Pregnancy-7

Management


See also: Prenatal care

Prenatal medical care is of recognized value throughout the developed world. Periconceptional folic acid supplementation is the only type of supplementation of proven efficacy.[citation needed]

Nutrition

Main article: Nutrition and pregnancy

A balanced, nutritious diet is an important aspect of a healthy pregnancy. Eating a healthy diet, balancing carbohydrates, fat, and proteins, and eating a variety of fruits and vegetables, usually ensures good nutrition. Those whose diets are affected by health issues, religious requirements, or ethical beliefs may choose to consult a health professional for specific advice.

Adequate periconceptional folic acid (also called folate or Vitamin B9) intake has been proven to limit fetal neural tube defects, preventing spina bifida, a very serious birth defect. The neural tube develops during the first 28 days of pregnancy, explaining the necessity to guarantee adequate periconceptional folate intake. Folates (from folia, leaf) are abundant in spinach (fresh, frozen, or canned), and are also found in green vegetables, salads, citrus fruit and melon, chickpeas (i.e. in the form of hummus or falafel), and eggs. 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 a mother 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 mother 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 prevalent.[46] In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may require supplementation.

Dangerous bacteria or parasites may contaminate foods, particularly listeria and toxoplasma, toxoplasmosis agent. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Soft cheeses may contain listeria; if milk is raw the risk may increase. Cat feces pose a particular risk of toxoplasmosis. Pregnant women are also more prone to catching salmonella infections from eggs and poultry, which should be thoroughly cooked. Practicing good hygiene in the kitchen can reduce these risks.
Weight gain

Caloric intake must be increased to ensure proper development of the fetus. The amount of weight gained during pregnancy varies among women. The National Health Service recommends that overall weight gain during the 9 month period for women who start pregnancy with normal weight be 10 to 12 kilograms (22–26 lb). During pregnancy, insufficient weight gain can compromise the health of the fetus. Likewise, excessive weight gain can pose risks to the woman and the fetus. Women who are prone to being overweight may choose to plan a healthy diet and exercise to help moderate the amount of weight gained.

Immune tolerance

Main article: Immune tolerance in pregnancy

The fetus inside a mother may be viewed as an unusually successful allograft, since it genetically differs from the mother. In the same way, many cases of spontaneous abortion may be described in the same way as maternal transplant rejection.

Drugs in pregnancy

Main article: Drugs in pregnancy

Drugs used during pregnancy can have temporary or permanent effects on the fetus. Therefore many physicians would prefer not to prescribe for pregnant women, the major concern being over teratogenicity of the drugs. This results in inappropriate treatment of pregnant women. Use of drugs in pregnancy is not always wrong. For example, high fever is harmful for the fetus in the early months. Use of paracetamol is better than no treatment at all. Also, diabetes mellitus during pregnancy may need intensive therapy with insulin. Drugs have been 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 like 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.

Exposure to toxins

Various toxins pose a significant hazard to fetuses during development:

Alcohol ingestion during pregnancy may cause fetal alcohol syndrome, a permanent and often devastating birth-defect syndrome. A number of studies have shown that light to moderate drinking during pregnancy might not pose a risk to the fetus, although no amount of alcohol during pregnancy can be guaranteed to be absolutely safe.

Women who have suffered mercury poisoning in pregnancy have sometimes given birth to children with serious birth defects, termed Minamata disease.

Sexual activity during pregnancy

Most pregnant women can enjoy sexual activity during pregnancy throughout gravidity. Most research suggests that, during pregnancy, both sexual desire and frequency of sexual relations decrease.[57][58] In context of this overall decrease in desire, some studies indicate a second-trimester increase, preceding a decrease. However, these decreases are not universal: a significant number of women report greater sexual satisfaction throughout their pregnancies.

Abortion

Main article: Abortion

An abortion is the removal or expulsion of an embryo or fetus from the uterus, resulting in or caused by its death. This can occur spontaneously or accidentally as with a miscarriage, or be artificially induced by medical, surgical or other means

Pregnancy-6

Physiological changes in pregnancy

The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required.[citation needed]

Hormonal changes

Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The woman and the placenta also produce many hormones.

