Round ligament pain

The round ligaments are a pair of cordlike structures in the pelvis that help support the uterus by connecting the front of the uterus to the groin region (Figure 1). During pregnancy, pain in the location of the round ligaments is common. Round ligament pain is most common during the second trimester. Round ligament pain is considered a normal part of pregnancy as your body goes through many different changes. As pregnancy your progresses, the round ligaments become softer and might stretch. It’s believed that pain associated with the round ligaments might be caused by the tightening or spasm of the ligaments or irritation of nearby nerve fibers.

Round ligament pain typically is experienced on the right side of the abdomen or pelvis, but discomfort can also occur on the left or both sides. Round ligament pain often occurs upon waking and rolling over in bed or during rapid movement or vigorous activity.

To relieve round ligament pain, try gentle stretching and changing your position. Avoid rapid or repetitive movement. Flexing your hips before you cough or sneeze might also provide relief. No medication is necessary. Taking acetaminophen (Tylenol, others) might help, however.

Note that pain in your lower abdomen can have other causes, some can be serious. If you have pain accompanied by fever or chills, nausea, vomiting, pain with urination, pain with bleeding, changes in vaginal discharge or moderate or severe pain, see your health care provider.

Figure 1. Round ligament anatomy

Round ligament pain causes

The round ligament supports the uterus and stretches during pregnancy. It connects the front portion of the uterus to the groin. These ligaments contract and relax muscles, but much more slowly.

Any movement (including going from a sitting to standing position quickly, laughing, or coughing) that stretches these ligaments by making them contract quickly, can cause a woman to experience pain. Round ligament pain should only last for a few seconds.

Round ligament pain symptoms

Round ligament pain is a brief, sharp, stabbing pain or a longer-lasting dull ache that pregnant women commonly feel in the lower abdomen or groin, starting in the second trimester. Women with round ligament pain may have a sharp pain in their abdomen or hip area that is either on one side or both. Some women even report pain that extends into the groin area.

You may feel round ligament pain as a short jabbing sensation if you suddenly change position, such as when you’re getting out of bed or out of a chair or when you cough, roll over in bed, or get out of the bathtub. You may feel it as a dull ache after a particularly active day – when you’ve been walking a lot or doing some other physical activity.

The round ligaments surround your uterus in your pelvis. As your uterus grows during pregnancy, the ligaments stretch and thicken to accommodate and support it. These changes can occasionally cause pain on one or both sides of your abdomen.

You may feel the pain starting from deep inside your groin, moving upward and downward on either side to the top of your hips. The pain is internal, but if you were to trace it on your skin, it would follow the bikini line in a very high-cut bathing suit.

Round ligament pain treatment

Resting comfortably is one of the best ways to help with round ligament pain. Changing positions slowly allows the round ligaments to stretch more gradually and can help alleviate any pain. You can also try flexing your knees towards your abdomen or lying on your side with a pillow under your belly for support and another between your legs. A warm bath and OTC acetaminophen may help, too.

If you know that you are going to sneeze, cough, or laugh you can bend and flex your hips, which can reduce the pull on the ligaments.

If you are having consistent round ligament pain, your health care provider may recommend daily stretching exercises. The most common exercise is done by placing your hands and knees on the floor, lowering your head to the floor, and keeping your bottom in the air.

If you find that you’re more prone to round ligament pain when you’re particularly active, cut back to see if that helps. Then, if you feel fine, you can gradually increase your activity until you find the level of exertion that’s comfortable for you.

What is placenta previa

Placenta previa means your placenta is lying unusually low in your uterus, next to or covering your cervix. The cervix is the opening to the uterus that sits at the top of the vagina. This means that the placenta is lying either totally across the cervix (opening of the womb) or partially so. Placenta previa can cause life-threatening blood loss. The placenta (afterbirth) is the pancake-shaped organ normally located near the top of the uterus that supplies your baby with nutrients through the umbilical cord.

Classically patients with placenta previa present with an unprovoked, painless episode of vaginal bleeding. The amount of vaginal blood loss varies between minor to massive hemorrhage. Blood loss is most frequently intermittent with unpredictable recurrence.

Following an episode of bleeding, it is most likely that you will need to stay in hospital for a period of time so that both you and your baby can be monitored closely.

Placenta previa happens in about 1 in 200 pregnancies. The incidence has increased over time due to the rising incidence of cesarean section, which is a risk factor and improved diagnostics. While placental abruption can occur in women with no risk factors, there are factors, listed below, that increase the risk of a mother experiencing placenta previa.

If you’re found to have placenta previa early in pregnancy, it’s not usually considered a problem. This is because your lower uterine segment only develops fully in the third trimester. This means that prior to the third trimester many placentas may appear to be located close to the cervix and are termed low lying placentas. However, as the pregnancy progresses and the lower segment develops fully, a large number (>90%) of low lying placentas detected in early pregnancy move away from the cervical opening. But if the placenta is still close to the cervix later in pregnancy, it can cause bleeding, which can lead to other complications and may mean that you’ll need to deliver early. If you have placenta previa when it’s time to deliver your baby, you’ll need to have a cesarean section.

If the placenta covers the cervix completely, it’s called a complete or total previa. If placenta previa is right on the border of the cervix, it’s called a marginal previa. (You may also hear the term “partial previa,” which refers to a placenta that covers part of the cervical opening once the cervix starts to dilate.) If the edge of the placenta is within two centimeters of the cervix but not bordering it, it’s called a low-lying placenta.

The location of your placenta will be checked during your mid-pregnancy ultrasound exam (usually done between 16 to 20 weeks) and again later if necessary.

Normally, the placenta grows into the upper part of the uterus wall, away from the cervix. It stays there until your baby is born. During the last stage of labor, the placenta separates from the wall, and your contractions help push it into the vagina (birth canal). This is also called the afterbirth.

During labor, your baby passes through the cervix into the birth canal. If you have placenta previa, when the cervix begins to efface (thin out) and dilate (open up) for labor, blood vessels connecting the placenta to the uterus may tear. This can cause severe bleeding during labor and birth, putting you and your baby in danger.

A low-lying placenta is relatively common on the second trimester morphology ultrasound scan. As the fetus grows and the uterus expands, the lower uterine segment thins and grows disproportionately, such that in most cases the placenta is no longer low-lying by a follow-up study (usually performed at 32-34 weeks). This prospective study ¹⁾ indicates that women with a prior cesarean delivery and complete placenta previa diagnosed at second‐trimester ultrasound are less likely to have subsequent resolution of the placenta previa when compared to those without a history of cesarean delivery.

What is the placenta

The placenta is an organ attached to the lining of your womb during pregnancy.

It keeps your unborn baby’s blood supply separate from your own blood supply, as well as providing a link between the two. The link allows the placenta to carry out functions that your unborn baby can’t perform for itself.

The placenta is connected to your baby by the umbilical cord. Your baby is inside a bag of fluid called the amniotic sac, which is made of membranes.

What does the placenta do?

Oxygen and nutrients pass from your blood supply into the placenta. From there, the umbilical cord carries the oxygen and nutrients to your unborn baby. Waste products from the baby, such as carbon dioxide, pass back along the umbilical cord to the placenta and then into your bloodstream, for your body to dispose of them.

The placenta produces hormones that help your baby grow and develop. The placenta also gives some protection against infection for your baby while it’s in the womb, protecting it against most bacteria. However, it doesn’t protect your baby against viruses.

Alcohol, nicotine and other drugs can also cross the placenta and can cause damage to your unborn baby.

Towards the end of your pregnancy, the placenta passes antibodies from you to your baby, giving them immunity for about three months after birth. However, it only passes on antibodies that you already have.

Figure 1. Normal placenta and pregnancy – the placenta attaches to the wall of the uterus (womb) and supplies the baby with food and oxygen through the umbilical cord.

Figure 2. Normal placental position

What happens after my baby is born?

After your baby is born, more contractions will push the placenta out through the vagina.

Your midwife will offer you a medicine to stimulate your contractions and help push the placenta out. They’ll inject the medicine into your thigh just as the baby is born. It makes your womb contract so the placenta comes away from the wall of your womb. This also helps prevent the heavy bleeding some women experience.

Breastfeeding your baby as soon as possible after the birth helps your womb to contract and push the placenta out.

You may choose to let your body push the placenta out in its own time, which may involve some loss of blood.

After the birth, your midwife will check the placenta and membranes, to make sure that they’re complete and nothing has been left behind.

If you have a caesarean section, after your baby is born, the placenta will also be delivered.

Placenta previa types

Low-lying placenta (Grade 1)

Low-lying placenta occurs when the placenta extends into the lower uterine segment and its edge lies too close to the internal os of the cervix, without covering it. The term is usually applied when the placental edge is within 0.5-5.0 cm of the internal cervical os ²⁾. Some alternatively give the term when the placental edge is within 2 cm from the internal cervical os ³⁾.

It has also classified under the benign end of the spectrum of type 1 placenta previa, although some restrict the term “previa” only for the situation in which the placenta covers the internal cervical os.

Figure 3. Low-lying placenta

The estimated prevalence of low-lying placenta may be as high as 10-30% of all pregnancies ⁴⁾. The majority of placentas classified as low-lying in early pregnancy (12-14 weeks) reach a normal position on subsequent scanning later during the pregnancy due to placental trophotropism.

Transvaginal ultrasound is more accurate for evaluation of a low-lying placenta than transabdominal ultrasound ⁵⁾.

Marginal placenta previa (Grade 2)

The placental tissue reaches the margin or right on the border of the internal cervical os, but does not cover it.

Figure 4. Marginal placenta previa

Partial placenta previa (Grade 3)

Refers to a placenta that covers part of the cervical opening once the cervix starts to dilate.

Figure 5. Partial placenta previa

Complete placenta previa (Grade 4)

If the placenta covers the the internal cervical os completely, it’s called a complete or total placenta previa. In the case of a complete placenta praevia, a cesarian section is required for delivery to avoid the risk of fetal and maternal hemorrhage.

Sometimes grades 1 and 2 are termed a “minor” or “partial” placenta previa, and grades 3 and 4 are termed a “major” placenta previa ⁶⁾.

Figure 6. Complete placenta previa

Figure 7. Placenta previa

Placenta previa causes

Scientists don’t know what causes placenta previa. However, you may be at higher risk for placenta previa if:

• You smoke cigarettes.
• You use cocaine.
• You’re 35 or older.
• You’ve been pregnant before.
• You’ve had placenta previa in a past pregnancy.
• You’re pregnant with twins, triplets or more.
• You’ve had surgery on your uterus, including a c-section or a D&C (dilation and curettage). A D&C is when a doctor removes tissue from the lining of a woman’s uterus. Some women have a D&C after a miscarriage.

If you’ve had placenta previa in a past pregnancy, you have a 2 to 3 in 100 (2 to 3 percent) chance of having it again.

Associated conditions with placenta previa include placenta accreta, malpresentation, preterm premature rupture of membranes, intrauterine growth restriction, and vasa previa ⁷⁾.

Risk Factors for placenta previa

The cause of placenta previa remains unknown, however risk factors include:

• High parity
• Increased maternal age
• Uterine abnormalities
• Smoking
• Cocaine use
• Multiple pregnancy
• Previous placenta previa
• Previous Cesarean section
• Termination of pregnancy
• Intrauterine surgery
• Maternal history of smoking
• Erythroblastosis fetalis. This occurs when the mother’s immune system attacks the blood cells of the baby. For example, a mother who has an Rh-negative blood type who is carrying a baby with an Rh-positive blood type may have an immune response that attacks and destroys the Rh-positive blood cells of the baby.
• Assisted reproductive techniques (in vitro fertilization and intracytoplasmic sperm injection).

The increased risk of placenta previa following caesarean section is highest for the pregnancy immediately following the caesarean and decreases in subsequent pregnancies. Prior cesarean delivery is one of the most important risk factors for development of placenta previa, and the risk of placenta previa increases as a woman has more cesarean deliveries. After 1 cesarean delivery, the risk of previa is reported to be approximately 1.9%; the risk increases to 5.5% after 2 cesarean deliveries and reaches 14.3% after 3 cesarean deliveries ⁸⁾.

Placenta previa prevention

Scientists don’t know how to prevent placenta previa. But you may be able to reduce your risk by not smoking and not using cocaine. You also may be able to lower your chances of having placenta previa in future pregnancies by having a c-section only if it’s medically necessary. If your pregnancy is healthy and there are no medical reasons for you to have a c-section, it’s best to let labor begin on its own. The more c-sections you have, the greater your risk of placenta previa.

Placenta previa prognosis

If your placenta was determined as low lying from an ultrasound scan performed prior to the third trimester of pregnancy, it is most likely that as the lower segment of the uterus develops fully that your placenta will move away from the opening of the cervix.

For those women in which this does not occur, placenta previa can be responsible for bleeding from the vagina either during pregnancy, during labor or following labor. This may result in anemia, hysterectomy, a blood transfusion and/or possible infection. In the Western world, placenta previa is a rare cause of maternal mortality, approximately 0.03%.

Fetal death is slightly higher than maternal mortality, approximately 4-8%, and is associated with pre-term birth (50%) and intrauterine growth restriction. While the cause is unknown, the risk of birth defects in the fetus are doubled.

Placenta previa complications

If you have placenta previa, your health care provider will monitor you and your baby to reduce the risk of these serious complications:

• Bleeding. Severe, possibly life-threatening vaginal bleeding (hemorrhage) can occur during labor, delivery or in the first few hours after delivery.
• Preterm birth. Severe bleeding may prompt an emergency C-section before your baby is full term.

Placenta previa signs and symptoms

The most common symptom of placenta previa is painless bright red vaginal bleeding during the second half of pregnancy. Some women also have contractions. However, not all women with placenta previa have vaginal bleeding. In fact, about one-third of women with placenta previa don’t have this symptom.

See your health care provider right away if you have vaginal bleeding anytime during your pregnancy. If the bleeding is severe, go to the hospital.

In many women diagnosed with placenta previa early in their pregnancies during their routine ante-natal check up and ultrasound scan, the placenta previa usually resolves. As your uterus grows, it might increase the distance between the cervix and the placenta. The more the placenta covers the cervix and the later in the pregnancy that it remains over the cervix, the less likely it is to resolve.

Placenta previa diagnosis

On examination, your doctor will be examining you for signs and symptoms of placental previa as well as other differential diagnoses depending on your presenting symptoms. They will be especially concerned with your vital signs, including heart rate and blood pressure to assess whether you are showing any signs of shock.

Other than your health, they will also be concerned with the health of your unborn child. They will be interested in if your baby is moving, its heart rate and how many weeks gestation your baby is. If there are any signs of fetal compromise, active bleeding, uterine activity or tenderness a cardiotocograph (CTG) will be applied for continuous monitoring.

Several blood tests will be ordered and an ultrasound may be necessary.

An ultrasound usually can find placenta previa and pinpoint the placenta’s location. In some cases, your provider may use a transvaginal ultrasound instead.

Diagnosis might require a combination of abdominal ultrasound and transvaginal ultrasound. Your health care provider will take care with the position of the transducer in your vagina so as not to disrupt the placenta or cause bleeding.

If your health care provider suspects placenta previa, he or she will avoid routine vaginal exams to reduce the risk of heavy bleeding. You might need additional ultrasounds to check the location of your placenta during your pregnancy to see if placenta previa resolves.

Even if you don’t have vaginal bleeding, a routine, second trimester ultrasound may show that you have placenta previa. Don’t be too worried if this happens. Placenta previa found in the second trimester fixes itself in most cases.

Ultrasound

Due to placental trophotropism, the diagnosis of a placenta previa is not usually made before 20 weeks.

During the ‘routine’ 18 to 21-week morphology scan, the distance between the lower edge of the placenta and the internal cervical os should be measured. If it lies within a few centimeters of the cervical os, then a repeat ultrasound at ~32 weeks should be performed to ensure that the edge has migrated further away.

MRI (Magnetic Resonance Imaging)

MRI is the gold standard imaging modality for the placenta and its relationship to the cervix, although in most instances it is not required. Sagittal images best demonstrate the relationship of the placenta to the internal cervical os.

Figure 8. Placenta previa MRI scan – MRI demonstrates a complete placenta previa

Placenta previa treatment

Treatment depends on how far along you are in your pregnancy, the seriousness of your bleeding and the health of you and your baby. The goal is to keep you pregnant as long as possible. Obstetricians recommend cesarean birth (c-section) for nearly all women with placenta previa to prevent severe bleeding.

Management of the bleeding depends on various factors, including:

• The amount of bleeding
• Whether the bleeding has stopped
• How far along your pregnancy is
• Your health
• Your baby’s health
• The position of the placenta and the baby

In cases where the fetus is pre-term and the bleeding is minimal, the goal is to delay the delivery to allow for maturation of the fetus without increasing the risk to the mother. In most cases this will involve admission to hospital where you and your baby can be monitored closely. Unless there is spontaneous labor of heavy sustained bleeding necessitating emergency caesarean delivery, delivery is by planned caesarean section at 37-38 weeks gestation.

If you are bleeding as a result of placenta previa, you need to be closely monitored in the hospital. If tests show that you and your baby are doing well, your obstetrician may give you treatment to try to keep you pregnant for as long as possible.

If you have a lot of bleeding, you may be treated with blood transfusions. A blood transfusion is having new blood put into your body. Your obstetrician also may give you medicines called corticosteroids. These medicines help speed up development of your baby’s lungs and other organs.

Your obstetrician may want you to stay in the hospital until you give birth. If the bleeding stops, you may be able to go home. If you have severe bleeding due to placenta previa at about 34 to 36 weeks of pregnancy, your obstetrician may recommend an immediate c-section.

At 36 to 37 weeks, your obstetrician may suggest an amniocentesis to test the amniotic fluid around your baby to see if her/his lungs are fully developed. If they are, your obstetrician may recommend an immediate c-section to avoid risks of future bleeding.

At any stage of pregnancy, a c-section may be necessary if you have dangerously heavy bleeding or if you and your baby are having problems.

If the bleeding becomes life threatening, resuscitation and stabilization of the mother is the primary focus followed by delivery of the baby by emergency cesarean section.

Coping and support

If you’re diagnosed with placenta previa, you’re sure to worry about how your condition will affect you, your baby and your family. Some of these strategies might help you cope:

• Learn about placenta previa. Having information about your condition can help ease your fears. Talk to your health care provider, research on your own and connect with other women who’ve had placenta previa.
• Prepare for a C-section. Placenta previa might prevent you from delivering your baby vaginally. Remind yourself that you and your baby’s health are more important than the method of delivery.
• Make the best of rest. Although you won’t be confined to bed, you will have to take it easy. Fill your days by planning for your baby’s arrival. Read about newborn care or purchase newborn necessities, either online or by phone. Or use the time to catch up on thank-you notes or other nontaxing tasks.
• Take care of yourself. Surround yourself with things that comfort you, such as good books or music you love. Give your partner, friends and loved ones suggestions for ways to help, such as visiting or making one of your favorite foods.

Duplex kidney

Duplex kidney also called duplicated renal collecting system, is a developmental condition in which one or both kidneys have two ureter tubes to drain urine into the bladder, rather than a single tube. Duplex kidneys can occur in one or both kidneys. Duplex kidneys are a normal variant, meaning that they occur commonly enough in healthy children to be considered normal and most cause no medical problems and will require no treatment. However, about 40% of patients with duplex kidneys have been reported to be associated with conditions that require treatment by a urologist, including flow of urine back into the kidney instead of to the bladder and obstruction of urine flow through the ureter tube ¹⁾. Furthermore, because duplex kidneys are frequently asymptomatic and therefore predominantly detected in patients who seek medical assistance, the actual percentage of patients with symptoms is likely to be lower. Symptoms associated with duplex kidneys can include pain, hematuria, dysuria (painful urination) and difficulty or abnormal frequency of micturition ²⁾. Specific manifestation of the pathology depends on the anatomy of each duplication event ³⁾. Furthermore, duplex kidneys are linked to a number of renal disorders, including pelvi-calyceal dilatation, cortical scarring, vesicoureteral reflux (VUR), hydronephrosis, ureterocoeles on the non-duplex side, caliculi or yo-yo reflux (in the incomplete duplication cases) ⁴⁾.

Other duplex kidneys can be associated with the following:

• Vesicoureteral reflux (VUR): Vesicoureteral reflux (VUR) occurs when urine flows back to the kidneys from the bladder, rather than from the bladder and out of the body through the ureter tubes. The valve that normally prevents urine reflux is called the vesicoureteral valve. The danger for children with VUR is that a resulting urinary tract infection (UTI) weakens the urinary tract’s ability to prevent bacteria from entering the kidney. In turn, this can result in kidney damage and infection. Serious conditions can even result in death due to acute infection and scarring of the kidney (reflux nephropathy).
• Ectopic insertion of the ureter: An ectopic ureter is when the ureter does not attach correctly to the bladder and urine empties outside of the bladder rather than inside it. In cases of duplex kidney, one ureter drains properly into the bladder while the duplicate ureter does not. The duplicate ureter is the ectopic ureter. In boys, the ectopic ureter drains into the urethra near the prostate; in girls it drains into the urethra or reproductive organs.
• Ureterocele: A ureterocele occurs when the ureter balloons just inside where it connects to the bladder. A ureterocele may also extend outside the bladder neck and the urethra. The ballooning of the ureter causes an obstruction of urine flow due to narrowing. Ureteroceles can vary in size from very small to almost filling up the bladder.

Duplex kidney occurs in about 1 percent of children and females are affected twice as frequently as males ⁵⁾. The reasons for this sex bias are unknown ⁶⁾.

Duplex kidney classification

Duplex systems can have a variety of phenotypes, and multiple classification systems have been proposed to categorise this pathology (Figure 1) ⁷⁾. In incomplete duplication, the two poles of a duplex kidney share the same ureteral orifice of the bladder. Such duplex kidneys with a bifid pelvis or ureter arise when an initially single ureteric bud bifurcates before it reaches the ampulla. This is likely caused by a premature first branching event that occurred before the ureter has reached the metanephric mesenchyme. Much more frequent are complete duplications, which occur when two ureteric buds emerge from the nephric duct. In most cases, the lower pole of the kidney is normal and the upper pole is abnormal ⁸⁾, an observation explained by the fact that the ectopic ureteric bud frequently emerges anteriorly to the position of the normal ureteric bud and drives the formation of the upper pole of a duplex kidney. Inverted Y-ureteral duplication is a rare condition in which two ureteral orifices drain from a single normal kidney. Inverted Y-ureteral duplication is believed to be caused by the merging of two independent ureteric buds just before or as they reach the kidney anlagen ⁹⁾. A very rare H-shaped ureter has also been reported ¹⁰⁾. Although the vast majority of cases involve a simple duplication, multiplex ureters with up to six independent buds have also been described ¹¹⁾. In some cases, the additional ureter or ureters are ectopic and fail to connect to the bladder or the kidney (blind ending ureter) ¹²⁾.

Figure 1. Duplex kidney classification

Footnote: Compared with a normal kidney (a), complete duplication produces a duplex kidney with two poles that drain into two ureters (b). Incomplete duplication leads to a Y-shaped ureter (c). Blind ureters do not drain into the bladder (d). In the rare case of inverted Y-ureteral duplication, two ureters fuse before entering the kidney (e).

[Source ¹³⁾ ]

Duplex kidney causes

The cause of most duplex kidneys can be traced back to the very first induction steps of the ureter. In the majority of cases, an additional ureteric bud emerges in a rostral (anterior) position to the normal outgrowth. By contrast, in adults, the upper (abnormal) kidney pole drains into the bladder at a site distal to the orifice of the lower kidney pole ¹⁴⁾. This paradoxical phenomenon, known as the Weigert–Meyer rule ¹⁵⁾, can be explained by the significant amount of remodelling occurring at the future ureter–bladder junction during development. As apoptosis eliminates the common nephric duct, the ureter inserts into the developing bladder and moves upwards (Figure 2) ¹⁶⁾. An initially anteriorly positioned ureter thus ends up with a more distal insertion site in the bladder, a model that has been proposed by Mackie and Stephens ¹⁷⁾. Correct positioning of the ureter into the bladder is important to allow formation of a normal trigone (the triangle formed by the two ureter orifices and the urethra) and prevent ureter reflux caused by a malfunctioning valve or a too-short ureter tunnel. Because the vast majority of duplex kidneys arise from an ectopic bud in a rostral position, it is usually the upper pole of the kidney that is affected by vesicoureteral reflux (VUR) and hydronephrosis.

To understand the cause of duplex kidneys, it is important to consider how the urinary system forms. From a developmental point of view, the urogenital tract derives from two independent germ layers with kidneys and ureters arising from the intermediate mesoderm and the bladder and urethra developing from cloacal endoderm ¹⁸⁾. Accordingly, malformations of the urinary system can be further classified into congenital abnormalities of the upper and lower urinary tract (sometimes abbreviated as CALUT). Despite this developmental distinction, it should be noted that some authors group malformations of the ureter as part of congenital abnormalities of the lower urinary tract.

Kidney development in mammals commences with the formation of the nephric duct at the anterior (rostral) pole of the intermediate mesoderm ¹⁹⁾. As development proceeds, epithelial cells of the nephric duct proliferate and actively migrate towards the caudal end of the nephrogenic cord ²⁰⁾. Eventually, the nephric duct fuses with the cloaca, a process that involves dedicated apoptosis and requires GATA3 and LHX1 as well as retinoic acid and RET and FGF signalling ²¹⁾.

As the nephric duct elongates caudally, a series of tubules forms within the nephrogenic cord. The most anteriorly positioned pronephric tubules are considered an evolutionary remnant and are non-functional in mammals. Subsequently, a wave of mesonephric tubules develop that fall into two groups. While rostrally positioned tubules are connected to the nephric duct and serve as an embryonic kidney, more caudally located tubules do not drain into the nephric duct and are non-functional ²²⁾. Both pronephros and mesonephros are transitory structures in the mammalian embryo and disappear (pronephros) or are remodelled (mesonephros) at later stages of development.

The metanephros represents the permanent kidney in mammals and develops at the most caudal position of the intermediate mesoderm. Metanephros development is first detectable as a population of slightly condensed mesenchymal cells within the nephrogenic cord which express a set of molecular markers (HOX11, SIX2, GDNF, EYA1) ²³⁾. In normal development, signalling from the metanephric mesenchyme induces the formation and outgrowth of a single ureteric bud from the nephric duct, which will invade the metanephric mesenchyme and undergo a first stereotypic dichotomous branching event (T-shaped ureter). The collecting duct system (ureteric tree) forms through further rounds of branching that often include tri-tips, which, however, eventually resolve into ureter bifurcations ²⁴⁾. In return, signals released from the ureter will induce the metanephric mesenchyme to differentiate into nephrons, the functional units of the kidney ²⁵⁾.

Development of the urinary system is not restricted to kidney formation but also involves extensive developmental remodeling of the lower tract. An excellent and detailed description of this complex process can be found in ²⁶⁾. In brief, the emerging ureteric bud is initially connected to the cloaca via the distal part of the nephric duct, also termed the common nephric duct. Downgrowth of the urorectal septum leads to a separation of the cloaca into a ventrally located urogenital sinus and a dorsally positioned anorectal sinus ²⁷⁾. The cranial urogenital sinus will further elongate to develop into the bladder, whereas its posterior portion will form the urethra. As development proceeds, apoptosis eliminates the common nephric duct, leading to the fusion of the ureter with the future bladder, thus creating the ureterovesical junction ²⁸⁾.

Figure 2. Duplex kidney formation

Footnote: Duplex kidneys form through the induction of two ureteric buds from the nephric duct that will invade the metanephric mesenchyme. Subsequently, apoptosis of the common nephric duct (CND) leads to the insertion of both ureters into the developing bladder with the orifice of the initially posteriorly positioned ureteric bud ending up in a superior position.

[Source ²⁹⁾ ]

Duplex kidney symptoms

Most duplex kidneys are asymptomatic and diagnosed incidentally during imaging studies. However, where symptoms do occur (infection, reflux or obstruction), the patient is likely to have completely duplicated ureters. Occasionally, hydronephrosis can be severe enough to result in flank discomfort or even a palpable mass.

Duplex kidney symptoms may include:

• Urinary tract infections (UTIs).
• An obstruction of the urinary tract resulting in poor urine flow.
• Urinary incontinence is marked by frequent leaking of urine.
• In girls, one symptom is tissue protruding from the urethra opening in the vagina.

Duplex kidney complications

Duplex kidney may result in urine flowing back into the kidney rather into the bladder and also may cause obstruction of urine.

Obstruction of urine

Two conditions related to duplex kidney that can result in obstruction of urine flow are ureterocele and an ectopic ureter.

Duplex kidney diagnosis

Ultrasound images before birth often detect duplex kidney. Aside from the ultrasound detection (using an x-ray-like machine that emits high-frequency sound waves), the symptoms above are caused by the following complications associated with duplex kidney.

Duplex kidney treatment

Since most duplex kidneys are a normal finding, no treatment is necessary. If a duplex renal collecting system is associated with vesicoureteral reflux (VUR), an ectopic ureter or a ureterocele, then they are treated according to the underlying condition.

Treatment for vesicoureteral reflux

Vesicoureteral reflux (VUR) may go away with no treatment in some children, which is more likely in younger children and in less severe cases. Antibiotics are generally the first treatment to stop the urinary tract infection (UTI).

Surgery can reconstruct the area where the ureter connects to the bladder. This lengthens the ureter tunnel and allows it to act as a valve that closes as the bladder fills, preventing urine reflux.

Treatment for ureteroceles

Ureteroceles may require simple management of symptoms or surgery, depending on the size of the ballooning, the functioning of the kidney and bladder, and the degree of urine obstruction.

• Endoscopic surgery involves a cytoscope, a lighted tube with a camera that generates images a urologist can view. The cytoscope is put into the urethral opening and if a ureterocele is found, it can be punctured with a small incision during the procedure.
• Ureteral reimplantation is a procedure in which a doctor connects the ectopic ureter correctly to the bladder.
• Partial nephrectomy is the removal of the upper portion of the duplex kidney that has the ectopic ureter.

Treatment for ectopic ureter

Surgical treatments include:

• Ureteral reimplantation is a procedure in which a doctor connects the ectopic ureter correctly to the bladder.
• Cutaneous distal ureterostomy involves bringing the ectopic ureter of a newborn to the skin’s surface so it drains externally (into the diaper). After about 18 months, the ureter is correctly implanted into the bladder.
• Partial nephrectomy is the removal of the upper portion of the duplex kidney that has the ectopic ureter.
• Ureteropyelostomy is an option when the ectopic ureter in the upper section of a duplex kidney can be connected to the lower section of the duplex kidney that is functioning normally.

Primary ciliary dyskinesia

Primary ciliary dyskinesia also called immotile cilia syndrome, is a rare inherited disorder which affects the movement of tiny hair-like structures on body cells, known as cilia. Cilia normally move together in wave-like motions. They carry mucus (a slimy substance) toward the mouth to be coughed or sneezed out of the body. The mucus contains inhaled dust, bacteria, and other small particles. If the cilia don’t work well, bacteria stay in your airways. This can cause breathing problems, infections, and other disorders. Primary ciliary dyskinesia is characterized by chronic respiratory tract infections, abnormally positioned internal organs, and the inability to have children (infertility). Some people who have primary ciliary dyskinesia have breathing problems from the moment of birth. The signs and symptoms of primary ciliary dyskinesia are caused by abnormal cilia and flagella. Cilia are microscopic, finger-like projections that stick out from the surface of cells. Cilia are found in the linings of the airway, the reproductive system, and other organs and tissues. Flagella are tail-like structures, similar to cilia, that propel sperm cells forward.

It is thought that about 1/16,000 – 1/20,000 people have primary ciliary dyskinesia. The incidence is higher in Norway and Japan. In the United States, it is estimated that about 12,000 to 17,000 people have primary ciliary dyskinesia ¹⁾.

About half of all people who have primary ciliary dyskinesia have Kartagener’s syndrome. Kartagener syndrome involves three disorders: chronic sinusitis, bronchiectasis and situs inversus. Chronic sinusitis is a condition in which the sinuses are infected or inflamed. The sinuses are hollow air spaces around the nasal passages. Bronchiectasis is a condition in which damage to the airways causes them to widen and become flabby and scarred. Situs inversus is a condition in which the internal organs (for example, the heart, stomach, spleen, liver, and gallbladder) are in opposite positions from where they normally are. Situs inversus can occur without primary ciliary dyskinesia. In fact, only 25 percent of people who have the condition also have primary ciliary dyskinesia. By itself, situs inversus may not affect your health. However, in primary ciliary dyskinesia, it’s a sign of Kartagener’s syndrome.

In the respiratory tract, cilia move back and forth in a coordinated way to move mucus towards the throat. This movement of mucus helps to eliminate fluid, bacteria, and particles from the lungs. Most babies with primary ciliary dyskinesia experience breathing problems at birth, which suggests that cilia play an important role in clearing fetal fluid from the lungs. Beginning in early childhood, affected individuals develop frequent respiratory tract infections. Without properly functioning cilia in the airway, bacteria remain in the respiratory tract and cause infection. People with primary ciliary dyskinesia also have year-round nasal congestion and a chronic cough. Chronic respiratory tract infections can result in a condition called bronchiectasis, which damages the passages, called bronchi, leading from the windpipe to the lungs and can cause life-threatening breathing problems.

Some individuals with primary ciliary dyskinesia have abnormally placed organs within their chest and abdomen. These abnormalities arise early in embryonic development when the differences between the left and right sides of the body are established. About 50 percent of people with primary ciliary dyskinesia have a mirror-image reversal of their internal organs (situs inversus totalis). For example, in these individuals the heart is on the right side of the body instead of on the left. Situs inversus totalis does not cause any apparent health problems. When someone with primary ciliary dyskinesia has situs inversus totalis, they are often said to have Kartagener syndrome.

Approximately 12 percent of people with primary ciliary dyskinesia have a condition known as heterotaxy syndrome or situs ambiguus, which is characterized by abnormalities of the heart, liver, intestines, or spleen. These organs may be structurally abnormal or improperly positioned. In addition, affected individuals may lack a spleen (asplenia) or have multiple spleens (polysplenia). Heterotaxy syndrome results from problems establishing the left and right sides of the body during embryonic development. The severity of heterotaxy varies widely among affected individuals.

