Pregnancy


Image by/from Ken Hammond (USDA)

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology. A pregnancy may end in a live birth, abortion, or miscarriage, though access to safe abortion care varies globally. Childbirth typically occurs around 40 weeks from the start of the last menstrual period (LMP). This is just over nine months, where each month averages 31 days. When measured from fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.

Pregnancy is divided into three trimesters, each lasting for approximately 3 months. The first trimester includes conception, which is when the sperm fertilizes the egg. The fertilized egg then travels down the fallopian tube and attaches to the inside of the uterus, where it begins to form the embryo and placenta. During the first trimester, the possibility of miscarriage (natural death of embryo or fetus) is at its highest. Around the middle of the second trimester, movement of the fetus may be felt. At 28 weeks, more than 90% of babies can survive outside of the uterus if provided with high-quality medical care.

Prenatal care improves pregnancy outcomes. Prenatal care may include taking extra folic acid, avoiding drugs and alcohol, regular exercise, blood tests, and regular physical examinations. Complications of pregnancy may include disorders of high blood pressure, gestational diabetes, iron-deficiency anemia, and severe nausea and vomiting among others. In the ideal childbirth labor begins on its own when a woman is “at term”. Babies born before 37 weeks are “preterm” and at higher risk of health problems such as cerebral palsy. Babies born between weeks 37 and 39 are considered “early term” while those born between weeks 39 and 41 are considered “full term”. Babies born between weeks 41 and 42 weeks are considered “late term” while after 42 week they are considered “post term”. Delivery before 39 weeks by labor induction or caesarean section is not recommended unless required for other medical reasons.

About 213 million pregnancies occurred in 2012, of which, 190 million (89%) were in the developing world and 23 million (11%) were in the developed world. The number of pregnancies in women ages 15 to 44 is 133 per 1,000 women. About 10% to 15% of recognized pregnancies end in miscarriage. In 2016, complications of pregnancy resulted in 230,600 maternal deaths, down from 377,000 deaths in 1990. Common causes include bleeding, infections, hypertensive diseases of pregnancy, obstructed labor, and complications associated with miscarriage, ectopic pregnancy, or elective abortion. Globally, 44% of pregnancies are unplanned. Over half (56%) of unplanned pregnancies are aborted. Among unintended pregnancies in the United States, 60% of the women used birth control to some extent during the month pregnancy occurred.

Associated terms for pregnancy are gravid and parous. Gravidus and gravid come from the Latin word meaning “heavy” and a pregnant female is sometimes referred to as a gravida. Gravidity refers to the number of times that a female has been pregnant. Similarly, the term parity is used for the number of times that a female carries a pregnancy to a viable stage. Twins and other multiple births are counted as one pregnancy and birth. A woman who has never been pregnant is referred to as a nulligravida. A woman who is (or has been only) pregnant for the first time is referred to as a primigravida, and a woman in subsequent pregnancies as a multigravida or as multiparous. Therefore, during a second pregnancy a woman would be described as gravida 2, para 1 and upon live delivery as gravida 2, para 2. In-progress pregnancies, abortions, miscarriages and/or stillbirths account for parity values being less than the gravida number. In the case of a multiple birth the gravida number and parity value are increased by one only. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as nulliparous.

A pregnancy is considered term at 37 weeks of gestation. It is preterm if less than 37 weeks and postterm at or beyond 42 weeks of gestation. American College of Obstetricians and Gynecologists have recommended further division with early term 37 weeks up to 39 weeks, full term 39 weeks up to 41 weeks, and late term 41 weeks up to 42 weeks. The terms preterm and postterm have largely replaced earlier terms of premature and postmature. Preterm and postterm are defined above, whereas premature and postmature have historical meaning and relate more to the infant’s size and state of development rather than to the stage of pregnancy.

The usual symptoms and discomforts of pregnancy do not significantly interfere with activities of daily living or pose a health-threat to the mother or baby. However, pregnancy complications can cause other more severe symptoms, such as those associated with anemia.

Common symptoms and discomforts of pregnancy include:

The chronology of pregnancy is, unless otherwise specified, generally given as gestational age, where the starting point is the beginning of the woman’s last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. Sometimes, timing may also use the fertilization age which is the age of the embryo.

According to American Congress of Obstetricians and Gynecologists, the main methods to calculate gestational age are:

Pregnancy is divided into three trimesters, each lasting for approximately 3 months. The exact length of each trimester can vary between sources.

Due date estimation basically follows two steps:

Naegele’s rule is a standard way of calculating the due date for a pregnancy when assuming a gestational age of 280 days at childbirth. The rule estimates the expected date of delivery (EDD) by adding a year, subtracting three months, and adding seven days to the origin of gestational age. Alternatively there are mobile apps, which essentially always give consistent estimations compared to each other and correct for leap year, while pregnancy wheels made of paper can differ from each other by 7 days and generally do not correct for leap year.

Furthermore, actual childbirth has only a certain probability of occurring within the limits of the estimated due date. A study of singleton live births came to the result that childbirth has a standard deviation of 14 days when gestational age is estimated by first trimester ultrasound, and 16 days when estimated directly by last menstrual period.