Prolactin levels increase due to maternal Pituitary gland enlargement by 50%. This mediates a change in the structure of the Mammary gland from ductal to lobular-alveolar. Parathyroid hormone is increased which leads to increases of calcium uptake in the gut and reabsorption by the kidney. Adrenal hormones such as cortisol and aldosterone also increase.

Placental lactogen is produced by the placenta and stimulates lipolysis and fatty acid metabolism by the woman, conserving blood glucose for use by the fetus. It can also decrease maternal tissue sensitivity to insulin, resulting in gestational diabetes.[citation needed]

Musculoskeletal changes

The body's posture changes as the pregnancy progresses. The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the fetus grows. These muscles are less able to contract and keep the lower back in proper alignment. The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture. On average, a woman's foot can grow by a half size or more during pregnancy. In addition, the increased body weight of pregnancy, fluid retention, and weight gain lowers the arches of the foot, further adding to the foot's length and width. The influences of increased hormones such as estrogen and relaxin initiate the remodeling of soft tissues, cartilage and ligaments. Certain skeletal joints such as the symphysis pubis and sacroiliac widen or have increased laxity.[citation needed]

Physical changes

One of the most noticeable alterations in pregnancy is the gain in weight. The enlarging uterus, the growing fetus, the placenta and liquor amnii, the acquisition of fat and water retention, all contribute to this increase in weight. The weight gain varies from person to person and can be anywhere from 5 pounds (2.3 kg) to over 100 pounds (45 kg). In America, the doctor-recommended weight gain range is 25 pounds (11 kg) to 35 pounds (16 kg), less if the woman is overweight, more (up to 40 pounds (18 kg)) if the woman is underweight.

Other physical changes during pregnancy include breasts increasing two cup sizes. Also areas of the body such as the forehead and cheeks (known as the 'mask of pregnancy') become darker due to the increase of melanin being produced.

Illustration of fundal height at various points during pregnancy

Cardiovascular changes

Blood volume increases by 40% in the first two trimesters. This is due to an increase in plasma volume through increased aldosterone. Progesterone may also interact with the aldosterone receptor, thus leading to increased levels. Red blood cell numbers increase due to increased erythropoietin levels.

Cardiac function is also modified, with increased heart rate and increased stroke volume. A decrease in vagal tone and increase in sympathetic tone is the cause. Blood volume increases act to increase stroke volume of the heart via Starling's law. After pregnancy the change in stroke volume is not reversed. Cardiac output rises from 4 to 7 liters in the 2nd trimester.

Blood pressure also fluctuates. In the first trimester it falls. Initially this is due to decreased sensitivity to angiotensin and vasodilation provoked by increased blood volume. Later, however, it is caused by decreased resistance to the growing uteroplacental bed.[citation needed]

Respiratory changes

The partial pressure of oxygen in arterial blood (PaO2) increases slightly and that of carbon dioxide (PaCO2) decreases during pregnancy. The resulting effects on blood pH are compensated for by increased excretion of bicarbonate via the urine, maintaining a normal acid-base balance.[41]

Progesterone may act centrally on chemoreceptors to reset the set point to a lower partial pressure of carbon dioxide. This maintains an increased respiration rate even at a decreased level of carbon dioxide.[41]

Decreased functional residual capacity is seen, typically falling from 1.7 to 1.35 litres,[citation needed] due to the compression of the diaphragm by the uterus. Tidal volume increases, from 0.45 to 0.65 litres,[citation needed] giving an increase in pulmonary ventilation. This is necessary to meet the increased oxygen requirement of the body, which reaches 50 mL/min, 20 mL of which goes to reproductive tissues. Overall, the net change in maximum breathing capacity is zero.[41]

Dyspnea (shortness of breath) is a symptom reported by the majority of women at some point during pregnancy. It typically begins during the first or second trimester, before chest volume is significantly restricted by growth of the uterus, so decreased lung capacity is not the primary cause. Possible factors include slightly decreased PaCO2 and the effects of progesterone on respiration, as well as the woman's subjective interpretation of increased respiratory rate in pregnancy.[41]

Metabolic changes

An increased requirement for nutrients is given by fetal growth and fat deposition. Changes are caused by steroid hormones, lactogen, and cortisol.