Primary ciliary dyskinesia can also lead to infertility. Vigorous movements of the flagella are necessary to propel the sperm cells forward to the female egg cell. Because their sperm do not move properly, males with primary ciliary dyskinesia are usually unable to father children. Infertility occurs in some affected females and is likely due to abnormal cilia in the fallopian tubes.

Another feature of primary ciliary dyskinesia is recurrent ear infections (otitis media), especially in young children. Otitis media can lead to permanent hearing loss if untreated. The ear infections are likely related to abnormal cilia within the inner ear.

Rarely, individuals with primary ciliary dyskinesia have an accumulation of fluid in the brain (hydrocephalus), likely due to abnormal cilia in the brain.

There is no specific treatment for primary ciliary dyskinesia ²⁾. Treatment is focused on the symptoms. People with primary ciliary dyskinesia may be treated with chest physical therapy and breathing exercises to help remove excess mucous. Other treatments may include inhalants to help with breathing, and antibiotics to help treat and prevent infections. Surgery may be necessary to correct heart defects, and to remove damaged lung tissue. For people with severe lung and airway damage, lung transplant may be an option. Males with infertility may want to consider using donor sperm or intracytoplasmic sperm injection (ICSI) to have children. People with primary ciliary dyskinesia should avoid smoking and exposure to smoke in general. In addition, regular exercise can strengthen the lungs and may improve lung function ³⁾.

Is there a support group for individuals and families with primary ciliary dyskinesia?

There are several online support groups for families and individuals with Primary Ciliary Dyskinesia:

• The Primary Ciliary Dyskinesia Family Support Group (http://pcdsupport.org.uk/) offers an “Online Community” feature on their website where people can post questions and discuss living with this condition.
• The Primary Ciliary Dyskinesia Foundation (https://pcdfoundation.org/) offers a forum for sharing information and resources.

Primary ciliary dyskinesia causes

Primary ciliary dyskinesia can result from mutations in many different genes ⁴⁾. No single faulty gene causes all cases of primary ciliary dyskinesia. Rather, many genes are associated with primary ciliary dyskinesia. These genes provide instructions for making proteins that form the inner structure of cilia and produce the force needed for cilia to bend. Coordinated back and forth movement of cilia is necessary for the normal functioning of many organs and tissues. The movement of cilia also helps establish the left-right axis (the imaginary line that separates the left and right sides of the body) during embryonic development.

Mutations in the genes that cause primary ciliary dyskinesia result in defective cilia that move abnormally or are unable to move (immotile). Because cilia have many important functions within the body, defects in these cell structures cause a variety of signs and symptoms. If the cilia don’t work well, bacteria stay in your airways. This can cause breathing problems, infections, and other disorders.

Mutations in the DNAI1 and DNAH5 genes account for up to 30 percent of all cases of primary ciliary dyskinesia. Mutations in the other genes associated with primary ciliary dyskinesia are found in only a small percentage of cases. In many people with primary ciliary dyskinesia, the cause of the disorder is unknown.

Primary ciliary dyskinesia inheritance pattern

Primary ciliary dyskinesia is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

It is rare to see any history of autosomal recessive conditions within a family because if someone is a carrier for one of these conditions, they would have to have a child with someone who is also a carrier for the same condition. Autosomal recessive conditions are individually pretty rare, so the chance that you and your partner are carriers for the same recessive genetic condition are likely low. Even if both partners are a carrier for the same condition, there is only a 25% chance that they will both pass down the non-working copy of the gene to the baby, thus causing a genetic condition. This chance is the same with each pregnancy, no matter how many children they have with or without the condition.

• If both partners are carriers of the same abnormal gene, they may pass on either their normal gene or their abnormal gene to their child. This occurs randomly.
• Each child of parents who both carry the same abnormal gene therefore has a 25% (1 in 4) chance of inheriting a abnormal gene from both parents and being affected by the condition.
• This also means that there is a 75% ( 3 in 4) chance that a child will not be affected by the condition. This chance remains the same in every pregnancy and is the same for boys or girls.
• There is also a 50% (2 in 4) chance that the child will inherit just one copy of the abnormal gene from a parent. If this happens, then they will be healthy carriers like their parents.
• Lastly, there is a 25% (1 in 4) chance that the child will inherit both normal copies of the gene. In this case the child will not have the condition, and will not be a carrier.

These possible outcomes occur randomly. The chance remains the same in every pregnancy and is the same for boys and girls.

Figure 1 illustrates autosomal recessive inheritance. The example below shows what happens when both dad and mum is a carrier of the abnormal gene, there is only a 25% chance that they will both pass down the abnormal gene to the baby, thus causing a genetic condition.

Figure 1. Primary ciliary dyskinesia autosomal recessive inheritance pattern

People with specific questions about genetic risks or genetic testing for themselves or family members should speak with a genetics professional.

Resources for locating a genetics professional in your community are available online:

• The National Society of Genetic Counselors (https://www.findageneticcounselor.com/) offers a searchable directory of genetic counselors in the United States and Canada. You can search by location, name, area of practice/specialization, and/or ZIP Code.
• The American Board of Genetic Counseling (https://www.abgc.net/about-genetic-counseling/find-a-certified-counselor/) provides a searchable directory of certified genetic counselors worldwide. You can search by practice area, name, organization, or location.
• The Canadian Association of Genetic Counselors (https://www.cagc-accg.ca/index.php?page=225) has a searchable directory of genetic counselors in Canada. You can search by name, distance from an address, province, or services.
• The American College of Medical Genetics and Genomics (http://www.acmg.net/ACMG/Genetic_Services_Directory_Search.aspx) has a searchable database of medical genetics clinic services in the United States.

Primary ciliary dyskinesia symptoms

Primary ciliary dyskinesia causes respiratory disease that mainly affects the sinuses, ear canals and lungs. One sign that you might have primary ciliary dyskinesia is if you have chronic (ongoing) infections in one or more of these areas. You may have continuous nasal congestion and coughing. More than 75% of full-term infants with primary ciliary dyskinesia have trouble breathing right after birth (neonatal respiratory distress) and require extra oxygen. On-going (chronic) airway infections begin in early childhood and can lead to permanent damage (bronchiectasis). Nasal congestion, sinus infections, and ear infections also begin in early childhood and continue throughout adulthood. Nearly all people with primary ciliary dyskinesia will cough frequently ⁵⁾.

About 50% of people with primary ciliary dyskinesia will have abnormalities in the placement of their body organs, known as situs abnormalities ⁶⁾. An example is having the heart on the right side of the chest instead of the left side. Situs abnormalities can include situs inversus totalis (mirror-image reversal of the internal organs with no apparent symptoms) or heterotaxy, where the organs are abnormally arranged. People with heterotaxy often have congenital heart defects. Almost all males with primary ciliary dyskinesia are infertile because of abnormal movement of the sperm. The symptoms of primary ciliary dyskinesia can vary and not everyone with primary ciliary dyskinesia has the same symptoms ⁷⁾.

Primary ciliary dyskinesia signs and symptoms vary and may include:

• Ear, nose, and paranasal sinuses
  • Chronic persistent runny nose with mucus and pus discharge, sensation of local fullness, and sinus pain
  • Recurrent sinusitis. The sinuses are hollow air spaces around the nasal passages. Chronic sinusitis is a condition in which the sinuses are infected or inflamed.
  • Anosmia, nasal character of speech, and halitosis
  • Recurrent acute middle ear infections (acute otitis media)
  • Chronic otitis media
  • Hearing loss
• CNS – Hydrocephalus in a few cases
• Reproductive system – fertility problems in men and women. Male infertility (common) ⁸⁾
  • In men, primary ciliary dyskinesia can affect cilia-like structures that help sperm cells move. Because the sperm cells don’t move well, men who have the disease usually are unable to father children.
  • Fertility problems also occur in some women who have primary ciliary dyskinesia. These problems likely are due to faulty cilia in the fallopian tubes. The fallopian tubes carry eggs from the ovaries to the uterus.
• Lungs (lower respiratory tract)
  • Respiratory distress (breathing problems) in newborns
  • Chronic productive cough
  • Bronchospastic symptoms (eg, wheeze and cough), usually responsive to bronchodilator therapy
  • Recurrent or persistent collapse of part or all of a lung (atelectasis) or pneumonia

Some people who have primary ciliary dyskinesia have abnormally placed organs and congenital heart defects.

When do symptoms occur?

The symptoms and severity of primary ciliary dyskinesia vary from person to person. If you or your child has primary ciliary dyskinesia, you may have serious sinus, ear, and/or lung infections. If the disease is mild, it may not show up until the teen or adult years.

The symptoms and severity of primary ciliary dyskinesia also vary over time. Sometimes, you may have few symptoms. Other times, your symptoms may become more severe.

Some people who have primary ciliary dyskinesia have breathing problems when they’re born and need extra oxygen for several days. Afterward, airway infections are common.

Diagnosing primary ciliary dyskinesia in children can be hard. This is because some primary ciliary dyskinesia symptoms—such as ear infections, chronic cough, and runny nose—are common in children, even if they don’t have primary ciliary dyskinesia. Also, the disease may be confused with another condition, such as cystic fibrosis.

A correct and early diagnosis of primary ciliary dyskinesia is very important. It will allow you or your child to get the proper treatment to keep your airways and lungs as healthy as possible. An early diagnosis and proper treatment also can prevent or delay ongoing and long-term lung damage.

Primary ciliary dyskinesia diagnosis

Your doctor or your child’s doctor will diagnose primary ciliary dyskinesia based on signs and symptoms and test results.

If your primary care doctor thinks that you may have primary ciliary dyskinesia or another lung disorder, he or she may refer you to a pulmonologist. This is a doctor who specializes in diagnosing and treating lung diseases and conditions.

Your doctor will look for signs and symptoms that point to primary ciliary dyskinesia, such as:

• Respiratory distress (breathing problems) at birth
• Chronic sinus, middle ear, and/or lung infections
• Situs inversus (internal organs in positions opposite of what is normal)

Your doctor also may ask whether you have a family history of primary ciliary dyskinesia. primary ciliary dyskinesia is an inherited disease. “Inherited” means the disease is passed from parents to children through genes. A family history of primary ciliary dyskinesia suggests an increased risk for the disease.

Diagnostic tests

If the doctor thinks that you or your child might have primary ciliary dyskinesia, he or she may recommend tests to confirm the diagnosis.

Genetic testing

Researchers have found many gene defects associated with primary ciliary dyskinesia. Genetic testing can show whether you have faulty genes linked to the disease.

Genetic testing is done using a blood sample. The sample is taken from a vein in your body using a needle. The blood sample is checked at a special genetic testing laboratory (lab).

Electron microscopy

Doctors can use a special microscope, called an electron microscope, to look at samples of your airway cilia. This test can show whether your cilia are faulty.

An ear, nose, and throat (ENT) specialist or a pulmonologist (lung specialist) will take samples of your cilia. He or she will brush the inside of your nose or remove some cells from your airways.

The doctor will send the samples to a lab. There, a pathologist will look at them under an electron microscope. (A pathologist is a doctor who specializes in identifying diseases by studying cells and tissues under a microscope.)

Other tests

Sometimes doctors use one or more of the following tests to help diagnose primary ciliary dyskinesia. These tests are less complex than genetic testing and electron microscopy, and they can be done in a doctor’s office.

However, these tests don’t give a final diagnosis. Based on the test results, doctors may recommend the more complex tests.

Video microscopy. For this test, a pulmonologist brushes the inside of your nose to get a sample of cilia. Then, he or she looks at the cilia under a microscope to see how they move. Abnormal movement of the cilia may be a sign of primary ciliary dyskinesia.

Radiolabeled particles. For this test, you breathe in tiny particles that have a small amount of radiation attached to them. When you breathe out, your doctor will test how well your cilia can move the particles.

If you breathe out a smaller than normal number of particles, your cilia may not be working well. This could be a sign of primary ciliary dyskinesia.

Nasal nitric oxide. This test measures the level of nitric oxide (a gas) when you breathe out. In people who have primary ciliary dyskinesia, the level of nitric oxide is very low compared with normal levels. Doctors don’t know why people who have primary ciliary dyskinesia breathe out such low levels of nitric oxide.

Semen analysis. This test is used for adult men. In men, primary ciliary dyskinesia can affect cilia-like structures that help sperm cells move. As a result, men who have primary ciliary dyskinesia may have fertility problems. “Fertility” refers to the ability to have children. For this test, a sample of semen is checked under a microscope. Abnormal sperm may be a sign of primary ciliary dyskinesia.

Tests for other conditions. Your doctor also might want to do tests to rule out diseases and disorders that have symptoms similar to those of primary ciliary dyskinesia. For example, you may have tests to rule out cystic fibrosis or immune disorders.

Primary ciliary dyskinesia treatment

Unfortunately, no treatment is available yet to fix faulty airway cilia. Cilia are tiny, hair-like structures that line the airways. Thus, treatment for primary ciliary dyskinesia focuses on which symptoms and complications you have.

The main goals of treating primary ciliary dyskinesia are to:

• Control and treat lung, sinus, and ear infections
• Remove trapped mucus from the lungs and airways

Specialists involved

Many doctors may help care for someone who has primary ciliary dyskinesia. For example, a neonatologist may suspect primary ciliary dyskinesia or another lung disorder if a newborn has breathing problems at birth. A neonatologist is a doctor who specializes in treating newborns.

A pediatrician may suspect primary ciliary dyskinesia if a child has chronic (ongoing) sinus, ear, and/or lung infections. A pediatrician is a doctor who specializes in treating children. This type of doctor provides children with ongoing care from an early age and treats conditions such as ear infections and breathing problems.

An otolaryngologist also called an ear, nose, and throat (ENT) specialist, may help diagnose and treat primary ciliary dyskinesia. This type of doctor treats ear, nose, and throat disorders. If a child has chronic sinus or ear infections, an ENT specialist may be involved in the child’s care.

A pulmonologist may help diagnose or treat lung problems related to primary ciliary dyskinesia. This type of doctor specializes in diagnosing and treating lung diseases and conditions. Most people who have primary ciliary dyskinesia have lung problems at some point in their lives.

A pathologist is a doctor who specializes in identifying diseases by studying cells and tissues under a microscope. This type of doctor may help diagnose primary ciliary dyskinesia by looking at cilia under a microscope.

A pathologist also may look at mucus samples to see what types of bacteria are causing infections. This information can help your doctor decide which treatments to prescribe.

Treatments for breathing and lung problems

Standard treatments for breathing and lung problems in people who have primary ciliary dyskinesia are chest physical therapy (chest physical therapy), exercise, and medicines.

One of the main goals of these treatments is to get you to cough. Coughing clears mucus from the airways, which is important for people who have primary ciliary dyskinesia. For this reason, your doctor also may advise you to avoid medicines that suppress coughing.

Chest physical therapy

Chest physical therapy also called chest clapping or percussion. Chest physical therapy involves pounding your chest and back over and over with your hands or a device to loosen the mucus from your lungs so that you can cough it up.

You might sit down or lie on your stomach with your head down while you do chest physical therapy. Gravity and force help drain the mucus from your lungs.

Some people find chest physical therapy hard or uncomfortable to do. Several devices have been made to help with chest physical therapy, such as:

• An electric chest clapper, known as a mechanical percussor.
• An inflatable therapy vest that uses high-frequency airwaves. The airwaves force the mucus that’s deep in your lungs toward your upper airways so you can cough it up.
• A small hand-held device that you breathe out through. The device causes vibrations that dislodge the mucus.
• A mask that creates vibrations to help break the mucus loose from your airway walls.

Breathing techniques also may help dislodge mucus so you can cough it up. These techniques include forcing out a couple of short breaths or deeper breaths and then doing relaxed breathing. This may help loosen the mucus in your lungs and open your airways.

Exercise

Aerobic exercise that makes you breathe harder helps loosen the mucus in your airways so you can cough it up. Exercise also helps improve your overall physical condition.

Talk with your doctor about what types and amounts of exercise are safe for you or your child.

Medicines

If you have primary ciliary dyskinesia, your doctor may prescribe antibiotics, bronchodilators, or anti-inflammatory medicines. These medicines help treat lung infections, open up the airways, and reduce swelling.

Antibiotics are the main treatment to prevent or treat lung infections. Your doctor may prescribe oral or intravenous (IV) antibiotics.

Oral antibiotics often are used to treat mild lung infections. For severe or hard-to-treat infections, you may be given IV antibiotics through a tube inserted into a vein.

To help decide which antibiotics you need, your doctor may send mucus samples to a pathologist. The pathologist will try to find out which bacteria are causing the infection.

Bronchodilators help open the airways by relaxing the muscles around them. You inhale these medicines. Often, they’re taken just before chest physical therapy to help clear mucus from your lungs. You also may take bronchodilators before inhaling other medicines into your lungs.

Anti-inflammatory medicines can help reduce swelling in your airways that’s caused by ongoing infections. These medicines may be inhaled or oral.

Treatments for sinus and ear infections

To treat infections, your doctor may recommend saline nasal washes and anti-inflammatory nasal spray. If these treatments aren’t enough, you may need medicines, such as antibiotics. If antibiotics don’t work, surgery may be an option.

Tympanostomy is a procedure in which small tubes are inserted into the eardrums to help drain mucus from the ears. This procedure may help children who have hearing problems caused by primary ciliary dyskinesia.

Nasal or sinus surgery may help drain the sinuses and provide short-term relief of symptoms. However, the long-term benefits of this treatment are unclear.

Treatments for advanced lung disease

People who have primary ciliary dyskinesia may develop a serious lung condition called bronchiectasis. Bronchiectasis often is treated with medicines, hydration (drinking plenty of fluids), and chest physical therapy.

If bronchiectasis severely affects part of your lung, surgery may be used to remove that area of lung.

In very rare cases, if other treatments haven’t worked, lung transplant may be an option for severe lung disease. A lung transplant is surgery to remove a person’s diseased lung and replace it with a healthy lung from a deceased donor.

Living with primary ciliary dyskinesia

If you or your child has primary ciliary dyskinesia, try to learn as much as you can about the disease. Work closely with your doctors or your child’s doctors to learn how to manage primary ciliary dyskinesia.

Ongoing care

You’ll need ongoing care to check your lung function and your general health. Ask your doctor how often you should schedule followup visits.

Your doctor will likely recommend periodic chest x rays and lung function tests. He or she will use the test results and information about your symptoms to plan your treatment.

Make sure to report new or worsening symptoms, such as increased coughing, to your doctor right away. This will allow him or her to find out whether you have an infection and what’s causing it. Your doctor can then prescribe medicine to prevent the infection from worsening.

Also, certain vaccines can lower your risk for some infections. Talk with your doctor about which vaccines may benefit you.

If your child has primary ciliary dyskinesia, encourage him or her to learn about the disease and take an active role in his or her treatment.

Healthy lifestyle

Between medical checkups, you can practice good self-care and follow a healthy lifestyle. An important part of a healthy lifestyle is following a healthy diet.

A healthy diet includes a variety of fruits, vegetables, and whole grains. It also includes lean meats, poultry, fish, beans, and fat-free or low-fat milk or milk products. A healthy diet is low in saturated fat, trans fat, cholesterol, sodium (salt), and added sugar.

Another important part of a healthy lifestyle is to quit smoking or not start smoking. Talk to your doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke.

If you have a child who has primary ciliary dyskinesia, avoid smoking anywhere your child spends time, including the home and car. Encourage your child to never start smoking.

Other steps you can take to follow a healthy lifestyle include:

• Washing your hands often to lower your risk of infection.
• Being physically active and drinking lots of fluids. Talk with your doctor about what types and amounts of activity are safe for you or your child.
• Doing chest physical therapy (as your doctor recommends).
• Avoiding medicines that suppress coughing. (Coughing helps clear mucus from your airways.)

Other concerns

Adults who have primary ciliary dyskinesia can expect to have normal sex lives. However, men and women who have the disease may have fertility problems. “Fertility” refers to the ability to have children. Fertility treatments may help some people who have primary ciliary dyskinesia.

If you have primary ciliary dyskinesia and fertility concerns, talk with your doctor. He or she can advise you about available treatment options.

People who have primary ciliary dyskinesia should still have protected sex to avoid sexually transmitted diseases.

Emotional issues and support

Living with primary ciliary dyskinesia may cause fear, anxiety, depression, and stress. Talk about how you feel with your health care team. Talking to a professional counselor also can help. If you’re very depressed, your doctor may recommend medicines or other treatments that can improve your quality of life.

Support from family and friends also can help relieve stress and anxiety. Let your loved ones know how you feel and what they can do to help you.

Genetic counseling

You may want to consider genetic counseling if you have:

• A family history of primary ciliary dyskinesia and you’re planning to have children
• A child who has primary ciliary dyskinesia and are planning to have more children

A genetic counselor can explain the risk (likelihood) of having children who have the disease. He or she also can help explain the choices that are available.

You can find information about genetic counseling from health departments, neighborhood health centers, and medical centers.

Primary ciliary dyskinesia prognosis

Many people who have primary ciliary dyskinesia have normal lifespans. The long-term outlook for people with primary ciliary dyskinesia is dependent on severity of respiratory symptoms. Generally, primary ciliary dyskinesia is not thought to be life-threatening, but severe lung and airway disease can lead to permanent damage. About 25 percent of people who have primary ciliary dyskinesia may develop respiratory failure, a life-threatening condition. A small number of people who have primary ciliary dyskinesia need lung transplants.

Ear infections that occur frequently can lead to hearing loss, which is sometimes permanent. Early diagnosis and treatment seems to improve long-term outcomes ⁹⁾.

Scientists continue to study the faulty genes that cause primary ciliary dyskinesia. Further studies of the disease will likely lead to earlier diagnoses, better treatments, and improved outcomes.

Best time to get pregnant

You’re most likely to get pregnant if you have sex within a day or so of ovulation (releasing an egg from the ovary). This is usually about 14 days after the first day of your last period, if your cycle is around 28 days long. An egg lives for about 12-24 hours after being released. For pregnancy to happen, the egg must be fertilized by a sperm within this time. Sperm can live for up to 7 days inside a woman’s body. So if you’ve had sex in the days before ovulation, the sperm will have had time to travel up the fallopian tubes to “wait” for the egg to be released. When the egg and sperm meet, it’s called fertilization. The fertilized egg also called an embryo moves through your fallopian tubes and attaches to the wall of your uterus where it grows and develops into a baby. When the embryo attaches to the uterus, it’s called implantation.

To get pregnant:

1. A woman’s body must release an egg from one of her ovaries (ovulation).
2. A man’s sperm must join with the egg along the way (fertilize).
3. The fertilized egg must go through a fallopian tube toward the uterus (womb).
4. The fertilized egg must attach to the inside of the uterus (implantation).
5. Infertility may result from a problem with any or several of these steps.
6. If you want to get pregnant, having sex every 2 to 3 days throughout the month will give you the best chance. You don’t need to time having sex only around ovulation.

Getting pregnant (conception) happens when a man’s sperm fertilizes a woman’s egg. For some women this happens quickly, but for others it can take longer.

You can get pregnant if you have unprotected sex any time from 5 days before and the day of ovulation. The more often you have sex during this time, the more likely you are to get pregnant. Your egg is fertile (can become an embryo) for 12 to 24 hours after ovulation. Your partner’s sperm can live inside you for up to 72 hours after you have sex.

However, it’s difficult to know exactly when your ovulation happen, unless you are practising natural family planning, or fertility awareness.

Out of every 100 couples trying for a baby, 80 to 90 will get pregnant within 1 year. The rest will take longer, or may need help to conceive.

To understand getting pregnant (conception) and pregnancy, it helps to know about the male and female sexual organs, and to understand how a woman’s monthly menstrual cycle and periods work.

The menstrual cycle is counted from the first day of a woman’s period (day 1). Some time after her period she will ovulate, and then around 12-16 days after this she’ll have her next period.

The average menstrual cycle lasts 28 days. But normal cycles can vary from 21 to 35 days. The amount of time before ovulation occurs is different in every woman and even can be different from month to month in the same woman, varying from 13 to 20 days long. Learning about this part of the cycle is important because it is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods or becomes pregnant) will have a period within 14 to 16 days.

Being aware of your menstrual cycle and the changes in your body that happen during this time can help you know when you are most likely to get pregnant. See how the menstrual cycle works by watching the video below. Each month your ovaries release an egg about 14 days before the first day of your period. This is called ovulation. When you and your partner have unprotected sex around the time of ovulation, his sperm swim to meet your egg. Unprotected sex means you don’t use any kind of birth control to help prevent pregnancy.

The male sexual organs

• The penis: this is made of sponge-like erectile tissue that becomes hard when filled with blood.
• Testes: men have two testes (testicles), which are glands where sperm are made and stored.
• Scrotum: this is a bag of skin outside the body beneath the penis. It contains the testes and helps to keep them at a constant temperature just below body temperature. When it’s warm, the scrotum hangs down, away from the body, to help keep the testes cool. When it’s cold, the scrotum draws up, closer to the body for warmth.
• Vas deferens: these are two tubes that carry sperm from the testes to the prostate and other glands.
• Prostate gland: this gland produces secretions that are ejaculated with the sperm.
• Urethra: this is a tube that runs down the length of the penis from the bladder, through the prostate gland to an opening at the tip of the penis. Sperm travel down this tube to be ejaculated.

The female sexual organs

A woman’s reproductive system is made up of both external and internal organs. These are found in the pelvic area, the part of the body below the belly button.

The external organs are known as the vulva. This includes the opening of the vagina, the inner and outer lips (labia) and the clitoris.

The woman’s internal organs are made up of:

• The pelvis: this is the bony structure around the hip area, which the baby will pass through when he or she is born.
• Womb or uterus: the womb is about the size and shape of a small, upside-down pear. It’s made of muscle and grows in size as the baby grows inside it.
• Fallopian tubes: these lead from the ovaries to the womb. Eggs are released from the ovaries into the fallopian tubes each month, and this is where fertilization takes place.
• Ovaries: there are 2 ovaries, each about the size of an almond; they produce the eggs, or ova.
• Cervix: this is the neck of the womb. It’s normally almost closed, with just a small opening through which blood passes during the monthly period. During labor, the cervix dilates (opens) to let the baby move from the uterus into the vagina.
• Vagina: the vagina is a tube about 3 inches (8cm) long, which leads from the cervix down to the vulva, where it opens between the legs. The vagina is very elastic, so it can easily stretch around a man’s penis, or around a baby during labor.

Figure 1. Female reproductive organs

What is ovulation?

Ovulation is when the ovary releases an egg so it can be fertilized by a sperm in order to make a baby. A woman is most likely to get pregnant if she has sex without birth control in the three days before and up to the day of ovulation (since the sperm are already in place and ready to fertilize the egg as soon as it is released). A man’s sperm can live for 3 to 5 days in a woman’s reproductive organs, but a woman’s egg lives for just 12 to 24 hours after ovulation.

Each woman’s cycle length may be different, and the time between ovulation and when the next period starts can be anywhere from one week (7 days) to more than 2 weeks (19 days) ¹⁾.

At different times in a woman’s life, ovulation may or may not happen:

• Women who are pregnant do not ovulate.
• Women who are breastfeeding may or may not ovulate. Women who are breastfeeding should talk to their doctor about birth control methods if they do not want to get pregnant.
• During perimenopause, the transition to menopause, you may not ovulate every month.
• After menopause you do not ovulate.

How do I know if I’m ovulating?

A few days before you ovulate, your vaginal mucus or discharge changes and becomes more slippery and clear. This type of mucus helps sperm move up into your uterus and into the fallopian tubes where it can fertilize an egg. Some women feel minor cramping on one side of their pelvic area when they ovulate. Some women have other signs of ovulation.

Luteinizing hormone (LH) is a hormone released by your brain that tells the ovary to release an egg (called ovulation). LH levels begin to surge upward about 36 hours before ovulation, so some women and their doctors test for LH levels. LH levels peak about 12 hours before ovulation ²⁾. Women who are tracking ovulation to become pregnant will notice a slight rise in their basal temperature (your temperature after sleeping before you get out of bed) around ovulation.

If I’ve stopped using birth control, how long should I wait before trying to get pregnant?

There’s no right or wrong amount of time to wait. You can start trying to get pregnant right away. But the kind of birth control you used may affect how soon you start ovulating. For example:

• If you were using birth control pills, you may begin ovulating about 2 weeks after you stop taking them. But your periods may not be regular for a month or 2 after. Your period is regular if it starts the same number of days apart each month.
• If you were taking Depo-Provera, it can take 10 months or more after your last shot before you ovulate regularly. Depo-Provera is a birth control shot that you get every 3 months.
• If you had an implant or an intrauterine device (IUD), you can start trying to get pregnant as soon as you have it removed. An implant is a tiny rod inserted under the skin of your upper arm. It releases a hormone called progestin that prevents you from releasing eggs. An IUD is a t-shaped piece of plastic that’s placed in your uterus to prevent you from getting pregnant.
• If you were using a barrier method of birth control, you can start trying to get pregnant as soon as you stop using it. A barrier method keeps a man’s sperm from reaching a woman’s egg, and some help protect against sexually transmitted infections (also called STIs). An STI is an infection, like HIV and syphilis, you can get by having unprotected sex with someone who’s infected. Barrier methods include dental dams and male and female condoms. A dental dam is a square piece of rubber.

Are there things your partner can do to help improve his sperm?

Yes. Your partner may be able to make his sperm healthier and to make more sperm to help you get pregnant. Here’s what he can do:

• Get treated for health conditions, like diabetes, kidney problems and being obese, that may affect his sperm. Diabetes is when you have too much sugar (called glucose) in your blood. Being obese means you have an excess amount of body fat and your body mass index (also called BMI) is 30 or higher.
• Talk to his doctor about any medicines he takes. This includes prescription and over-the-counter (also called OTC) medicine, supplements and herbal products. A prescription medicine is medicine a health care provider says you can take to treat a health condition. You need a prescription (order) from a provider to get the medicine. OTC medicines, like pain relievers and cough syrup, are medicines you can buy without a prescription. Supplements, like vitamin B and C, are products you take to make up for certain nutrients you don’t get enough of in food. Herbal products, like Ginkgo biloba or green tea, are made from herbs (plants that are used in cooking and medicine). Ask your partner to talk to his provider to make sure the medicine he takes doesn’t affect his sperm.
• Stop smoking, drinking alcohol and using drugs that can affect his fertility (his ability to get you pregnant). Street drugs that can affect your partner’s fertility include marijuana and cocaine. Anabolic steroids also can affect his fertility. An anabolic steroid is a man-made form of testosterone (a male hormone). Providers may prescribe steroids to treat certain hormone problems and diseases, like cancer and AIDS. Some athletes and bodybuilders use steroids to improve physical performance and appearance. If your partner needs help to quit smoking, drinking alcohol or using certain drugs, encourage him to talk to his provider.
• Talk to his doctor about chemicals that can affect fertility, including metals (like lead) and radiation and chemotherapy for cancer.

What if I’ve trying to get pregnant, but I don’t get pregnant right away?

If you’ve been trying to get pregnant for 3 or 4 months, keep trying. It may just take more time. You may want to think about fertility treatment (medical treatment to help you get treatment) if:

• You’re younger than 35 and have been trying to get pregnant for more than a year.
• You’re older than 35 and have been trying to get pregnant for 6 months.

Your provider can give you and your partner some tests to help find out why you’re having trouble getting pregnant. If there’s a problem, there’s a good chance it can be treated.

Your menstrual cycle

Menstruation often called your “period”, is a woman’s monthly vaginal bleeding that occurs as part of a woman’s monthly menstrual cycle. When you menstruate, your body discards the monthly buildup of the lining of your uterus (womb). Menstrual blood and tissue flow from your uterus through the small opening in your cervix and pass out of your body through your vagina.

During the monthly menstrual cycle, the uterus lining builds up to prepare for pregnancy. If you do not get pregnant, estrogen and progesterone hormone levels begin falling. Very low levels of estrogen and progesterone tell your body to begin menstruation.

Your menstrual cycle is the monthly hormonal cycle a female’s body goes through to prepare for pregnancy. Your menstrual cycle is counted from the first day of your period up to the first day of your next period. Your hormone levels (estrogen and progesterone) usually change throughout the menstrual cycle and can cause menstrual symptoms.

The typical menstrual cycle is 28 days long, but each woman is different ³⁾. Also, a woman’s menstrual cycle length might be different from month-to-month. Your periods are still “regular” if they usually come every 24 to 38 days ⁴⁾. This means that the time from the first day of your last period up to the start of your next period is at least 24 days but not more than 38 days.

Some women’s periods are so regular that they can predict the day and time that their periods will start. Other women are regular but can only predict the start of their period within a few days.

Periods usually start between age 11 and 14 (a girl’s first period is called menarche) and continue until menopause at about age 51 ⁵⁾. In the United States, most girls start menstruating shortly after 12 years of age ⁶⁾. The average menstruation time in normally menstruating women is 3 to 5 days ⁷⁾ but a normal menstrual period can lasts up to 8 days ⁸⁾. Besides bleeding from the vagina, you may have:

• Abdominal or pelvic cramping pain
• Lower back pain
• Bloating and sore breasts
• Food cravings
• Mood swings and irritability
• Headache and fatigue

Premenstrual syndrome or PMS, is a group of symptoms that start before the period. It can include emotional and physical symptoms.

Consult your health care provider if you have big changes in your cycle. They may be signs of other problems that should be treated.

Bleeding in any of the following situations is considered abnormal uterine bleeding:

• Bleeding or spotting between periods
• Bleeding or spotting after sex
• Heavy bleeding during your period
• Menstrual cycles that are longer than 38 days or shorter than 24 days
• “Irregular” periods in which cycle length varies by more than 7–9 days
• Bleeding after menopause

Some of the causes of abnormal bleeding include the following:

• Problems with ovulation
• Fibroids and polyps
• A condition in which the endometrium grows into the wall of the uterus
• Bleeding disorders
• Problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills
• Miscarriage
• Ectopic pregnancy
• Certain types of cancer, such as cancer of the uterus

Your obstetrician–gynecologist (ob-gyn) or other health care professional may start by checking for problems most common in your age group. Some of them are not serious and are easy to treat. Others can be more serious. All should be checked.

