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Discomforts of pregnancy
MRS RAMESHWORI. TH
ASSOCIATE PROFESSOR
Discomforts of pregnancy
The common discomforts are listed below, system wise:
A. Digestive system
1. Nausea & Vomiting:-
Very common in the morning but can occur any time, commonly
known as 'morning sickness'.
It is seen in nearly 50% of women during the first trimester. The
hormones that can be responsible for this are- hCG, estrogen and
progesterone.
Nursing implication- to relieve nausea and vomiting, following measures
should be instituted:
• Light snacks should always be with the mother. Do not be empty
stomach, as the nausea can get worse.
• Eat small frequent meals as the first step in the treatment of nausea and
Vomiting.
• After waking up in the morning, consider eating a small piece of
unbuttered toast or salty crackers before getting out of bed.
• Avoid fatty, greasy and spicy foods. It takes longer for fats to be
digested during pregnancy.
2. Bleeding from gums:-
Mainly because of increased blood supply to the gums and response to
higher blood level of progesterone
3. Flatulence:-
Increase gas in bowels, caused by swallowing air in order to Relieve
nausea.
4. Constipation:-
Constipation during pregnancy is a very common complaint.
This is mainly due to the effect of progesterone, which relaxes the smooth
muscles,causing decreased peristalsis of the gut.
• Hemorrhoids (or piles) is a condition in which the veins at the lower end of
the intestine (called rectum) become congested, swollen and dilated. Initially,
hemorrhoids begin in the blood vessels of the rectum.
• If they continue to grow, they can spread to include veins at the entrance of
the anus (the end of the digestive tract through which the stools pass out)
and finally protrude outside the anus.
Nursing implication-advise woman to-
• Eat foods rich in fiber, green leafy vegetables and fruits.
• Drink an additional 6-8 glasses of water a day.
• Eat frequent, small meals throughout the day.
• Regular exercise can help keep your intestines moving efficiently during
pregnancy
•Eat foods low in fat and prepared with little grease. High fat foods are hard to
digest and can stay in the intestines for a longer time.
• Take a glass of warm water in the morning to activate the gut for regularity
bowel movements.
•Avoid fatty foods in the evening because they promote gastric heartburn.
5. Heartburn:-
 Heartburn is the condition in which the partially digested food from the
stomach goes back in to the food pipe and the acids from the stomach
juices that are mixed with the partially digested food cause burning
sensation in the middle of the chest.
 It is due to the effect of Progesterone, which relaxes the cardiac
sphincter during pregnancy. The stomach is compressed and pushed
up higher in the abdomen by the growing uterus.
 As a result, digestion of food in the stomach is affected and it takes
longer to empty the food.
Nursing implication- Advise woman to-
• Eat small, frequent meals.
• Avoid foods that commonly cause heartburn: fatty,
• Avoid lying flat immediately after eating spicy foods.
• Avoid bending or kneeling while doing household chores.
• Avoid eating late at night.
• Sleep on pillows.
• Avoid drinking a lot of liquid with meals.
6. Pica:- It is a craving for certain foods or unnatural substances. It should be
considered that the substance craved should not be harmful to mother or baby.
B. Circulatory System-
1. Dizziness and fainting:
 It occurs mainly because of fall in blood pressure progesterone relaxes the
muscles of blood vessels.
 Blood therefore tends to collect in the lower part of the body resulting in low
blood pressure. It subsides after the compensatory increase in blood
volume.
 In later period, mother may feel faint while lying on her back, as the gravid
uterus puts pressure on the inferior venacava anddiminishes blood return to
the heart..
• Nursing implication- Advice the mother not to lie on her of pregnancy and to
avoid long periods of standing back in later months
2. Swelling of the Feet:-
 The fluid gained by the woman during pregnancy tends to accumulate in the
feet and ankles during the day and cause these areas to swell.
 There is venous and lymphatic stasis. Swelling of the feet and ankles can also
occur due to hot weather and after standing continuously for a long time.
 In such cases, the swelling will subside when you lie down or prop up your feet.
The blood pressure should be checked to rule out pregnancy induced
hypertension.
Nursing implication- advise the mother not to sit with the feet hanging down and
elevate legs.
3. Varicose Veins:-
 This is the term used for tortuous and dilated veins.
Progestrone relaxes the smooth muscles of veins which
results in diminished circulation.
 The valves of the dilated veins become inefficient and
varicosities result.
It is more common in the veins of the legs.
 Varicose veins can be seen as reddish or bluish lines
under the skin, especially on the legs and ankles.
 Excessive weight gain increases the risk of developing
varicose veins.
Varicose Veins:-
Nursing implication- Advice the mother to-
• Rest the legs vertically against the wall.
• Perform circulatory exercise for toes and ankles.
• Wear support tights before rising or after resting with
legs elevated.
C. Musculoskeletal System
1. Leg cramps:
The exact cause of cramps in the leg, especially calf muscles
is not known. It is however suspected to be because of
low calcium levels and vitamin B1 or pressure of the uterus
on the nerves of the leg. Leg cramps occur more frequently
at night. Fatigue can worsen leg cramps.
Nursing implication- Advice the mother to-
• Take calcium and vitamin B complex supplements.
• While sleeping, elevate the foot end of the bed.
• Before sleeping at night, make gentle leg movements in
the warm bath.
• Wear support tights before rising or after resting with legs
elevated.
2. Back Pain:
Back pain in pregnancy is very common and usually develops during the
third trimester, because of the weight gain and change in the body's
center of gravity.
There are three main causes of back pain during pregnancy:-
• Change in the posture:
With the uterus growing in size, the center of gravity
of the body changes and in order to compensate for the change in center
of gravity,the posture and style of walking changes. This can cause back
pain, or other injuries.
Softening of the bones:-
Hormones of pregnancy, especially, Relaxin, that is
secreted during the pregnancy relaxes the joints between
the pelvic bones, making them soft during pregnancy.
This is preparation for the baby to pass through the pelvis
during birth as softened joints help expand the pelvis cavity,
while this change is essential for normal birth of baby, it can
cause pain in lower back.
Separation of muscles of the abdomen:-
 There are two parallel sets of muscles in the middle and
front part of the abdomen that joins the lower end of the
rib cage above and upper end of the pelvis below.
As the uterus grows in size, these muscles can separate
lower in the center and worsen back pain.
Nursing implication-
Advice the mother to-
• Use leg muscles to lower and raise yourself.
• Wear low heeled and supportive shoes.
• Avoid standing for long periods and frequently change
sitting position.
• Do a pelvic rocking exercise a few times a day.
D.Genitourinary System
1. Increased frequency of passing urine and Difficulty in
holding urine-
Two in causes for this are-
 The size of uterus grows and therefore presses against urinary
bladder, so urge for passing urine, and secondly, Kidney begins to
function more efficiently, so the volume of urine produced
increases.
 The uterus exerts maximum pressure on the urinary bladder
during the first and third trimester.
• As a result, small amount of urine may leak out involuntarily,
especially when mother laughs, coughs or sneezes.
• This is because all these actions increase the pressure on the
abdomen and put greater pressure on the bladder.
• Difficulty in holding urine disappears after delivery.
2. Leukorrhea-
During pregnancy, there is increased white, non-irritant
vaginal discharge. In case of, disturbing discharge, medical
advice should be taken.
Nursing implication- Advice the mother to frequently wash
the vulva, avoid tight undergarments.
E. Integumentary System
1. Itching of the skin:-
 The skin of the abdomen stretches during the third trimester and
becomes dry and itchy.
 There are stretch marks on breasts, abdomen and upper thighs.
 These will appear as reddish or whitish streaks on the skin.
Stretch marks tend to be lighter after delivery.
Integumentary System
2. Darkening of the skin:-
Several skin changes are common during pregnancy. Of
these, darkening of the skin is perhaps the most common.
Although the exact cause for darkening is not known, it is
believed to be due to higher levels of the female hormone
estrogen in the body.
There are three main areas of the darkening of the skin:
a) around the nipples
b) around the navel and
c) Between external genitalia and the anus.
Other areas that may also darken are the arm pits, inner
side of the thighs, the central line between the naval and
pubic bone and rarely, the face.
F. Nervous System
1. Carpel Tunnel Syndrome-
There is fluid retention in the pregnancy, which
creates edema and pressure on the median nerve.
Mother feels numbness and 'pins and needles' in
fingers and hands.
Nursing implication-
Advice the mother to restrict salt intake in diet, rest
the hand on pillows and wear splint at night, flex the
fingers while holding the arm above the head.
