Linea nigra and Striae gravidarum

Linea nigra :-
It is the bluish pigmentation area in the mid line of xiphisternum to the pubis. 
It disappear after the delivery. 

Striae gravidarum :-
These are slightly depressed linear marks with varying length & width in pregnancy. 
Striae gravidarum are a cutaneous condition characterized by stretch marks on the 
abdominen during and following pregnancy.

Chloasma gravidarum

It is an extreme form of pigmentation around the cheek, forehead and 
around the eyes. A patchy brown or dark brown skin discoloration that 
usually occur on a woman's face. It may result from hormonal changes.
Disappear spontaneously after the delivery.

Braxton-Hicks Contractions

The Braxton Hicks contractions are irregular, infrequent, spasmodic 
and painless without any effect on dilation of the cervix. The patient is
not conscious about the contractions. Near term, the contractions become
frequent with increase in intensity so as to produce some discomfort to
the patient. Ultimately, it merges with the painful uterine contractions
of labour. In abdominal pregnancy, Braxton Hicks contraction is not felt.

FETUS-IN-UTERO (Lie, Presentation and Position)

LIE - 
The lie refers to the relationship of the long axis of the fetus
to the long axis of the centralized uterus or maternal spine.
The commonest lie being longitudinal (99.5%). 
The lie may be transverse or oblique.

PRESENTATION - 
The part of fetus which occupies the lower pole of the uterus is called
presentation of the fetus. The presentation may be -
     Cephalic - 96.5% ( Vertex- 96%, Face-0.5% )
      Podalic - 3%
     Shoulder and other - 0.5%
Presenting part -
The part of presentation which overlies the internal cervical os (opening).

DENOMINATOR -
It is an arbitrary bony fixed point on the presenting part which comes
in relation with the various quadrants of the maternal pelvis.
The following are the denominator of the different presentation -
- Occiput in vertex
- Mentum in face
- Frontal eminence in brow
- Sacrum in breech
- Acromion in shoulder

POSITION -
It is relation of the denominator to the different quadrants
of the pelvis. There are 8 positions with each presenting part.

Gravida and Parity

Que. -  What is Gravida and Parity ?

Ans. -   Gravida means number of pregnancy. A pregnant woman referred to as 

             primigravida during the first pregnancy, gravida 2 during the second pregnancy.

             Parity means number of delivery. 

Que. -  What is difference between Gravida and Parity ?

Ans. -   The number of  pregnancy is counted in Gravida, not the number of birth.

             The number of birth is counted in Parity, not the number of fetus.

              Example -

                            Twins birth in first pregnancy then

                                       Gravida - 1

                                        Parity  -  2 (number of birth)

NOTE -  In abortion condition : 

             It is included in gravida if it occur before 20 week gestation, 

             and include in parity if it occur after 20 week gestation.

Nulligravida - 

A woman who have never been pregnant.

EDD (Expected date of delivery)

Negele's formula -:
- Add 7 days to 1st day of last menstrual period (LMP).
- Subtract 3 months.
- Add 1 year.

Expected date of delivery is estimated by negele's rule.
( Not applicable in Jan, Feb and March )

           Example -
                                  LMP        10  /  07  /  2011
                                                 +7     -3        +1    
                                  EDD         17 /  04  /  2012

Que. -  What is the simple method of EDD ?

 Ans. -  Simple method of EDD - 
                                                      LMP + 9 months 7 days

Goodell's sign in pregnancy

Goodell's sign :- 
Softening of the cervix at the beginning of the 2nd month of pregnancy. 

It is also probable sign of pregnancy. 

Que. -  What is the cause of softening of cervix in pregnancy ? 

Ans. -   Softening of the cervix is because of fluid collection in fiber tissues 

            due to hypertrophy. It is also due to increased vascularization.

            It is indication of pregnancy.

Chadwick's sign in pregnancy

Chadwick's sign :-
Bluish coloration of the mucous membrane of the cervix, vagina and vulva 
that occur at about 6 week of pregnancy. It is probable sign of pregnancy. 
It is considered an indication of pregnancy.

Que. -  Why is blue color of cervix and vagina during pregnancy ?

Ans. -  Bluish coloration of vagina, vulva and cervix is due to the appearance 
           of blood vessels and excessive blood supply to the area.

CST (Contraction stress test) or OCT (Oxytocin challenged test)

It is an invasive method to assess the fetal well being alteration in fetal
heart rate in response to uterine contraction.

Principal -
The test is based on determination of the respiratory function of the
fetoplacental unit during induced contraction when the blood flow
through the unit is curtained. The objective is to detect the degree of
fetal compromise, so that a suitable time can be selected to terminate
the pregnancy.

