The first trimester
Getting pregnant is a life-changing moment, one that in 9 months time is literally going to change your life forever. It’s funny that in our society we wait until we are 12 weeks pregnant until we start telling people - this is the perceived ‘safe zone’. This is mostly true, your risk of having a miscarriage has significantly decreased by the time you reach 12 weeks, but if you end up being one of the one in four women whose pregnancy ends in a miscarriage, wouldn’t you want the support of your closest friends and family? Now you might not want to announce on social media that you are pregnant at 5 weeks, but pregnancy, especially that first trimester, can be very overwhelming and lonely to navigate all on your own. This article will give you an insight into what to expect during the first trimester.
I’m pregnant, now what do I do?
Congratulations you are pregnant! The first thing you need to do is to call and book yourself in with a LMC. In New Zealand we have Lead Maternity Carers (LMC) who look after pregnant women and these are either a community or independent midwife, which is free to you and government funded, or a private obstetrician who you will need to pay for. However, as there are not enough independent midwives or private obstetricians to look after all the pregnant women in NZ, if you miss out on booking a LMC then you will be cared for by the community team of midwives at the hospital.
The community team of midwives at the hospital are wonderful, experienced midwives but what you will miss out on is continuity of care as you probably won't see the same midwife at every antenatal appointment, you will have a different midwife at the birth and then possibly a different midwife again at your 6 week postnatal check.
With an independent midwife or private obstetrician you will see the same person or small team of people through your whole pregnancy, birth and the postnatal period, you will have continuity of care, you will know the people looking after you really well and you will have created a great rapport with them. This can be helpful in giving you a sense of security, particularly as you head into labour and birth as you have had months to create rapport and trust the people looking after you.
So, if you are wanting to be cared for by an independent midwife or a private obstetrician you need to book in early! The second you have a positive pregnancy test you need to call. Women are even testing as early as 3 weeks and a few days pregnant to ensure they get in with the LMC they want. Even if the pregnancy ends in a miscarriage it is still better to have booked in early than it is to wait until the ‘safe zone’ because you will most likely miss out.
Lots of people see their GP as the first port of call after a positive pregnancy test but as we have discussed, your LMC should be the first. Then you don't necessarily need to see your GP as the LMC should be able to provide you with a blood test form and ultrasound scan form that you do before your first visit with them. However some LMCs may request you see your GP for these tests so just double check with them when you are booking in. You will usually meet your LMC and have your first booking appointment at around 8 - 10 weeks pregnant.
Early first trimester testing
The first blood test your LMC or GP will get you to do will test for two main things, your HCG levels and your 1st antenatal bloods. Your HCG or Human Chorionic Gonadotropin, is a hormone produced when you are pregnant and it is the hormone that is present in your urine and picked up by your at home urine pregnancy test but it is more accurately measured in your blood. You are technically pregnant if there is more than 5IU/L HCG present in your blood and in early pregnancy we would expect your HCG levels to double every 2-3 days. Some people require repeat HCG blood tests every few days to make sure the levels are climbing at the expected rate, most will just need the one to confirm that you are indeed pregnant.
The other thing the blood test for is called your 1st antenatal bloods. These would ideally be done in the first 12 weeks of your pregnancy. You may be given this blood test form before or during your 1st visit with your LMC. So your first antenatal bloods will test to see what blood group you are, mostly to see if you are a negative blood group because if you are you will then require ‘Anti-D’ injections at certain times during your pregnancy and then within 72 hours of you giving birth. It's really important for your LMC to know if you are a negative blood group and to follow the correct protocol as if they don’t your future pregnancies could be at risk.
You will also have a full or complete blood count test, this tests for a whole bunch of things such as red and white blood cells, platelets, hemoglobin and many more blood components.
Next that is tested is your immunity to Rubella. If the mother contracts Rubella during her pregnancy then her baby is at risk of severe and permanent birth defects such as deafness, blindness, heart and brain damage and can lead to miscarriage.
You will also be tested to see if you have syphilis antibodies present in your blood, if there are then it is likely the mother has syphilis. syphilis can spread from the mother to the baby during pregnancy and this can result in stillbirth or miscarriage. It is also possible for the syphilis infection in the mother to cross over and infect the baby. An infected baby might be born without any symptoms but these could develop within a few weeks and the baby then becomes very sick. Proper treatment of the mother during pregnancy will prevent the baby being born with syphilis.
