The entire body participates in the changes brought about by pregnancy. The hips and breasts become fuller, the back broadens, and the woman puts on fat. She becomes mature in appearance, but, of course, the phenomena connected with alterations in the breasts and genitals are most important, and late in pregnancy, most conspicuous.

The uterus exhibits the most marked alteration. From an organ that weighs two ounces, it becomes the largest in the body, and increases in size from two and one-half or three inches to fifteen inches. The typical pear-shape becomes spheroidal near the end of the third month, becomes pyriform again at the fifth month, and continues thus until term.

Up to the fourth month the walls become thicker, heavier and more muscular, but as pregnancy advances, more and more tissue is demanded, until at the end, a muscle wall of only moderate thickness protects the ovum. Meanwhile the muscular functions of contractibility and irritability are greatly increased.

At the fourth month the womb, which has occupied a position of anteversion against the bladder, rises out of the pelvis. It is now an abdominal organ and as it gets heavier and heavier, it rests a certain amount of its bulk on the brim of the pelvis. About the sixth month, the uppermost part of the uterus (fundus) is at the level of the umbilicus. At the eighth month, the fundus is found a little more than midway between the umbilicus and the ensiform cartilage. About two weeks before term, it reaches its highest point, the ensiform cartilage, and then sometimes sinks a little lower in the abdomen.

The ovum, or egg, does not completely fill the uterine cavity at first, but grows from its side like a fungus until the third month. Then the uterine cavity is entirely occupied and thereafter the egg and the uterus develop at an equal rate. As the uterus rises in the abdomen, it rotates to one side, usually the right, forward on its vertical axis.

The blood vessels and lymphatics also increase in size, number, and tortuosity. Many of the veins become sinuses as large as the little finger. This increased amount of fluid both within and without the uterus has a marked effect upon its consistency. The walls of the uterus, vagina, and cervix become softened, infiltrated and more distensible. There is also an increase in size and in number of the muscle cells.

During pregnancy the uterine muscle exhibits a definite functional activity. Intermittent contractions occur, feeble at first, but growing markedly stronger as pregnancy advances. These are the contractions of Braxton Hicks. They are irregular and painless, but can be felt by the examining hand. At term they merge into, and are lost in, the regular, painful contractions of labor.

The breasts can not be said to be fully developed until lactation has occurred, nevertheless, the glands show pronounced changes as a result of marriage and pregnancy.

The size of the gland, as well as the size and appearance of the nipple and areola, varies greatly in different women; but under the stimulation of pregnancy the whole gland enlarges, including the connective tissue stroma.

About the fourth month a pale yellow secretion can be squeezed from the nipple. This is called colostrum. The pigmentation extends over a wider area and deepens in color, while the increased vascularity is shown by the appearance of the blue veins under the thin tender skin. Light pinkish lines sometimes radiate from the nipple. These are striÆ and are more evident in blondes.

The milk comes into the breasts about the third day after labor, and normally continues to flow for six, to ten or twelve months.

Why the pregnancy and labor induce such marked mammary activity is not known, but the fact is patent.

The skin reacts both mechanically and biologically to the stimulus of pregnancy.

StriÆ Gravidarum.—StriÆ gravidarum appear on the abdomen similar to those observed on the breasts and are due to the same cause—mechanical stretching. When fresh, they are pinkish in color and variable in length and breadth, but attain the greatest size below the umbilicus. Occasionally they extend to the thighs and buttocks.

After labor, they become pale, silvery, and scar-like and are called linea albicantes. They are sometimes found in other conditions than pregnancy, such as tumors or ascites.

Increased Pigmentation.—Pigmentation is not limited to the breasts. On the abdomen, a dark line will appear between the umbilicus and the pubes. This is the linea nigra, and it becomes most conspicuous in the latter half of pregnancy. In the groins, the axillÆ, and over the genitals, the deposit is common, and sometimes patches appear on the face, either discrete or in coalescence, to form a continuous discoloration, called chloasma; or when extensive, the “mask of pregnancy.” The pigmentation is absorbed, or at least greatly diminished, after labor. The sebaceous and sweat glands are more active.

The hair may fall out and the teeth decay. “With every child a tooth,” is the cry of tradition. These changes are due to imperfect nutrition, or to the presence of toxins in the circulation.

Eruptions of an erythematous, eczematous, papular or pustular type are not uncommon; and itching, either local or general, may make life miserable.

