Diagnosis of pregnancy

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 INTRODUCTION
Every physician, must always consider the possibility
of pregnancy in women of reproductive age.
Early diagnosis of pregnancy is important:
1.To prevent exposure of the fetus to hazardous
substances, such as x-rays, teratogenic drugs.
2.To manage ectopic or nonviable pregnancies.
3.To provide better health care for the mother.

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 Diagnosis of pregnancy
 Is usually very easy to establish, but this is
not always the case.
 The endocrinological, physiological and
anatomical alterations clue for Dx.
 Symptoms and signs are classified in to
three groups:
1. Presumptive (possible) evidences
2. Probable evidences
3. Positive signs

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 A. Presumptive evidences
Not related to either the fetus or the placenta
This are not confirmatory signs.
1. Cessation of menses (amenorrhea)
2. Nausea and vomiting
3. Breast changes
4. Quickening
5. Disturbance in urination
6. Skin changes
7. Fatigue
8. Strange cravings, food aversion
9. Increased BBT
10. Discoloration of the vaginal mucosa
11. Change in cervical mucus
12. Does the woman believes that she is pregnant?
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 B. Probable evidences
This is something related to the uterus not
related to the fetus.
1. Enlargement of the abdomen
2. Changes in the shape, size and consistency of the
uterus
3. Anatomical changes in the cervix
4. Braxton Hicks contractions
5. Ballottement
6. Physical out line of the fetus
7. Presence of hCG in urine or serum
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 c. Positive signs of pregnancy
This is a confirmatory test and related to the
fetus
1. Fetal heart beat detection
2. Perception of active fetal movements by
the examiner
3. Recognition of the embryo and fetus by
ultrasound or X-ray

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 Amenorrhea
Is a fairly reliable sign of conception in women
with regular menstrual cycles.
Important considerations:
1. Conception can occur without prior menstruation
(before menarche)
2. In nursing mothers, who sustain amenorrhea during
lactation
3. In women who believe they have passed the
menopause (may ovulate again after a few months of
anovulation/amenorrhea).

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 Cont.
Delayed menses can also be due to anovulation
secondary to
1. Severe illness
2. Physical or emotional stress, eg. Fear of
pregnancy
3. Environmental changes
4. Chronic disease process
5. Opioid and dopaminergic medications
6. Endocrine disorders
7. Certain gynecologic tumors
8. Persistent corpus luteum cyst
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 Nausea and vomiting
Also called morning sickness of pregnancy.
It is most severe in the morning, but can occur at any
time.
It usually begins about 6 weeks of gestation and
disappears spontaneously 6 to12 weeks later.
Occurs in about 50% of pregnancies.
Cause is unknown but seems to be associated with
higher levels of hCG.
Emotional tension may play a role.

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 Cont….
Multiple gestation and molar pregnancy should be
ruled out.
Protracted vomiting associated with dehydration,
weight loss (>5 %) and ketonuria (hyperemesis
gravidarum) may require hospitalization.
Rx includes light dry foods, small frequent meals, and
emotional support.
Addition of Vit B and preconceptional use of prenatal
6
vitamins can give some improvement.
Antinauseant /antiemetic drugs are used as a final
measure.
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 Breast changes
1. Mastodynia/breast tenderness
 May range from tingling to frank pain
 Breast engorgement
 Similar tenderness may occur just before menses.
2. Enlargement of sebaceous glands of the areola
(Montgomery’s tubercles).
3. Colostrum secretion- may begin after 16 weeks.
 Breasts of multiparas may contain a small amount of milky material or
colostrum for months or even years after the birth of their last child.
4. Increased size of the breast, nipple and areola; darkening of
the nipple and areola.

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 Cont….
• Similar changes can occur in
• Prolactin secreting pituitary tumors
• Women taking prescribed drugs like anxiolytic
agents (e.g. Benzodiazepines)
• Women with imaginary pregnancy(pseudosyasis )

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 Quickening
 The first perception of fetal movement
 Occurs at 18-20 wks in primis and at 14-16 wks in
multis.
 Intestinal peristalsis may be mistaken for fetal movement.
 It is useful in determining the duration of pregnancy.

