This document provides information about diagnosing pregnancy in the three trimesters. In the first trimester, subjective symptoms include amenorrhea and morning sickness. Objective signs include breast changes and vaginal signs like increased pulsation. HCG blood tests can detect pregnancy 8-10 days after conception. Ultrasound can visualize the gestational sac at 5 weeks. In the second trimester, the uterus enlarges and quickening is felt at 18 weeks. Fetal heart sounds are usually detected between 18-20 weeks by ultrasound. In the third trimester, symptoms include lightening and increased fetal movements. Leopold's maneuvers are used to determine fetal position and presentation by palpating the uterus starting at 32 weeks.

1. Diagnosis Of
Pregnancy
Presenter: Anushika Kedawat

2. Duration Of Pregnancy
• 10 lunar months
• 9 months + 7 days
• 280 days / 40 weeks
• Naegele’s formula = first day of LMP + 7 days – 3 months
• E.g. Lmp= 22 June 2020. 22+7= 29 - 3 months = 29 March 2021.
• Three Trimesters –
• First trimester- 1st 12 weeks; Second trimester- 13-28 weeks; Third
trimester- 29 - 40 weeks

3. Diagnosis in first trimester
[ first 12 weeks]
SUBJECTIVE SYMPTOMS IN FIRST TRIMESTER:
• Amenorrhea/ Cessation of menstruation –
Slight bleeding at the expected time of menstruation rarely occurs
in first 3 months [Hartman’s sign/ Placental sign]
Shouldn’t get confused with – Threatened Abortion.
• Morning Sickness (nausea & vomiting)- rarely lasts
beyond 16 weeks.
Usually appears soon following the missed period.
• Fatigue

4. • Breast discomfort
• Frequency of micturition [ Bladder
irritability ]
During 8-12th week of pregnancy
• Appetite Changes- cravings/ refusal to eat
certain foods.

5. OBJECTIVE SIGNS OF FIRST TRIMESTER:
• Breast Changes –
Evident in primi.
Evident b/w 6-8 weeks
Increased vascularity & size → dilated visible veins.
Nipple & areola become more pigmented
Montgomery’s tubercles are prominent.
Expression of thick yellowish secretion
[colostrum] earliest by 12 weeks.

6. • PER ABDOMEN:
Uterus – till 12th week: pelvic organ. → felt as a suprapubic bulge
• PELVIC CHANGES :
• JACQUEMIER’S SIGN/ CHADWICK’S SIGN
• VAGINAL SIGNS [OSIANDER’S SIGN]
• CERVICAL SIGNS [GOODELL’S SIGN]
• UTERINE SIGNS

7. JACQUEMIER’S / CHADWICK’S SIGN:
• Dusky hue of vestibule & anterior
vaginal wall
• Visible at 8th week of pregnancy
• Due to local vascular congestion.
• More pronounced as pregnancy
advances & definitely present in
multipara.

8. Vaginal signs
• Softened vaginal walls
• 6th wk- copious mucoid discharge (non irritating)
• OSIANDER’S SIGN: increased pulsation felt through lateral
fornices at 8th week

9. CERVICAL SIGNS
• GOODELL’S SIGN: cervix becomes soft as early as 6th wk.
Pregnant cervix feels like lips of mouth.
p/s examination- bluish discolouration visible [ due to increased
vascularity]

10. UTERINE SIGNS
• Size: Enlarged
PISKACEK’S SIGN: Asymmetric enlargement of
uterus in lateral implantation.
Pregnant uterus is soft & elastic.
• HEGAR’S SIGN: B/w 6-10 weeks. On
Bimanual examination: two fingers in
anterior fornix, fingers of other hand on
abdomen behind the uterus → abdominal &
vaginal fingers seem to appose below body
of uterus.

11. •PALMER’S SIGN:
As early as 4-8 weeks, on Bimanual Examination:
Regular & Rhythmic uterine contractions
elicited.
Uterus is cupped b/w internal & external fingers
for 2-3 min. During contraction – uterus
becomes firm & well defined; relaxation- soft &
ill defined.
Contraction phase → 30 sec. ; with increasing
duration of preg – relaxation phase ↑.
≥ 10 weeks = test difficult to perform.

12. Immunological test in 1st trimester
HCG:
Released by trophoblastic tissue only; produced by a growing fetus and
placenta.
Present in maternal circulation as either an intact dimer [ α & β
subunit] & degraded form or β core form
Detection of HCG in maternal serum & urine : 8 – 10 days after
conception.