Indication - 
i) IUGR (Intrauterine growth retardation).
ii) Post maturity.
iii) Hypertensive disorder of pregnancy.
iv) Diabetes mellitus.
v) Woman with non-reactive NST.

Contraindication -
- Third trimester bleeding.
- Incompetent cervix.
- Multiple gestation.
- Previous classical uterine incision.
- Hydramnios.
- History of preterm labour.
- Premature rupture of membrane

Procedure - 
The oxytocin infusion is started. The initial rate of infusion is 1 mu/min which
is stepped up at intervals of 20 min until the effective uterine contraction are
established. The alteration of the fetal heart rate during concentration is recorded
by electronic monitoring. Alternatively clinical monitoring can effectively be
performed using hand to palpate the hardening of the uterus during contraction
and auscultation of fetal heart rate during contraction and for 1 min. There after
it takes at least 1-2 hours to perform the test.

NST (Non Stress Test) in pregnancy

The non stress test ( NST ) monitors the fetal heart rate in response to
the fetal well being. It has advantage of involving no external stimulation
( eg.- oxitocin stimulating ) in the conduct of test.

Indication -
i) Maternal -
   -  Post dated pregnancy.
   -  Rh sensitization.
   -  Maternal age 35 or more.
   -  Chronic renal disease.
   -  Hypertension.
   -  Sickle cell disease.
   -  Diabetes.
   -  Premature rupture of membrane.
   -  History of still birth.
   -  Trauma.
   -  Vaginal bleeding in 2nd and 3rd trimester.

ii) Fetal -
    -  Decreased fetal movement.
    -  Intrauterine growth retardation (IUGR).
    -  Oligohydramnios / polyhydramnios.
    -  Fetal evaluation after amniocentesis.


Preparation and Positioning - 
The woman bladder should be empty and provide semi-fawler's and left 
lateral position. Her blood pressure (BP) should be checked to obtainted
a baseline recording.


Procedure - 
                    NST is based on pattern of fetal heart rate reactivity to fetal
movement. Normally the fetal heart rate decreased and variable increased
with gestation age, probably in relation to the development of the central nervous
system (CNS).

Diagnosis of pregnancy in third trimester

Third Trimester -

Last trimester - 29 to 40 week of pregnancy.

Symptoms -
-  Amenorrhoea persists.
-  Enlargement of abdomen is progressive which produce some mechanical
    discomfort to the patient such as palpitation and dyspnea.
-  Lightening at about 38 weeks specially in primigravida.
-  Frequency of micturition reappear.
-  Fetal movements are more pronounced.

Signs -
-  Cutaneous changes are more prominent with increased pigmentation and striae.
-  Uterine shape is changed from cylindrical to spherical behind 36 week.
-  Braxton Hick's contration are more evident.
-  Fetal movements are easily felt.
-  Palpation of fetal parts and there identification much easier.
-  Fetal heart sound heard easily.

Investigation -

Sonography -
Gastational age estimated by sonography and detected by complication.

NST ( Non Stress Test ) - 
The NST monitors the fetal heart rate in response to the fetal well being.

Contration Stress Test ( CST ) / Oxytocin Challanged Test ( OST ) -
It is an invasive method to assess the fetal well being alteration in fetal heart rate
in response to uterine contraction.                              

Uterine souffle and Fetal souffle

Uterine souffle - 
It is a soft blowing and systolic murmur heard low down at the sides
of the uterus, best on the left side. The sound is synchronous with 
the maternal pulse and is due to increase in blood flow through the
dilated uterine vessels.

Funic or Fetal souffle - 
It is due to rush of blood through the umbilical arteries. It is a soft,
blowing murmur synchronous with the fetal heart sound.

Diagnosis of pregnancy in second trimester

Second Trimester - 

Subjective symptoms - 
The subjective symptoms such as nausea, vomiting and frequency of
micturition usually subside while amenorrhoea continue. The new features
that appears are -
1. Quickening (feeling of life) -  Denotes the perception of action fetal movement
                                              by the women. It is usually felt about the 18th week,
                                              above 2 weeks early in multipara.
2.  Progressive  enlargement -  Progressive enlargement of the lower abdomen by the
                                              growing uterus.


General examination / Objective symptoms - 
1. Chloasma - pigmentation over the forehead and chick may appaer at about 24th week.
2. Breast changes - breast are more enlarged with prominent vein under the skin.


Abdominal examination - 

1. Inspection - 
    a)  Liner pigmented zone ( Linea nigra may be visible at 20th week ).
    b)  Straie ( both pink and white ) of varying degree are visible in the
         lower abdomen, more towards the flanks.