2. Insomnia-
It results as the mother feels more discomforts during later months of
pregnancy, such as uncomfortable posture, frequency of micturition,
fetal movements etc.
Nursing implication-
• Advice the mother to have a glass of warm milk at bed time, lie in
lateral position with the support of pillows, take rest in afternoon and
share her anxiety and fears.
DIAGNOSIS
OF
PREGNANCY
DIAGNOSIS OF PREGNANCY
• The reproductive period of a woman
begins at menarche and ends in
menopause. It usually extends from 13–
45 years.
• While biological variations may occur in
different geographical areas, pregnancy is
rare below 12 years and beyond 50
years.
• Lina Medina in Lima, Peru was the
youngest one, delivery by cesarean
section when she was only 5 years and 7
months old and the oldest one at 57
years and 4 months old.
DIAGNOSIS OF PREGNANCY
DURATION OF PREGNANCY:
• The duration of pregnancy has traditionally been calculated by the clinicians in terms of 10
lunar months or 9 calendar months and 7 days or 280 days or 40 weeks, calculated from the
first day of the last menstrual period. This is called menstrual or gestational age.Q
• But, fertilization usually occurs 14 days prior to the expected missed period and in a
previously normal cycle of 28 days duration, it is about 14 days after the first day of the
period.
• Thus, the true gestation period is to be calculated by subtracting 14 days from 280 days, i.e.
266 days. This is called fertilization or ovulatory age and is widely used by the embryologist.
FIRST TRIMESTER (FIRST 12 WEEKS)
SUBJECTIVE SYMPTOMS
The following are the presumptive symptoms of early months of
pregnancy:
• Amenorrhea
Amenorrhea means missing of menses. This will be up to three months in a
menstruating women means pregnancy unless otherwise proven.
• Implantation [placental sign] bleeding- small blood discharge at the first
missed period [28-35] is noticed by some women.
• Morning sickness
 (Nausea and vomiting) is inconsistently present in about 70%
cases, more often in the first pregnancy than in the subsequent
one.
 It usually appears soon following the missed period and rarely
lasts beyond 16 weeks.
 Its intensity varies from nausea on rising from the bed to loss of
appetite or even vomiting.
 But it usually does not affect the health status of the mother
Frequency of micturition is quite troublesome symptom during 8–
12th week of pregnancy. It is due to:-
(1) resting of the bulky uterus on the fundus of the bladder because
of exaggerated anteverted position of the uterus,
(2) congestion of the bladder mucosa and
(3) change in maternal osmoregulation causing increased thirst and
polyuria . As the uterus straightens up after 12th week, the symptom
disappears
• Breast discomfort in the form of feeling of fullness and
‘pricking sensation’ is evident as early as 6–8th week specially in
primigravidae.
• Increased size of the breast become evident in the early weeks of
pregnancy
• It is due to the marked hypertrophied and proliferation of the ducts
and the alveoli by the hormones(estrogen &progesterone) which
are marked in the peripheral lobules.
• Fatigue, Tiredness, Sleepiness
 Easy fatigue is not uncommon during pregnancy.
 This is due to increase in physiological changes in cardiovascular
system.
 Women describe this variously as weakness, disinclination to
work, or the desire to keep themselves on bed.
OBJECTIVE SIGNS:
• Breast are enlarged and often
contain milk for years.
• The breast changes are evident
between 6 and 8 weeks.
• The nipple and the areola (primary)
become more pigmented specially in
dark women.
• Montgomery’stubercles are
prominent.
• Thick yellowish secretion (colostrum)
can be expressed as early as 12th
week.
Breast changes during pregnancy;
(A) Pronounced pigmentati on of the primary areola
and nipple;
(B) Appearance of secondary areola, development of
Montgomery tubercles and increased vascularity
Per abdomen —
• Uterus remains a pelvic organ until 12th
week, it may be just felt per abdomen as a
suprapubic bulge.
• Fundus is not felt at early pregnancy
Pelvic changes—
The pelvic changes are diverse and appear at different periods.
Collectively, these may be informative in arriving at a diagnosis of
pregnancy.
Jacquemier’s or Chadwick’s sign:
 It is the dusky hue of the vestibule and anterior vaginal wall visible
at about 8th week of pregnancy.
 The discoloration is the result of pelvic congestion due to increase
in vascularity.
Vaginal sign:
• (a) Apart from the bluish discoloration of the anterior
vaginal wall
• (b) The walls become softened and
• (c) Copious non-irritating mucoid discharge appears at
6th week
• (d) There is increased pulsation, felt through the lateral
fornices at 8th week called Osiander’s sign.
Cervical signs:
(a) Cervix becomes soft as early as 6th week (Goodell’s sign), a
little earlier in multiparae. The pregnant cervix feels like the lips of
the mouth, while in the non-pregnant state, like that of tip of the
nose.
(b) On speculum examination, the bluish discoloration of the cervix
is visible. It is due to increased vascularity.
Uterine signs:
(a) Size, shape and consistency —
• 6th week- size of hen egg
• 8th week- size of cricket ball
• 12th week- size of fetal head
• Pyriform shape of non-pregnant uterus becomes globular
at 12th week
As pregnancy advances symmetry is restored and the
uterus feels soft and elastic
• PISKACEK'S SIGN
 One half of the uterus is firmer than the other
since blastocyst usually implant laterally resulting
in asymmetrical growth of the uterus with the
area of ​​implantation being softer than the rest
• HEGAR'S SIGN
 Demonstrated between 6-10th week.
 Upper part of the body of the uterus is enlarged
by the growing fetus, lower part of the body is
empty and extremely soft.
 Examination must be gentle to avoid the risk of
abortion.
(c) Palmer’s sign:
• Regular and rhythmic uterine
contraction can be elicited during
bimanual examination as early as 4–
8 weeks.
• Palmer in 1949, first described it and
it is a valuable sign when elicited.
• After 10th week, the relaxation
phase is so much increased that the
test is difficult to perform.
SECOND TRIMESTER:
A) SUBJECTIVE SYMPTOMS:
• Amenorrhoea: continues.
• Uterus enlargement:
There is progessive enlargement of the uterus.
• Quickening:
• It is a feeling of life,as the mother feels active fetal
movements at around 16 weeks (multigravida), 18 weeks
(primigravida)
B) Objective signs
Chloasma-
Around 24" week of pregnancy, there appears pigmentation on face
and forehead.
Breast changes-
• From 20 week, pigmentation appears around primary areola in breasts, which
is called as secondary areola.
• Breasts are more enlarged and Montgomery’s tubercle are
prominent,extending to secondary areola.straie becomes visible and
colostrum becomes thick and yellowish.
Abdominal findings-
Inspection
• After 20 weeks, there is appearance of a linear
pigmentation in the middle of abdomen,
extending from symphysis pubis to ensiform
cartilage, called as linea nigra.
• Varying degree of striae is also visible on the
lower abdomen.
Palpation-
• As there is enlargement of uterus;
• Fundal height is also increased and can be felt
in the midline as a soft elastic lump.
• It is ovoid in shape.
Uterus is:
• at 16th week - midway between
symphysis pubis and umbilicus
• at 20th week - 2.5 cm below umbilicus
• at 22 to 24th week at the level of
umbilicus and near xiphoid process
• at 28 week - at the junction of lower
third and upper two-third of distance
between the umbilicus and ensiform
cartilage.
• Braxton Hicks contractions (irregular, infrequent, spasmodic and
painless contractions) are also felt. Woman cannot feel the
contractions at this time, but these can be felt, by placing a palm
on the uterus.
• Active fetal movements can also be felt by placing the palms on
the sides of the uterus.It is the positive evidence of a live fetus
and by palpating the fetal parts, presentation and position of fetus
can be determined during later weeks.
• Palpation of fetal parts- By 20th week, fetal parts can be palpated.
External ballotment-
• Around 20th week, when the fetus is
smaller than the volume of amniotic fluid,
external ballotment can be elicited.
• By keeping the mother in dorsal position,
with one hand tapping of uterus is done
from one side, while the other hand, which
is kept outstretched on the other side feels
the impulse.
Auscultation-
• By 20th week, one can hear the fetal heart sound with the
help of a stethoscope.
• It is heard like a ticking of a watch under a pillow.
• As the position of the fetus changes, the location of FHS
also changes. Normally, the FHS is 140-160/ min.
There are two other sounds, which can be confused with fetal heart
sound. These are:
Uterine soufflé-
• Soft blowing systolic murmur which is heard low down at the sides
of the uterus.