Through an interplay of hormones that includes follicle stimulating hormone that stimulates folliculogenesis and oogenesis creates a mature egg cell, the female gamete. Fertilization is the event where the egg cell fuses with the male gamete, spermatozoon. After the point of fertilization, the fused product of the female and male gamete is referred to as a zygote or fertilized egg. The fusion of female and male gametes usually occurs following the act of sexual intercourse. Pregnancy rates for sexual intercourse are highest during the menstrual cycle time from some 5 days before until 1 to 2 days after ovulation. Fertilization can also occur by assisted reproductive technology such as artificial insemination and in vitro fertilisation.

Fertilization (conception) is sometimes used as the initiation of pregnancy, with the derived age being termed fertilization age. Fertilization usually occurs about two weeks before the next expected menstrual period.

A third point in time is also considered by some people to be the true beginning of a pregnancy: This is time of implantation, when the future fetus attaches to the lining of the uterus. This is about a week to ten days after fertilization.

The sperm and the egg cell, which has been released from one of the female’s two ovaries, unite in one of the two fallopian tubes. The fertilized egg, known as a zygote, then moves toward the uterus, a journey that can take up to a week to complete. Cell division begins approximately 24 to 36 hours after the female and male cells unite. Cell division continues at a rapid rate and the cells then develop into what is known as a blastocyst. The blastocyst arrives at the uterus and attaches to the uterine wall, a process known as implantation.

The development of the mass of cells that will become the infant is called embryogenesis during the first approximately ten weeks of gestation. During this time, cells begin to differentiate into the various body systems. The basic outlines of the organ, body, and nervous systems are established. By the end of the embryonic stage, the beginnings of features such as fingers, eyes, mouth, and ears become visible. Also during this time, there is development of structures important to the support of the embryo, including the placenta and umbilical cord. The placenta connects the developing embryo to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother’s blood supply. The umbilical cord is the connecting cord from the embryo or fetus to the placenta.

After about ten weeks of gestational age, the embryo becomes known as a fetus. At the beginning of the fetal stage, the risk of miscarriage decreases sharply. At this stage, a fetus is about 30 mm (1.2 inches) in length, the heartbeat is seen via ultrasound, and the fetus makes involuntary motions. During continued fetal development, the early body systems, and structures that were established in the embryonic stage continue to develop. Sex organs begin to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the last weeks of pregnancy.

Electrical brain activity is first detected between the fifth and sixth week of gestation. It is considered primitive neural activity rather than the beginning of conscious thought. Synapses begin forming at 17 weeks, and begin to multiply quickly at week 28 until 3 to 4 months after birth.

Although the fetus begins to move during the first trimester, it is not until the second trimester that movement, known as quickening, can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. It is common for some women not to feel the fetus move until much later. During the second trimester, most women begin to wear maternity clothes.

Embryo at 4 weeks after fertilization. (Gestational age of 6 weeks.)

Fetus at 8 weeks after fertilization. (Gestational age of 10 weeks.)

Fetus at 18 weeks after fertilization. (Gestational age of 20 weeks.)

Fetus at 38 weeks after fertilization. (Gestational age of 40 weeks.)

Relative size in 1st month (simplified illustration)

Relative size in 3rd month (simplified illustration)

Relative size in 5th month (simplified illustration)

Relative size in 9th month (simplified illustration)

During pregnancy, a woman undergoes many physiological changes, which are entirely normal, including behavioral, cardiovascular, hematologic, metabolic, renal, and respiratory changes. Increases in blood sugar, breathing, and cardiac output are all required. Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and therefore also the menstrual cycle. A full-term pregnancy at an early age reduces the risk of breast, ovarian and endometrial cancer and the risk declines further with each additional full-term pregnancy.

The fetus is genetically different from its mother, and can be viewed as an unusually successful allograft. The main reason for this success is increased immune tolerance during pregnancy. Immune tolerance is the concept that the body is able to not mount an immune system response against certain triggers.

During the first trimester, minute ventilation increases by 40%. The womb will grow to the size of a lemon by eight weeks. Many symptoms and discomforts of pregnancy like nausea and tender breasts appear in the first trimester.

During the second trimester, most women feel more energized, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. The uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy.

Final weight gain takes place during the third trimester, which is the most weight gain throughout the pregnancy. The woman’s abdomen will transform in shape as it drops due to the fetus turning in a downward position ready for birth. During the second trimester, the woman’s abdomen would have been upright, whereas in the third trimester it will drop down low. The fetus moves regularly, and is felt by the woman. Fetal movement can become strong and be disruptive to the woman. The woman’s navel will sometimes become convex, “popping” out, due to the expanding abdomen.

Head engagement, where the fetal head descends into cephalic presentation, relieves pressure on the upper abdomen with renewed ease in breathing. It also severely reduces bladder capacity, and increases pressure on the pelvic floor and the rectum.

It is also during the third trimester that maternal activity and sleep positions may affect fetal development due to restricted blood flow. For instance, the enlarged uterus may impede blood flow by compressing the vena cava when lying flat, which is relieved by lying on the left side.

Childbirth, referred to as labor and delivery in the medical field, is the process whereby an infant is born.