Based on your symptoms and your age, other tests may be needed. Some of these tests can be done in your ob-gyn’s office. Others may be done at a hospital or surgical center:

• Ultrasound exam—Sound waves are used to make a picture of the pelvic organs.
• Hysteroscopy—A thin, lighted scope is inserted through the vagina and the opening of the cervix. It allows your ob-gyn or other health care professional to see the inside of the uterus.
• Endometrial biopsy—A sample of the endometrium is removed and looked at under a microscope.
• Sonohysterography—Fluid is placed in the uterus through a thin tube while ultrasound images are made of the inside of the uterus.
• Magnetic resonance imaging (MRI)—An MRI exam uses a strong magnetic field and sound waves to create images of the internal organs.
• Computed tomography (CT)—This X-ray procedure shows internal organs and structures in cross section.

You also may have a pregnancy test and tests for sexually transmitted infections (STIs).

Medications often are tried first to treat irregular or heavy menstrual bleeding. The medications that may be used include the following:

• Hormonal birth control methods—Birth control pills, the skin patch, and the vaginal ring contain hormones. These hormones can lighten menstrual flow. They also help make periods more regular.
• Gonadotropin-releasing hormone (GnRH) agonists—These drugs can stop the menstrual cycle and reduce the size of fibroids.
• Tranexamic acid—This medication treats heavy menstrual bleeding.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)—These drugs, which include ibuprofen, may help control heavy bleeding and relieve menstrual cramps.
• Antibiotics—If you have an infection, you may be given an antibiotic.
• Special medications—If you have a bleeding disorder, your treatment may include medication to help your blood clot.
• If medication does not reduce your bleeding, a surgical procedure may be needed. There are different types of surgery depending on your condition, your age, and whether you want to have more children.

Endometrial ablation destroys the lining of the uterus. It stops or reduces the total amount of bleeding. Pregnancy is not likely after ablation, but it can happen. If it does, the risk of serious complications, including life-threatening bleeding, is greatly increased. If you have this procedure, you will need to use birth control until after menopause.

Uterine artery embolization is a procedure used to treat fibroids. This procedure blocks the blood vessels to the uterus, which in turn stops the blood flow that fibroids need to grow. Another treatment, myomectomy, removes the fibroids but not the uterus.

Hysterectomy, the surgical removal of the uterus, is used to treat some conditions or when other treatments have failed. Hysterectomy also is used to treat endometrial cancer. After the uterus is removed, a woman can no longer get pregnant and will no longer have periods.

Figure 2. Menstrual cycle

Figure 3. Pituitary gland hormones under the influence of the hypothalamus controlling the ovaries production of egg cell, ovulation and development of the female secondary sex characteristics

Abbreviations: GnRH = Gonadotropin-Releasing Hormone; FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

Figure 4. Ovarian Follicle Maturation

Figure 5. Ovarian activity during the Menstrual cycle

Footnote: Major events in the female menstrual cycle. (a) Plasma hormonal concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) affect follicle maturation in the ovaries. (b) Plasma hormonal concentrations of estrogen and progesterone influence changes in the uterine lining.

Abbreviations: FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

How does my menstrual cycle affect my health?

Changing hormone levels throughout your menstrual cycle can cause health problems or make health problems worse:

• Anemia. Heavy menstrual bleeding is the most common cause of iron-deficiency anemia in women of childbearing age. Anemia is a condition that happens when your blood cannot carry enough oxygen to all of the different parts of your body because it does not have enough iron. This makes you pale or feel tired or weak.
• Asthma. Your asthma symptoms may be worse during some parts of your cycle.
• Depression. Women with a history of depression are more likely to have PMS or premenstrual dysphoric disorder (PMDD). Symptoms of depression may be worse just before their periods.
• Diabetes. Women with irregular menstrual cycles, especially those longer than 40 days, have a higher risk for type 2 diabetes.
• Irritable bowel syndrome (IBS). IBS causes cramping, bloating, and gas. Your IBS symptoms may get worse right before your period.
• Problems getting pregnant. Health problems, such as endometriosis, polycystic ovary syndrome (PCOS) or underweight or obesity, can cause irregular periods. This can make it harder to get pregnant.

How long does a woman usually have periods?

On average, women get a period for about 40 years of their life ⁹⁾. Most women have regular periods until perimenopause, the time when your body begins the change to menopause. Perimenopause, or transition to menopause, may take a few years. During this time, your period may not come regularly. Menopause happens when you have not had a period for 12 months in a row. For most women, this happens between the ages of 45 and 55. The average age of menopause in the United States is 52.

Periods also stop during pregnancy and may not come back right away if you breastfeed.

But if you don’t have a period for 90 days (three months), and you are not pregnant or breastfeeding, talk to your doctor or nurse. Your doctor will check for pregnancy or a health problem that can cause periods to stop or become irregular.

Day 1

The first day of bleeding is considered the first day of the menstrual cycle. After bleeding ends, usually around day 5, levels of the hormone estrogen begin to rise. The rise in estrogen causes the lining of the uterus to thicken as it prepares to hold a fertilized egg. At the same time, the changes in hormone levels cause follicles (the sacs in the ovary that contain eggs) to grow and mature, in preparation for one follicle to go through ovulation.

Ovulation

Around day 12 to 14 in an average 28-day cycle, the egg is released from a follicle on the ovary in a process called ovulation. Ovulation can occur anywhere between 10 and 21 days after the first day of a woman’s menstrual cycle. Ovulation is when the ovary releases an egg so it can be fertilized by a sperm to make a baby. A woman is most likely to get pregnant if she has sex without birth control in the three days before and up to the day of ovulation.

It may be difficult to know when you ovulate, but you can watch for signs. A few days before you ovulate, your vaginal mucus or discharge changes and becomes
more slippery and clear. A woman can also tell when she has begun ovulating using several methods, including at-home tests that measure levels of luteinizing hormone (LH) in the urine and keeping track of her body temperature, which typically rises slightly at ovulation. At mid-cycle, some women experience pain on one side of their pelvic area; this pain is called “Mittelschmerz” (meaning “middle pain,” because it occurs in the middle of the cycle) and may be a signal of ovulation ¹⁰⁾.

More than 90 percent of women say they get symptoms of premenstrual syndrome (PMS) in the time after ovulation and before their period starts.

If a pregnancy does not occur, decreasing hormone levels signal for the lining of the uterus, called the endometrium, to be shed during menstruation.

The endometrium builds up and breaks down during the menstrual cycle. The endometrium is thickest halfway through the 28-day cycle. Then, if there is no pregnancy, it breaks down. This breakdown causes the bleeding of the menstrual phase. Figure 5 above illustrates an average 28-day cycle.

How do I know if I’m ovulating?

A few days before you ovulate, your vaginal mucus or discharge changes and becomes more slippery and clear. This type of mucus helps sperm move up into your uterus and into the fallopian tubes where it can fertilize an egg. Some women feel minor cramping on one side of their pelvic area when they ovulate. Some women have other signs of ovulation.

Luteinizing hormone (LH) is a hormone released by your brain that tells the ovary to release an egg (called ovulation). LH levels begin to surge upward about 36 hours before ovulation, so some women and their doctors test for LH levels. LH levels peak about 12 hours before ovulation ¹¹⁾. Women who are tracking ovulation to become pregnant will notice a slight rise in their basal temperature (your temperature after sleeping before you get out of bed) around ovulation.

How long is a typical menstrual cycle?

The typical menstrual cycle is 28 days long, but each woman is different ¹²⁾. Also, a woman’s menstrual cycle length might be different from month-to-month. Your periods are still “regular” if they usually come every 24 to 38 days ¹³⁾. This means that the time from the first day of your last period up to the start of your next period is at least 24 days but not more than 38 days.

Some women’s periods are so regular that they can predict the day and time that their periods will start. Other women are regular but can only predict the start of their period within a few days.

How can I keep track of my menstrual cycle?

You can keep track of your menstrual cycle by marking the day you start your period on a calendar. After a few months, you can begin to see if your periods are regular or if your cycles are different each month.

You may want to track:

• Premenstrual syndrome (PMS) symptoms: Did you have cramping, headaches, moodiness, forgetfulness, bloating, or breast tenderness?
• When your bleeding begins: Was it earlier or later than expected?
• How heavy the bleeding was on your heaviest days: Was the bleeding heavier or lighter than usual? How many pads or tampons did you use?
• Period symptoms: Did you have pain or bleeding on any days that caused you to miss work or school?
• How many days your period lasted: Was your period shorter or longer than the month before?

You can also download apps (sometimes for free) for your phone to track your periods. Some include features to track your PMS symptoms, energy and activity levels, and more.

How does my menstrual cycle change as I get older?

Your cycles may change in different ways as you get older. Often, periods are heavier when you are younger (in your teens) and usually get lighter in your 20s and 30s. This is normal.

• For a few years after your first period (menarche), menstrual cycles longer than 38 days are common. Girls usually get more regular cycles within three years of starting their periods. If longer or irregular cycles last beyond that, see your doctor or nurse to rule out a health problem, such as polycystic ovary syndrome (PCOS) ¹⁴⁾.
• In your 20s and 30s, your cycles are usually regular and can last anywhere from 24 to 38 days.
• In your 40s, as your body starts the transition to menopause, your cycles might become irregular. Your menstrual periods might stop for a month or a few months and then start again. They also might be shorter or last longer than usual, or be lighter or heavier than normal.

Talk to your doctor or nurse if you have menstrual cycles that are longer than 38 days or shorter than 24 days, or if you are worried about your menstrual cycle.

Why should I keep track of my menstrual cycle?

If your periods are regular, tracking them will help you know when you ovulate, when you are most likely to get pregnant, and when to expect your next period to start.

If your periods are not regular, tracking them can help you share any problems with your doctor or nurse.

If you have period pain or bleeding that causes you to miss school or work, tracking these period symptoms will help you and your doctor or nurse find treatments that work for you. Severe pain or bleeding that causes you to miss regular activities is not normal and can be treated.

When does a girl usually get her first period?

The average age for a girl in the United States to get her first period is 12 ¹⁵⁾. This does not mean that all girls start at the same age.

A girl may start her period anytime between 8 and 15. The first period normally starts about two years after breasts first start to develop and pubic hair begins to grow. The age at which a girl’s mother started her period can help predict when a girl may start her period.

A girl should see her doctor if:

• She starts her period before age 8.
• She has not had her first period by age 15.
• She has not had her first period within three years of breast growth.

What is a normal amount of bleeding during my period?

The average woman loses about two to three tablespoons of blood during her period. Your periods may be lighter or heavier than the average amount. What is normal for you may not be the same for someone else. Also, the flow may be lighter or heavier from month to month.

Your periods may also change as you get older. Some women have heavy bleeding during perimenopause, the transition to menopause. Symptoms of heavy menstrual bleeding may include:

• Bleeding through one or more pads or tampons every one to two hours
• Passing blood clots larger than the size of quarters
• Bleeding that often lasts longer than eight days

How often should I change my pad, tampon, menstrual cup, sponge, or period panties?

Follow the instructions that came with your period product. Try to change or rinse your feminine hygiene product before it becomes soaked through or full.

• Most women change their pads every few hours.
• A tampon should not be worn for more than 8 hours because of the risk of toxic shock syndrome
• Menstrual cups and sponges may only need to be rinsed once or twice a day.
• Period panties (underwear with washable menstrual pads sewn in) can usually last about a day, depending on the style and your flow.

Use a product appropriate in size and absorbency for your menstrual bleeding. The amount of menstrual blood usually changes during a period. Some women use different products on different days of their period, depending on how heavy or light the bleeding is.

What is toxic shock syndrome?

Toxic shock syndrome (TSS) is a rare but sometimes deadly condition caused by bacteria that make toxins or poisons. In 1980, 63 women died from toxic shock syndrome. A certain brand of super absorbency tampons was said to be the cause. These tampons were taken off the market.

Today, most cases of toxic shock syndrome are not caused by using tampons. But, you could be at risk for toxic shock syndrome if you use more absorbent tampons than you need for your bleeding or if you do not change your tampon often enough (at least every four to eight hours). Menstrual cups, cervical caps, sponges, or diaphragms (anything inserted into your vagina) may also increase your risk for toxic shock syndrome if they are left in place for too long (usually 24 hours). Remove sponges within 30 hours and cervical caps within 48 hours ¹⁶⁾.

If you have any symptoms of toxic shock syndrome, take out the tampon, menstrual cup, sponge, or diaphragm, and call your local emergency services number or go to the hospital right away.

Symptoms of toxic shock syndrome include ¹⁷⁾:

• Sudden high fever
• Muscle aches
• Vomiting
• Nausea
• Diarrhea
• Rash
• Kidney or other organ failure

Charting your fertility pattern

Knowing when you’re most fertile will help you plan pregnancy. There are three ways you can keep track of your fertile times. They are:

1. Basal body temperature method – Basal body temperature is your temperature at rest as soon as you awake in the morning. A woman’s basal body temperature rises slightly with ovulation. So by recording this temperature daily for several months, you’ll be able to predict your most fertile days. Basal body temperature differs slightly from woman to woman. Anywhere from 96 to 98 degrees Fahrenheit orally is average before ovulation. After ovulation most women have an oral temperature between 97 and 99 degrees Fahrenheit (36.1 and 37.2 degrees Celsius). The rise in temperature can be a sudden jump or a gradual climb over a few days. Usually a woman’s basal body temperature rises by only 0.4 to 0.8 degrees Fahrenheit. To detect this tiny change, women must use a basal body thermometer. These thermometers are very sensitive. Most pharmacies sell them for about $10. The rise in temperature doesn’t show exactly when the egg is released. But almost all women have ovulated within three days after their temperatures spike. Body temperature stays at the higher level until your period starts.
   • You are most fertile and most likely to get pregnant:
     1. Two to three days before your temperature hits the highest point (ovulation)
     2. And 12 to 24 hours after ovulation
   • A man’s sperm can live for up to three days in a woman’s body. The sperm can fertilize an egg at any point during that time. So if you have unprotected sex a few days before ovulation, you could get pregnant.
   • Many things can affect basal body temperature. For your chart to be useful, make sure to take your temperature every morning at about the same time. Things that can alter your temperature include:
     • Drinking alcohol the night before
     • Smoking cigarettes the night before
     • Getting a poor night’s sleep
     • Having a fever
     • Doing anything in the morning before you take your temperature — including going to the bathroom and talking on the phone
2. Calendar method – This involves recording your menstrual cycle on a calendar for eight to 12 months. The first day of your period is Day 1. Circle Day 1 on the calendar. The length of your cycle may vary from month to month. So write down the total number of days it lasts each time. Using this record, you can find the days you are most fertile in the months ahead:
   1. To find out the first day when you are most fertile, subtract 18 from the total number of days in your shortest cycle. Take this new number and count ahead that many days from the first day of your next period. Draw an X through this date on your calendar. The X marks the first day you’re likely to be fertile.
   2. To find out the last day when you are most fertile, subtract 11 from the total number of days in your longest cycle. Take this new number and count ahead that many days from the first day of your next period. Draw an X through this date on your calendar. The time between the two Xs is your most fertile window.
   3. This method always should be used along with other fertility awareness methods, especially if your cycles are not always the same length.
3. Cervical mucus method also known as the ovulation method – This involves being aware of the changes in your cervical mucus throughout the month. The hormones that control the menstrual cycle also change the kind and amount of mucus you have before and during ovulation. Right after your period, there are usually a few days when there is no mucus present or “dry days.” As the egg starts to mature, mucus increases in the vagina, appears at the vaginal opening, and is white or yellow and cloudy and sticky. The greatest amount of mucus appears just before ovulation. During these “wet days” it becomes clear and slippery, like raw egg whites. Sometimes it can be stretched apart. This is when you are most fertile. About four days after the wet days begin the mucus changes again. There will be much less and it becomes sticky and cloudy. You might have a few more dry days before your period returns. Describe changes in your mucus on a calendar. Label the days, “Sticky,” “Dry,” or “Wet.” You are most fertile at the first sign of wetness after your period or a day or two before wetness begins. The cervical mucus method is less reliable for some women. Women who are breastfeeding, taking hormonal birth control (like the pill), using feminine hygiene products, have vaginitis or sexually transmitted infections (STIs), or have had surgery on the cervix should not rely on this method.

To most accurately track your fertility, use a combination of all three methods. This is called the symptothermal method. You can also purchase over-the-counter ovulation kits or fertility monitors to help find the best time to conceive. These kits work by detecting surges in a specific hormone called luteinizing hormone (LH), which triggers ovulation.

Early miscarriage

Miscarriage also called early pregnancy loss is when a baby dies in the womb (uterus) before 20 weeks of pregnancy. A miscarriage is also known as the spontaneous abortion or unexpected loss of a pregnancy before the 20th week. For women who know they’re pregnant, about 10 to 15 in 100 pregnancies (10 to 15 percent) end in miscarriage. Most miscarriages happen in the first trimester before the 12th week of pregnancy. Miscarriage in the second trimester (between 13 and 19 weeks) happens in 1 to 5 in 100 (1 to 5 percent) pregnancies.

Miscarriage is a somewhat loaded term — possibly suggesting that something was amiss in the carrying of the pregnancy. This is rarely true. Most miscarriages occur because the fetus isn’t developing normally.

In some cases, the cause of your early miscarriage is unknown. Often, it is a random problem with chromosomes that happens at conception. You might be afraid that you did something that caused your miscarriage. But things like working, exercising, having sex, or morning sickness do not cause miscarriage. Any kind of fall or blow is rarely to blame. The research on the effects of alcohol, tobacco, and caffeine is unclear. So there is nothing you could have done to prevent it. It is not the result of anything you did or didn’t do. You should never blame yourself for a miscarriage.

As many as half of all pregnancies may end in miscarriage. But researchers don’t know the exact number because many miscarriages occur so early in pregnancy that a woman doesn’t realize she’s pregnant. Fortunately most women who miscarry go on to have a healthy pregnancy later.

The main sign of a miscarriage is vaginal bleeding. This may be followed by cramping or pain in the lower abdomen and fluid or tissue passing from the vagina. Most miscarriages happen very early in the pregnancy, often before a woman even knows she is pregnant. However, bear in mind that light vaginal bleeding is relatively common during the first trimester of pregnancy (the first 12 weeks) and doesn’t necessarily mean you’re having a miscarriage. To be sure, contact your health care provider right away if you have vaginal bleeding.

Factors that may contribute to miscarriage include:

• A genetic problem with the fetus
• Problems with the uterus or cervix
• Chronic diseases, such as polycystic ovary syndrome (PCOS)

Women who miscarry early in their pregnancy usually do not need any treatment. In some cases, there is tissue left in the uterus. Doctors use a procedure called a dilatation and curettage (D&C) or medicines to remove the tissue.

Miscarriage is a relatively common experience — but that doesn’t make it any easier. Take a step toward emotional healing by understanding what can cause a miscarriage, what increases the risk and what medical care might be needed.

Counseling may help you cope with your grief. Later, if you do decide to try again, work closely with your health care provider to lower the risks. Many women who have a miscarriage go on to have healthy babies.

What is recurrent miscarriage?

If you have recurrent miscarriages also called repeat miscarriages, you have two or more miscarriages in a row. About 1 in 100 women (1 percent) have repeat miscarriages. Most women who have recurrent miscarriages (50 to 75 in 100 or 75 percent) have an unknown cause. And most women with recurrent miscarriages with an unknown cause (65 in 100 women or 65 percent) go on to have a successful pregnancy.

Do I need any medical tests after a miscarriage or recurrent miscarriages?

If you miscarry in your first trimester, you probably don’t need any medical tests. Because doctors don’t often know what causes a miscarriage in the first trimester, tests may not be helpful in trying to find out a cause.

If you have recurrent miscarriages in the first trimester, or if you have a miscarriage in the second trimester, your doctor usually recommends tests to help find out the cause. Tests can include:

• Chromosome tests. You and your partner can have blood tests, like karyotyping, to check for chromosome problems. Karyotyping can count how many chromosomes there are and check to see if any chromosomes have changed. If tissue from the miscarriage is available, your provider can test it for chromosomal conditions.
• Hormone tests. You may have your blood tested to check for problems with hormones. Or you may have a procedure called endometrial biopsy that removes a small piece of the lining of the uterus to check for hormones.
• Blood tests to check your immune system. Your provider may test you for autoimmune disorders like, antiphospholipid syndrome (APS) and lupus (systemic lupus erythematosus or SLE).
• Looking at the uterus. You may have an ultrasound, a hysteroscopy (when your provider inserts a special scope through the cervix to see your uterus) or a hysterosalpingography (an X-ray of the uterus).

How long does it take to recover from a miscarriage?

It can take a few weeks to a month or more for your body to recover from a miscarriage. Depending on how long you were pregnant, you may have pregnancy hormones in your blood for 1 to 2 months after you miscarry. Most women get their period again 4 to 6 weeks after a miscarriage.

It may take longer to recover emotionally from a miscarriage. You may have strong feelings of grief about the death of your baby. Grief is all the feelings you have when someone close to you dies. Grief can make you feel sad, angry, confused or alone. It’s OK to take time to grieve after a miscarriage. Ask your friends and family for support, and find special ways to remember your baby. For example, if you already have baby things, like clothes and blankets, you may want to keep them in a special place. Or you may have religious or cultural traditions that you’d like to do for your baby. Do what’s right for you.

Certain things, like hearing names you were thinking of for your baby or seeing other babies, can be painful reminders of your loss. You may need help learning how to deal with these situations and the feelings they create. Tell your doctor if you need help to deal with your grief. And visit Share Your Story online community (https://share.marchofdimes.org) where you can talk with other parents who have had a miscarriage.

If I miscarry, when can you try to get pregnant again?

This is a decision for you to make with your partner and your doctor. It’s probably OK to get pregnant again after you’ve had at least one normal period. If you’re having medical tests to try to find out more about why you miscarried, you may need to wait until after you’ve had these tests to try to get pregnant again.

You may not be emotionally ready to try again so soon. Miscarriage can be hard to handle, and you may need time to grieve. It’s OK if you want to wait a while before trying to get pregnant again.

Miscarriage Facts

• As many as 1 in 4 pregnancies end in miscarriage ¹⁾.
• Among women who know they are pregnant, it is estimated that 1 in 6 pregnancies end in miscarriage.
• 1 in 4 women experience a miscarriage in their lifetime ²⁾.
• The majority of miscarriages happen in the first trimester – about three in every four miscarriages happen during this period.
• Most miscarriages in the first trimester are caused by chromosomal abnormalities in the baby.
• The overall risk of miscarriage under 12 weeks in known pregnancies is 1 in 5.
• In women with a BMI (body mass index) over 30, the risk is 1 in 4.
• 1 in every 80-90 pregnancies is ectopic, which is around 12,000 pregnancies a year.
• About 1 in 100 women in the US experience recurrent miscarriages (three or more in a row) and more than 60% of these women go on to have a successful pregnancy.

Recurrent miscarriages

Many women who have a miscarriage worry they’ll have another if they get pregnant again. But most miscarriages are a one-off event.

About 1 in 100 women experience recurrent miscarriages (three or more in a row) and more than 60% of these women go on to have a successful pregnancy.

The age of the mother also influences the risk of miscarriage:

• In women under 30, 1 in 10 pregnancies will end in miscarriage.
• In women aged 35-39, this increases to up to 2 in 10 pregnancies.
• In women over 45, more than half of all pregnancies will end in miscarriage.
• In 2016, the average age of mothers increased to 30.4 years, compared with 30.3 years in 2015.

Misconceptions about miscarriage

What does NOT cause miscarriage:

• a mother’s emotional state during pregnancy, such as being stressed or depressed
• having a shock or fright during pregnancy
• exercise during pregnancy, including high-intensity activities such as jogging and cycling – but discuss with your doctor or midwife what type and amount of exercise is suitable for you during pregnancy
• lifting or straining during pregnancy
• working during pregnancy – or work that involves sitting or standing for long periods. Provided you’re not exposed to harmful chemicals or radiation. Talk with your doctor if you are concerned about work-related risks.
• having sex during pregnancy
• traveling by air
• eating spicy food

Miscarriage types

• Threatened miscarriage. If you’re bleeding but your cervix hasn’t begun to dilate, there is a threat of miscarriage. Such pregnancies often proceed without any further problems.
• Inevitable miscarriage. If you’re bleeding, cramping and your cervix is dilated, a miscarriage is considered inevitable.
• Incomplete miscarriage. If you pass fetal or placental material but some remains in your uterus, it’s considered an incomplete miscarriage.
• Missed miscarriage. In a missed miscarriage, the placental and embryonic tissues remain in the uterus, but the embryo has died or was never formed.
• Complete miscarriage. If you have passed all the pregnancy tissues, it’s considered a complete miscarriage. This is common for miscarriages occurring before 12 weeks.
• Septic miscarriage. If you develop an infection in your uterus, it’s known as a septic miscarriage. This can be a severe infection and demands immediate care.
• Recurrent miscarriage. If you have 3 or more miscarriages in your first trimester.

Miscarriage complications

Some women who miscarry develop a uterine infection, also called a septic miscarriage. Signs and symptoms of this infection include:

• Fever
• Chills
• Lower abdominal tenderness
• Foul-smelling vaginal discharge

When is the best time for pregnancy after miscarriage?

Miscarriage can cause intense feelings of loss. You and your partner might also experience anger, sadness or guilt. Don’t rush the grieving process.

Typically, sex is not recommended for two weeks after a miscarriage to prevent an infection. Talk to your health care provider about any recommendations or restrictions. Your period will likely return within six weeks; however, it’s possible to become pregnant if you have sex before your period returns.

Once you feel ready for pregnancy after miscarriage, ask your health care provider for guidance. Also, consider these guidelines if you’ve had:

• 1 miscarriage. Some research has shown that women who conceived within six months of having a miscarriage in their first pregnancy had fewer complications than did those who waited longer to conceive. If you’re healthy and feel ready, there might be no need to wait to conceive after miscarriage.

• 2 or more miscarriages. If you’ve had two or more miscarriages, talk to your health care provider. He or she might recommend testing to determine any underlying issues, as well as possible treatments, before attempting another pregnancy.

Is there anything that can be done to improve the chances of a healthy pregnancy?

Often, there’s nothing you can do to prevent a miscarriage. However, making healthy lifestyle choices before conception and during pregnancy is important for you and your baby. Take a daily prenatal vitamin or folic acid supplement, ideally beginning a few months before conception. Maintain a healthy weight and limit caffeine. Avoid alcohol, smoking and illegal drugs.

If you’ve had multiple miscarriages, future pregnancies need to be carefully planned and monitored. Consult your health care provider before conceiving again and see your doctor as soon as you think you might be pregnant.

What emotions are likely during subsequent pregnancies?

Once you become pregnant again after miscarriage, you’ll likely feel joyful — as well as anxious and scared. You might be hesitant to share your good news until later in your pregnancy. Feelings of grief over your loss also might return after you give birth. This is normal.

Talk about your feelings and allow yourself to experience them fully. Turn to your partner, family and friends for comfort. If you’re having trouble coping, consult your health care provider or a counselor for extra support.

Causes of miscarriage

There are probably many reasons why a miscarriage may happen, although the cause isn’t usually identified. The majority aren’t caused by anything the mother has done.

It’s thought most miscarriages are caused by abnormal chromosomes in the baby. Chromosomes are genetic “building blocks” that guide the development of a baby. If a baby has too many or not enough chromosomes, it won’t develop properly.

• If a miscarriage happens during the first trimester of pregnancy (the first three months), it’s usually caused by problems with the unborn baby (fetus). About three in every four miscarriages happen during this period.
• If a miscarriage happens during the second trimester of pregnancy (between weeks 14 and 26), it’s sometimes the result of an underlying health condition in the mother.
• These late miscarriages may be caused by an infection around the baby, which leads to the bag of waters breaking before any pain or bleeding. In rare cases, they can be caused by the neck of the womb opening too soon.

For most women, a miscarriage is a one-off event and they go on to have a successful pregnancy in the future.

Problems with chromosomes

About half of all miscarriages are caused when an embryo (fertilized egg) gets the wrong number of chromosomes. This usually happens by chance and not from a problem passed from parent to child through genes. Chromosomes are the structures in cells that holds genes. Each person has 23 pairs of chromosomes, or 46 in all. For each pair, you get one chromosome from your mother and one from your father. Examples of chromosome problems that can cause miscarriage include:

• Blighted ovum. This is when an embryo implants in the uterus but doesn’t develop into a baby. If you have a blighted ovum, you may have dark-brown bleeding from the vagina early in pregnancy. If you’ve had signs or symptoms of pregnancy, like sore breasts or nausea (feeling sick to your stomach), you may stop having them.
• Intrauterine fetal demise. This is when an embryo stops developing and dies.
• Molar pregnancy. This is when tissue in the uterus forms into a tumor at the beginning of pregnancy. But it still causes regular pregnancy symptoms. These include a missed period, positive pregnancy test, and nausea.
• Translocation. This is when part of a chromosome moves to another chromosome. Translocation causes a small number of repeat miscarriages.

Problems with the uterus or cervix

The cervix is the opening to the uterus that sits at the top of the vagina. Problems with the uterus and cervix that can cause miscarriage include:

• Septate uterus. This is when a band of muscle or tissue (called a septum) divides the uterus in two sections. If you have a septate uterus, your provider may recommend surgery before you try to get pregnant to repair the uterus to help reduce your risk of miscarriage. Septate uterus the most common kind of congenital uterine abnormality. This means it’s a condition that you’re born with that affects the size, shape or structure of the uterus. Septate uterus is a common cause of repeat miscarriages.
• Asherman syndrome. If you have this condition, you have scars or scar tissue in the uterus that can damage the endometrium (the lining of the uterus). Before you get pregnant, your provider may use a procedure called hysteroscopy to find and remove scar tissue. Asherman syndrome may often cause repeat miscarriages that happen before you know you’re pregnant.
• Uterine fibroids (growths) in the uterus or scars from surgery on the uterus. Fibroids and scars can limit space for your baby or interfere with your baby’s blood supply. Before you try to get pregnant, you may need a surgery called myomectomy to remove them.
• Cervical insufficiency also called incompetent cervix. This is when your cervix opens (dilates) too early during pregnancy, usually without pain or contractions. Contractions are when the muscles of your uterus get tight and then relax to help push your baby out during labor and birth. Cervical insufficiency may lead to miscarriage, usually in the second trimester. To help prevent this, your provider may recommend cerclage. This is a stitch your provider puts in your cervix to help keep it closed.

Infections

Infections, like sexually transmitted infections also called STIs and listeriosis, can cause miscarriage. An sexually transmitted infection, like genital herpes and syphilis, is an infection you can get from having sex with someone who is infected. If you think you may have an sexually transmitted infection, tell your health care provider right away. Early testing and treatment can help protect you and your baby. Listeriosis is a kind of food poisoning. If you think you have listeriosis, call your provider right away. Your provider may treat you with antibiotics to help keep you and your baby safe. Having certain infections may cause miscarriage, but they’re not likely to cause repeat miscarriages.

First trimester miscarriages (early miscarriage)

Most first trimester miscarriages are caused by problems with the chromosomes of the fetus.

Chromosomes are blocks of DNA. They contain a detailed set of instructions that control a wide range of factors, from how the cells of the body develop to what color eyes a baby will have.

Sometimes something can go wrong at the point of conception and the fetus receives too many or not enough chromosomes. The reasons for this are often unclear, but it means the fetus won’t be able to develop normally, resulting in a miscarriage.

It’s estimated up to two-thirds of early miscarriages are associated with chromosome abnormalities. This is very unlikely to recur and doesn’t mean there’s any problem with the mother or father’s chromosomes.

Abnormal genes or chromosomes

Most miscarriages occur because the fetus isn’t developing normally. About 50 percent of miscarriages are associated with extra or missing chromosomes. Most often, chromosome problems result from errors that occur by chance as the embryo divides and grows — not problems inherited from the parents.

Chromosomal abnormalities might lead to:

• Blighted ovum. Blighted ovum occurs when no embryo forms.
• Intrauterine fetal demise. In this situation, an embryo forms but stops developing and dies before any symptoms of pregnancy loss occur.
• Molar pregnancy and partial molar pregnancy. With a molar pregnancy, both sets of chromosomes come from the father. A molar pregnancy is associated with abnormal growth of the placenta; there is usually no fetal development. A partial molar pregnancy occurs when the mother’s chromosomes remain, but the father provides two sets of chromosomes. A partial molar pregnancy is usually associated with abnormalities of the placenta, and an abnormal fetus. Molar and partial molar pregnancies are not viable pregnancies. Molar and partial molar pregnancies can sometimes be associated with cancerous changes of the placenta.
• Translocation. This is when part of a chromosome moves to another chromosome. Translocation causes a small number of repeat miscarriages.

Placental problems

The placenta is the organ linking the mother’s blood supply to her baby’s. If there’s a problem with the development of the placenta, it can also lead to a miscarriage.

Things that increase your risk:

An early miscarriage may happen by chance. But there are several things known to increase your risk of problems happening.

The age of the mother has an influence:

• in women under 30, 1 in 10 pregnancies will end in miscarriage
• in women aged 35-39, up to 2 in 10 pregnancies will end in miscarriage
• in women over 45, more than half of all pregnancies will end in miscarriage

Other risk factors include:

• obesity
• smoking during pregnancy
• drug misuse during pregnancy
• drinking more than 200mg of caffeine a day – one mug of tea contains around 75mg of caffeine, and one mug of instant coffee contains around 100mg of caffeine; caffeine is also found in some fizzy drinks, energy drinks and chocolate bars
• drinking more than two units of alcohol a week – one unit is half a pint of bitter or ordinary strength lager, or a 25 ml measure of spirits, and a small 125 ml glass of wine is 1.5 units

Second trimester miscarriages

Maternal health conditions

In a few cases, a mother’s health condition might lead to miscarriage. Examples include:

• Uncontrolled diabetes
• Infections
• Hormonal problems
• Uterus or cervix problems
• Thyroid disease
• Severe high blood pressure
• Lupus
• Kidney disease
• An overactive thyroid gland (hyperthyroidism)
• An underactive thyroid gland (hypothyroidism)
• Autoimmune disorders
• Obesity

Preexisting diabetes (also called type 1 or type 2 diabetes). Diabetes is when you have too much sugar (also called glucose) in your blood. Preexisting diabetes means you have diabetes before you get pregnant.