• It is synchronous with the maternal pulse and is due to increase in
blood flow through the dilated arteries.
Fetal soufflé-
• Soft blowing murmur synchronous with the fetal heart sound.
• It is due to rush of blood through the umbilical arteries.
Per Vaginam-
• There is bluish discoloration of
vulva, vagina and cervix. Vagina
and cervix become soft and moist.
Internal Ballotment:
 It can be elicited around 16-28 weeks,as the fetus is too
small before 16 weeks and too large after 28 weeks.
 Woman is kept in dorsal position and two fingers are
placed on anterior vaginal fornix in front of cervix and
other hand is placed firmly on the uterine fundus.
 When the head or breech is gently pushed with the
internal fingers, the fetus displaces upwards but quickly
rebounds to its original position.
Clinical investigations.
• Ultrasonography- With the help of sonography, gestational age is determined
by biparietal diameter (BPD), and femur length(FL).
• Fetal organ anatomy is surveyed to detect any malformation. Fetal viability is
determined by realtime ultrasound. Absence of fetal cardiac motion confirms
fetal death.
• Magnetic Resonance Imaging (MRI): MRI can be used for fetal anatomy
survey, biometry and evaluation of complex malformations
• Radiologic evidence of fetal skeletal shadow may be visible as early as 16th
week
Third trimester-
A) Subjective symptoms
• Amenorrhoea - Amenorrhoea continues.
• Enlargement of the abdomen is present. With the enlargement of the
abdomen, mother may feel discomfort such as palpitation, dyspnoea after
exertion.
• Pressure symptoms- Oedema of dorsum of feet up to ankle.
• Fetal movements are more evident during this period.
• Lightening- It is the sense of relief felt by the mother from the pressure
symptoms due to the engagement of the presenting part into the pelvis.
B) Objective signs
Skin changes-
• Linea nigra and striae gravidarum become more
prominent.
• Chloasma also becomes more prominent.
Uterine shape becomes cylindrical to spherical.
Fundal height.
Height of fundus increases as follows:
• At 32 weeks- corresponding to the junction of upper and middle third
• At 36 weeks- up to the level of ensiform cartilage
• At 40 weeks- fundus comes down to the level of 32 weeks due to
engagement of head.
Symphysis fundal height (SFH).
• The upper border of the fundus is located by the
ulnar border of the left hand and this point is marked.
• The distance between the upper border of the
symphysis pubis up to the marked point is measured
by a tape in centimeter .
• After 24 weeks, the SFH measured in cm
corresponds to the number of weeks up to 36 weeks.
• A variation of ± 2 cm is accepted as normal.
• Variation beyond the normal range needs further
evaluation
• Braxton Hicks contractions are more evident.
It becomes more regular during last two weeks of pregnancy.
• Fetal movements and palpation of fetal parts are felt more easily.
F.H.S. is heard distinctly according to the presentation and position of
the fetus.
• Ultrasonography-
Estimation of gestational age is done by BPD, FL, AC and HC, but it is
not very accurate.
1.Presumptive signs-
This includes maternal physiological changes, which the
woman experiences, indicating that she is pregnant.
Signs included in this are:
Amenorrhea
 Nausea and vomiting in first trimester
Frequency of micturition in first trimester
Fatigue of mother
Enlargement of breasts along with tingling sensation.
Development of primary and secondary areola.
Appearance of Montgomery's tubercles.
Expression of colostrums from nipples.
Pigmentation of skin (chloasma, linea nigra, striae).
 Quickening.
2. Probable signs-
These are the maternal physiological changes, which are
detected upon examination by the examiner.
Signs included in this are:
• Changes in the shape of uterus and enlargement in the size.
• Positive pregnancy test through presence of hCG in urine.
• Hegar's sign.
• Chadwick's sign/ jacquemier's sign
• Osiander's sign. Goodell's sign
• Ballotment of fetus.
• Braxton Hick's contractions.
3. Positive signs.
These signs directly tell about the presence of the fetus and are detected by
the examiner.
Signs included in this are:
• Visualization of the fetus by ultrasound.
• Visualization of fetal skeleton by radiology.
• F.H.S by ultrasound and later on by fetoscope.
• Fetal movements palpable by examiner.
• Visualization of fetal movements in late pregnancy.
• Palpation of the fetal parts.
Differential diagnosis
The differential diagnosis for Presumptive and probable signs are as follows:
Presumptive Signs of pregnancy Differential diagnosis
Amenorrhoea
Breast changes
Nausea and vomiting
Frequency of micturition, bladder
-irritability
Quickening
Emotional stress, illness, imbalance in
hormones
Contraceptive pill
Gastrointestinal disorders, cerebral
irritation
Intestinal movement
Probable signs of pregnancy Differential diagnosis
HCG in urine
HCG in blood
Uterine growth
Osiander's sign, Hegar's sign, Chadwick's sign
Uterine soufflé
Choriocarcinoma
Hydatidiform mole
Tumors
Pelvic congestion
Increased blood flow to uterus (ovarian
tumors
Important fact- there cannot be any alternative diagnosis for positive signs of pregnancy.
Confirmatory tests
A) Urinary Immunological Tests-
Urinary immunological tests include
Latex agglutination slide test and
Immunochromatographic test.
1.Latex Agglutination Slide test-
 In slide test, when hCG antesera is
combined with urine with hCG, if no
agglutination appears, then the
pregnancy is positive.
 If there is visible agglutination, there
is no pregnancy.
 This test comes positive after 2 weeks
of missed menses.
2.Immunochromatographic test-
 These tests are available in market
as Pregcolor Card or Ascutest hCG
etc.
 This test is more sensitive than the
former test and comes positive after
one week of missed menses.
3.Immunoassays without radioisotopes
(ELISA )
This test is specially indicated in patients with
trophoblastic disease.
It can detect hCG on the 8th day of fertilization,
before menses are missed.
4.Immunoassays with radioisotopes
(Radioimmunoassay (RIA)
 It is more sensitive and can detect β subunit of hCG up to 0.002 IU/mL
in the serum.
 It can detect pregnancy as early as 8–9 days after ovulation (day of
blastocyst implantation).
 Radio receptor assay gives highest sensitivity of 0.001 IU/mL in the
serum.
 RIAs are quantitative, so can be used for determining the doubling
time of hCG (ectopic pregnancy monitoring).
 RIAs require 3–4 hours to perform.
5.Biological Tests, Achheim and Zondek test-
As there is problem of availing animals, this test is no
more used.
B) Ultrasonography-
1.Ultrasonography of abdomen
• At 5th week - spherical gestation sac is
visible.
• At 6th week - fetal pole can be seen.
• At 7th week - one can see crown-rump
length.
• At 10th week - fetal heart sound is
heard by ultrasound Doppler.
• At 12th week - biparietal diameter (2.1
cm) is seen.
2.Transvaginal ultrasonography
can diagnose earlier than
abdominal sonography.
• At 4 weeks - visualization of
gestational sac.
• At 5 weeks - yolk sac and fetal
cardiac motion
Pregnancy tests / Immunological
test
These depend on the presence of
human chorionic gonadotrophin (hCG)
in maternal serum and urine.
• Urine pregnancy tests :
• Agglutination Test: Latex particles,
or sheep erythrocyte (tube) coated
with anti-hCG.
• Agglutination Inhibition Tests
• Dip stick
• Rapid and simple tests based on
enzyme-labelled monoclonal
antibodies assay can detect low
level of hCG in urine.
Causes of false positive results:
• Proteinuria.
• Haematuria.
• At the time of ovulation (cross reaction with LH)
• HCG injection for infertility treatment within the previous 30 days.
• Thyrotoxicosis (high TSH). Premature menopause (high LH &
FSH).
• Early days after delivery or abortion.
• Trophoblastic diseases. hCG secreting tumors.
Causes of false negative results:
• Missed abortion.
• Ectopic pregnancy. Too early pregnancy.
• Urine stored too long in room temperature.
• Interfering medications. Serum pregnancy tests:
• Radioimmunoassay of subunit of hGG.
• Radio receptor assay.
• Enzyme-linked immunosorbent assay (ELISA).
can be used for urine and serum.
The pregnancy test becomes negative about:
• one week after labour,
• 2 weeks after abortion, and
• 4 weeks after evacuation of vesicular mole.
• Uses of pregnancy test
• Diagnosis of pregnancy.
• Diagnosis of fetal death.
• Diagnosis of ectopic pregnancy.
