Certain characteristic symptoms occur very early in pregnancy and most women go to their doctor for confirmation of pregnancy as soon as they are aware of them.
Absence of Menstrual Period (Amenorrhoea)
Failure of the period to come at the usual time is generally the first sign of pregnancy. A missed menstrual period in any woman of child-bearing age who is having sexual intercourse should be presumed to be due to pregnancy until proved otherwise. Once the menstrual periods have established a normal rhythm, pregnancy is the commonest cause for their delay or absence. Stress, strain, psychological upset, severe systemic diseases such as anaemia, diabetes, and tuberculosis, or change of climate, change of occupation or sudden shock may all be the reason for the absence of a menstrual period. Some women do not have any periods while they are using the contraceptive pill.
Partially Suppressed Periods
Occasionally in early pregnancy the level of progesterone produced by the corpus luteum is inadequate to suppress completely the menstrual period, in this circumstance a small amount of uterine bleeding may occur which the woman naturally interprets as a normal period. The amount of loss, however, is usually less than normal and occurs for a shorter duration than usual. It is very seldom accompanied by any pain. Partially suppressed periods confuse not only the diagnosis of pregnancy but also the date of fertilization and, therefore, the expected date of delivery. Women who have partially suppressed periods during the early part of their pregnancy usually only do so for the first one or perhaps two, the second one being shorter than the first. On very rare occasions a woman will ‘menstruate’ throughout the duration of her pregnancy and it is not unknown for periods to occur for the first four, five or even six months. The presence of such partially suppressed periods does not appear to affect the foetus adversely, but ‘bleeding in early pregnancy although recognized as a partially suppressed period, must be considered as a threatened abortion and treated by bed rest. Obviously such a condition will not arise until the time of the second suppressed period because the woman will only then consider a diagnosis of pregnancy and appreciate in retrospect that the first period was not entirely normal.
Frequently women will feel most of the premonitory symptoms of menstruation and be sure that a period is about to appear. Symptoms of impending menstruation vary greatly from person to person and they frequently include a variable degree of engorgement and tenderness in the breasts, lower abdominal discomfort, a feeling or sensation of tension together with many other ill-defined and minor phenomena. These rather vague premenstrual symptoms do not prejudice a pregnancy in any way. They frequently continue for a day or two after the expected date of the period.
Nausea or a sensation of feeling sick is very common in the first three months of pregnancy and is frequently the first symptom noticed by women. The nausea tends to be more severe in the early morning although it can occur at any time of the day. It follows an individual pattern not only in each person but also in each pregnancy. Some women experience nausea in the morning alone, others in the evening. The more unfortunate may suffer for most of the day. It is frequently, although not necessarily, followed by vomiting, when it is known as ‘early morning sickness’. Nausea is accompanied by a sensation of fullness in the upper abdomen which may become so severe that women will actually make themselves vomit in order to relieve this pressure.
The exact cause of the nausea is not known but it is probably associated with a high hormone level especially that of progesterone. It may be provoked by sickly smells and especially the smell of cooking fat, and can be considerably alleviated by avoiding these and any other factors which tend to precipitate it. It is also relieved by raising the blood sugar level which can be easily accomplished by taking small frequent meals. These should not contain large quantities of sugar because a high concentration of sugar in the stomach will itself increase the amount of nausea. A drink of tea or milk together with a piece of dry toast is usually sufficient.
Nausea can be controlled to a certain extent by the doctor’s or midwife’s reassurance. It is a phenomenon of normal pregnancy and, generally speaking, a lot of nausea means a better and more secure pregnancy. This docs not mean that a woman who does not suffer nausea does not have a good or a stable pregnancy. The symptom can usually be controlled by careful attention to diet, but for those who find it too severe there are some antihistamines which can safely be taken in early pregnancy to control the nausea or at least improve the symptom even if they do not completely eliminate it.
Nausea usually diminishes in severity after about the 10th week of pregnancy and decreases quite dramatically from the 13th week, disappearing completely by the end of the 14th week. It is unusual for it to continue into the 15th week but if it does do so it does not indicate abnormality.