Maternal insulin resistance can lead to gestational diabetes. Increased liver metabolism is also seen, with increased gluconeogenesis to increase maternal glucose levels.[citation needed]

Renal changes

Renal plasma flow increases, as does aldosterone and erthropoietin production as discussed. The tubular maximum for glucose is reduced, which may precipitate gestational diabetes.[citation needed]

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Prenatal development and sonograph images

See also: Prenatal development

Prenatal development is divided into two primary biological stages. The first is the embryonic stage, which lasts for about two months. At this point, the fetal stage begins. At the beginning of the fetal stage, the risk of miscarriage decreases sharply, all major structures including hands, feet, head, brain, and other organs are present, and they continue to grow and develop. When the fetal stage commences, a fetus is typically about 30 mm (1.2 inches) in length, and the heart can be seen beating via sonograph; the fetus bends the head, and also makes general movements and startles that involve the whole body. Some fingerprint formation occurs from the beginning of the fetal stage.

Electrical brain activity is first detected between the 5th and 6th week of gestation, though this is still considered primitive neural activity rather than the beginning of conscious thought, something that develops much later in fetation. Synapses begin forming at 17 weeks, and at about week 28 begin multiply at a rapid pace which continues until 3–4 months after birth. It isn't until week 23 that the fetus can survive, albeit with major medical support, outside of the womb. It is not until then that the fetus possesses a sustainable human brain.

Embryo at 4 weeks after fertilization

Fetus at 8 weeks after fertilization

Fetus at 18 weeks after fertilization

Fetus at 38 weeks after fertilization

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)

One way to observe prenatal development is via ultrasound images. Modern 3D ultrasound images provide greater detail for prenatal diagnosis than the older 2D ultrasound technology.[37] While 3D is popular with parents desiring a prenatal photograph as a keepsake,[38] both 2D and 3D are discouraged by the FDA for non-medical use,[39] but there are no definitive studies linking ultrasound to any adverse medical effects.[40] The following 3D ultrasound images were taken at different stages of pregnancy:

75-mm fetus (about 14 weeks gestational age)

Fetus at 17 weeks

Fetus at 20 weeks

Some people are confused about the differences between an ultrasound and a sonogram. An ultrasound is the actual machine that lets you observe pregnancy. A sonogram is the image of the baby that the ultrasound produces. 4D Ultrasounds take 3D sonograms. Some people refer to the procedure as prenatal imaging, 3D imaging, a 3D scan, or 4D scan.

Pregnancy-4

Physiology

The term trimester redirects here. For the term trimester used in academic settings, see Academic term

Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.

First trimester

Traditionally, doctors have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implantation and chemical detection. In medicine, pregnancy is often defined as beginning when the developing embryo becomes implanted into the endometrial lining of a woman's uterus. In some cases where complications may have arisen, the fertilized egg might implant itself in the fallopian tubes or the cervix, causing an ectopic pregnancy. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding at implantation. Some women will also experience cramping during their first trimester. This is usually of no concern unless there is spotting or bleeding as well. After implantation the uterine endometrium is called the decidua. The placenta, which is formed partly from the decidua and partly from outer layers of the embryo, is responsible for transport of nutrients and oxygen to, and removal of waste products from the fetus. The umbilical cord is the connecting cord from the embryo or fetus to the placenta.The developing embryo undergoes tremendous growth and changes during the process of fetal development.

Morning sickness occurs in about seventy percent of all pregnant women and typically improves after the first trimester.

In the first 12 weeks of pregnancy the nipples and areolas darken due to a temporary increase in hormones.

Most miscarriages occur during this period.[citation needed]

Second trimester

Months 4 through 6 of the pregnancy are called the second trimester. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away.