• Diagnosis and follow up of gestational trophoblastic diseases.
2. Early pregnancy factor
• EPF assay is an immunosuppressive protein isolated in the
maternal serum after conception.
• It is peak in the first trimester and it is undetectable at term.
• It is usually seen in the induce fertilization at 36-48 hours in
serum after fertilization.
3. Ultrasonography
• Abdominal USG : It can diagnose pregnancy at the earliest.
Spherical gestational sac-5 weeks
• Fetal pole-6 weeks
• Crown-rump length-7th week
• Visualization of fetal heart motion-7th week
• Biparietal diameter (BPD)-2.1 cm at 12 week
• Fetal heart sound (by ultrasound Doppler)-10 weeks
• Trans-vaginal USG : It can diagnose
3. Ultrasonography
• Abdominal USG : It can diagnose pregnancy at the earliest.
• Spherical gestational sac-5th week
• Fetal pole-6th week
• Crown-rump length-7th week
• Visualization of fetal heart motion-7th week
• Biparietal diameter [BPD]-2.1 cm at 12th week
• Fetal heart sound (by ultrasound Doppler)-10th week
• Trans-vaginal USG: It can diagnose earlier than abdominal sonography.
• Gestational sac - 4th week
• Yolk sac- 5th week
• Fetal cardiac motion - 5th week
• Fetal pole- 5th week
• Second Trimester [13- 28 Weeks / 3-6 Months]
• [Subjective Symptoms/Presumptive Symptoms/Possible
Symptoms]
IMMUNOLOGICAL TESTS FOR DIAGNOSIS OF
PREGNANCY
Principle:
Pregnancy tests depend on detection of the antigen (hCG)
present in the maternal urine or serum with antibody either
polyclonal or monoclonal available commercially.
Tests used: A. Immunoassays without radioisotopes
Agglutination inhibition tests — Using latex (LAI). The materials for
these tests are supplied in kits containing all the reagents needed to do
a test.
Principle of agglutination inhibition tests:
• One drop of urine is mixed with one drop of a solution that contains hCG
antibody. If hCG is not present in the urine sample (e.g. the woman is not
pregnant), the antibody remains free. Now one drop of another solution that
contains latex particles coated with hCG is added. Agglutination of the latex
particles can be observed easily this time. Therefore, the pregnancy test is
negative if there is agglutination.On the other hand, if hCG were present in the
urine sample (e.g. woman was pregnant), it would bind the available antibody.
There would be no further agglutination when the solution containing hCG coated
latex particles was added. Therefore, pregnancy test is positive if there is no
agglutination
• Direct agglutination test (hCG direct test) —
Latex particles coated with anti-hCG monoclonal antibodies
are mixed with urine. An agglutination reaction indicates a
positive result when the urine sample contains hCG.
• Absence of agglutination (urine without hCG) indicates a
negative one. The sensitivity is 0.2 IU hCG/mL.
• Enzyme-linked immunosorbent assay (ELISA) —
• It is based on one monoclonal antibody that binds the
hCG in urine and serum.
• A second antibody that is linked with enzyme alkaline
phosphatase is used to ‘sandwich’ the bound hCG.
• It is detected by color change after binding. This is more
sensitive and specific.
• ELISA can detect hCG in serum up to 1–2 mIU/mL and
as early as 5 days before the first missed period.
• Fluoroimmunoassay (FIA)—
• It is a highly precise sandwich assay.
• It uses a second antibody tagged with a fluorescent label.
• The fluorescence emitted is proportional to the amount of
hCG. It can detect hCG as low as 1 mIU/mL.
• FIA takes 2–3 hours. It is used to detect hCG and for
follow up hCG concentrations.
B. Immunoassays with radioisotopes
• Radioimmunoassay (RIA) —
• It using I125 ido hCG antibodies. It is more sensitive and can detect
β subunit of hCG up to 0.002 IU/mL in the serum.
• It can detect pregnancy as early as 8–9 days after ovulation (day
of blastocyst implantation).
• Radio receptor assay gives highest sensitivity of 0.001 IU/mL in the
serum. RIAs are quantitative, so can be used for determining the
doubling time of hCG (ectopic pregnancy monitoring). RIAs require
3–4 hours to perform.
• Immunoradiometric assay (IRMA) — It uses sandwich
principle to detect whole hCG molecule.
• IRMAs use I125 labeled hCG and require only 30
minutes. It can detect hCG as low as 0.05 mIU/mL.
• Selection of time: Diagnosis of pregnancy by detecting
hCG in maternal serum or urine can be made
• by 8 to 11 days after conception. The test is not reliable
after 12 weeks.
• Collection of urine: The patient is advised to collect the
first voided urine in the morning in a clean container (not
to wash with soap). Kits to perform the test at home are
also available.
• Other uses of pregnancy tests:
Apart from diagnosis of uterine pregnancy, the tests are employed in
the diagnosis of ectopic pregnancy to monitor pregnancy following
in vitro fertilization and embryo transfer and to follow up cases of
hydatidiform mole and choriocarcinoma.
• Test accuracy ranges from 98.6 – 99%. Non-pregnant level is
below 1 mIU/mL.
• Limitations: Test accuracy is affected due to presence of (i)
hemoglobin (ii) albumin (iii) LH and (iv) immunological diseases.
• Advantages: They are advantageous over the biological
methods because of their speed, simplicity, accuracy and
less cost. Biological tests were based on the classic
discovery of Aschheim and Zondek in 1927. All these
tests are of historical interest.
ULTRASONOGRAPHY:
• Intradecidual gestational sac (GS) is identified as early as 29 to 35 days of
gestation.
• Fetal viability and gestational age is determined by detecting the following
structures by transvaginal ultrasonography.
• Gestational sac and yolk sac by 5 menstrual weeks ;
• Fetal pole and cardiac activity — 6 weeks;
• Embryonic movements by 7 weeks.
• Fetal gestational age is best determined by measuring the CRL between 7
and 12 weeks (variation ± 5 days).
• Doppler effect of ultrasound can pick up the fetal heart rate reliably by 10th
week. The instrument is small, handy and cheap .
• The gestational sac (true) must be differentiated from pseudogestational sac
SECOND TRIMESTER (13–28 WEEKS)
• SYMPTOMS: The subjective symptoms — such as nausea,
vomiting and frequency of micturition usually subside, while
amenorrhea continues. The new features that appear are:
• “Quickening” (feeling of life) denotes the perception of active fetal
movements by the women.
• It is usually felt about the 18th week, about 2 weeks earlier in
multiparae. Its appearance is an useful guide to calculate the
expected date of delivery with reasonable accuracy.Progressive
enlargement of the lower abdomen by the growing uterus.
GENERAL EXAMINATION
• Chloasma: Pigmentation over the forehead and cheek may
appear at about 24th week.
• Breast changes:
(a) Breasts are more enlarged with prominent veins under the skin
(b) Secondary areola specially demarcated in primigravidae, usually appears at
about 20th week
(c) Montgomery’s tubercles are prominent and extend to the secondary areola
(d) Colostrum becomes thick and yellowish by 16th week
(e) Variable degree of striae may be visible with advancing weeks.
ABDOMINAL EXAMINATION
• Inspection:
(1) Linear pigmented zone (linea nigra) extending from
the symphysis pubis to ensiform cartilage may be visible
as early as 20th week
(2) Striae (both pink and white) of varying degree are
visible in the lower abdomen, more towards the flanks .
• Palpation: Fundal heightis increased with progressive
enlargement of the uterus. Approximate duration of
pregnancy can be ascertained by noting the height of
the uterus in relation to different levels in the
abdomen. The following formula is an useful guide for
the purpose
Cervical Signs
• As early as the sixth week, the cervix becomes soft and
congested. On inspection through the speculum it
appears bluish-violet. On digital examination the
pregnant cervix feels soft like the lobule of the ear, as
compared to the nonpregnant cervix which feels like the
tip of the nose (Goodell's sign).
Uterine Signs
• The uterus enlarges progressively during pregnancy. It becomes softer in
consistency and elastic in feel. Its shape gradually changes from pyriform to
globular.
• The size of the gravid uterus is akin to that of a hen's egg at six weeks, that
of a cricket ball at eight weeks, and that of the fetal head at twelve weeks.
