DIAGNOSIS

OF
PREGNANCY
-RN AASTHA BISTA
 INTRODUCTION

• The diagnosis of pregnancy requires a 3 multifaceted approach using

main diagnostic tools; history and physical examination, hormonal
assays, and ultrasonography (USG).
• Currently, physicians may utilize all of these tools to diagnose pregnancy
at early gestation and to help rule out other pathologies
 INTRODUCTION

• The signs and symptoms of pregnancy have been grouped into

following categories:
1. Presumptive signs.
2. Probable signs
3. Positive signs
• Knowledge of physiology of early pregnancy is necessary for
understanding the presumptive and probable signs of pregnancy.
PRESUMPTIVE SIGNS (SUBJECTIVE)
• These are the signs/symptoms which are noted by
the patient, which impel her to make an
appointment with a physician.
• Each of these presumptive signs and symptoms are
subjective and nonspecific and could easily be
caused by conditions unrelated to pregnancy.
• These signs and symptoms are not a concussive
diagnosis of pregnancy but they will make the
physician and women suspicious of pregnancy.
 AMENORRHEA
• It is one of the earliest clues of pregnancy.

• The majority young women have no periodic bleeding after the

on set of pregnancy.

• However, cyclic bleeding may occur up to 12 weeks until

decidua space is obliterated by the fusion of decidua's vera with
decidua's capsularis. (Implantation bleeding/ Placental sign)

• Such bleeding is scanty, lasting for shorter duration and

corresponds with date of expected periods
 DIFFERENTIAL DIAGNOSIS
• Extreme weight loss
• Emotional or physical stress
• Rigorous exercise.
• Severe illness
• Hypothyroidism
• Polycystic ovarian syndrome.
 MORNING SICKNESS
(HYPEREMISES GRAVIDARUM)
• Hyperemesis Gravidarum is a condition which
involves extreme morning sickness, including
nausea, vomiting, and weight loss as its major
symptoms.
• More than 50-70% of pregnant woman
experience nausea and some vomiting.
• It usually appears soon following the missed
period and rarely lasts beyond the 3rd month.
 MORNING SICKNESS
(HYPEREMISES
GRAVIDARUM)

• It usually occurs on rising in the morning, but may

continue throughout the day.

• It usually does not affect the health status of the mother.

