The occurrence of the common danger symptoms that can be felt or noticed by the pregnant woman vary in their timing in relation to the gestational age.
What is meant by the first, second and third trimester of pregnancy?
Trimester means 'three month period'. The first trimester is the first 3 months of the pregnancy (i.e. from conception to the 14th completed week of gestation, measured from the woman's last normal menstrual period or LNMP); the second trimester is from 3-6 months (i.e. from 15 to 27 completed weeks); and the third trimester is the final 3 months of pregnancy (i.e. from 28 weeks to delivery at up to 42 weeks).
You have already learnt about the assessment of some pregnancy-related and medical problems by taking the woman's history and doing a physical examination (recall Study Sessions 8 and 9). However, you can only detect health risks to the mother or to the baby during the routine antenatal checkups, so it is very important to help the mother detect any symptoms by herself and know when to come to you quickly.
First, you have to know very well the timing of occurrence of common pregnancy-related or other medical problems, taking the gestational age as the milestones (see Table 15.1). Secondly, you have to be selective not to overwhelm the pregnant mother with too much information at a time. Thirdly, remember that counselling is not a one-time business - you should be prepared to repeat the messages about danger symptoms at every visit and check that the woman has understood correctly.
You already know about some of the conditions listed in Table 15.1 (e.g. ectopic and molar pregnancy). Later in this Module, you will learn in detail about the other common causes of maternal and fetal mortality and morbidity during pregnancy: hyperemesis gravidarum was in Study Session 12; premature rupture of membranes (PROM) is in Study Session 17; malaria, anaemia and urinary tract infections are covered in Study Session 18; hypertensive disorders of pregnancy are in Study Session 19; and spontaneous and induced abortion and vaginal bleeding in early and late pregnancy are in Study Sessions 20 and 21 respectively.
On and off lower abdominal pain alone is very common in early pregnancy and is not a danger symptom on its own.
Table 15.1 Danger symptoms during pregnancy.
Symptoms the mother experiences
(terms in italics are the most important)
|She may have this medical condition|
|Conception to 20 weeks of pregnancy|
|Persistent vomiting, weight loss||Hyperemesis gravidarum
Characterised by persistent vomiting, weight loss of 5 kg and above, urine analysis shows ketones 2+ or more (You learnt about this in Study Session 12; how to do the urine analysis is in Study Session 19)
|Vaginal bleeding (fresh), may include passage of clots and fleshy material, with crampy lower abdominal pain||Abortion (acute)
All types of spontaneous abortions except missed abortion are acute 'sudden' events (You will learn about abortions in Study Session 20)
|Pregnancy symptoms disappear, abdomen is not growing or is even decreasing in size, there may be minimal dark vaginal bleeding||Missed abortion
When the fetus or fetal tissue is entirely in the uterus, but it has no signs of life and the cervix is completely closed
|Vaginal bleeding (menstrual-like), lower abdominal pain, missed or irregular period||Ectopic pregnancy
(covered in Study Sessions 5 and 12)
|Vaginal bleeding (fresh), passage of tissues which look like an ice spoiled with blood (grape-like tissues), fast abdominal growth||Molar pregnancy
(covered in Study Sessions 10 and 20)
|20 weeks to full term pregnancy|
|Headache, burning epigastric pain (Figure 15.4), blurred vision, generalised body swelling (involving the back, abdominal wall, hands and face), decreased urine output||
Hypertensive disorders of pregnancy
(pre-eclampsia and eclampsia were introduced in Study Sessions 8 and 9; you will learn more in Study Session 19)
|Vaginal bleeding in late pregnancy, even a minimal amount||Late abortion (20-27 weeks) or antepartum haemorrhage (28 weeks +) (You will learn more in Study Session 20)|
|Leakage of watery fluid from the vagina that wets her underwear significantly and may be extensive||Premature rupture of membranes (PROM)
(You will learn about PROM in Study Session 17)
|Progressively increasing pushing down pain in the lower abdomen before 9 months of gestation||Preterm labour
(This is covered in the Module on Labour and Delivery Care)
|No change in abdominal growth, fetal kick felt less than 10 times in 12 hours. (Any number of fetal kicks felt in one minute is counted as one kick)||Intrauterine fetal growth restriction (IUGR) (Briefly mentioned in Study Session 7)|
|Absent fetal kick for more than 6 hours||Intrauterine fetal death (IUFD)|
|At any time during pregnancy|
|Fever, headache, chills, rigor, sweating, feels thirsty, generalised aching pain, lost appetite||Malaria, typhoid fever, typhus fever or relapsing fever
(You will learn about these infections in the Module on Communicable Diseases)
|Urination becomes painful, frequent, urgent and may be bloody or look like pus||Urinary tract infections (UTIs, cystitis or urethritis)
(You will learn about UTIs in Study Session 18)
|Pain in the sides (flanks), fever, vomiting, bloody urine, urgency and frequency in urination||Acute pyelonephritis
(Figure 15.5 shows the specific area in the kidney where this infection can occur)
|Yellowish discolouration of the eyes, loss of appetite, hate spicy food smell, feels exhausted, nausea and vomiting||Liver disease|
|Thirsty, drinks excessive amounts of water, urinates a lot, feels hungry, weight loss||Diabetes mellitus|
|Persistent cough||Lung and heart disease|
Table 15.1 is a detailed summary for you to study as a healthcare provider. It would not be appropriate or useful to show it to pregnant women during antenatal visits.
Can you suggest why not?
The table uses medical language that the woman is unlikely to understand (unless she is also a health worker), and it may overwhelm her with too much information all at once and make her anxious to see so many potential risks to herself and her baby.
Table 15.2 is a simplified summary in two parts, which can be shared with pregnant women at the appropriate stage of gestation. Women in the basic component of the focused antenatal care (FANC) programme, described in Study Session 13, should be seen for the first antenatal visit before 16 weeks of gestation if possible, and for the second visit at 20-24 weeks. Make sure every woman knows the common danger symptoms that are more likely to occur at each stage.
Table 15.2 Danger symptoms all pregnant women should know.
|In all visits before 20 weeks||In all visits after 20 weeks|
No change in abdominal growth
Burning epigastric pain (see Figure 15.4)
Leakage of fluid
No change in abdominal growth