- Diagnosis of pregnancy is confirmed through visualization of gestational sac, yolk sac, and fetal pole inside the uterus using ultrasound. Hormonal assays can also detect hCG. - Common minor symptoms in early pregnancy include nausea and vomiting, backache, leg cramps, heartburn, and fatigue. These are usually managed with lifestyle changes and over-the-counter medications. - It is important to rule out other potential issues like ectopic pregnancy or molar pregnancy in patients with bleeding in the first trimester before attributing it to implantation bleeding. Minor symptoms should also not be assumed to be from pregnancy alone without ruling out other diseases.

1. Diagnosis of pregnancy and Minor disorders of pregnancy
Ephrem Yohannes

2. Diagnosis of pregnancy
• 3 main diagnostic tools. These are history and physical examination,
hormonal assays, and ultrasonography (US).
HISTORY AND PHYSICAL EXAMINATION
• Traditionally based on history and physical examination findings
• On menstrual history the woman should describe her menstrual pattern, date
of onset of last menses, duration, flow, and frequency
• Atypical last menstrual period, contraceptive use, and a history of irregular
menses may confuse the diagnosis of early pregnancy.
• Additionally 25% of women bleed during their first trimester, further
complicating the assessment.

3. Diagnosis of pregnancy
HISTORY AND PHYSICAL EXAMINATION
• Upon physical examination, you may find an enlarged uterus after bimanual
examination, breast changes, and softening and enlargement of the cervix
(Hegar sign; observed at approximately 6 wk).
• The Chadwick sign is a bluish discoloration of the cervix from venous
congestion and observed by 8-10 weeks.
• A gravid uterus may be palpable low in the abdomen, usually by 12 weeks.
• The classic presentation of pregnancy is a woman with menses of regular
frequency who presents with amenorrhea, nausea, vomiting, generalized
malaise, and breast tenderness.
• Amenorrhea is not a reliable pregnancy indicator until 10 days after expected
menses.

4. Diagnosis of pregnancy
HISTORY AND PHYSICAL EXAMINATION
Fetal Movement
• Maternal perception of fetal movement depends on factors such as parity and
habitus.
• In general, after a first successful pregnancy, a woman may first perceive fetal
movements between 16 and 18 weeks’ gestation.
• A primigravida may not appreciate fetal movements until approximately 2 weeks
later.
• At about 20 weeks, depending on maternal habitus, an examiner can begin to
detect fetal movements.

5. Diagnosis of pregnancy
HORMONAL ASSAYS
Beta-human chorionic gonadotropin
• hCG is a glycoprotein similar in structure to FSH, LH, and thyrotropin.
• The free beta subunit of hCG differs from the others.
• The beta-hCG subunit is present in the syncytial layer of the blastomere.
• Detection in maternal serum and urine is evident only after implantation
• Vascular communication has been established with the decidua by the
syncytiotrophoblast 8-10 days after conception

6. Diagnosis of pregnancy
HORMONAL ASSAYS
Beta-human chorionic gonadotropin
• 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
• Failure to achieve the projected rate of rise may suggest an ectopic pregnancy
or spontaneous abortion
• High level or accelerated rise can prompt investigation into the possibility of
molar pregnancy, multiple gestations, or chromosomal abnormalities.

7. Diagnosis of pregnancy
ULTRASOUND
• TVUS is the most accurate means of confirming intrauterine pregnancy and
gestational age during the early first trimester.
• With the advent of transvaginal US (TVUS), the diagnosis of pregnancy can be
made even earlier than is possible with transabdominal US (TAUS).
• TVUS can help detect signs of intrauterine pregnancy approximately 1 week
earlier than TAUS.
• The earliest structure identified is the Gestational Sac (GS). The GS can be seen
on TVUS images by 4-5 weeks' gestation and grows at a rate of 1 mm/d in early
gestation.
• By 5.5-6 weeks' gestation, a double-decidual sign can be seen, which is the GS
surrounded by the thickened decidua

8. Diagnosis of pregnancy
• The yolk sac can be recognized by 4-5 weeks' gestation and is seen until
approximately 10 weeks' gestation
• The presence of an early GS can be confused with a small collection of fluid or
blood or the pseudo GS of an ectopic pregnancy.
• Because of this, the diagnosis of intrauterine pregnancy should not be made
on the basis of visualization of the GS alone
• The fetal or embryonic pole is first seen on TVUS images at approximately 5-6
weeks' gestation.
• It should always be seen by TVUS when the GS is larger than 18 mm or by TAUS
when the GS is larger than 2.5 cm.
ULTRASOUND

9. Minor disorders of pregnancy
1.Nausea and Vomiting in pregnancy
• These are common complaints during the first half of pregnancy
• Nausea and vomiting of varying severity usually commence between the first
and second missed menstrual period and continue until 14 to 16 weeks’
gestation.
• Although nausea and vomiting tend to be worse in the morning—thus
erroneously termed morning sickness—both symptoms frequently continue
throughout the day.
• 80 percent of these women, nausea lasted all day.

