Which of the following indicates presumptive signs of pregnancy select all that apply?

Summary

Pregnancy begins with the fertilization of the ovum and its subsequent implantation into the uterine wall. The duration of pregnancy is counted in weeks of gestation from the first day of the last menstrual period and on average lasts 40 weeks. Presumptive signs of pregnancy include amenorrhea, nausea and vomiting, and breast enlargement and tenderness. Preconception counseling assists in the planning of pregnancy through education and risk assessment to help ensure best possible outcomes. Pregnancy can be confirmed definitively via positive serum or urine hCG tests and detection of the embryo on ultrasound. Ultrasound is also used to determine the gestational age and date of delivery. Women experience several physiological changes during pregnancy (e.g., increased plasma volume, venous stasis, increased insulin secretion, increased oxygen demand), which can lead to symptoms and conditions that may require treatment (e.g., peripheral edema, insulin resistance, hypercoagulability, dyspnea). Regular check-ups should be performed to detect potential high-risk pregnancies as well as fetal and maternal complications.

See also “Prenatal care” and “Maternal complications during pregnancy.”

Definitions

Gravidity, parity, and duration of pregnancy [1]

• Gravidity: the number of times a woman has been pregnant, regardless of pregnancy outcome
• Parity: the number of pregnancies that a woman carries beyond 20 weeks of gestation and ends with the birth of an infant weighing > 500 g
• Fetal age [2]
  • Counted as completed weeks of gestation and completed days (0–6) of the current week of pregnancy
  • Gestational age: estimated fetal age (in weeks and days) calculated from the first day of the last menstrual period
  • Conceptional age: the age (in weeks and days) of the fetus calculated from the day of conception (fertilization)
• Duration of pregnancy
  • Normal duration of pregnancy: 40 weeks (280 days)
  • Postterm pregnancy: a pregnancy that extends beyond 42 weeks' gestation or the estimated date of delivery plus 14 days
  • Periviable birth: live birth occurring between 20–25 weeks of pregnancy
  • Preterm birth: live birth before the completion of 37 weeks (< 37 0/7) of pregnancy
  • Postterm birth: live birth after 42 weeks (> 42 0/7) of pregnancy
• Trimesters of pregnancy

Clinical signs of early pregnancy

Diagnosis of pregnancy

Human chorionic gonadotropin (hCG)

• Site of production: placental syncytiotrophoblast
• Structure
• Function
• Pregnancy test: measurement of human chorionic gonadotropin (β-hCG)
  • Urine β-hCG test (e.g., home pregnancy test)
    • Qualitative test (less sensitive than serum pregnancy test)
    • β-hCG can be detected in urine 14 days after fertilization
  • Serum β-hCG test

Interpretation of β-hCG findings

Physiological changes during pregnancy

Cardiovascular system [8][9]

• ↑ Progesterone → ↓ vascular tone → ↓ peripheral vascular resistance (↓ afterload)
  • ↑ Cardiac output by up to 40% (↑ preload)
  • ↑ Stroke volume (by 10–30%)
  • ↑ Heart rate (by ∼ 12–18 bpm) → ↑ uterine perfusion
  • ↓ Mean arterial pressure
• Innocent systolic murmur
• The apex beat is displaced upward.
• ↑ Plasma volume → ↓ oncotic pressure → edema of lower limbs
• Varicosities
• Aggravation of preexisting valvular diseases

A physiological systolicmurmur may be heard due to increased cardiac output and increased plasma volume.

Respiratory system [10]

• ↑ Oxygen consumption (by approx. 20%)
• ↑ Intraabdominal pressure through uterine growth → dyspnea (the diaphragm is displaced upwards →↓ total lung capacity, residual volume, functional residual capacity, and expiratory reserve volume)
• Progesterone stimulates the respiratory centers in the brain →hyperventilation (to eliminate fetal CO2 more efficiently) →physiological, chronic compensated respiratory alkalosis

Renal system [9][11]

• ↑ Renal plasma flow → ↑ GFR →↓ BUN and creatinine
• ↑ Aldosterone → ↑ plasma volume and hypernatremia
• ↑ Progesterone and intraabdominal pressure → dilation of kidney, pelvis, and calyceal systems → reduced tone and peristalsis
• ↑ Glucose levels in urine: Increased glomerular filtration results in overload of the glucose carrier responsible for its resorption.
• Mild proteinuria: Increased GFR and glomerular permeability to albumin increases protein excretion.

Endocrine system [9][12][13]

• Progesterone
• Human placental lactogen: a hormone synthesized by syncytiotrophoblasts of the placenta, which promotes the production of insulin-like growth factors.
• Thyroid hormones
• ↑ SHBG and corticosteroid-binding globulin
• ↑ Triglycerides and cholesterol (due to increased lipolysis and fat utilization)
• Hyperplasia of lactotroph cells in the anterior pituitary → physiological enlargement of the pituitary gland (up to 40% increase from pregestational volume)

Hematologic system [9][14][15]

• ↑ Plasmavolume →↓ hematocrit, especially towards the end of pregnancy (30–34th week of gestation) →dilutional anemia (hemoglobin value rarely drops below 11 g/dL)
• Hypercoagulability is due to an increase in fibrinogen, factor VII, and factor VIII and a decrease in protein S; (reduces the risk of intrapartum blood loss).
• ↓ Platelet count
  • Etiology
  • Diagnostics: peripheral blood smear to exclude pseudothrombocytopenia, repeat CBC using citrate or heparin, and comparison with previous platelet counts.
  • Management: no treatment is required for mild gestational thrombocytopenia (100,000–150,000/μL) or gestational pseudothrombocytopenia.
• ↑ RBC mass (increases from 8–10th week of gestation until the end of pregnancy)
• ↓ Iron and folate levels due to increased vitamin and mineral requirements
• ↑ WBC count
• ↓ Albumin
• ↑ Alkaline phosphatase (placental isoenzymes)

Physiological hypercoagulability during pregnancy leads to an increased risk of thrombosis. Patients with thrombophilia should receive adequate thrombosis prophylaxis.