Hepatitis B antibodies will also be tested for in your first antenatal bloods. Women who are carriers of hepatitis B often are unaware of this as they have no or very mild symptoms. Hepatitis B usually doesn’t cause problems during pregnancy but can pass to your baby during the birth through contact with blood and body fluids in both vaginal and c-section births. If your baby was to get infected they don't tend to get sick but are at much higher risk of remaining a hepatitis B carrier and developing ongoing health problems this is why soon after birth, if the baby’s mother is hepatitis B positive, then the baby will be given a hepatitis b vaccine and hepatitis B immunoglobulin and may even be bathed to wash off the mothers body fluids. Sometimes if the mothers infection is very high during pregnancy she will be treated to reduce the viral load in her body before delivery.
HIV is also tested so that if positive the mother can be treated so that she does not pass the virus onto her baby.
The last thing that is tested for in your first antenatal bloods is your HbA1c levels. This test shows the average of your blood sugar levels for the past 4-6 weeks and if high means that you are at higher risk of getting diabetes in your pregnancy. There are many things you can do to lower your blood sugar levels such as eating healthy and exercising and you may want to do these in your early pregnancy to reduce your risk of getting gestational diabetes. At 24-28 weeks you will be given an oral glucose challenge test or polycose test and this test measures how well your body can process sugar. If you fail this blood test then you will need to do the oral glucose tolerance test and this test will confirm if you have gestational diabetes or not. If you do have gestational diabetes that is a whole kettle of fish that involves a special diet and blood testing throughout the day etc to keep them stable and your risks of having a large baby, going into preterm labour and having a stillbirth increase.
A mid-stream urine (MSU) sample is also recommended to be taken as part of the first routine antenatal screening. It is common for women to have some bacteria in the bladder that does not have any symptoms but if not treated in pregnancy can lead to severe bladder or kidney infections and also cause miscarriage or premature birth. Antibiotics can be taken to treat any bladder infections during pregnancy.
And lastly you might be offered a dating and viability ultrasound scan to be done around 6-12 weeks pregnant. This ultrasound scan will detect the baby’s heartbeat and make sure that it is the correct size for its expected gestational age. Your baby’s due date should also be confirmed by this scan based on its size and your last menstrual period. It also will confirm how many embryos you are carrying and will rule out an ectopic pregnancy.
Common symptoms of the first trimester
During the first trimester your baby develops from a single fertilised cell to an embryo and then a fetus with a heart, nervous system, head and brain and is moving its limbs by the end of this time. At the same time the mother has a huge surge of pregnancy hormones, and may experience fatigue, morning sickness, breast tenderness, increased urination and constipation.
It makes perfect sense that you are exhausted! Your body is doing a huge job growing a human being and adjusting to all the changes not just physically but also emotionally. You are embarking on a new and exciting journey but one that is unfamiliar and overwhelming at times. This is the time to rest, take naps when you can and have lots of grace for yourself and your amazing body to get through this little season. The second trimester often brings with it a boost of energy so this current level of exhaustion won’t last forever.
Morning sickness can be all day sickness for some people and it affects up to half of all pregnant women. You may have mild to extreme nausea, with or without vomiting and if you are really unfortunate, be diagnosed with hyperemesis gravidarum, nausea and vomiting that is so severe that it can lead to dehydration and hospitalisation. If you have mild or no nausea there is no need to be concerned, some women are worried because they have such a mild symptom that something is wrong. This is not the case, count yourself lucky! The only time to be concerned is that if you had this symptom and then it suddenly disappears, then you need to contact your GP or LMC.
For those of you that are struggling with the nausea and vomiting, it can be an extremely tough, lonely road for those few months, especially if you haven’t told anyone you are pregnant. Everything about life is hard when you feel sick, getting up in the morning, cooking, eating, staying hydrated, doing your job, driving, maintaining relationships etc becomes extremely difficult, you just go into survival mode for a time and you know what - this is totally OK. You do whatever you need to do to get through. Apart from all the classic tips like eating dry crackers before you get up in the morning, drinking ginger drinks, eating every 2 hours etc there are medications that your GP or LMC can prescribe you to ease the symptoms. Again have lots of grace for yourself during this time, most women find this symptom has eased or disappeared altogether by 12-16 weeks.