Thyroid problems, including hypothyroidism and hyperthyroidism. They thyroid is a butterfly-shaped gland in your neck. Hypothyroidism is when the thyroid gland doesn’t make enough thyroid hormones. Hyperthyroidism is when the thyroid gland makes too many thyroid hormones.

Autoimmune disorders. These are health conditions that happen when antibodies (cells in the body that fight off infections) attack healthy tissue by mistake. Autoimmune disorders that may increase your risk of miscarriage include antiphospholipid syndrome (also called APS) and lupus (also called systemic lupus erythematosus or SLE). If you have APS, your body makes antibodies that attack certain fats that line the blood vessels; this can sometimes cause blood clots. If you have APS and have had repeat miscarriages, your provider may give you low-dose aspirin and a medicine called heparin during pregnancy and for a few weeks after you give birth to help prevent another miscarriage. Lupus can cause swelling, pain and sometimes organ damage. It can affect your joints, skin, kidneys, lungs and blood vessels. If you have lupus, your provider may treat you with low-dose aspirin and heparin during pregnancy.

Obesity. This means you have too much body fat and your body mass index (also called BMI) is 30 or higher. BMI is a measure of body fat based on your height and weight. If you’re obese, your chances of having a miscarriage may increase.

Womb structure

Problems and abnormalities with your womb can also lead to second trimester miscarriages. Possible problems include:

• non-cancerous growths in the womb called uterine fibroids
• an abnormally shaped womb

Septate uterus. This is when a band of muscle or tissue (called a septum) divides the uterus in two sections. If you have a septate uterus, your provider may recommend surgery before you try to get pregnant to repair the uterus to help reduce your risk of miscarriage. Septate uterus the most common kind of congenital uterine abnormality. This means it’s a condition that you’re born with that affects the size, shape or structure of the uterus. Septate uterus is a common cause of repeat miscarriages.

Asherman syndrome. If you have this condition, you have scars or scar tissue in the uterus that can damage the endometrium (the lining of the uterus). Before you get pregnant, your provider may use a procedure called hysteroscopy to find and remove scar tissue. Asherman syndrome may often cause repeat miscarriages that happen before you know you’re pregnant.

Weakened cervix

In some cases, the muscles of the cervix (neck of the womb) are weaker than usual. This is known as a weakened cervix or cervical incompetence.

A weakened cervix may be caused by a previous injury to this area, usually after a surgical procedure. This is when your cervix opens (dilates) too early during pregnancy, usually without pain or contractions, leading to a miscarriage. Contractions are when the muscles of your uterus get tight and then relax to help push your baby out during labor and birth. Cervical insufficiency may lead to miscarriage, usually in the second trimester. To help prevent this, your provider may recommend cerclage. This is a stitch your provider puts in your cervix to help keep it closed.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a condition where the ovaries are larger than normal. It’s caused by hormonal changes in the ovaries.

PCOS is known to be a leading cause of infertility as it can lower the production of eggs. There’s some evidence to suggest it may also be linked to an increased risk of miscarriages in fertile women.

However, the exact role polycystic ovary syndrome plays in miscarriages is unclear. No treatment has been proven to make a difference and the majority of women with PCOS have successful pregnancies with no increased risk of miscarriage.

Infections

The following infections may also increase your risk:

• rubella (German measles)
• cytomegalovirus
• bacterial vaginosis
• HIV
• chlamydia
• gonorrhea
• syphilis
• malaria

An sexually transmitted infection (STI), like genital herpes and syphilis, is an infection you can get from having sex with someone who is infected. If you think you may have an sexually transmitted infection (STI), tell your health care provider right away. Early testing and treatment can help protect you and your baby.

Food poisoning

Food poisoning, caused by eating contaminated food, can also increase the risk of miscarriage. For example:

• listeriosis – most commonly found in unpasteurized dairy products, such as blue cheese
• toxoplasmosis – which can be caught by eating raw or undercooked infected meat, particularly lamb, pork or venison
• salmonella – most often caused by eating raw or partly cooked eggs

Listeriosis is a kind of food poisoning. If you think you have listeriosis, call your provider right away. Your provider may treat you with antibiotics to help keep you and your baby safe. Having certain infections may cause miscarriage, but they’re not likely to cause repeat miscarriages.

Foods to avoid in pregnancy

There are some foods to avoid or take care with when you’re pregnant as they might make you ill or harm your baby.

Make sure you know the important facts about which foods you should avoid or take precautions with when you’re pregnant.

AVOID some raw or partially cooked eggs if you’re pregnant

AVOID all types of pâté, including vegetable pâtés, as they can contain listeria.

Liver can harm your unborn baby. Don’t eat liver or products containing liver, such as liver pâté, liver sausage or haggis, as they may contain a lot of vitamin A. Too much vitamin A can harm your baby.

Raw or undercooked meat is risky in pregnancy

Do not eat raw or undercooked meat, including meat joints and steaks cooked rare, because of the potential risk of toxoplasmosis.

Cook all meat and poultry thoroughly so it’s steaming hot and there’s no trace of pink or blood – especially with poultry, pork, sausages and minced meat, including burgers.

Wash all surfaces and utensils thoroughly after preparing raw meat to avoid the spread of harmful bugs. Wash and dry your hands after touching or handling raw meat.

Toxoplasmosis is an infection caused by a parasite found in raw and undercooked meat, unpasteurised goats’ milk, soil, cat poo, and untreated water.

If you’re pregnant, the infection can damage your baby, but it’s important to remember toxoplasmosis in pregnancy is very rare.

Toxoplasmosis often has no symptoms, but if you feel you may have been at risk, discuss it with your doctor, midwife or obstetrician. If you’re infected while you’re pregnant, treatment for toxoplasmosis is available.

Game

It’s best to avoid eating game that has been shot with lead pellets while you’re pregnant, as it may contain higher levels of lead. Venison and other large game sold in supermarkets is usually farmed and contains no or very low levels of lead. If you’re not sure whether a product may contain lead shot, ask a retailer.

Cheeses to AVOID in pregnancy

• Soft cheeses with white rinds

Don’t eat mould-ripened soft cheese (cheeses with a white rind) such as brie and camembert. This includes mould-ripened soft goats’ cheese, such as chèvre. These cheeses are only safe to eat in pregnancy if they’ve been cooked.

• Soft blue cheeses

You should also avoid soft blue-veined cheeses such as danish blue, gorgonzola and roquefort. Soft blue cheeses are only safe to eat in pregnancy if they’ve been cooked.

It’s advised pregnant women avoid some soft cheeses because they’re less acidic than hard cheeses and contain more moisture, which means they can be an ideal environment for harmful bacteria, such as listeria, to grow in.

Although infection with listeria (listeriosis) is rare, it’s important to take special precautions in pregnancy – even a mild form of the illness in a pregnant woman can lead to miscarriage, stillbirth or severe illness in a newborn baby.

Cheeses that are SAFE TO EAT in pregnancy

All hard cheeses are safe in pregnancy

You can eat hard cheeses, such as cheddar, parmesan and stilton, even if they’re made with unpasteurized milk. Hard cheeses don’t contain as much water as soft cheeses, so bacteria are less likely to grow in them. It’s possible for hard cheese to contain listeria, but the risk is considered to be low.
Soft cheeses that are safe to eat in pregnancy

Other than mold-ripened soft cheeses, all other soft types of cheese are OK to eat, provided they’re made from pasteurized milk.

These include:

• cottage cheese
• mozzarella
• feta
• cream cheese
• paneer
• ricotta
• halloumi
• goats’ cheese
• processed cheeses, such as cheese spreads

Cooked soft cheeses that are safe to eat in pregnancy

Thorough cooking should kill any bacteria in cheese, so it should be safe to eat cooked mold-ripened soft cheese, such as brie, camembert and chèvre, and cooked soft blue cheese, such as roquefort or gorgonzola, or dishes that contain them.

It’s important to make sure the cheese is thoroughly cooked until it’s steaming hot all the way through.

Be cautious with cold cured meats in pregnancy

Many cold meats, such as salami, prosciutto, chorizo and pepperoni, are not cooked, they’re just cured and fermented. This means there’s a risk they contain toxoplasmosis-causing parasites.

It’s best to check the instructions on the pack to see whether the product is ready to eat or needs cooking first.

For ready-to-eat meats, you can reduce any risk from parasites by freezing cured or fermented meats for four days at home before you eat them. Freezing kills most parasites and makes the meat safer to eat.

If you’re planning to cook the meat – for instance, pepperoni on pizza – you don’t need to freeze it first.

If you’re eating out in a restaurant that sells cold cured or fermented meats, they may not have been frozen. If you’re concerned, ask the staff or avoid eating it.

Pre-packed meat is safe to eat if you’re pregnant

Pre-packed meats such as ham and corned beef are safe to eat in pregnancy. Some websites based in other countries may suggest that you avoid pre-packed meats when pregnant.

Vitamin and fish oil supplements

Don’t take high-dose multivitamin supplements, fish liver oil supplements, or any supplements containing vitamin A.

Fish in pregnancy

You can eat most types of fish when you’re pregnant. Eating fish is good for your health and the development of your baby, but you should avoid some types of fish and limit the amount you eat of some others.

Recommendations from the Dietary Guidelines for Americans: The 2015–2020 Dietary Guidelines for Americans states that women who are pregnant or breastfeeding should consume 8–12 ounces of seafood per week, choosing from varieties that are higher in EPA and DHA and lower in methyl mercury, such as salmon, herring, sardines, and trout. These women should not consume certain types of fish, such as king mackerel, shark, swordfish, and tilefish that are high in methyl mercury, and they should limit the amount of white (albacore) tuna they consume to 6 ounces a week. The American Academy of Pediatrics has similar advice for breastfeeding women, recommending intakes of 200–300 mg DHA per day by consuming one to two servings of fish per week to guarantee a sufficient amount of DHA in breast milk ³⁾.

[Source ⁴⁾]

Fish to avoid:

When you’re pregnant or planning to get pregnant, you shouldn’t eat shark, swordfish or marlin.

Fish to restrict:

You should also limit the amount of tuna you eat to:

• no more than two tuna steaks a week (about 140g cooked or 170g raw each), or
• four medium-sized cans of tuna a week (about 140g when drained)

This is because tuna contains more mercury than other types of fish. The amount of mercury you get from food isn’t harmful for most people, but could affect your baby’s developing nervous system if you take in high levels of mercury when you’re pregnant.

When you’re pregnant, you should also avoid having more than two portions of oily fish a week, such as salmon, trout, mackerel and herring, as it can contain pollutants like dioxins and polychlorinated biphenyls (PCBs).

Remember, fresh tuna is an oily fish, so if you eat two fresh tuna steaks in one week, you shouldn’t eat any other oily fish that week.

Tinned tuna doesn’t count as oily fish, so you can eat this on top of the maximum amount of two portions of oily fish (as long as it’s not fresh tuna).

But remember not to eat more than four medium-sized cans of tinned tuna a week when you’re pregnant or trying to get pregnant.

Fish that’s safe to eat:

There’s no need to limit the amount of white fish and cooked shellfish you eat when you’re pregnant or breastfeeding.

Shellfish in pregnancy

Always eat cooked, rather than raw, shellfish – including mussels, lobster, crab, prawns, scallops and clams – when you’re pregnant, as they can contain harmful bacteria and viruses that can cause food poisoning. Cold pre-cooked prawns are fine.

Smoked fish in pregnancy is safe

Smoked fish, which includes smoked salmon and smoked trout, is considered safe to eat in pregnancy.

Sushi and pregnancy

It’s fine to eat raw or lightly cooked fish in dishes like sushi when you’re pregnant, as long as any raw wild fish used to make it has been frozen first.

This is because, occasionally, wild fish contains small parasitic worms that could make you ill. Freezing kills the worms and makes raw fish safe to eat. Cooking will also kill them.

Certain farmed fish destined to be eaten raw in dishes like sushi, such as farmed salmon, no longer need to be frozen beforehand.

This is because farmed fish are very unlikely to contain parasitic worms as a result of the rearing methods used. If you’re unsure, contact the U.S. Food and Drug Administration ⁵⁾ for advice.

Lots of the sushi sold in shops is not made at the shop. This type of sushi should be fine to eat – if a shop or restaurant buys in ready-made sushi, the raw fish used to make it will have been subject to an appropriate freezing treatment.

If you’re in any doubt, you might want to avoid eating the kinds of sushi that contain raw fish, such as tuna.

The safest way to enjoy sushi is to choose the fully cooked or vegetarian varieties, which can include:

• cooked seafood – for example, fully cooked eel (unagi) or shrimp (ebi)
• vegetables – for example, cucumber (kappa) maki
• avocado – for example, California roll
• fully cooked egg

If a shop or restaurant makes its own sushi on the premises, it must still be frozen first before being served. If you’re concerned, ask the staff.

If you make your own sushi at home, freeze the fish for at least four days before using it.

Peanuts are safe in pregnancy

You can eat peanuts or food containing peanuts, such as peanut butter, during pregnancy, unless you’re allergic to them or a health professional advises you not to.

You may have heard peanuts should be avoided during pregnancy. This is because the government previously advised women to avoid eating peanuts if there was a history of allergy – such as asthma, eczema, hay fever and food allergy – in their child’s immediate family.

This advice has now changed because the latest research has shown no clear evidence that eating peanuts during pregnancy affects the chances of your baby developing a peanut allergy.

Milk and yoghurt in pregnancy

Stick to pasteurized or ultra-heat treated (UHT) milk, which is sometimes called long-life milk.

If only raw (unpasteurized) milk is available, boil it first. Don’t drink unpasteurized goats’ or sheep’s milk, or eat foods made from them, such as soft goats’ cheese.

All types of yogurt, including bio, live and low fat, are fine. Just check that any homemade yoghurt is made with pasteurized milk, and, if not, avoid it.

Ice cream in pregnancy

Soft ice creams should be fine to eat when you’re pregnant, as they are processed products made with pasteurized milk and eggs, so any risk of salmonella food poisoning has been eliminated.

For homemade ice cream, use a pasteurized egg substitute or follow an egg-free recipe.

Foods with soil on them

Wash fruit, vegetables and salads to remove all traces of soil and visible dirt.

Caffeine in pregnancy

High levels of caffeine can result in babies having a low birthweight, which can increase the risk of health problems in later life. Too much caffeine can also cause miscarriage.

Caffeine is naturally found in lots of foods, such as coffee, tea (including green tea) and chocolate, and is added to some soft drinks and energy drinks.

Some cold and flu remedies also contain caffeine. Talk to your midwife, doctor or pharmacist before taking these remedies.

You don’t need to cut out caffeine completely, but don’t have more than 200mg a day.

The approximate amount of caffeine found in food and drinks is:

• one mug of instant coffee: 100mg
• one mug of filter coffee: 140mg
• one mug of tea: 75mg
• one can of cola: 40mg
• one 250ml can of energy drink: 80mg (larger cans of energy drink may have up to 160mg caffeine)
• one 50g bar of plain (dark) chocolate: most US brands contain less than 25mg
• one 50g bar of milk chocolate: most US brands contain less than 10mg

So, if you have one can of cola and one mug of filter coffee, for example, you have reached almost 200mg of caffeine. Don’t worry if you occasionally have more than this amount – the risks are small.

To cut down on caffeine, try decaffeinated tea and coffee, fruit juice or mineral water instead of regular tea, coffee, cola and energy drinks.

Herbal and green teas in pregnancy

There’s little information on the safety of herbal and green teas in pregnancy, so it’s best to drink them in moderation.

The food safety authority recommends drinking no more than around four cups of herbal or green tea a day during pregnancy, and to seek advice from your doctor or midwife if you’re unsure about which herbal products are safe to consume.

Bear in mind that green tea contains caffeine.

Liquorice

You can have moderate amounts of liquorice sweets or liquorice teas in pregnancy – there’s no recommendation to avoid them. However, you should avoid the herbal remedy liquorice root.

Medicines

Medicines that increase your risk include:

• misoprostol – used for conditions such as rheumatoid arthritis
• retinoids – used for eczema and acne
• methotrexate – used for conditions such as rheumatoid arthritis
• non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen; these are used for pain and inflammation

To be sure a medicine is safe in pregnancy, always check with your doctor, midwife or pharmacist before taking it.

Risk factors for miscarriage

Some things may make you more likely than other woman to have a miscarriage. These are called risk factors. Risk factors for miscarriage include:

• Age. Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it’s about 80 percent.
• Previous miscarriages. Women who have had two or more consecutive miscarriages are at higher risk of miscarriage.
• Chronic conditions. Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage.
• Uterine or cervical problems. Certain uterine abnormalities or weak cervical tissues (incompetent cervix) might increase the risk of miscarriage.
• Smoking, alcohol and illicit drugs. Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage.
• Weight. Being underweight or being overweight has been linked with an increased risk of miscarriage.
• Invasive prenatal tests. Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage.
• Being exposed to harmful chemicals. You or your partner having contact with harmful chemicals, like solvents, may increase your risk of miscarriage. A solvent is a chemical that dissolves other substances, like paint thinner. Talk to your provider about what you can do to protect yourself and your baby.

Some health conditions may increase your risk for miscarriage. Treatment of these conditions before and during pregnancy can sometimes help prevent miscarriage and repeat miscarriages. If you have any of these health conditions, tell your health care provider before you get pregnant or as soon as you know you’re pregnant:

• Autoimmune disorders. These are health conditions that happen when antibodies (cells in the body that fight off infections) attack healthy tissue by mistake. Autoimmune disorders that may increase your risk of miscarriage include antiphospholipid syndrome also called APS and lupus also called systemic lupus erythematosus or SLE. If you have antiphospholipid syndrome, your body makes antibodies that attack certain fats that line the blood vessels; this can sometimes cause blood clots. If you have antiphospholipid syndrome and have had repeat miscarriages, your provider may give you low-dose aspirin and a medicine called heparin during pregnancy and for a few weeks after you give birth to help prevent another miscarriage. Lupus can cause swelling, pain and sometimes organ damage. It can affect your joints, skin, kidneys, lungs and blood vessels. If you have lupus, your provider may treat you with low-dose aspirin and heparin during pregnancy.
• Obesity. This means you have too much body fat and your body mass index (BMI) is 30 or higher. BMI is a measure of body fat based on your height and weight. If you’re obese, your chances of having a miscarriage may increase.
• Hormone problems, like polycystic ovary syndrome (PCOS) and luteal phase defect. Hormones are chemicals made by the body. PCOS happens when you have hormone problems and cysts on the ovaries. A cyst is a closed pocket of that contains air, fluid or semi-solid substances. If you’re trying to get pregnant, your provider may give you medicine to help you ovulate (release an egg from your ovary into the fallopian tubes). Luteal phase defect can cause repeat miscarriages. It’s when you have low levels of progesterone over several menstrual cycles. Progesterone is a hormone that helps regulate your periods and gets your body ready for pregnancy. If you have luteal phase defect, your provider may recommend treatment with progesterone before and during pregnancy to help prevent repeat miscarriages.
• Preexisting diabetes also called type 1 or type 2 diabetes. Diabetes is when you have too much sugar (also called glucose) in your blood. Preexisting diabetes means you have diabetes before you get pregnant.
• Thyroid problems, including hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid). They thyroid is a butterfly-shaped gland in your neck. Hypothyroidism is when the thyroid gland doesn’t make enough thyroid hormones. Hyperthyroidism is when the thyroid gland makes too many thyroid hormones.
• Having certain prenatal tests, like amniocentesis and chorionic villus sampling. These tests have a slight risk of miscarriage. Your provider may recommend them if your baby is at risk for certain genetic conditions, like Down syndrome.
• Having an injury to your belly, like from falling down or getting hit, isn’t a high risk for miscarriage. Your body does a good job of protecting your baby in the early weeks of pregnancy.

You may have heard that getting too much caffeine during pregnancy can increase your risk for miscarriage. Caffeine is a drug found in foods, drinks, chocolate and some medicine. It’s a stimulant, which means it can help keep you awake. Some studies say caffeine may cause miscarriage, and some say it doesn’t. Until scientists know more about how caffeine can affect pregnancy, it’s best to limit the amount you get to 200 milligrams each day. This is what’s in about one 12-ounce cup of coffee.

How to prevent miscarriage

There is no conclusive research that says there is anything you can do to prevent a miscarriage. You didn’t cause it, so you couldn’t have prevented it. Often, there’s nothing you can do to prevent a miscarriage. Simply focus on taking good care of yourself and your baby:

• Seek regular prenatal care.
• Avoid known miscarriage risk factors — such as smoking, drinking alcohol and illicit drug use.
• Take a daily multivitamin.
• Limit your caffeine intake. A recent study found that drinking more than two caffeinated beverages a day appeared to be associated with a higher risk of miscarriage.
• Eating a healthy, balanced diet with at least five portions of fruit and vegetables a day
• Making attempts to avoid certain infections during pregnancy, such as rubella
• Avoiding certain foods during pregnancy, which could make you ill or harm your baby
• Being a healthy weight before getting pregnant

If you have a chronic condition, work with your health care team to keep it under control.

Your weight

Obesity increases your risk of miscarriage. A person is obese when they have a body mass index (BMI) of over 30. You can check your BMI using the healthy weight calculator. If you’re pregnant, your midwife or doctor may be able to tell you your BMI.

The best way to protect your health and your baby’s wellbeing is to lose weight before you become pregnant. By reaching a healthy weight, you cut your risk of all the problems associated with obesity in pregnancy. Contact your doctor for advice about how to lose weight. They may be able to refer you to a specialist weight-loss clinic.

As yet, there’s no evidence to suggest losing weight during pregnancy lowers your risk of miscarriage, but eating healthily and activities such as walking and swimming are good for all pregnant women.

If you weren’t active before becoming pregnant, you should consult your midwife or doctor before starting a new exercise regimen while you’re pregnant.

Treating an identified cause

Sometimes the cause of a miscarriage can be identified. In these cases, it may be possible to have treatment to prevent this causing any more miscarriages. Some treatable causes of miscarriage are outlined below.

Antiphospholipid syndrome

Antiphospholipid syndrome (APS), also known as Hughes syndrome, is a condition that causes blood clots. It can be treated with medication. Research has shown that a combination of aspirin and heparin (a medicine used to prevent blood clots) can improve pregnancy outcomes in women with the condition.

Treatment for antiphospholipid syndrome during pregnancy

Women diagnosed with antiphospholipid syndrome are strongly advised to plan for any future pregnancy. This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive. Some medications used to treat antiphospholipid syndrome can also harm an unborn baby.

If you don’t plan your pregnancy, it may be several weeks before you realize you’re pregnant. This may increase the risk of treatment to safeguard the pregnancy being unsuccessful.

Treatment during pregnancy involves taking daily doses of aspirin or heparin, or a combination of both. This depends on whether you have a history of blood clots and previous complications during pregnancy. Warfarin isn’t recommended during pregnancy because it carries a small risk of causing birth defects.

Treatment with aspirin and/or heparin is usually started at the beginning of the pregnancy and may continue for one to six weeks after you have given birth.

Lifestyle changes

If you’re diagnosed with antiphospholipid syndrome, it’s important to take all possible steps to reduce your risk of developing blood clots. Effective ways of achieving this include:

• not smoking
• eating a healthy, balanced diet – low in fat and sugar and containing plenty of fruit and vegetables
• taking regular exercise
• maintaining a healthy weight and losing weight if you are obese (have a body mass index of 30 or more)

Weakened cervix

A weakened cervix, also known as cervical incompetence, can be treated with an operation to put a small stitch of strong thread around your cervix to keep it closed. This is usually carried out after the first 12 weeks of your pregnancy, and is removed around week 37.

Miscarriage signs and symptoms

Most miscarriages occur before the 12th week of pregnancy.

Signs and symptoms of a miscarriage might include:

• Vaginal spotting or bleeding
• Pain or cramping in your abdomen or lower back
• Fluid or tissue passing from your vagina

If you have passed fetal tissue from your vagina, place it in a clean container and bring it to your health care provider’s office or the hospital for analysis.

Keep in mind that most women who experience vaginal spotting or bleeding in the first trimester go on to have successful pregnancies.

Miscarriage diagnosis

If you see your doctor or midwife because of vaginal bleeding or other symptoms of miscarriage, you may be referred to an early pregnancy unit at a hospital for tests.

If you’re more than 18 weeks pregnant, you’ll usually be referred to the maternity unit at the hospital.

Your health care provider might do a variety of tests:

• Pelvic exam. Your health care provider might check to see if your cervix has begun to dilate.
• Ultrasound. During an ultrasound, your health care provider will check for a fetal heartbeat and determine if the embryo is developing normally. If a diagnosis can’t be made, you might need to have another ultrasound in about a week.
• Blood tests. Your health care provider might check the level of the pregnancy hormone, human chorionic gonadotropin (HCG), in your blood and compare it to previous measurements. If the pattern of changes in your HCG level is abnormal, it could indicate a problem. Your health care provider might check to see if you’re anemic — which could happen if you’ve experienced significant bleeding — and may also check your blood type.
• Tissue tests. If you have passed tissue, it can be sent to a lab to confirm that a miscarriage has occurred — and that your symptoms aren’t related to another cause.
• Chromosomal tests. If you’ve had two or more previous miscarriages, your health care provider may order blood tests for both you and your partner to determine if your chromosomes are a factor.

Recurrent miscarriages

If you’ve had three or more miscarriages in a row (recurrent miscarriages), further tests are often used to check for any underlying cause. However, no cause is found in about half of cases. These further tests are outlined below.

If you become pregnant, most units offer an early ultrasound scan and follow-up in the early stages to reassure and support parents.

Karyotyping

If you’ve had a third miscarriage, it’s recommended that the foetus is tested for abnormalities in the chromosomes (blocks of DNA).

If a genetic abnormality is found, you and your partner can also be tested for abnormalities with your chromosomes that could be causing the problem, which is the rarest of known causes. This type of testing is known as karyotyping.

If karyotyping detects problems with your or your partner’s chromosomes, you can be referred to a clinical geneticist (gene expert).

They’ll be able to explain your chances of a successful pregnancy in the future and whether there are any fertility treatments, such as in vitro fertilisation (IVF), that you could try. This type of advice is known as genetic counseling.

Ultrasound scans

A transvaginal ultrasound can be used to check the structure of your womb for any abnormalities. A second procedure may be used with a 3D ultrasound scanner to study your lower abdomen and pelvis to provide a more accurate diagnosis.

The scan can also check if you have a weakened cervix. This test can usually only be carried out when you become pregnant again, in which case you’ll usually be asked to come for a scan when you are between 10 and 12 weeks pregnant.

Blood testing

Your blood can be checked for high levels of the antiphospholipid (aPL) antibody and lupus anticoagulant. This test should be done twice, six weeks apart, when you’re not pregnant.

Antiphospholipid (aPL) antibodies are known to increase the chance of blood clots and alter the way the placenta attaches. These blood clots and changes can reduce the blood supply to the foetus, which can cause a miscarriage.

Missed or delayed miscarriage

Sometimes a miscarriage is diagnosed during a routine scan carried out as part of your antenatal care. A scan may reveal your baby has no heartbeat, or that your baby is too small for the date of your pregnancy. This is called a missed or delayed miscarriage.

Miscarriage treatment

If there’s no pregnancy tissue left in your womb, no treatment is required.

Threatened miscarriage

For a threatened miscarriage, your health care provider might recommend resting until the bleeding or pain subsides. Bed rest hasn’t been proved to prevent miscarriage, but it’s sometimes prescribed as a safeguard. You might be asked to avoid exercise and sex, too. Although these steps haven’t been proved to reduce the risk of miscarriage, they might improve your comfort.

In some cases, it’s also a good idea to postpone traveling — especially to areas where it would be difficult to receive prompt medical care. Ask your doctor if it would be wise to delay any upcoming trips you’ve planned.

Miscarriage

With ultrasound, it’s now much easier to determine whether an embryo has died or was never formed. Either finding means that a miscarriage will definitely occur. In this situation, you might have several choices:

Expectant management

If you have no signs of infection and the embryo has died, you might choose to let the miscarriage progress naturally. It’s usually recommended you wait 7 to 14 days after a miscarriage for the tissue to pass out naturally. This is called expectant management. Unfortunately, it might take up to three or four weeks. This can be an emotionally difficult time. If expulsion doesn’t happen on its own, medical or surgical treatment will be needed.

If the pain and bleeding have lessened or stopped completely during this time, this usually means the miscarriage has finished. You should be advised to take a home pregnancy test after three weeks.

If the test shows you’re still pregnant, you may need to have further tests to make sure you don’t have a molar pregnancy or an ectopic pregnancy.

If the pain and bleeding haven’t started within 7 to 14 days or are continuing or getting worse, this could mean the miscarriage hasn’t begun or hasn’t finished. In this case, you should be offered another scan.

Contact your hospital immediately if the bleeding becomes particularly heavy, you develop a high temperature (fever), or you experience severe pain.

After this scan, you may decide to either continue waiting for the miscarriage to occur naturally, or have drug treatment or surgery. If you choose to continue to wait, your healthcare professional should check your condition again up to 14 days later.

Medical treatment

If, after a diagnosis of certain pregnancy loss, you’d prefer to speed the process, medication can cause your body to expel the pregnancy tissue and placenta. The medication can be taken by mouth or by insertion in the vagina. Your health care provider might recommend inserting the medication vaginally to increase its effectiveness and minimize side effects such as nausea and diarrhea. For about 70 to 90 percent of women, this treatment works within 24 hours.

You’ll experience symptoms similar to a heavy period, such as cramping and heavy vaginal bleeding. You may also experience vaginal bleeding for up to three weeks.

In most units, you’ll be sent home for the miscarriage to complete. This is safe, but ring your hospital if the bleeding becomes very heavy.

You should be advised to take a home pregnancy test three weeks after taking this medication. If the pregnancy test shows you’re still pregnant, you may need to have further tests to make sure you don’t have a molar pregnancy or an ectopic pregnancy.

You may be advised to contact your healthcare professional to discuss your options if bleeding hasn’t started within 24 hours of taking the medication.

Surgical treatment

Another option is a minor surgical procedure called suction dilation and curettage (D&C). During this procedure, your health care provider dilates your cervix with a small tube known as a dilator and removing any remaining tissue with a suction device. You should be offered a choice of general anesthetic or local anesthetic if both are suitable. Complications are rare, but they might include damage to the connective tissue of your cervix or the uterine wall.

In some cases, surgery is used to remove any remaining pregnancy tissue. You may be advised to have immediate surgery if:

• you experience continuous heavy bleeding
• there’s evidence the pregnancy tissue has become infected
• medication or waiting for the tissue to pass out naturally has been unsuccessful

If your blood group is RhD negative, you should be offered injections of a medication called anti-D immunoglobin afterwards. This is necessary to prevent rhesus disease.

Physical recovery

In most cases, physical recovery from miscarriage takes only a few hours to a couple of days. In the meantime, call your health care provider if you experience heavy bleeding, fever or abdominal pain.

You may ovulate as soon as two weeks after a miscarriage. Most women get their period again 4 to 6 weeks after a miscarriage. You can start using any type of contraception immediately after a miscarriage. However, avoid having sex or putting anything in your vagina — such as a tampon — for two weeks after a miscarriage.

Coping and support

Emotional healing can take much longer than physical healing. A miscarriage can have a profound emotional impact, not only on the woman herself, but also on her partner, friends and family. Your emotions might range from anger and guilt to despair. Give yourself time to grieve the loss of your pregnancy, and seek help from loved ones.

You may have strong feelings of grief about the death of your baby. Grief is all the feelings you have when someone close to you dies. Grief can make you feel sad, angry, confused or alone. It’s OK to take time to grieve after a miscarriage. Ask your friends and family for support, and find special ways to remember your baby. For example, if you already have baby things, like clothes and blankets, you may want to keep them in a special place. Or you may have religious or cultural traditions that you’d like to do for your baby. Do what’s right for you.

You’ll likely never forget your hopes and dreams surrounding this pregnancy, but in time acceptance might ease your pain. Talk to your health care provider if you’re feeling profound sadness or depression.

It’s usually possible to arrange a memorial and burial service if you want one. In some hospitals or clinics, it may be possible to arrange a burial within the grounds.

You can also arrange to have a burial at home, although you’ll need to consult your local authority before doing so.

Cremation is an alternative to burial and can be performed at either the hospital or a local crematorium. However, not all crematoriums provide this service and there won’t be any ashes for you to scatter afterwards.

Unlike a stillbirth, you don’t need to formally register a miscarriage. However, some hospitals can provide a certificate to mark what has happened if you want one.

Emotional impact

Sometimes the emotional impact is felt immediately after the miscarriage, whereas in other cases it can take several weeks. Many people affected by a miscarriage go through a bereavement period.

Certain things, like hearing names you were thinking of for your baby or seeing other babies, can be painful reminders of your loss. You may need help learning how to deal with these situations and the feelings they create. Tell your provider if you need help to deal with your grief. And visit Share Your Story, the March of Dimes online community ⁶⁾ where you can talk with other parents who have had a miscarriage. We also offer the free booklet From hurt to healing that has information and resources for grieving parents.

It’s common to feel tired, lose your appetite and have difficulty sleeping after a miscarriage. You may also feel a sense of guilt, shock, sadness and anger – sometimes at a partner, or at friends or family members who have had successful pregnancies.

Different people grieve in different ways. Some people find it comforting to talk about their feelings, while others find the subject too painful to discuss.

Some women come to terms with their grief after a few weeks of having a miscarriage and start planning for their next pregnancy. For other women, the thought of planning another pregnancy is too traumatic, at least in the short term.

The father of the baby may also be affected by the loss. Men sometimes find it harder to express their feelings, particularly if they feel their main role is to support the mother and not the other way round. It may help to make sure you openly discuss how both of you are feeling.

Miscarriage can also cause feelings of anxiety or depression, and can lead to relationship problems.

Getting support

If you’re worried that you or your partner are having problems coping with grief, you may need further treatment and counseling. There are support groups that can provide or arrange counseling for people who have been affected by miscarriage.

Future pregnancies

It’s possible to become pregnant during the menstrual cycle immediately after a miscarriage. But if you and your partner decide to attempt another pregnancy, make sure you’re physically and emotionally ready. Ask your health care provider for guidance about when you might try to conceive.

Keep in mind that miscarriage is usually a one-time occurrence. Most women who miscarry go on to have a healthy pregnancy after miscarriage. Less than 5 percent of women have two consecutive miscarriages, and only 1 percent have three or more consecutive miscarriages.

The predicted risk of miscarriage in a future pregnancy remains about 14 percent after one miscarriage. After two miscarriages the risk of another miscarriage increases to about 26 percent, and after three miscarriages the risk of another miscarriage is about 28 percent.

If you experience multiple miscarriages, generally two or three in a row, consider testing to identify any underlying causes — such as uterine abnormalities, coagulation problems or chromosomal abnormalities. If the cause of your miscarriages can’t be identified, don’t lose hope. About 60 to 80 percent of women with unexplained repeated miscarriages go on to have healthy pregnancies.

Are special tests recommended before attempting pregnancy after miscarriage?

If you experience two or more consecutive miscarriages, talk with your health care provider about whether further testing is needed to identify any underlying causes before attempting to get pregnant again. For example:

• Blood tests. A sample of your blood is evaluated to help detect problems with hormones or your immune system.
• Chromosomal tests. You and your partner might both have your blood tested to determine if your chromosomes are a factor. Tissue from the miscarriage — if it’s available — also might be tested.

Procedures can be done to detect uterine problems. For example:

• Ultrasound. This imaging method uses high-frequency sound waves to produce precise images of structures within the body. Your health care provider places the ultrasound device (transducer) over your abdomen or places it inside your vagina to obtain images of your uterus. An ultrasound might identify uterine problems such as fibroids within the uterine cavity.
• Hysteroscopy. Your health care provider inserts a thin, lighted instrument called a hysteroscope through your cervix into your uterus to diagnose and treat identified intrauterine problems.
• Hysterosalpingography. Your health care provider inserts a catheter inside your cervix, which releases a liquid contrast material into your uterus. The dye traces the shape of your uterine cavity and fallopian tubes and makes them visible on X-ray images. This procedure provides information about the internal contours of the uterus and any obstructions in the fallopian tubes.
• Sonohysterogram. This ultrasound scan is done after fluid is injected into your uterus though your vagina and cervix. This procedure provides information about the internal contours of the uterus, the outer surface of the uterus and any obstructions in the fallopian tubes.

If the cause of your miscarriages can’t be identified, don’t lose hope. Most women who experience repeated miscarriages are likely to eventually have healthy pregnancies.

Twin pregnancy

Twin pregnancy account for approximately 3% of live births in the United States. In the absence of assisted reproductive technology, dizygotic twins (when two eggs are fertilized by two separate sperm) are far more common than monozygotic twins (created with one egg and one sperm or one zygote which then splits into two) and account for 70% of all twin pregnancies ¹⁾. Whereas the instance of dizygotic twins (fraternal twins) is variable in different populations, the prevalence of monozygotic twinning is globally constant at 3 to 5 per a thousand births. Except for post-term pregnancy and fetal macrosomia, pregnancy-related risks are increased. Preterm birth is a prominent risk associated with twin pregnancy with others at risk for fetal growth restriction, congenital anomalies, and abnormal placentation. Other obstetric risks that increase with twin pregnancy include the risk of preeclampsia and gestational diabetes.

Most twin or multiple pregnancies are discovered during an ultrasound. During this exam, sound waves are used to create images of your uterus and baby or babies.

The normal length of gestation (period of time spent developing in the womb) for a single baby is around 40 weeks. However, gestation for twins, either identical or fraternal, is usually around 38 weeks. This shorter time is due to the increased demands on the mother’s body, and the inability of the babies to receive all the nutrients they need in the womb.

As twins are usually premature, they are more likely to have lower birthweights. Prematurity is associated with increased risk of a number of disorders, including jaundice.

Because a twin pregnancy can be more complicated than a single pregnancy, health professionals usually recommend specialist antenatal care, rather than shared care or midwife-only care. If you have any complications, specialist checks can pick them up early, which means they can be treated early.

You might be advised to see an obstetrician. Obstetricians are skilled and experienced in providing antenatal care for twin pregnancies.

Also, health professionals will usually recommend that you give birth in a hospital, rather than in a birth center or at home. Hospitals have the facilities needed to manage any complications of a twin pregnancy, like premature birth.

Some people think that if you are pregnant with twins, you need a lot of extra food. Whereas single-born pregnancies require 300 extra calories a day, most experts agree that twin pregnancies need around 1,000 extra calories a day. The type of food you eat is more important for your babies than how much you eat. Talk to your midwife or doctor about the best diet for you. You might also be advised to take certain supplements, such as folate and iron supplements.

Morning sickness or in most women’s cases, all-day sickness can be eased by eating small snacks frequently. Keeping a little something in your stomach at all times can help take the edge off of the nausea. Low-fat yogurt, fruit, smoothies, crackers, and protein shakes are all good snack options.

In addition to the extra calories, it is important to sip on water throughout the day. Keeping well hydrated may drive you crazy in later months when it seems like you’re running to the bathroom every 5 minutes; however, your babies’ extra blood flow and removal of wastes depends on it. It may help to drink more water earlier in the day and then stop after 8:00 pm so that you can sleep longer stretches at night between bathroom breaks.

Having a healthy lifestyle and diet during pregnancy is important. Eat well, take gentle exercise, drink lots of fluid and, if you feel stressed, ask for support from friends and family, or talk to your midwife or doctor.

Make sure you look after yourself. Being pregnant with twins can be more tiring both physically and emotionally. All of the common pregnancy discomforts are likely to be more noticeable with twins.

Mothers of multiple births also face higher rates of postpartum depression. Talk to your doctor or other health professional if you feel you may be experiencing this.

What does having twin pregnancy or multiple pregnancy mean for you?

Taking care of yourself is the best way to take care of your babies. If you’re carrying multiples, you can expect:

• More-frequent checkups. You’ll see your health care provider often to track your babies’ growth and development, monitor your health, and watch for signs of preterm labor. You might need frequent ultrasounds or other tests, especially as your pregnancy progresses.
• More weight gain. Gaining the right amount of weight can support your babies’ health. For twins, the recommendation is typically 37 to 54 pounds (about 17 to 25 kilograms) for women who have a normal weight before pregnancy. This can typically be accomplished by eating an extra 600 calories a day. Work with your health care provider to determine what’s right for you.
• Earlier delivery. If labor doesn’t start on its own first, your health care provider might recommend labor induction or a C-section at a certain point in your third trimester to decrease the risk of complications in the third trimester.

Will your twins be born early?

Health professionals usually aim for twins to be born at 37-38 weeks unless problems develop earlier or there’s a good reason to delay birth.

About 60% of twins are born before 37 weeks, while single babies are born at around 40 weeks.

If you know your twins will be born early, you can get ready for premature birth.

What are identical twins?

Twins conceived from one egg and one sperm are called identical or ‘monozygotic’ (one-cell) twins. Identical twins occur when the fertilized egg divides in two while it is still a tiny collection of cells. The self-contained halves then develop into two babies, with exactly the same genetic information. Around one in three sets of twins is identical. What causes the fertilized egg to split in two remains a mystery.

Types of identical twins

Depending on when the fertilized egg divides in two, monozygotic twins may:

• each have their own placenta, inner membrane (amnion) and outer membrane (chorion)
• share one placenta and one outer membrane, but have two inner membranes
• share one placenta, one outer membrane and one inner membrane.

If the division of the fertilized egg is incomplete, the twins will be conjoined (previously known as ‘Siamese’ twins).

Approximately one-quarter of identical twins are mirror images of each other, which means the right side of one child matches the left side of their twin. It is not known what causes this.

Twin pregnancy causes

Sometimes a twin or triplet pregnancy just happens. In other cases, specific factors are at play. For example, a twin pregnancy is more likely as you get older because hormonal changes can cause more than one egg to be released at a time. Use of assisted reproductive technologies — such as in vitro fertilization (IVF) also increases the odds of twins or other multiples.

Multiple births are more common than they used to be, due to the increased use of assisted reproductive techniques, in particular the use of fertility drugs. Older women are more likely to have a multiple pregnancy and, because the average age at which women give birth is rising, this is also a contributing factor. Twins account for more than 90 per cent of multiple births. There are two types of twins – identical (monozygotic) and fraternal (dizygotic).

1. Fraternal twins or dizygotic twins is the most common kind of twins — occur when two separate eggs are fertilized by two different sperm and produce two genetically unique children, who are no more alike than individual siblings born at different times. Each twin has his or her own placenta and amniotic sac (inner membrane and outer membrane). The twins can be two girls, two boys, or a boy and a girl. Contrary to popular belief, the incidence of twins does not skip generations. Twins are equally likely to be female or male.
2. Identical twins or monozygotic twins occur when a single fertilized egg splits and develops into two babies with exactly the same genetic information. Identical twins might share a placenta and an amniotic sac or the twins might share a placenta and each have separate amniotic sacs. Genetically, the two babies are identical. They’ll be the same sex and share physical traits and characteristics. Rarely, identical twins fail to completely separate into two individuals. These babies are known as conjoined twins.

Triplets and other higher order multiples can be identical, fraternal or a combination of both. Triplets or more require a closely monitored pregnancy.

Factors that increases the likelihood of having twins

Some women are more likely than others to give birth to twins. The factors that increase the likelihood include the following:

• Age of the mother – women in their 30s and 40s have higher levels of the sex hormone estrogen than younger women, which means that their ovaries are stimulated to produce more than one egg at a time
• Number of previous pregnancies – the greater the number of pregnancies a woman has already had, the higher her likelihood of conceiving twins
• Heredity – a woman is more likely to conceive fraternal twins if she is a fraternal twin, has already had fraternal twins, or has siblings who are fraternal twins
• Race – black African women have the highest incidence of twins, while Asian women have the lowest
• Assisted reproductive techniques (ART)– many procedures rely on stimulating the ovaries with fertility drugs to produce eggs, which can result in several eggs being released per ovulation
• In vitro fertilization (IVF) – multiple embryos are often transferred to the woman’s uterus to increase the chance of success.

Twin pregnancy signs and symptoms

Many women who are expecting twins find that they have quite noticeable and very early pregnancy symptoms, including tiredness, emotional ups and downs, nausea, vomiting and constipation.

Also, body changes with a twin pregnancy are much more obvious than with a single pregnancy. If you’re pregnant with twins, you might gain 16-20 kg (compared to 10-15 kg with a single pregnancy). Unfortunately, stretch marks, bloating, varicose veins and hemorrhoids are all more common in a twin pregnancy. These changes might affect the way you feel about your body.

You can talk with your doctor or midwife about the changes in your body and how you feel about these changes.

Sacroiliac joint dysfunction is a common involvement in twin gestations and prophylactic spine strengthening exercises in early second trimester can be helpful.

Because twins have an increased chance of being born early, any symptoms or concerns must be addressed for the safety of your babies. Bleeding or vaginal discharge, contractions that are becoming more frequent, pressure in the pelvis or lower back, or even diarrhea can all be signs of preterm labor. And while early bleeding in the first trimester could be the normal phenomenon of the twins implanting in the uterine wall, you should call your obstetrician if you experience bleeding at any point.

Twin pregnancies can also increase the chances of preeclampsia, a condition in which the mother has increased blood pressure, protein in the urine (detectable by urinalysis), and more swelling than is normal in pregnancy. If you notice rapid weight gain or headaches, alert your obstetrician so you may be examined as soon as possible. Depending on the severity of the situation, treatment may range from bed rest, to hospital-administered medications, to immediate delivery of the babies (the only “cure” for preeclampsia).

Twin pregnancy potential complications

Twin pregnancies are associated with more frequent complications for both the mother and the babies. However, healthy twin pregnancies and multiple pregnancies are born every day. Still, it’s important to be aware of possible complications. For example:

• Women with twin pregnancies are more likely to have pregnancy health problems and complications like severe morning sickness that is persistent, gestational diabetes, pre-eclampsia, premature labor due to waters breaking prematurely giving rise to preterm delivery of babies and bleeding.
• Gestational diabetes. If you’re carrying multiples, you’re at increased risk of gestational diabetes. This condition causes high blood sugar that can affect your pregnancy and your babies’ health. An endocrinologist, a registered dietitian or a diabetes educator can help you learn to manage your blood sugar level during your pregnancy.
• High blood pressure (pre-eclampsia). If you’re carrying multiples, you’re at increased risk of developing high blood pressure disorders during pregnancy.
• Twin-twin transfusion. Twins who share a placenta might have extra complications. Sometimes their blood supply is shared unequally, which can cause health problems for both twins. Or if the placenta itself is shared unequally, this can mean that one twin doesn’t get enough nutrients and doesn’t grow as well. This is a serious complication for both babies that might result in heart complications and the need for fetal procedures while you’re still pregnant.
• Premature birth. The more babies you’re carrying, the less likely you are to carry your pregnancy to term. If you have signs of preterm labor, you might be given injections of a steroid medication to speed your babies’ lung development. Even then, your baby might experience complications, including breathing and digestive difficulties, vision problems, and infection. Interventions to prolong pregnancy, such as bedrest, aren’t recommended because they haven’t been proved to decrease disease and death in newborns.
• C-section delivery. For twins, vaginal delivery is often possible if the first baby is in a head-down position. If not, a C-section might be recommended. In some cases, complications after the vaginal delivery of the first twin might require a C-section delivery for the second twin. For higher order multiples, the more common route of delivery is a C-section.
• Miscarriage
• Vanishing twin syndrome — a twin that is seen on ultrasound early but disappears by the next ultrasound.
• Hemorrhage (bleeding) around the birth
• Complications during labor
• Low birth weight

You can’t stop some of these complications from happening. But you can reduce your risk of having them or stop them from getting worse – by going to your antenatal appointments and telling your obstetrician, doctor or midwife if you have any physical symptoms or you feel that something is wrong.

Twin pregnancy diagnosis

The only definite way to find out whether you’re having twins or other multiples is to have an ultrasound scan. You can’t rely on hormone tests to find out whether you’re pregnant with twins.

The best time to have this ultrasound is at 10-12 weeks of pregnancy. This is usually when your health professional can say for sure how many fetuses, placentas and amniotic sacs there are. This information can tell you whether you have identical or fraternal twins. And the information also helps your health professionals recommend the right pregnancy care for you.

It is important to know whether your twins are sharing a placenta, as sharing a placenta also means sharing the blood supply from the mother. If the sharing of the blood supply is unequal, this can lead to complications. For this reason, women carrying twins sharing a placenta will need to have more frequent antenatal check-ups.

Twins sharing an inner membrane (which means they share the amniotic sac) carry an even higher risk of complications, as there is the potential for their umbilical cords to become tangled and to cut off their blood supply. In this case the pregnancy is monitored even more closely, and it may be recommended that your twins be delivered earlier.

Sometimes a seemingly normal twin pregnancy is later found to have only one baby. This is known as vanishing twin syndrome. Such an episode can be heartbreaking, frustrating and confusing. Often, there’s no clear explanation for the loss.

Zygosity testing

It is difficult to tell if twins are identical or fraternal at birth. Fraternal twins are born with individual sets of membranes, but some identical twins can also be.

One way to tell the difference is to have the twins DNA-tested this is also known as zygosity testing. Identical twins share the same genetic information, while fraternal twins share around half.

DNA testing can be done with a sample of cheek cells, collected painlessly, or by performing blood group examinations, which require a blood sample to be taken.

While the distinction may not seem important if you have two (or more) healthy babies, it can be useful to know for health reasons because identical twins have a high likelihood of experiencing the same illnesses or having the same health condition. Identical twins are also compatible for organ transplantation, should it be required.

Twin pregnancy treatment

If you’re pregnant with twins, you’ll need a higher level of care, which means more frequent antenatal appointments and tests during your pregnancy. Routine obstetric care includes review every 4 weeks until 24 weeks and after that every 2 weeks until 32 weeks when weekly evaluations occur. Antenatal appointments are a good chance to get health and lifestyle support if you need it. You can also get information about pregnancy, labor, birth and early parenting. You probably won’t need lots of extra blood tests, but you will need more ultrasounds.

If you have twins with separate placentas, it’s generally recommended that you have ultrasounds at 12-13 weeks, 20 weeks, and then every four weeks until your babies are born. You might have more frequent ultrasounds than this.

A twin pregnancy with babies sharing one placenta might be more complicated, so it’s generally recommended that you have ultrasounds about every two weeks from 12 weeks.

Twin gestations typically concluded around 36 weeks of gestation. Elective delivery in dizygotic twin gestation that is addressed and without any complications can be deferred to the 38 to 39-week obstetric window. Monochorionic diamniotic twin gestations are best managed expectantly until her to 34 weeks, and after that, delivery becomes an option should significant complications established. Typically elective delivery is deferred to the 36 to 37-week window as long as the obstetric course is entirely stable. The mode of delivery depends on prior obstetric history, current obstetric history, as well as fetal presentation. Vaginal delivery is entirely permissible and indeed recommended cephalic-cephalic presentations and may be considered for cephalic-nonspecific presentations. Breech presentation suppressed delivery device elective cesarean section. Intrapartum obstetric care includes surveillance for dysfunctional labor and risk for postpartum hemorrhage. In event of prematurity, appropriate neonatal care should be arranged.

Unique treatment options for complications of monochorionic dichorionic gestation may be necessary such as laser photoablation of the vascular connections when twin-twin transfusion syndrome occurs ²⁾. In such scenarios, fetal echocardiography is also warranted to exclude acquired pulmonary stenosis in the donor twin. The occurrence of hydrops fetalis represents an advanced age for twin-twin transfusion syndrome, and as definitive fetal treatment is not available after 26 weeks, delivery may represent the best obstetric intervention. In the context of monochorionic diamniotic twin gestation, the demise of a single fetus places the surviving fetus at risk of acute hypotension and resultant 10% to 15% risk for death. Surviving fetuses may bear stigmata of visceral ischemic injury that may include porencephalic brain cysts or disruption anterior abdominal wall. When a fetal demise occurs, in addition to obstetric challenges, there are additional emotional challenges for the couple, and they deserve supportive care. Fetal treatments are best deferred to tertiary centers. More unusual fetal treatments may include photocoagulation of the umbilical cord to optimize chances for survival of a single fetus when the survival of both the fetuses is not an achievable obstetric goal (such as twin reversed arterial perfusion). In monochorionic monoamniotic twin gestations, severing of the occluded cord may be preferred if cord entanglement is present.

Healthy eating

Healthy eating in pregnancy is about a healthy, well-balanced diet, full of vitamins and minerals.

When you’re pregnant with twins, your doctor or midwife might recommend that you get expert advice about your dietary intake of protein, carbohydrates, folate, iron, calcium, iodine, fats and overall nutrients. Dietitians have qualifications and skills to give you expert nutrition and dietary advice.

Vaginal or caesarean birth

It’s good to talk with your obstetrician and midwife about your health and your babies’ health and whether vaginal or caesarean birth will be better for you and your twins.

If you’re having twins, you’re almost twice as likely to have a caesarean birth.

You can discuss with your obstetrician the most appropriate time and ‘way’ for you to give birth to your twins.

Caring for twins

Healthy multiples have the same needs as other newborns. But you might need more rest and support than you imagined, especially if your babies are born prematurely or need special medical care after birth. You’re also at higher risk of postpartum depression. If you experience any symptoms of postpartum depression, talk to your doctor.

Take time to enjoy your babies — and ask friends, loved ones and others for help when you need it.

Second trimester pregnancy

The second part of your pregnancy is the second trimester. Second trimester begins with week 13 of your pregnancy. The 2nd trimester goes from week 13 through week 27. By the second trimester of your pregnancy, your baby is fully formed and growth continues. If you’ve had morning sickness, you should find that it starts to ease off around this time.

Most women find the second trimester of pregnancy easier than the first trimester. But it is just as important to stay informed about your pregnancy during these months.

You might notice that symptoms like nausea and fatigue are going away. But other new, more noticeable changes to your body are now happening. Your abdomen will expand as the baby continues to grow. And before this trimester is over, you will feel your baby beginning to move.

As your body changes to make room for your growing baby, you may have:

• Body aches, such as back, abdomen, groin, or thigh pain
• Stretch marks on your abdomen, breasts, thighs, or buttocks
• Darkening of the skin around your nipples
• A line on the skin running from belly button to pubic hairline
• Patches of darker skin, usually over the cheeks, forehead, nose, or upper lip. Patches often match on both sides of the face. This is sometimes called the mask of pregnancy.
• Numb or tingling hands, called carpal tunnel syndrome
• Itching on the abdomen, palms, and soles of the feet. (Call your doctor if you have nausea, loss of appetite, vomiting, jaundice or fatigue combined with itching. These can be signs of a serious liver problem.)
• Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling or if you gain a lot of weight really quickly, call your doctor right away. This could be a sign of preeclampsia.)

When will I feel my baby move?

Near the middle of your second trimester, you may begin to feel the baby. In the beginning, this feels like fluttering movements deep in your belly. Your baby moved before this, but it was too deep for you to fill it. If you have been pregnant before, you might notice the movements earlier because you’re familiar with how they feel. Mark your calendar when you first feel movements so you can let your doctor know.

Will my interest in sex come back?

You may not have felt like having sex during the first trimester. Symptoms such as morning sickness, mood swings, and low energy can affect your interest. Many women find that their desire for sex returns during the second trimester. Having sex is fine anytime during pregnancy, unless your doctor says otherwise.

Pregnancy week 13 to 16

At 14 weeks, your baby is about 85 mm long from head to bottom. If you have morning sickness it should subside around 13 or 14 weeks pregnant.

Your baby

Week 13

Your baby weighs around 25 grams. Your baby’s ovaries or testes are fully developed inside their body, and the genitals are forming outside their body. Where there was a swelling between the legs, there will now be a penis or clitoris growing, although you usually won’t be able to find out the sex of your baby at an ultrasound scan at this stage. Even the fingerprints are now formed.

Week 14

At 14 weeks, the baby is about 85mm long from head to bottom. It has hair all over its body, called lanugo. Around now, the baby begins to swallow little bits of amniotic fluid, which pass into the stomach. The kidneys start to work and the swallowed fluid passes back into the amniotic fluid as urine.

Week 15

Around this time, your baby will start to hear — it may hear muted sounds from the outside world, and any noises your digestive system makes, as well as the sound of your voice and heart.

The eyes also start to become sensitive to light. Even though your baby’s eyes are closed, they may register a bright light outside your tummy. They may also develop hiccups, a precursor to breathing.

Week 16

The muscles of the baby’s face can now move and the beginnings of facial expressions appear. Your baby can’t control these yet.

The nervous system continues to develop, allowing the muscles in your baby’s limbs to flex. Around this time, your baby’s hands can reach each other — they can form a fist, and hold each other when they touch and grab onto the umbilical cord.

You

If you’ve been feeling sick and tired with morning sickness, you’ll probably start to feel better when you’re around 13 or 14 weeks pregnant.

Some women start to experience an increased sex drive around this time, possibly due to pregnancy hormones or increased blood flow to the pelvic area. Some women don’t, and this is perfectly normal. You can find out more about sex in pregnancy.

You’ll notice a small bump developing as your womb grows and moves upwards. If you’ve been feeling the urge to pass urine more often over the last few months, that’s due to your womb pressing on your bladder and other changes in your circulation. This should ease off now but you will still pass more urine than is usually normal. See your doctor if you notice any pain when you urinate. Urinary infections can happen in pregnancy and it’s important to treat them quickly to reduce the risk of kidney infections.

Things to think about and talk to your doctor about:

• Headaches — headaches can occur more commonly during pregnancy, but if they’re distressing or severe they may be a sign of something more serious.
• Teeth and gums — your teeth and gums need a little extra care during pregnancy.

Pregnancy week 17 to 20

At 17 weeks, your baby’s body grows bigger so that the head and body are more in proportion and the baby doesn’t look so top heavy.

Your baby

By the time you’re 17 weeks pregnant, your baby is growing quickly and now weighs around 150 grams. The body grows bigger so that the head and body are more in proportion.

The face begins to look much more human, and eyebrows and eyelashes are beginning to grow. Your baby’s eyes can move now, although the eyelids are still shut, and the mouth can open and close.

The lines on the skin of the fingers are now formed, so the baby already has his or her own individual fingerprints. Fingernails and toenails are growing and the baby has a firm hand grip.

The baby moves around quite a bit, and may respond to loud noises from the outside world, such as music. You may not feel these movements yet, especially if this is your first pregnancy. If you do, they’ll probably feel like a soft fluttering or rolling sensation.

Your baby is putting on a bit of weight but still doesn’t have much fat. If you could see your baby now, it would look a bit wrinkled, although it will continue to put on weight for the rest of the pregnancy and will ‘fill out’ by the last few weeks before birth.

By 20 weeks your baby’s skin is covered in a white, greasy substance called vernix. It’s thought that this helps to protect the skin during the many weeks in the amniotic fluid.

You

At 20 weeks, you’re halfway through your pregnancy. You will probably feel your baby move for the first time when you’re around 17 or 18 weeks pregnant. Most first-time mums notice the first movements when they are between 18 and 20 weeks pregnant.

At first, you feel a fluttering or bubbling, or a very slight shifting movement, maybe a bit like indigestion. Later on, you can’t mistake the movements and you can even see the baby kicking about. Often you can guess which bump is a hand or a foot.

You may develop a dark line down the middle of your tummy and chest. This is normal skin pigmentation as your tummy expands to accommodate your growing bump. Normal hair loss slows down, so your hair may look thicker and shinier.

You’ll be offered an ultrasound scan when you are 18 to 20 weeks pregnant — this is to check for abnormalities in the baby. Your midwife or doctor can give you information about this and answer any questions.

Common minor problems can include tiredness and lack of sleep. Sleeplessness is common, but there is plenty you can do to help yourself sleep, including using pillows to support your growing bump. Some women also get headaches. Headaches in pregnancy are more common, but if they’re frequent and severe, and paracetamol doesn’t help, they could be a sign of something serious. Additionally you may get aches and pains in the lower back which can be common in pregnancy, but are not usually serious. If you experience vaginal bleeding or severe itching, see your doctor immediately.

Always consult your doctor if concerned about a condition that has come on since being pregnant. No complaint is seen as unimportant.

Things to think about:

• Keeping active — exercise in pregnancy is good for you and your baby. Find out what’s safe and when you should take care.
• Having a healthy diet — eating healthily during pregnancy will help your baby to develop and grow, and will keep you fit and well.
• Ultrasound scans — you’ll be offered ultrasound scans in pregnancy, including the anomaly scan between 18 weeks and 21 weeks and six days.

Pregnancy week 21 to 24

At 24 weeks, the baby has a chance of survival if it is born. Most babies born before this time may not live because vital organs are not developed enough.

Your baby

By 21 weeks your baby weighs around 350g. From about this stage onwards your baby will weigh more than the placenta (which, until now, was heavier than your baby). The placenta will keep growing throughout pregnancy, but not as fast as your baby.

Your baby is beginning to get into a pattern of sleeping and waking, which won’t necessarily be the same as yours. When you’re in bed at night, feeling relaxed and trying to sleep, your baby may be wide awake and moving about.

The lungs are not yet able to work properly, but your baby is practising breathing movements to prepare for life outside the uterus. Your baby gets all their oxygen from you via the placenta, and will do so until they are born.

By the time you are 24 weeks pregnant, the baby has a chance of survival if he or she is born. Most babies born before this time cannot live because their lungs and other vital organs are not developed enough. The care that can now be given in neonatal (baby) units means that more and more babies born early do survive. But for babies born at around this time, there are increased risks of disability.

You

Your womb will begin to get bigger more quickly and you will really begin to look pregnant. You may feel hungrier than before — try to stick to a sensible, balanced diet, and make sure you know what foods to avoid.

Not everybody gets stretch marks, but if you do develop them they will probably start becoming noticeable when you’re around 22 to 24 weeks pregnant. They may appear on your stomach, breasts and thighs. At first they look red and then fade to a silvery grey. Your breasts may start to leak a little pre-milk, this is normal.

Additionally you may get aches and pains in the lower back which can be common in pregnancy and are not usually serious. If you experience vaginal bleeding or severe itching, see your doctor immediately.

Always consult your doctor if concerned about a condition that has come on since being pregnant. No complaint is seen as unimportant.

Things to think about:

• Breastfeeding has lots of benefits for you and your baby. Consider how you are going to feed your baby when he or she arrives.
• Common minor problems can include backache, indigestion and piles.

Pregnancy week 25 to 28

Your baby may begin to follow a pattern for waking and sleeping. Very often this is a different pattern from yours.

Your baby

The baby is moving about vigorously and responds to touch and sound. A very loud noise may make him or her jump and kick, and you’ll be able to feel this.

Your baby is regularly passing urine into the amniotic fluid. Sometimes the baby may get hiccups and you can feel the jerk of each hiccup.

The baby’s eyelids open for the first time and he or she will soon start blinking. The eyes are almost always blue or dark blue, although some babies do have brown eyes at birth. It’s not until some weeks after the birth that your baby’s eyes become the colour that they will stay. You can find out more about your baby after the birth.

By now your baby’s heart rate will have changed to around 140 beats per minute. This is still considerably faster than your own heart rate.

Your baby’s brain, lungs and digestive system are formed but not fully mature — they’ll spend the rest of your pregnancy developing so that they work properly when your baby is born.

By 28 weeks, your baby weighs around 1kg and is perfectly formed. The baby’s heartbeat can now be heard through a stethoscope. Your partner may even be able to hear it by putting an ear to your abdomen, but it can be difficult to find the right place.

Your baby continues to put on weight as more and more fat appears under the skin.

You

You may get indigestion or heartburn, and it might be hard to eat large meals as your baby grows and takes up some of the space where your stomach normally is. You may also find you are quite often getting tired.

You may have some swelling of your face, hands or feet. This might be caused by water retention, which is normal (try resting and lifting up your swollen feet to ease it). Be sure to mention any swelling to your midwife or doctor so that they can take your blood pressure and rule out a condition called pre-eclampsia, which can cause swelling.

It is recommended that all pregnant women receive a pertussis (whooping cough) vaccination during each of their pregnancies. The vaccination is usually given around 28 weeks, but can be given anytime between 20 and 32 weeks. Women who are at risk of having an early delivery should get it at 20 weeks.

Vaccinating you is the best way to protect your baby against whooping cough. When you are vaccinated, your antibodies transfer from you to your developing baby. They receive protection from you when they are too young to be vaccinated themselves. Speak to your doctor or antenatal care provider to schedule an appointment.

The flu vaccine is also recommended during every pregnancy and at any stage of your pregnancy.

Things to think about:

• Maternity leave — if you are taking maternity leave from work, you need to tell your employer in writing before your baby is due. Check with your employer for their requirements. If your partner plans to take paternity leave (female partners can take paternity leave too) they also need to inform their employer at this time.
• Starting your birth plan — think about your preferences for labor and birth, such as pain relief, and the positions you would like to be in.

Second trimester symptoms

Most women who didn’t feel good in the first trimester of pregnancy usually start to feel better in the second trimester. The nausea and vomiting from morning sickness should lessen over time. You may have more energy and fewer mood swings as your hormones balance out. This is a good time to tackle many tasks necessary to get ready for your baby.

Be prepared to gain weight more rapidly in the second trimester. This means you may need to start wearing maternity clothes.

Breasts

Your breasts may not be as tender as they were in the first trimester, but they will continue to grow. Enlarging milk glands and deposits of fat cause the growth. These changes prepare you for breastfeeding. You may notice that the skin on and around your nipples darkens. You may also have small bumps around your nipples. The bumps are glands that make an oily substance to keep your nipples from drying out. A yellowish fluid, called colostrum, might begin to leak from your nipples.

Stretch marks

As your body grows, some areas of skin may become stretched tight. Elastic fibers right beneath the skin may tear. This creates streaks of indented skin called stretch marks. Stretch marks are likely to occur on your belly and breasts.

Not every pregnant woman gets stretch marks, but they are very common. Unfortunately, there is no way to prevent them completely. Try to manage your weight and not gain more than what your doctor recommends. There are some lotions and oils that claim to prevent stretch marks. The effects of these products are not proven. However, keeping your skin well moisturized can help cut down on itchiness. Stretch marks should fade and become less noticeable after pregnancy.

Other skin changes

Not all pregnant women have skin changes. Most often, these changes may lessen or go away after pregnancy. Common skin changes include:

• Dry, itchy skin, especially on the belly.
• Increased sensitivity to the sun. This means you might burn more easily. Make sure you wear sunscreen when spending time outside.
• A dark line (“linea nigra”) down the middle of your belly from your navel to your pubic hair.
• Patches of darkened skin on the face (sometimes called the “mask of pregnancy”).

Leg pain

You may have leg cramps, especially when you sleep. These may be related to the pressure your growing baby puts on the nerves and blood vessels that go to your legs. Make sure you sleep on your side instead of your back.

Another leg condition, deep vein thrombosis (DVT), can be serious. DVT is a blood clot that forms in a vein, and causes pain and swelling in one leg. Contact your doctor right away if you have these symptoms.

Puffiness

Your ankles, hands, and face may swell during the second trimester. This happens because your body retains more fluid for the baby. You also have slower blood circulation.

Aching back, pelvis, and hips

The job of supporting your growing belly puts stress on your back. Your hips and pelvis may begin to ache as pregnancy hormones relax the ligaments that hold your bones together. Your bones move to prepare for childbirth.

Stomach pain

The muscles and ligaments supporting your uterus stretch as your uterus grows. These can cause mild pain or cramping.

Loose teeth

Pregnancy hormones also affect the ligaments and bones in your mouth, so teeth may loosen. They return to normal after pregnancy. Contact your dentist if you have bleeding or swelling of your gums. These symptoms can be signs of periodontal disease. This condition has been linked to preterm (early) birth and low birth weight. The second trimester is the best time to have dental work done.