2. Palpation - 
    -  The uterus feels soft and elastic.
    -  Braxton Hick's contraction are evident.
    -  Palpation of fetal part can be made distinctly by 20th week.
    -  Active fetal movement can be felt at intervals by placing hand over
        the uterus as early as 20th week, it not only gives positive evidence
        of pregnancy but of a live fetus.
    -  External ballotement

3. Auscultation - 
    a)  Fetal heart sound is the most conclusive clinical sign of the pregnancy
         with an ordinary stethoscope, it can be detected 18 to 20 week.
    b)  Uterine souffle and funic or fetal souffle (for details, see further posts)

Diagnosis of pregnancy in first trimester

The reproductive period of a woman begins at menarche (Menarche is the first 
menstrual cycle or first menstrual bleeding in females) and ends in menopause. 
It usually extends from 13-45 years. pregnancy is rare below 12 years and 
behind 50 years.

Diagnosis in first trimester - 

Subjective symptoms -

The following are the presumptive symptoms of early months of pregnancy.

           - Amenorrhoea

           - Morning sickness - It usually appears soon after following the missed
              period and rarely last behind the 3rd months.

           - Frequency of micturition - It is the quite common symptoms during
              8th to 12th week of pregnancy.

           - Breast discomfort - breast discomfort in the form of feeling of fullness
              and ''prinking sensation'' is evident early as 6 to 8 weeks.

           - Fatigue is a frequent symptoms which may occur early in pregnancy.

Que. - Why the frequency of micturition increases in pregnancy ?

Ans. -  It is due to -

           i)  Resting of the bulking uterus on the bladder because of exaggerated
               anteverted portion of the uterus.
          ii)  Congestion of the bladder.

Objective signs - 

1. Breast changes - The breast are enlarged and often contain milk for years.
The breast changes are evident between 6-8 weeks. Their is enlargement with
vascular enlargement evidented by the dedicated vein visible under skin.
The nipple and areola becomes mare pigmented specially in dark women.

Duration of pregnancy and Trimester of pregnancy

Duration - 

The duration of pregnancy has traditionally being calculated by clinicians in term of
                                     10 lunar months 
                                               or
                           9 calendar months and 7 days 
                                               or
                                          280 days
                                               or
                                          40 week
calculated from 1st day of the last menstrual period. this is called
menstrual or gestational age. But, fertilization usually occurs 14 days
prior to the expected missed period and in a previously normal cycle
of 28 days duration, it is about 14 days after the first day of the period.
Thus, the true gestation period is to be calculated by subtracting
14 days from 280 days i.e. 266 days. This is called fertilization age 
or ovulatory age and widely used by the embryologist.

Trimester -    Pregnancy is divided into 3 trimester-

                     1st Trimester -  01-12 week
                    2nd Trimester - 13-28 week
                  3rd Trimester -  29-40 week

Changes in the Endocrine system

Pituitary hormones of the pituitary gland -
  The secretion of prolactin, adenocorticotrophic hormone, thyrotrophic 
     hormone and melanocyte stimulating hormone increase follicle stimulating 
       hormone and leutinizing hormone secretion is greatly inhibited by placental 
         progesterone and estrogen. The posterior pituitary gland release oxytocin 
           in low frequencies pulses throughout pregnancy. At term, the frequency of 
              pulses increases which stimulate uterine contractions.

Thyroid gland -
   In the normal pregnancy the thyroid gland increases in size 
       by about 13% due to hyperplasia of glandular tissues and 
          increased vascularity. Rising level of T4 and T3 contribute 
             to the increased metabolic rate.

Adrenal gland - 
   The adrenal gland is stimulated by estrogen to produce increasing
      level of total and free plasma cortisol and other corticosteroids
        including ACTH from 12th week to term.

Respiratory changes during pregnancy

The shape of chest changes because uterus enlarges. The diaphragm
is elevated as much as 4cm and rib cage displaced upwards.

Que. -  How it can possible to transfer of oxygen (O2) from mother to fetus ?
Ans. -  There is progressive increase in oxygen consumption which is caused
            by the increased metabolic need of mother and fetus. The hyperventilation
            causes change in acid base balance.The arterial PaCO2 falls from
            38 to 32 mm Hg and PaO2 from 95 to 105 mm Hg. This facilitate
            transfer of CO2 from the fetus to the mother and O2 from the mother
            to the fetus.

