During pregnancy there are many pregnancy signs.

by Dr. Derrick Thompson (Obstetrician and Gynaecologist)


In the first 20 weeks of pregnancy, most complications are associated with bleeding.  If 12-week ultrasound scan is normal, no bleeding has occurred, and the uterus is the appropriate size, your pregnancy should be progressing normally.   There are two aspects to managing a pregnancy, and both are of equal importance.  One is monitoring your health.  The other is monitoring the health and growth of your baby.  All the pregnancy signs are described below.  Use the scroll bar on the side to skip to what you are want to read about.

Your health.

At each antenatal visit, you will be assessed as healthy if:

  • your weight gain is not excessive.
  • your fasting morning specimen of urine does not show any presence of protein or sugar.
  • your blood pressure is normal.
  • you have not experienced any vaginal bleeding or abnormal discharge.
  • any underlying medical condition that you may have is under control (for example, diabetes, chronic kidney disease, and so on).

However you should be aware of the following signs that may indicate potential problems in your pregnancy.

[scroll_to link=”#Abdominal pain” title=”Abdominal pain”]

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Abdominal pain

Low abdominal pain and abdominal swelling and bloating are very common during pregnancy.  This is because the uterus is growing rapidly, from the size of a small pear at 6 weeks gestation to the size of an Aussie rules football or American Gridiron ball at 20 weeks gestation.  Of course, the uterus continues to enlarge until at term (40 weeks) when it measures about 35-40 cm from pubic bone to the top of the uterus.

The enlarging uterus puts pressure on your bladder, causing you to pass urine more often.  You may notice bowel pressure giving you the urge to open your bowels as well.

Abdominal pain may be caused by constipation.  If constipation is a problem, make sure you have adequate fluid intake of 2-3 litres of water per day.  You should also increase your fibre intake.  Try drinking a variety of fibre drinks, eat bran cereals and bran flakes, and of course have plenty of fruit and vegetables.  It is important to open your bowels at least every 3 days.  If this is not occurring naturally, I recommend you try drinking lactulose, 5-10 ml, 3 times per day.

Lactulose acts as a bowel softener, easing the passage of faeces through your large bowel.  If you are still constipated despite using the above measures, I recommend the use of suppositories, for example 2 glycerine suppositories, rather than laxatives which can cause abdominal cramps and pain.  If constipation still persists, I would advise you to consult your doctor.

Constipation can cause haemorrhoids to develop.  Chronic constipation is pregnancy can be very distressing.  The ultimate treatment is a bowel washout under general anaesthetic, which is better avoided.  Prevention is better than cure.

Abdominal bloating frequently occurs due to the accumulation of gas in your bowel.  Bowel peristalsis is reduced in pregnancy, and bloating is more noticeable.  Bloating tends to increase as the day progresses.  You can relieve bloating by drinking peppermint water or by taking one of a variety of medications available from your chemist.  Smaller, more frequent, regular, non-spicy, unhurried meals are less likely to cause bloating.  Bloating is relieved overnight and is much less noticeable in the morning.

Abdominal pain and discomfort can also be caused by stretching and distention of the round ligaments.  These ligaments extend from the lateral wall of your pelvis and insert into the left and rights sides of the uterine fundus or top of the uterus.  In pregnancy the ligaments become very engorged and swollen with blood.  Their stretching or slight twisting is thought to be responsible for this sort of pain.  Round ligament pain is often associated with sudden movement, coughing or stretching.  This phenomenon of round ligament pain is more common during the first 20 weeks of pregnancy.  There is no associated vaginal bleeding, and the pain is usually relieved by rest and/or paracetamol.  If your pain is constant and not relieved by rest and 2 paracetamol, you need to consult your doctor.

Other causes of abdominal pain not associated with vaginal bleeding or relieved by rest and simple analgesia include the following:

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[scroll_to link=”#Heartburn” title=”Heartburn”]

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Heartburn

Heartburn is due to reflux of the acid contents of your stomach into your lower oesophagus or food-pipe.  It is more common in pregnancy because of the increased abdominal pressure due to your growing uterus.  Heartburn can be relieved by eating small meals more frequently, reducing your caffeine intake, and eating fewer foods containing spices or a high fat content, or pastries.  Treatment for heartburn can include drinking a glass of low fat milk, taking antacids, or ranitidine, 150 mg twice daily.  If the above measures do not relive your heartburn, you can consult your doctor for other medications available on prescription.

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[scroll_to link=”#Complications of an ovarian cyst.” title=”Ovarian cyst.”]

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Complications of an ovarian cyst.

Your doctor may detect an ovarian cyst when you have an ultrasound scan.  Providing it is less than 5-6 cm in diameter, you will not require treatment.  Ovarian cysts only cause pain if they become complicated.

Cysts greater than 6 cm are more likely to produce complications, and you will probably need treatment.  Unless you have suffered acute pain, ovarian cysts are not normally treated before 14 weeks gestation.  This is because some cysts are corpus luteum cysts of pregnancy which tend to naturally resolve by 12 weeks.  Treatment of a cyst before 12 weeks gestation can result in a miscarriage.

There are three potential complications of ovarian cysts.  They can rupture, undergo torsion, or bleed into the cyst’s cavity, known as hemorrhage.  You need to consult your doctor if you experience constant, sever, low abdominal pain, usually one or other side which is not relieved by rest and analgesia.

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[scroll_to link=”#Placental abruption” title=”Placental abruption”]

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Placental abruption

Placental abruption is when the placenta separated form the wall of the uterus, causing bleeding.  This can occur in varying degrees and is graded as mild, moderate or severe.  Factors that might predispose to this condition are:

  • no or infrequent antenatal check-ups
  • poor diet (folic acid deficiency has been suggested)
  • smoking
  • increased alcohol and caffeine intake
  • high blood pressure
  • chronic kidney disease

Vaginal bleeding of < 250 ml is usually, but not always, associated with mild placental abruption.  It is unlikely that the woman will experience abdominal pain and uterine tenderness.  The management is rest and fetal monitoring.

Moderately severe placental disruption presents with vaginal bleeding, the amount varying between 250 and 500 ml.  The woman is likely to feel abdominal pain and uterine tenderness, and may need to be delivered if fetal monitoring shows the baby to be distressed.

With a severe placental disruption, heavy vaginal bleeding ( greater than 500 ml), acute abdominal pain, and a very tender uterus occur.  The patient may go into shock, and often baby may die in utero.  The woman needs to be under the care of an obstetrician to have these conditions managed.

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[scroll_to link=”#Red degeneration in a fibroid” title=”Fibroids”]

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Red degeneration in a fibroid

A Fibroid is a spherical lesion of fibromuscular tissue commonly present in the muscle or myometrium of the uterus.  In pregnancy, fibroid’s tend to swell and enlarge.  Red degeneration occurs when the blood vessels to the fibroid become enlarged and rupture.  The fibroid is surrounded by a pseudocapsule, and it is the distention of the fibroid which causes the pain.  It can be compared to the swelling that occurs when you bruise yourself.  The treatment is bed rest and analgesia.  Your pain will resolve as the swelling subsides; however this can take 2-3 weeks.

Red degeneration usually occurs at about 18-22 weeks gestation.  there is usually no ill-effect on your pregnancy.  Occasionally miscarriage can occur, which is known as mid-trimester  miscarriage.

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[scroll_to link=”#Cholelithiasis and cholecystitis” title=”Cholelithiasis and cholecystitis”]

[scroll_to link=”#Cystitis” title=”Cystitis”]

[scroll_to link=”#Pyelonephritis” title=”Pyelonephritis”]

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Cholelithiasis and cholecystitis

Cholelithiasis is the presence of gall stones in your gall bladder.  Cholecystitis is inflammation or infection of your gall bladder.  Symptoms of these conditions include right-sided upper abdominal pain just beneath your rib-cage.  Fatty foods can cause the onset of symptoms.  The pain can be colicky or constant.  You may feel nauseous and need to vomit, and you may also develop a fever.  Management consists of rest, intravenous fluids and pain relief.  Sometimes surgery is required.

Cystitis

Cystitis is a bladder infection or urinary tract infection which can cause central low abdominal (suprapubic) pain and discomfort.  Associated symptoms are frequency of passing urine, burning or scalding “dysuria”, and you may notice blood in the urine.   Your doctor can diagnose this condition by examining a mid-stream urine sample.  It can be treated by a course of antibiotics and a medication to make your urine less acidic if burning or scalding is causing discomfort .  I recommend a high fluid intake.

Pyelonephritis

This condition usually develops following a bladder infection where the bacteria infect one or the other kidney.  The pain tends to be severe, more to one side in the upper abdomen and radiating into the loin.  Most women look flushed and ill with a high fever, about 38°C – 39°C.  Hospital admission is often required, and intravenous fluids and antibiotics often need to be administered.

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[scroll_to link=”#Engagement of your baby’s head” title=”Engagement of your baby’s head”]

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Engagement of your baby’s head

Low abdominal pain can develop in later pregnancy when your baby’s head is descending into the birth canal.  This usually occurs after 36 weeks gestation.  The pain is just above your pubic bone, and you often notice that your abdomen seems smaller becuase your baby has dropped.  Once this has happened, you may get releif form your epigastric discomfort and indigestion.  However, pelvic pressure increases, and there is often pain radiating into your lower back.  You may also notice that you pass urine more often.

The benefit’s of your baby’s head engaging are:

  • You are less likely to go overdue
  • you are less likely to have a prolonged labour
  • there is a better chance of a normal delivery, that is, less chance of needing an instrumental delivery or C-section

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[scroll_to link=”#Glycosuria (sugar in the urine)” title=”Glycosuria or Gestational diabetes”]

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Glycosuria (sugar in the urine)

You will need to provide your doctor with a fasting urine specimen to assess the level of sugar in your urine.  You should fast for at least 6-8 hours before collecting the specimen, and preferably overnight.  Your urine specimen may test positive for sugar if you have had something to eat or drink within 4 hours.  Your doctor will order a glucose tolerance test (GTT) if sugar is detected in a fasting urine specimen.

A glucose tolerance test is performed by measuring firstly your fasting blood sugar level.  You are then given a drink of 75 gams of glucose, and your blood sugar is measured again 2 hours later.

If your fasting blood sugar level is greater than 5.4 mmol/liter of your 2-hour blood sugar level is greater than 7.9 mmol/Liter, you are diagnosed as having Gestational diabetes.  The initial treatment of this condition is to control your sugar levels by managing your diet.  If facilities are available, your doctor will make you an appointment with a diabetic educator and a dietitian to help you manage your diabetes.

Other risk factors for developing diabetes in pregnancy include:

  • maternal body mass index (BMI) greater than 30 kg/m2
  • maternal age greater than 35 years
  • a previous unexplained stillbiirth or fetal abnormality
  • delivery of a previous baby weighing more than 4.0 kg – 4.5 kg at birth.
  • a first degree relative who has diabetes
  • If the condition is not controlled, the mother may develop
  • pre-eclamplsia
  • polyhydramnios (excess amniotic fluid around baby)
  • excess weight gain
  • vaginal candidiasis (thrush)

Additionally the baby may suffer from:

  • macrosomia (a big baby who often responds as a premature baby born baby after birth)
  • shoulder dystocia t delivery if the baby is big
  • occasional death in utero (fetal death in utero, FDIU)

If diabetes cannot be adequately controlled by adjusting the diet, the mother may require insulin.  Once diabetes is under control, a decision needs to be made by the doctor as to when is the best time to deliver the baby.

If you have gestational diabetes and have managed to control it by dieting and your baby is not showing any effects of diabetes (such as macrosomia or polyhydramnios), then most obstetricians would recommend delivery around your EDD.  Some will let you go overdue and only induce you to prevent your baby being postmature, that is, 10-14 days overdue, or post-term.

If you have needed insulin to control your diabetes, you will usually be induced between 36-38 weeks gestation.  The decision to deliver and how you will be delivered will depend on the level of control and whether you or your baby has developed any complications, for example pre-eclampsia or macrosomia, respectively.  Once you have delivered you will find that your diabetes usually resolves quite rapidly.  I recommend a glucose tolerance test at your 6 week post-natal visit to confirm you are no longer diabetic.  You should be aware that gestational diabetes is likely to recur in your next pregnancy, and you are at risk of developing diabetes in later life.  Therefore it is important that oyu attend to your long-term management of your diet and wight control.

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[scroll_to link=”Hypertension” title=”Hypertension or pre-eclampsia”]

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Hypertension (high blood pressure)

Normal systolic pressure is about 120 mmHg and the diastolic blood pressure is about 80 mmHg recorded as 120 over 80 or 120/80.

Hypertension is one of the most common problems in pregnancy and is diagnosed or develops in about one in 7 women.  Hypertension is defined when blood pressure measures more than 140/90 mmHg – some doctors use 135/85 as the upper limit of normal.

The detection of high blood pressure in early pregnancy means that there is probably an underlying cause.  Your doctor will need to order the appropriate investigations.  You may be referred to a physician – preferably a specialist physician interested in medical problems associated with pregnancy – for management during pregnancy.   You may be started on medication to lower your blood pressure.  If you develop high blood pressure after 20 weeks gestation, this is considered to be pre-eclampsia also known as toxaemia of pregnancy until proven otherwise.

Pre-eclampsia

Pre-eclampsia is a triad of symptoms and signs, namely fluid retention and oedema, high blood pressure and proteinurea.  It is a condition peculiar to pregnancy.  It is thought to be a result of inflammation of blood vessels (vasculitis) in the pregnant woman.  Various organs are affected in particular:

  • the kidneys
  • the placenta
  • the haemopoietic system (the blood)
  • the liver
  • less commonly, the brain, which may result in the mother having convulsions.

The severity of pre-eclampsia can vary depending on the level of blood pressure and the amount of protein in the urine, known as proteinurea.  Signs of fluid retention (with generalised swelling especially of the hands and feet, accompanied by sudden weight gain) may occur.

Other tests to assess the severity of pre-eclampsia include:

  • blood tests to check low platelets, increased uric acid, protein/creatinine ratio, abnormal liver function.
  • fetal monitoring (cardiotocography) for signs of fetal distress
  • an ultrasound examination for fetal well being
  • urine output measurements

The best cure for pre-eclampsia is to deliver the baby.  Of course, this depends on gestation.  It can be a fine balancing act deciding to deliver the baby against the risk of pre-maturity.  It goes without saying that the aim is to achieve always a healthy mother and a healthy baby.

For management of pre-eclampsia, the mother should be under the care of an obstetrician if possible and may need to be referred to a hospital with an intensive care unit and a neonatal unit with facilities to ventilate the baby, if necessary.

The following factors may predispose you to developing pre-eclampsia:

  • more common in your first pregnancy (primigravida), unless you are pregnancy to a new partner in a subsequent pregnancy.
  • pre-existing hypertension
  • lack of antenatal care and supervision
  • underlying kidney disease
  • if you suffer form diabetes
  • a multiple pregnancy
  • if you smoke

You can reduce your risk of developing pre-eclampsia if you:

  • have regular check ups
  • ensure you drink more than 2 litres of water per day
  • have an afternoon rest for 1-2 hours with your feet elevated
  • do not smoke
  • maintain a well balanced diet
  • avoid excessive weight gain

As pre-eclampsia tends to develop after 34 weeks gestation, you should consider stopping work at this stage to enable you to have more rest.

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[scroll_to link=”#Proteinuria (protein in the urine)” title=”Proteinuria (protein in the urine)”]

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Proteinuria (protein in the urine)

When you provide your fasting specimen of urine, its best to collect a mid-stream sample.  The presence of significant proteinuria (more than just a trace of protein on dipstick testing) after 20 weeks gestation is a sign that you might be developing pre-eclampsia, until proved otherwise.   Usually high blood pressure develops before proteinurua appears, but not always.

Other causes of proteinuria include:

  • a urinary tract infection
  • vaginal infection with excess vaginal discharge
  • some less common kidney causes, for example, glomerulonephritis or orthostatic proteinuria.

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[scroll_to link=”#Vaginal bleeding” title=”Vaginal Bleeding”]

[scroll_to link=”#Placenta previa” title=”Placenta previa”]

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Vaginal bleeding

If your 12 week ultrasound scan shows a healthy intrauterine pregnancy, a placenta that is not low-lying and a cervical canal that is not shortened, it is unlikely you will experience vaginal bleeding.  Vaginal bleeding, during the first 20 weeks of pregnancy is classified as threatened miscarriage.  After 20 weeks gestation it is classified as an antepartum haemorrhage and is based on the following factors:

  • placenta previa
  • placental abruption
  • incidental causes

Placenta previa

Placenta previa is a condition where the placenta lies wholly or partly across the cervix.  The classic symptoms include recurrent painless bleeding at varying intervals throughout your pregnancy.  As your pregnancy progresses the bleeding tends to become heavier.  Providing you live within 20 minutes from your maternity hospital, you can monitor light bleeding from home.  However, if you suffer a moderately severe bleed, 250-500 ml of blood, it is safer for you to be managed as an in-patient in hospital.  You may be reassured to know that the blood that you are losing comes from the circulation and therefore, unless your bleeding is severe (greater than 500 ml), your baby is not at risk.

Most women with placenta previa will be delivered by C-section at 37 – 38 weeks gestation.  Signs that you may need to be delivered earlier are:

  • continuous bleeding
  • the onset of labour
  • rupture of the membranes

Some women with a minor grade of placenta previa (where the placenta is low but not covering the cervix) can plan to have a vaginal delivery.  However, your obstetrician would need to make this decision.  Placenta previa occurs in about one in 100 – 200 pregnancies.

Placental abruption

This occurs when there is bleeding beneath the placenta where it is attached to the wall of the uterus.  This can happen at any stage of the pregnancy.  Usually there is associated vaginal bleeding but not always.  If it occurs once your uterus has enlarged into your abdomen, the symptoms of the condition include localised tenderness when feeling your uterus.  The diagnosis may be confirmed on ultrasound where an accumulation of blood can be seen beneath the placental bed.

Again the treatment is rest and pain relief.  In early pregnancy miscarriage can occur.  In later pregnancy, complications include premature labour, premature ruptured membranes, poor fetal growth (IUGR) and feral death in utero (FDIU) if bleeding is severe.

Placental abruption is when the placenta separated form the wall of the uterus, causing bleeding.  This can occur in varying degrees and is graded as mild, moderate or severe.  Factors that might predispose to this condition are:

  • no or infrequent antenatal check-ups
  • poor diet (folic acid deficiency has been suggested)
  • smoking
  • increased alcohol and caffeine intake
  • high blood pressure
  • chronic kidney disease

Vaginal bleeding of < 250 ml is usually, but not always, associated with mild placental abruption.  It is unlikely that the woman will experience abdominal pain and uterine tenderness.  The management is rest and fetal monitoring.

Moderately severe placental disruption presents with vaginal bleeding, the amount varying between 250 and 500 ml.  The woman is likely to feel abdominal pain and uterine tenderness, and may need to be delivered if fetal monitoring shows the baby to be distressed.

With a severe placental disruption, heavy vaginal bleeding ( greater than 500 ml), acute abdominal pain, and a very tender uterus occur.  The patient may go into shock, and often baby may die in utero.  The woman needs to be under the care of an obstetrician to have these conditions managed.

Incidental causes of vaginal bleeding

A variety of conditions can cause vaginal bleeding, usually light, during pregnancy.  These include:

  • a cervical polyp
  • a prolapsed uterine fibroid polyp
  • decidual tissue on the cervix
  • threatened premature labour

NOTE: You might mistake bleeding from a haemorrhoid, which is quite common in pregnancy, for vaginal bleeding.  Similarly, blood-stained urine from an acute urinary tract infection can also be mistaken for vaginal bleeding.

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