Between the sixth to the tenth week of pregnancy, the upper part of the
uterus enlarges due to the growing ovum, the lower isthmical part of the
softened uterus remains empty; the cervix, though softened, continues to be
relatively more firm than the isthmus. Hence on bimanual examination the
examiner's fingers seem to meet between the corpus the uterus and the
cervix (Hegar's sign) . After the tenth week of pregnancy, of the ovum grows
to occupy the entire uterine cavity, the above sign disappears. Early in as
Discomforts of pregnancy.pptx

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Discomforts of pregnancy.pptx

  • 1. Discomforts of pregnancy MRS RAMESHWORI. TH ASSOCIATE PROFESSOR
  • 2. Discomforts of pregnancy The common discomforts are listed below, system wise: A. Digestive system 1. Nausea & Vomiting:- Very common in the morning but can occur any time, commonly known as 'morning sickness'. It is seen in nearly 50% of women during the first trimester. The hormones that can be responsible for this are- hCG, estrogen and progesterone.
  • 3. Nursing implication- to relieve nausea and vomiting, following measures should be instituted: • Light snacks should always be with the mother. Do not be empty stomach, as the nausea can get worse. • Eat small frequent meals as the first step in the treatment of nausea and Vomiting. • After waking up in the morning, consider eating a small piece of unbuttered toast or salty crackers before getting out of bed. • Avoid fatty, greasy and spicy foods. It takes longer for fats to be digested during pregnancy.
  • 4. 2. Bleeding from gums:- Mainly because of increased blood supply to the gums and response to higher blood level of progesterone 3. Flatulence:- Increase gas in bowels, caused by swallowing air in order to Relieve nausea.
  • 5. 4. Constipation:- Constipation during pregnancy is a very common complaint. This is mainly due to the effect of progesterone, which relaxes the smooth muscles,causing decreased peristalsis of the gut. • Hemorrhoids (or piles) is a condition in which the veins at the lower end of the intestine (called rectum) become congested, swollen and dilated. Initially, hemorrhoids begin in the blood vessels of the rectum. • If they continue to grow, they can spread to include veins at the entrance of the anus (the end of the digestive tract through which the stools pass out) and finally protrude outside the anus.
  • 6. Nursing implication-advise woman to- • Eat foods rich in fiber, green leafy vegetables and fruits. • Drink an additional 6-8 glasses of water a day. • Eat frequent, small meals throughout the day. • Regular exercise can help keep your intestines moving efficiently during pregnancy •Eat foods low in fat and prepared with little grease. High fat foods are hard to digest and can stay in the intestines for a longer time. • Take a glass of warm water in the morning to activate the gut for regularity bowel movements. •Avoid fatty foods in the evening because they promote gastric heartburn.
  • 7. 5. Heartburn:-  Heartburn is the condition in which the partially digested food from the stomach goes back in to the food pipe and the acids from the stomach juices that are mixed with the partially digested food cause burning sensation in the middle of the chest.  It is due to the effect of Progesterone, which relaxes the cardiac sphincter during pregnancy. The stomach is compressed and pushed up higher in the abdomen by the growing uterus.  As a result, digestion of food in the stomach is affected and it takes longer to empty the food.
  • 8. Nursing implication- Advise woman to- • Eat small, frequent meals. • Avoid foods that commonly cause heartburn: fatty, • Avoid lying flat immediately after eating spicy foods. • Avoid bending or kneeling while doing household chores. • Avoid eating late at night. • Sleep on pillows. • Avoid drinking a lot of liquid with meals. 6. Pica:- It is a craving for certain foods or unnatural substances. It should be considered that the substance craved should not be harmful to mother or baby.
  • 9. B. Circulatory System- 1. Dizziness and fainting:  It occurs mainly because of fall in blood pressure progesterone relaxes the muscles of blood vessels.  Blood therefore tends to collect in the lower part of the body resulting in low blood pressure. It subsides after the compensatory increase in blood volume.  In later period, mother may feel faint while lying on her back, as the gravid uterus puts pressure on the inferior venacava anddiminishes blood return to the heart.. • Nursing implication- Advice the mother not to lie on her of pregnancy and to avoid long periods of standing back in later months
  • 10. 2. Swelling of the Feet:-  The fluid gained by the woman during pregnancy tends to accumulate in the feet and ankles during the day and cause these areas to swell.  There is venous and lymphatic stasis. Swelling of the feet and ankles can also occur due to hot weather and after standing continuously for a long time.  In such cases, the swelling will subside when you lie down or prop up your feet. The blood pressure should be checked to rule out pregnancy induced hypertension. Nursing implication- advise the mother not to sit with the feet hanging down and elevate legs.
  • 11. 3. Varicose Veins:-  This is the term used for tortuous and dilated veins. Progestrone relaxes the smooth muscles of veins which results in diminished circulation.  The valves of the dilated veins become inefficient and varicosities result. It is more common in the veins of the legs.  Varicose veins can be seen as reddish or bluish lines under the skin, especially on the legs and ankles.  Excessive weight gain increases the risk of developing varicose veins.
  • 12. Varicose Veins:- Nursing implication- Advice the mother to- • Rest the legs vertically against the wall. • Perform circulatory exercise for toes and ankles. • Wear support tights before rising or after resting with legs elevated.
  • 13. C. Musculoskeletal System 1. Leg cramps: The exact cause of cramps in the leg, especially calf muscles is not known. It is however suspected to be because of low calcium levels and vitamin B1 or pressure of the uterus on the nerves of the leg. Leg cramps occur more frequently at night. Fatigue can worsen leg cramps.
  • 14. Nursing implication- Advice the mother to- • Take calcium and vitamin B complex supplements. • While sleeping, elevate the foot end of the bed. • Before sleeping at night, make gentle leg movements in the warm bath. • Wear support tights before rising or after resting with legs elevated.
  • 15. 2. Back Pain: Back pain in pregnancy is very common and usually develops during the third trimester, because of the weight gain and change in the body's center of gravity. There are three main causes of back pain during pregnancy:- • Change in the posture: With the uterus growing in size, the center of gravity of the body changes and in order to compensate for the change in center of gravity,the posture and style of walking changes. This can cause back pain, or other injuries.
  • 16. Softening of the bones:- Hormones of pregnancy, especially, Relaxin, that is secreted during the pregnancy relaxes the joints between the pelvic bones, making them soft during pregnancy. This is preparation for the baby to pass through the pelvis during birth as softened joints help expand the pelvis cavity, while this change is essential for normal birth of baby, it can cause pain in lower back.
  • 17. Separation of muscles of the abdomen:-  There are two parallel sets of muscles in the middle and front part of the abdomen that joins the lower end of the rib cage above and upper end of the pelvis below. As the uterus grows in size, these muscles can separate lower in the center and worsen back pain.
  • 18. Nursing implication- Advice the mother to- • Use leg muscles to lower and raise yourself. • Wear low heeled and supportive shoes. • Avoid standing for long periods and frequently change sitting position. • Do a pelvic rocking exercise a few times a day.
  • 19. D.Genitourinary System 1. Increased frequency of passing urine and Difficulty in holding urine- Two in causes for this are-  The size of uterus grows and therefore presses against urinary bladder, so urge for passing urine, and secondly, Kidney begins to function more efficiently, so the volume of urine produced increases.  The uterus exerts maximum pressure on the urinary bladder during the first and third trimester.
  • 20. • As a result, small amount of urine may leak out involuntarily, especially when mother laughs, coughs or sneezes. • This is because all these actions increase the pressure on the abdomen and put greater pressure on the bladder. • Difficulty in holding urine disappears after delivery.
  • 21. 2. Leukorrhea- During pregnancy, there is increased white, non-irritant vaginal discharge. In case of, disturbing discharge, medical advice should be taken. Nursing implication- Advice the mother to frequently wash the vulva, avoid tight undergarments.
  • 22. E. Integumentary System 1. Itching of the skin:-  The skin of the abdomen stretches during the third trimester and becomes dry and itchy.  There are stretch marks on breasts, abdomen and upper thighs.  These will appear as reddish or whitish streaks on the skin. Stretch marks tend to be lighter after delivery.
  • 23. Integumentary System 2. Darkening of the skin:- Several skin changes are common during pregnancy. Of these, darkening of the skin is perhaps the most common. Although the exact cause for darkening is not known, it is believed to be due to higher levels of the female hormone estrogen in the body.
  • 24. There are three main areas of the darkening of the skin: a) around the nipples b) around the navel and c) Between external genitalia and the anus. Other areas that may also darken are the arm pits, inner side of the thighs, the central line between the naval and pubic bone and rarely, the face.