Changes in the respiratory system -

	Non     Pregnant	Pregnancy   Near term	Changes
Respiratory rate             (per min)	15	15	Unaffected
Vital capacity                 (ml)	3200	3300	Increased
Tidal volume               (ml)	475	675	+40%   Increased
Residential  volume                 (ml)	965	765	-20%   Decreased
Total lung capacity                (ml)	5000	4750	-5%     Slightly   decreased

Systemic changes during pregnancy

Urinary system -
Renal blood flow increased by as much as 70-80%. Kidney
enlarge in length by 1%. Renal plasma flow is increased by
50-75% maximum by 16th week and is maintained until 34 week.
Glomerular filtration rate (GFR) is increased by 50% all through
pregnancy. Increased GFR causes reduction in maternal plasma
level of creatinine. In late pregnancy, the bladder mucosa become
edematous due to venous and lymphatic obstruction specially in
primary gravida. Increased frequency of micturition is noticed at
6-8 weeks of pregnancy which subside after 12 week.


Alimentary system -
The gums become congested and spongy. Muscle tone and motility
of entire gastrointestinal tract are diminished due to high progesterone
level. Cardiac sphincter is relaxed and regurgitation of acid, gastric
content into the esophagus (This is known as Morning sickness),
may produce esophagitis and heart burn. Around 4-8 week most
woman start complaining of nausea and vomiting witch may
continued until about 14-16 week.


Liver and gall bladder - 
There is no histological changes in liver cells but the functions are
depressed. There is marked atonicity of gall bladder. This, together
will high blood cholesterol level during pregnant which can lead to
gall stone.


Nervous system - 
Some Temperamental changes are found during pregnancy and
in the puerperium. Nausea, vomiting, mental irritability and
sleeplessness are probably due to some psychological background.
Postpartum blues, depression or psychosis may develop in a
susceptible individual.

Dietary and Metabolic changes during pregnancy

Total metabolism is increased due to the needs of growing uterus and fetus. There is increased food intake during pregnancy. Gastrointestinal changes lead to characteristic alteration in the metabolism of carbohydrate, protein and fat. These changes which are brought about by human placental lactogen ensure that glucose is readily available for body and brain growth in the developing fetus and protect against nutritional deficiency. A continuous supply of glucose must be available to transfer to the fetus.

As the nutritional demand of fetus increases in 2nd half of pregnancy, and insulin resistance increases metabolisation of fat stores laid down in 1st half of pregnancy which provide extra energy to mother, However because of increase concentration of fatty acid resulting from this process , the mother is more prone to ketosis. Even and overnight fast of 12 hr will result in hypoglycemia and increased production of keton bodies. Restriction of carbohydrate in any diet may be avoided and mother may be encouraged to take bed time snacks.

Iron is very important mineral in pregnancy. Iron is absorbed in ferrous form by duodenum and jejunum. Iron is transported actively across the placenta to fetus. Total iron requirement during pregnancy is estimated approximately 1000 mg. In second half, daily requirement actually becomes very much increased to the extend of about 6-7 mg


Que.-  Why the continuous supply of glucose is necessary in pregnancy ?
           Why should pregnant woman not be skip meals ?

Ans.-  Pregnant woman should not keep fast and skip meals meals for following reasons -
          1. Maternal blood glucose level is critically important for the fetal well being.
          2. Fasting in pregnancy produce more intense ketosis known as accelerated starvation,
              that may be dangerous to fetal health.



Related  Articles :

• Respiratory changes during pregnancy
• Vomiting in pregnancy (morning sickness)
• Changes occur during 11th week of pregnancy
• Diagnosis of pregnancy in third trimester
• Causes of IUGR
• Abruptio placentae (Early separation of placenta)

Heart and Circulatory changes during pregnancy

• The heart muscles particularly the left ventricle hypertrophy leading to enlargement of heart. The growing uterus pushes the heart upwards and to the left side.
• During pregnancy the heart rate and stroke volume ( The amount of blood pumped by the heart each beat ) increased.
• The cardiac output ( The rate which blood is pumped by heart expressed as liter/min. ) increased markedly  by end of the first trimester.
• Femoral venous pressure is markedly raised specially in the later months. It is due to pressure exerted by the gravid uterus on common iliac vein, more on right side due to dextrarotation of the uterus.

Que.-  Why the heart rate and stroke volume is increased during pregnancy ?

Ans.-  It is due to increased oxygen requirement of the maternal tissue and growing fetus. 
          Normal heart rate and stroke volume is not fulfill the needs of mother and fetus. So it is 
          increase in normal way.


Que.-  Why BP does not rise in pregnancy, although the cardiac output increased ?

Ans.-  In pregnancy, the BP does not rise because of the reduction in peripheral resistance. 
          The capacity of vein and venules increase. Arterial wall reflex and dilate due to the 
          effect of progesterone.