• The cause is thought to be due to the high blood levels

of HCG and estrogen.
BLADDER IRRITABILITY
• Frequency of micturition without any signs of infection
such as burning or pain often occurs in early pregnancy,
particularly 8- 12 weeks.
• It is due to the increased renal blood flow and glomerular
filtration rate, with pressure of the expanding uterus on
the bladder.
• It subsides as pregnancy progresses, and the uterus rises
out of the pelvic cavity or uterus straightens up after 12
weeks, the symptoms disappear.
• Frequent urination is not a definite sign since other factors
can be apparent (such as tension, diabetes, urinary tract
infection, or tumors)
 DIFFERENTIAL DIAGNOSIS
• U.T.I
• Vaginitis
• Diuretics medications
• Over active bladder syndrome
• Tumors in pelvis.
 BREAST CHANGES
• From 6 to 8 weeks, early symptoms and signs such as
tingling of the breast and breast heaviness and
enlargement may be the first indication of pregnancy.
• Such features may be experienced by nonpregnant
woman, particularly immediately prior to
menstruation, due to high hormonal levels.
• As pregnancy continue the woman may notice
darkening of the areola enlargement of Montgomery
gland, more prominent and veins, presence of thin
yellowish fluid from nipple.
 DIFFERENTIAL DIAGNOSIS
• Breast contusion
• Chest trauma/Chest wall injury
• Mastitis
• Breast abscess
• Neoplastic disorder
 QUICKENING
• When the pregnant woman first notices fetal movements within the
uterus, it is referred to as quickening.
• It is recognized earlier in the pregnancy by woman who has
previously been pregnant, and have, therefore, felt quickening
before.
• In multigravida , it is often recognized as early as 16 weeks and in
primigravida, at about 18- 20 weeks.
• These intra abdominal movements could be due to causes such as
increased peristalsis flatus and abdominal muscle contractions.
• Fatigue is a frequent symptoms which may occur early in pregnancy.
OBJECTIVE SINGS OF PREGNANCY
(PROBABLE)
• These signs commonly noted by the
physician or midwife upon examination of
the woman.
• These signs include skin changes, breast
changes, uterine change, abdominal
changes, cervical changes, positive
pregnancy test etc.
SKIN
CHANGES
• Pigmentation of the skin often
occur during pregnancy and
chloasma is usually noticeable
from the 16th week of pregnancy.
• Pigmentation over the forehead,
cheek and sometimes abdomen.
BREAST
CHANGES
• From 6 to 8 weeks subcutaneous veins
become noticeable and there is an increase
in the size and pigmentation of the nipple
and areola, and Montgomery’s tubercles
appear.
• From 16 weeks, colostrum can be
expressed.
 PER ABDOMEN
• Uterus remains a pelvic organ until 12th week, it may be just felt per
abdomen as a suprapubic bulge.
• From 12th week, as the uterus grows and the height of the fundus rises
and abdomen enlarges.
 CHANGES IN THE PELVIC ORGANS
• These signs are demonstrated during vaginal examination which are:
1. Jacqueminer’s or Chadwick’s sign
2. Osiander’s sign
3. Cervical’s sign
JACQUEMINER’S OR CHADWICK’S
SIGN
• From the 8th week, there is a dark purplish
coloration of the mucous membranes of the
cervix, vagina and vulva, which is brought
about by the increased blood volume
causing congestion of these tissues.
• The discoloration is due to local vascular
congestion and as such, it may be brought
about by pelvic Tumors such as fibroid.
 OSIANDER’S SIGN
• From the 8th week, increased pulsation is felt in the lateral fornixes of
the vagina, due to the increase in vascularity.
• Similar pulsation is, however, felt in acute pelvic inflammation.
 CERVICAL’S
SIGN
• It becomes soft as early as 6th week, a little earlier
in multiparae.
• The softening is pronounced surrounding the
external os and in the upper part.
• The pregnant cervix feels like the lips of the
mouth, while in the non-pregnant state, like that
top of the nose.
• Such degree of softening may be evident in cases
that are using combination pill for contraception.
 UTERINE CHANGES
• Uterine change in size, shape and consistency .
• The uterus is enlarged to the size of hen’s egg at 6th week; size of a
cricket ball at 8 the week (increases in size and becomes more globular
in shape).
• From about the 12th week, the fundus can be palpated abdominally,
just above the symphysis pubis and with the gradual increases in size.
• From the 12th week, the cervix begins to soften and from 16th week,
the uterus becomes more ovoid in shape.
 HEGAR’S SIGN
• It is present in two thirds of cases and it can be demonstrated
between 6-10 weeks, a little early in, multiparae.
• At 6-10 weeks, this early sign is due to the following.
• The embryo still only occupies the upper part of the uterus
and the isthmus has softened and elongated, the cervix is
comparatively firm.
• On bimanual examination with two finger of one hand in the
vagina and the fingers of the other pressing downwards and
backwards on the anterior abdominal wall, the fingers of the
two hands almost meet because of the soft, elongated
isthmus which is in contrast to the rounded full upper
segment above and to the much harder cervix below.
 UTERINE SOUFFLE
• From the 16th week, a soft blowing sound that synchronizes with the
pregnant woman’s pulse(normally about 80 beat per minute) can be
heard on auscultation.
• It is the sound of the maternal blood coursing through the enlarged
uterine vessels and it must not be confused with the sound of the fetal
heart, which is a much more definite and rapid double beat and it can
be heard in big uterine fibroid.
BRAXTON HICKS
CONTRACTION

• From 20th weeks, these

painless contractions
may be felt on
abdominal palpation.
 BALLOTTEMENT
• A sharp upward pushing against the uterine wall with a finger inserted
into the vagina for diagnosing pregnancy by feeling the return impact
of the displaced fetus.
• Ballotable means that when you push on the baby's head, it floats up
out of the pelvis and away from your fingers
 BALLOTTEMENT

• External ballottement is usually done as early as 20 th

week when the fetus is relatively smaller than the
volume of the amniotic fluid and it is difficult to elicit
in obese patients and in case with scanty liquor amnii.
• It is best elicited in breech presentation with the head
at the fundus.
• It can be done in the patient in dorsal position and one
hand taps the uterus on the side to displace the fetus,
the other hand which is placed on the other side to
steady the uterus can perceive the impulse.
Cont…
• Internal ballottement can be
elicited between 16-28th week and
the fetus is too small before 16th
week and too large to displace
after 28th week.
• Can be done by a push to the
foetal parts with the two fingers
through the anterior fornix.
POSITIVE SIGNS OF PREGNANCY