A woman is considered to be in labour when she begins experiencing regular uterine contractions, accompanied by changes of her cervix – primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours, while others find that concentrating on the birth helps to quicken labour and lessen the sensations. Most births are successful vaginal births, but sometimes complications arise and a woman may undergo a cesarean section.

During the time immediately after birth, both the mother and the baby are hormonally cued to bond, the mother through the release of oxytocin, a hormone also released during breastfeeding. Studies show that skin-to-skin contact between a mother and her newborn immediately after birth is beneficial for both the mother and baby. A review done by the World Health Organization found that skin-to-skin contact between mothers and babies after birth reduces crying, improves mother-infant interaction, and helps mothers to breastfeed successfully. They recommend that neonates be allowed to bond with the mother during their first two hours after birth, the period that they tend to be more alert than in the following hours of early life.

In the ideal childbirth labor begins on its own when a woman is “at term”.
Events before completion of 37 weeks are considered preterm. Preterm birth is associated with a range of complications and should be avoided if possible.

Sometimes if a woman’s water breaks or she has contractions before 39 weeks, birth is unavoidable. However, spontaneous birth after 37 weeks is considered term and is not associated with the same risks of a pre-term birth. Planned birth before 39 weeks by Caesarean section or labor induction, although “at term”, results in an increased risk of complications. This is from factors including underdeveloped lungs of newborns, infection due to underdeveloped immune system, feeding problems due to underdeveloped brain, and jaundice from underdeveloped liver.

Babies born between 39 and 41 weeks gestation have better outcomes than babies born either before or after this range. This special time period is called “full term”. Whenever possible, waiting for labor to begin on its own in this time period is best for the health of the mother and baby. The decision to perform an induction must be made after weighing the risks and benefits, but is safer after 39 weeks.

Events after 42 weeks are considered postterm. When a pregnancy exceeds 42 weeks, the risk of complications for both the woman and the fetus increases significantly. Therefore, in an otherwise uncomplicated pregnancy, obstetricians usually prefer to induce labour at some stage between 41 and 42 weeks.

The postnatal period, also referred to as the puerperium, begins immediately after delivery and extends for about six weeks. During this period, the mother’s body begins the return to pre-pregnancy conditions that includes changes in hormone levels and uterus size.

The beginning of pregnancy may be detected either based on symptoms by the woman herself, or by using pregnancy tests. However, an important condition with serious health implications that is quite common is the denial of pregnancy by the pregnant woman. About one in 475 denials will last until around the 20th week of pregnancy. The proportion of cases of denial, persisting until delivery is about 1 in 2500. Conversely, some non-pregnant women have a very strong belief that they are pregnant along with some of the physical changes. This condition is known as a false pregnancy.

Most pregnant women experience a number of symptoms, which can signify pregnancy. A number of early medical signs are associated with pregnancy. These signs include:

Pregnancy detection can be accomplished using one or more various pregnancy tests, which detect hormones generated by the newly formed placenta, serving as biomarkers of pregnancy. Blood and urine tests can detect pregnancy 12 days after implantation. Blood pregnancy tests are more sensitive than urine tests (giving fewer false negatives). Home pregnancy tests are urine tests, and normally detect a pregnancy 12 to 15 days after fertilization. A quantitative blood test can determine approximately the date the embryo was conceived because HCG doubles every 36 to 48 hours. A single test of progesterone levels can also help determine how likely a fetus will survive in those with a threatened miscarriage (bleeding in early pregnancy).

Obstetric ultrasonography can detect fetal abnormalities, detect multiple pregnancies, and improve gestational dating at 24 weeks. The resultant estimated gestational age and due date of the fetus are slightly more accurate than methods based on last menstrual period. Ultrasound is used to measure the nuchal fold in order to screen for Down syndrome.

Pre-conception counseling is care that is provided to a woman and/ or couple to discuss conception, pregnancy, current health issues and recommendations for the period before pregnancy.

Prenatal medical care is the medical and nursing care recommended for women during pregnancy, time intervals and exact goals of each visit differ by country. Women who are high risk have better outcomes if they are seen regularly and frequently by a medical professional than women who are low risk. A woman can be labeled as high risk for different reasons including previous complications in pregnancy, complications in the current pregnancy, current medical diseases, or social issues.

The aim of good prenatal care is prevention, early identification, and treatment of any medical complications. A basic prenatal visit consists of measurement of blood pressure, fundal height, weight and fetal heart rate, checking for symptoms of labor, and guidance for what to expect next.

Nutrition during pregnancy is important to ensure healthy growth of the fetus. Nutrition during pregnancy is different from the non-pregnant state. There are increased energy requirements and specific micronutrient requirements. Women benefit from education to encourage a balanced energy and protein intake during pregnancy. Some women may need professional medical advice if their diet is affected by medical conditions, food allergies, or specific religious/ ethical beliefs.

Adequate periconceptional (time before and right after conception) folic acid (also called folate or Vitamin B9) intake has been shown to decrease the risk of fetal neural tube defects, such as spina bifida. The neural tube develops during the first 28 days of pregnancy, a urine pregnancy test is not usually positive until 14 days post-conception, explaining the necessity to guarantee adequate folate intake before conception. Folate is abundant in green leafy vegetables, legumes, and citrus. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.

DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for the woman to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the woman through the placenta during pregnancy and in breast milk after birth.

Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is common. Women living in low and middle income countries are suggested to take multiple micronutrient supplements containing iron and folic acid. These supplements have been shown to improve birth outcomes in developing countries, but do not have an effect on perinatal mortality. Adequate intake of folic acid, and iron is often recommended. In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may also require supplementation. Vitamin E supplementation has not been shown to improve birth outcomes. Zinc supplementation has been associated with a decrease in preterm birth, but it is unclear whether it is causative. Daily iron supplementation reduces the risk of maternal anemia. Studies of routine daily iron supplementation for pregnant women found improvement in blood iron levels, without a clear clinical benefit. The nutritional needs for women carrying twins or triplets are higher than those of women carrying one baby.

Women are counseled to avoid certain foods, because of the possibility of contamination with bacteria or parasites that can cause illness. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Unpasteurized dairy and deli meats may contain Listeria, which can cause neonatal meningitis, stillbirth and miscarriage. Pregnant women are also more prone to Salmonella infections, can be in eggs and poultry, which should be thoroughly cooked. Cat feces and undercooked meats may contain the parasite Toxoplasma gondii and can cause toxoplasmosis. Practicing good hygiene in the kitchen can reduce these risks.

Women are also counseled to eat seafood in moderation and to eliminate seafood known to be high in mercury because of the risk of birth defects. Pregnant women are counseled to consume caffeine in moderation, because large amounts of caffeine are associated with miscarriage. However, the relationship between caffeine, birthweight, and preterm birth is unclear.

The amount of healthy weight gain during a pregnancy varies. Weight gain is related to the weight of the baby, the placenta, extra circulatory fluid, larger tissues, and fat and protein stores. Most needed weight gain occurs later in pregnancy.

The Institute of Medicine recommends an overall pregnancy weight gain for those of normal weight (body mass index of 18.5-24.9), of 11.3-15.9 kg (25-35 pounds) having a singleton pregnancy. Women who are underweight (BMI of less than 18.5), should gain between 12.7-18 kg (28-40 lbs), while those who are overweight (BMI of 25-29.9) are advised to gain between 6.8-11.3 kg (15-25 lbs) and those who are obese (BMI>30) should gain between 5-9 kg (11-20 lbs). These values reference the expectations for a term pregnancy.

During pregnancy, insufficient or excessive weight gain can compromise the health of the mother and fetus. The most effective intervention for weight gain in underweight women is not clear. Being or becoming overweight in pregnancy increases the risk of complications for mother and fetus, including cesarean section, gestational hypertension, pre-eclampsia, macrosomia and shoulder dystocia. Excessive weight gain can make losing weight after the pregnancy difficult.

Around 50% of women of childbearing age in developed countries like the United Kingdom are overweight or obese before pregnancy. Diet modification is the most effective way to reduce weight gain and associated risks in pregnancy.

Drugs used during pregnancy can have temporary or permanent effects on the fetus. Anything (including drugs) that can cause permanent deformities in the fetus are labeled as teratogens. In the U.S., drugs were classified into categories A, B, C, D and X based on the Food and Drug Administration (FDA) rating system to provide therapeutic guidance based on potential benefits and fetal risks. Drugs, including some multivitamins, that have demonstrated no fetal risks after controlled studies in humans are classified as Category A. On the other hand, drugs like thalidomide with proven fetal risks that outweigh all benefits are classified as Category X.

The use of recreational drugs in pregnancy can cause various pregnancy complications.

Intrauterine exposure to environmental toxins in pregnancy has the potential to cause adverse effects on prenatal development, and to cause pregnancy complications. Air pollution has been associated with low birth weight infants. Conditions of particular severity in pregnancy include mercury poisoning and lead poisoning. To minimize exposure to environmental toxins, the American College of Nurse-Midwives recommends: checking whether the home has lead paint, washing all fresh fruits and vegetables thoroughly and buying organic produce, and avoiding cleaning products labeled “toxic” or any product with a warning on the label.

Pregnant women can also be exposed to toxins in the workplace, including airborne particles. The effects of wearing N95 filtering facepiece respirators are similar for pregnant women as for non-pregnant women, and wearing a respirator for one hour does not affect the fetal heart rate.

Most women can continue to engage in sexual activity throughout pregnancy. Most research suggests that during pregnancy both sexual desire and frequency of sexual relations decrease. In context of this overall decrease in desire, some studies indicate a second-trimester increase, preceding a decrease during the third trimester.

Sex during pregnancy is a low-risk behavior except when the healthcare provider advises that sexual intercourse be avoided for particular medical reasons. For a healthy pregnant woman, there is no safe or right way to have sex during pregnancy. Pregnancy alters the vaginal flora with a reduction in microscopic species/genus diversity.

Regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness. Physical exercise during pregnancy does appear to decrease the need for C-section. Bed rest, outside of research studies, is not recommended as there is no evidence of benefit and potential harm.

