Changes occur during 19th week of pregnancy

Baby's Development -

In this week baby is now covered with a white, waxy substance called vernix caseosa, which helps prevent delicate skin from becoming chapped or scratched. Premature babies may be covered in this cheesy coating at delivery. Baby is still tiny, but this week brings the development of brown fat, which will help keep baby warm after birth. During the last trimester, baby will add more layers of fat for warmth and protection.


Woman's Body -

Woman feels baby's movements, which often happens between weeks 18 and 20. These first movements are known as quickening, and they may feel like butterflies in stomach or a growling stomach. Later in pregnancy, woman will feel kicks, punches, and possibly hiccups. Each baby has different movement patterns. 

Many women wonder around this time whether having sex. Sex is considered safe at all stages of pregnancy, as long as pregnancy is normal. But that doesn't necessarily mean woman are going to want to have it. Many expectant women find that their desire for sex fluctuates during the various stages of pregnancy, depending on their fatigue, growing size, anxiousness over the birth, and a host of other body changes.


Related  Articles :

• Multiple pregnancy (Twins)
• What do you know about silent miscarriage (missed abortion)
• Antepartum haemorrhage
• Blood or Hematological changes during pregnancy
• Changes occur during 20th week of pregnancy

What is Premature or Preterm labour

Preterm labour is one where the labour starts before the 37th completed week (<259 days), counting from the first day of the last menstrual period. Preterm labour is also called premature labour. It starts more than three weeks before estimated date of delivery. 

Management of HIV infection in pregnancy

Prenatal care -

• All clients should be offered voluntary serologic testing for HIV infection.
• In seropositive cases additional investigation should be done to test for other STD's.
• Husband should be offered serological test for HIV.
• Counselling about the risk of HIV transmission to the fetus and neonates should be made and termination of pregnancy offered.
• Progressive of the disease is assessed by CD-4, T-lymphocyte count and HIV RNA.
• Assessment is done at every 3-4 months internal.

Care during intrapartum period - 

• Zidovudine is given IV infusion starting at the onset of labour (vaginal delivery) or 4 hours before caesarean section.
• Mechanical suctioning devices should be used to remove secretions from the neonates airways.
• Health care workers should be protected from contact with potentially infected body fluids.
• Disposable syringes and needles are used and they are deposited in the puncture proof containers.

Postpartum care -

• Mother must be counselled about risk and benefits of breast feeding and helped to make an informed choice.
• Zidovudine syrup 2 mg/kg is given to the neonates four time daily for first 6 weeks.
• Mother should be encouraged to manage the babies care herself with the support of midwife.
• Glove must be worn for examination the perineum, lochia and caesarean wound.
• Disposal of sanitary napkin and disinfection and cleaning of any spilled blood must be done correctly.

Contraceptive method -

Barrier method of contraception (condom or female condom) is effective in preventing transmission of virus. Thus the disease could be prevented predominantly by health education and by practice of safer sex.


Related Articles :

• HIV infection in pregnancy
• What is Intrauterine growth retardation (IUGR)
• Classification of hypertensive disorders in pregnancy
• Hyperemesis gravidarum during pregnancy
• Diagnosis of pregnancy in first trimester
• Changes occur during 20th week of pregnancy

HIV infection in pregnancy

HIV causes an incurable infection that leads ultimately to a terminal disease called AIDS which is a group retrovirus. Worldwide 25 - 30% of infected patients are woman and 90% of them are 22 - 49 of age.


Incidence -

Estimate at national level are that about 3.7 million people were suffering from HIV infection in most Asian countries. The infection rate is less than 0.5%.


Mode of transmission -

The mode of transmission of HIV are :

• Sexual contact.
• Exposure to infected blood or tissue fluid.
• Through breast milk.

HIV infection in pregnancy -

The transmission from mother to fetus is about 30% in seropositive mothers. The fetus may be affected through uteroplacental transfer during delivery by contaminated secretion and blood of the birth canal and through breast milk in the neonatal period.

