Diagnosis of pregnancy

1. BY DR
KETKI
Diagnosis of Pregnancy
y

2. Introdcution
Presumptive signs
 Probable signs
Positive signs

3.  Menstrual Age
-from first day of last menstrual peroid
- 9 months and 7 days /280 days/ 40 weeks
- also known as Gestational age
• Ovulatory age
-14 days after first day of peroid
-266 days
-also known as Fertilization age / Ovulatory
Age

6. First trimester
 SUBJECTIVE SIGNS
1.Ammenorrhea- Abrupt cessation of
menstruation at 4th week ,
2.Morning sickness- (nausea and vomitting)from
4th -14th week
3.Frequency of micturition –due to resting of
bulky uterus on bladder , congestion of bladder
mucosa
4.Breast discomfort-feeling of fullness and
pricking sensation
5.Fatigue

7.  OBJECTIVE SYMPTOMS
1.Breast signs-valuable only in
Primigravidae
2.Per abdomen findings
3.Pelvic Changes

8. Breast signs
-6-8 weeks
-Increased size and
vascularity(dilated
visible
veins )
-Increased pigmenation
of
nipple and primary
areola
- Appearance of
montogomery tubercles
in the areola

9. Per adomen findings-
Uterus remains pelvic organ untill 12
weeks,
it may be just felt per abdomen as
suprapubic
bulge.

10. Pelvic changes
1.Osiander’s Sign- increased pulsation in lateral
fornices( 8th week)
2. Chadwigs Sign-Dusky hue of vestibule and
anterior
vaginal wall (8 weeks ), due to
local
vascular congestion .
3.Goodell’s Sign – Cervix becomes soft, seen at 6
weeks

11. 4. Hegar’s Sign- elicited at 6-10 weeks,
(Bimanual exm)
Two fingers in the anterior fornix , the
finger of other hand over the abdomen behind
the uterus . The finger of both hand can be
approximated as the lower part of uterine body
is soft and empty

12. 5.Piskacek’s Sign- Uterus is enlarged and
becomes acutely anteverted (6-8 weeks). If
there is lateral implantation , there may b
asymm enlargement of uterus know as
Piskacek sign(one half is more firm then
other)
6. Palmar’s Sign- Eliciated by bimanual
examination , Regular and rhythmic uterine
contraction felt at 4- 8 weeks

13.  IMMUNOLOGICAL TESTS
Principle- depends on detection of
Ag(HCG)present in maternal urine / serum with
Ab either polyclonal or monoclonal

14. HCG
-This hormone is released by syntiotrohoblastic
tissue produced by growing foetus and its
associated placenta.
-hCG is present in maternal circulation as either
an intact dimer , alpha or beta subunit and
degraded from , or beta core fragment.
- Detection of hCG in maternal serum and urine
is evident only 8-10 days of conception .

15. -hCG is detectable in serum of appromiately
5% of patient 8 days after conception and in more
than 98% of patient by Day 11.
- Diagnostic levels in urine seen only about
23-24 days after conception .
- level peaks at 10-12 weeks of gestation
and then plateau before falling.

16. TEST USED
 Immuno Assays without Radioisotopes
1.Agglutination Inhibition test :
2.Direct Agglutination test:
ELISA(enzyme – linked immunosorbent
assay)
FIA(Fluoroimmnunoassay)
 Immuno Assays with Radioisotopes
-RIA(Radioimmunoassay)
-IRMA(Immuno radiometric assay)

17.  Enzyme-linked immunosorbent assay (more
sensitive) – Sensitivity - 25 mIU/mL
-Time to complete - 80 minutes
– Postconception age when first
positive - 14-17 days
– Gestational age when first positive -
3.5 weeks
 Enzyme-linked immunosorbent assay (less
sensitive) Sensitivity- Less than 50 mIU/mL
-Time to complete - 5-15 minutes
- Postconception age when first
positive - 18-22 days
- Gestational age when first
positive - 4 weeks

18.  Fluoroimmunoassay –
Sensitivity -1 mIU/mL
Time to complete - 2-3 hours
Postconception age when first positive - 14-
17 days .
Gestational age when first positive - 3.5
weeks

19. Radioimmunoassay (RIA)
-Sensitivity - 5 mIU/mL
-Time to complete - 4 hours
-Postconception age when first positive - 10-18 days
-Gestational age when first positive - 3-4 weeks
Immunoradiometric assay (IRMA)(more
sensitive)
-Sensitivity - 150 mIU/mL
-Time to complete - 30 minutes
-Postconception age when first positive - 18-22 days
-Gestational age when first positive - 4 weeks

20. ULTRASOUND
• Intra decidual gestational sac is identified
as early as 29 – 35 days of gestation
• Gestational sac & yolk sac -5 menstrual
weeks
• Fetal pole and cardiac activity – 6 weeks
• Embryonic movements -7 weeks
• Doppler effect of US can pick heart rate
reliably by 10th week.

21. DIAGNOSIS IN THE SECOND TRIMESTER (
13-28 WKS)
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 weeks in multipara.
4. Abdominal enlargement.

22. ABDOMINAL EXAMINATION…
• INSPECTION:
– Linea nigra extending
from symphysis pubis
to ensiform cartilage
 20th week…

23. – STRIAE ( both pink and white) visible in the
lower abdomen more towards the flanks…

24. • PALPATION:
– Fundal height – increased with progressive
enlargement of the uterus.

25. 1. The uterus is abdominally felt (ovoid). The
uterus feels soft and elastic
2. Braxton Hicks contractions; intermittent painless
contractions detected by abdominal
examination.
3. Active fetal movements can be felt at intervals
by placing the hand over the uterus as early as
20th week.
4. External ballottement : elicited at 20 week
through abdominal examination.
5. Palpation of the fetal parts and palpation of fetal
movements by the obstetrician at 20 weeks.

26. Auscultation:
• Auscultation of FHS as early as 20-24 weeks by Pinard
stethoscope
• Auscultation of funic/fetal souffle  due to rush of
blood through the umblical artery
• Auscultation of uterine souffle (soft blowing and
systolic murmur heard low own at the sides of the
uterus)  synchronous with the maternal pulse

27. INVESTIGATIONS…
• SONOGRAPHY:
– Routine sonography at 18 – 20 weeks permits a
detailed survey of fetal anatomy, placental
localisation and the integrity of the cervical canal.
• FETAL ORGAN ANATOMY :
– Todetect any malformation.
• FETAL VIABILITY
• RADIOLOGIC:
– 16TH WEEK – FETAL SKELETALSHADOW.

28. DIAGNOSIS IN THE THIRD TRIMESTER
(29 - 40WEEKS)
• SYMPTOMS:
– Amenorrhoea persists
– Enlargement of the abdomen  leading to
discomfort to the patient (palpitaion or dyspnoea
following exertion)
– LIGHTENING: 38th week  sense of relief of the
pressure symptoms due to engagement of the
presenting part.

29. – Frequency of micturition reappears
– Fetal movements are more pronounced.

30. • SIGNS:
– Cutaneous changes are more prominent with
increased pigmentation and striae.
– Uterine shape – from cylindrical to spherical
beyond 36th week
– FUNDAL HEIGHT (distance between the umbilicus
and ensiform cartilage)
• Junction of the upper and middle third at 32 weeks.
• Level of ensiform cartilage at 36th week
• Comes down to 32 weel level at 40th week becauseof
the engagement of the presenting part.

31. • SYMPHYSIS FUNDAL HEIGHT:
– Upper border of the fundus located by ulnar
border of the left hand and point is marked.
– Distance between the upper border of the
symphysis pubis upto the point marked is
measured in centemetre
– After 24 weeks, the SFH in cm corresponds to the
number of weeks upto 36 weeks.
• Braxon-Hicks contraction – more evident
• Fetal movements – easily felt

32. • Palpation of the fetal parts and their identification
become much easier.
• F.H.S – heard distinctly
• SONOGRAPHY:
– Fetal growth assessment can be made more
accurate.
• Amniotic fluid volume assessment – for oligo / poly.

34. • UTERINE FIBROID
• CYSTIC OVARIAN TUMOUR (Amenorrhoea absent
firm, hard, positive sign absent, USG)
• ENCYSTED TUBERCULAR PERITONITIS (H/O Koch’s
infection, swelling ill defined, positive signs absent,
USG)
• HAEMATOMETRA
• DISTENDED URINARY BLADDER (Catheterisation
solves the problem)
• PSEUDOCYESIS

35. MATERNALASSESSMENT
aims of maternal assessment are:
 To identify the high risk cases.
 To prevent and detect and treat at the earliest
any complications.
 To ensure continued risk assessment and to
provide ongoing primary prevention health
care.
 To educate the mother about the physiology of
pregnancy, labour, newborn care and
lactation.
 To discuss with the couple about the place,
time, and the mode of delivery.