10. Minor disorders of pregnancy
Treatment of Nausea and Vomiting in pregnancy
• Treatment of pregnancy-associated nausea and vomiting seldom provides
complete relief, but symptoms can be minimized.
• Eating small meals at more frequent intervals but stopping short of satiation is
valuable. Herbal remedy(Ginger) is also effective.
• Mild symptoms usually respond to vitamin B6 given along with doxylamine, but
some women require phenothiazine or H1-receptor blocking antiemetics.
• In some, hyperemesis gravidarum develops—vomiting so severe that
dehydration, electrolyte and acid-base disturbances, and starvation ketosis
become serious problems. Such patients require inpatient management

11. Minor disorders of pregnancy
Backache
• Low back pain to some extent is reported by nearly 70 percent of pregnant
women
• Minor degrees follow excessive strain or significant bending, lifting, or walking
• It can be reduced by squatting rather than bending when reaching down, by
using a pillow back support when sitting, and by avoiding high-heeled shoes.
• Back pain complaints increase with progressing gestation and are more
prevalent in obese women and those with a history of low back pain.
• In some cases, troublesome pain may persist for years after the pregnancy

12. Minor disorders of pregnancy
Backache
• Severe back pain should not be attributed simply to pregnancy until a thorough
orthopedic examination has been conducted.
• Severe pain also has other uncommon causes, such as pregnancy-associated
osteoporosis, disc disease, vertebral osteoarthritis, or septic arthritis
• More commonly, muscular spasm and tenderness are classified clinically as
acute strain or fibrositis.
• Although evidence-based clinical research directing care in pregnancy is limited,
such low back pain usually responds well to analgesics, heat, and rest.
• There may also be a role for chiropractic manipulation in selected women

13. Minor disorders of pregnancy
Varicosities and Hemorrhoids
• Venous leg varicosities have a congenital predisposition and accrue with
advancing age. They can be aggravated by factors that cause increased lower
extremity venous pressures.
• Thus, susceptible women develop leg varicosities that typically worsen as
pregnancy advances, especially with prolonged standing.
• Symptoms vary from cosmetic blemishes and mild discomfort at the end of the
day to severe discomfort that requires prolonged rest with feet elevation.
• Treatment is generally limited to periodic rest with leg elevation, elastic
stockings, or both. IF severe injection, ligation, stripping of the veins is necessary

14. Minor disorders of pregnancy
Varicosities and Hemorrhoids
• Vulvar varicosities frequently coexist with leg varicosities, but they may appear
without other venous pathology.Uncommonly, they become massive and almost
incapacitating.
• If these large varicosities rupture, blood loss may be severe. Treatment is with
specially fitted pantyhose that will also minimize lower extremity varicosities.
• Hemorrhoids are rectal vein varicosities and may first appear during pregnancy
as pelvic venous pressures increase.
• Commonly, they are recurrences of previously encountered hemorrhoids. Pain
and swelling usually are relieved by topically applied anesthetics, warm soaks,
and stool-softening agents.

15. Minor disorders of pregnancy
Heartburn
• This symptom is one of the most common complaints of pregnant women and is
caused by gastric content reflux into the lower esophagus.
• The increased frequency of regurgitation during pregnancy most likely results
from upward displacement and compression of the stomach by the uterus,
combined with relaxation of the lower esophageal sphincter.
• In most pregnant women, symptoms are mild and are relieved by a regimen of
more frequent but smaller meals and avoidance of bending over or lying flat.
• Antacids may provide considerable relief. Aluminum hydroxide, magnesium
trisilicate, or magnesium hydroxide alone or in combination are given.

16. Minor disorders of pregnancy
Pica and Ptyalism
• The craving of pregnant women for strange foods is termed pica. At times, nonfoods such as
ice—pagophagia, starch-amylophagia, or clay—geophagia may predominate. This desire has
been considered by some to be triggered by severe iron deficiency
• Although such cravings usually abate after iron deficiency correction, not all pregnant women
with pica are iron deficient.
• The prevalence of anemia was 15 percent in women with pica compared with 6 percent in
those without it. Interestingly, the rate of spontaneous preterm birth before 35 weeks was
twice as high in women with pica.
• Women during pregnancy are occasionally distressed by profuse salivation—ptyalism.
Although usually unexplained, ptyalism sometimes appears to follow salivary gland
stimulation by the ingestion of starch.

17. Minor disorders of pregnancy
Sleeping and Fatigue
• Beginning early in pregnancy, many women experience fatigue and need
increased amounts of sleep.
• This likely is due to the soporific effect of progesterone but may be compounded
in the first trimester by nausea and vomiting and in the latter stages of
pregnancy by general discomforts, urinary frequency, and dyspnea.
• Moreover, sleep efficiency appears to progressively diminish as pregnancy
advances.

18. Minor disorders of pregnancy
Restless Legs Syndrome
• About 1 in 10 women will develop restless legs syndrome (RLS) during the
second half of pregnancy.
• RLS usually occurs as women fall asleep and is characterized by tingling or other
uncomfortable sensations in the lower legs, resulting in the overwhelming urge
to move the legs.
• Unfortunately, movement, walking around, or other measures do not relieve
RLS.
• Iron deficiency anemia has been associated with an increased chance of RLS,
and in anemic women, iron supplementation may reduce leg restlessness.
• Avoiding caffeine-containing drinks such as coffee, tea, or sodas in the last half
of the day should also be recommended, as caffeine may increase symptoms.