The blood undergoes certain modifications that are fairly constant. The total amount is increased, but the quality is poorer, especially by an increase in water and white cells and a diminution of red cells. The amount of calcium is slightly increased and the fibrin is diminished up to the sixth month, when it rises to normal again at term.

The heart is slightly hypertrophied on the right side and blood pressure somewhat raised. A marked increase in blood pressure is suggestive of eclampsia.

The thyroid gland enlarges frequently, both as a consequence of menstrual irritation and of pregnancy. Goiters may show an increase of development, which remains after labor.

The urine is diminished in amount, but increased in frequency of evacuation. The bladder is more irritable during the first and last months, and micturition may be painful and unsatisfactory. The kidneys must be watched carefully during gestation.

The nervous system is disordered in most women, but especially in those of neurotic tendencies.

Irritability, insomnia, neuralgia of face or teeth, or perversion of appetite in the so-called “longings” are the more common manifestations.

Cramps occur in the muscles of the legs, owing to varicose veins or pressure upon the lumbar and sacral plexus of nerves.

The lungs are crowded by the growing uterus and the respiration interfered with.

The liver is enlarged, but functionally it is less competent, and constipation is common.

It is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of foetal activity, which is more or less toxic in character. The more pronounced effects of this toxin will be studied under the abnormal conditions of pregnancy.

Generally, if the pregnancy is normal, the whole body responds to the stimulating influence. After the nausea and vomiting of the early months subside, the woman feels energetic and ambitious. She is eager to do something at all times and feels fatigue but slightly. Music, literature or housework engages her attention and is zealously and joyfully practiced. The world seems bright and the thought of her labor does not bring solicitude, but pleasant anticipations. The body fills out in all directions and the woman takes on the appearance of maturity.

DIAGNOSIS OF PREGNANCY

The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces.

During the second half of the period the foetus can be made out distinctly by palpation, or by its movements, and the heart tones observed by auscultation.

During the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician.

It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhoea, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable.

Amenorrhoea.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of hÆmorrhage. Sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of pregnancy. Why a developing ovum causes an immediate arrest of menstruation is not understood.

Amenorrhoea may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhoea affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later.

Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on rising or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of extreme severity (hyperemesis) and will be discussed elsewhere.

The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accompanied by morning sickness, but with it the tongue is furred.

Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irritability may be much relieved by putting the patient in the knee-chest position night and morning.

Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at menstrual periods in nervous women. Tingling, pricking and shooting sensations may also be noted.

Enlargement of the abdomen is only noticeable toward the latter part of the first half, when the uterus rises out of the abdomen.

Quickening means “coming to life,” and refers to the first movements of the foetus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth week of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening.

The movements are important in the second half as indicating that the child is alive.

Physical Signs.—During the first weeks no conclusive changes occur that can be detected by examination, and unless conditions are especially favorable, the earliest time for the definite diagnosis of pregnancy is the eighth week. Previous to this it is presumptive only.

At the eighth week, the breasts may show enlargement and tenderness, with some secretion. In the multipara, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids).

Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness.

Softening of the lips of the os (Goodell’s sign) may be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips.

The increased size and globular shape must also be considered as confirmatory.

Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value.

At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhoea, morning sickness, irritability of bladder, slight breast changes in primiparas, lips of os externum softened, uterine body enlarged, softened, and nearly globular in shape, and Hegar’s sign.

Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the formation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and when it is worked out, it will be of immense value not alone in early uterine pregnancies, but in extrauterine pregnancy. This view very properly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth week to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy.

Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhoea remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is due to the congestion and is called Jacquemins’ sign.

Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement.

The contractions of Braxton Hicks now become more easily palpable.

Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the foetus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the foetus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be regarded as a positive sign.

During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdominal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnoea, and palpitations.

Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hypertrophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the umbilicus.

Spontaneous foetal movements appear and may be felt by the palpating hand.

Auscultation reveals the uterine souffle and the foetal heart sounds. The heart sounds and the foetal movements, when obtained by the observer, are positive signs.

Uterine souffle is a soft, blowing murmur, synchronous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus.

The foetal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valuable information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more distinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The foetal heart tones have no significance as an indication of sex.

Funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope. It is synchronous with the foetal heart tones, but of no great practical importance when the heart tones can be obtained.

Determination of the period to which pregnancy has advanced is sometimes important. This can be approximated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but it is not often required.

A method of estimation in gross, that is approximately correct, in many cases depends on the observation of the steady growth of the womb.

Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening.