DIAGNONSIS OF PREGNANCY AND MATERNAL PHYSIOLOGICAL CHANGES OF PREGNANCY BY Dr : A/ ILLAH KUNNA
DIAGNOSIS OF PREGNANCY Diagnosis in the first trimester (first 12 weeks)Symptoms:1- Cessation of menstruation :(missed period): due to increased estrogen and progesterone production by the corpus Luteum. However it may be absent in cases of: pregnancy during lactation amenorrhea. Threatened abortion. Slight bleeding at the expected time of
2- Morning sickness: - Nausea , vomiting especially in the morning. - Usually disappears after the third month. - May be due to allergy to hCG.3- Freguency of micturition: - Due to congestion. Irritation of the bladder by the pregnant uterus. - Usually disappears after the third month.
4- Breast symptoms:Enlargement , heaviness , discomfort andtinling sensation.5- Appetite changes:Craving for certain types of food andrefusal of other types.
Signs:1. Breast signs : ( evident in a primigravida). Increased size and vascularity. Dilated visible veins. Increased pigmentation of the nipple and 1ry areola. Appearance of 2ry areola. Appearance of Montgomery tubercles in the areola ( dilated sebaceous glands).
2. Uterine sign ; felt by bimanual examination: Size : enlarged. consistency : soft. Shape : globular. Hegar sign : ( elicited between 6-10 weeks). Two fingers in the anterior fornix, the fingers of the other hand over the abdomen behind the uterus . The fingers of both hands can be approximated as the lower part of the uterine body is soft and empty. Palmer sign: Uterine contractions felt on bimanual examination.
3- Cervical and vaginal signs: Leucorrhea : Increased vaginal discharge. Chadwick s sign: Bluish discoloration of the vagina and cervix. Goodell s sign: Cyanosis and softening of the cervix at 4 weeks
Investigations:1. Pregnancy test: All depend on the detection of hCG either in serum or in urine . Simple urine pregnancy tests are now available to be used at home giving an accurate result within 5 minutes.A. Estimation of beta subunit of hCG in the serum: Using radioimmunoassay , sensitivity : 5 mIU/ml. Positive I week BEFORE the expected menstuation ( I week after fertilization ).
B. ELISA pregnancy slide test: can detect pregnancy starting from 48 hours after the missed period.C. Immunologic pregnancy tests: Detect hCG in urine by an antigen antibody reaction. The sensitivity of these tests ranges between 25-250 mIU/ ml. positive few days AFTER the missed period.
Uses of pregnancy tests: Diagnosis of normal pregnancy. Diagnosis of missed abortion. Diagnosis of ectopic pregnancy ( see ectopic pregnancy) . Diagnosis and follow – up of vesicular mole and choriocarcinoma .
2. Ultrasonography: Vaginal: Gestational sac : 4 weeks. One fetal pole : 5 weeks. Two fetal poles : 6 weeks. Fetal heart activity : 7 weeks. Abdominal: The previous findings can be detected one week later.3. Auscultation of FHS : Using the Doptone (sonicaid ) starting from 10 weeks.
Diagnosis in the second trimester ( 13-28 weeks)Symptoms:1. Amenorrhea.2. Morning sickness and urinary symptoms gradually decrease .3. “Quickening “ : perception of fetal movements by the pregnant woman: a. 18-20 weeks in primigravida. b. 16-18 week s in multipara.4. Abdominal enlargement.
Signs:1. Breast changes become more evident.2. The uterus is abdominally felt.3. Braxton Hicks contractions; intermittent painless contractions detected by abdominal examination.4. Internal ballottement : elicited at 16 week , it can be demonstrated by by pushing the fetus through the anterior fornix using 2 fingers.5. External ballottement : elicited at 20 week through abdominal examination.6. Palpation of the fetal parts and palpation of fetal movements by the obstetrician at 20 weeks.7. Auscultation of the F.H.S. at 20- 24 weeks by
MATERNAL PHYSIOLOGICAL CHANGES OF PREGNANCYpregnancy is a peculiar physiological state in which many changes take place ; mostly due to the effect of pregnancy hormones. These changes help adaptation of the woman s body to pregnancy . Understanding these changes is essential for the following reason: to discriminate between symptoms related to pregnancy and those of pathological conditions, to understand the effect of pregnancy on pre-existing diseases e.g diabetes and
1. Genital organs:A. The uterus : Increase in : size : 7.5 to 35 cm. weight : 50 to 1000 gms.Due to: Effect of pregnancy hormones leading to hypertrophy ( mainly ) and hyperplasia. Stretching by the growing fetus. Shape : Globular until 14 weeks then pyrifrom. Ligament: Hypertrophy .
Dextro rotation : ( 80 % of cases). The uterus is tilted and twisted to the right .Braxton Hicks contractions: Irregular , usually painless, with no effect on cervical dilatation. Promoting placental circulation.The lower uterine segment:Is formed from the isthmus , starting from the fourth month to reach 10 cm by full term.
Upper segment Lower segment-Active -Passive-Contracts and retracts - Dilates , stretches toto become shorter and become thinner andthicker longer- Thick wall: - thin wall, the obliqueOuter longitudinal layer is poorlyMiddle oblique ( main developed.bulk – most important forhemostasis ).Inner circular ( especiallyaround orifices)- Covered by adherent - Covered by loosepertoneum peritoneum- Membranes are firmly -Membranes are looselyattached attached.
Obstetric singnificance of L.U.S.:1. Site of lower segment cesarean section (LSCS).2. Site of rupture in obstructed labor.3. Site of implantation of placenta previa.
B. The cervix: Edema. Increased vascularity. Hypertrophy of glands. The cervix becomes soft and bluish ; the secretions from the mucus plug in the cervical canal. Hormonal erosion sometimes occurs. Near term , prostaglandins induce changes in collagen fibers and ground substances making the cervix softer and easily dilatable.
C. The vulva: Varicosities may develop.D. The vagina: Increased vascularity makes it soft, moist, bluish and warm.E. The ovaries: Edema , increased vasceularity . One of the ovaries contains the corpus luteum which may reach up to 5-6 cm then in starts to degenerate by the 10 th week.
2. Breasts: changes are induced by estrogen and progesterone:1. Early in pregnancy , breasts show increased size and vascularity , become warm, tense, nodular and slighty tender.2. Increased pigmentation of nipple and 1 ry areola.3. Secondary areola appears later: a lightly pigmented area around the (1ry) areola.4. Montgomery s tubercles appear on the areola ( dilated sebaceous glands).5. colostrum may be expressed at the end of the third month.
3. Skin:1. pigmentation : may be due to MSH or estrogen:Linea nigra: pigmentation appears in the midline of the abdomen , more evident below the umbilicus.Chloasma : pigmentation of the face with butterfly distibution.2. Striae gravidarum : ( stretch marks). Pink line in the flanks due to stretch of the abdominal wall which causes rupture of the subcutaneous elastic tissue, and also due to increased cortisol. After labor , the color turns to white ; “ striae albicans” due to fibrosis.3. Signs of malnutrition and vitamin deficiency
4. Cardiovascular system:1) Blood volume : Increased by about 45% , half of this rise is achieved by 8 week and the maximum increased in blood volume is mainly due to expansion of plasma volume more than the increase in R.B.Cs . Volume resulting in physiological hydremia and drop of hemoglobin level.
2) Cardiac output: ( = SV X HR) Increases by 30 – 50 % to reach a maximum at 32-34 weeks and then it is maintained up to full term. The increased CO is mainly due to increased SV as the HR increases only by 15%.3) Leucocytes : increase to about 16.000/cc.4) Platelets , fibrinogen : increase , fibrinogen reaches 600 mg %.5) Venous stasis : in the lower half of the body due to compression of the pelvic veins by the gravid uterus and to relaxation of the venous wall by the effect of progesterone , this may lead to varicose veins, ankle edema and
6) Blood pressure : Decreases slightly during the second trimester due to opening of A-V shunts in the placenta. Any rise to 140/90 or 30 mm Hg systolic or 15 mm Hg diastolic (above the base line reading before pregnancy or during the first trimester) is considered abdominal . “ Supine hypotension syndrome”: Hypotension may develop in supine position especially during late pregnancy due to pressure by the gravid uterus on the in inferior vena cava with subsequent reduction in cardiac output.7) The apex: Is displaced upwards in late pregnancy by elevation of the diaphragm(ECG changes).
5. Urinary system:1. Frequency of micturition : Early in pregnancy : due to congestion and pressure on the bladder by the enlarged uterus . Late in pregnancy : due to pressure by the presenting part2. Dilatation of the ureters due to: pressure against the pelvic brim by the uterus especially on the right side. Effect of progesterone and relaxin hormone. Hypertrophy of the wall of the lower end of the ureters caused by estrogen . * Dilatation leads to stasis of urine which in turn predisposes to infection.
6. Respiratory system: Dyspnea is common due to: Hyperventilation ( progesterone effect). Elevation of the diaphragm ( especially during the 8th month ).
7. Gastrointestinal tract: Increased salivation with increased acidity predisposing to dental caries. Hypertrophy of the gums ( sometimes bleeding gums) Morning sickness in early pregnancy. decreased gastric acidicity ( by 50% ) and motility that may cause flatulence and interference with iron a bsorption. Heart burn due to reflux esophagitis. Tendency to constipation due to relaxation of the smooth muscles by progesterone . Slight impairment of liver functions. Relaxation of the wall of gallbladder ( cholestasis, predisposing to stone formation).
8. Musculoskeletal system: Increased lumbar lordosis. Relaxation of pelvic joints and ligaments( progesterone and relaxin).
9. Endocrine system:1) pituitary : Anterior pituitary increases in size and activity but the blood supply is NOT increased. Posterior pituitary produces oxytocin thus stimulating onset of labor.1) Thyroid : Increased size and activity ; physiological goiter may occur. Total T3 and T4 are increased .1) parathyroid: Increased size and activity ; to regulate the increased calcium metabolism.4) Adrenals: Increased activity ; total cortisol is increased but the free portion calcium metabolism.5) Placental hormones :
10. Metabolic changes:1. Proteins: Tendency to nitrogen retention.2. Carbohydrates: Carbohydrates metabolism is slightly DISTURBED.- Anti – insulin : are increased . * HPL ( human placental lactogen) favors transfer of glucose to the fetus. * Cortisol. Estrogen. * progesterone Insulinase enzymeAll , except cortisol , are produced by the plasenta.
Alimentary glycosuria : due to rapid absorption of glucose . Renal glycosuria : due to lowering of renal thrshold.3. Fats: Fats metabolism is disturbed secondary to disturbance of carbohydrate metabolism.3. Minerals: Increased requirements of : iron , calcium , phosphorus and Iodine . Tendency to NaCl retention ( effect of pregnancy hormones).3. Water : Tendency to salt and water retention.
11. Weight :The average total weight gain is11- 16 kg, most of it occurs duringthe 3rd trimester.