  • 25. F. Nervous System 1. Carpel Tunnel Syndrome- There is fluid retention in the pregnancy, which creates edema and pressure on the median nerve. Mother feels numbness and 'pins and needles' in fingers and hands. Nursing implication- Advice the mother to restrict salt intake in diet, rest the hand on pillows and wear splint at night, flex the fingers while holding the arm above the head.
  • 26. 2. Insomnia- It results as the mother feels more discomforts during later months of pregnancy, such as uncomfortable posture, frequency of micturition, fetal movements etc. Nursing implication- • Advice the mother to have a glass of warm milk at bed time, lie in lateral position with the support of pillows, take rest in afternoon and share her anxiety and fears.
  • 28. DIAGNOSIS OF PREGNANCY • The reproductive period of a woman begins at menarche and ends in menopause. It usually extends from 13– 45 years. • While biological variations may occur in different geographical areas, pregnancy is rare below 12 years and beyond 50 years. • Lina Medina in Lima, Peru was the youngest one, delivery by cesarean section when she was only 5 years and 7 months old and the oldest one at 57 years and 4 months old.
  • 29. DIAGNOSIS OF PREGNANCY DURATION OF PREGNANCY: • The duration of pregnancy has traditionally been calculated by the clinicians in terms of 10 lunar months or 9 calendar months and 7 days or 280 days or 40 weeks, calculated from the first day of the last menstrual period. This is called menstrual or gestational age.Q • But, fertilization usually occurs 14 days prior to the expected missed period and in a previously normal cycle of 28 days duration, it is about 14 days after the first day of the period. • Thus, the true gestation period is to be calculated by subtracting 14 days from 280 days, i.e. 266 days. This is called fertilization or ovulatory age and is widely used by the embryologist.
  • 30. FIRST TRIMESTER (FIRST 12 WEEKS) SUBJECTIVE SYMPTOMS The following are the presumptive symptoms of early months of pregnancy: • Amenorrhea Amenorrhea means missing of menses. This will be up to three months in a menstruating women means pregnancy unless otherwise proven. • Implantation [placental sign] bleeding- small blood discharge at the first missed period [28-35] is noticed by some women.
  • 31. • Morning sickness  (Nausea and vomiting) is inconsistently present in about 70% cases, more often in the first pregnancy than in the subsequent one.  It usually appears soon following the missed period and rarely lasts beyond 16 weeks.  Its intensity varies from nausea on rising from the bed to loss of appetite or even vomiting.  But it usually does not affect the health status of the mother
  • 32. Frequency of micturition is quite troublesome symptom during 8– 12th week of pregnancy. It is due to:- (1) resting of the bulky uterus on the fundus of the bladder because of exaggerated anteverted position of the uterus, (2) congestion of the bladder mucosa and (3) change in maternal osmoregulation causing increased thirst and polyuria . As the uterus straightens up after 12th week, the symptom disappears
  • 33. • Breast discomfort in the form of feeling of fullness and ‘pricking sensation’ is evident as early as 6–8th week specially in primigravidae. • Increased size of the breast become evident in the early weeks of pregnancy • It is due to the marked hypertrophied and proliferation of the ducts and the alveoli by the hormones(estrogen &progesterone) which are marked in the peripheral lobules.
  • 34. • Fatigue, Tiredness, Sleepiness  Easy fatigue is not uncommon during pregnancy.  This is due to increase in physiological changes in cardiovascular system.  Women describe this variously as weakness, disinclination to work, or the desire to keep themselves on bed.
  • 35. OBJECTIVE SIGNS: • Breast are enlarged and often contain milk for years. • The breast changes are evident between 6 and 8 weeks. • The nipple and the areola (primary) become more pigmented specially in dark women. • Montgomery’stubercles are prominent. • Thick yellowish secretion (colostrum) can be expressed as early as 12th week. Breast changes during pregnancy; (A) Pronounced pigmentati on of the primary areola and nipple; (B) Appearance of secondary areola, development of Montgomery tubercles and increased vascularity
  • 36. Per abdomen — • Uterus remains a pelvic organ until 12th week, it may be just felt per abdomen as a suprapubic bulge. • Fundus is not felt at early pregnancy
  • 37. Pelvic changes— The pelvic changes are diverse and appear at different periods. Collectively, these may be informative in arriving at a diagnosis of pregnancy. Jacquemier’s or Chadwick’s sign:  It is the dusky hue of the vestibule and anterior vaginal wall visible at about 8th week of pregnancy.  The discoloration is the result of pelvic congestion due to increase in vascularity.
  • 38. Vaginal sign: • (a) Apart from the bluish discoloration of the anterior vaginal wall • (b) The walls become softened and • (c) Copious non-irritating mucoid discharge appears at 6th week • (d) There is increased pulsation, felt through the lateral fornices at 8th week called Osiander’s sign.
  • 39. Cervical signs: (a) Cervix becomes soft as early as 6th week (Goodell’s sign), a little earlier in multiparae. The pregnant cervix feels like the lips of the mouth, while in the non-pregnant state, like that of tip of the nose. (b) On speculum examination, the bluish discoloration of the cervix is visible. It is due to increased vascularity.
  • 40. Uterine signs: (a) Size, shape and consistency — • 6th week- size of hen egg • 8th week- size of cricket ball • 12th week- size of fetal head • Pyriform shape of non-pregnant uterus becomes globular at 12th week As pregnancy advances symmetry is restored and the uterus feels soft and elastic
  • 41. • PISKACEK'S SIGN  One half of the uterus is firmer than the other since blastocyst usually implant laterally resulting in asymmetrical growth of the uterus with the area of ​​implantation being softer than the rest • HEGAR'S SIGN  Demonstrated between 6-10th week.  Upper part of the body of the uterus is enlarged by the growing fetus, lower part of the body is empty and extremely soft.  Examination must be gentle to avoid the risk of abortion.
  • 42. (c) Palmer’s sign: • Regular and rhythmic uterine contraction can be elicited during bimanual examination as early as 4– 8 weeks. • Palmer in 1949, first described it and it is a valuable sign when elicited. • After 10th week, the relaxation phase is so much increased that the test is difficult to perform.
  • 43. SECOND TRIMESTER: A) SUBJECTIVE SYMPTOMS: • Amenorrhoea: continues. • Uterus enlargement: There is progessive enlargement of the uterus. • Quickening: • It is a feeling of life,as the mother feels active fetal movements at around 16 weeks (multigravida), 18 weeks (primigravida)
  • 44. B) Objective signs Chloasma- Around 24" week of pregnancy, there appears pigmentation on face and forehead. Breast changes- • From 20 week, pigmentation appears around primary areola in breasts, which is called as secondary areola. • Breasts are more enlarged and Montgomery’s tubercle are prominent,extending to secondary areola.straie becomes visible and colostrum becomes thick and yellowish.
  • 45. Abdominal findings- Inspection • After 20 weeks, there is appearance of a linear pigmentation in the middle of abdomen, extending from symphysis pubis to ensiform cartilage, called as linea nigra. • Varying degree of striae is also visible on the lower abdomen. Palpation- • As there is enlargement of uterus; • Fundal height is also increased and can be felt in the midline as a soft elastic lump. • It is ovoid in shape.
  • 46.
  • 47. Uterus is: • at 16th week - midway between symphysis pubis and umbilicus • at 20th week - 2.5 cm below umbilicus • at 22 to 24th week at the level of umbilicus and near xiphoid process • at 28 week - at the junction of lower third and upper two-third of distance between the umbilicus and ensiform cartilage.
  • 48. • Braxton Hicks contractions (irregular, infrequent, spasmodic and painless contractions) are also felt. Woman cannot feel the contractions at this time, but these can be felt, by placing a palm on the uterus. • Active fetal movements can also be felt by placing the palms on the sides of the uterus.It is the positive evidence of a live fetus and by palpating the fetal parts, presentation and position of fetus can be determined during later weeks. • Palpation of fetal parts- By 20th week, fetal parts can be palpated.
  • 49. External ballotment- • Around 20th week, when the fetus is smaller than the volume of amniotic fluid, external ballotment can be elicited. • By keeping the mother in dorsal position, with one hand tapping of uterus is done from one side, while the other hand, which is kept outstretched on the other side feels the impulse.
  • 50. Auscultation- • By 20th week, one can hear the fetal heart sound with the help of a stethoscope. • It is heard like a ticking of a watch under a pillow. • As the position of the fetus changes, the location of FHS also changes. Normally, the FHS is 140-160/ min.
