DIAGNOSIS OF PREGNANCY
As pregnancy continues the
PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
→ Presumptive signs and symptoms of
pregnancy are those signs and symptoms
that are usually noted by the patient,
which impel her to make an appointment
with a physician.
→ These signs and symptoms are not proof
of pregnancy but they will make the
physician and woman suspicious of
pregnancy.
→ They could easily indicate other
conditions.
1. Amenorrhea (Cessation of Menstruation).
a. One of the earliest clues of
pregnancy.
2. Nausea and Vomiting (Morning Sickness).
a. Usually occurs in early morning
during the first 2 weeks of
pregnancy.
b. Usually spontaneous and subsides
in 6 to 8 weeks or by the twelfth to
sixteenth week of pregnancy.
c. Hyperemesis gravidarum.
→ This is referred to as
nausea and vomiting that
is severe and lasts
beyond the fourth month
of pregnancy. It causes
weight loss and upsets
fluid and electrolyte
balance of the patient.
3. Frequent Urination.
a. Frequent urination is caused by
pressure of the expanding uterus
on the bladder.
b. It subsides as pregnancy
progresses and the uterus rises
out of the pelvic cavity.
c. The uterus returns during the last
weeks of pregnancy as the head of
the fetus presses against the
bladder.
4. Breast Changes.
a. In early pregnancy, changes start
with a slight, temporary
enlargement of the breasts,
causing a sensation of weight,
fullness, and mild tingling.
b.
patient may notice:
→ Darkening of the areola
the brown part around the
nipple.
→ Enlargement of
Montgomery glands the
tiny nodules or sebaceous
glands within the areola.
→ Increased firmness or
tenderness of the breasts.
→ More prominent and visible
veins due to the increased
blood supply.
→ Presence of colostrum
(thin yellowish fluid that is
the precursor of breast
milk). ▪ This can be
expressed during the
second trimester and may
even leak out in the latter
part of the pregnancy.
5. Vaginal Changes
a. Leukorrhea.
→ This is an increase in the
white or slightly gray
mucoid discharge that has
a faint musty odor.
→ It is due to hyperplasia of
vaginal epithelial cells of
the cervix because of
increased hormone level
from the pregnancy.
Leukorrhea is also present
in vaginal infections.
6. Quickening (Feeling of Life).
a. This is the first perception of fetal
movement within the uterus.
→ It usually occurs toward the
18th week.
→ A multigravida can feel
quickening as early as 16
weeks
→ A primigravida usually
cannot feel quickening until
after 18 weeks.
7. Skin Changes.
a. Striae gravidarum (stretch marks).
→ These are marks noted on
the abdomen and/or
buttocks.
→ These marks are caused
by increased production or
sensitivity to adrenocortical
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 hormones during
pregnancy, not just weight
gain.
b. Linea nigra.
→ This is a black line in the
midline of the abdomen
that may run from the
sternum or umbilicus to the
symphysis pubis.
→ This appears on the
primigravida by the 3rd
month and keeps pace with
the rising height of the
fundus.
→ The entire line may appear
on the multigravida before
the third month.
c. Chloasma (Melasma).
→ This is called the "Mask of
Pregnancy."
→ It is a bronze type of facial
coloration seen more on
dark-haired women.
→ It is seen after the 16th wk
of pregnancy.
8. Fatigue.
a. This is a common complaint by
most patients during the first
trimester.
b. Fatigue may also be a result of
anemia, infection, emotional
stress, or malignant disease.
PROBABLE SIGNS OF PREGNANCY
→ Probable signs of pregnancy are those
signs commonly noted by the physician
upon examination of the patient.
→ These signs include uterine changes,
abdominal changes, cervical changes,
basal body temperature, positive
pregnancy test by physician, and fetal
palpation.
1. Uterine Changes.
a. Position.
→ By the twelfth week, the uterus
rises above the symphysis pubis
and it should reach the xiphoid
process by the 36th week of
pregnancy.
b. Size.
→ The uterine increases in width
and length approximately five
times its normal size. Its weight
increases from 50 grams to
1,000 grams.
c. Hegar's sign.
→ Softening of the lower uterine
segment just above the cervix.
→ When the uterine is
compressed between
examining fingers, the wall
feels tissue paper thin.
→ The Hegar's sign is noted by
the 6th to 8th week of
pregnancy.
d. Ballottement.
→ This is demonstrated during
the bimanual exam at the 16th
to 20th week.
→ Ballottement is when the lower
uterine segment or the cervix is
tapped by the examiner's finger
and left there, the fetus floats
upward, then sinks back and a
gentle tap is felt on the finger.
2. Cervical Changes.
a. Goodell's sign.
→ The cervix is normally firm
like the cartilage at the end
of the nose.
→ The Goodell's sign is when
there is marked softening
of the cervix.
→ This is present at 6 weeks
of pregnancy.
b. Formation of a mucous plug
(Operculum).
→ This is due to hyperplasia
of the cervical glands as a
result of increased
hormones.
→ It serves to seal the cervix
of the pregnant uterus and
to protect it from
contamination by bacteria
in the vagina.
3. Braxton-Hick's contractions.
→ This involves painless uterine
contractions occurring throughout
pregnancy.
→ It usually begins about the 12th
week of pregnancy and becomes
progressively stronger.
→ These contractions will, generally,
cease with walking.
→ Do not cause the cervix to dilate.
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 4. Positive Pregnancy Test by the Physician.
→ Even if the test is positive, it could
be the result of ectopic pregnancy
or a hydatidiform mole (an
abnormal growth of a fertilized
ovum).
5. Fetal outline Palpation.
→ This is a probable sign in early
pregnancy. The physician can
palpate the abdomen and identify
fetal parts.
→ It is not always accurate.
POSITIVE SIGNS OF PREGNANCY
• Positive signs of pregnancy are those
signs that are definitely confirmed as a
pregnancy.
• They include fetal heart sounds,
ultrasound scanning of the fetus, palpation
of the entire fetus, palpation of fetal
movements, x-ray, and actual delivery of
an infant.
1. Fetal Heart Sounds.
a. 5 weeks
→ echocardiography can
demonstrate a heartbeat
b. 6 th to 7th week
→ An ultrasound can reveal a
beating fetal heart
c. 10th to 12th week of gestation.
→ able to detect fetal heart sounds
thru doppler
d. 18 to 20 weeks of pregnancy
→ fetal heart beat can be heard
through an ordinary stethoscope
→ The normal fetal heart rate is
120 to 160 beats/min.
2. Ultrasound Scanning of the Fetus.
→ The gestation sac can be seen and
photographed.
→ An embryo as early as the 4th week
after conception can be identified.
→ The fetal parts begin to appear by the
10th week of gestation.
3. Palpation of the Entire Fetus.
→ Palpation must include the fetus head,
back, and upper and lower body parts.
→ This is a positive sign after the 24th
week of pregnancy if the woman is not
obese.
4. Palpation of Fetal Movement.
→ This is done by a trained examiner. It is
easily elicited at 20th – 24th week of
pregnancy.
Physiologic changes that occur during pregnancy
are the basis for the signs and symptoms used to
confirm a pregnancy. They can be categorized
as:
1. local (i.e., confined to the reproductive
organs)
2. systemic (i.e., affecting the entire body).
Local Changes
1. Uterine changes
→ Length grows from approx. 6.5 to 32
cm.
→ Depth increases from 2.5 to 22 cm.
→ Width expands from 4 to 24 cm
→ Weight increases from 50 to 1,000
gms.
→ Early pregnancy – uterine wall
thickens from 1 cm to 2 cm
→ End of pregnancy – the wall thins to
become supple and only about 0.5
cm thick.
→ Due partly to formation of new muscle
fibers in the uterine myometrium.
(progesterone)
→ Principally due to stretching of
existing muscle fibers (estrogen)
→ Uterus is able to withstand the
stretching of its muscle fibers due to
formation of fibroelastic tissue
between fibers that binds them
together.
→ Volume of uterus increases from
about 2 ml to more than 1,000 ml
→ Uterus can hold a 7 lb fetus and
1,000 ml 0f amniotic fluid for a total
of about 4,000 gms
→ Hegar’s sign – softening of the lower
uterine segment
→ Ballotement - “ to toss about”; fetus
can be felt to bounce and rise in the
amniotic fluid
→ Braxton Hick Contractions “practice
contractions”; also play a role in
ensuring the placenta receives
adequate blood.
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2. Cervical Changes
a. Goodell’s sign
→ Softening of the cervix
→ The cervix of the uterus
Systemic Changes
becomes more vascular and
edematous than usual
causing it to soften in
consistency (due to estrogen)
b. Operculum
→ A mucus plug forms to seal
out bacteria and help
prevent infection in the
fetus and membranes.
3. Vaginal Changes
a. Chadwicks Sign
→ The resulting increase in
circulation (due to
estrogen) changes the
color of the vaginal walls
from their normal light pink
to a deep violet.
b. Leukorrhea
→ increase in the activity of
the epithelial cells
c. Change of vaginal ph
→ fall from ph of greater than
7 (an alkaline ph) to 4 or 5
(acid ph)
→ Under the influence of
estrogen, the vaginal
epithelium and underlying
tissues increase in size as
they become enriched with
glycogen where
Lactobacillus acidophilus
(Doderlein bacillus) grow
freely and producing lactic
acid.
4. Ovarian Changes
→ Cessation of ovulation
5. Changes in the Breasts
→ Feeling of tingling , fullness or
tenderness in her breast (due to
high estrogen).
→ Increase of the breast size
→ Areola of the nipple darkens and
its diameter increase from about
3.5 cm to 5 or 7.5 cm
6. Changes in the Breasts
7. Montgomery’s tubercles
→ The sebaceous glands of the
areola become enlarged and
protuberant, which keep the nipple
supple and help to prevent nipples
from cracking and drying during
lactation.
1. Integumentary System
a. Striae gravidarum
b. Diastasis
→ Rectus muscles separate
→ Abdominal wall unable to
withstand the tension created
by the enlarging uterus.
c. Linea nigra
→ Brown line from umbilicus to
symphysis pubis
d. Melasma – “mask of pregnancy “
→ Due to melanocyte-
stimulating hormone
e. Vascular spiders
→ due to increase of estrogen
2. Respiratory Changes
a. Congestion or “ Stuffiness “ of the
nasopharynx
→ Due to increased estrogen
level
b. Dyspnea ( end of 3rd trimester )
→ Enlarging uterus places
pressure upward toward
the lungs and elevates the
diaphragm.
→ Residual volume (air
remaining in the lungs after
expiration) up to 20% by
the pressure of the
diaphragm
→ Tidal volume (volume of air
inspired) up to 40%
→ O2 consumption by 20%
c. Mild hyperventilation
→ to blow off excess CO2
being shifted to her by the
fetus
d. Temperature
→ Slight increase due to
progesterone
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3. Cardiovascular System
a. increase in cardiac output (the amount
of blood ejected from the heart each
minute).
→ Due to the expanded blood
volume of pregnancy
→ It is based on stroke volume
(the amount of blood pumped
from the heart with each
contraction) and heart rate.
b. increase in cardiac output—the
amount of blood ejected from the heart
each minute.The expanded blood
volume of pregnancy causes an It is
based on stroke volume (the amount
of blood pumped from the heart with
each contraction) and heart rate (the
number of times the heart beats each
minute). Cardiac output rises up to
50% with half of the rise occurring in
the first 8 weeks of gestation
(Beckmann, Ling, Barzansky, et al.,
2010). The increase in cardiac output
is caused primarily by a gain in stroke
volume, but the heart rate also rises
about 15 to 20 beats per minute (bpm)
(Bond, 2011). Cardiac output is most
efficient when the woman is lying in
the lateral position and least efficient in
the supine position.