In the 20th week the uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy. Although the fetus begins to move and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to 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. However, it is not uncommon for some women not to feel the fetus move until much later. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproductive organs distinguish the fetus as male or female.

Third trimester

Comparison of growth of the abdomen between 26 weeks and 40 weeks gestation.Final weight gain takes place, which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28g per day. The woman's belly will transform in shape as the belly drops due to the fetus turning in a downward position ready for birth. During the second trimester, the woman's belly would have been very upright, whereas in the third trimester it will drop down quite low, and the woman will be able to lift her belly up and down. The fetus begins to move regularly, and is felt by the woman. Fetal movement can become quite strong and be disruptive to the woman. The woman's navel will sometimes become convex, "popping" out, due to her expanding abdomen. This period of her pregnancy can be uncomfortable, causing symptoms like weak bladder control and back-ache. Movement of the fetus becomes stronger and more frequent and via improved brain, eye, and muscle function the fetus is prepared for ex utero viability. The woman can feel the fetus "rolling" and it may cause pain or discomfort when it is near the woman's ribs and spine.

There is head engagement in the third trimester, that is, the fetal head descends into the pelvic cavity so that only a small part (or nothing) of it can be felt abdominally.

It is during this time that a baby born prematurely may survive. The use of modern medical intensive care technology has greatly increased the probability of premature babies surviving, and has pushed back the boundary of viability to much earlier dates than would be possible without assistance. In spite of these developments, premature birth remains a major threat to the fetus, and may result in ill-health in later life, even if the baby survives.

Pregnancy-3

Diagnosis

Main article: Obstetrics

The beginning of pregnancy may be detected in a number of different ways, either by a pregnant woman without medical testing, or by using medical tests with or without the assistance of a medical professional.

Most pregnant women experience a number of symptoms, which can signify pregnancy. The symptoms can include nausea and vomiting, excessive tiredness and fatigue, craving for certain foods not normally considered a favorite, and frequent urination particularly during the night.

A number of early medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained for over 2 weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the uterus isthmus), and pigmentation of linea alba - Linea nigra, (darkening of the skin in a midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy).

Pregnancy detection can be accomplished using one or more of various pregnancy tests, which detect hormones generated by the newly formed placenta. Clinical blood and urine tests can detect pregnancy 12 days after implantation , which is as early as 6 to 8 days after fertilization. Blood pregnancy tests are more accurate than urine tests. Home pregnancy tests are personal urine tests, which normally cannot detect a pregnancy until at least 12 to 15 days after fertilization. Both clinical and home tests can only detect the state of pregnancy, and cannot detect the age of the embryo.

In the post-implantation phase, the blastocyst secretes a hormone named human chorionic gonadotropin, which in turn stimulates the corpus luteum in the woman's ovary to continue producing progesterone. This acts to maintain the lining of the uterus so that the embryo will continue to be nourished. The glands in the lining of the uterus will swell in response to the blastocyst, and capillaries will be stimulated to grow in that region. This allows the blastocyst to receive vital nutrients from the woman.

Despite all the signs, some women may not realize they are pregnant until they are quite far along in their pregnancy, in some cases not even until they begin labour. This can be caused by many factors, including irregular periods (quite common in teenagers), certain medications (not related to conceiving children), and obese women who disregard their weight gain. Others may be in denial of their situation.

An early sonograph can determine the age of the pregnancy fairly accurately. In practice, doctors typically express the age of a pregnancy (i.e., an "age" for an embryo) in terms of "menstrual date" based on the first day of a woman's last menstrual period, as the woman reports it. Unless a woman's recent sexual activity has been limited, she has been charting her cycles, or the conception is the result of some types of fertility treatment (such as IUI or IVF), the exact date of fertilization is unknown. Without symptoms such as morning sickness, often the only visible sign of a pregnancy is an interruption of the woman's normal monthly menstruation cycle, (i.e., a "late period"). Hence, the "menstrual date" is simply a common educated estimate for the age of a fetus, which is an average of 2 weeks later than the first day of the woman's last menstrual period. The term "conception date" may sometimes be used when that date is more certain, though even medical professionals can be imprecise with their use of the two distinct terms. The due date can be calculated by using Naegele's rule. The expected date of delivery may also be calculated from sonogram measurement of the fetus. This method is slightly more accurate than methods based on LMP. The beginning of labour, which is variously called confinement or childbed, begins on the day predicted by LMP 3.6% of the time and on the day predicted by sonography 4.3% of the time.

