Pregnancy is a time of joy and great anticipation for most expectant families. However, that happiness and tremendous hope for the future can suddenly be halted by the diagnosis of a complicated pregnancy. Every expectant mother should savor the changes that accompany the progression of her pregnancy, but at the same time be aware that certain occurrences are not considered normal.

Bleeding
Bleeding at any time during the pregnancy should be immediately reported to your health care provider. Bleeding can be a sign of a potential spontaneous abortion (mis.carriage) in the first trimester. In the second and third trimesters, it can be a sign of abnormal placental (afterbirth) implantation to the uterine wall, or premature separation of the placenta. Bleeding can also occur after in.tercourse through pressure on or irritation of the vagina and/or cervix.

Execessive Vomiting
Many women in the first trimester experience what is commonly called "morning sickness." This is usually due to hormones produced/released during pregnancy influencing the gastrointestinal tract. Excessive vomiting can lead to weight loss and an imbalance in your electrolytes and should be reported to your health care provider so that your weight, and possibly your blood count, can be monitored. Do not assume that vomiting is a normal occurrence of pregnancy if it interferes with your normal day-to-day activities.

Headaches, Blurred Vision, Epigastric Pain and Swelling
Put all of these symptoms together and you may have what used to be called "toxemia of pregnancy." Pregnancy-induced hypertension, preeclampsia or toxemia, is a disease state of pregnancy that is very complicated in nature and manifests itself in the late second trimester and third trimester. It can present itself with any or all of the above symptoms. One of the reasons that your health care provider asks for a urine specimen every visit is to check for the presence of protein in the urine, which is one of the manifestations of pregnancy-induced hypertension. This is also why your blood pressure is monitored during the pregnancy.

Keep in mind that every pregnant woman experiences a headache now and then for a variety of reasons-such as tension, stress, allergies-just as in non-pregnant situations. Many pregnant women also experience swelling in their hands and lower extremities, especially in the third trimester. This can be due to the increased blood volume and the pressure that the growing fetus exerts on veins in the leg, which slows down the blood flow returning to the heart. Swelling can also be caused by warm weather. Reflux and heartburn are common in pregnant women and can be mistaken for epigastric pain-pain that occurs right under your ribcage. Heartburn can be caused by liver congestion, a complication of pregnancy-induced hypertension. Blurred vision can occur from a variety of reasons, including factors not related to pregnancy. Always report vision problems to your health care provider.

Cramping, Backache and Thigh Pain
These symptoms may occur with or without bleeding. One of the early signs of an impending pregnancy loss is the start of abdominal cramping, a backache or pain radiating into the front part of your thigh. Do not assume that the pain stems from the weight of your belly or that bag of groceries you carried up the stairs. If any or all of these symptoms occur, call your health care provider.

Shortness of Breath, Heart Palpitations
Shortness of breath and heart palpitations should never be taken lightly. Women in their third trimester often ex.perience a shortness of breath as the growing fetus ex.pands into the ribcage. If the shortness of breath persists beyond climbing a flight of stairs or comes and goes, call your health care provider. Palpitations are another reason to pick up the phone for an appointment. The body has one-third more blood volume when it is pregnant, which can tax the heart and circulatory system. The increased blood volume and hormones can sometimes cause the palpitations.

Fluid Leaking from the Vagina
Urine leakage can be caused from something as simple as the baby pressing on your bladder. Fluid leakage can also be the result of a spontaneous rupture of the "bag of waters" or membranes. The membranes are a protective mechanism for the baby-they cushion him or her and allow room for fetal movement growth and provide a barrier against infection. Fluid leakage should always be reported to your health care provider.

Pregnancy is a great time! Enjoy it, savor it, be astounded by the changes that are occurring every day. At the same time, protect yourself and your baby by being aware of the warning signs of problem pregnancies.

Compiled by Denise A. Rosa, BS, RN, nurse manager of labor and delivery/antepartum at Hackensack (NJ) University Medical Center.