diagnosis of pregnancy

1. DIAGNOSIS
OF
PREGNANCY
Dr. Salini Mandal B.G.
Lecturer
Dept of OBG
FMHMC

2. MENSTRUAL AGE
• Also known  GESTATIONAL AGE
• From the first day of the last menstrual period…
• 9 MONTHS AND 7 DAYS
• 280 DAYS
• 40 WEEKS

4. • FIRST TRIMESTER  1ST 12 weeks
• SECOND TRIMESTER  13 – 28 weeks
• THIRD TRIMESTER  29 – 40 weeks

5. Diagnosis in the first trimester
(first 12 weeks)
Symptoms:
1- Cessation of menstruation
:(missed period):
due to increased estrogen and progesterone
production by the corpus Luteum. (Pregnancy during
lactation amenorrhea).
• Slight bleeding at the expected time of menstruation
rarely occurs in the first 3 months (Hartman‘s sign /
placental sign) – scanty.
• Shouldn’t get confused with Threatened abortion.

6. 2- Morning sickness: 50% cases
- usually appears soon following the missed
period.
- Nausea , vomiting especially in the morning
on rising from the bed.
- Usually disappears after the third month.

7. 3- Freguency of micturition:
- Due to congestion of bladder mucosa. Irritation of
the bladder by the pregnant uterus.
- resting of bulky uterus on the bladder (anteverted
position of the uterus).
- change in maternal osmoregulation  leads to
increased thirst and polyuria.
- Usually disappears after the third month.

8. 4- Breast symptoms:
Enlargement , heaviness , discomfort and
pricking sensation  6th – 8th week specially in
primigravidae.
5- Appetite changes:
Craving for certain types of food and refusal of
other types.
6- Fatigue:
- frequent symptom that may occur in
pregnancy and tendency to sleep

10. 1. Breast signs : ( evident in a primigravida).
– 6 - 8 weeks
– Increased size and vascularityDilated
visible veins.
– Increased pigmentation of the nipple and
1ry areola. Appearance of 2ry areola.
– Appearance of Montgomery tubercles in
the areola ( dilated sebaceous glands).
– Expression of colostrum (thick yellowish
secretion) – as early as 12th week

12. Appearance of Montgomery tubercle in the
areola
• dilated sebaceous glands

13. • PER ABDOMEN:
– Uterus remains a pelvic organ until 12th week,it
may be just felt per abdomen a suprapubic bulge.
• PELVIC CHANGES:
– JACQUEMIER’S OR CHADWICK’S SIGN
– OSIANDER’S SIGN
– GOODELL’S SIGN

14. JACQUEMIER’S SIGN
• Also known as Chadwick’s sign
• Dusky hue of the vestibule and anterior vaginal wall
visible at 8th week
• More pronounced as pregnancy advances and is
more definitely present in multiparae.
• Due to local vascular congestion.

15. OSIANDER’S SIGN
• Increased pulsation , felt through the lateral fornices
at 8th week.

16. GOODELL’S SIGN
• Cervix becomes soft as early as 6th week
• Softening is more surrounding the external os and
also in the upper part.
• The pregnant cervix feels like the lips of the mouth.
• On speculum examination. The bluish discolouration
of the cervix is visible  due to the increased
vascularity.

17. 2. Uterine sign ; felt by bimanual examination:
– Size : enlarged.
– consistency : soft.
– Shape : globular.
– Hegar sign : ( elicited between 6-10 weeks).
Two fingers in the anterior fornix, the fingers of
the other hand over the abdomen behind the
uterus . The fingers of both hands can be
approximated as the lower part of the uterine
body is soft and empty.
– Palmer sign:
Uterine contractions felt on bimanual
examination.

19. • This hormone is only released by trophoblastic tissue produced
by a growing fetus and its associated placenta.
• hCG is present in the maternal circulation as either an intact
dimer, alpha or beta subunit, and degraded form, or beta core
fragment
• Detection of HCG in maternal serum and urine is evident only 8-
10 days after conception

20. • hCG is detectable in the serum of approximately
5% of patients 8 days after conception and in
more than 98% of patients by day 11
• Diagnostic levels in Urine seen only about 23-24
days after conception.
• Levels peak at 10-12 weeks' gestation and then
plateau before falling

21. In general, the HCG level will double every two to three days in early pregnancy

22. Currently, 4 main hCG assays are used,
(1) radioimmunoassay,
(2) immunoradiometric assay,
(3) enzyme-linked immunosorbent assay (ELISA),
(4) fluoroimmunoassay.
- Used only in special cases
( bad obstetric history, suspicion of ectopic,etc.)
- Require special labs and expertise.

23. Radioimmunoassay
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 (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

24. • Immunoradiometric assay (less sensitive)
– Sensitivity - 1500 mIU/mL
– Time to complete - 2 minutes
– Postconception age when first positive - 25-28 days
– Gestational age when first positive - 5 weeks
• 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

25. 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
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

26. 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.

27. Diagnosis in the second trimester
( 13-28 weeks)
Symptoms:
1. Amenorrhea.
2. Morning sickness and urinary symptoms gradually
decrease .
3. “Quickening “ : perception of fetal movements by
the pregnant woman:
a. 18-20 weeks in primigravida.
b. 16-18 week s in multipara.
4. Abdominal enlargement.

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

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

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

31. 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.

32. 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

33. 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 :
– To detect any malformation.
• FETAL VIABILITY
• RADIOLOGIC:
– 16TH WEEK – FETAL SKELETAL SHADOW.

34. 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.

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

36. • 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 because of
the engagement of the presenting part.

37. • 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

38. • 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.

40. • 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