Vomiting in early pregnancy is usually associated with severe nausea, but this is not an unbroken rule. The vomiting, or ‘morning sickness’, generally occurs in the early morning relieving a fairly severe degree of nausea. Actual vomiting often happens rather suddenly without the disagreeable symptoms that precede it in the non-pregnant person. Vomiting itself can be most unpleasant especially in the early morning because there is no food in the stomach and only a small quantity of mucus is brought up. It may occur at any time later in the day and will usually be worse if a woman is subjected to stress, strain or worry.
Excessive vomiting known as hyperemesis gravidarum occasionally occurs and the woman is usually treated in hospital . The vomiting itself does not harm the woman nor does the exertion harm the uterus or the foetus. It is not true that an excessive amount of vomiting is associated with any abnormality of either the pregnant woman or her baby, except in very rate instances. Excessive vomiting, however, should always be carefully investigated and any woman who is being sick more frequently than three or four times a day should consult her doctor or midwife.
Early morning sickness can be controlled by a very careful diet regime first thing in the morning. The woman should rest quietly on waking and not leap out of bed to start her housework. One of the easiest and best methods of controlling the sickness is to have a small drink of some bland fluid such as sweetened tea containing a
small amount of milk and a dry biscuit or some dry toast. Butter and other fats are better avoided especially in the early morning. For the rest of the day her diet should consist of small and frequent meals again avoiding fat and excessive intake of concentrated sugar. Some anti-histamine drugs, such as Avomine, will help to control vomiting and may even eliminate this unpleasant symptom. The intensity of the vomiting may vary from day to day but it usually starts to decrease spontaneously about the 10th week of pregnancy and is usually gone completely by the end of the 14th week.
Sometimes one of the earliest signs of pregnancy is an increase in the frequency of micturition. The majority of women pass urine between two and six times each day and do not have to get up to empty their bladder at night. It is not unusual in the early months of pregnancy for a pregnant woman to have to pass urine every two hours during the day and for her to get up at least twice during the night. This is not abnormal so long as there is no pain or discomfort and is due to pressure from the enlarging uterus, which is still within the pelvis, on the bladder. Frequency of micturition tends to become less marked during the fourth month but may again become more severe towards the end of pregnancy, especially after the baby’s head has engaged in the pelvis.
Constipation is an early symptom of pregnancy but is not sufficiently definite to assist in its diagnosis. The action of the hormone progesterone relaxes the muscle of the intestine reducing its movement and causing varying degrees of constipation which, unless treated, will probably continue throughout the whole pregnancy.
Alterations in taste may be among the earliest of pregnancy symptoms. Some women will recognize a strange taste in their mouth even before they miss their first period. Such a taste is characteristic to each individual and is usually described as metallic.
Shortly after the first missed period the majority of pregnant women start to ‘go off’ certain things. A dislike of cigarettes or tobacco smoke is probably the most commonly noticed of these early changes and may be followed shortly afterwards by a dislike of other things that are normally very much appreciated such as alcohol, especially spirits and red wine, coffee, fat and occasionally meat itself.
It is very difficult to differentiate between smell and taste and a pregnant woman often has a different appreciation for different smells and perfumes and usually an intense dislike of the smell of cooking fat.
Changes in the skin are not very common in early pregnancy but in some people they do occur relatively early and occasionally they are noticeable. Dry skin tends to become drier quite early in pregnancy. Some women develop spots on the face, especially around the mouth, such as they had many years before, especially preceding a period, and from which they have not suffered recently. These spots may disappear quite quickly and the complexion returns to normal. On rare occasions, however, they may persist for several weeks or even months.
Together with the missing of a period the breast changes are usually the most convincing evidence of early pregnancy. The premenstrual fullness of the breasts continues when the period does not appear and within a matter of days the symptoms become even more marked. The breasts feel full, slightly tender and more sensitive than usual, especially in the region of the areola (the pink area around the nipple) and the nipple. There may also be a sensation of tingling. The breasts enlarge quite slowly but definitely so that by the end of the sixth week after the lastmenstrual period there is a very appreciable change in their size. The small tail of breast tissue that lies almost inside the front of the armpit may become particularly swollen and tender. There is also an increase in the superficial veins over the breasts, and at about the same time tiny nodules called Montgomery’s tubercles appear on the areola. Six or twelve of these small raised bumps will be found on each breast. The nipple also enlarges and becomes more prominent.
