: 28 weeks of completed gestation to the first 7 days
of life.
2. Perinatal period II: 20 weeks of gestation through 27 days of life.

Diagnosis

 The diagnosis of pregnancy is usually made on the basis of a history of

amenorrhea, an enlarging uterus, and a positive pregnancy test.
 Nausea and breast tenderness are also often present.
 The manifestations of pregnancy are classified into 3 groups:
presumptive, probable, and positive.

Presumptive Manifestations

A. Symptoms
1. Amenorrhea

 Cessation of menses is caused by increasing estrogen and progesterone

levels produced by the corpus luteum
 Spotting due to bleeding at the implantation site may occur from the time
of implantation (about 6 days after fertilization) until 29-35 days after the
LMP in many women

2. Nausea and vomiting

 This common symptom occurs in approximately 50% of pregnancies and

is most marked at 2-12 weeks' gestation.
 It is usually most severe in the morning but can occur at any time and
may be precipitated by cooking odors and pungent smells.
 Extreme nausea and vomiting may be a sign of multiple gestation or
molar pregnancy.
 The nausea probably results from rapidly rising serum levels of human
chorionic gonadotropin (hCG).
 During the first trimester, serum hCG levels may be as high as
100,000mIU/mL.
 Protracted vomiting associated with dehydration and ketonuria
(hyperemesis gravidarum) may require hospitalization and relief of
symptoms with a droperidol drip.
 Treatment for uncomplicated nausea consists of light dry foods, small
frequent meals, and emotional support.
 Some improvement can be seen with the addition of high-dose B6
therapy and the preconceptional use of prenatal vitamins.

3. Breasts

 Mastodynia-Mastodynia, or breast tenderness, may range from tingling

to frank pain caused by hormonal responses of the mammary ducts and
alveolar system.
 Circulatory increases result in breast engorgement and venous
prominence.
 Similar tenderness may occur just before menses.
 Enlargement of circumlacteal sebaceous glands of the areola
(Montgomery's tubercles) Enlargement of these glands occurs at 6-8
weeks' gestation and is due to hormonal stimulation.
 Colostrum secretion-Colostrum secretion may begin after 16 weeks'
gestation.
 Secondary breasts-Secondary breasts may become more prominent both
in size and in coloration.

4. Quickening

 The first perception of fetal movement occurs at 18-20 weeks in

primigravidas and at 14-16 weeks in multigravidas.

5. Urinary tract

 Bladder irritability, frequency, and nocturia-These conditions occur

because of increased bladder circulation and pressure from the enlarging
uterus.
 Urinary tract infection- Urinary tract infection must always be ruled out
because pregnant women are more likely than nonpregnant women to
have significant bacteriuria which may be asymptomatic (7% versus 3%).

B. Signs

1. Increased basal body temperature

 Persistent elevation of basal body temperature over a 3-week period

usually indicates pregnancy if temperatures have been carefully charted.

2. Skin

 Chloasma
 Linea nigra
 Stretch marks
 Spider telangiectases

Probable Manifestations

A. Symptoms
 Symptoms are the same as those discussed under Presumptive
Manifestations, above

1. Pelvic organs

 Chadwick's sign
 Leukorrhea
 Goodell's sign
 Ladin's sign
 Hegar's sign
 McDonald's sign
 Von Fernwald's sign

2. Abdominal enlargement
3. Uterine contractions
4. Ballottement of the uterus
5. Uterine souffle

Positive Manifestations

A. Fetal Heart Tones (FHTs)

 It is possible to hear FHTs with a fetoscope in a slender woman at 17-18

weeks.
 The normal fetal heart rate is 120-160 beats per minute.
 It is best to palpate the maternal pulse for comparison
 Doppler devices detect FHTs as early as 10 weeks.

B. Palpation of Fetus

 After 22 weeks, the fetal outline can be palpated through the maternal
abdominal wall.
 Fetal movements may be palpated after 18 weeks.

C. X-Ray of Fetus

D. Ultrasound Examination of Fetus

Pregnancy Tests

 hCG is produced by the syncytiotrophoblast 8 days after fertilization and

may be detected in the maternal serum as early as 9 days.
 hCG levels peak approximately 65 days after conception.
 Levels gradually decrease in the second and third trimesters and increase
slightly after 34 weeks.
 The half-life of hCG is 1.5 days.
 After termination of pregnancy, levels drop exponentially.
 Normally, serum and urine hCG levels return to nonpregnant values (< 5
mIU/mL) 21-24 days after delivery

A. Biologic Tests

B. Immunologic Tests

C. Radioimmunoassay for hCG

D. Radioreceptor Assay

E. Home Pregnancy Tests

CALCULATION OF GESTATIONAL AGE & ESTIMATED DATE

OF CONFINEMENT

 After the diagnosis of pregnancy is made, it is imperative to determine

the duration of pregnancy and the estimated date of confinement (EDC).