The Clinical Practice Obstetrics Committee of Canada recommends that “All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy”. Although an upper level of safe exercise intensity has not been established, women who were regular exercisers before pregnancy and who have uncomplicated pregnancies should be able to engage in high intensity exercise programs. In general, participation in a wide range of recreational activities appears to be safe, with the avoidance of those with a high risk of falling such as horseback riding or skiing or those that carry a risk of abdominal trauma, such as soccer or hockey.

The American College of Obstetricians and Gynecologists reports that in the past, the main concerns of exercise in pregnancy were focused on the fetus and any potential maternal benefit was thought to be offset by potential risks to the fetus. However, they write that more recent information suggests that in the uncomplicated pregnancy, fetal injuries are highly unlikely. They do, however, list several circumstances when a woman should contact her health care provider before continuing with an exercise program: vaginal bleeding, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness, preterm labor, decreased fetal movement, amniotic fluid leakage, and calf pain or swelling (to rule out thrombophlebitis).

It has been suggested that shift work and exposure to bright light at night should be avoided at least during the last trimester of pregnancy to decrease the risk of psychological and behavioral problems in the newborn.

The increased levels of progesterone and estrogen during pregnancy make gingivitis more likely; the gums become edematous, red in colour, and tend to bleed. Also a pyogenic granuloma or “pregnancy tumor,” is commonly seen on the labial surface of the papilla. Lesions can be treated by local debridement or deep incision depending on their size, and by following adequate oral hygiene measures. There have been suggestions that severe periodontitis may increase the risk of having preterm birth and low birth weight, however, a Cochrane review found insufficient evidence to determine if periodontitis can develop adverse birth outcomes.

In low risk pregnancies, most health care providers approve flying until about 36 weeks of gestational age. Most airlines allow pregnant women to fly short distances at less than 36 weeks, and long distances at less than 32 weeks. Many airlines require a doctor’s note that approves flying, specially at over 28 weeks. During flights, the risk of deep vein thrombosis is decreased by getting up and walking occasionally, as well as by avoiding dehydration.

Full body scanners do not use ionizing radiation, and are safe in pregnancy. Airports can also possibly use backscatter X-ray scanners, which use a very low dose, but where safety in pregnancy is not fully established.

Each year, ill health as a result of pregnancy is experienced (sometimes permanently) by more than 20 million women around the world. In 2016, complications of pregnancy resulted in 230,600 deaths down from 377,000 deaths in 1990. Common causes include bleeding (72,000), infections (20,000), hypertensive diseases of pregnancy (32,000), obstructed labor (10,000), and pregnancy with abortive outcome (20,000), which includes miscarriage, ectopic pregnancy, and elective abortion.

The following are some examples of pregnancy complications:

There is also an increased susceptibility and severity of certain infections in pregnancy.

A pregnant woman may have intercurrent diseases, defined as disease not directly caused by the pregnancy, but that may become worse or be a potential risk to the pregnancy.

Medical imaging may be indicated in pregnancy because of pregnancy complications, intercurrent diseases or routine prenatal care. Medical ultrasonography (including obstetric ultrasonography) as well as magnetic resonance imaging (MRI) in pregnancy without MRI contrast agents are not associated with any risk for the mother or the fetus, and are the imaging techniques of choice for pregnant women. Projectional radiography, X-ray computed tomography and nuclear medicine imaging result in some degree of ionizing radiation exposure, but in most cases the absorbed doses are not associated with harm to the baby. At higher dosages, effects can include miscarriage, birth defects and intellectual disability.

About 213 million pregnancies occurred in 2012 of which 190 million were in the developing world and 23 million were in the developed world. This is about 133 pregnancies per 1,000 women between the ages of 15 and 44. About 10% to 15% of recognized pregnancies end in miscarriage. Globally, 44% of pregnancies are unplanned. Over half (56%) of unplanned pregnancies are aborted. In countries where abortion is prohibited, or only carried out in circumstances where the mother’s life is at risk, 48% of unplanned pregnancies are aborted illegally. Compared to the rate in countries where abortion is legal, at 69%.

Of pregnancies in 2012, 120 million occurred in Asia, 54 million in Africa, 19 million in Europe, 18 million in Latin America and the Caribbean, 7 million in North America, and 1 million in Oceania. Pregnancy rates are 140 per 1000 women of childbearing age in the developing world and 94 per 1000 in the developed world.

The rate of pregnancy, as well as the ages at which it occurs, differ by country and region. It is influenced by a number of factors, such as cultural, social and religious norms; access to contraception; and rates of education. The total fertility rate (TFR) in 2013 was estimated to be highest in Niger (7.03 children/woman) and lowest in Singapore (0.79 children/woman).

In Europe, the average childbearing age has been rising continuously for some time. In Western, Northern, and Southern Europe, first-time mothers are on average 26 to 29 years old, up from 23 to 25 years at the start of the 1970s. In a number of European countries (Spain), the mean age of women at first childbirth has crossed the 30-year threshold.

This process is not restricted to Europe. Asia, Japan and the United States are all seeing average age at first birth on the rise, and increasingly the process is spreading to countries in the developing world like China, Turkey and Iran. In the US, the average age of first childbirth was 25.4 in 2010.

In the United States and United Kingdom, 40% of pregnancies are unplanned, and between a quarter and half of those unplanned pregnancies were unwanted pregnancies.