Nasal congestion, nosebleeds, and bleeding gums

These result from increased blood flow to the mucous membranes in your nose and mouth.

Heartburn

Heartburn may begin or worsen in the second trimester. Your growing uterus presses on your stomach, which can force food and acid up into your esophagus, causing the burn.

Urinary tract infections (UTIs)

You may develop an infection in the second trimester. Hormonal changes slow the flow of urine and your bladder doesn’t empty completely because your enlarged uterus pushes on it. Untreated urinary tract infections (UTIs) can lead to preterm labor, so tell your doctor if you think you have one. Symptoms include needing to urinate more often, a burning sensation when you urinate, or the presence of blood or a strong odor in your urine.

Braxton Hicks contractions

Also called “false labor,” Braxton Hicks contractions are a tightening of your uterine muscles. It’s one of the ways your uterus prepares for labor and delivery. Braxton Hicks make your belly feel very tight and hard, and may cause discomfort. The contractions are irregular in timing and should go away within a few minutes. See your doctor if they become regular and painful, and don’t go away when you change your position or walk around. It might be preterm labor.

At 13 weeks

A small baby bump may now be visible as your womb grows upwards and outwards. If you’ve been feeling the urge to pee a lot, then that should stop as the womb shifts away from your bladder. By the way, it shouldn’t hurt when you pee. If it does, then see your doctor, as you could have a urine infection.

Meanwhile, there’s a lot more blood pumping around your pelvic area and some women find that it sends their sex drive through the roof. It could also make you feel more thirsty. So drink more water or have more sex. Sex during pregnancy is perfectly safe, unless your midwife or doctor has advised you otherwise.

Your signs of pregnancy could include:

• swollen and bleeding gums. Your teeth are more likely to get covered in sticky plaque, and if it’s not removed then that can lead to gum disease. This is due to your pregnancy hormones – you can pretty much blame your hormones for everything over the next six months.
• pains on the side of your belly caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 13 weeks

Your baby or fetus is around 7.4 cm long from head to bottom, which is about the size of a nice ripe peach. The weight is about 25 grams, which is as heavy as a toothbrush with toothpaste on it.

Your baby’s ovaries or testes are fully developed inside and final tweaks are being made on the outside. The baby is moving around, doing a strange dance. At first the movements are very jerky and random but then they start to look more deliberate. You won’t feel the kicks and punches until around week 17. Some babies suck their thumb in the womb. It’s so cute but it actually serves a purpose as it helps to develop their sucking reflex. They’ll need this when it comes to feeding time in the big wide world.

At 14 weeks

You’re probably feeling more like yourself again now, after the tricky first trimester. As your energy soars, you may find that your appetite does too… but take it easy. Your baby doesn’t need any extra calories now, and too much weight gain in pregnancy isn’t good for you or the baby. If you get hungry between meals then ditch the crisps and top yourself up with super snacks that will give you a healthy boost.

You have an extra organ in your body that wasn’t there 14 weeks ago, and that’s the placenta. The placenta is pancake shaped – the word placenta means ‘flat cake’ in Latin. It’s full of blood and pumps out nutrients, oxygen and hormones, while removing waste products such as carbon dioxide. The placenta is firmly attached to your womb and links up with your baby through the umbilical cord.

Your blood and the baby’s blood come into close contact in the placenta – but they won’t ever mix. That’s because you might be different blood groups, and mixing them up could be dangerous.

Many women love it when their breasts get bigger. However others hate the extra weight, as it gives them backache, and swollen breasts can be painful. You could also get stretch marks and big blue veins. As usual, your hormones are to blame, along with the extra blood that’s now circulating around your body.

Keep an eye out for any yellow stains in your bra. This is probably colostrum, which is the first milk produced by mums-to-be. It’s telling you that your breasts are raring to go, so go with the flow. If it’s a problem, then start using breast pads.

Ask your doctor or midwife to have a look if you’re worried about any changes.

Your signs of pregnancy could include:

• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 14 weeks

Your baby or fetus is around 8.5cm long from head to bottom, which is the size of a kiwi fruit. The head is getting rounder and more in proportion with the rest of the body. Your baby is kicking around, but you probably won’t feel it yet. However your midwife might be able to hear the heartbeat, using a handheld monitor placed on your tummy.

Inside you, your baby is doing something quite miraculous – having a wee! This might not seem impressive, but it’s a first for them! Small amounts of the amniotic fluid are swallowed by the baby and pass into the stomach. The kidneys then kick in and the fluid is passed back out again as urine.

At 15 weeks

Your baby’s growing quickly and comes with a lot of packaging (the amniotic sac and fluid) and their own food supply (placenta). You could start getting the odd jabbing pain on the sides of your bump. It’s known as ’round ligament pain’, and putting your feet up and resting can help.

Your skin could also feel a bit itchy. Try rubbing an unperfumed moisturizer over your stomach, wear loose cotton clothing and have a cool bath. If the itching starts to drive you crazy, and particularly if it strikes at night, then see your doctor or midwife, as it could be the sign of a liver condition called ‘obstetric cholestasis’. However, it’s much more likely to be caused by your hormones.

Your signs of pregnancy could include:

• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 15 weeks

Your baby or fetus is around 10.1 cm long from head to bottom, which is about the size of an apple. The weight is around 70 grams, which is the same as a small bag of salad.

This week, your baby has been busy growing a soft layer of hair, called ‘lanugo’, all over the body. Yes, you’ve got a mini Yeti in there! The eyebrows and eyelashes are also starting to sprout.

Your baby’s eyes are now sensitive to light. Although they’re firmly shut, they could pick up a bright light in the world outside your womb.

Around now, your baby will start hearing too. Talk to your baby and they will probably hear you. They will also hear your heartbeat and any noises made by your digestive system.

At 16 weeks

Your baby is growing quickly and about to undergo another massive growth spurt. You will probably have put on some weight over the past few weeks (2 to 4 kg) but that’s just a guide, as every pregnancy is different.

You’ll probably see a midwife around now, who’ll weigh you and talk to you about how you’re getting on. You might get to hear your baby’s heartbeat for the first time. You will also get the results of any blood tests that you had at your booking appointment, which could reveal everything from your blood type to whether your iron levels are low.

You will probably have been offered a test for three infectious diseases: HIV, hepatitis B and syphilis. If an infection has been picked up, then your midwife or doctor will talk to you about the best ways to protect your health and reduce the risk of passing on the infection to your baby.

Your blood pressure will be checked and you’ll pee into a tiny cup to give a urine sample. This will be checked for signs of protein that could show if you’re at risk of developing a dangerous condition called pre-eclampsia.

Your signs of pregnancy could include:

• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding).

Your baby at 16 weeks

Your baby or fetus is around 11.6 cm long from head to bottom, which is the size of an avocado. The weight is around 100g, which is the same as a medium bag of salad.

Your baby is starting to pull faces now, but any smiling or frowning will be completely random, as there’s no muscle control yet.

The nervous system continues to develop, and this enables your baby to start moving their arms and legs. You might be able to feel your baby kicking from next week onwards, which is something exciting to look forward to.

Your baby’s hands can form fists and they may start punching around inside you too.

At 17 weeks

This is a major milestone and a highlight of many pregnancies. The big news of the week is that you may start to feel your baby move.

You may be getting a few pains and niggles as your bump gets bigger. Your symptoms should be manageable, and if they’re not, talk to your doctor or midwife.

Week by week, your baby’s getting bigger, and so is your placenta, which is feeding your baby and also removing waste. By the end of your pregnancy the placenta will weigh around 500g, which is as heavy as a packet of pasta.

Your waist will start to vanish as your womb moves up and out of your pelvis. This will make you look more obviously ‘pregnant’ and, with any luck, you’ll start to ‘bloom’ too. Many women look and feel amazing when they’re pregnant. They have glossy, full hair (as hair loss is slowed down) and radiant skin (caused by a boost in blood volume and hormones).

However, everyone’s different, and some women feel unattractive and overwhelmed by their changing body, the responsibility of having a baby and the strain it can put on relationships. Around 1 in 10 women feel stressed or anxious during their pregnancy, and your hormones can make even small problems feel so much worse than they really are. If you feel sad or worried, then talk to your doctor or midwife – there’s a big support network out there for you.

Your signs of pregnancy could include:

• tiredness and sleeping problems
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 17 weeks

Your baby or fetus is around 12 cm long, from head to bottom, and weighs around 150 grams. That’s roughly the size of a pomegranate and the weight of a ball of mozzarella. The baby’s skin is wrinkled and there’s a lot of fattening up to do. By the end of your pregnancy, your little one will be much plumper and will fit into their skin better, although they may still come out looking rather creased.

Plus:

• your baby’s eyes can move, although they’ll stay shut for now
• they can react to loud noises
• their mouth can open and close
• fingernails are starting to grow

Your baby will have their own unique fingerprints. Even identical twins have different fingerprints.

At 18 weeks

You could feel your baby move for the first time. Plus you could see your baby in close-up if you choose to have an anomaly scan. You may feel happy, sad, excited or nervous – sometimes all at once! It’s an emotional roller-coaster.

You might be starting to feel a bit clumsier as your belly gets bigger. Your breasts may have gone up a size, too, particularly if it’s your first pregnancy. Your blood pressure is probably a bit lower than it was, so don’t leap up from the sofa, or it could make you feel dizzy.

Your baby has been moving around for the past couple of months, but you wouldn’t have noticed because they were so small. Now, you might start to feel some movement – it’s like a bubbling or fluttering inside your belly.

You may also notice a line down your stomach, called the linea nigra (Latin for ‘black line’). This is normal skin pigmentation and nothing to worry about. It will probably vanish a few months after your baby’s born.

Your signs of pregnancy could include:

• stretch marks
• tiredness and sleeping problems
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 18 weeks

Your baby or fetus is around 14.2 cm long from head to bottom, and weighs around 190 grams. That’s approximately the size and weight of a sweet red pepper.

Your baby’s reflexes are developing this week and on the agenda will be hearing, feeling, swallowing and sucking. They will also be doing a lot of wriggling around and moving their little arms and legs.

At 19 weeks

You’re probably starting to feel less agile now and may be getting tired from lack of sleep or lugging around the extra weight. Tempting though it is to stay on the sofa, get out there and do some exercise, but try not to overdo it, as you’re carrying precious cargo.

It’s great for you and baby to stay active, but some exercises, such as running, could become uncomfortable. That’s because the hormone, relaxin, loosens up your ligaments, leaving your back, knees and ankles without their usual support.

Meanwhile, your baby’s moving. You might think that bubbling is wind, but it could be your baby moving. You’ll soon be able to pinpoint every kick, punch and somersault.

Your signs of pregnancy this week could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your pregnant belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 19 weeks

Your baby or fetus is around 15.3 cm long from head to bottom, and weighs around 240 grams. That’s approximately the size of a beef tomato and weight of two salmon fillets. Your baby’s fattening up, ready for their big appearance in about 21 weeks’ time.

The baby’s adult teeth are starting to grow, and they’re lining up behind the first set. You won’t get to see any teeth at all until your baby’s about six months old.

At 20 weeks

You may have your anomaly scan this week, where you can meet and greet your baby. The sonographer will be checking on your baby’s development and will also examine your placenta (that’s the pancake-shaped organ in your body that feeds your baby and removes waste). Seeing your baby at the anomaly scan gives many women a real boost. However not everyone’s the same, and you could be starting to get tired and even a bit grumpy as your body changes and life as you knew it starts to slip away.

You might find yourself being woken up at night by sudden sharp pains in your calves. That’s probably cramp, which is common in pregnancy. It’s caused by muscular spasms, and it can feel like you’re being stabbed in the leg for up to 10 minutes. Rub the muscle hard or pull your toes up towards your ankle. Exercising more in the day could help you avoid this.

Your signs of pregnancy this week could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (known as ’round ligament pains’)
• headaches
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• sore breasts
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, such as morning sickness, weird pregnancy cravings, a heightened sense of smell, mood swings, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 20 weeks

Your baby or fetus is around 25.6 cm long, which is the size of a banana. Measurements are now taken from head to heel. In earlier weeks, babies are measured from the head to the bottom because the legs are curled up and hard to see. Your baby weighs around 300 grams. That’s approximately the weight of three juicy apples.

Your baby is now covered in a white, greasy layer of something called ‘vernix’. It’s thought that this protects their delicate skin from drying out in the amniotic fluid. This slippery layer also helps babies to make their way down the birth canal.

Your baby will be doing acrobatics in your womb, getting more active each day. As well as kicking, punching and turning around, your baby could be sucking their thumb – this develops their sucking reflex, which they’ll need to suck milk once they’re born.

You may start to feel a bubbling or fluttering in your pregnant belly. That could be your baby moving.

At 21 weeks

You could start feeling rather wobbly as your bump gets bigger. It’s hardly surprising if you’re clumsier than usual, as your centre of gravity has changed and your joints are looser. If you fall over, don’t panic, as there’s lots of cushioning in your belly to protect your baby. That’s what the amniotic sac is for. However, for peace of mind, you should get checked out by your midwife or doctor if you do take a tumble.

Your baby is moving around a lot now, and establishing waking and sleeping patterns. The only trouble is, your baby may be raring to go just when you want to nod off. Have power naps when you can to make up for lost sleep at night.

Don’t ignore any painful symptoms and assume they’ll go away. If you have a severe headache that lasts for more than two or three hours, and isn’t helped by paracetamol, then call your midwife or doctor. It’s very unlikely, but it could be a sign of a dangerous condition called pre-eclampsia. This affects some women in the second half of their pregnancy. However it’s much more likely that you’re not drinking enough water, so make sure that you stay hydrated and drink at least eight medium glasses of fluid a day (for example, fruit juice, water, fruit teas and milk).

This week, your signs of pregnancy could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 21 weeks

Your baby or fetus is around 26.7 cm long from head to toe, and weighs about 350 grams. That’s approximately the size of a carrot, and the weight of five wholemeal pitta breads.

Your baby is now heavier than the placenta. The placenta basically doubles up as a larder and toilet, by providing food and removing waste. It will keep on growing during your pregnancy so it can do its vital work.

Meanwhile your baby has been cultivating a fine, downy layer of hair called lanugo – the purpose of this fur coat is probably to keep your baby at the perfect temperature, and it usually vanishes before the birth. Your baby is also sprouting hair and eyebrows – some babies are born with very little hair, others rock up with a big mop top. It doesn’t make as much difference, within the first year of their life, they’ll probably lose all the hair they were born with as their hormone levels change.

Your baby can now hear noises and voices outside their cosy womb.

At 22 weeks

Many women are excited to see their bump grow, but less happy when they notice that it’s covered in red and purple streaks. These are stretch marks, caused by your pregnancy hormones and the rapid stretching of your skin. They might look scary, but they’re harmless to you and the baby. There’s not a lot that you can do to either prevent them or make them vanish, but you could try gently massaging your bump with a non-perfumed moisturizer. After the birth, the marks will probably fade to silver.

You might also notice that your breasts are becoming a bit leaky. This is their way of prepping for the birth. Use breast pads to stop your clothes getting stained – you might as well stock up, as you’ll probably need a stack after the birth.

This week, your signs of pregnancy could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding).

Your baby at 22 weeks

Your baby or fetus is around 27.8 cm long from head to toe, and weighs about 430 grams. That’s approximately the size of a papaya and the weight of five tangerines.

The lungs are developing and your little one will be doing some breathing practice in your womb. Your baby is now swallowing small amounts of the amniotic fluid. This will usually stay in the bowels and then come out after the birth as a dark, sticky poo (‘meconium’).

Your baby’s taste buds are developing and could be influenced by what you eat. Try and eat healthily and tuck into lots of fresh fruit and vegetables.

At 23 weeks

Around this time, your baby is practising breathing, and getting into patterns of sleeping and waking. Unfortunately, they won’t always coincide with when you want to sleep – but that’s babies for you.

Your breasts may be starting to leak colostrum, which is an early type of milk. This gives your baby a flying start by boosting their immunity so they can fight off infections. It’s good for you too, as it lowers your risk of breast cancer and burns around 300 calories a day.

This week, you may start to get rib pain as your rib cage expands to accommodate your bump. You could be feeling a bit more breathless than usual as the growing baby puts pressure on your lungs. The best remedy is to put your feet up and relax. If you’re worried about any symptoms of pregnancy, talk to your midwife or doctor.

This week, your signs of pregnancy could also include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 23 weeks

Your baby or fetus is around 28.9 cm long from head to heel and weighs about 500 grams. That’s approximately the size of a squash and the weight of a packet of wholewheat dried pasta.

The limbs are now in proportion. Over the next few weeks, you’re going to be kicked around by your baby and will start to see your tummy move too, which looks very strange. Get to know your baby’s rhythms and talk to your midwife or doctor if the kicking slows down.

At 24 weeks

You may start to feel really hungry, but you don’t actually need to eat any more until the third trimester of your pregnancy – that’s from week 28 onwards. You’re likely to be putting on weight, but do not worry if you can barely see your bump, as every pregnancy is different. Your midwife or doctor will tell you if everything’s coming along nicely.

Around now, you could be getting pains around your ribs, back, breasts, bottom, stomach, basically anywhere and everywhere. This is partly due to your pregnancy hormones loosing up your ligaments and muscles, and also due to that growing baby of yours pushing onto various parts of your body.

This week, your signs of pregnancy could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 24 weeks

Your baby or fetus is around 30 cm long from head to heel, and weighs about 600 grams. That’s approximately the size of an ear of corn, and the weight of a big tub of low fat cottage cheese.

Your baby looks like a baby with everything in proportion, they’re just skinnier and smaller than a baby who’s been in the womb for longer.

The amazing news is that there’s a chance of survival if your baby is born now. Their lungs and other vital organs might just be able to cope with life outside the womb. There are specialist neonatal units for very tiny babies that can help them breathe, feed, keep warm and fight infections. However the earlier the baby is born, the more likely it is that they will have a disability. If you go into labor before your 37th week of pregnancy, it’s called premature labor. However it’s much more likely that you’ll have to wait at least another three months before meeting your baby.

At 25 weeks

You could be starting to get a bit puffy and swollen in your face, hands and feet. This is probably completely harmless and caused by water retention – but do mention it to your midwife or doctor. They will want to check your blood pressure, just in case it’s a sign of a dangerous condition called pre-eclampsia. This tends to strike in the second half of pregnancy or after the baby is born. If you get any other signs, such as splitting headaches, vision problems, or pain just below the ribs, then see your doctor.

Your energy levels could be flagging now, and you might be struggling to digest large meals, as your baby takes over your belly.

This week, your signs of pregnancy could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 25 weeks

Your baby or fetus is around 34.6 cm long from head to heel, and weighs about 660 grams. That’s approximately the size of a head of cauliflower, and the weight of four jacket potatoes.

This is an active time for your baby, who will be throwing some crazy shapes inside you (kicking, punching and doing somersaults). A loud noise could make your baby jump and kick, which shouldn’t hurt, but might take you by surprise. You might also feel the occasional hiccup.

Your baby is now peeing into the amniotic fluid. By now, most of the liquid around your baby is urine, but it’s providing cushioning and helping to keep the temperature snug and stable.

At 26 weeks

As you approach the third trimester, you might be feeling more tired, and a bit more clumsy and uncoordinated. That’s understandable. It’s hard carrying around all that extra weight and also your center of gravity will have changed with your growing bump, and that affects your sense of balance. You may need to allow yourself more time to do your usual activities, like your daily walk to the bus stop.

There’s a lot of activity going on inside your bump – kicking, punching, somersaults and hiccupping. Get to know your baby’s patterns, and if you’re worried that the movements have slowed down or stopped, then contact your midwife or maternity unit straight away.

You may be getting more leg cramps now, particularly during the night when you really want to sleep. Try doing foot and ankle exercises. Just pulling your toes upwards could help, or rubbing the muscle where it hurts.

This week, your signs of pregnancy could include:

• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• bloating and constipation
• indigestion and heartburn
• leg cramps](/start4life/pregnancy/week-by-week/2nd-trimester/week-20 “Leg cramps”)
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings,a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding).

Your baby at 26 weeks

Your baby or fetus is around 35.6 cm long from head to heel, and weighs about 760 grams. That’s approximately the size of small marrow, and the weight of six large carrots.

Around now, your baby’s eyes will be opening for the first time and the next trick will be to learn how to blink. It’s a myth that all babies are born with blue eyes – the color will depend on the parents’ genetics, and brown is very common. You won’t know the permanent color for a while, as they can keep on changing right into adulthood. However they will have probably settled on a color by the time your baby’s three.

At 27 weeks

You’re probably putting on a few pounds now, and your waist is a distant memory. You could be feeling bloated and constipated, and having problems keeping down food. This is partly because your stomach is being squeezed by your growing baby, and also due to the pregnancy hormone, progesterone. It might help if you drink lots of water, choose high fiber options and eat lots of fresh fruit and vegetable.

You could be feeling tired now, so nap when you can in the day. Your partner might mention that you’re snoring more. Snoring is very common in pregnancy as your nasal passages are more likely to become swollen and blocked.

Your signs of pregnancy could also include:

• sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• nosebleeds
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding).

Your baby at 27 weeks

Your baby or fetus is around 36.6 cm long from head to heel, and weighs about 875 grams. That’s approximately the size of a big leek, and the weight of a head of cauliflower.

Your baby’s lungs are now capable of breathing and that’s a big deal. Your baby is also getting plumper by the day. A few weeks ago, your baby looked a bit like a wrinkled prune. Now the folds of skin are being filled out by fat, and all their organs are maturing, as your baby prepares for life outside the womb.

Third trimester pregnancy

The final part of your pregnancy is the third trimester. Third trimester begins with week 28 of your pregnancy. The third trimester goes from week 28 through week 40 (or birth). This is the last 12 weeks of your pregnancy. In some ways, these final three months are a bit like the first three. You may be more tired and more emotional during this time. A lot of your body’s energy is directed toward supporting a rapidly growing fetus. It’s common to feel the need to reduce your activities and your work load. Try to rest as much as you can. Aches and discomforts in your belly and back are more common.

Heartburn and low back pain are also common complaints at this time in pregnancy. When you’re pregnant, your digestive system slows down. This can cause heartburn as well as constipation. Also, the extra weight you are carrying puts stress on your muscles and joints.

It is important that you continue to:

• Eat well — including protein rich foods and vegetables frequently and in small amounts
• Rest as needed
• Get exercise or get a walk in on most days

In your third trimester, you will have a prenatal visit every 2 weeks until week 36. After that, you will see your doctor every week. The visits may be quick, but they are still important. It is OK to bring your partner or labor coach with you.

During your visits, your doctor or midwife will:

• Weigh you
• Measure your abdomen to see if your baby is growing as expected
• Check your blood pressure
• Take a urine sample to test for protein in your urine, if you have high blood pressure

Your doctor may also give you a pelvic exam to see if your cervix is dilating.

At the end of each visit, your doctor or midwife will tell you what changes to expect before your next visit. Tell your doctor if you have any problems or concerns. It is OK to talk about them even if you DO NOT feel they are important or related to your pregnancy.

There are no other routine lab tests or ultrasounds for every pregnant woman in the third trimester. Certain lab tests and tests to monitor the baby may be done for women who:

• Have a high-risk pregnancy, such as when the baby is not growing
• Have a health problem, such as diabetes or high blood pressure
• Have had problems in a prior pregnancy
• Are overdue (pregnant for more than 40 weeks)

Checking your baby’s movement

In between your appointments, you will need to pay attention to how much your baby is moving. As you get closer to your due date, and your baby grows bigger, you should notice a different pattern of movement than earlier in your pregnancy.

• You will notice periods of activity and periods of inactivity.
• The active periods will be mostly rolling and squirming movements, and a few very hard and strong kicks.
• You should still feel the baby move frequently during the day.

Watch for patterns in your baby’s movement. If the baby suddenly seems to be moving less, eat a snack, then lie down for a few minutes. If you still don’t feel much movement, call your doctor or midwife.

See your doctor any time you have any concerns or questions. Even if you think you are worrying over nothing, it is better to be on the safe side and call.

Pregnancy week 29 to 32

By about 32 weeks the baby is usually lying with its head pointing downwards, ready for birth. Your baby continues to be very active at this stage, and you’ll probably be aware of lots of movements. Leg cramps at night are common around 29 to 32 weeks pregnant.

Your baby

Your baby continues to be very active at this stage, and you’ll probably be aware of lots of movements. There is no set number of movements you should feel each day — every pregnancy is different. You should be aware of your baby’s own pattern of movements, and if this pattern changes contact your midwife or hospital to tell them.

The sucking reflex is developing by now and your baby can suck its thumb or fingers. The baby is growing plumper and the skin begins to look less wrinkled and much smoother.

The white, greasy vernix and the soft, furry lanugo (fine hair) which have covered your baby’s skin for some time begin to disappear. Your baby’s eyes can focus now. The lungs are developing rapidly, but your baby wouldn’t be fully able to breathe on its own until about 36 weeks.

By about 32 weeks the baby is usually lying with their head pointing downwards ready for birth. This is known as ‘cephalic presentation’. If your baby isn’t lying head down at this stage, it’s not a cause for concern — there is still time for them to turn.

The amount of amniotic fluid in your uterus is increasing, and your baby is still swallowing fluid and passing it out as urine.

You

As your bump pushes up against your lungs and you have extra weight to carry around, you may feel breathless.

Leg cramps at night are common around 29 to 32 weeks pregnant. You may find it hard to sleep because you can’t get comfortable. Try lying curled up on your side with a pillow between your legs and a cushion under your bump to see if it feels more comfortable. You might find you need to pass urine a lot as well. You can find out about more common pregnancy health problems.

Your midwife or doctor will measure the size of your womb and check which way up the baby is at every antenatal visit. They will also measure your blood pressure, test your urine for protein and discuss the results of any screening tests from your last appointment. If you experience vaginal bleeding or severe itching, see your doctor immediately.

Things to think about

• Maternity leave — if you are taking maternity leave from work, you need to tell your employer in writing before your baby is due. Check with your employer for their requirements. If your partner plans to take paternity leave (female partners can take paternity leave too) they also need to inform their employer at this time.
• Starting your birth plan — think about your preferences for labour and birth, such as pain relief, and the positions you would like to be in.

If something happens during your pregnancy, it’s very important you have all the support you need. You can get support from your care team.

Pregnancy week 33 to 36

Your baby

By 33 weeks of pregnancy the baby’s brain and nervous system are fully developed. Your baby’s bones are also continuing to harden, apart from the skull bones. These will stay soft and separated until after the birth to make the journey through the birth canal easier — the bones can move gently and slide over each other so that the head can be born safely while still protecting the brain.

Your baby is curled up in the uterus now, with legs bent up towards the chest. There is little room to move about, but they will still change position, so you’ll still feel movements and be able to see them on the surface of your bump.

If your baby is a boy, his testicles are beginning to descend from his abdomen into his scrotum.

By 36 weeks your baby’s lungs are fully formed and ready to take their first breath when they’re born. They will also be able to suckle for feeds now, and the digestive system is fully prepared to deal with breast milk.

You

You need to slow down because the extra weight will make you tired, and you may get backache. From about 34 weeks pregnant, you may be aware of your womb tightening from time to time. These are practice contractions known as ‘Braxton Hicks’ contractions, and are a normal part of pregnancy. It’s only when they become painful or frequent that you need to contact your midwife or hospital.

Only around 5% of babies arrive on their due date. If you have children already, you may want to make childcare arrangements for when you go into labor. Pack your bag ready for the birth if you are planning to give birth in hospital or a midwifery unit.

When you are around 36 weeks pregnant, make sure you have all your important telephone numbers handy in case labor starts.

During this stage of pregnancy, your midwife or doctor will also measure the size of your womb and check which way up the baby is at every antenatal visit. They will also measure your blood pressure, test your urine for protein and discuss the results of any screening tests from your last appointment. If you experience vaginal bleeding or severe itching, see your doctor immediately.

Things to think about

• Pain relief during labor — be prepared by learning about all the ways you can relieve pain during labor, so you can decide what’s best for you.
• Make your birth plan — think about your preferences for labor, such as pain relief and positions you might want to be in.
• If labor starts early — labor that starts before 37 weeks is considered premature. If your baby is born early, they may need special care in hospital.

Pregnancy week 37 to 40

Your baby

At 37 weeks, your pregnancy is considered full-term. The baby’s gut (digestive system) now contains meconium — the sticky, green substance that will form your baby’s first poop after birth. It may include bits of the lanugo (fine hair) that covered your baby earlier in pregnancy. If your baby does a poop during labor, which can sometimes happen, the amniotic fluid will contain meconium. If this is the case, your midwife will want to monitor your baby closely as it could mean they are stressed.

In the last weeks, some time before birth, the baby’s head should move down into your pelvis. When your baby’s head moves down like this, it is said to be ‘engaged’. When this happens, you may notice that your bump seems to move down a little. Sometimes the head doesn’t engage until labor starts.

The average baby weighs around 3-4 kg by now.

The lanugo that covered your baby’s body is now almost all gone, although some babies may have small patches of it when they’re born. Due to the hormones in your body, the baby’s genitals may look swollen when they’re born, but they will soon settle down to their normal size.

Your baby is ready to be born, and you’ll be meeting them some time in the next couple of weeks.

You

When you are around 37 weeks pregnant, if it’s your first pregnancy you may feel more comfortable as your baby moves down ready to be born, although you will probably feel increased pressure in your lower abdomen. If it’s not your first pregnancy, the baby may not move down until labor.

Most women will go into labor between 38 and 42 weeks of pregnancy. Your midwife or doctor should give you information about your options if you go beyond 41 weeks pregnant.

Call your hospital or midwife at any time if you have any worries about your baby or about labor and birth. If you experience vaginal bleeding or severe itching, see your doctor immediately.

Find out what to expect if your baby is overdue.

Get ready for labor

• What happens in labor — find out how to tell if labor is starting, and what happens in each of the three stages of labor.
• Pain relief during labor — be prepared by learning about all the ways you can relieve pain during labor so you can decide what’s best for you.

Be ready for the birth

• When to go to the hospital and what to expect — find out at what point during your labor you should contact your hospital or birth centre, and what to expect when you get there.
• What to take — find out what to take to the hospital for you and your baby.

Common concerns you may have about birth

• Breech birth — a breech birth is when a baby is born bottom first, which is more complicated than a head-first birth.
• Cesarean section — a caesarean section is when you have surgery to deliver your baby.
• Induction — your maternity team may recommend that your labor be started artificially. This is called ‘induction’.

If your baby is born too soon

• If labor starts early — labor that starts before 37 weeks is considered premature.
• If your baby is born early, they may need special care in hospital.

Overdue

Pregnancy normally lasts about 40 weeks (that’s around 280 days from the first day of your last period). Most women go into labor within a week either side of this date, but some women go overdue.

If your labor doesn’t start by the time you are 41 weeks pregnant, your midwife or doctor may offer you a ‘membrane sweep‘ to see if this will trigger labor.

This involves having a vaginal examination, which stimulates the neck of your womb (known as the ‘cervix’) to produce hormones that may trigger natural labor. You don’t have to have this — you can discuss it with your midwife or doctor.

If your labor still doesn’t start naturally after this, your midwife or doctor will suggest a date to have your labor induced, which is when your doctor or midwife uses drugs or tools and techniques to get your labor to start.

If you don’t want your labor to be induced, and your pregnancy continues to 42 weeks or beyond, you and your baby will be closely monitored every 3 to 4 days.

Your midwife or doctor will check that both you and your baby are healthy by giving you ultrasound scans and checking your baby’s movement and heartbeat. If your baby is not doing well, your doctor and midwife will again suggest that labor is induced.

Induction is always planned in advance, so you’ll be able to discuss the advantages and disadvantages with your doctor and midwife, and find out why they think your labor should be induced. It’s your choice whether to have your labor induced or not.

Over 42 weeks pregnant

Most women go into labor spontaneously by the time they are 42 weeks pregnant.

If your pregnancy lasts longer than 42 weeks and you decide not to have your labor induced, you should be offered increased monitoring to check your baby’s wellbeing.

Once your baby is overdue for sure, an ultrasound might sometimes show that your placenta isn’t supplying as much oxygen and as many nutrients to your baby as it was. There might also be other concerns about you or your baby.

In these cases, your doctor or midwife will probably suggest an induction or a caesarean. If tests show that your baby is fine and your health is good, you might choose to wait and see whether labor starts naturally.

There is a higher risk of stillbirth or fetal compromise (your baby’s health being put at risk) if you go over 42 weeks pregnant, but not every pregnancy over 42 weeks is affected this way. At the moment, there is no way to find out which babies might be affected, so induction is offered to all women who don’t go into labor by 42 weeks.

Third trimester trimester symptoms

As your baby grows, your body will feel even more awkward and heavy. Everyday things—like getting out of bed or standing up from a chair—will require extra effort.

Your body, and your body’s hormones, will affect how you feel during this time.

• The tiredness you felt early in pregnancy may return. Making time for naps is a good idea.
• You will feel your baby move, especially at the beginning of this trimester.
• The “nesting instinct” may kick in. You may feel a need to clean the house or finish getting things ready for baby. Take it slow so you don’t wear yourself out.
• You may feel more emotional as you prepare for labor, delivery, and parenthood.

Your body may experience some physical changes during the 3rd trimester.

Puffiness

Slowed blood circulation and fluid retention are to blame for swelling in your legs, ankles, feet, hands, and face.

If swelling in your hands and face becomes extreme, call your doctor. See your doctor right away if you also have a headache, blurred vision, dizziness, and belly pain. These may be signs of a dangerous condition called preeclampsia.

Tingling and numbness

The swelling in your body may press on nerves, causing tingling and numbness. This can happen in your legs, arms, and hands. The skin on your belly may feel numb because it is so stretched out.

Tingling and numbness in the hands usually occurs because of carpal tunnel syndrome. That is caused by pressure on a nerve in the wrist. You may be able to get rid of these symptoms by wearing wrist splints at overnight. Otherwise, the problem usually ends after pregnancy.

Varicose veins

These are bluish, swollen, sometimes painful veins beneath the surface of the skin. They often show up on the backs of the calves or the inside of the legs.