Calculation of Gestational Age

A. Pregnancy Calendar or Calculator

 Normally, human pregnancy lasts 280 days or 40 weeks (9 calendar

months or 10 lunar months) from the last normal menstrual period
(LNMP).
 This may also be calculated as 266 days or 38 weeks from the last
ovulation in a normal 28-day cycle.
 The easiest method of determining gestational age is with a pregnancy
calendar or calculator.
B. Clinical Parameters of Gestational Age

1. Uterine size

 An early first-trimester examination usually correlates well with the

estimated gestational age.
 The uterus is palpable just at the pubic symphysis at 8 weeks.
 At 12 weeks, the uterus becomes an abdominal organ and at 16 weeks is
usually at the midpoint between the pubic symphysis and the umbilicus.
 The uterus is palpable at 20 weeks at the umbilicus.

 Fundal height (determined by measuring the distance in centimeters from

the pubic symphysis to the curvature of the fundus) correlates roughly
with the estimated gestational age at 26-34 weeks
 After 36 weeks, the fundal height may decrease as the fetal head
descends into the pelvis.

2. Quickening

 The first fetal movement is usually appreciated at 17 weeks in the

average multipara and at 18 weeks in the average primipara.

3. Fetal heart tones

 FHTs may be heard by fetoscope at 20 weeks, whereas Doppler
ultrasound usually detects heart rates by 10 weeks.

5. Ultrasonography

 Ultrasonography is now the most widely used technique for

determination of gestational age; there is now little or no justification for
the use of x-ray for this purpose.

Estimated Date of Confinement (Nagele's Rule)

 The EDC can be determined mathematically using Nagele's rule: Subtract

3 months from the month of the LNMP, and add 7 to the first day of the
LNMP.
 Example: With an LNMP of July 14, the EDC is April 21.
 This rule is based on a normal 28-day cycle.
 In women with a longer proliferative phase, add to the first day of the
LNMP the usual 7 days plus the number of days that the cycle extends
beyond 28 days.

PRENATAL CARE

Laboratory Tests

A. Blood Screening

 At the first visit, the following is obtained: hematocrit, hemoglobin,

white blood cell count and differential, blood type group, Rh factor and
antibodies to blood group antigens; also needed are a serologic test for
syphilis (VDRL), rubella, hepatitis B, and HIV
 Women with prior gestational diabetes should be given early 1-hour post
glucose testing.
 The glucose level is checked after ingestion of 50 g of glucose.
 In a woman with no increased risk, this is done at 24-28 weeks' gestation
 If the test is abnormal, a 3-hour glucose tolerance test is obtained (fasting
glucose level, followed by glucose levels 1, 2, and 3 hours after a 100-g
glucose load).
 Hematocrit should be repeated in the third trimester.
Urine Testing

 Perform urinalysis and screening tests (eg, dipstick nitrite testing) or

culture for urinary tract infection.
 Testing for urinary protein, glucose, and ketones should be done at each
prenatal visit.

Subsequent visits

 The standard schedule for prenatal office visits is 0-32 weeks: once every
4 weeks; 32-36 weeks: once every 2 weeks; and 36 weeks to delivery:
once each week.
 At each visit, weight gain, blood pressure, fundal height, and findings on
abdominal examination by Leopold's maneuvers should be recorded.
 Additionally, FHTs should be documented and urine should be checked
for glucose and protein.
 These findings should be reviewed and compared with those of previous
examinations.

Maternal well-being as a sign of fetal well-being

Fundal Height

 Fundal height should be measured and recorded at each visit after 20

weeks.
 Measurements should be made with a centimeter tape (McDonald's
technique) from the pubic symphysis to the top of the uterine mass over
the curvilinear abdominal surface.
 Progress is especially important in the third trimester, when fetal growth
retardation is most easily determined.

Preparation for labor

 She should be told to seek medical advice for any of the following danger
signals:
1. Rupture of membranes,
2. Vaginal bleeding,
3. Decreased fetal movement,
 4. Evidence of preeclampsia (e.g. marked swelling of the hands and
face, blurring of vision, headache, epigastric pain, convulsions),
5. Chills or fever,
6. Severe or unusual abdominal or back pain, or
7. Any other severe medical problems.

Weight gain

 The American College of Obstetricians and Gynecologists recommends a

weight gain of 11.5-16 kg (25-35 lb) during singleton pregnancy.
 Underweight women may need to gain more, while obese women should
gain only 7-11.5 kg (15-25 lb).
 Heavier women or those with excessive weight gain during pregnancy
are likely to have macrosomic infants.
 Inadequate weight gain is associated with small-for-gestational age
(SGA) infant.
1. The fetus accounts for about one-third of the normal weight gain
(3500 g);
2. The placenta, amniotic fluid, and uterus for 650-900 g;
3. Interstitial fluid and blood volume for 1200-1800 g each; and
4. Breast enlargement for 400 g.
5. The remaining 1640 g or more is largely maternal fat.

BOIWO W.
LECTURER, OBS/GYN