• Positive signs of pregnancy are those signs that are definitely

confirmed as a pregnancy.
• They include fetal heard sounds, ultrasound scanning of the fetus,
palpation of the entire fetus, palpation of the total movement, x-ray
and actual delivery of an infant.
FETAL HEART SOUNDS
• The fetal heart begins beating by the 24th day following conception
and it is audible with doppler by 10 weeks of pregnancy and with a
fetoscope after 16th week.
• It is not to be confused with uterine souffle or swish like tone from
pulsating uterine arteries and the normal fetal heart rate is 120 to 160
beats perminute.
 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
and the total parts begin to appear by the 10 week of gestation.
PALPATION OF THE ENTIRE FETUS
• Palpation must be included the fetus head, back and upper and lower
body parts.
• This is a positive signs after the 24th week of pregnancy if the women
is not obese.
PALPATION OF FETAL MOVEMENT
• This is done by a trained examiner and it s easily elicited after 24th
weeks of pregnancy.
 X-RAY
• A x-ray will identify the entire fetal skeleton by the 12th in week.
• In utero, the fetus receive total radiation that may lead to genetic or
gonadal alterations.
• It is not a recommended test for identifying pregnancy.
 SPECIAL INVESTIGATION USED TO
DIAGNOSE OF PREGNANCY

• Urinalysis
• Blood
• Ultrasonogram
• The basis for all these special pregnancy tests is the presence of human chronic
gonadotrophin (HCG) in the body of the pregnant woman and the urine of the
presumably pregnant woman is used in most of these tests.
• However, maternal blood is used in the sensitive serum assays, which are the later
tests available and these tests, although reliable in most instances, are not conclusive
proof of pregnancy.
 IMMUNOLOGICAL TESTS FOR
PREGNANCY
1. Urine test
• The immunological tests are at present the most frequently used tests,
as they are reliable and easy to use and they are available in kit form
and contain reagents, which are added to the urine of the presumably
pregnant woman.
• The object of these tests is to detect any human chorionic
gonadotraphin (HCG) which may have been excreted in the urine for
testing and this hormone is mostly found in urine after few days of
missed period.
TECHNIQUES CURRENTLY IN USE
TEST
• Latex particle test- slide test
1. This is simple, cost efficient and can be read
after only 2 minutes and it is about 97%
accurate when the pregnancy has progressed
beyond 40 days(6 weeks) after the last
menstrual period (LMP).
2. The urine specimen used for these tests should
15 ml of the first early morning mid stream
specimen, which should be free as possible
from any contamination.
 HAEMOGGLUTINATION TEST
(TUBE TEST)
• In this test, tanned erythrocytes are used and although the test is more
sensitive than the slide test, it is slightly more costly and can be read
after 2 hours, it is about 97% accurate when the pregnancy has
progressed beyond 28 days after the LMP.
 FALSE REACTION
• A negative pregnancy result may be obtained if the tests are under taken earlier than 14 days
after LMP and should than be repeated after at least a 7 days interval, when the HCG levels
in the urine have increased.
• A false negative pregnancy result may also be obtained if the urine is contaminated with
protein, which may coat the particles carrying the immunological reagent and should also
be repeated as above.
• Conditions such as hydatidiform mole and choriocarcinoma will give a strong positive
pregnancy rection due to high levels of HCG in the urine.
• A positive pregnancy test 8 days after the first missed period, indicates that the woman is
probably pregnant.
 SENSITIVE SERUM ASSAYS (BLOOD
TESTS)
• The principle of the these tests is similar to that of the urine test, which is
the detection of HCG, but instead of urine, the blood of the presumably
pregnant woman is tested.
• These test are much more sensitive than the urine tests, but are also much
more expensive are require a laboratory with gamma counter and the test
requires sending the blood sample to the lab for analysis.
• Blood test to detect pregnancy is rarely done as a routine measure and they
reserved for special conditions, which need greater sensitivity such as
ectopic pregnancy, threatened and missed abortion .
Cont…..
• They could also be used in cases of rape and woman who are
undergoing infertility treatment or when a problem is suspected and it
can provide a more accurate answer vary early on in the pregnancy
within about 7-12 days after conception.