Varicose veins are caused by:

• Pressure your growing uterus puts on the large veins behind it, which slows blood circulation.
• Pregnancy hormones, which cause the walls of veins to relax and possibly swell.
• Constipation, which makes you strain to pass hard bowel movements.
• Increased fluid retention.

Hemorrhoids

These are varicose veins in the rectum. They may stick out of the anus and cause itching, pain, and sometimes bleeding. Ask your doctor about taking a stool softener (not a laxative).

Aching back, pelvis, and hips

This may have started in the second trimester. The stress on your back will increase as your belly grows larger. Your hips and pelvic area may hurt as pregnancy hormones relax the joints between the pelvic bones in preparation for childbirth. Sleeping with a pillow behind your back may help with the pain.

Abdominal pain

The muscles and ligaments (tough, ropelike bands of tissue) that support the uterus will continue to stretch as your baby grows. They may be painful.

Shortness of breath

As your uterus grows upward, your lungs will have less room to expand for breathing.

More breast growth

Your nipples may leak a yellowish liquid, called colostrum. If you breastfeed, this fluid will be your baby’s first food.

More weight gain

You’ll likely add pounds at the beginning of your third trimester. Your weight should even out as you get closer to delivery.

Vaginal discharge

Discharge may increase. If you have fluid leaking or see any blood, call your doctor right away.

Stretch marks

As the baby grows, your skin will get stretched more and more. This may lead to stretch marks. These can look like small lines on your skin. They often appear on your stomach, breasts, and thighs.

Less fetal movement

As your baby continues to grow, he or she will start to run out of room to move around in your uterus. That might make you notice fewer movements during the day. If you’re concerned about lack of movement, see your doctor.

Sleeping

As you get bigger, you might have difficulty finding a comfortable sleeping position. You may also find it harder to change positions while sleeping. Side sleeping will be best. Try to fall asleep on your left side. This will help circulation, which is important for the baby. If you wake up, return to that position before going back to sleep. Putting a pillow between your knees or behind your back may make you comfortable.

Sleeping on your back will be uncomfortable because the weight of your baby presses on the veins in your lower back. Also, this can slow the blood flow from the lower body to the heart.

Other things that disrupt sleep may include:

• Nasal congestion, caused by increased blood flow to the mucous membranes in the nose and mouth.
• Heartburn, the burning feeling in your lower chest. This may get worse as your uterus grows, pushing your stomach out of its usual position. Ask your doctor if you can take an antacid, if needed.
• The need to urinate. This is partly due to hormones. And partly due the fact your growing baby is pushing on your bladder.
• Leg cramps, which may be related to the pressure your uterus puts on the nerves and blood vessels that go to your legs.
• Restless legs syndrome, in which you feel a need to move your legs often because of an unpleasant feeling in them.
• Strange dreams, which some women have in the last weeks of pregnancy.
• Your baby’s movements.

Sex

You may lose the desire for sex. That may be because of your size and because you are focused on getting ready for labor, delivery, and parenthood. But it’s still fine to have sex, unless your doctor has told you not to.

Labor

Talk to your doctor about the signs of labor. He or she will tell you what to expect and when to call or go to the hospital. But here are some common changes you may notice.

• Your baby may change position, with his or her head moving down in your pelvis. People may notice your belly is lower and say that you have “dropped.”
• Your cervix (the lower end of your uterus) will begin to thin (effacement) and open (dilate).
• Braxton Hicks contractions (tightening of your uterine muscles) may happen more often and become stronger. These are often a sign labor will be starting soon.
• You may have a constant backache and cramping, diarrhea, and gas before labor begins.
• You will probably be in labor if your contractions seem to happen in a pattern. Also, the time between each contraction will get shorter. Labor contractions are usually more painful than Braxton Hicks contractions. If your contractions are so painful you can’t talk, call your doctor.
• Your “water” may break. This is caused when a tear in the sac that encloses your baby causes fluid to be released. See your doctor or go to the hospital if you think this has happened. However, for many women, the water doesn’t break until contractions start.

At 28 weeks

You may start getting new symptoms now, such as nosebleeds, heartburn and indigestion. That’s your growing baby and hormones creating havoc with your digestive system.

Your back will also be under strain, thanks to all the extra weight you’re now carrying around. It won’t help that your joints and ligaments are also looser than usual.

Your ankles, feet and face could be puffing out a bit, particularly when it’s hot. This is probably due to water retention, but get it checked out, just in case it’s pre-eclampsia. This is a condition where you may feel perfectly well, but then your blood pressure can get dangerously high, very quickly.

A quick-fix for many niggling conditions in the third trimester is to put your feet up.

Your signs of pregnancy could also include:

• sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 28 weeks

Your baby or fetus is around 37.6cm long from head to heel, and weighs about 1 kg. That’s approximately the size of a pineapple and the weight of a big bag of brown sugar.

Your baby’s heart rate is changing all the time. Around week 5 or 6, when it was first detectable, it was around 110 beats per minute (bpm). Then it soared to around 170 bpm in week 9-10. Now, it’s slowed down to around 140 bpm and it will be around 130 bpm at birth. That’s still a lot faster than your heart rate, which will be around 80-85 beats per minute. This is partly because babies’ hearts are so small that they can’t pump much blood, but they can make up for this by going faster. It also helps to keep them warm.

Your baby’s heart can be heard through a stethoscope. Your partner might be able to hear it by putting an ear to your pregnant belly – give it a go, but it’s tricky finding the right spot.

At 29 weeks

You might be feeling a bit breathless, as your baby pushes up against your lungs. It puts a strain on your body carrying all that extra weight around too.

You could be feeling awkward and uncoordinated. It takes a while to get used to having a bump and your sense of balance could be all over the place, as your center of gravity changes. If you fall over, don’t panic, you’ve got plenty of padding in there, but let your midwife or doctor know.

You’ll probably feel annoyed when people tell you to enjoy your sleep ‘while you can’, as it’s not very easy right now. You could be getting leg cramps. Plus if the baby’s pressing up against your bladder, then you’ll be up and down all night on the toilet.

Babies seem to have a habit of being really active just as you want to drop off. They have their own sleeping and waking patterns, and you’ll be lucky if your schedules coincide! Get to know your baby’s patterns, and if they change or stop, then contact your midwife or hospital.

Rest when you can in the day. Try supporting your body when you lie down by putting a pillow under your bump, and another one between your legs. It’s best to try and sleep on your side. If you feel unable to cope, because you’re just too tired, then talk to your midwife or doctor.

Your signs of pregnancy could also include:

• sleeping problems
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 29 weeks

Your baby or fetus is around 38.6 cm long from head to heel, and weighs about 1.2 kg. That’s approximately the size of a butternut squash and the weight of a small chicken.

Your baby is perfectly formed. Over the next few weeks, the baby has an important ‘to do’ list:

• grow
• get fatter
• let the organs mature

Your baby is also trying out a new look. For the past few weeks, they’ve been covered by a greasy white layer of something called ‘vernix’ (that protects the skin) and soft, downy hair (for warmth). This starts to disappear now. Your baby is getting ready for the big reveal in about 11 weeks’ time.

At 30 weeks

You may be having problems sleeping and then when you do, you could be getting vivid and disturbing dreams. You might dream about going into labor in the middle of the supermarket, or giving birth to a toothbrush, or leaving your baby on the bus. These dreams can be very frightening. The important thing to remember is that they aren’t real! They’re fueled by your hormones, and the anxiety that you’re probably feeling about the big changes ahead. Maybe you’re worried about the birth, or that you won’t be a good enough mother. Talking about your dreams will help you to put everything into perspective. If you are feeling under stress, then discuss it with your midwife or doctor.

It’s probably more of an effort now to walk up the stairs without getting out of breath, that’s because your baby is pushing up against your lungs.

Your signs of pregnancy could also include:

• sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 30 weeks

Your baby or fetus is around 39.9 cm long from head to heel, and weighs about 1.3 kg. That’s approximately the size of a cabbage and the weight of a big bag of muesli.

Your baby’s eyes can now focus and their vision will continue to develop inside and outside the womb. After the birth, your baby will be able to focus on your face, when you’re around 20-25cm away, which is almost exactly the distance that most people automatically position themselves when they’re talking to or feeding a baby.

Your baby won’t be able to follow moving objects with their eyes until they’re about three months old.

At 31 weeks

Your baby and your bump are still growing. In a couple of weeks, you will both go through a final growth spurt. Your baby still has lots of fattening up to do before the big day arrives.

If this is your first baby, then your midwife or doctor will probably get out a measuring tape and check the size of your womb. This can be estimated by measuring up your stomach, from the top of your pubic bone, to the top of your bump.

They will also gently feel your pregnant belly to work out which way up your baby is positioned. Some babies will be head down, all ready for birth. You may have felt your baby move into place and seen your bump shift downwards.

If your baby is head up, then there’s still plenty of time for your little one to do a big somersault and get into position. Some babies don’t move down into the pelvis (‘engage’) until labor starts.

If your baby stays head up, in the ‘breech’ position, then that could affect the type of birth you are able to have. In some cases, if the baby is in an awkward position, or the placenta is blocking their way down, then a caesarean may be recommended. You will be able to talk through the risks and benefits with your midwife or doctor before making your decision.

Are you getting fake contractions? You may feel your bump tighten up for 20-30 seconds, then relax again. It shouldn’t hurt. These are known as Braxton Hicks contractions and often referred to as ‘practice contractions’. You can get them after sex and other vigorous activities, or if someone touches your bump. These are perfectly normal and harmless. However, if they’re painful, or you start to get them at regular intervals, then it could be a sign of early labor, so contact your midwife or doctor.

Your signs of pregnancy could also include:

• sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 31 weeks

Your baby or fetus is around 41.1 cm long from head to heel, and weighs about 1.5 kg. That’s approximately the size and weight of a coconut.

Your baby is very active, moving around, sucking their fingers, and doing the odd somersault. Day by day, your baby is getting plumper and looking less wrinkled. The amount of amniotic fluid surrounding your baby is increasing and that’s due to your baby peeing into it.

Your baby will start to recognize voices outside the womb, so encourage your partner and any other children to talk to your bump, to help create a strong bond between them.

At 32 weeks

It’s quite normal to start waddling like a penguin, when your bump gets big. That’s your body’s way of compensating for all that extra weight up front. It might look a bit silly but it’s your best chance of staying stable. So happy waddling!

You probably thought you couldn’t get any bigger, but over the next 4 weeks, you’ll be gaining around a pound a week. Your baby will be bulking up too, with around a kilogram of extra fat. The extra chubbiness will help your baby to stay at the right temperature after they’re born – it’s very easy for little bodies to get too hot or too cold.

Your baby is probably head down now, ready for birth (the fancy term for this is cephalic presentation). Don’t worry if your baby’s not there yet, there’s still time for a cheeky turn or two. If you get to week 36, and your baby’s still not playing ball, then your doctor or midwife might offer a gentle helping hand, to encourage the baby to turn into position.

Are you tired of feeling tired? Remember that putting your feet up every now and then isn’t a sign of weakness, it’s a sensible strategy to help you get through the day.

Your signs of pregnancy could also include:

• sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 32 weeks

Your baby or fetus is around 42.4 cm long from head to heel, and weighs about 1.7 kg. That’s approximately the size of a kale leaf and the weight of a joint of beef.

Your baby is perfectly formed but needs more fattening up. That’s what the next few weeks are all about. As your baby gets bigger, space will get tighter in your womb. However it’s a myth that your baby will stop moving as they get more cooped up. You should still feel movements, at the same rate, until you give birth. If there are any changes to the patterns, or your baby stops moving, then contact your midwife or hospital as soon as possible.

At 33 weeks

Your bump is probably getting in the way of everything now – sitting down at a table, fitting into the car or cuddling up to your partner. It’s also very hard to judge how big you are, particularly as you’re expanding all the time, so allow more space than you think you’ll need.

You may start to feel like something’s weighing down on your pelvis and the heavy feeling can be a sign that your baby’s in the head down position, all ready for birth.

You might be feeling really tired now, which is hardly surprising, as you’re carrying around an extra couple of kilos. However, bear in mind that the end is in sight. In around 7 weeks, you’ll have a beautiful baby.

Your womb could start preparing for the birth with Braxton Hicks contractions, which are sometimes referred to as practice contractions. These can feel like a tightening over your bump for 20-30 seconds, before the muscles relax again. It shouldn’t hurt. If the contractions become painful or strike at regular intervals, then contact your midwife or hospital, in case you’re going into labor.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 33 weeks

Your baby or fetus is around 43.7cm long from head to heel, and weighs about 1.9kg. That’s approximately the size of pineapple and the weight of a laptop computer.

Your baby’s brain and nervous system are now fully developed. The bones are hardening up, apart from the skull bones, which will stay soft and separated until the baby’s around 12 to 18 months old. Having this slight flexibility with the head makes the journey down the birth canal a bit easier.

At 34 weeks

You may be feeling all squashed up inside and some of your pregnancy symptoms could have vanished almost overnight. This can happen when your baby moves head down into the pelvis, in a staged process called ‘engagement’. It frees up space in your abdomen, and gives your lungs a bit of a break, so if you’ve been feeling breathless, then that should ease off. It also reduces the pressure on your stomach, so symptoms such as heartburn could disappear as well.

This drop down is called ‘lightening’, and for many women, it’s a welcome relief. However it doesn’t mean you’re about to give birth, as you’ll probably have to wait several more weeks for that to happen. Also, you may find that you now need to wee more, and walking could be more difficult. But at least you can eat more, without feeling ill.

Your breasts could feel huge and they may be leaking small amounts of yellowish colostrum. This is an early milk that’s rich in antibodies and will help to protect your baby from diseases if you choose to breastfeed. If your breasts are sore, then it may help to wear a light bra at night, and a more supportive bra during the day.

Continue to eat healthily, take gentle exercise, be kind to yourself and rest when you can. Also, don’t forget to attend your antenatal appointments as they’re important for you and the baby, and will make sure that everything’s on track for the big day.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 34 weeks

Your baby or fetus is around 45 cm long from head to heel, and weighs about 2.1 kg. That’s approximately the size of a school bag and the weight of a cantaloupe melon.

Your baby is curled up inside your womb, with the little legs bent up towards the chest. There’s not a lot of space in there, but you should still feel your baby shifting around and see your bump change shape too.

If you’ve got a little boy in there, then his testicles will be descending from his abdomen into his scrotum. When he’s born, his genitals may look quite enlarged – this is swelling caused by extra fluid or a late rush of hormones, it goes down after a few days.

At 35 weeks

Your breasts are probably busting out of your bras, as your breasts prepare for the birth. The first milk you’ll produce is colostrum, which is a yellowish liquid that is rich in antibodies. Some pregnant women start to make it weeks or even months before the birth. If you’ve spotted any stains in your bra, then that’s probably colostrum. This early type of milk is a superfood for babies and sometimes referred to as ‘liquid gold’. When you breastfeed, this will helps to protect your little baby from stomach bugs and other infections.

Around 3 to 5 days after the birth, your milk will come in, and your breasts will look even bigger. Make sure you’re ready for this by getting measured for a feeding bra that will allow a bit of growth. You could also stock up on breast pads to soak up any extra milk, so that you don’t stain your clothes.

You may be getting sore ribs now. That could be because your baby is head down, and kicking away. If the pain is really bad, or under your ribs, then talk to your midwife or doctor, just in case it’s a sign of a dangerous condition called pre-eclampsia. However it’s far more likely that your little one is just doing a bit of football training.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 35 weeks

Your baby or fetus is around 46.2 cm long from head to heel, and weighs about 2.4 kg. That’s approximately the height of two bananas and the weight of a honeydew melon.

Your baby is getting chubbier, which will help them to stay at the right temperature when they’re born. It’s getting rather cramped in your womb now, but your baby should still be moving around, and you should feel movements as strongly and regularly as you have done in previous weeks. If the movements change or stop, then talk to your doctor or midwife.

At 36 weeks

Do you feel an urgent need to clean the cooker, tidy the cutlery drawer and sort your baby’s clothes into alphabetical order? This is typical nesting behavior and something that many women and their partners report around this time. It can be therapeutic and very useful, but don’t overdo it. Put your feet up in between bouts of activity.

You may noticed a bit of urine leaking out when you laugh or cough. This is your body’s way of preparing for the birth by relaxing the pelvic floor muscles around your bladder. If it’s a problem, then try wearing maternity pads. Also practise your pelvic floor exercises.

You’ll have an antenatal appointment around now with your doctor or midwife. This will check on your blood pressure, urine, and the size of your bump. You may not feel like going, as it’s such an effort to get anywhere, but make them a priority. These appointments save lives as they can pick up on changes in your body that you might not be aware of, such as very high blood pressure.

Your baby may already have moved head down into your pelvis, which means that they’re good to go (or ‘engaged’). However this doesn’t mean that labor’s on the way – it could still be weeks away.

If your baby’s not head down yet, then you may be offered external cephalic version (ECV). This is where your doctor or midwife gently applies a helping hand to your bump to encourage the baby to turn – it’s successful around half the time.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions.
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 36 weeks

Your baby or fetus is around 47.4 cm long from head to heel, and weighs about 2.6 kg. That’s approximately the size of a romaine lettuce and the weight of a small turkey.

By now, your baby’s lungs are probably mature enough to breathe outside the womb without any help. Your baby will also be able to suck and digest breast milk. If you’re not sure about breastfeeding yet, then check out the benefits. Breastfeeding is good for your baby, as it helps to fight off infections, and it’s good for you too, as it burns around 300 calories per day. It’s also great for bonding. Some women think that their breasts are too small, but that’s a myth – your baby will be very happy, whatever size and shape you are!

At 37 weeks

Your baby could come any day now and it wouldn’t be ‘early’. That’s right, your baby is now ‘full term’, which means that they’re probably big enough, and mature enough, to survive in the outside world. However you still may have to wait another few weeks, as babies tend to come in their own sweet time. If you’re carrying twins, then you will probably give birth this week. Twin pregnancies rarely go beyond 38 weeks.

Around 95 per cent of babies will now be head down, facing their mother’s back, which is the best position for labor. When the baby’s head moves down into the pelvis, it’s said to be ‘engaged’. You might see your bump drop a bit when this happens.

As your baby moves down into your pelvis, you may start to feel some relief from pregnancy symptoms such as heartburn, indigestion and going to the toilet every 5 minutes. Alternatively, you may still be suffering, in which case, hang on in there, it really won’t be long now.

If your baby’s still in the bottom-down position (breech) don’t worry, there’s still time for them to turn. Some babies don’t move into place until labor starts. When you’re sitting down, try leaning forwards, with your hips above your knees. It’s not a proven technique but many women say that it coaxes the baby into position and it certainly can’t do any harm.

You might find that you’re getting more vaginal discharge now and Braxton Hicks contractions – these are the ‘practice’ contractions around your bump, which can feel uncomfy but shouldn’t be painful. You could also be getting a sudden urge to spring clean. That’s your ‘nesting’ instinct kicking in, and partners can get it too! It’s not a scientifically proven phenomenon but many people report feeling the urge to tidy and clean shortly before the baby comes. Just don’t overdo it, you should try to rest as much as possible.

5 signs that baby’s on the way

Look out for these telltale signs – and be patient. Remember, babies come when they’re good and ready.

1. The ‘show’: you may see a sticky blob of mucus in your pants, which might be yellow or bloody. This plug used to seal up your cervix and the fact that it’s come undone shows that something’s happening down there. It’s called a ‘show’ and can be one of the first signs of labor. However, you could still have days, or even weeks to wait…
2. Your waters break (rupturing of the membranes): don’t expect a massive gush like you see in films – it could just be a little ‘pop’ and a trickle. The liquid should be clear. If it drips, then use a pad, not a tampon. Contact your midwife or doctor immediately if it’s smelly or colored.
3. Backache: this is caused by your baby’s head bashing away at your spine. When their head meets your sacrum (tailbone) it’s agony!
4. The urge to go to the toilet: this is caused by your baby’s head pressing on your bladder or bowels. You may find that you wet or poo yourself. It’s very common, so don’t be embarrassed!
5. Contractions or tightening around your bump: it hurts when your bump goes hard, and then the pain goes away when the muscles relax. It feels like period pains to start with or a heavy dragging feeling in your pelvis and legs. Then your contractions get longer, stronger and more frequent.

It’s time to call your doctor or hospital when your contractions last for at least 60 seconds and come every 5 minutes. Phone straight away if you’re losing blood, in too much pain, worried that something’s wrong, or if your baby stops moving.

Your signs of pregnancy could include:

• painless contractions around your pregnant belly, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your baby bump, caused by your expanding womb (’round ligament pains’)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the ‘mask of pregnancy’
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 37 weeks

Your baby or fetus is around 48.6 cm long from head to heel, and weighs about 2.9 kg. That’s approximately the length of 2 cucumbers and the weight of 14 baked potatoes.

Your baby will be trying out different facial expressions, such as frowning and smiling. They might also practise silent crying. This is just random – it’s not linked to sadness or happiness.

By now, you will hopefully know when your baby’s active and when they’re calmer. These patterns are likely to continue after the birth.

At 38 weeks

There’s a chance that your baby might be due this week. Only about 5% of babies are born on their due date. Don’t forget that your due date is only a guide. It’s not necessarily the best day for the birth. Your baby tends to decide on that. One new symptom this week could be frustration or even boredom, and the wait can be maddening.

At your antenatal appointment, around now, your midwife or doctor will measure the size of your bump with a tape measure, check your blood pressure and look for any protein in your urine that could indicate that you’ve got a dangerous condition called pre-eclampsia. This tends to strike in the second half of pregnancy or after the baby is delivered.

If you’re having a planned caesarean, otherwise known as an elective caesarean, then you’ll probably be booked in when you’re at least 39 weeks’ pregnant. This is to give your baby’s lungs the best chance of being fully developed.

You’ll have a chat about what might happen if you go beyond 41 weeks. There could be risks for you or the baby, so you may be offered induction. This is where labor can be brought on artificially by putting a tablet or gel in your vagina. Around 1 in 5 labors are started this way.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your pregnant belly, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts, a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 38 weeks

Your baby or fetus is around 49.8 cm long from head to heel, and weighs just over 3 kg. That’s approximately the length of 3 carrots and the weight of 3 butternut squash.

In the second trimester, your baby was covered in a furry coat of soft, downy hair (lanugo). That’s mostly gone now, although some babies are born with patches here and there.

Your baby is storing up some sticky green slime in their bowels (meconium). This is made up of everything they swallow in the womb, including bits of amniotic fluid and hair. It will normally come out after the birth as the first poop. If the baby does a poop during labor, it can be a sign of distress and your baby will need close monitoring.

At 39 weeks

Pregnancy normally lasts around 40 weeks and most women will go into labor a week either side of their due date. That means your baby is due any time now.

Check your pants, you might be getting a lot more discharge than usual. This should be thin, white and not smell of very much. If you spot a slimy blob of mucus that’s yellow or bloody, then that’s a show. This sticky stuff used to plug up your cervix and when it comes out, it can be one of the first signs that your baby’s on the way. However don’t grab your hospital bag just yet, as you could still have days to wait.

You may be getting back pain as your baby moves down your pelvis and starts head butting your spine. You’ll probably feel increased pressure at the bottom of your bump now.

You could be getting a lot of practice contractions, but if they start getting painful, then they could be the real deal. Phone your hospital or midwife when your contractions last for at least 60 seconds and come every 5 minutes – or call any time if you’re worried that something is wrong, such as if your baby stops moving or if you’re losing blood.

You could also be getting sudden bursts of energy and urgently want to fold baby clothes or tidy drawers that you haven’t opened for years. That’s your nesting instinct kicking in.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts , a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 39 weeks

Your baby or fetus is around 50.7 cm long from head to heel, and weighs about 3.3 kg. That’s approximately the length of 5 courgettes and the weight of a mini watermelon.

A few weeks ago, your baby’s skin was almost transparent but now they’re growing a tougher new layer that’s looks more solid. This is better at protecting their internal organs and helping with temperature control.

The skin will be coated in a white, waxy substance called vernix, which means varnish in Latin. This creamy layer helps to protect their skin and eases your baby down the birth canal. Your baby could come out covered it in, or it could be mostly gone by the time they emerge – you’ll just have to wait and see.

At 40 weeks

If this is your first baby, then you’ll have an antenatal appointment this week. Your blood pressure will be checked, your bump will be measured and you’ll hand over a urine sample. You know the drill! Your midwife or doctor will be checking for signs of pre-eclampsia, a dangerous condition that’s characterized by high blood pressure and protein in the urine.

You’re probably getting a lot of practice contractions now, which shouldn’t be painful. These are Braxton Hicks contractions. When you start getting labor pains, you’ll know all about it! Real contractions hurt when your bump goes tight, and then the pain goes away when the muscles relax.

Labor is divided into 3 stages:

1. The first stage is when you have contractions and your cervix opens up until it’s 10cm across (fully dilated). The first stage lasts 6-12 hours, or less if you’ve had other children.
2. The second stage is where the baby is delivered.
3. The third stage is when the placenta comes out.

Do you feel like you’ve got premenstrual syndrome (PMS)? Or do you have lower backache? These could be early signs of labor.

Your signs of pregnancy could also include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts , a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 40 weeks

Your baby or fetus is around 51.2 cm long from head to heel, and weighs about 3.5 kg. That’s approximately the size of 2 Romano peppers and the weight of a small pumpkin.

Your baby is getting rather squashed up now, but should still be moving around in their usual pattern. Movements shouldn’t slow down or stop, and if they do, it could be an important sign that something’s wrong. If you notice any changes, contact your midwife or maternity unit straight away – there will be someone there to answer calls 24 hours a day.

At 40+ weeks

It’s not unusual to go past your due date, but obviously this can’t go on forever. It’s usually fine to go over by a week or so without any extra risks. However about 10 or 12 days after your due date, your placenta starts to work less well, and your chance of a stillbirth increases. Your doctor will discuss the best ways forward with you, which could involve extra monitoring or induction.

You might be offered a membrane sweep to start with. This is where your midwife or doctor sweeps their finger around inside you and separates your cervix from the membranes around your baby. The idea is to stimulate hormones that could bring on your contractions. You can watch a little video about it here.

For many women, it does the trick, and labor starts within 24-48 hours. However you may need a couple of sweeps to get going, and it doesn’t work for everyone.

Around 1 in 5 births are induced, which means that drugs are used to get the labor going.

You might be offered a membrane sweep to start with – this can feel uncomfortable, but it doesn’t harm you or the baby.

A drug called prostaglandin is then used to open up the cervix and get contractions going. It’s put into the vagina as a gel or tablet. It can also be delivered through a pessary, which looks like a mini tampon and releases the drug over 24 hours.

You may need to have your waters broken if they don’t break naturally. You may also be offered a drip containing another drug called syntocinon if the labour needs to be speeded up.

There’s a lot to consider when you’re offered an induction, so ask as many questions as you like. Here are a few things to consider:

• there could be medical reasons why it’s important for your baby to be delivered sooner rather than later
• induction can often avoid the need for a cesarean (C-section)
• it could be more painful than a spontaneous delivery – you may end up with an assisted delivery using forceps (which are a bit like tongs) or a ventouse (which is a special suction cup).

Your signs of pregnancy could include:

• painless contractions around your bump, known as Braxton Hicks contractions
• tiredness and sleeping problems
• stretch marks
• swollen and bleeding gums
• pains on the side of your belly, caused by your expanding womb (round ligament pains)
• piles
• headaches
• backache
• indigestion and heartburn
• bloating and constipation
• leg cramps
• feeling hot
• dizziness
• swollen hands and feet
• urine infections
• vaginal infections
• darkened skin on your face or brown patches – this is known as chloasma or the mask of pregnancy
• greasier, spotty skin
• thicker and shinier hair
• symptoms from earlier weeks, caused by pregnancy hormones, such as mood swings, morning sickness, weird pregnancy cravings, a heightened sense of smell, sore or leaky breasts , a white milky pregnancy discharge from your vagina and light spotting (seek medical advice for any bleeding)

Your baby at 40+ weeks

The average baby is now around 3-4 kg. The fast period of growth is now over. Your baby should be chubby enough, and mature enough, to survive in the big wide world, without any assistance.

Overdue babies tend to have red, dry and peeling skin. This is usually because they’ve lost their vernix, which is the greasy layer that stops their skin from drying out in the amniotic fluid. Don’t be tempted to moisturize your baby’s rough skin, as it could make it even worse. The red layer will peel off after a few days, without any help, revealing perfect skin underneath.

First trimester pregnancy

Trimester means 3 months. The first trimester of pregnancy is defined as the first three months (the first 12 weeks) of pregnancy after conception. Pregnancy is dated from the first day of your last period. For around the first 15 days your body will be going through its normal routine – thickening the womb (uterus) and releasing an egg or two. You’re not technically pregnant then. But around week 2 or 3, if an egg meets sperm and fertilization occurs. The fertilized egg (zygote) then travels down your fallopian tube, dividing and redividing, until it reaches your womb. It will then bury itself into the wall (implantation) where your little baby will make itself very comfy for the next nine months. At four weeks, your egg is now an embryo and you are pregnant!

A normal pregnancy is around 9 months and has 3 trimesters:

1. First trimester (week 1–week 12)
2. Second trimester (week 13–week 28)
3. Third trimester (week 29–week 40)

Signs of early pregnancy are missed menstrual periods, fatigue, breast enlargement, abdominal distention, and nausea. During the first trimester of pregnancy all fetal organ development takes place, so the fetus is most susceptible to damage from toxins, drugs, and infections.

During your first trimester, you probably don’t look pregnant at all. Most first-time mums don’t start showing signs of pregnancy until at least week 12. However, if this isn’t your first baby, then you may start showing sooner, as the muscles in your uterus (womb) and belly may have been stretched from your last pregnancy.

Once you know you are pregnant, your doctor or midwife will help you work out when your baby is due also known as the ‘estimated date of confinement’ (EDC) or ‘estimated date of delivery’ (EDD). This is done by adding 40 weeks to the date of the beginning of your last normal menstrual period (LMP). Most pregnancies last around 40 weeks or 38 weeks from conception, so typically the best way to estimate your due date is to count 40 weeks or 280 days, from the first day of your last menstrual period (LMP).

In order to calculate your baby’s due date, add seven days to the date of your last period and then add nine months. For example, if your last period started on 1 March, adding seven days will make that 8 March. Then adding nine months will give a due date of 8 December. If your periods are irregular or you are unsure of the date, an ultrasound will help determine the development of the embryo and your due date. Ultrasound scans can be done at any stage of pregnancy after the first six weeks.

Or another way to do it is to subtract three months from the first day of your last period and add seven days. So if your last period started on April 11, you’d count back three months to January 11 and then add seven days, which means your due date would be January 18.

This is how your doctor will estimate your due date and it’s a pretty accurate target. But remember: It’s just as normal to deliver a week or two before or after your due date, so a full-term pregnancy can be anywhere between 37 and 42 weeks. A baby born before 37 weeks is considered to be premature and anything past 42 weeks is considered overdue.

Due dates are usually calculated on your last period instead of the date of conception because of a number of reasons:

• Although the average woman ovulates (releases an egg) approximately 2 weeks after her period, the exact time is not always known.
• Once an egg has been released, it can remain fertile for up to 24 hours.
• Sperm can last for up to 7 days after intercourse to fertilize an egg.

Some doctors will refer to your due date as ‘expected date of confinement’ (EDC).

Note that calculating your due date based on the first day of your last normal menstrual period (LMP) works well for women who have a relatively regular menstrual cycle. But if your menstrual cycle is irregular, the LMP method may not work for you.

Calculating your due date based on the first day of your last period works well for women who have a relatively regular menstrual cycle. But if your cycle is irregular, the last normal menstrual period (LMP) method may not work for you. Because a reliable estimated date of delivery (EDD) is important, you and your doctor can use your conception date instead if you remember it. Just add 266 days to get your estimated due date.

Ultrasound scan

Even if you can’t pinpoint when you conceived, forget the day of your last menstrual period (LMP) or aren’t sure when your ovulation occurred, other clues can help you and your doctor determine your due date at your first prenatal appointment, including:

• An early ultrasound, which can more accurately date the pregnancy. Just be aware, however, that not all women get an early ultrasound. Some doctors perform them routinely, but others only recommend one if your periods are irregular, you’re 35 or older, you have a history of miscarriages or pregnancy complications or the due date can’t be determined based on your physical exam and LMP.
• Pregnancy milestones such as the first time the baby’s heartbeat is heard (around week 9 or 10, though it can vary) and when you first feel fetal movement (on average between 18 and 22 weeks, but it can be earlier or later), can give clues as to whether your due date is accurate.
• Your fundal height, which is the measurement from your pubic bone to the top of your uterus, is checked by your practitioner at each prenatal visit and helps confirm your due date.
  The size of your uterus, which will be noted when your initial internal pregnancy exam is performed, can also be a factor in pinpointing the estimated date of delivery.