c. Increase in blood volume
→ To provide for an adequate
exchange of nutrients in the
placenta
d. Pseudoanemia
→ Plasma volume increase
faster than RBC, conc. of
hemoglobin and erythrocytes
may decline.
e. Decreased Systemic Vascular
Resistance due to:
→ vasodilation caused by the
effects of progesterone and
prostaglandins;
→ the addition of the
uteroplacental unit, which
provides low resistance and a
greater area for circulation;
→ fetal, maternal, and placental
heat production, which causes
vasodilation;
→ decreased vascular sensitivity to
angiotensin II; and
→ endothelial prostacyclin and
endothelial-derived relaxant
factors such as nitric oxide
(Blackburn, 2013).
f. Iron, Folic acid, Vitamin needs
→ Iron absorption and iron-binding
power are increased during
pregnancy.
→ Iron supplementation is needed
to promote hemoglobin synthesis
and ensure that erythrocyte
production is sufficient to prevent
iron deficiency anemia
→ Fetus requires 350 – 400 mg of
iron to grow
→ Increase in the mother’s
circulatory RBC mass require an
additional 400 mg of iron
→ Total requirement for iron = 800
mg
→ Lack of folic acid have been
linked to increased risk for neural
tube disorder in fetuses.
→ Foods high in folic acid:
→ Spinach, asparagus, legumes
g. Peripheral blood flow
→ During 3rd tri, blood flow to lower
extremities is impaired due to
pressure of gravid uterus to veins
and arteries
→ Can lead to edema and
varicosities of the vulva, rectum,
legs ▪
h. Supine Hypotension Syndrome
→ Weight of growing uterus
presses the vena cava against
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 the vertebrae obstructing the
blood flow from the lower
extremities.
→ This causes a decrease in blood
return to the heart, and
consequently, decreased cardiac
output and hypotension
(lightheadedness, faintness,
palpitation)
→ Can result to fetal hypoxia.
i. Increased fibrinogen (necessary for
clotting)
→ Due to increased estrogen
→ Safeguard against major
bleeding.
→ Pre-pregnancy - 300 mg/dL
→ Pregnancy - 450 g/dL
j. Increased WBC
→ Protective mechanism
→ Reflection of the woman’s
increased blood volume
k. Protein level decreased
→ Indicating amount of protein
used by the fetus.
4. Gastrointestinal System
a. Heartburn ( pyrosis )
→ Due to reflux of stomach
content s into the esophagus
and a relaxed
cardioesophageal sphincter
caused by the action of relaxin
and progesterone
b. flatulence, constipation
→ Slow emptying time of the
stomach, slow intestinal
peristalsis
→ Due to relaxin and
progesterone.
c. nausea and vomiting
→ due to increased hCG,
estrogen and progesterone
levels and decreased glucose
levels (glucose being used by
the growing fetus) = FBS 95
mg/dL or lower
d. Hyperptyalism
→ increased in saliva formation
→ A local response to increased
levels of estrogen
e. Subclinical jaundice
→ Due to decreased emptying
of bile from the gallbladder
that leads to reabsorption of
bilirubin into the maternal
bloodsteam causing
generalized itching.
→ Increased tendency to stone
formation due to additional
cholesterol incorporated in
bile.
f. Hypertrophy of gumlines and
bleeding of gingival tissue when they
brush their teeth.
5. Urinary System
a. Fluid retention
→ Under the influence of
progesterone, there is an
increased response of the
angiotensin-renin system in
the kidney, leading to increase
aldosterone production
→ The renin-angiotensin-
aldosterone system (RAAS)
plays an important role in
regulating blood volume and
systemic vascular resistance
which together influence
cardiac output and arterial
pressure.
→ Renin is released primarily by
the kidneys, stimulates the
formation of angiotensin in
blood and tissues which in
turn stimulates the release of
aldosterone from the adrenal
cortex.
→ Aldosterone aids in Na
reabsorption
→ Water is retained to aid the
increase in blood volume, and
as a ready source of fluid for
the fetus.
b. Renal function
→ Gradual Increase in urine
output by 60 – 80%
→ Specific gravity of urine
decrease
→ Glomerular filtration rate
(GFR) and renal plasma flow
→ Increased by 30 – 50% by 2nd
trimester
c. Ureter and Bladder function
→ Due to progesterone during
pregnancy, ureters increase
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 in diameter, bladder capacity
increases to 1,500 ml
6. Skeletal System
a. Gradual softening of pelvic
ligaments and joints due to:
→ Ovarian hormone relaxin and
placental progesterone ▪
→ Lordosis (pride of pregnancy)
forward curve of the spine.
7. Endocrine System
a. Placenta
→ Estrogen
i. It stimulates uterine growth
and increases blood supply
to uterine vessels;
ii. it aids in developing the
ductal system in the breasts
in preparation for lactation;
and
iii. it is associated with
hyperpigmentation, vascular
changes in the skin,
increased activity of the
salivary glands, and
hyperemia of the gums and
nasal mucous membranes.
iv. Causes palmar erythema
(redness on palms)
→ Progesterone
i. Progesterone is produced
first by the corpus luteum
and then by the fully
developed placenta. The
major functions include:
(1) Maintaining the
endometrial layer for
implantation of the fertilized
ovum (2) Preventing
spontaneous abortion by
relaxing the smooth muscles
of the uterus (3) Stimulating
the development of the
lobes and lobules in the
breast in preparation for
lactation (4) Facilitating the
deposit of maternal fat
stores, which provide a
reserve of energy for
pregnancy and lactation (5)
Relaxing smooth muscle of
the uterus and other areas
(gastric sphincter, intestines,
ureters, and bladder) 6)
Increasing respiratory
sensitivity to carbon dioxide,
stimulating ventilation
→ hCG
i. Secreted by the trophoblast cells
of the placenta in early pregnancy
ii. this hormone stimulates the corpus
luteum to produce progesterone
and estrogen until the placenta is
sufficiently developed to assume
that function at about 10 to 12
weeks after conception (Blackburn,
2008)
→ hPL
i. Antagonist to insulin which allows
more glucose to become available
for fetal growth
→ Relaxin
i. Secreted primarily by corpus
luteum
ii. Inhibit uterine activity
iii. Soften the cervix and collagen in
joints ▪
→ Prostaglandins
i. Affect smooth muscle contractility
ii. They may be the trigger that
initiates labor at term.
b. Pituitary Gland
→ production of GH & MSH
→ Oxytocin is produced by post.
Pituitary gland late in pregnancy
needed to aid in labor
→ Prolactin begun late in pregnancy to
prepare for lactation.
c. Thyroid & Parathyroid
→ Thyroid gland enlarges early in
pregnancy causing increased basal
body metabolic rate by 20%.
→ Parathyroid glands necessary for
calcium metabolism.
d. Adrenal Glands
→ levels of corticosteroids and
aldosterone
→ Aids in suppressing an inflammatory
reaction ▪ Help reduce the possibility
of a woman’s body rejecting the
fetus.
→ Help regulate glucose metabolism.
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 → aldosterone aids in promoting
sodium reabsorption and maintaining
osmolarity in the amount of fluid
retained.
e. Pancreas
→ production of insulin in response to
higher levels of glucocorticoid
produced by the adrenal glands
→ Glucose level of fetus is 30 mg/100
ml
→ Pregnant woman should keep her
diet high in calories and should
never go longer than 12 hrs.
between meals
→ In early pregnancy, FBS is 80 – 85
mg/100 ml

f. Immune System
→ Immunoglobulin G (IgG) is
decreased making the woman more
prone to infection during pregnancy.
→ IgG comprise 80% of the antibodies
in adults (main type of antibody).
→ IgG is the only immunoglobulin that
can pass through the placenta.

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