Breast tenderness is often the first sign of pregnancy and can occur as early as 2 weeks after conception and will usually last through the whole first trimester. They might feel swollen, sore, tingly and uncomfortable and your nipples may feel extra sensitive too. A surge in your hormones estrogen, progesterone as well as the breastfeeding hormone prolactin, trigger a boost of blood flow to your breast tissues causing changes and its normal for your breasts to grow a cup size or two by the end of your pregnancy.
If you need to pee a thousand times a day, then you can thank the increased levels of HCG and progesterone for this. Increased urination is a common pregnancy symptom in the first trimester and these hormones bring an increased flow of blood to your pelvic area to support your growing uterus and baby, as well making your kidneys more efficient at processing your blood throughout pregnancy, thus increasing your need to urinate. You might also find you have an increase in thirst too. If you develop any signs of a urinary tract infection like pain when urinating, fever, cloudy or yucky smelling urine, then you need to contact your LMC asap.
Constipation is also a common symptom of the first trimester and pregnancy in general due to the increase in the hormone progesterone. Progesterone causes the muscles in the intestines to relax which causes your food to move through the digestive system more slowly. It does this so that there is additional time for nutrients to be absorbed by the mother to be passed on to the baby. Pretty clever really but constipation is not a fun side effect. Constipation is when bowel movements are infrequent, hard and difficult to pass and affects nearly half of all pregnant women at some point in their pregnancy. Things like eating a high fibre diet, exercising regularly, drinking plenty of water, eating smaller, more frequent meals and probiotics can all help, along with laxatives that your LMC can prescribe.
Late first Trimester testing
When you are nearing the end of your first trimester your LMC will offer you some antenatal screening options if you want to test your baby for chromosomal and genetic conditions. We have two options in New Zealand, the first is the combined Maternal Serum Screening or MSS1 and the second the Non-Invasive Prenatal Testing otherwise known as the NIPT test. It's important to note that both the MSS1 and NIPT tests are screening tests, not diagnostic tests, therefore they will only give you a risk-based ratio of whether your baby has an increased chance of having one of these conditions. The NIPT is slightly more accurate but it still will not give you a definitive, 100% conclusive answer, you will need to have an amniocentesis for that.
The MSS1 is a two part, combined screening that involves a blood test and ultrasound scan that gets done when you are between 9 and 14 weeks pregnant and will give you a risk-based ratio of whether your baby has an increased chance of having Down syndrome, Turner syndrome, Trisomy 13 and Trisomy 18. As well as the blood and ultrasound scan it also is combined with other information like your age, weight and how many weeks pregnant you are. The blood test is best done when you are 10 weeks pregnant but can be done between 9 and 13 weeks and 6 days and the ultrasound is best taken around 12 weeks but can be done between 11 weeks and 2 days and 13 weeks and 6 days. The ultrasound scan is often called the nuchal translucency scan as it measures the fluid filled space at the base of the baby’s neck. This measurement tends to be larger in babies that have some conditions.
The NIPT test is a maternal blood test that detects and can test the genetic material from the placenta that naturally passes into the mother’s bloodstream from 10 weeks pregnant onwards. The NIPT differs from the MSS screening as the MSS screening has to be done in a certain time frame whereas the NIPT can be done any time from 10 weeks pregnant up until you are full term. It also differs from the MSS where the MSS looks at hormones and proteins in your blood and then combines as discussed above, whereas the NIPT looks at the whole genome; all 23 pairs of your baby’s chromosomes are screened. The NIPT is not currently funded in New Zealand and costs upwards of $600 for a basic screening test. In some cases the more conditions you test for the more the cost increases. Chat to your LMC about their recommendation as there are a few providers around so make sure you do your research and choose the right package for you. Bonus - if you do the NIPT then you get the option to find out the sex of your baby as early at 10 weeks!
My hope is that after reading this article you feel a little less lonely in how you are feeling and a little less overwhelmed as to what to expect in the first trimester. Remember to find a LMC asap and to open up to your friends and family about how you are feeling and to get all the help and support you need to get you through this life-changing experience. Have lots of grace for yourself, get lots of rest and sleep and know that this won’t last forever, this is just a season and that you are doing amazing growing a human life!