Diagnostic criteria are: Women who have menstrual cycles and are sexually active, a period delayed by a few days or weeks is suggestive of pregnancy; elevated B-hcG to around 100,000 mIU/mL by 10 weeks of gestation.

Pregnancy-2

Progression

Stages in prenatal development, with weeks and months numbered by gestation.

Initiation

Pregnancy occurs as the result of the female gamete or oocyte merging with the male gamete, spermatozoon, in a process referred to, in medicine, as "fertilization", or more commonly known as "conception". After the point of "fertilization", it is referred to as an egg. The fusion of male and female gametes usually occurs through the act of sexual intercourse, resulting in spontaneous pregnancy. However, the advent of artificial insemination and in vitro fertilisation have also made achieving pregnancy possible in cases where sexual intercourse does not result in fertilization (e.g., through choice or male/female infertility).

Perinatal period

Perinatal defines the period occurring "around the time of birth", specifically from 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g) to 7 completed days after birth.

Legal regulations in different countries include gestation age beginning from 16 to 22 weeks (5 months) before birth.

Postnatal period

Main article: Postnatal

The postnatal period begins immediately after the birth of a child and then extends for about six weeks. During this period the mother's body returns to prepregnancy conditions as far as uterus size and hormone levels are concerned.

Duration

The expected date of delivery (EDD) is 40 weeks counting from the last menstrual period (LMP), and birth usually occurs between 37 and 42 weeks. The actual pregnancy duration is typically 38 weeks after conception. Though pregnancy begins at conception, it is more convenient to date from the first day of a woman's last menstrual period, or from the date of conception if known. Starting from one of these dates, the expected date of delivery can be calculated. Forty weeks is 9 months and 6 days, which forms the basis of Naegele's rule for estimating date of delivery. More accurate and sophisticated algorithms take into account other variables, such as whether this is the first or subsequent child (i.e., pregnant woman is a primip or a multip, respectively), ethnicity, parental age, length of menstrual cycle, and menstrual regularity.

Pregnancy is considered "at term" when gestation attains 37 complete weeks but is less than 42 (between 259 and 294 days since LMP). Events before completion of 37 weeks (259 days) are considered preterm; from week 42 (294 days) events are considered postterm. When a pregnancy exceeds 42 weeks (294 days), the risk of complications for woman and fetus increases significantly. As such, obstetricians usually prefer to induce labour, in an uncomplicated pregnancy, at some stage between 41 and 42 weeks.

Recent medical literature prefers the terminology preterm and postterm to premature and postmature. Preterm and postterm are unambiguously defined as 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.

Fewer than 5% of births occur on the due date; 50% of births are within a week of the due date, and almost 90% within 2 weeks. It is much more useful, therefore, to consider a range of due dates, rather than one specific day, with some online due date calculators providing this information.

Accurate dating of pregnancy is important, because it is used in calculating the results of various prenatal tests (for example, in the triple test). A decision may be made to induce labour if a fetus is perceived to be overdue. Furthermore, if LMP and ultrasound dating predict different respective due dates, with the latter being later, this might signify slowed fetal growth and therefore require closer review.

The Age of Viability has been receding relentlessly as medical revolution continues to unfold. Whereas it used to be 28 weeks, it has been brought back to as early as 23, or even 22 weeks in some countries. Unfortunately, there has been a profound increase in morbidity and mortality associated with the increased survival to the extent it has led some to question the ethics and morality of resuscitating at the edge of viability.[citation needed]

Pregnancy-1

Terminology

One scientific term for the state of pregnancy is gravid, and a pregnant female is sometimes referred to as a gravida. Neither word is used in common speech. Similarly, the term "parity" (abbreviated as "para") is used for the number of previous successful live births. Medically, 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 as a "primigravida", and a woman in subsequent pregnancies as a multigravida or "multiparous". Hence, during a second pregnancy a woman would be described as "gravida 2, para 1" and upon live delivery as "gravida 2, para 2". An in-progress pregnancy, as well as abortions, miscarriages, or stillbirths account for parity values being less than the gravida number, whereas a multiple birth will increase the parity value. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as "nulliparous". The medical term for a woman who is pregnant for the first time is primigravida.

The term embryo is used to describe the developing offspring during the first 8 weeks following conception, and the term fetus is used from about 2 months of development until birth.

In many societies' medical or legal definitions, human pregnancy is somewhat arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of prenatal development. The first trimester carries the highest risk of miscarriage (natural death of embryo or fetus). During the second trimester, the development of the fetus can be more easily monitored and diagnosed. The beginning of the third trimester often approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus.

Pregnancy Test

History

Jan Steen's The Doctor's Visit. Included in this 17th century painting is a depiction of a dubious pregnancy test: a ribbon dipped in the patient's urine and then burned. Records of attempts at pregnancy testing have been found as far back as the ancient Greek and ancient Egyptian cultures. The ancient Egyptians watered bags of wheat and barley with the urine of a possibly pregnant woman. Germination indicated pregnancy. The type of grain that sprouted was taken as an indicator of the fetus's sex. Hippocrates suggested that a woman who had missed her period should drink a solution of honey in water at bedtime: resulting abdominal distention and cramps would indicate the presence of a pregnancy. Avicenna and many physicians after him in the Middle Ages performed uroscopy, a nonscientific method to evaluate urine.

Selmar Aschheim and Bernhard Zondek introduced testing based on the presence of human chorionic gonadotropin (hCG) in 1928. Early studies of hCG had concluded that it was produced by the pituitary gland. In the 1930s, Georgeanna Jones discovered that hCG was produced not by the pituitary gland, but by the placenta. This discovery was important in relying on hCG as an early marker of pregnancy. In the Aschheim and Zondek test, an infantile female mouse was injected subcutaneously with urine of the person to be tested, and the mouse later was killed and dissected. Presence of ovulation indicated that the urine contained hCG and meant that the person was pregnant. A similar test was developed using immature rabbits. Here, too, killing the animal to check her ovaries was necessary. An improvement arrived with the frog test, introduced by Lancelot Hogben, which still was used in the 1950s and allowed the frog to remain alive and be used repeatedly: a female frog was injected with serum or urine of the patient; if the frog produced eggs within the next 24 hours, the test was positive. This was called the Bufo test, named after the toad genus Bufo, which was originally used for the test. Other species of toads and frogs have been used later on.

Direct measurement of antigens, such as hCG, was made possible with the invention of the radioimmunoassay in 1959, . Radioimmunoassays require sophisticated apparatus and special radiation precautions and are expensive. In the 1970s, the discovery of monoclonal antibodies led to the development of the relatively simple and cheap immunoassays, such as agglutination-inhibition-based assays and sandwich ELISA, used in modern home pregnancy tests.

Modern tests

The test for pregnancy which can give the quickest result after fertilisation is a rosette inhibition assay for early pregnancy factor (EPF). EPF can be detected in blood within 48 hours of fertilization. However, testing for EPF is expensive and time-consuming.

Most chemical tests for pregnancy look for the presence of the beta subunit of hCG or human chorionic gonadotropin in the blood or urine. hCG can be detected in urine or blood after implantation, which occurs six to twelve days after fertilization. Quantitative blood (serum beta) tests can detect hCG levels as low as 1 mIU/mL, while urine tests have published detection thresholds of 20 mIU/mL to 100 mIU/mL, depending on the brand. Qualitative blood tests generally have a threshold of 25 mIU/mL, and so are less sensitive than some available home pregnancy tests. Most home pregnancy tests are based on lateral-flow technology.