  • 51. There are two other sounds, which can be confused with fetal heart sound. These are: Uterine soufflé- • Soft blowing systolic murmur which is heard low down at the sides of the uterus. • It is synchronous with the maternal pulse and is due to increase in blood flow through the dilated arteries. Fetal soufflé- • Soft blowing murmur synchronous with the fetal heart sound. • It is due to rush of blood through the umbilical arteries.
  • 52. Per Vaginam- • There is bluish discoloration of vulva, vagina and cervix. Vagina and cervix become soft and moist.
  • 53. Internal Ballotment:  It can be elicited around 16-28 weeks,as the fetus is too small before 16 weeks and too large after 28 weeks.  Woman is kept in dorsal position and two fingers are placed on anterior vaginal fornix in front of cervix and other hand is placed firmly on the uterine fundus.  When the head or breech is gently pushed with the internal fingers, the fetus displaces upwards but quickly rebounds to its original position.
  • 54. Clinical investigations. • Ultrasonography- With the help of sonography, gestational age is determined by biparietal diameter (BPD), and femur length(FL). • Fetal organ anatomy is surveyed to detect any malformation. Fetal viability is determined by realtime ultrasound. Absence of fetal cardiac motion confirms fetal death. • Magnetic Resonance Imaging (MRI): MRI can be used for fetal anatomy survey, biometry and evaluation of complex malformations • Radiologic evidence of fetal skeletal shadow may be visible as early as 16th week
  • 55. Third trimester- A) Subjective symptoms • Amenorrhoea - Amenorrhoea continues. • Enlargement of the abdomen is present. With the enlargement of the abdomen, mother may feel discomfort such as palpitation, dyspnoea after exertion. • Pressure symptoms- Oedema of dorsum of feet up to ankle. • Fetal movements are more evident during this period. • Lightening- It is the sense of relief felt by the mother from the pressure symptoms due to the engagement of the presenting part into the pelvis.
  • 56. B) Objective signs Skin changes- • Linea nigra and striae gravidarum become more prominent. • Chloasma also becomes more prominent. Uterine shape becomes cylindrical to spherical.
  • 57. Fundal height. Height of fundus increases as follows: • At 32 weeks- corresponding to the junction of upper and middle third • At 36 weeks- up to the level of ensiform cartilage • At 40 weeks- fundus comes down to the level of 32 weeks due to engagement of head.
  • 58. Symphysis fundal height (SFH). • The upper border of the fundus is located by the ulnar border of the left hand and this point is marked. • The distance between the upper border of the symphysis pubis up to the marked point is measured by a tape in centimeter . • After 24 weeks, the SFH measured in cm corresponds to the number of weeks up to 36 weeks. • A variation of ± 2 cm is accepted as normal. • Variation beyond the normal range needs further evaluation
  • 59. • Braxton Hicks contractions are more evident. It becomes more regular during last two weeks of pregnancy. • Fetal movements and palpation of fetal parts are felt more easily. F.H.S. is heard distinctly according to the presentation and position of the fetus. • Ultrasonography- Estimation of gestational age is done by BPD, FL, AC and HC, but it is not very accurate.
  • 60. 1.Presumptive signs- This includes maternal physiological changes, which the woman experiences, indicating that she is pregnant. Signs included in this are: Amenorrhea  Nausea and vomiting in first trimester Frequency of micturition in first trimester Fatigue of mother
  • 61. Enlargement of breasts along with tingling sensation. Development of primary and secondary areola. Appearance of Montgomery's tubercles. Expression of colostrums from nipples. Pigmentation of skin (chloasma, linea nigra, striae).  Quickening.
  • 62. 2. Probable signs- These are the maternal physiological changes, which are detected upon examination by the examiner. Signs included in this are: • Changes in the shape of uterus and enlargement in the size. • Positive pregnancy test through presence of hCG in urine. • Hegar's sign.
  • 63. • Chadwick's sign/ jacquemier's sign • Osiander's sign. Goodell's sign • Ballotment of fetus. • Braxton Hick's contractions.
  • 64. 3. Positive signs. These signs directly tell about the presence of the fetus and are detected by the examiner. Signs included in this are: • Visualization of the fetus by ultrasound. • Visualization of fetal skeleton by radiology. • F.H.S by ultrasound and later on by fetoscope. • Fetal movements palpable by examiner. • Visualization of fetal movements in late pregnancy. • Palpation of the fetal parts.
  • 65. Differential diagnosis The differential diagnosis for Presumptive and probable signs are as follows: Presumptive Signs of pregnancy Differential diagnosis Amenorrhoea Breast changes Nausea and vomiting Frequency of micturition, bladder -irritability Quickening Emotional stress, illness, imbalance in hormones Contraceptive pill Gastrointestinal disorders, cerebral irritation Intestinal movement
  • 66. Probable signs of pregnancy Differential diagnosis HCG in urine HCG in blood Uterine growth Osiander's sign, Hegar's sign, Chadwick's sign Uterine soufflé Choriocarcinoma Hydatidiform mole Tumors Pelvic congestion Increased blood flow to uterus (ovarian tumors Important fact- there cannot be any alternative diagnosis for positive signs of pregnancy.
  • 67. Confirmatory tests A) Urinary Immunological Tests- Urinary immunological tests include Latex agglutination slide test and Immunochromatographic test. 1.Latex Agglutination Slide test-  In slide test, when hCG antesera is combined with urine with hCG, if no agglutination appears, then the pregnancy is positive.  If there is visible agglutination, there is no pregnancy.  This test comes positive after 2 weeks of missed menses.
  • 68. 2.Immunochromatographic test-  These tests are available in market as Pregcolor Card or Ascutest hCG etc.  This test is more sensitive than the former test and comes positive after one week of missed menses.
  • 69. 3.Immunoassays without radioisotopes (ELISA ) This test is specially indicated in patients with trophoblastic disease. It can detect hCG on the 8th day of fertilization, before menses are missed.
  • 70. 4.Immunoassays with radioisotopes (Radioimmunoassay (RIA)  It is more sensitive and can detect β subunit of hCG up to 0.002 IU/mL in the serum.  It can detect pregnancy as early as 8–9 days after ovulation (day of blastocyst implantation).  Radio receptor assay gives highest sensitivity of 0.001 IU/mL in the serum.  RIAs are quantitative, so can be used for determining the doubling time of hCG (ectopic pregnancy monitoring).  RIAs require 3–4 hours to perform.
  • 71. 5.Biological Tests, Achheim and Zondek test- As there is problem of availing animals, this test is no more used.
  • 72. B) Ultrasonography- 1.Ultrasonography of abdomen • At 5th week - spherical gestation sac is visible. • At 6th week - fetal pole can be seen. • At 7th week - one can see crown-rump length. • At 10th week - fetal heart sound is heard by ultrasound Doppler. • At 12th week - biparietal diameter (2.1 cm) is seen.
  • 73. 2.Transvaginal ultrasonography can diagnose earlier than abdominal sonography. • At 4 weeks - visualization of gestational sac. • At 5 weeks - yolk sac and fetal cardiac motion
  • 74. Pregnancy tests / Immunological test These depend on the presence of human chorionic gonadotrophin (hCG) in maternal serum and urine. • Urine pregnancy tests :
  • 75. • Agglutination Test: Latex particles, or sheep erythrocyte (tube) coated with anti-hCG. • Agglutination Inhibition Tests • Dip stick • Rapid and simple tests based on enzyme-labelled monoclonal antibodies assay can detect low level of hCG in urine.
  • 76. Causes of false positive results: • Proteinuria. • Haematuria. • At the time of ovulation (cross reaction with LH) • HCG injection for infertility treatment within the previous 30 days. • Thyrotoxicosis (high TSH). Premature menopause (high LH & FSH). • Early days after delivery or abortion. • Trophoblastic diseases. hCG secreting tumors.
  • 77. Causes of false negative results: • Missed abortion. • Ectopic pregnancy. Too early pregnancy. • Urine stored too long in room temperature. • Interfering medications. Serum pregnancy tests: • Radioimmunoassay of subunit of hGG. • Radio receptor assay. • Enzyme-linked immunosorbent assay (ELISA). can be used for urine and serum.
  • 78. The pregnancy test becomes negative about: • one week after labour, • 2 weeks after abortion, and • 4 weeks after evacuation of vesicular mole. • Uses of pregnancy test • Diagnosis of pregnancy. • Diagnosis of fetal death. • Diagnosis of ectopic pregnancy. • Diagnosis and follow up of gestational trophoblastic diseases.