13. HCG is detectable in serum of : 5% pt
8 days after conception
≥ 98% pt by Day 11
Diagnostic levels in urine seen = 23-
24 days after conception.
Levels peak at 10- 12 weeks gestation
& plateau before falling.

14. Blood tests for HCG
• Require special labs & expertise.
• Used only in special cases [ bad obs history, suspected ectopic etc.]
• 4 main hcg assays used:
1] Radioimmunoassay
2] Immunoradiometric Assay
3] Enzyme linked immunosorbent assay [ELISA]
4] Fluoroimmunoassay

15. •Radioimmunoassay:
Sensitivity- 0.002 IU/ ML
Time to complete- 4 hours
Post conception age when first positive- 10- 18 days
Gestational age when first positive- 3-4 weeks
Quantitative (determine doubling time of Hcg→ ectopic pregnancy monitoring)
•Immunoradiometric assay [ IRMA ]:
Sensitivity: 0.05 MIU/ ML (serum)
Time taken – 30 minutes
Positive on: 8 days after conception.
Sandwich principle

16. • Agglutination inhibition test [Latex test]:
Test sensitivity: 0.5- 1 IU/ ML (urine)
Time taken- 2 minutes
Inference- Absence of agglutination
Positive on- 2 days after missed period.
• Direct agglutination test (hcg direct test):
Test sensitivity: 0.2 IU/ ML (urine)
Time taken- 2 minutes
Inference: presence of agglutination
Positive on: 2-3 days after missed period

17. • Enzyme linked immunosorbent assay (ELISA):
Test sensitivity: 1-2 MIU/ML
Time Taken: 2-4 hrs
Positive on: 5 days before the first missed period
• Fluoroimmunoassay (FIA):
Test sensitivity: 1 MIU/ML.
Time taken: 2-3 hours
Used to detect Hcg & for follow up hcg concentrations.

18. ULTRASONOGRAPHY
• Intradecidual gestational sac (GS) identified as
early as 29- 35 days of gestation.
• TVS:
Gestational sac- 5 wks; Yolk sac- 5.5 menstrual
wks.
Fetal pole & cardiac activity- 6 wks
Embryonic movements- 7 weeks
Fetal gestational age best determined by – CRL
(B/w 7 – 12 wks ± 5 days.)
Doppler effect of USG can pick up Fetal heart rate
reliably by 10th wk.

19. Diagnosis In Second Trimester
[ 13- 28 Weeks]
SYMPTOMS:
• Nausea, vomiting gradually subside.
Amenorrhea continues.
• Quickening (feeling of life) – perception
of active fetal movements by the woman.
Felt at approx. 18 wk.
• Progressive enlargement of lower
abdomen by growing uterus.

20. GENERAL EXAMINATION:
CHLOASMA- Pigmentation over forehead & cheek – approx. 24th
wk.
BREAST CHANGES- enlarged in size, prominent veins under skin;
Montgomery’s tubercles prominent; variable degree of striae
visible.

21. ABDOMINAL EXAMINATION IN 2ND TRIMESTER
INSPECTION:
• LINEA NIGRA (Linear
pigmented zone) from
symphysis pubis to ensiform
cartilage
As early as 20th wk
• STRIAE (Both pink & white)
seen in lower abdomen,
more towards flanks.

22. PALPATION:
Fundal height increases with
progressive enlargement of uterus.
Ht of uterus –
midway b/w symphysis pubis &
umbilicus = 16th wk
At level of umbilicus = 24th wk
At junction of lower 1/3rd & upper
2/3rd btw umbilicus & ensiform
cartilage – 28th wk

23. • Uterus = soft & elastic; Ovoid shape.
• BRAXTON- HICKS CONTRACTIONS =
irregular, infrequent, spasmodic &
painless; no effect on dilation of cervix.
Detected by abdominal examination.
Intrauterine Pressure<8mmHg.
Pt. not conscious about contractions.
Ultimately, merges with painful
contractions of labour.
• Palpation of fetal parts= felt by 20 wks.
Useful to identify presentation &
positon of fetus in later wks.

24. • Active fetal movements -
felt at intervals by placing hands over uterus; 20
wks.
positive evidence of pregnancy & of a live fetus.
• External Ballottement –
As early as 20 wks (fetus smaller than amniotic
fluid volume).
Difficult in obese pt; cases with scanty liquor
amnii.
Best elicited in Breech presentation.