With obstetric ultrasonography the gestational sac sometimes can be visualized as early as four and a half weeks of gestation (approximately two and a half weeks after ovulation) and the yolk sac at about five weeks' gestation. The embryo can be observed and measured by about five and a half weeks. The heartbeat may be seen as early as six weeks, and is usually visible by seven weeks' gestation.

Accuracy

Negative pregnancy test, human subject.A systematic review published in 1998 showed that home pregnancy test kits, when used by experienced technicians, are almost as accurate as professional laboratory testing (97.4%). When used by consumers, however, the accuracy fell to 75%: the review authors noted that many users misunderstood or failed to follow the instructions included in the kits. Improper usage may cause both false negatives and false positives.

Timing of test

False negative readings can occur when testing is done too early. Quantitative blood tests and the most sensitive urine tests usually detect hCG shortly after implantation, which can occur anywhere from 6 to 12 days after ovulation. Less sensitive urine tests and qualitative blood tests may not detect pregnancy until three or four days after implantation. Menstruation occurs on average 14 days after ovulation, so the likelihood of a false negative is low once a menstrual period is late.

Ovulation may not occur at a predictable time in the menstrual cycle, however. A number of factors may cause an unexpectedly early or late ovulation, even for women with a history of regular menstrual cycles. Using ovulation predictor kits (OPKs), or charting the fertility signs of cervical mucus or basal body temperature give a more accurate idea of when to test than day-counting alone.

The accuracy of a pregnancy test is most closely related to the day of ovulation, not of the act of intercourse or insemination that caused the pregnancy. It is normal for sperm to live up to five days[11] in the fallopian tubes, waiting for ovulation to occur.[12] It could take up to twelve further days for implantation to occur, meaning even the most sensitive pregnancy tests may give false negatives up to seventeen days after the act that caused the pregnancy. Because some home pregnancy tests have high hCG detection thresholds (up to 100 mIU/mL), it may take an additional three or four days for hCG to rise to levels detectable by these tests — meaning false negatives may occur up to three weeks after the act of intercourse or insemination that causes pregnancy.

False positives

False positive test results may occur for several reasons. These include: errors of test application, use of drugs containing the assay molecule, and non-pregnant production of the assay molecule.

Spurious evaporation lines may appear on many home pregnancy tests if read after the suggested 3–5 minute window or reaction time, independent of an actual pregnancy. False positives may also appear on tests used past their expiration date.

A woman who has been given an hCG injection as part of infertility treatment will test positive on pregnancy tests that assay hCG, regardless of her actual pregnancy status. However, some infertility drugs (e.g., clomid) do not contain the hCG hormone.[13]

Some diseases of the liver, cancers, and other medical conditions may produce elevated hCG and thus cause a false positive pregnancy test. These include choriocarcinoma and other germ cell tumors, IgA deficiencies, heterophile antibodies, enterocystoplasties, gestational trophoblastic diseases (GTD), and gestational trophoblastic neoplasms (GTN).

Viability

Pregnancy tests may be used to determine the viability of a pregnancy. Serial quantitative blood tests may be done, usually 2–3 days apart. Below an hCG level of 1,200 mIU/ml the hCG usually doubles every 48–72 hours, though a rise of 50–60% is still considered normal. Between 1,200 and 6,000 mIU/ml serum the hCG usually takes 72–96 hours to double, and above 6,000 mIU/ml, the hCG often takes more than four days to double. Failure to increase normally may indicate an increased risk of miscarriage or a possible ectopic pregnancy.

Ultrasound is also a common tool for determining viability. A lower than expected heart rate or missed development milestones may indicate a problem with the pregnancy.[9] Diagnosis should not be made from a single ultrasound, however. Inaccurate estimations of fetal age and inaccuracies inherent in ultrasonic examination may cause a scan to be interpreted negatively. If results from the first ultrasound scan indicate a problem, repeating the scan 7–10 days later is reasonable practice.