The document describes the diagnosis of pregnancy through various signs and symptoms. It distinguishes between possible/presumptive signs (based on a woman's subjective reports), probable signs (combining subjective and objective findings), and positive signs (conclusive proof of pregnancy). Possible signs include missed period, morning sickness, breast changes, frequent urination, and quickening. Probable signs involve pelvic exam findings, abdominal enlargement, and ballottement. Positive signs are fetal heart tones, palpation of the fetus, ultrasound examination, and fetal movement. Diagnosis progresses from possible to probable to positive as the pregnancy advances.

1. Diagnosis of pregnancy
By Ritbano Ahmed(BSc, MSc)
Assistant professor of maternity nursing
November, 2022

2. Objectives
At the end of this session, the students will be able to
• Describe diagnosis of pregnancy
• Differentiate sign and symptom of pregnancy

3. Diagnosis of pregnancy
• Many changes women experience during pregnancy are
used to diagnose the pregnancy itself.
• Sign and symptom of pregnancy can be classified in to
three
1. Possible/Presumptive (Based on what the mother will
recognize)
2. Probable (Based on both what the mother will recognize
and what you will find)
3. Positive (No doubt of pregnancy)

4. • Means a symptom of pregnancy, when it is impossible to
confirm pregnancy with certainness (sure)
• i.e. Many other DDx other than pregnancy can be sited as
a possible cause
• The possible symptoms means changes in her body
that a woman can identify for herself and tell you
about.
• But they could also be caused by something else
1. A possible (presumptive) symptoms

5. 1. A possible……
• In the possible symptoms you only have the
woman’s subjective report on which to base
your diagnosis
• Possible symptoms sometimes also called
‘presumptive signs’ because pregnancy is often
‘presumed/assumed’ by the health professional on
the basis subjective reports from the mother

6. • Is a sign and symptoms which often but not always
is present when the woman is pregnant
• i.e. Other DDx is possible
• The probable signs and symptoms some of
these indicators are reported by the woman
(symptoms), but also see by the examiner (sign)
• For Dx of pregnancy you based both subjective
report and objective findings
2. Probable sign and symptoms

7. 3. A positive signs
• Completely objective can not be confused with
pathologic states and offer conclusive proof of
pregnancy
1. Fetal Heart Tones (FHTs)
2. Palpation of Fetus
3. Ultrasound Examination of Fetus
4. Fetal movement

8. Possible (presumptive) symptoms
1. Missing a Menstrual Period (Amenorrhea)
2. Morning sickness
3. Breast changes
4. Urinary frequency
5. Quickening
6. Fatigue

9. 1.1. Missing a Menstrual Period (Amenorrhea)
 Amenorrhea is often the first symptom that women
notice when they become pregnant
 Other possible causes of amenorrhea are:
• Poor nutrition
• Emotional tension
• Menopause
• Endocrine disorders
• Obesity
• Chronic disease
• Infection……

10. • Is a common symptom occurs in appr. 50% of
pregnancies during the first three months
• More often in the first pregnancy than in the subsequent
one
• It is usually most severe in the morning, which is why
this feeling is often called morning sickness
• But it can occur at any time and may be stimulated by
cooking odours and spicy smells
• DDx- PUD, gastritis, parasites, Cerebral irritation
1.2. Morning Sickness

11. Nausea and Vomiting

12. • Is experienced during the first trimester as enlarged
uterus exerts pressure on the bladder
• The increased vascularization and pelvic congestion
that occur in each pregnancy can also cause frequent
voiding
• This symptom decrease during the second trimester
when the uterus is an abdominal organ but reappears
during third trimester when the presenting part
descends in to the pelvis.
1.3. Urinary frequency

13. • Pregnant women may report feelings of breast
tenderness, fullness, tingling and enlargement
and darkening of the areola
• But other DDx is possible that breasts often get
bigger just:
• Before the monthly menstruation in women who
are not pregnant
• And also a change who took a contraceptives
1.4. Breast changes

14. Breast changes…..
The changes on the breasts during pregnancy are:
• 3-4 weeks: tingling sensation to pain caused by
hormonal responses of the mammary ducts and alveolar
system
• 6th –8th weeks –enlargement and tenderness of the
breast and visible surface veins appear.
• 12 week: Primary areola becomes darker
• 16 week: Colostrum's can be expressed
• 20 week: Appearance of secondary areola

15. 15

16. • Women start to feel their baby moving very lightly before
they are half-way through the pregnancy
• This feeling is known as ‘quickening’ that is the first fetal
movement felt by the mother
• Multigravida mothers are sensitive to these tiny movements
sooner than primigravida mothers
• Quickening usually occurs at 18–20 weeks in primigravida
and 16–18 weeks in multigravida
• DDX----Intestinal peristalsis
1.5. Quickening

17. 2. Probable Signs and Symptoms of Pregnancy
1. Change in the pelvic organs
2. Abdominal enlargement
3. Braxton-Hicks contractions
4. External ballottement
5. Internal ballottement
6. Immunological test
7. Skin change

18. 2.1. Change in the pelvic organs
• Caused by increased vascular congestion are the only
physical signs detectable with in the first 3 months of
pregnancy
• This changes are noted on pelvic examination
• Softening of cervix- Goodell’s sign
• Chadwick’s(Jacquemiers )sign is the deep red to purple
or bluish discoloration of mucus membrane of cervix, due
to increased vasocongestion of the pelvic vessels

19. 2.1. Change in the pelvic organs….
• Hegar’s sign is softening of the isthmus of the uterus
weeks (6-12 weeks)
• On bimanual examination (two fingers in the anterior
vaginal fornix and the abdominal fingers behind the
uterus), the abdominal and vaginal fingers seem to
appose below the body of the uterus

20. 2.1. Change in the pelvic organs….
Hegar’s sign…….
• Due to the softening of the lower segments of the
uterus and to the fact that the ovum does not fill
the lower uterine cavity at this stage
• An empty space in the lower part is detected
• This sign is based on the fact that:
• Upper part of the body of the uterus is occupied by the
growing embryo
• Lower part of the body is empty and extremely soft
• The cervix is comparatively firm

21. 21
Figure of Hegars Sign

22. 2.2. Enlargement of the abdomen
• There is progressive enlargement of the abdomen
(belly) from 9 to 28 weeks of pregnancy
• At 16 to 22 weeks, growth may appear more rapid as
the uterus rises higher into the abdomen
• The uterus is enlarged to the size of:
• A hen’s egg at 6th week
• A cricket ball at 8th week
• A fetal head by 12th week

23. 2.2. Enlargement of the abdomen….

24. 2.3. Braxton hicks contraction—16wks
• BH Contractions are Irregular, painless and occur
intermittently that throughout pregnancy
• It facilitate uterine blood flow through the intervillous
spaces of the placenta and thereby promote o2 to the
fetus
• They usually begin at about 16 weeks' gestation and
increase in regularity.
• These contractions usually disappear with walking or
exercise, whereas true labor contractions become
more intense

25. 2.4. Uterine souffle
• Soft, blowing sound made by the blood in the arteries
of the pregnant uterus
• It is the same (synchronous) rate as the maternal
pulse
• This may be confused with FHB
• DDX—increased BF to the uterus, uterine myoma and
ovarian tumours

26. 2.5. Funic or fetal souffle
• Is due to rush of blood through the umbilical arteries
• It is a soft, blowing murmur synchronous with the
fetal heart sounds
• This may also confused with FHB

27. 2.6. Ballottement
A. Internal Ballottement
• Maybe felt by the 16th week on an examination
carried out by the doctor
• Passive fetal movement elicited by pushing up
against the cervix with two fingers
• This pushes the fetal body up and as it falls back
the examiner feel rebound
(Fig. B and C)

28. 2.6. Ballottement ….
B. External Ballottement
• Maybe felt by the 16th week on an examination carried
out by the doctor
• Two examining hands kept to the side of the mother
abdomen externally (Parallel)
• One examining hand pushes the contents of the
uterine cavity to the opposite hand
• Immediately a bound of fetus on the opposite hand
is felt (Fig. A)

29. 29

30. 2.7. Skin change
• Chloasma (Or the ‘Mask of Pregnancy’)
• Darkening of the skin over the forehead, bridge of
the nose, or cheekbones, is called chloasma
• Signs of chloasma usually occur after 16 weeks
gestation
• Are also intensified by exposure to sunlight

31. Melasma

32. 2.7. Skin change ….
• Stretch Marks or striae of the breast and
abdomen:
• Are caused by separation of the underlying collagen tissue
and appear as irregular scars
• In addition to stretching this is probably due to response of
ACTH (Aldosterone)
• These marks generally appear later in pregnancy when the
skin is under greater tension

33. 2.7. Skin change ….
Linea Nigra
• Is darkening of lower midline of the abdomen
from the umbilicus to the pubis (darkening of the
linea alba)
• The basis of these changes is stimulation of the
melanophores by an increase in melanocyte-
stimulating hormone

34. 2.7. Skin change ….
Striae gravidarum Linea nigra

35. 2.7. Pregnancy test
• Are based on analysis of maternal blood or urine for detection
of HCG
• This test are not considered positive signs of pregnancy because
similarity of HCG and the luteinizing hormone (LH)
occasionally result in cross reaction
• In addition certain conditions other than the pregnancy can cause
elevated levels of HCG
• Earliest biochemical marker for pregnancy.
• Production of β-hcG begins as early as the day of implantation
and can be detected as early as 7 to 10 days

36. Pregnancy test
• Blood > 3 weeks
• Urine >6 weeks
Differential diagnoses
• Hydatidiform mole
• Choriocarcinoma

37. 3. Diagnostic ( positive changes)
3.1. Visualization of gestational sack by:
Transvaginal ultrasound------4.5wks
Transabdominal U/S-----------5.5wks
 Visualization of fetus by x ray
16wks +

38. 3. Diagnostic …….
3.2. The fetal heart beat
• FHBs is the most conclusive clinical sign of pregnancy
• Detected with fetoscope by approximately 20 -24weeks
• With the electronic Doppler device it is possible to detect
10-12 weeks
• Ultrasound – 6 weeks +
• Rate 120-160 beat per minute

39. Two other sounds are confused with fetal heart
sounds. These are:
A. Uterine soufflé:
• Is a soft blowing and systolic murmur heard low down at
the sides of the uterus, best on the left side
• The sound is synchronous with the maternal pulse
• It can be heard in big uterine fibroid
B. Funic or fetal soufflé:
• Is due to rush of blood through the umbilical arteries
• It is a soft blowing murmur synchronous with the fetal
heart sounds
3. Diagnostic …….

40. 3. Diagnostic …….
3.3. Fetal movement
• Palpable 22 weeks +
• Visible late pregnancy
Fetal part
• Fetal part palpated 24 weeks

41. Summary of sign and symptom of
pregnancy
41

43. Reference Books
1. DC Dutta’s Text books of Obstetrics 7th edition
2. Current text book of obstetrics and gynecology
24th edition
3. Blueprints Obstetrics & gynecology 6th Edition
4. Gabbe: Obstetrics: Normal and Problem
Pregnancies, 5th ed.
5. Williams Obstetrics 24thEdition

44. Quiz 1
1. List subjective, probable and objective signs of
pregnancy
2. Discuss the difference b/n subjective and sure signs
of pregnancy
10 minutes only