Gastrointestinal system [9]

• ↑ Salivation
• ↓ Lower esophageal sphincter tone → gastroesophageal reflux
• ↓ Motility → constipation
• Gallbladder stasis → gallstones
• Hemorrhoids

Pelvic girdle pain [17]

• Etiology: increased pressure from the uterus, lumbar lordosis, and relaxation of the ligaments supporting the joints of the pelvic girdle
• Clinical features: lower back pain
• Diagnosis: positive pelvic pain provocation tests (e.g., posterior pelvic pain provocation test, FABER test, active straight leg raise)
• Management
  • Nonpharmacological: heat therapy, manual therapy (e.g., massage, spinal manipulation), braces, physical therapy
  • Pharmacological: acetaminophen

Round ligament pain

Skin

• Spider angioma
• Palmar erythema
• Striae gravidarum: scarring that manifests as erythematous, violaceous, and/or hypopigmented linear striations on the abdomen
• Hyperpigmentation: chloasma, linea nigra, hyperpigmentation of the nipples

Reproductive system

• Uterus: increase in size
• Vulva and vagina
  • Vaginal discharge
  • Formation of varicose veins
• Mammary glands increase in size

Nutrition during pregnancy

Physical activity during pregnancy

High-risk pregnancy

Early identification of high-risk pregnancies is vital in order to prevent the occurrence of maternal and fetal complications. They require regular prenatal care to monitor and support the pregnant mother (see “Prenatal care”).

Postterm pregnancy

• Definition: Pregnancy that progresses beyond 42 weeks (294 days) since the first day of the last menstrual period or beyond 14 days of the estimated delivery date. [33]
• Etiology: unknown
• Risk factors
• Management
• Complications

Fetal complications during pregnancy

Oligohydramnios [35]

• Definition: amount of amniotic fluid is less than expected for gestational age
• Etiology
  • Fetal anomalies
    • Urethral obstruction (e.g., posterior urethral valves)
    • Bilateral renal agenesis
    • Autosomal recessive polycystic kidney disease (ARPKD)
    • Chromosomal aberrations (e.g., trisomy 18)
    • Intrauterine infections (e.g., congenital TORCH infections)
    • In multiple pregnancies: twin-to-twin transfusion syndrome
  • Maternal conditions
    • Placental insufficiency
    • Late or postterm pregnancies (> 42 weeks of gestation)
    • Premature rupture of membranes
    • Preeclampsia
  • Idiopathic
• Diagnosis [36]
• Treatment
  • Amnioinfusion: infusion of fluid into the amniotic cavity through amniocentesis
  • Treat underlying cause: See “Preeclampsia,” “Premature rupture of membranes,” and “Placental insufficiency.”
  • Delivery is advised if the fetus is close to term.
• Complications
  • Intrauterine growth restriction (due to diminished mobility of the fetus)
  • Birth complications (e.g., umbilical cord compression)
  • Potter sequence
    • Etiology
    • Pathophysiology: oligohydramnios → intrauterine compression and decreased amniotic fluid ingestions →↓ space for fetal development → internal and external deformations
    • Clinical features
      • Pulmonary hypoplasia (cause of death due to severe neonatal respiratory insufficiency)
      • Craniofacial abnormalities (e.g., prominent epicanthal and infraorbital folds, flattened nose, receding chin, low set ears)
      • Wrinkling of the skin
      • Limb anomalies (e.g., bowed legs, clubbed feet)

Potter babies cannot Pee.

POTTER sequence: Pulmonary hypoplasia (lethal), Oligohydramnios (origin), Twisted facies, Twisted skin, Extremity deformities, and Renal agenesis (classic form).

Polyhydramnios [37]

• Definition: excessive amniotic fluid volume expected for gestational age that results in uterine distention.
• Etiology
  • Typically idiopathic (∼ 70% of cases) [38]
  • Fetal anomalies
    • Gastrointestinal (e.g., esophageal atresia, duodenal atresia and stenosis): reduced swallowing and absorption of amniotic fluid
    • CNS: anencephaly; (leads to impaired swallowing of amniotic fluid, leakage of cerebrospinal fluid, and increased urination due to lack of fetal ADH), meningomyelocele (due to leakage of cerebrospinal fluid) [39]
    • Pulmonary: cystic lung malformations
    • Multiple pregnancy: twin-to-twin transfusion syndrome
    • Fetal anemia [40]
    • Chromosomal aberrations
    • Intrauterine infections (e.g., congenital TORCH infections)
  • Maternal conditions
    • Diabetes mellitus
    • Rh incompatibility (e.g., hemolytic disease of the newborn)
• Diagnostics
• Management
• Complications

Related One-Minute Telegram

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

References

Which are the presumptive signs of pregnancy select all that apply?

Which of the following would the nurse expect to find as presumptive signs of pregnancy?

Which of the following assessment data is a most accurate indication that a woman is pregnant?

Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy?