Pregnancy is usually an exciting and special time in a woman’s life. The duration of human pregnancy is 9 calendar months, 10 lunar months, 40 weeks, or 280 days. The length of pregnancy is divided into three trimesters, or 3-month periods. Each trimester is characterized by its own unique and predictable developments for the mother and her baby. To accommodate the changes taking place throughout the gestational period, the pregnant woman’s body undergoes changes in size and shape, and all of her organ systems modify their various functions to create an environment that is protective and nurturing for the growing fetus.

The female body undergoes many physiological and anatomic changes during pregnancy. Several factors are responsible for the woman’s adaptation to pregnancy.Hormonal influences, mechanical pressure arising from growth of the fetus inside the uterus, and the mother’s physical adaptation to her changing body all account for the changes that take place during pregnancy. The majority of these changes are brought about by the hormones of pregnancy, primarily estrogen and progesterone.Although the most dramatic changes occur in the reproductive system, every other body system is also affected by pregnancy.Although pregnancy is a normal event, problems can occur. Therefore, you need an understanding of normal maternal physiology so that you can recognize potential or actual problems that warrant attention. Also, your understanding of the normal physiological and psychological events that take place during pregnancy will assist you in teaching your patient and her family about changes that are normal and expected and how to identify signs and symptoms that should be reported to her healthcare provider.

SYSTEM/STRUCTURE/CHANGES SYSTEM/STRUCTURE/CHANGESIntegumentarySkin■ Changes result from hormones and mechanical stretching. Increased skin thickness and hyperpigmentation are caused by increased secretion of melanotropin, an anterior pituitary hormone.

■ Increased action of adrenocorticosteroids occurs in 50 to 90 percent of pregnant women, causing cutaneous elastic tissue to become more fragile.

■ Increased estrogen results in color and vascular changes.

■ Chloasma, the “mask of pregnancy,” is a brownish hyperpigmentation of the skin over the cheeks, nose, and forehead. It appears in 50 to 70 percent of pregnant women and occurs most often in those with dark complexions, usually after the 16th week. Sunlight enhances the heightened pigmentation, which generally fades after delivery.

■ Darkening of the nipples, areolae, axillae, and vulva also occur, and scars and moles may darken.

■ The linea alba may become pigmented (linea nigra) and extends from the symphysis pubis to the umbilicus.

■ Stretch marks (striae gravidarum)—pinkish-red streaks with slight depressions in the skin—may appear over the abdomen, thighs, breasts, and buttocks, fading to silvery or white after pregnancy.

■ Angiomas, or vascular spiders, are tiny, branched, pulsating end-arterioles on the neck, chest, face, and arms. These skin lesions are bluish, do not blanch with pressure, and usually disappear after the baby’s birth.

■ Palmar erythema is characterized by a pinkish-red, diffuse mottling over the palms of the hands.

■ Increased sebaceous gland secretions.

■ Increased blood supply to skin, increased basal metabolic rate (BMR), and progesterone-induced increased body temperature.

■ The skin develops increased oiliness and acne or takes on a “healthy glow.”■ Increased perspiration and feeling “hotter.”

Hair■ Increased hair growth during pregnancy as a result of hormonal influences.

Nails■ Changes in nail growth and texture as a result of hormonal influences.

HEENTEar■ Increased vascularity of upper respiratory tract may cause swelling of the tympanic membrane and eustachian tube.Nose■ Estrogen-induced edema and vascular congestion of the nasal mucosa and sinuses.

Mouth/Throat■ Edema of the larynx.■ Higher estrogen levels increase vascularity and connective tissue proliferation.

Respiratory■ Estrogen promotes relaxation of the ligaments and joints of ribs.

■ Increase in oxygen consumption by 15 to 20 percent.

■ Higher levels of progesterone increase sensitivity of respiratory receptors, increasing tidal volume, which results in respiratory alkalosis with compensated mild metabolic acidosis.

Cardiovascular■ Increase in cardiac output and maternal blood volume by approximately 40 to 50 percent. Because the heart must pump harder, it actually increases in size. The body adapts to increase in blood volume with peripheral dilation to maintain BP. Hormones cause peripheral dilation.

■ Some women may have excessive hair growth in unusual places (hirsutism). Increase in fine body hair growth also occurs but disappears after delivery. Increase in brittle hair growth usually does not.Excessive scalp oiliness or dryness may also occur.

■ Nails may grow longer, soften, or thin.

■ Decreased hearing, a sense of fullness in the ears, or earaches.

■ Nasal stuffiness and epistaxis (nosebleed).

■ Some women may experience vocal changes.

■ Gum hypertrophy and bleeding of gums while brushing teeth is common. Epulis—raised, red nodules on gums that bleed easily—may develop but generally regress after delivery.

■ Increase in transverse diameter by 2 cm with a total circumference increase of 6 cm. Increase in the costal angle > 90 degrees.■ Thoracic breathing as pregnancy progresses.■ The diaphragm becomes displaced as pregnancy progresses.

■ Slight increase in respiratory rate.■ 30 to 40 percent increase in tidal volume.■ Increase in inspiratory capacity.■ Decrease in expiratory volume.■ Total lung capacity slightly decreased.

■ Decrease in PCO2 (27 to 32 mm Hg) leads to increase in pH (more alkaline) and decrease in bicarbonate (18 to 21 mEq/L).

■ Heart rate may increase by 10 to 15 beats per minute, and systolic murmurs may be heard. Increase in blood volume may cause physiological or “pseudo” anemia because the plasma increase exceeds red blood cell production. Sinus arrhythmias and premature atrial or ventricular contractions may occur. BP is normal in firstand third trimesters; systolic and diastolic BP drops

■ Compression of vena cava impairs venous return and results in decreased cardiac output when woman is supine during second half of pregnancy.

5 to 10 mm Hg during second trimester.■ Orthostatic hypotension can occur as a result of decreased venous return and decreased cardiac output.

■ Compression of iliac veins and inferior vena cava increases venous pressure and decreases blood flow to extremities.

Breasts■ Increase in estrogen and progesterone soon after conception causes many changes in mammary glands.

■ Increased blood supply to breasts.■ Increased growth of mammary glands.

■ Increase in luteal and placental hormones leads to increase in lactiferous ducts and lobule-alveolar tissue.Gastrointestinal■ Increased levels of hCG and altered carbohydrate metabolism.■ Change in senses of taste and smell.

■ Decreased swallowing and increased stimulation of salivary glands by starch ingestion.

■ After the 7th month of pregnancy, the upper portion of the stomach may herniate.■ Increased progesterone decreases tone and motility of smooth muscles.

■ Increased estrogen leads to decrease in hydrochloric acid.■ Increased progesterone decreases muscle tone and peristalsis.

■ Gallbladder becomes increasingly distended because of decreased muscle tone. Emptying time is prolonged and bile thickens.

■ Displacement of intestines by uterus.

■ Dependent edema, varicose veins in legs and vulva, hemorrhoids.

■ Breasts may feel full, with increased sensitivity, tingling, and heaviness. Increased nipple erectility and hypertrophy of Montgomery’s tubercles (glands).■ Blood vessels become more visible.■ Increase in breast size.■ Striae gravidarum (stretch marks) on breasts.■ Breasts become softer, looser, and nodular. Colostrum produced by 16th week.

■ Morning sickness during first trimester.

■ May result in decreased appetite or unusual nonfood cravings (pica).■ Nausea.■ Some women develop ptyalism, or excessive salivation.■ Hiatal hernia is more likely to occur in older, obese, or multiparous women.■ Esophageal regurgitation, reverse peristalsis, and delayed stomach emptying result in heartburn (pyrosis).■ Peptic ulcers rarely occur.

■ Constipation can be caused by hypoperistalsis, increased water absorption from large intestines, decreased physical activity, displacement of intestines, abdominal distension, and iron supplements.

■ Increased risk for gallstones.

■ Abdominal changes include round ligament tension, flatulence, distension, cramping, pelvic heaviness, and contractions.

Genitourinary■ Changes caused by increased estrogen and progesterone. By 10th week of pregnancy, renal pelvis and ureters have already begun to dilate. As pregnancy progresses, smooth muscle walls of ureters undergo hypertrophy and hyperplasia and muscle tone relaxes. Ureters become elongated and tortuous, resulting in larger volume of urine held in pelvis and ureters, slower urine flow rate, and urinary stasis.

■ Increased risk for urinary tract infections (UTIs).

■ Increased vascularity in pelvic area.■ Decreased bladder tone.■ Increased pressure on bladder by uterus.■ Increase in renal blood flow.■ Decrease in renal blood flow in latter part of pregnancy

Reproductive■ Increased pelvic congestion.

■ Increased levels of estrogen and progesterone.

Musculoskeletal■ Increase in abdominal size with decreased muscle tone and increased weight-bearing capacity.

■ Increased mobility of pelvic joints.■ Abdominal musculature stretches as uterus enlarges.

Neurologic■ Hypoglycemia, postural hypotension, or vasomotor instability.■ Anxiety.■ Hormonal changes.■ Edema compresses median nerve beneath carpal ligament of wrist, producing paresthesia and pain radiating to thumb, index, middle, and part of ring fingers, especially in dominant hand.■ Inadequate calcium intake.■ Enlarged uterus may compress pelvic nerves.■ Accentuated lumbar curve (lordosis) compresses or pulls lumbar nerve roots.■ Stoop-shouldered posture puts pressure on brachial plexus.■ Change in body’s center of gravity during pregnancy.

■ Hyperemia of bladder and urethra.■ Increased bladder capacity to 1500 mL.■ Increased urge to void.■ Increased glomerular filtration rate.■ Physiological/dependent edema.

■ Softening of cervix (Goodell’s sign). Bluish coloration of cervix and vaginal mucosa (Chadwick’s sign).■ Hypertrophy of glands in cervical canal. Softening and compressibility of lower end of uterus (Hegar’s sign).■ Vaginal smooth muscle and connective tissue loosen up and expand to accommodate passage of fetus through birth canal.■ Uterus undergoes cell hypertrophy and hyperplasia and grows to a capacity of approximately 1000 g. Once conception occurs, ovulation ceases, uterine endometrium thickens, and number and size of uterine blood vessels increase. As fetus grows, uterus continues to enlarge throughout pregnancy.

■ Causes forward tilting of pelvis and changes in posture and walking style. To maintain balance, the lumbosacral curve becomes more exaggerated, and woman develops exaggerated anterior flexion of head.

■ Facilitates labor and birth process.■ Rectus abdominis muscles may stretch to the extent that a permanent separation occurs (diastasis recti abdominis).

■ Syncope and lightheadedness, often seen in early pregnancy.■ Tension headaches may be related to anxiety.■ Emotional lability.■ Carpal tunnel syndrome.

■ Leg cramps or tetany.■ Sensory changes in lower extremities.■ Low back pain.

■ Numbness and tingling in hands (acroesthesia).

■ Body’s base of support widens.

EndocrinePituitary and Placental Hormones■ Decreased follicle-stimulating hormone. ■ Amenorrhea.

■ Fat deposits in subcutaneous tissue over abdomen, back, and thighs.

■ Increased progesterone relaxes smooth muscles, which results in decreased uterine contractions and prevents spontaneous abortion.■ Increased estrogen.

■ Increased prolactin.

■ Increased oxytocin.■ Human placental lactogen or hCG acts as a growth hormone and decreases glucose metabolism and increases fatty acids.

Thyroid■ BMR gradually increases throughout pregnancy.

■ Hyperplasia and increased vascularity of thyroid gland.

Parathyroid■ Increased parathyroid hormone peaks between 15 and 35 weeks’ gestation to meet increased requirements for calcium and vitamin D for fetal skeletal growth.

Pancreas■ As fetus grows, it requires increasing amounts of glucose.Adrenals■ Increase in cortisol.

Immunologic/Hematologic■ Increased coagulability results from increases in clotting factors VII, VIII, IX, X, and fibrinogen. Fibrinolytic activity is depressed to minimize risk of bleeding.■ Increase in blood volume 40 to 50 percent > nonpregnant state, about 1500 mL; 1000 mL is plasma, 500 red blood cells.■ Increase in white blood cells during second and third trimesters.

■ Maintains pregnancy.

■ Enlarges uterus, breasts, and genitals; increases vascularity.■ Causes lactation.

■ Causes uterine contractions at time of delivery and letdown milk reflex.■ Contributes to breast development.

■ May cause heat intolerance, fatigue, and lassitude.■ Enlargement of thyroid gland.

■ Slight hyperparathyroidism develops.

■ As mother’s glucose stores are depleted, she experiences decreasing blood glucose levels.

■ Increases production of insulin and mother’s resistance to insulin.

■ Increased risk for thrombus formation.

■ Hemodilution causes physiological anemia.

■ Increase is seen in granulocytes.

Performing the assessment

Your patient’s prenatal workup includes a health history and physical assessment. A complete health history is essential to providing optimal care for the pregnant woman. If there is no recent complete health history available, you should perform one before proceeding with the specific pregnancy-related questions.

After the health history comes the physical examination. Keep the key history findings in mind as you perform it. Taken together, the history and physical examination form a complete picture of your patient’s prenatal health.

Health HistoryThis section focuses specifically on the current pregnancy. The first prenatal visit involves collection of baseline information about your patient and her partner and identification of risk factors.Key points to remember when obtaining a prenatal history:

■ Focus on the current pregnancy and the presenting presumptive symptoms. Take a detailed obstetric/ gynecologic history.■ Use the past medical history to identify anything that would affect or be affected by pregnancy.■ Pay special attention to the nutritional history.■ Pay special attention to the use of prescribed,over-thecounter (OTC), and illegal drugs; it may have a major impact on the developing fetus.■ Determine the patient’s reaction to pregnancy—was it planned?■ Identify major supports—family, spouse, significant other.■ Assess for history or risk of physical abuse.■ After you have completed your questions, ask the patient if she has any problems or concerns that have not been covered, and give her an opportunity to discuss them.

Biographical DataA careful review of the biographical data will be helpful in identifying actual or potential problems. Collecting this data also allows your patient to answer uncomplicated questions comfortably and sets the tone for the remainder of the interview.

First, clarify your patient’s name, address, and date of birth. Geographic location may have a bearing on pregnancy outcome because women residing in the southern and western regions of the United States have a higher incidence of preeclampsia. Women who will be age 35 or older at the time of delivery should be offered genetic counseling and testing. Determine what effect the patient’s occupation may have on her pregnancy. Also identify the patient’s religious preference and cultural/ ethnic group and incorporate them into her care, if appropriate. Biographical data will also be helpful in identifying your patient’s supports.

Current Health StatusThe current health status includes verifying the patient’s pregnancy, performing a symptom assessment, and calculating the estimated date of birth (EDB) or “due date.”

Documenting PregnancyIt is useful to document the patient’s pregnancy before proceeding with the initial comprehensive prenatal evaluation. Both urine and serum pregnancy tests are based on levels of human chorionic gonadotropin (hCG), which are secreted into the mother’s bloodstream and then excreted into the urine.Urine pregnancy tests are 95 to 98 percent accurate and are sensitive within 7 days after implantation.The test is inexpensive and widely available without prescription, so many women test themselves at home. The first voided specimen of the morning is best to use for testing because concentrated urine improves the pregnancy detection rate. Serum pregnancy tests do not indicate pregnancy until levels rise above baseline values— usually around 25 to 30 metric International Units (mIU)/ mL. The hCG is detectable in serum as early as 7 to 9 days after ovulation, or just after implantation. During the first 3 to 4 weeks after implantation, the hCG level doubles every 2 days, then peaks at 60 to 70 days.The diagnosis of pregnancy is based on the following indicators:■ Presumptive signs (experienced by the patient).■ Probable signs (observed by the examiner).■ Positive signs (attributed only to the presence of the fetus).

Symptom AssessmentThe presenting symptoms usually relate to the presumptive signs of pregnancy. Your patient may present with multiple symptoms and vague complaints, all related to the pregnancy. Because pregnancy affects every system of the body, the review of systems (ROS) will address every presenting sign and symptom. Remember to perform a symptom analysis (PQRST) for all presenting symptoms.

Calculating the Estimated Date of BirthOnce the pregnancy has been confirmed, the EDB, also termed the estimated date of confinement (EDC), is calculated.Establishing the baby’s due date involves obtaining accurate information regarding the mother’s menstrual history, including the last menstrual period (LMP). To calculate the EDB, apply Naegele’s

rule:Add 7 days to the first day of the LMP, and then subtract 3 months from that date. Considerations in calculating the EDB include:■ Find out the first day of the LMP. Make sure that the patient is sure of the date because the EDC is based on the LMP. Conception usually occurs around 2 weeks after the LMP in a 28-day cycle.■ Review the patient’s menstrual history, including frequency of menses,length of flow,normalcy of the LMP, and contraceptive use.■ Ultrasound studies may also be used to estimate the gestational age.

Past Health HistoryThe purpose of the past health history is to uncover diseases or other risk factors that could affect the woman’s health or the fetus’s well-being during pregnancy. Allergies to food, drugs, or environmental factors need to be noted because they can be exacerbated during pregnancy. Ask about exposure to toxins (e.g., radiation or chemicals) in the environment or at work, because this can affect fetal health. Is your patient on any medications? Identify all prescribed and OTC drugs (including alcohol and tobacco) your patient took before and during her pregnancy for their potential effects on the developing fetus.Also take an obstetric history. Has your patient had previous pregnancies? If so, ask how many and if complications occurred during pregnancy or labor. Also ask about neonatal complications, such as birth defects, jaundice, infection, or death. Be sure to follow up on unclear or vague answers, and remember that sometimes rewording the question may help the patient find a relevant response.Ask your patient if she has any of the diseases listed in the following paragraphs,which pose a particular risk to the expectant mother and/or fetus.DiabetesIf your patient has diabetes, ask about the age of onset. If she is insulin dependent, ask what type and amount of insulin she takes. If her diabetes is diet controlled, ask about use of oral hypoglycemics. If she has had other pregnancies, did she have gestational diabetes?Uncontrolled diabetes in pregnancy can cause congenital anomalies, fetal overgrowth (macrosomia), intrauterine fetal death, delayed fetal lung maturation, and neonatal death. Oral hypoglycemics may cause fetal damage and are contraindicated. Women with a history of gestational diabetes are more likely to develop it again with subsequent pregnancies.HypertensionIf your patient has chronic HTN, ask how she controls it. Does she take antihypertensive medication? If so, explain that these drugs may be contraindicated in pregnancy.HTN may result in decreased placental perfusion and intrauterine fetal growth restriction. PIH may recur.Cardiac DiseasePatients with mitral valve prolapse (MVP) may need prophylactic antibiotics during labor to prevent streptococcal infections and subsequent bacterial endocarditis and valve disease.Liver DiseaseIf your patient has hepatitis B, the infant may require treatment (hepatitis B immunoglobulin and hepatitis vaccine) after birth.CancerPatients with cervical cancer who were treated with cone biopsy (cone-shaped section of the cervix is removed for examination) are at risk for preterm labor.Infectious DiseasesRubella,mononucleosis, and other viral infections in the first trimester can cause fetal abnormalities.Pulmonary DiseaseMedications and inhalers used for asthma may be harmful to the fetus or may affect anesthesia used during labor. Inhalants and general anesthesia may be contraindicated for patients with asthma.Gastrointestinal DiseaseAsk about previous abdominal surgery and note the type of scarring;this may influence the type of delivery. Colitis and other bowel problems may be exacerbated in pregnancy.Other Medical ProblemsVaricosities and renal, gallbladder, genitourinary, autoimmune, neurological, and psychiatric conditions may be exacerbated in pregnancy.Gynecologic Diseases and Sexually Transmitted DiseasesVaginitis should be identified and treated early to prevent intrauterine complications. Untreated sexually transmitted diseases (STDs), such as genital herpes and gonorrhea, can be transmitted to the

fetus during passage through the birth canal. The transmission rate for babies born to human immunodeficiency virus (HIV)–infected mothers is 20 to 35 percent.

Family HistoryThe purpose of the family history is to identify potential physical and emotional complications of pregnancy and familial patterns of health or illness. Ask specific questions to pinpoint inherited diseases. Some questions to ask include:■ “Was anyone in your family diagnosed with heart disease before age 50?” (Cardiovascular disease or heart defects may be inherited.)■ “Does anyone in your family have lung disease, tuberculosis, or asthma?” (Pulmonary disorders may be familial; tuberculosis is contagious.)■ “Do any family members have diabetes?” (Endocrine problems are genetically linked.)■ “Does anyone in your family have cancer?” (There is a genetic component with certain types of cancer.)■ “Is there a history of birth defects, inherited genetic disorders, blood disorders, or mental retardation in your family?” (There is a genetic risk for Down syndrome, spina bifida, brain defects, anencephaly, heart defects, muscular dystrophy, cystic fibrosis, hemophilia, thalassemia, and other disorders.)■ “Did your mother or sisters have complications during pregnancy or labor?” (Daughters and sisters ofpreeclamptic women have a higher tendency toward preeclampsia.)

Be sure to consider your patient’s race/ethnic background when taking a family history. For example, children of African American women are at risk for sickle cell disease. Identification of sickle cell disease will prevent a crisis; testing the mother-to-be is appropriate if status isuncertain.

Review of SystemsNormal changes that occur during pregnancy have an impact on every body system.The ROS will help you to identify normal physiological changes as well as alert you to abnormal findings.

Psychosocial ProfileThe psychosocial profile is an important component of the assessment because it lays the groundwork for a trusting nurse-patient relationship. The profile provides an opportunity to explore the patient’s reactions to the pregnancy and to identify lifestyle patterns that may pose a threat to her or her baby’s well-being. Start by asking your patient about her health practices and beliefs. Is she proactive (getting regular preventive healthcare) or reactive (seeking healthcare only when ill)? Also inquire about self-care, such as breast self examinations (BSEs). Determine the patient’s acceptance

Review of SystemsAREA/QUESTIONS TO ASK RATIONALE/SIGNIFICANCEGeneral Health Survey■ How have you been feeling?

■ Feelings of fatigue and ambivalence are normal during the first trimester.■ During the second trimester, mothers-to-be are introspective and energetic.■ The third trimester is characterized by restlessness, mood swings, and interest in preparing for the baby.Denial of the pregnancy, withdrawal, depression, or psychosis signal psychological problems that warrant referral.

Body Weight■ What is your normal weight (before pregnancy)?■ Have you lost or gained weight since a year ago? How much?

■ Optimal weight gain during pregnancy depends on patient’s heightand normal weight. Recommended weight gain in pregnancy is:■ Underweight patient: 28 to 40 lb.■ Normal weight patient: 25 to 35 lb.■ Overweight patient: 15 to 25 lb.■ Twin gestation: 35 to 45 lb.

Low pregnancy weight and inadequate weight gain during pregnancy contribute to fetal growth restriction and low birth weight.

Integumentary■ Have you noticed any changes in your skin, hair, or nails?

■ Hormonal changes cause hyperpigmentation of skin (chloasma, linea nigra), thin nails, oily hair.

HEENTEyes■ Do you have any vision problems? ■ Excessive tearing may be associated with

allergies; blurred vision or spots before the eyes may indicate preeclampsia.

Ears■ Do you have any hearing problems? ■ Decreased hearing, earaches, or sense of

fullness in ears occurs because tympanic membranes swell as a result of increasedvascularity.

Nose■ Do you have nasal stuffiness?■ Nosebleeds?

■ Increased vascularity from increased estrogen causes nasal edema.

Neck■ Have you noticed any masses in your neck? ■ Slight thyroid enlargement is normal; marked

enlargement may indicate hyperthyroidism.Mouth/Throat■ Do you have any trouble with your throat?■ Since your LMP, have you had a fever or chills without a cold?■ Do you have a cough that doesn’t go away or frequent chest infections?

■ Prolonged nasal congestion with sore throat, fever, and chills may be an upper respiratory infection.■ Fetal exposure to viral illnesses is associated with fetal growth restriction, developmental delays, hearing impairment, and mentalretardation.■ Persistent cough and frequent chest infections may indicate pneumonia or tuberculosis.

■ Do your gums bleed? When was your last dental exam?

■ Gum hypertrophy is common; bleeding during tooth brushing may be associated with gum disease and warrants further dental evaluation.

■ Do you have increased saliva? ■ Ptyalism (excessive saliva) often occurs within 2 to 3 weeks after the first missed period and is not associated with pathology.

Respiratory■ Do you have shortness of breath? Dyspnea? Other breathing problems?

■ Thoracic breathing, slight hyperventilation, and shortness of breath occur in late pregnancy.■ Dyspnea may be associated with respiratory distress; dyspnea with markedly decreased activity tolerance may indicate cardiovascular disease.

Cardiovascular■ Do you have a history of cardiovascular disease? Palpitations? Dizziness?

■ Pregnant women with pre-existing cardiovascular disease, such as MVP, can decompensate as a result of increased workload of the heart. Be alert for cardiovascular changes associated with PIH and eclampsia.■ Supine hypotension can occur from vena caval compression.Lying supine compresses vena cava and aorta, decreasing cardiac output. Advise patient to lie on left side to increase renal perfusion and output and reduce edema.

■ Do your ankles swell? ■ Dependent edema and varicose veins in legs frequently occur in pregnancy, but may also be

associated with PIH and eclampsia.

Breasts■ Have you noticed pain, lumps, or fluid leaking from your breasts?

■ Fullness, increased sensitivity, tingling, and heaviness are common early in pregnancy; however, lumps and pain may also indicate breast disease.■ Colostrum secretion from breasts is normal during pregnancy and varies in color.

Gastrointestinal■ Do you have nausea and vomiting that do not go away?

■ Excessive nausea and vomiting may be associated with hyperemesis gravidarum; sudden, excessive weight gain could indicate a multifetal gestation or fluid retention associated with PIH.

■ Are you more thirsty than usual? ■ Abdominal pain or cramping may be related to round ligament pain or may signal impending miscarriage.■ Hydration must be maintained because the patient may be at risk for hypovolemia, cholecystitis, or cholelithiasis.Appendicitis during pregnancy may be difficult to diagnose because the appendix is displaced upward and laterally.

■ Do you ever notice black or bloody stools? ■ Blood in the stools or a change in bowel habits may indicate constipation or hemorrhoids.

■ Do you have diarrhea or trouble passing stools? Genitourinary■ Do you ever have burning or pain when you urinate?

■ Urinary urgency and frequency are common during pregnancy and are not cause for concern unless accompanied by pain or burning, which may signal a UTI.

■ Do you have to urinate more often than normal?

■ During pregnancy, women may have asymptomatic bacteriuria.UTIs must be promptly diagnosed and treated because untreatedUTIs predispose patient to complications such as preterm labor,pyelonephritis, and sepsis.

Reproductive■ When was your LMP? ■ Needed to determine EDC.■ Do you have increased vaginal discharge? ■ Increased white vaginal discharge (leukorrhea)

is normal during pregnancy. Discharge accompanied by a foul odor, itching, or burning may indicate infection.

■ Have you experienced any vaginal bleeding, leakage of fluid, or unusual vaginal discharge?

■ Vaginal bleeding, fluid leakage, or vaginal discharge may indicate placenta previa, rupture of membranes, or vaginal infection.Untreated vaginal infections predispose patient to preterm labor or fetal infections.

Musculoskeletal■ Do you have leg cramps? ■ Leg cramps may indicate calcium deficiency.■ Do you have back pain? ■ Curvature of the lumbar spine may be

accentuated during pregnancy, resulting in backache.■ Severe back pain may be associated with disc disease.

Neurologic

■ Do you have a history of depression, difficulty sleeping, loss of appetite?

■ Emotional lability can occur during pregnancy; however, these symptoms also may indicate psychological disorders.Patients with a history of psychological disorders must be continually monitored for signs and symptoms and referred when appropriate.

■ Have you experienced light-headedness, dizziness, or fainting?

■ Fainting may indicate anemia.

■ Do you have wrist pain, numbness, or tingling? ■ Wrist pain, especially in the dominant hand, may indicate carpal tunnel syndrome.

Endocrine■ Do you have increased fatigue or heat intolerance?

■ Common symptoms associated with increase in BMR and hormonal changes.

■ Do you have a history of diabetes or gestational diabetes?

■ Positive history of diabetes calls for close monitoring.

Immunological/Hematological■ Do you have a history of anemia? ■ Physiological anemia may occur during

pregnancy. As a result, preexisting anemia may worsen.

■ History of thrombophlebitis? ■ Increase of clotting factors increases risk of thrombus formation.

Complications can occur during each trimester of pregnancy. The following is a list of signs and symptoms of complications and their causes.First Trimester■ Severe vomiting: Hyperemesis gravidarum.■ Chills, fever: Infection.■ Burning on urination: Infection.■ Abdominal cramping, bloating, vaginal bleeding: Spontaneous abortion, miscarriage.

Second and Third Trimesters■ Severe vomiting: Hyperemesis gravidarum.■ Leakage of amniotic fluid from vagina before labor begins: Premature rupture of membranes.■ Vaginal bleeding, severe abdominal pain: Miscarriage, placental separation.■ Chills, fever, diarrhea, burning on urination: Infection.■ Change in fetal activity: Fetal distress, intrauterine fetal demise.■ Uterine contractions before due date: Preterm labor.■ Visual disturbances (blurring, double vision, spots): Hypertensive disorders (PIH).■ Swelling of face, fingers, eye orbits, sacral area: PIH.■ Severe, frequent, or continuous headaches: PIH.■ Muscular irritability or convulsions (seizures): PIH.■ Severe stomachache (epigastric pain): PIH.■ Glucosuria, positive glucose tolerance test result: Gestational diabetes mellitus.