Physical features of IUGR baby at birth

In IUGR (intrauterine growth retardation), the baby fails to grow at the expected rate during the pregnancy. After birth, the physical features of IUGR baby are following -

• Weight deficit at birth about 600 gm and below. Every hospital have their own birth weight-gestational age chart.
• Length is unaffected.
• Head circumference is relatively larger than the body.
• Physical features show dry and wrinkled skin because of less subcutaneous fat.
• The baby is alert, active and having normal cry, eyes are open.
• Reflexes are normal.

Related  Articles :

• What is Intrauterine growth retardation (IUGR)
• Causes of IUGR
• Causes of premature labour
• Multiple pregnancy (Twins)
• Causes of ectopic preganancy (Tubal pregnancy)
• Factors responsible for abortion
• Mechanism of birth
• Diagnosis of pregnancy in first trimester

Causes of IUGR

The causes of fetal growth restriction can be divided into four groups :

1. Maternal

2. Fetal

3. Placental

4. Unknown

Maternal -

• Small woman have small babies. These babies are not at increased risk.
• Maternal nutrition before and during pregnancy -: As most of the fetal weight gain occurs behind 24th week of pregnancy. Malnutrition, anemia and oxygen deficiency during significant role in the reduction of the birth weight.
• Toxins -: Alcohol, smoking, cocaine, heroine, drugs.
• Maternal diseases -: Anemia, hypertension, heart disease, chronic renal failure.

What is Intrauterine growth retardation (IUGR)

IUGR is said to be present in those babies whose birth weight is below the 10th percentile of the average for the gestational age. In other way, it is poor growth of a baby in the mother's uterus during pregnancy.


Incidence - 

The incidence among term babies is about 5% and that among post term babies is about 15%.


Types -

Based on clinical evaluation and ultrasound examination the fetuses are divided into two types :

• Fetuses that are small and healthy -                                                                          The birth weight less than 10th percentile for the gestational age. They have normal subcutaneous fat and usually uneventful neonatal course. 

• Fetuses where growth is restricted by pathological process (true IUGR) -                   Depending upon the relative size of their head, abdomen and femur. The fetuses are subdivided into two types :

What is Superfetation and Superfecundation

Superfetation - 
Superfetation is the fertilization of two ova released in different menstrual cycles. Ovulation is usually suspended during pregnancy time to prevent chance of fertilization of other ova. If an ovum is released after the female was already pregnated, there is a chance of second pregnancy. This is called superfetation. The nidation and development of one fetus over another fetus is theoretically possible until the decidual space is obliterated by 12 weeks of pregnancy.

Management of twin pregnancy

Early management of twin pregnancy is important to prepare the parents by giving the special and advice. This will help to mother to take additional care not only for her own benefit also for the fetuses.

Advice -

• Diet – Increased dietary supplement is needed for increased energy supply to the extent of 300 Kcal per day, over and above that needed in a single pregnancy.

• Rest – Increased risk at home and early cessation of work is advised to prevent preterm labour and other complications.

• Supplement – Additional vitamins, calcium and folic acid are to be given, over and above those prescribed for a singleton pregnancy.

• More antenatal visit should be advised.

• Fetal growth assessment must be done at 2-3 week.

Hospitalization –

The woman may be admitted around the 32^nd week if she prefers it. This result in increase birth weight of babies, decreased frequency of preeclampsia, decrease frequency of preterm labour and lowered perinatal mortality.

Causes of genesis of twins

The exact cause of twinning is not known. The frequency of monozygotic twins remains constant through the globe and is probably related to maternal environmental factors. It is the wide variation in the prevalence of dizygotic twins which is responsible for the fluctuation in the overall incidence of twins in different populations. Possible causes are following :

1. Superfetation is the fertilization of two ova released in different menstrual cycles. The nidation and development of one fetus over another fetus is theoretically possible until the decidual space is obliterated by 12 weeks of pregnancy.                                                                                                                                                

Description of genesis of twins

                                  Genesis of twins

A. Dizygotic twins - 

Dizygotic twins results from fertilization of two ova, most likely ruptured from two distinct graafian follicles usually of the same or one from each ovary, by two sperms during a single ovarian cycle. Their subsequent implantation and development differ little from those of a single fertilized ovum.