In most cultures, pregnant women have a special status in society and receive particularly gentle care. At the same time, they are subject to expectations that may exert great psychological pressure, such as having to produce a son and heir. In many traditional societies, pregnancy must be preceded by marriage, on pain of ostracism of mother and (illegitimate) child.

Overall, pregnancy is accompanied by numerous customs that are often subject to ethnological research, often rooted in traditional medicine or religion. The baby shower is an example of a modern custom.

Pregnancy is an important topic in sociology of the family. The prospective child may preliminarily be placed into numerous social roles. The parents’ relationship and the relation between parents and their surroundings are also affected.

A belly cast may be made during pregnancy as a keepsake.

Images of pregnant women, especially small figurines, were made in traditional cultures in many places and periods, though it is rarely one of the most common types of image. These include ceramic figures from some Pre-Columbian cultures, and a few figures from most of the ancient Mediterranean cultures. Many of these seem to be connected with fertility. Identifying whether such figures are actually meant to show pregnancy is often a problem, as well as understanding their role in the culture concerned.

Among the oldest surviving examples of the depiction of pregnancy are prehistoric figurines found across much of Eurasia and collectively known as Venus figurines. Some of these appear to be pregnant.

Due to the important role of the Mother of God in Christianity, the Western visual arts have a long tradition of depictions of pregnancy, especially in the biblical scene of the Visitation, and devotional images called a Madonna del Parto.

The unhappy scene usually called Diana and Callisto, showing the moment of discovery of Callisto’s forbidden pregnancy, is sometimes painted from the Renaissance onwards. Gradually, portraits of pregnant women began to appear, with a particular fashion for “pregnancy portraits” in elite portraiture of the years around 1600.

Pregnancy, and especially pregnancy of unmarried women, is also an important motif in literature. Notable examples include Hardy’s Tess of the d’Urbervilles and Goethe’s Faust.

Anatomical model of a pregnant woman; Stephan Zick (1639-1715); 1700; Germanisches Nationalmuseum

Statue of a pregnant woman, Macedonia

Bronze figure of a pregnant naked woman by Danny Osborne, Merrion Square

Marcus Gheeraerts the Younger Portrait of Susanna Temple, second wife of Sir Martin Lister, 1620

Octave Tassaert, The Waif aka L’abandonnee 1852, Musee Fabre, Montpellier

Modern reproductive medicine offers many forms of assisted reproductive technology for couples who stay childless against their will, such as fertility medication, artificial insemination, in vitro fertilization and surrogacy.

An abortion is the termination of an embryo or fetus, either naturally or via medical methods. When done electively, it is more often done within the first trimester than the second, and rarely in the third. Not using contraception, contraceptive failure, poor family planning or rape can lead to undesired pregnancies. Legality of socially indicated abortions varies widely both internationally and through time. In most countries of Western Europe, abortions during the first trimester were a criminal offense a few decades ago[when?] but have since been legalized, sometimes subject to mandatory consultations. In Germany, for example, as of 2009 less than 3% of abortions had a medical indication.

Many countries have various legal regulations in place to protect pregnant women and their children. Maternity Protection Convention ensures that pregnant women are exempt from activities such as night shifts or carrying heavy stocks. Maternity leave typically provides paid leave from work during roughly the last trimester of pregnancy and for some time after birth. Notable extreme cases include Norway (8 months with full pay) and the United States (no paid leave at all except in some states). Moreover, many countries have laws against pregnancy discrimination.

In the United States, some actions that result in miscarriage or stillbirth are considered crimes. One law that does so is the federal Unborn Victims of Violence Act. In 2014, the American state of Tennessee passed a law which allows prosecutors to charge a woman with criminal assault if she uses illegal drugs during her pregnancy and her fetus or newborn is considered harmed as a result.

Nutrition and pregnancy


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Nutrition and pregnancy refers to the nutrient intake, and dietary planning that is undertaken before, during and after pregnancy. Nutrition of the fetus begins at conception. For this reason, the nutrition of the mother is important from before conception (probably several months before) as well as throughout pregnancy and breast feeding. An ever-increasing number of studies have shown that the nutrition of the mother will have an effect on the child, up to and including the risk for cancer, cardiovascular disease, hypertension and diabetes throughout life.

An inadequate or excessive amount of some nutrients may cause malformations or medical problems in the fetus, and neurological disorders and handicaps are a risk that is run by mothers who are malnourished. An estimated 24% of babies worldwide are born with lower than optimal weights at birth due to lack of proper nutrition. Personal habits such as consumption of alcohol or large amounts of caffeine can negatively and irreversibly affect the development of the baby, which happens in the early stages of pregnancy.

Caffeine consumption during pregnancy is associated with increased risk of pregnancy loss. The available research favors the notion that the benefits of fish consumption during pregnancy outweigh the risks; however, the type of fish is important. Folic acid, which is the synthetic form of the vitamin folate, is critical both in pre-and peri-conception.

As with most diets, there are chances of over-supplementing, however, as general advice, both state and medical recommendations are that mothers follow instructions listed on particular vitamin packaging as to the correct or recommended daily allowance (RDA). Daily prenatal use of iron substantially improves birth weight, potentially reducing the risk of Low birth weight.

