Pregnancy
Pregnancy (latin graviditas) is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field that studies and treats pregnancy. Midwifery is the non-surgical field that cares for pregnant women.
Childbirth usually occurs about 38 weeks after fertilization (conception), i.e., approximately 40 weeks from the the last normal menstrual period (LNMP) in humans. The date of delivery is considered normal medically if it falls within two weeks of the calculated date. The calculation of this date involves the assumption of a regular 28-day period. Thus, pregnancy lasts almost ten months, although the exact definition of the English word “pregnancy” is a subject of controversy.
Characteristics
Pregnancy occurs as the result of the female gamete or oocyte (egg) being penetrated by the male gamete spermatozoon in a process referred to, in medicine, as "fertilization", or more commonly known as "conception". The fusion of male and female gametes usually occurs through the act of sexual intercourse. However, the advent of artificial insemination has also made achieving pregnancy possible in such cases where sexual intercourse is not potentially fertile (through choice or male/female infertility).
A number of medical signs are associated with pregnancy. 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 Gonadotropins (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 two 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; it usually appears around the middle of pregnancy).
Duration
The expected date of delivery (EDD) is 40 weeks counting from the last menstrual period (LMP) and usually lasts between 37 and 42 weeks, The actual pregnancy duration is 38 weeks after conception typically. Though pregnancy begins at conception, it is more convenient to date from the first day of a woman's last menstrual period, or from the date of conception if known. Starting from one of these dates, the expected date of delivery can be calculated. 40 weeks is nine months and six days, which forms the basis of Naegele's rule for estimating date of delivery. More accurate algorithms which take into account other variables, such as whether this is the first or subsequent child (i.e. mother is a primip or a multip, respectively), ethnicity, parental age, length of menstrual cycle and menstrual regularity form the basis for more sophisticated online calculation methods,
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 pre-term; from week 42 (294 days) events are considered post-term. When a pregnancy exceeds 42 weeks (294 days), the risk of complications for mother and fetus increases significantly. As such, obstetricians usually prefer to induce labour, in an uncomplicated pregnancy, at some stage between 41 and 42 weeks.
Recent medical literature prefers the terminology pre-term and post-term to premature and post-mature. Pre-term and post-term 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.
Fewer than 5% of births occur on the due date; 50% of births are within a week of the due date, and almost 90% within two weeks. It is much more useful to consider therefore a range of due dates, rather than one specific day, with some online due date calculators providing this information, e.g. here.
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 a difference of predicted due date is highlighted between dates based on LMP and ultrasound dating, with the latter being later, this might signify slowed fetal growth and therefore the need for closer review.
Diagnosis
The beginning of pregnancy may be detected in a number of ways, including various pregnancy tests which detect hormones generated by the newly-formed placenta. Clinical blood and urine tests can detect pregnancy soon after implantation, which is as early as 6-8 days after fertilization. Home pregnancy tests are personal urine tests, which normally cannot detect a pregnancy until at least 12-15 days after fertilization. Both clinical and home tests can only detect the state of pregnancy, and cannot detect the age of the embryo.
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.
An early sonograph can determine the age of the pregnancy fairly accurately. In practice, doctors 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, or she has been charting her cycles, or the conception is as the result of some types of fertility treatment (such as IUI or IVF) the exact date of fertilization is unknown. Absent symptoms such as morning sickness, often the only visible sign of a pregnancy is an interruption of her 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 two 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. The beginning of labour, which is variously called confinement or childbed, begins on the day predicted by LMP 3.6% of the time and on the day predicted by sonography 4.3% of the time.
Diagnostic criteria are: Women who have menstrual cycles and are sexually active, a period delayed by a few days or weeks is suggestive of pregnancy; elevated B-hcG to around 100,000 mIU/mL by 10 weeks of gestation.
Physiology
Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.
First trimester
Traditionally, doctors 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 into the endometrial lining of a woman's uterus. In some cases where complications may have arisen, the fertilized egg might implant itself in the fallopian tubes or the cervix, causing an ectopic pregnancy. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience light bleeding at implantation. Some women will also experience cramping during their first trimester. This is usually of no concern unless there is spotting or bleeding as well. The outer layers of the embryo grow and form a placenta, for the purpose of receiving essential nutrients through the uterine wall, or endometrium. The umbilical cord in a newborn child consists of the remnants of the connection to the placenta. The developing embryo undergoes tremendous growth and changes during the process of foetal development.
Morning sickness can occur in about seventy percent of all pregnant women and typically improves after the first trimester. Most miscarriages occur during this period.
Second trimester
Months 4 through 6 of the pregnancy are called the second trimester. Most women feel more energized in this period, and begin to seriously put on weight as the symptoms of morning sickness subside and eventually fade away. Although the fetus begins moving 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 by the fourth month. The placenta is now fully functioning and the fetus is making insulin and urinating. The reproductive organs can be recognized, and can distinguish the fetus as male or female.
Third trimester
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 28g per day. The woman's belly will transform in shape as the belly drops due the 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, 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 back-ache. 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.
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. 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.
Physiological changes in pregnancy
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.
Hormonal changes
Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The mother and the placenta also produces many hormones.
Prolactin levels increase due to maternal Pituitary gland enlargement by 50%. This mediates a change in the structure of the Mammary gland from ductal to lobular-alveolar. Parathyroid hormone is increased due to increases of calcium uptake in the gut and reabsorption by the kidney. Adrenal hormones such as cortisol and aldosterone also increase.
Placental lactogen is produced by the placenta and stimulates lipolysis and fatty acid metabolism by the mother, conserving blood glucose for use by the fetus. It also decreases maternal tissue sensitivity to insulin, resulting in gestational diabetes.
Musculoskeletal changes
The body's posture changes as the pregnancy progresses. The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the baby grows. These muscles are less able to contract and keep the lower back in proper alignment. The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture. On average, a woman's foot can grow by a half size or more during pregnancy. In addition, the increased body weight of pregnancy, fluid retention, and weight gain lowers the arches of the foot, further adding to the foot's length and width. The influences of increased hormones such as estrogen and relaxing initiate the remodeling of soft tissues, cartilage and ligaments. Certain skeletal joints such as the symphonists pubis and sacroiliac widen or have increased laxity.
Physical changes
Weight is gained during pregnancy due to increased appetite, fat deposition, and growth of the reproductive organs and fetus, as well as increased blood volume and water retention. Anywhere from 5 to over 100 pounds can be gained during pregnancy. In America, the doctor-recommended weight gain range is 25-35 pounds, less if the woman is overweight, more (up to 40) if the woman is underweight.
Cardiovascular changes
Blood volume increases by 40% in the first two trimesters. This is due to an increase in plasma volume through increased aldosterone. Progesterone may also interact with the aldosterone receptor, thus leading to increased levels. Red blood cell numbers increase due to increased erythropoietin levels.
Cardiac function is also modified, with increase heart rate and increased stroke volume. A decrease in vagal tone and increase in sympathetic tone is the cause. Blood volume increases act to increase stroke volume of the heart via Starling's law. After pregnancy the change in stroke volume is not reversed. Cardiac output rises from 4 to 7 litres in the 2nd trimester
Blood pressure also fluctuates. In the first trimester it falls. Initially this is due to decreased sensitivity to angiotensin and vasodilation provoked by increased blood volume. Later, however, it is caused by decreased resistance to the growing uteroplacental bed.
Respiratory changes
Decreased functional residual capacity is seen, typically falling from 1.7 to 1.35 litres, due to the compression of the diaphragm by the uterus. Tidal volume increases, from 0.45 to 0.65 litres, giving an increase in pulmonary ventilation. This is necessary to meet the increased oxygen requirement of the body, which reaches 50ml/min - 20ml of which goes to reproductive tissues.
Progesterone may act centrally on chemoreceptors to reset the set point to a lower partial pressure of carbon dioxide. This maintains an increased respiration rate even at a decreased level of carbon dioxide.
Metabolic changes
An increased requirement for nutrients is given by fetal growth and fat deposition. Changes are caused by steroid hormones, lactogen and cortisol.
Maternal insulin resistance can lead to gestational diabetes. Increase liver metabolism is also seen, with increased gluconeogenesis to increase maternal glucose levels.
Renal changes
Renal plasma flow increases, as does aldosterone and erthropoietin production as discussed. The tubular maximum for glucose is reduced, which may precipitate gestational diabetes.
Management
Prenatal medical care is of recognized value throughout the developed world. Periconceptional Folic acid supplementation is the only type of supplementation of proven efficacy.
Nutrition
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. Folates (from folia, leaf) are abundant in spinach (fresh, frozen, or canned), and are also found in green vegetables, salads, melon, hummus, and eggs. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.
Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is prevalent. 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.
There is some evidence that long-chain omega-3 (n-3) fatty acids have an effect on the developing fetus, but further research is required. At this time, supplementing the diet with foods rich in these fatty acids is not recommended, but is not harmful.
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 catching salmonella infections from eggs and poultry, which should be thoroughly cooked. Practicing good hygiene in the kitchen can reduce these risks.
Weight gain
Caloric intake must be increased, to ensure proper development of the fetus. The amount of weight gained during pregnancy varies between women. The National Health Service recommends that overall weight gain during the 9 month period for women who start pregnancy with normal weight be 10 to 12 kilograms (22–26 lb). During pregnancy, insufficient weight gain can compromise the health of the fetus. Women with fears of weight gain or with eating disorders may choose to work with a health professional, to ensure that pregnancy does not trigger disordered eating. Likewise, excessive weight gain can pose risks to the woman and the fetus. Women who are prone to being overweight may choose to plan a healthy diet and exercise plan to help moderate the amount of weight gained.
Sexuality during pregnancy
Most pregnant women can enjoy sexual intercourse throughout gravidity. Most research suggests that, during pregnancy, both sexual desire and frequency of sexual relations decrease. In context of this overall decrease in desire, some studies indicate a second-trimester increase, preceding a decrease. However, these decreases are not universal: a significant number of women report greater sexual satisfaction throughout their pregnancies.
Sex during pregnancy is a low-risk behaviour except when the physician advises that sexual intercourse be avoided, which may, in some pregnancies, lead to serious pregnancy complications or health issues such as a high-risk for premature labour or a ruptured uterus. Such a decision may be based upon a history of difficulties in a previous childbirth.
Some psychological research studies in the 1980s and '90s contend that it is useful for pregnant women to continue to have sexual activity, specifically noting that overall sexual satisfaction was correlated with feeling happy about being pregnant, feeling more attractive in late pregnancy than before pregnancy and experiencing orgasm. During pregnancy, the baby is protected from penetrative thrusting by the amniotic fluid in the womb and by the woman's abdomen.
Abortion
An abortion is the removal or expulsion of an embryo or fetus from the uterus, resulting in or caused by its death. This can occur spontaneously or accidentally as with a miscarriage, or be artificially induced by medical, surgical or other means.
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