19. Minor disorders of pregnancy
Sciatica
• Sciatica refers to nerve pain that shoots rapidly down from the buttocks and
unilaterally down one leg, usually ending in the foot.
• True sciatica is rare in pregnancy, affecting only about 1% of pregnancies.
• True sciatica is caused either by a herniated disc or, less commonly, by uterine
pressure on the sciatic nerve.
• In addition to pain, other signs of nerve compression include numbness in the
affected leg.
• True sciatica should prompt referral to a neurologist or an orthopedic surgeon
for further evaluation.

20. Minor disorders of pregnancy
Carpal Tunnel Syndrome
• The extra fluid retention of pregnancy can exacerbate carpal tunnel syndrome; higher weight
gain during pregnancy is also a risk factor.
• The most common symptoms of carpal tunnel syndrome are pain and numbness in the
thumb, index, and middle fingers and weakness in the muscle that moves the thumb.
• 25% to 50% of pregnant women will notice some symptoms of carpal tunnel syndrome.
• Treatment during pregnancy is usually limited to supportive measures such as nighttime
splinting that may help reduce increased pressure on the nerve that occurs when the wrist is
bent. About 80% of women will notice reduction in symptoms with splinting alone.
• Severe cases of carpal tunnel syndrome can be treated with steroid injections into the area
around the carpal tunnel to reduce swelling and inflammation.After delivery, symptoms
generally resolve within 4 weeks

21. Minor disorders of pregnancy
Constipation
• Constipation is physiologic during pregnancy with decreased bowel transit time,
and the stool may be hardened.
• Dietary modification with increased bulk such as with fresh fruit and vegetables
and plenty of water can usually help this problem.
• Constipation is aggravated by the addition of iron supplementation; if dietary
measures are inadequate, patients may require stool softeners.
• Additional dietary fibers such as Metamucil (psyllium hydrophilic muciloid) or
surface-active agents such as Colace (docusate) can be used, if indicated.
Laxatives are rarely necessary.

22. Minor disorders of pregnancy
Urinary Frequency and Incontinence
• During the first 3 months of pregnancy, the growing uterus places increased pressure on the
bladder. Urinary frequency usually will improve as the uterus rises out of the pelvis by the
second trimester.
• However, as the head engages near the time of delivery, urinary frequency may return as the
head presses against the bladder.
• About 40% to 50% of women will experience urinary incontinence during their pregnancy.
• The risk of incontinence of urine is highest in the third trimester. The chances of experiencing
incontinence are increased in multiparous women, especially those with a history of
incontinence.
• Incontinence during pregnancy is a risk factor for persistent incontinence.
• If the patient experiences pain with urination or new-onset incontinence, it is appropriate to
check for infection.

23. Minor disorders of pregnancy
Round Ligament Pain
• Frequently, patients will notice sharp groin pains caused by spasm of the round ligaments
associated with movement.
• This is more frequently felt on the right side as a result of the usual dextrorotation of the
uterus.
• The pain may be helped by application of local heat such as with hot soaks or a heating pad.
• Patients may awaken at night with this pain after having suddenly rolled over in their sleep
without realizing it.
• During the daytime, however, modification of activity with gradual rising and sitting down, as
well as avoidance of sudden movement, will decrease problems with this type of pain.
• An elastic fourway stretch can minimize movement of the uterus. Analgesics are rarely

24. Minor disorders of pregnancy
Syncope
• Compression of the veins in the legs from the advancing size of the uterus
places patients at risk of venous pooling associated with prolonged standing.
This may lead to syncope.
• Measures to avoid this possibility include wearing support stockings and
exercising the calves to increase venous return.
• In later pregnancy, patients may have problems with supine hypotension, a
distinct problem when undergoing a medical evaluation or an ultrasound
examination.
• A left lateral tilt position with wedging below the right hip will help keep the
weight of the uterus and fetus off the inferior vena cava.

25. Summary
• Diagnosis of pregnancy is confirmed by visualization of gestational sac, yolk
sac and fetal pole inside the uterus.
• In a patient with 1st trimester vaginal bleeding ectopic pregnancy, abortion
and molar pregnancy should be ruled out before ascribing the source of
bleeding as an implantation bleeding.
• Minor symptoms of pregnancy are common conditions in pregnancy but
other serious disease conditions should be ruled out.

26. References
1. e-BOOKS eMedicine - Pregnancy Diagnosis Article by Randle L Likes.mht1.
2. F. Gary Cunningham KJL, Steven L. Bloom , Catherine Y. Spong , Jodi S. Dashe,
Barbara L. Hoffman , Brian M. Casey , Jeanne S. Sheffield. Williams Obstetrics
24th edition. 2014.
3. STEVEN G. GABBE M, et al. Obstetrics Normal and Problem Pregnancies, 6th
edition. 2012.

27. Thank you!!