Figure 1. Female reproductive organs

Pregnancy key points

• If you think you’re pregnant, see your doctor straight away to start your pregnancy care. Your doctor will:
  • confirm that you’re pregnant
  • organize routine tests, including a blood test
  • check your health
  • talk with you about pregnancy care options
  • refer you to the health professionals you want to care for you or the place you want to give birth.
• It’s important to go to your antenatal appointments right from the start, so your doctor or midwife can check how you and your baby are going. This includes following your baby’s growth and watching you both for any health problems or risks. Antenatal appointments are also a chance to make decisions about things like tests in pregnancy. Some of these appointments and tests need to happen at particular times.
• Regular exercise, healthy eating and side sleeping during pregnancy are good for you and your baby.
  • Physical activity in pregnancy. Being physically active while you’re pregnant is good for you and your baby. It can help you be at a healthy weight, keep strong for birth, and reduce stress. If you’re healthy with an uncomplicated pregnancy, you can probably start or keep going with light to moderate exercise during pregnancy – but check with your midwife or doctor first. Brisk walking or swimming are good options. Aim for around 30 minutes, for most days of the week.
  • Daily pelvic floor exercises: Daily pelvic floor exercises will help to prevent urinary problems like incontinence later in pregnancy or after birth. Pelvic floor exercises might also help with your labor and recovery after birth.
  • Sleep in pregnancy: The safest sleeping position for pregnancy is on your side, because this position reduces the risk of stillbirth. This is especially important in the third trimester. It’s best to sleep on your left side when you can. Sleeping on your left side can increase the flow of blood and nutrients to your baby. To sleep comfortably on your side, try putting a pillow between your legs and another behind your back. This can ease and prevent back pain. It’s OK if you wake up during the night on your back. Just roll over to sleep on your side.
  • Healthy eating in pregnancy: Healthy eating helps you feel good and gives your baby the nutrients he needs to grow.
    • Eat plenty of vegetables, fruit and wholegrain breads and cereals for a wide range of vitamins, minerals and fiber.
    • Choose low-fat dairy food (or alternatives like soy, rice or oat milk products) for calcium, protein and iodine
    • Eat lean red meat for iron and protein, and oily fish like sardines for omega-3 fatty acids and protein.
    • Try to choose small, healthy snacks that are low in sugar and fat.
    • Foods to avoid in pregnancy: For your health and your baby’s health, it’s best to avoid ready-to-eat chilled foods (like coleslaw and other deli salads), soft cheeses, raw eggs and raw seafood. It’s also good to avoid drinking too much coffee and tea, and too many energy drinks and other drinks with caffeine.
• Smoking, alcohol and other drugs in pregnancy. If you’re taking prescribed drugs, check with your doctor that these are safe to take during pregnancy. Your doctor and midwife will advise you to stop smoking, drinking alcohol and stop taking non-prescribed drugs. Try to stay away from people who are smoking.
• Expect emotional and physical changes in pregnancy, including tender breasts, thicker hair and morning sickness.
• If you need support, talk to your doctor, midwife or a counselor.

Menstrual cycle

The menstrual cycle is the monthly process in which female hormones stimulate an ovary to release an egg, thicken the lining of the uterus to support a pregnancy, and then cause the uterus to shed this lining (through menstruation) if there is no pregnancy. The average menstrual cycle is 28 days, but this varies between women and from month to month. In teens, the menstrual cycle can range from 21 to 45 days, but for most women, it is 21 to 35 days ¹⁾.

The menstrual cycle is characterized by regular, recurring changes in the endometrium, which culminate in menstrual bleeding (menses). Such cycles usually begin around age thirteen and continue into the early fifties, then cease.

A female’s first menstrual cycle, called menarche, occurs after the ovaries and other organs of the reproductive control system mature and begin responding to certain hormones. Then, the hypothalamic secretion of gonadotropin-releasing hormone (GnRH) stimulates the anterior pituitary to release threshold levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Follicle-stimulating hormone (FSH) stimulates the final maturation of an ovarian follicle. The follicular cells produce increasing amounts of estrogens and some progesterone. Luteinizing hormone (LH) stimulates certain ovarian cells to secrete precursor molecules (such as testosterone), also used to produce estrogens.

In a young female, estrogens stimulate the development of secondary sex characteristics. Estrogens secreted during subsequent menstrual cycles continue the development and maintenance of these characteristics.

Figure 2. Menstrual cycle

Can I plan my due date?

Whether you’re trying to avoid being very pregnant in the middle of summer or are a teacher who wants to maximize time off with your little one, you can try to time when you conceive in order to “plan” your due date.

But even if you’re one of the lucky ones who’s able to get pregnant when she really wants to, just remember that you probably won’t be able to map out exactly when you’ll give birth to the day or even the week or month.

Can my due date change?

Yes, your estimated due date can change. While it’s definitely not a reason to worry, your doctor may change your due date for a number of reasons as your pregnancy progresses.

It may be that your periods are irregular and your early ultrasound dating was off or that your first ultrasound was in the second trimester.

It could also be because your fundal height is abnormal or your levels of alpha-fetoprotein (AFP), a protein made by the baby, are outside the usual range. Talk to your doctor if you have any questions or concerns.

How does pregnancy happen?

Each month your ovaries release an egg about 14 days before the first day of your period. This is called ovulation. When you and your partner have unprotected sex around the time of ovulation, his sperm swim to meet your egg. Unprotected sex means you don’t use any kind of birth control to help prevent pregnancy.

When the egg and sperm meet, it’s called fertilization. The fertilized egg (also called an embryo) moves through your fallopian tubes and attaches to the wall of your uterus where it grows and develops into a baby. When the embryo attaches to the uterus, it’s called implantation.

You can get pregnant if you have unprotected sex any time from 5 days before and the day of ovulation. The more often you have sex during this time, the more likely you are to get pregnant. Your egg is fertile (can become an embryo) for 12 to 24 hours after ovulation. Your partner’s sperm can live inside you for up to 72 hours after you have sex.

How long does it usually take to get pregnant?

It’s impossible to say how long it takes to get pregnant because it’s different for each woman.

Many factors can affect a couple’s chances of conceiving, such as:

• your age
• your general health
• your reproductive health
• how often you have sex

Some women become pregnant quickly, while others take longer. This may be upsetting, but it’s normal.

Fertility

Most couples (about 84 out of every 100) will get pregnant within a year if they have regular sex and don’t use contraception. However, women become less fertile as they get older. One study found that among couples having regular unprotected sex:

• aged 19-26 – 92% will conceive after one year and 98% after two years
• aged 35-39 – 82% will conceive after one year and 90% after two years

The effect of age on men’s fertility is less clear.

What does ‘have regular sex’ mean?

Having regular sex means having sex every two to three days throughout the month.

Some couples may try to time having sex with when the woman ovulates (releases an egg). However, guidance from the National Institute for Health and Care Excellence advises that this can be stressful and is not recommended.

Fertility problems

Fertility problems affect ten to 15 percent of couples in the United States.

Lots of factors can cause fertility problems, including:

• hormonal (endocrine) disorders, such as polycystic ovary syndrome (PCOS) and problems with the thyroid or pituitary glands
• physical disorders such as obesity, anorexia nervosa or excessive exercise
• disorders of the reproductive system, such as infections, blocked fallopian tubes, endometriosis or a low sperm count

Some of these factors affect either women or men. In around 40% of infertile couples, there is a problem with both the man and woman.

The most common cause is ovulation failure (which can be caused by lots of different things) and sperm disorders. In 25% of couples, fertility problems cannot be explained.

How do I know if I’m pregnant?

You may be pregnant if:

• You miss your period.
• Your breasts are big and sore. The area around your nipples gets darker.
• You have to urinate (pee) a lot.
• You feel sick to your stomach or throw up.
• You feel tired all the time.
• You feel moody.
• You feel bloated. This means your body feels full or like it’s swollen.

If you have any of these signs and symptoms and you think you may be pregnant, there are home urine pregnancy tests that can be bought over the counter to check your human chorionic gonadotrophin (hCG) levels which may indicate you are pregnant. It is always important to see your doctor to confirm whether you’re pregnant, work out your due date and what foods you should be eating.

Once your pregnancy is confirmed, you should start thinking about the type of care you want throughout your pregnancy and the birth. If you are in the workforce this is also the time to find out about your rights at work and about maternity leave.

There are several ways to find out if you are pregnant.

Your doctor can give you a blood test and a physical exam to confirm that you’re pregnant. Home pregnancy tests can give you a false-positive result — this means the test says you’re pregnant but you’re really not. This is why it’s a good idea to see your doctor to make sure you really are pregnant.

Pregnancy urine tests

You can buy home pregnancy urine testing kits from your local pharmacy. The tests check for the pregnancy hormone, human chorionic gonadotrophin (hCG).

With home pregnancy tests:

• Make sure you follow the instructions on the test very carefully to get the most accurate result.
• Wait until at least a week after your expected period before testing to get the most reliable result.
• If you are taking fertility drugs or you are an older woman, you may get a false result.
• If you use a home pregnancy kit, always see a doctor to confirm the pregnancy.

You can also have a urine test done at a hospital clinic by your doctor, or at a family planning clinic.

Figure 3. Home pregnancy urine test

Pregnancy blood test

A blood test will give you a reliable result, even at the earliest stage of pregnancy. Your doctor will order the test, which will check for the human chorionic gonadotrophin hormone in your blood. You can have this test done as soon as you have missed your period.

Internal examination

At least 2 weeks after your missed period, your doctor may examine you internally to check for changes in your uterus and cervix (the lowest part of your uterus). When you are pregnant, your doctor will be able to tell that your cervix has changed color and is softer. Your uterus is already getting bigger in the first few weeks of pregnancy. Most doctors will still do a blood or urine test to confirm your pregnancy.

How soon can I take a pregnancy test?

All pregnancy tests detect the hormone human chorionic gonadotrophin (hCG), which starts to be produced around six days after fertilization. When you suspect that you are pregnant, pregnancy tests are can be done reliably from the first day up to 10 days of your missed menstrual period, although some tests can detect human chorionic gonadotropin (hCG) as early as four or five days before your menstrual period is due. A urine sample collected first thing in the morning or a blood sample drawn from a vein in your arm is usually done to detect early pregnancy.

Check the packaging of your home pregnancy test kit to find out when it can be used.

If you have regular periods, you’ll probably know when your next period is due. If you’re not sure, it’s a good idea to wait at least three weeks after you think you may have conceived before doing a pregnancy test.

Pregnancy Test Preparation Needed

No test preparation is needed. However, do not drink large amounts of fluid before collecting a morning urine sample for a pregnancy test because overly diluted urine may result in a false negative; however, no preparation is needed if you’re having a pregnancy test through a blood sample drawn from a vein in your arm. A false negative pregnancy test means the test result inappropriately indicating negative pregnancy result when, in fact, you’re pregnant.

How accurate are home pregnancy tests?

Most home pregnancy tests claim to be up to 99% accurate. But the accuracy depends on:

• How you use them. Be sure to check the expiration date and follow the instructions. Wait up to 10 minutes after taking the test to check the results window. Research suggests that waiting 10 minutes will give the most accurate result.
• When you use them. The amount of human chorionic gonadotropin (hCG) or pregnancy hormone in your urine increases with time. The earlier you take the test, the harder it is for the test to detect the hCG. Most home pregnancy tests can accurately detect pregnancy after a missed period. Also, testing your urine first thing in the morning can boost the accuracy.
• Who uses them. Each woman ovulates at a different time in her menstrual cycle. Plus, the fertilized egg can implant in a woman’s uterus at different times. Your body makes human chorionic gonadotropin (hCG) after implantation occurs. In up to 10% of women, implantation does not occur until after the first day of a missed period. This means home pregnancy tests can be accurate as soon as 1 day after a missed period for some women but not for others.
• The brand of the home pregnancy test kit. Some home pregnancy tests are more sensitive than others. For that reason, some tests are better than others at detecting human chorionic gonadotropin (hCG) early on. Talk to your pharmacist about which brand may be best for you.

What should I consider when buying a pregnancy test?

Make sure that the pregnancy test you are purchasing is U.S. Food and Drug Administration (FDA)-approved.

The FDA requires manufacturers to meet stringent controls for quality, precision, and accuracy. Approved pregnancy test tests must also meet U.S. Food and Drug Administration (FDA) labeling requirements.

• For all over-the-counter (OTC) U.S. Food and Drug Administration (FDA) approved home pregnancy test kits, please go here to find details about each product: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfIVD/Search.cfm

According to the U.S. Food and Drug Administration (FDA) ²⁾, the accuracy of home pregnancy test depends on how well you follow the instructions and interpret the results. “If you mishandle or misunderstand the home pregnancy test kit, you may get poor results. Most pregnancy tests have about the same ability to detect hCG, but their ability to show whether or not you are pregnant depends on how much hCG you are producing. If you test too early in your cycle or too close to the time you became pregnant, your placenta may not have had enough time to produce hCG. This would mean that you are pregnant but you got a negative test result. Because many women have irregular periods, and women may miscalculate when their period is due, 10 to 20 pregnant women out of every 100 will not detect their pregnancy on the first day of their missed period”.

Other things to consider when buying a home pregnancy test kit:

• Cost. Home pregnancy tests come in many different types. Most stores sell them over the counter (without a doctor’s prescription). The cost varies depending on the brand and how many tests come in the box.
• Accuracy. Most tests can be taken as soon as you miss your period. Some newer, more expensive tests say they can be used 4 or 5 days before your period. Even so, they claim the best accuracy only after the date of your expected period.

When should I take a home pregnancy test?

Many home pregnancy tests claim to be accurate as early as the first day of a missed period — or even before. You’re likely to get more accurate results, however, if you wait until after the first day of your missed period or, better yet, one week after your missed period.

Why wait?

Shortly after a fertilized egg attaches to your uterine lining (implantation), the placenta forms and produces the hormone human chorionic gonadotropin (HCG). This hormone enters your bloodstream and urine. During early pregnancy, the human chorionic gonadotropin (hCG) concentration increases rapidly — doubling every two to three days. The earlier you take the home pregnancy test, the harder it might be for the test to detect human chorionic gonadotropin (hCG). Keep in mind that the exact timing of ovulation might vary among women or even from month to month, and the fertilized egg can implant in the uterus at different times. This can affect when human chorionic gonadotropin (hCG) production begins and becomes detectable.

If it’s important to confirm your pregnancy right away, depending on how far along you are in your pregnancy, your health care provider might recommend that you have an ultrasound, repeat a urine test in the hospital or clinic lab, or have a blood test to measure your human chorionic gonadotropin (hCG).

When can I take a pregnancy test?

You can carry out most pregnancy tests from the first day of a missed menstrual period. If you don’t know when your next menstrual period is due, do the test at least 21 days after you last had unprotected sex.

Some very sensitive pregnancy tests can be used even before you miss a period, from as early as eight days after conception.

You can do a pregnancy test on a sample of urine collected at any time of the day. It doesn’t have to be in the morning. However, you can improve your chances for an accurate result by using your first morning urine for the pregnancy test, because it will have more human chorionic gonadotropin (hCG) in it than in urines collected later in the day. Make sure you carefully follow the home pregnancy test kit directions. If the home pregnancy test is negative, it is often repeated several days later. Since human chorionic gonadotropin (hCG) rises rapidly, an initial negative test can turn positive within this time period. Some home pregnancy test kits come with more than one test in them to allow you to repeat the test.

I have irregular periods and don’t know when my next period will start. When should I take a pregnancy test?

Most pregnancy tests claim to be the most accurate after a missed period. But irregular periods can make it hard to predict when to take the test.

Menstrual periods are considered irregular if:

• The number of days between periods is either shorter than 21 days or longer than 35 days
• The number of days in the menstrual cycle varies from month to month. For example, your cycle may be 22 days one month and 33 days the next month.

If you have irregular periods, try counting 36 days from the start of your last menstrual cycle or four weeks from the time you had sex. At this point, if you are pregnant, your levels of human chorionic gonadotropin (hCG) should be high enough to detect the pregnancy.

If your test says you are not pregnant, but you still think you may be pregnant, wait a few more days and take another pregnancy test. Or, see your doctor for a blood test.

What are early signs of pregnancy?

For women who have a regular monthly menstrual cycle, the earliest and most reliable sign of pregnancy is a missed period. Some of the other early pregnancy signs and symptoms are listed below. Every woman is different and not all women will notice all these symptoms.

Missed period

If your period doesn’t arrive as expected, you may be pregnant, but there can be other reasons for a missed period, such as illness, stress and strenuous activity.

Sometimes women who are pregnant have a very light period, losing only a little blood.

Feeling sick and vomiting

You may feel sick and nauseous, and you may vomit. This is commonly known as morning sickness, but it can happen at any time of the day or night. If you’re being sick all the time and can’t keep anything down, contact your doctor.

Feeling very tired

It’s common to feel very tired, or even exhausted, during pregnancy, especially during the first 12 weeks or so. Hormonal changes taking place in your body at this time can make you feel tired, nauseous, emotional and upset.

Changes in your breasts

Your breasts may become larger and feel tender, just as they might do before your period. They may also tingle. The veins may be more visible, and the nipples may darken and stand out.

Bladder changes

You may feel the need to pass urine more often than usual, including during the night. This is caused by pregnancy hormones and usually settles after a few months.

Other signs of pregnancy

Other signs of pregnancy that you might notice are:

• constipation
• an increased vaginal discharge without any soreness or irritation
• a strange taste in your mouth, which many women describe as metallic
• changes in what you want to eat, such as craving new foods and losing interest in certain foods or drinks that you previously enjoyed, such as tea, coffee or fatty food
• losing interest in tobacco if you smoke
• having a more sensitive sense of smell than usual, for example to the smell of food or cooking.

First trimester pregnancy symptoms

Early pregnancy symptoms at 4 weeks

• To start with, you might have no symptoms at all – but then the pregnancy hormone, human chorionic gonadotrophin (hCG) starts to kick in.

During your first trimester you might experience early pregnancy symptoms, such as:

• a missed period (often one of the first signs of pregnancy)
• a metallic taste in your mouth
• sore breasts
• nausea (also known as morning sickness, although it can strike at any time)
• tiredness
• new likes and dislikes – anyone for blueberry muffins with pickle? You can read our advice in week 5
• a heightened sense of smell
• needing to wee more frequently
• a milky white pregnancy discharge from your vagina
• light spotting as the fertilized egg burrows into your uterus (see your doctor if you get bleeding during pregnancy)
• cramping, a bit like period pains
• darkened skin on your face or brown patches – this is known as chloasma faciei or the “mask of pregnancy”
• thicker and shinier hair
• bloating and the feeling of being bloated

If you think you could be pregnant but haven’t noticed any symptoms, you still might be. You could just be lucky. Some women sail through their pregnancy feeling on top of the world. Everyone’s different and nobody else will have a pregnancy just like yours.

1 week pregnant

This week you have your period. Your pregnancy is calculated from the first day of this period. This is because it can be hard – impossible, even – to know exactly when your baby was conceived. But most women can remember the day their period started.

Figure 4. First week pregnant

If you’re hoping to get pregnant, doctors recommend that you:

• Take folic acid for at least three months before the pregnancy and the first three months of your pregnancy. All women and teen girls who could become pregnant should consume 400 mcg of folic acid daily from supplements, fortified foods, or both in addition to the folate they get from following a healthy eating pattern ³⁾.
• Get immunized against rubella – if you’re not already – and avoid getting pregnant for one month after the vaccination
• Speak to a doctor or a genetic counselor if there’s a history of hereditary disease in your family
• Check the safety of any medications you’re taking by talking with your doctor
• Stop drinking alcohol, and avoid drinking too much coffee, tea and others drinks with caffeine in them
• Cut out smoking and non-prescribed drugs
• Eat a healthy, well-balanced diet, full of vitamins and minerals
• Be physically active and talk to your doctor about a healthy weight for pregnancy if you’re overweight
• Have a medical check if you have a chronic health problem like high blood pressure, diabetes or epilepsy.

You might also want to think about practical things like your parental leave entitlements, your family finances, your home, your transport, and how you and your partner – if you have one – plan to organize child care.

Your pregnancy might not have been planned. That’s OK. It’s a very good idea to see your doctor as soon as possible to start planning your pregnancy care.

2 weeks pregnant

Your period has finished by now. One of your ovaries is getting ready to release an egg. The ovaries are also producing lots of oestrogen. Oestrogen kick-starts some important processes in your body:

• Your fallopian tubes and cervix produce ‘fertile mucus’, which helps and protects any sperm along its way.
• A new lining – the endometrium – starts growing in your uterus. A fertilized egg will bury itself in the endometrium.
• By the end of this week, the ovary is ready to release an egg – this is called ovulation.

Ovulation usually happens around day 14 if you have a 28-day menstrual cycle. You’ll be more likely to get pregnant if you have sex 1-3 days before ovulation.

Figure 5. Pregnancy week 2

3 weeks pregnant

The egg (sometimes two, if you’re having fraternal twins) travels down your fallopian tube in the direction of your uterus. If you’ve had sex, sperm are moving upwards through your cervix and uterus.

For conception to occur, a sperm must burrow through the outer layers of the egg to the very middle. This process usually happens in the fallopian tube. If it does happen, you’re pregnant.

Your progesterone levels increase now. This hormone lets your body know you’re pregnant, causing the endometrium to build up its nutrient supply, which stops you from having your period.

Figure 6. Pregnancy week 3

4 weeks pregnant

The fertilized egg moves down your fallopian tube to the uterus, where it implants itself in the endometrium. This can take 3-10 days. Some women have a small amount of bleeding or ‘spotting’ around the time of implantation.

You might not notice any changes in your body such as sore breasts and tiredness, but by the end of the week you’ll probably have missed your period and could be wondering if you’re pregnant.

From the moment of conception, the fertilized egg called a blastocyst, starts dividing itself. By the end of this week, it’s a ball of about 200 cells and is about 4-5 mm across. Inside the ball, three layers are forming:

• The ectoderm – this becomes your baby’s nervous system, brain, hair and skin.
• The endoderm – this becomes the gut and other internal organs.
• The mesoderm – this develops into the skeleton, blood systems and muscles.

The outside of the blastocyst divides into two parts:

1. The outside part sends out little tentacles – called chorionic villi – which bury into your endometrium. The chorionic villi develop into the placenta.
2. The inside part becomes the amniotic sac – the protective bubble filled with fluid where the embryo develops.

Identical twins

Identical, or monozygotic, twins are conceived when a single sperm fertilizes an egg. At a very early stage in the cell division process, the fertilized egg divides into two and starts forming two babies. Identical twins have the same genes, so they’re the same gender.

Figure 7. Pregnancy week 4

5 weeks pregnant

Now could be a good time to do a home pregnancy test if you’ve missed a period and you’ve been sexually active. Pregnancy tests measure the amount of a hormone called human chorionic gonadotropin (HCG). Different kits show results in different ways, so read and follow the instructions carefully.

A positive pregnancy test

For many women, pregnancy is something to celebrate. For some women, it might come as a complete surprise or shock. Even if you’ve been planning to have a baby, finding out that you’re pregnant can bring some mixed emotions or uncertainty about what lies ahead.

Your pregnancy experience can be affected by other things going on in your life, such as:

• whether your pregnancy was planned
• whether you have a partner
• how much help you expect to have with raising your child
• how long it took you to get pregnant
• whether you’ve had any pregnancy losses such as miscarriage or stillbirth in the past
• whether you’ve had medical assistance, such as IVF
• whether you’re in a stable relationship
• whether you’ve felt pressure from your partner or family to get pregnant.

Signs of early pregnancy

This week you might be experiencing some signs of early pregnancy, including:

• more tired than usual
• wanting to go to the toilet more often – especially at night
• nauseous, or even vomiting
• feeling some tenderness in your breasts.

Every woman is different when it comes to morning sickness. Some women don’t get it at all, and some get it all day. A few (about 1%) get it so severely they can’t keep any food or fluids down. This is called hyperemesis gravidarum. If you’re having very severe symptoms, see your doctor.

From now, your baby is called an embryo. Inside the amniotic sac, from head to tail, it’s about 2.5 mm long at the end of this week. Its brain, heart and spinal column have started to form.

Figure 8. Pregnancy week 5

6 weeks pregnant

Your sense of smell might be stronger, and ordinary smells might make you feel sick. It’s the same with your appetite and sense of taste. Watch out for dizzy spells – if you’re feeling faint, make sure you sit down. And if you have any bleeding or cramping, see your doctor or midwife.

If you’ve just found out or think that you’re pregnant, make an appointment to see your doctor to start your pregnancy care.

Your doctor will:

• organize some routine tests, including a blood test
• check your health
• talk with you about pregnancy care options
• refer you to the health professionals you’d like to care for you or the place where you’d like to give birth.

Looking after yourself and baby

This is a very important time for your baby’s development, but it’s a time when many women don’t know they’re pregnant. If there’s any chance you could be pregnant, check with your doctor that any medications you’re taking are OK for your baby.

It’s also a good idea to talk about any lifestyle changes you might need to make. For example, if you smoke, drink alcohol, or use other drugs, you could ask your doctor for advice about quitting. Eating healthy foods and taking a folic acid supplement are also important, as well as avoiding some foods that can make you sick and harm your baby.

Your baby when you’re 6 weeks pregnant

Overall, your baby looks a bit like a tadpole, and is about 5 mm from head to tail. On an ultrasound (not usually done at this stage), your baby looks like a tiny bright dot, with its heart beating really quickly and rhythmically.

Here are some other key developments:

• Your baby’s heart has begun to beat – about 24 days after conception.
• Small buds are appearing at the top and bottom of the embryo – these will become your baby’s arms and legs.
• The neural tube closes over the brain and bottom of the spinal cord.

Figure 9. Pregnancy week 6

7 weeks pregnant

At this stage, some women have glowing skin. Others experience skin problems, such as pimples. There’s not much you can do about this, except cleanse your face regularly, use as little make-up as possible and stick to eating healthy foods and drinking lots of water.

Your breasts might be tender, and your nipples browner and more bumpy. Your breasts might also be noticeably bigger. If so, you might need a maternity bra, or at least a bigger one. It’s a good idea to be properly fitted.

A common health problem around now is constipation. To help with this, you can increase your dietary fiber by eating more fruit, vegetables, wholegrains and other high-fiber foods. Drink lots of water too – more than you usually would.

Life as usual

You might be surprised that life still feels pretty normal even though you have this amazing thing happening inside you. Many women feel full of energy and just keep doing their usual things – working, playing sport, going for walks, catching up with people and all the rest. But it’s also common to feel really tired and like you need more sleep than usual. Rest as much as you can and try to get to bed earlier at night. You might not want to go out as much as you used to.

Your baby when you’re 7 weeks pregnant

Amazing things are happening with your baby:

• The embryo is about 1 cm long from head to tail – about the size of a coffee bean. Body parts are usually out of proportion at this stage.
• The face is forming around the mouth. The embryo has large eyes, ear buds and a wide forehead. Inside the head cavity, the brain is developing.
• Internal organs are taking shape, including the stomach, kidneys, bowel and lungs.
• The heart is beating at 150-180 beats per minute.
• Hands are starting to develop at the end of the arm buds.

Figure 10. Pregnancy week 7

8 weeks pregnant

Your uterus is about the size of a tennis ball. It’s putting pressure on your bladder, so you might be feeling the need to go to the toilet more often. Your body is zinging with hormones to help your baby grow. Nausea peaks around this time, so you might feel quite sick. You might also feel more emotional, and you could be happy or grumpy at a moment’s notice. Or you could feel like you have loads of energy. Either way, lots of emotional swings are normal when you’re pregnant.

Early ultrasound

If you’re not sure when you became pregnant, or if you’ve had a previous miscarriage or ectopic pregnancy, your doctor or midwife might recommend an ultrasound scan in very early pregnancy, often at 8-10 weeks. This ultrasound scan can check for the baby’s heartbeat and work out the age and due date.

Your baby when you’re 8 weeks pregnant

This is what’s going on with your baby:

• The embryo is about 1.2 cm long from head to tail.
• The eyes have formed underneath a layer of skin. The nose is starting to show. The upper jaw and roof of the mouth come together. The inner ear and tongue are developing.
• Webbed fingers are taking shape.
• The reproductive organs are developing, but it’s too early to tell whether it’s a girl or a boy.
• The embryo’s tail is getting smaller – it will eventually disappear.

Figure 11. Pregnancy week 8

9 weeks pregnant

Most women will start to put on some weight at this stage, which is normal. But most still won’t have a noticeable baby bump. Headaches are common. You can take paracetamol according to the instructions on the packet. Also, nausea peaks around this time. Talk with your health professional if there are problems or changes that are really bothering you. You can also read more about health problems in pregnancy.

You’re more prone to dental infections during pregnancy, so take extra care of your teeth and gums. Use soft toothbrushes and dental floss. Consider seeing your dentist for a check-up.

Pelvic floor muscles

The pelvic floor is a group of muscles and ligaments that support the bladder, uterus and bowel. It’s recommended that all women exercise their pelvic floor muscles every day to prevent weakness and improve strength.

Keeping your pelvic floor muscles in good shape with pelvic floor exercises will help to prevent urinary problems like incontinence later in pregnancy or after the birth. Pelvic floor exercises can also help with labor and recovery after birth. Regular light exercise like walking can also help to strengthen your pelvic floor muscles.

Your baby when you’re 9 weeks pregnant

Your baby is tiny, but growing very quickly:

• The embryo is about 1.7 cm long, from head to tail.
• The head looks much more like a baby now, although it’s big compared to the rest of the body. The facial features are more defined. The external and middle ear are taking shape, but babies can’t hear until about 24 weeks.
• Tiny blood vessels are visible underneath the embryo’s transparent skin.
• Your baby’s skeleton is starting to form.
• Arms and legs are longer and slightly bent. It looks a bit like your baby is hugging itself.
• The umbilical cord and placenta are developing.

Figure 12. Pregnancy week 9

10 weeks pregnant

It’s completely normal to feel more:

• emotional and moody than usual
• hungry than usual
• hot than usual
• vulnerable and tired than usual.

Some women also feel less attractive and less interested in sex than before, although some find pregnancy increases their sex drive. Being open and honest about your feelings with people you know and trust can avoid hurt and misunderstanding.

Antenatal tests at this stage of pregnancy

Your doctor or midwife might talk to you about antenatal tests for chromosomal abnormalities, including non-invasive prenatal testing. Non-invasive prenatal testing looks at the risk of your baby having certain chromosomal abnormalities. Non-invasive prenatal testing can be done anytime from 10 weeks onwards.

There are two types of tests for chromosomal abnormalities and other conditions – screening tests and diagnostic tests.

1. Antenatal screening tests work out the risk of your baby having certain chromosomal abnormalities or other conditions. The results will say that your baby has a high risk or that your baby has a low risk of having a chromosomal abnormality or other condition. Screening tests don’t detect all chromosomal abnormalities and don’t tell you whether your baby is definitely affected. If you have a high-risk result from a screening test, you’ll be offered diagnostic tests.
2. Diagnostic tests can give you a yes or no answer – yes, your baby has a condition, or no, your baby doesn’t have a condition. Diagnostic tests can also pick up a wider range of chromosomal abnormalities.

Your doctor will offer you screening and diagnostic tests, but these tests are optional. It’s your choice to have antenatal tests for chromosomal abnormalities and other conditions.

Food and exercise during pregnancy

After checking with your doctor, most women who are healthy with an uncomplicated pregnancy can keep doing their regular, moderate exercise during pregnancy, or start light to moderate exercise. Aim for around 30 minutes of exercise a few times a week. Walking and swimming are good options. If you’re feeling more hungry than usual, avoid satisfying your hunger with unhealthy food. Try to stick with healthy foods.

Your baby when you’re 10 weeks pregnant

From this point on, the baby is called a fetus:

• It’s about 3.5 cm long from head to bottom, and weighs about 8 gm.
• All the organs are formed, but few are actually working yet.
• The heart has four separate chambers.
• It’s developing elbows, knees, wrists and ankles. The bones are all very soft. The webbing between the fingers and toes has gone. Your baby can almost touch its own face.
• The internal sex organs are finished, but you can’t see the external parts yet.
• The tail has gone.

Figure 13. Pregnancy week 10

11 weeks pregnant

Many women find that morning sickness starts to settle down after this point in pregnancy.

You might be having leg or foot cramps – this is common. Make sure you get lots of calcium by eating calcium-rich foods like milk, cheese and yoghurt, and stay active. If you have special dietary needs, seeing a dietitian might be a good idea.

The 11 to 13 week ultrasound scan

You can have this ultrasound scan at 11-13 weeks of pregnancy to check your baby’s development. It will also show if you’re having more than one baby. It can be really exciting – it’s often when you get to see your baby for the first time. But this ultrasound scan is usually also part of a screening procedure that checks your baby’s risk of having a condition like Down syndrome.

It’s a good idea to think about how you might feel and what you’d do if you’re told your baby has a high risk of complications or an abnormality. If you need to, you can talk about this with your partner or another trusted person or health professional.

Your baby when you’re 11 weeks pregnant

Your baby is ready for a growth spurt:

• It’s about 4.5 cm from head to bottom. It weighs about 10 grams.
• The heart is completely formed and pumping.
• Fingers are growing nails.
• The brain and nervous system are almost finished developing.
• Nerves and muscles are starting to work together. This means that your baby is starting to make small, jerky movements. It’s too early for you to feel them, though.

Figure 14. Pregnancy week 11

12 weeks pregnant

Your uterus shifts upwards about now, so the pressure on your bladder won’t be so bad. For a little while at least, you probably won’t need to go to the toilet so often. Many women start feeling a little less tired now. Others still feel very low on energy. You might notice brown patches on your face or neck. This is called ‘chloasma’ or the ‘mask of pregnancy’ and it’s normal. Also normal is the linea nigra, a brown line that shows up on the skin of your belly, running from your belly button to your pubic area. You might see it now, or not until much later in your pregnancy. Chloasma and the linea nigra are caused by hormonal changes that increase the amount of melanin in your body.

Many women have their first pregnancy care visit with an obstetrician around this time. It’s important to go to your antenatal appointments right from the start, so your health professional can see how you and your baby are going and you can talk about any concerns you might have. If there’s a problem, usually it can be picked up and treated, or checked. Certain tests are also recommended at certain times.

Antenatal appointments are a good chance to get health and lifestyle support if you need it and to get information about your pregnancy, labor, birth and early parenting.

Your baby eats and drinks what you eat and drink

The placenta is working now, sending oxygen and nutrients through the umbilical cord and taking waste products away. Most things that you eat and drink pass through to your baby. This is why you need to eat healthy food, not have too many caffeinated drinks – like coffee, tea and energy drinks – and quit alcohol and other non-prescribed drugs.

You also need to check with your doctor that any medicines you’re taking are safe for pregnancy. This includes prescribed medicines, natural supplements and medicines from chemists and supermarkets.

Other things that you might take in, like cigarette smoke, pass through to your baby as well, even when you’re around other people who are smoking.

Your baby when you’re 12 weeks pregnant

Here’s what’s happening with your baby:

• Your baby is about 6 cm long from head to bottom, and weighs about 18 grams.
• The kidneys are working and the baby can pass urine and swallow amniotic fluid.
• Your baby’s chest rises and falls, practising breathing movements. The digestive system is also in test mode.
• Twenty teeth have formed in your baby’s gums.

Figure 15. Pregnancy week 12