36. PROCEDURES AT THE FIRST VISIT
The initial interview
 Demographic data
 Chief concern
 Family profile
 Present history
 Past history
 Obstetric history

37.  Menstrual history
 Gynaecological history
 Personal history
 Family history
PHYSICAL EXAMINATION
 Baseline height and weight
measurement
 Vital signs
 Head and scalp
 Eyes
 Nose
 Ears
 Mouth and oral cavity

38.  Neck
 Breasts
 Thorax
 Back
 Rectum
 Extremities and skin
ABDOMINAL EXAMINATION
 Preliminaries
 Inspection
 Palpation
 Height of the uterus
 Obstetric grips

39. Auscultation
The relationship of the fetus to the
uterus and pelvis
 Lie
 Presentation
 Attitude
 Denominator
 Position
 Presenting part

40. PELVIC EXAMINATION
 External genetalia
 Internal genetalia
 Vaginal inspection
 Examination of pelvic organs
 Estimating pelvic size
The diagonal conjugate
The true conjugate
The ischial tuberosity

41. LABORATORY METHODS:
 BLOOD STUDIES:
A complete blood count:
Blood typing
Serologic test for syphyllis
Antibody titres for hepatitis B
HIV testing
Glucose tolerance test
 URINALYSIS

42. ULTRASONOGRAPHY
1ST TRIMESTER 2ND 3RD TRIMESTER
Confirm pregnancy Establish or Confirm gestational age
Confirm viability confirm date Confirm viability
Determine gestational Confirm viability Detect macrosomia
age Detect Detect congenital
Rule out ectopic polyhydramnios, anomalies
pregnancy oligohy- dramnios Detect IUGR
Detect multiple Detect congenital Determine fetal position
gestation anomalies Detect placenta previa or
Use for visualization Detect IUGR abruptio placentae
during chori- onic Confirm placenta visualization during
villus sampling placement amnio- centesis, external
Detect maternal visualization version
abnormalities during amnio- Biophysical profile
centesis Amniotic fluid volume
Detect placental maturity

43. First Trimester Second and Third Trimester
1. Gestational sac location
2. Embryo and/or yolk sac
identification 3. Crown-rump
length
4. Cardiac activity
5.Fetal number, including
amnionicity and chorionicity of
multiples when possible
6.Assessment of
embryonic/fetal anatomy
appropriate for the first
trimester 7. Evaluation of the
uterus, adnexa, and cul-de-sac
8. Assessment of the fetal
nuchal region if possible
1.Fetal number; multifetal
gestations: amnionicity, chorionicity,
fetal sizes, amnionic fluid volume,
and fetal genitalia, if visualized
2. Presentation
3. Fetal cardiac activity
4.Placental location and its
relationship to the internal cervical
os
5. Amnionic fluid volume
6. Gestational age
7. Fetal weight
8.Evaluation of the uterus, adnexa,
and cervix
9.Fetal anatomical survey,
including documentation of
technical limitations
Components of Ultrasound Examination by Trimester

44. SONOGRAPHIC EVALUATIONS
 The standard
 specialized examinations
 limited examination
 Nuchal Translucency
 Fetal Biometry
 Gestational Age
 Amnionic Fluid
 Fetal weight
 Shepard’s formula:
 Log 10
EFW[gm]=1.2508+(0.166*BPD)+0.046*AC)-
(0.002646*AC*BPD).
 Hadlock’s formula:
 Log 10 EFW[gm]= 1.3596-
0.00386(AC*FL)+0.0064(AC)=0.00061
(BPD*AC)+0.0425(AC)

45. SPECIAL INVESTIGATIONS IN HIGH
RISK PREGNANCY
 Maternal serum alpha fetoprotein
 Triple test
 Acetyl choline esterase (AChE)
 Amniocentesis
 Chorionic villous sampling
 Fetal movement count
 Cordocentesis
 Vibroacoustic stimulation (VAS)
 Fetal biophysical profile (BPP)
 Modified biophysical profile

46. Fetal cardiotocography (CTG)
Doppler ultrasound velocimetry
Placental grading
Contraction stress test ( CST)
Amniotic fluid volume assessment
(AFV)
Amniocentesis in late pregnancy:
Pulmonary maturity:
Assessment of severity of Rh-
isoimmunisation
Amnioscopy

47. SIGNS INDICATING COMPLICATIONS OF
PREGNANCY
Vaginal bleeding
Persistent vomiting
Chills and fever
Sudden escape of clear fluid from
vagina
Abdominal or chest pain
Increase or decrease in fetal
movement

48. MINOR AILMENTS DURING
PREGNANCY
Morning sickness
Heartburn
Varicose veins
Backache
Breathlessness
Palpitations
Vaginal discharge
Constipation