  • 79. 2. Early pregnancy factor • EPF assay is an immunosuppressive protein isolated in the maternal serum after conception. • It is peak in the first trimester and it is undetectable at term. • It is usually seen in the induce fertilization at 36-48 hours in serum after fertilization.
  • 80. 3. Ultrasonography • Abdominal USG : It can diagnose pregnancy at the earliest. Spherical gestational sac-5 weeks • Fetal pole-6 weeks • Crown-rump length-7th week • Visualization of fetal heart motion-7th week • Biparietal diameter (BPD)-2.1 cm at 12 week • Fetal heart sound (by ultrasound Doppler)-10 weeks • Trans-vaginal USG : It can diagnose
  • 81. 3. Ultrasonography • Abdominal USG : It can diagnose pregnancy at the earliest. • Spherical gestational sac-5th week • Fetal pole-6th week • Crown-rump length-7th week • Visualization of fetal heart motion-7th week • Biparietal diameter [BPD]-2.1 cm at 12th week • Fetal heart sound (by ultrasound Doppler)-10th week • Trans-vaginal USG: It can diagnose earlier than abdominal sonography. • Gestational sac - 4th week • Yolk sac- 5th week • Fetal cardiac motion - 5th week • Fetal pole- 5th week
  • 82.
  • 83. • Second Trimester [13- 28 Weeks / 3-6 Months] • [Subjective Symptoms/Presumptive Symptoms/Possible Symptoms]
  • 84. IMMUNOLOGICAL TESTS FOR DIAGNOSIS OF PREGNANCY Principle: Pregnancy tests depend on detection of the antigen (hCG) present in the maternal urine or serum with antibody either polyclonal or monoclonal available commercially.
  • 85.
  • 86. Tests used: A. Immunoassays without radioisotopes Agglutination inhibition tests — Using latex (LAI). The materials for these tests are supplied in kits containing all the reagents needed to do a test. Principle of agglutination inhibition tests: • One drop of urine is mixed with one drop of a solution that contains hCG antibody. If hCG is not present in the urine sample (e.g. the woman is not pregnant), the antibody remains free. Now one drop of another solution that contains latex particles coated with hCG is added. Agglutination of the latex particles can be observed easily this time. Therefore, the pregnancy test is negative if there is agglutination.On the other hand, if hCG were present in the urine sample (e.g. woman was pregnant), it would bind the available antibody. There would be no further agglutination when the solution containing hCG coated latex particles was added. Therefore, pregnancy test is positive if there is no agglutination
  • 87. • Direct agglutination test (hCG direct test) — Latex particles coated with anti-hCG monoclonal antibodies are mixed with urine. An agglutination reaction indicates a positive result when the urine sample contains hCG. • Absence of agglutination (urine without hCG) indicates a negative one. The sensitivity is 0.2 IU hCG/mL.
  • 88. • Enzyme-linked immunosorbent assay (ELISA) — • It is based on one monoclonal antibody that binds the hCG in urine and serum. • A second antibody that is linked with enzyme alkaline phosphatase is used to ‘sandwich’ the bound hCG. • It is detected by color change after binding. This is more sensitive and specific. • ELISA can detect hCG in serum up to 1–2 mIU/mL and as early as 5 days before the first missed period.
  • 89. • Fluoroimmunoassay (FIA)— • It is a highly precise sandwich assay. • It uses a second antibody tagged with a fluorescent label. • The fluorescence emitted is proportional to the amount of hCG. It can detect hCG as low as 1 mIU/mL. • FIA takes 2–3 hours. It is used to detect hCG and for follow up hCG concentrations.
  • 90. B. Immunoassays with radioisotopes • Radioimmunoassay (RIA) — • It using I125 ido hCG antibodies. It is more sensitive and can detect β subunit of hCG up to 0.002 IU/mL in the serum. • It can detect pregnancy as early as 8–9 days after ovulation (day of blastocyst implantation). • Radio receptor assay gives highest sensitivity of 0.001 IU/mL in the serum. RIAs are quantitative, so can be used for determining the doubling time of hCG (ectopic pregnancy monitoring). RIAs require 3–4 hours to perform.
  • 91. • Immunoradiometric assay (IRMA) — It uses sandwich principle to detect whole hCG molecule. • IRMAs use I125 labeled hCG and require only 30 minutes. It can detect hCG as low as 0.05 mIU/mL. • Selection of time: Diagnosis of pregnancy by detecting hCG in maternal serum or urine can be made • by 8 to 11 days after conception. The test is not reliable after 12 weeks.
  • 92.
  • 93. • Collection of urine: The patient is advised to collect the first voided urine in the morning in a clean container (not to wash with soap). Kits to perform the test at home are also available.
  • 94. • Other uses of pregnancy tests: Apart from diagnosis of uterine pregnancy, the tests are employed in the diagnosis of ectopic pregnancy to monitor pregnancy following in vitro fertilization and embryo transfer and to follow up cases of hydatidiform mole and choriocarcinoma. • Test accuracy ranges from 98.6 – 99%. Non-pregnant level is below 1 mIU/mL. • Limitations: Test accuracy is affected due to presence of (i) hemoglobin (ii) albumin (iii) LH and (iv) immunological diseases.
  • 95. • Advantages: They are advantageous over the biological methods because of their speed, simplicity, accuracy and less cost. Biological tests were based on the classic discovery of Aschheim and Zondek in 1927. All these tests are of historical interest.
  • 96. ULTRASONOGRAPHY: • Intradecidual gestational sac (GS) is identified as early as 29 to 35 days of gestation. • Fetal viability and gestational age is determined by detecting the following structures by transvaginal ultrasonography. • Gestational sac and yolk sac by 5 menstrual weeks ; • Fetal pole and cardiac activity — 6 weeks; • Embryonic movements by 7 weeks. • Fetal gestational age is best determined by measuring the CRL between 7 and 12 weeks (variation ± 5 days). • Doppler effect of ultrasound can pick up the fetal heart rate reliably by 10th week. The instrument is small, handy and cheap . • The gestational sac (true) must be differentiated from pseudogestational sac
  • 97. SECOND TRIMESTER (13–28 WEEKS) • SYMPTOMS: The subjective symptoms — such as nausea, vomiting and frequency of micturition usually subside, while amenorrhea continues. The new features that appear are: • “Quickening” (feeling of life) denotes the perception of active fetal movements by the women. • It is usually felt about the 18th week, about 2 weeks earlier in multiparae. Its appearance is an useful guide to calculate the expected date of delivery with reasonable accuracy.Progressive enlargement of the lower abdomen by the growing uterus.
  • 98. GENERAL EXAMINATION • Chloasma: Pigmentation over the forehead and cheek may appear at about 24th week. • Breast changes: (a) Breasts are more enlarged with prominent veins under the skin (b) Secondary areola specially demarcated in primigravidae, usually appears at about 20th week (c) Montgomery’s tubercles are prominent and extend to the secondary areola (d) Colostrum becomes thick and yellowish by 16th week (e) Variable degree of striae may be visible with advancing weeks.
  • 99. ABDOMINAL EXAMINATION • Inspection: (1) Linear pigmented zone (linea nigra) extending from the symphysis pubis to ensiform cartilage may be visible as early as 20th week (2) Striae (both pink and white) of varying degree are visible in the lower abdomen, more towards the flanks . • Palpation: Fundal heightis increased with progressive enlargement of the uterus. Approximate duration of pregnancy can be ascertained by noting the height of the uterus in relation to different levels in the abdomen. The following formula is an useful guide for the purpose
  • 100. Cervical Signs • As early as the sixth week, the cervix becomes soft and congested. On inspection through the speculum it appears bluish-violet. On digital examination the pregnant cervix feels soft like the lobule of the ear, as compared to the nonpregnant cervix which feels like the tip of the nose (Goodell's sign).
  • 101. Uterine Signs • The uterus enlarges progressively during pregnancy. It becomes softer in consistency and elastic in feel. Its shape gradually changes from pyriform to globular. • The size of the gravid uterus is akin to that of a hen's egg at six weeks, that of a cricket ball at eight weeks, and that of the fetal head at twelve weeks. Between the sixth to the tenth week of pregnancy, the upper part of the uterus enlarges due to the growing ovum, the lower isthmical part of the softened uterus remains empty; the cervix, though softened, continues to be relatively more firm than the isthmus. Hence on bimanual examination the examiner's fingers seem to meet between the corpus the uterus and the cervix (Hegar's sign) . After the tenth week of pregnancy, of the ovum grows to occupy the entire uterine cavity, the above sign disappears. Early in as