Related  Articles :

• Dietary and Metabolic changes during pregnancy
• Management of HIV infection in pregnancy
• Classification of hypertensive disorders in pregnancy
• Changes occur during 24th week of pregnancy
• Physiological changes after delivery
• What do you know about silent miscarriage (missed abortion)

Plasma protein changes during pregnancy

During the first 20 weeks of pregnancy, the plasma protein concentration reduced as a result of the increased plasma volume. This leads to lowered osmotic pressure contributing to edema of the lower limbs seen in late pregnancy.

Important - 

Plasma protein concentration falls from 7 gm% to 6 gm% due to hemodilusion. This result in diminished viscosity of the blood and reduce colloid osmotic tension because of marked fall in albumin level from 4.3 gm% to 3 gm%, a fall about 30%. And only slight rise of globulin (mainly alpha-globulin).

Plasma protein changes - 

	Non   Pregnant	Pregnancy  Near Term	Changes
Total protein (gm)	180	230	Increased
Plasma protine     concentration               (gm/100ml)	7	6	Decreased
Albumin        (gm/100ml)	4.3	3	Decreased
Globulin      (gm/100ml)	2.7	3	Slightly  Increased
Albumin : Globulin	1.7 : 1	1 : 1	Decreased

Related  Articles :

• Blood or Hematological changes during pregnancy
• Respiratory changes during pregnancy
• Diagnosis of pregnancy in second trimester
• Immunological disorders are responsible for abortion
• Causes of genesis of twins
• Changes occur during 24th week of pregnancy

Blood or Hematological changes during pregnancy

During pregnancy, there is increased vascularity of the enlarging uterus with the interposition of uteroplacental circulation.


Principal blood changes during pregnancy -


                                                 Non pregnant           Pregnancy             Changes
                                                                                near term

         Blood volume (ml.) -             4000                      5500                   + 30-40 %

       Plasma volume (ml.) -            2500                      3750                   + 40-50 %

      Red cell volume (ml.) -            1400                       1750                   + 20-30 %

    Total hemoglobin (gm) -             475                        560                     + 18-20 %

Hematocrit (whole body) -              38 %                      32 %                   Diminished


Important - 

• There is increase in plasma volume which reduce the viscosity of blood and improves capillary blood.
• As increase in plasma volume is greater than that of red blood cell mass, hemodilution occurs. It is characterized by a lowered RBC count and hemoglobin level.

Que.-  Why the high volume of blood is required in pregnancy ?

Ans.-  A higher circulating volume is required for the following functions -

• To provide extra blood flow for placental circulation.
• To supply the extra metabolic needs of the fetus.
• To provide extra perfusion of kidney and other organs.
• To compensate for blood loss at delivery.

Related  Articles :

• Plasma protein changes during pregnancy
• Diagnosis of pregnancy in first trimester
• Factors responsible for abortion
• Causes of premature labour

Weight gain in pregnancy

In early weeks, the patient may loose weight because of nausea and vomiting. The weight gain is progressive until the last 1-2 week. 

The total weight gain during the course of pregnancy for a healthy woman is average 12 kg.

Reproductive weight gain - 6 kg
                Net weight gain - 6 kg


Reproductive weight gain -

   Fetus - 3.3 kg

   Placenta - 0.6 kg
   Liquor - 0.8 kg

   Uterus - 0.9 kg
   Breast - 0.4 kg

Cutaneous changes during pregnancy

The distribution of pigment changes in selective -

Face - (Chloasma gravidarum or pregnancy mask) -

• It is an extreme form of pigmentation around the cheek, forehead and around the eyes. Disappears spontaneously after the delivery.

Breast - 

• Increase size of breast becomes evident even in early weeks. This is due to marked hypertrophy and proliferation of ducts and alveoli. Vascularity is increased which results in appearance of bluish vein which running under skin. The nipples become larger, erectile and deeply pigmented. 
• About 5th month, a less pigmented area forms around the primary areola witch is known as secondary areola.

Abdomen -

• Linea nigra - It is brownish black pigmented area in the middle stretching from xiphisternum to pubic symphysis. Pigmentary changes are due to probably melanocyte stimulating hormone (MHS) from the anterior pituitary. Pigmentation disappear after delivery.
• Straie gravidarum - These are slightly depressed liner mark with varying length and width found in pregnancy. They are predominantly found in abdominal wall below the umbilicus, sometimes over the thigh and breast.

Related  Articles :

• Blood or Hematological changes during pregnancy
• Changes in the Endocrine system
• Diagnosis of pregnancy in first trimester
• Changes occur during 8th week of pregnancy