The United States and the European Union have established vitamin and mineral recommendations for during pregnancy and lactation. The amounts in the table below are the higher of the two. The citations separately list recommendations for pregnancy and lactation. Recommendations (RDAs = Recommended Dietary Allowances and PRIs = Population Reference Intakes) are set higher than what has been determined to be average requirements so as to address women who have above average needs. For some nutrients there is not enough information to set a recommendation, so the term Adequate Intake (AI) is used based on what appears to be sufficient.

*Adequate Intake
†Not established. EU has not identified an AI for sodium or chloride, and does not consider chromium to be an essential mineral nutrient.

Multiple micronutrient supplements taken with iron and folic acid may improve birth outcomes for women in low income countries. These supplements reduce numbers of low birth weight babies, small for gestational age babies and stillbirths in women who may not have many micronutrients in their usual diets. Undernourished women can benefit from having dietary education sessions and, balanced energy and protein supplements. A review showed that dietary education increased the mother’s protein intake and helped the baby grow more inside the womb. The balanced protein and energy supplement lowered risk of stillbirth and small babies and increased weight gain for both the mother and baby. Although more research is needed into the longer term effects on the mothers’ and infants’ health, the short term effects look promising.

Supplementing one’s diet with foods rich in folic acid, fruits and dark green leafy vegetables helps to prevent neural tube birth defects in the fetus. In addition, prenatal vitamins typically contain increased amounts of folic acid, iodine, iron, vitamin A, vitamin D, zinc, and calcium over the amounts found in standard multi-vitamins. Zinc supplements have reduced preterm births by around 14% mainly in low income countries where zinc deficiency is common. However, the World Health Organisation does not routinely recommend zinc supplementation for all pregnant women.

For women with low calcium diets, there is low quality evidence to suggest that calcium supplementation during pregnancy may reduce the risk of preeclampsia. Low-quality evidence also suggests that calcium supplementation may reduce the risk of the mother having the baby before 37th week of pregnancy (preterm birth). The protective effect of calcium supplementation is not clear and there is not enough good quality to research to suggest best doses and timing of calcium supplementation.

Pregnant women are advised to pay attention to the foods they eat during pregnancy in order to reduce the risk of exposure to substances or bacteria that may be harmful to the developing fetus. This can include potentially harmful pathogens such as listeria, toxoplasmosis, and salmonella. Intake of large amounts of retinol has been linked to birth defects and abnormalities. Although seafood contains high levels of Omega-3 fatty acids which are beneficial for both mother and the baby, there is no consensus on consuming seafood during pregnancy. Pregnant women are advised to eat seafood in moderation.

During pregnancy, a woman’s mass increases by about 12 kg (26 lb). The European Food Safety Authority recommends an increase of 300 mL per day compared to the normal intake for non-pregnant women, taking the total adequate water intake (from food and fluids) to 2,300 mL, or approximately 1,850 mL/ day from fluids alone

A mother’s nutritional intake during pregnancy is believed to influence and possibly offer protective effects against the development of allergenic diseases and asthma in children. Maternal intake of vitamin D, vitamin E, and zinc have all been associated with a lower likelihood of wheezing in childhood, suggesting a protective effect. Additionally, maternal intake of omega-3 long chain polyunsaturated fatty acids (n-3 LC-PUFAs) has been associated with a reduced risk of development of eczema in childhood and reduced likelihood to for infants exhibit sensitivity to foods in the first year of life.

Caffeine consumption during pregnancy is associated with increased risk of pregnancy loss and increased risk of low birth weight, defined as below 2500 grams (5.5 pounds). The European Food Safety Authority and the American Congress of Obstetricians and Gynecologists concur that habitual caffeine consumption up to 200 mg per day by pregnant women does not give rise to safety concerns for the fetus. The United Kingdom Food Standards Agency had recommended that pregnant women should limit their caffeine intake to less than 300 mg of caffeine a day, but in 2009 revised that downward to less than 200 mg of caffeine a day.

Fetal alcohol spectrum disorders are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. The most severe form of the condition is known as fetal alcohol syndrome. Problems may include an abnormal appearance, short height, low body weight, small head size, poor coordination, low intelligence, behavior problems, hearing loss and vision problems. Those affected are more likely to have trouble in school, legal problems, participate in high-risk behaviors, and have trouble with alcohol and recreational drug use. Fetal alcohol syndrome usually occurs when a pregnant woman has more than four drinks per day. Milder symptoms have been found with two drinks per day during the early part of pregnancy. Evidence of harm from less than two drinks per day or 10 drinks per week is not clear.

The American Academy of Pediatrics established a conservative set of recommendations in 2015: “During pregnancy:no amount of alcohol intake should be considered safe; there is no safe trimester to drink alcohol; all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and binge drinking poses dose-related risk to the developing fetus.” The World Health Organization recommends that alcohol should be avoided entirely during pregnancy, given the relatively unknown effects of even small amounts of alcohol during pregnancy.

Fish consumption during pregnancy is encouraged by European, Australian, and American guidelines. The reason given is that fat-containing fish such as salmon and tuna contain eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These are termed long chain, omega-3, polyunsaturated fatty acids, and are considered as important for fetal neurodevelopment. Additionally, fish are good sources of vitamins A, D, and B12, as well as the mineral iodine.

Due to risks of heavy-metal toxicity on fetal neurodevelopment, many mothers are concerned about eating fish during pregnancy. Overall, current research favors the notion that the benefits of fish consumption during pregnancy outweigh the risks; however, the type of fish is important. Current research suggests that 2-3 servings of low-methylmercury containing fish per week in pregnancy is both safe and beneficial. Mercury accumulates in fish through their own diet (bioaccumulation). A general rule of thumb is that fish higher up on the food chain, and with longer life spans will contain higher levels of mercury. Fish lower on the food chain and with shorter life spans will have lower metal content. However, it is important to note that the bioaccumulation of metals in fish is also dependent on geographical location, so it is hard to make global recommendations on specific fish species. An alternative to consuming fish is to use fish oil dietary supplements containing both EPA and DHA, or algae-derived DHA-only oils. The New York Times reported on a laboratory evaluation of 30 popular fish oil supplements. Some of those had less than the label claimed amounts of DHA. As for safety, “All of the products tested contained only very low levels of mercury, ranging from one to six parts per billion per serving. That range is far below the upper safety limit of 100 parts per billion set by the Global Organization for EPA and DHA Omega-3s, an industry trade group.”

Folic acid, which is the synthetic form of the vitamin folate, is critical both in pre-and peri-conception. Deficiencies in folic acid may cause neural tube defects (NTDs). Women who had 0.4 mg of folic acid in their systems due to supplementing 3 months before childbirth significantly reduced the risk of NTDs. More than 80 countries use fortification of certain foods with folic acid as a measure to decrease the rate of NTDs.

The combination of vitamin E and vitamin C supplemented to pregnant women does not appear to be efficacious for reducing risk of stillbirth, neonatal death, preterm birth, preeclampsia or any other maternal or infant outcomes, either in healthy women or those considered at risk for pregnancy complications. Antioxidant vitamins as dietary supplements had been proposed as having benefits if consumed during pregnancy. For the combination of vitamin E with vitamin C supplemented to pregnant women, a Cochrane review of 21 clinical trials concluded that the data do not support vitamin E supplementation – majority of trials alpha-tocopherol at 400 IU/day plus vitamin C at 1000 mg/day – as being efficacious for reducing risk of stillbirth, neonatal death, preterm birth, preeclampsia or any other maternal or infant outcomes, either in healthy women or those considered at risk for pregnancy complications. The review identified only three small trials in which vitamin E was supplemented without co-supplementation with vitamin C. None of these trials reported any clinically meaningful information. A second Cochrane review of 29 trials, published same year, reported on the same combination trials but added analysis of trials with vitamin C alone. The conclusion was that the data do not support routine vitamin C supplementation alone or in combination with other supplements for the prevention of fetal or neonatal death, poor fetal growth, preterm birth or preeclampsia.

Proper nutrition is important after delivery to help the mother recover, and to provide enough food energy and nutrients for a woman to breastfeed her child. Women having serum ferritin less than 70 µg/L may need iron supplements to prevent iron deficiency anaemia during pregnancy and postpartum.

During lactation, water intake may need to be increased. Human milk is made of 88% water, and the IOM recommends that breastfeeding women increase their water intake by about 300 mL/day to a total volume of 3000 mL/day (from food and drink); approximately 2,400 mL/day from fluids.

A Look At The Best Workout Routines For Moms

fitness photoWhen it comes to the best workout routines for moms, there are quite a few options. In this article, we will look at these workout routines that will undoubtedly help you to lose any of that extra fat that comes with pregnancy or just being a busy mom. Many of the best workouts are ones that be done in 15 – 45 minutes since most moms don’t have much time to workout. However, don’t think that you need to work out for hours in order to get your dream body. Once you properly use the time you have available and watch your diet, you will achieve your fitness and body goals.

Now, one of the best type of workout routines is HIIT cardio. This basically means high intensity interval training where you train a particular exercise at high intensity for a small period of time, followed by rest that is no more than double that time. For example, if you’re doing a jumping jack HIIT routine, then you can do jumping jacks for 30 seconds followed by 30 seconds of rest. After the rest period is complete, you can do another 30 seconds of jumping jacks and then rest again for the same period. You can then repeat this exercise for as long as you like, however, the optimal time range for HIIT is between 15 and 45 minutes. You will be able to burn tons of calories and lose weight as quickly as possible. However, it is advisable that you don’t do HIIT more than 4 times per week.
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Another great workout routine for moms is Zumba. This is basically an aerobic exercise, however, it is targeted to people that aren’t very fit or simply don’t like exercising. I don’t know about you, but exercising isn’t my favorite thing to do! As a result, Zumba is a great option for the mom that wants to ease back into exercising or just wants to have fun while doing so. Zumba classes are basically aerobic dance classes and it is a good activity to do with your friends or you can even make new friends in most Zumba classes.

In summary, we have just looked at the best workout routines for moms. Sure, working out is tough, but it can be done. Once you start and make it a part of your daily life, you will become accustomed and even look forward to your workout as a source of stress relief. Once you are consistent in your efforts, you will soon see a difference in how you look and feel.