B. Monozygotic twins (identical) -

The twinning may occur at different periods after fertilization and this markedly influences the process of implantation and the formation of the fetal membranes. After the fertilization, the following possibilities may occur -

• If the division takes place within 72 hours after fertilization (prior to morula stage) the resulting embryos will have two separate placenta, chorions and amnions (diamniotic - dichorionic or D/D)

• If the division take place between the 4th and 8th day after the formation of inner cell mass when chorion has already developed - diamniotic monochorionic twins develop (D/M).

• If the division occur after 8th day of fertilization when the amniotic cavity has already formed, a monoamniotic - monochorionic twins develops (M/M).

• Rare occasion, division occurs after two weeks of the development of embryonic disc resulting in the formation of conjoined twins called siamese twins. Four types of fusion may occur -

       i) Thoracopagus - conjoined twins at the thorax.

       ii) Pyopagus - conjoined twins at the posterior site.

       iii) Craniopagus - twins joint at the head.

       iv) Ischiopagus - twins joint at the ischeum.


Related articles :

• Multiple pregnancy (Twins)
• Causes of genesis of twins
• Management of twin pregnancy
• What is Superfetation and Superfecundation

Multiple pregnancy (Twins)

When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy. Simultaneous development of two fetuses (twins) is the commonest. Although rare, development of three fetuses (triplets), four fetuses (quadraplets), five fetuses (quintuplets) or six fetuses (sextuplets) may also occur.

                                                 Twins 

Definition - 

Simultaneous development of two fetuses in the uterus is the commonest variety of multiple pregnancy.


Varieties -

i) Dizygotic twins - It is the commonest (2/3) and result from the fertilization of two ova.

ii) Monozygotic twins - It is rare (1/3) result from the fertilization of a single ovum.


Related articles :

• Description of genesis of twins
• Causes of genesis of twins
• What is Superfetation and Superfecundation
• Management of twin pregnancy

Treatment of eclampsia

The patient if at home or in peripheral health centres, should be shifted urgently to the referral hospital. The aim of immediate management in the hospital are :

• Clear and maintain the airway.
• Prevent injuries.
• Prevent hypoxia.
• Arrest convulsions.

General management -

- The patient should be placed in a railed cot in an isolated room, protected from 
   noxious stimuli which might provoke further fits.
- Detailed history is to be taken from the relatives, relevant to the diagnosis of 
   eclampsia, duration of pregnancy and number of fits.
- When the patient is properly stabilized, general abdominal and vaginal examination 
   are done.
- If the patient is unconscious, catheter is introduced and urine is tested for protein.
- Pulse, respiration and BP should be recorded half hourly.
- Fluid balance- Ringer's solution is started.
  Total fluids = Previously 24 hours urinary output + 1000 ml (insensible loss through 
   lungs and skin).

Four stages of convulsion or fits

Eclamptic convulsion or fits are epileptiform and consist of four stages :

Premonitory stage -

The patient becomes unconscious. There is twitching of the muscles of the face, tongue and limbs. Eye ball roll or are turned to one side and become fixed. This stage lasts for about 30 seconds.

Tonic stage -

The whole body goes into a tonic spasm - the trunk-opisthotonus, limbs are flexed and hand clenched. Respiration ceases and the tongue protrudes between the teeth. Cyanosis appears. Eye balls become fixed. This stage lasts for about 30 seconds.

Difference between eclampsia and preeclampsia

Preeclampsia -

Preeclampsia is a multi system disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20th week in a previously normotensive and non-proteinuric patient.