25. AUSCULTATION:
FETAL HEART SOUND (FHS):
Most conclusive clinical sign of pregnancy.
Detected b/w 18- 20 wks.
Resembles the tick of a watch under the pillow.
Location varies with fetal position
Fetal heart rate = 110- 160 beats/ minute.
2 other sounds confused with FHS:
• Uterine souffle
• Funic/ fetal souffle

26. UTERINE SOUFFLE:
Soft blowing & systolic murmur; heard low down at side of uterus; best on LEFT
side.
Synchronous with maternal pulse
It is due to increased blood flow through the dilated uterine vessels.
FUNIC/ FETAL SOUFFLE:
Due to rush of blood through the umblical arteries.
Soft, blowing murmur synchronous with FHS.

27. Vaginal examination:
Bluish discolouration of vulva, vagina,
cervix & softening of cervix is more
evident.
Internal ballottement – elicited b/w 16-
28th wk.
May not be elicited in cases with scanty
liquor or in transversely placed.

28. INVESTIGATIONS (Imaging Studies)
• SONOGRAPHY:
routine USG at 18-20 wks: detailed
survey of fetal anatomy, placental
localization, integrity of cervical
canal.
Gestational age determined by
measuring Biparietal diameter
(BPD), Head circumference (HC),
Abdominal Circumference (AC),
Femur length (FL).

29. • FETAL ORGAN ANATOMY:
To detect any malformation.
• MRI:
To detect any complex malformations in
fetus.
• RADIOLOGIC EVIDENCE of
fetal skeletal shadow
As early as 16th wk.

30. Diagnosis in last trimester
[ 29- 40 weeks]
SYMPTOMS:
• Amenorrhea persists.
• Progressive enlargement of abdomen; may produce
mechanical discomfort to patient.
• Lightening – at approx. 38th wk- sense of relief of
pressure symptoms due to engagement of
presenting part.
• Frequence of micturition reappears.
• Fetal movements are more pronounced.

31. SIGNS:
Cutaneous changes - ↑ pigmentation & striae.
Uterine shape- changes from cylindrical to spherical at
> 36th wk
Fundal Height: (dist b/w umbilicus & ensiform
cartilage):
Junction of upper & middle third = 32 wks
Upto ensiform cartilage = 36th wk
Comes down to 32nd wk level at 40th wk (due to
engagement of presenting part)
If head is floating: 32 wks; engaged: 40 wk.

32. SYMPHYSIS FUNDAL
HEIGHT (SFH):
• Upper border of the
fundus located by ulnar
border of left hand &
the point is marked.
• Dist b/w upper border
of symphysis pubis upto
the marked point is
measured in centimeter.
• > 24 wks: SFH in cm
corresponds to number
of wks upto 36 wks.

33. Braxton hicks contractions- more evident.
Fetal movements- easily felt.
Palpation of fetal parts- lie, presentation & position
determined easily.
FHS heard distinctly.

34. LEOPOLD’S MANEUVERS:
Four specific steps in palpating the uterus through the
abdomen in order to determine the lie and presentation of
the fetus. In summary the steps are :
1. FUNDAL GRIP: Palpate fundus of uterus to establish
fetal pole in the upper part of the uterus.
2. UMBLICAL GRIP: Firm pressure applied to the sides of
the abdomen to establish the location of the spine and
extremities (small parts).
3. FIRST PELVIC GRIP/ PAWLIK’S GRIP: Grasp lower
abdomen just above pubic symphysis to establish if the
presenting part is engaged. If not engaged a movable body
part will be felt. The presenting part is the part of the fetus
that is felt to be in closest proximity to the birth canal.
4. SECOND PELVIC GRIP: to locate the fetus’ brow.

35. SONOGRAPHY:
Fetal growth assessment can be
made more accurate.
Amniotic volume assessment
(oligo/ poly)
Placental anatomy: location,
thickness, other abnormalities.
Fetal AC at level of umblical vein
used to assess gestational age &
fetal growth profile

36. Differential Diagnosis Of Pregnancy
• Uterine fibroid
• Cystic ovarian tumor (Amenorrhea absent; firm, hard, positive sign
absent, USG shows absence of fetus.)
• Encysted tubercular peritonitis (h/o Koch’s infection, swelling ill-
defined, positive sign absent, USG)
• Hematometra
• Distended urinary bladder (catheterization of bladder solves the
problem.)
• PSEUDOCYESIS (Phantom, Spurious, false pregnancy)

37. Thank You !
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