Feeling foetal movements is not really a sign of early pregnancy since the baby’s movements are not normally felt in a woman having her first baby until between the 18th and 20th week of pregnancy or in a subsequent pregnancy between the 16th and 18th week. It only too often happens, however, that for some reason or other this is the first symptom recognized by a pregnant woman. The movements themselves are difficult to recognize at first, being very similar to the sensation of wind moving around inside the abdomen, and have often been likened to a butterfly fluttering.
The diagnosis of early pregnancy is most easily and satisfactorily accomplished by performing a pregnancy test on the urine of the pregnant woman.
Many people want to know how a pregnancy test works. It is really very simple, but in order to understand it completely you will have to read the section that explains the production of chorionic gonadotrophin. This is a hormone produced by the new pregnancy as soon as it embeds in the lining of the uterus on the 21 st day of the menstrual cycle. Its production increases day by day so that by the 28th day there is sufficient to suppress the next menstrual period, and by the 35th day there is so much that it can be detected in the urine by means of special tests. Chorionic gonadotrophin is found in its most concentrated form in the first specimen of urine passed in the early morning since nothing has been drunk for six to eight hours.
The former tests for pregnancy involved injecting the urine into animals. The chorionic gonadotrophin caused characteristic changes in the ovaries or in other parts of the genital tract of the various animals. These changes in the laboratory animals indicated the presence of a high concentration of chorionic gonadotrophin in the injected urine and therefore meant that the urine came from a pregnant woman. These tests used to take anything from twenty-four hours to seven days according to the different type of animal used.
The purely laboratory tests of today use an immunological technique. A specific antibody has been developed to chorionic gonadotrophin which makes it easily detectable in a test tube or on a simple microscope slide. These modem tests for pregnancy are as accurate as the use of laboratory animals, if not more so; they are much quicker, much more simple, much kinder and, of course, cheaper. The tests take anything from about two minutes to two hours depending on the particular type of test being used.
A positive result indicates pregnancy in over 99 per cent of instances. A negative test, however, does not necessarily mean that a pregnancy is not present because the test may have been performed too early in the pregnancy or for some particular reason the level of chorionic gonadotrophin may not yet have become sufficiently high for the test to become positive. If all the signs and symptoms of pregnancy are otherwise present the test should be repeated after a further seven days.
X-rays are no longer used merely for the diagnosis of early pregnancy, having been superseded by electronic methods of listening to the foetal heart, although there are some special circumstances where an X-ray in later pregnancy may be necessary. Until recently X-rays were used for the diagnosis of pregnancy but even in the best hands it was not possible to confirm a pregnancy by X-ray until after the 14th week which is the earliest time at which the bones of the foetus can be discerned.
An extension of the simple ultrasonic device used for listening to the baby’s heart is the ultrasound machine: high frequency sound waves above those the human ear can detect may be used, without harm to mother or baby, to diagnose a pregnancy as early as six weeks from the last period. In addition, ultrasound is used extensively in later pregnancy to study the growth of the baby, diagnose twins and find out to which part of the uterus the placenta has become attached.
The Foetal Heart
The foetal heart can normally be heard by the stethoscope at about the 24th week of pregnancy. The more modern method of listening to the baby’s heart is by means of ultrasonics, using either the Doptone of the Sonicaid apparatus which can detect the foetal heart at the 14th week of pregnancy and frequently as early as the 12th week. They have, therefore, replaced the use of X-rays as a means of determining the presence of a foetus in the uterus in early pregnancy, and furthermore they do not carry the disadvantages of X-rays.
The diagnosis of pregnancy before the 8th week by simple clinical examination alone is extremely difficult. The most certain method of establishing an early diagnosis is by means of a pregnancy test which will be positive about 12 days after the first day of the missed period.
Most doctors get a pretty shrewd idea that a pregnancy is present from the history given by the patient. If all the usual symptoms of early pregnancy are present then it is fairly good presumptive evidence that the woman is pregnant. Most women, however, want a definitive answer which it is impossible to give based on the symptoms alone. Examination of the patient herself may show the characteristic breast changes. Vaginal or internal examination will not show any significant changes until about 6 weeks after the first day of the last period. These changes when they do appear will include a bluish or violet discoloration of the vagina, a softening of the cervix, a slight enlargement and softening of the uterus together with a palpable pulsation of the uterine artery which cannot be detected in the non-pregnant state. All these physical signs are rather uncertain and if a definite answer is required then the pregnancy will usually have to be confirmed by performing a pregnancy test upon the urine.