About 5-8% of all pregnancies are complicated with preeclampsia. Abnormal or rapid weight gain and edema over ankles are the main alarming sign and symptoms.

Eclampsia -

Preeclampsia when complicated with convulsion and/or coma is called eclampsia. Convulsion or fits are consist of four stages- premonitory, tonic, clonic and stage of coma. Mostly 50% fits occur during antepartum period (before the onset of labour).


Related Articles :

• Treatment of eclampsia
• Four stages of convulsion or fits

Classification of hypertensive disorders in pregnancy

Hypertension is a common disorder of pregnancy. Hypertension may appear for the first time during pregnancy as a direct result of the gravida state.

Classification of hypertensive disorders in pregnancy :-

A. Pregnancy induced hypertension (PIH) -

   1. Gestational hypertension - without protein-urea or pathological edema.
                    2. Preeclampsia - hypertension and protein-urea with or without edema.
                         3. Eclampsia - preeclampsia complicated with convulsion and/or coma.

What is cervical pregnancy ?

It is occurs due to implantation of the fertilized ovum in the cervical canal. It may be due to rapid passes of fertilized ovum or fertilization of the ovum after it reaches in the cervical canal. The morbidity and mortality is high because of profuse haemorrhage.

Sign and symptoms -

• Painless bleeding after the time of implantation.
• Thinning of the cervical wall.
• Dilatation of the external Os (opening of cervix).

Treatment -

Sonography reveals the pregnancy in the cervical canal and an empty uterine cavity. The treatment is removal of the product of conception by curettage. Hysterectomy is often required to stop bleeding.


Related Articles :

• How abdominal pregnancy occurs ?
• Causes of ectopic preganancy (Tubal pregnancy)
• What are the early symptoms of pregnancy ?

How abdominal pregnancy occurs ?

Abdominal pregnancy is rare. A primary abdominal ectopic pregnancy is the result of implantation of the fertilized ovum on the peritoneal surface. A secondary abdominal pregnancy forms when an embryo expelled through rupture or abortion of a tubal pregnancy. The embryo does not died because of its chorionic attachment to the uterine tube and grows by forming attachment to the pelvic peritoneum, intestine etc.
                   The fetus grows in the peritoneal cavity but the majority of these pregnancy do not survive. If the fetus die early in pregnancy, it may be reabsorb.

If pregnancy is continue following symptoms are appears -

• Lower abdominal pain.
• Nausea and vomiting.
• Constipation or/and diarrhoea.
• Urinary frequency.

Abdominal pregnancy is treated or delivered by laparotomy (It is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity).

What are the early symptoms of pregnancy ?

Every woman is different, so they experience different symptoms of pregnancy. Not every woman has the same symptoms. Some of the most common early symptoms of pregnancy are described following. These symptoms may be caused by other things besides being pregnant. So the fact that some of these symptoms does not necessarily mean pregnancy. It is only confirmed by a pregnancy test.

Spotting and Cramping - 

- A few days after conception the fertilized egg attaches itself to wall of the uterus. This can cause
  one of the earliest signs of pregnancy spotting and cramping.
- That's called implantation bleeding. It occurs anywhere from 6 to 12 days after the egg is
  fertilized.
- The cramps resemble menstrual cramps, so some women mistake them and the bleeding for the
  start of their period. The bleeding and cramps are slight.

- Besides bleeding, a woman  may notice a white, milky discharge from her vagina. That's related
  to the thickening of the vagina's walls. The increased growth of cells lining the vagina causes the
  discharge.

- This discharge, which can continue throughout pregnancy, is typically harmless and doesn't
  require treatment.

Breast Changes -

Breast changes are very early sign of pregnancy. A woman's hormone levels rapidly change after conception. Because of the changes, her breasts may become swollen a week or two later. They may feel heavier or fuller or feel tender to the touch. The area around the nipples, called the areola, may also darken.