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 Disturbance in urination
Bladder irritability, frequency of urination and nocturia:
Due to increased bladder circulation and pressure from the
enlarging uterus.
UTI must always be ruled out.

Discoloration of the vaginal mucosa

Pregnancy causes bluish or purplish discoloration of the
vagina (Chadwick’s sign)
Similar changes may be induced by any condition that causes
intense congestion of the pelvic organs.

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 Skin changes
1. Chloasma or mask of pregnancy:
• Is darkening of the skin over the forehead, bridge of
the nose, or cheekbones.
• Most marked in those with dark complexions.
• Intensified by exposure to sunlight.
2. Linea nigra:

Darkening of the lower midline of the abdomen from the
umbilicus to the pubis
 Are due to stimulation of the melanophores by an increase
in MSH
Increased BBT
 Persistent elevation of BBT over a 3-week period usually
indicates pregnancy if temperature have been carefully charted.

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Cont.

3. Stretch marks/striae gravidarum:

 Occur on the abdomen, breast, thigh,
buttock, etc.
 Caused by separation of the underlying
collagen tissue with resultant bleeding in
to the epidermis.
 Generally appear late in pregnancy when
the skin is under greater tension.
4. Spider telangiectases and palmar
erythema:
 These are due to high levels of circulating
estrogen
 Both these signs are also seen in patients
with liver failure.
NB: These signs may be absent during
pregnancy and can occur with
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ingestion of estrogen-progestin 02/20/2024
contraception.
 Changes in the cervix

 Cyanosis and softening (Goodell’s sign), are due to

increased vascularity. (DDx- Estrogen-progestin
contraceptives).
 With advanced pregnancy, the cervical canal may become
sufficiently patulous to admit a fingertip.
 Thick relatively little cervical mucus with loss of
streachability.
 Loss of the fernlike/arborization/palm leaf pattern to
beaded or cellular pattern.

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 Abdominal enlargement
 By 12 weeks, the uterus is usually palpable through the
abdominal wall.
 Then gradually increases in size until the end of pregnancy.
 Uterus becomes globular and rotates to right, the body
feels doughy or elastic and sometimes becomes
exceedingly soft.
 At 6-8 weeks the Hegar sign (compressible soft
isthmus) becomes evident.
NB: The pregnant uterus should be differentiated from other
conditions like full bladder or pelvic tumors.

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 Braxton Hicks contractions
 Palpable, painless, and irregular uterine contractions, that
are felt as tightening or pressure.
 Usually begin at about 28 weeks of gestation and increase
in regularity and frequency, especially during nighttimes.
 Usually disappear with walking and exercise.
 Increase in number and amplitude when the uterus is
massaged.
 Similar contractions are sometimes observed with
hematometra, soft myomas (submucous myomas).
 Excludes the possibility of abdominal ectopic pregnancy

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 Outlining the fetus
 In the second half of pregnancy, the outline of the fetal
body may be palpated.
 Sometimes, subserous myomas may be of such a size and
shape as to simulate the fetal head, small parts, or both.
 Near mid-pregnancy, ballottement of the uterus may give
the impression that a floating object occupies the uterus.
(DDx- Myomas, ascites, or ovarian cysts)

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 Presence of hCG in urine or serum
 hCG is a glycoprotein, composed of two dissimilar
subunits: the  and  subunits.
 The  subunit is specific to hCG, while  subunit has
cross-reaction with LH.
 hCG is produced exclusively by the syncytiotrophoblast,
not by cytotrophoblast.
 Production begins early in pregnancy, almost certainly by
the day of implantation (day 6).
 With sensitive test, it can be detected in the blood or urine
by 8 - 9 days after ovulation.
 The doubling time of plasma hCG concentration is 1.4 to
2.0 days.

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 Cont.
 Peak level is reached at about 60 – 70 days.
 Level gradually decrease in the second and third trimesters and increase slightly
after 34 weeks.
 The half life of hCG is 1.5 days.
 After termination of pregnancy, levels drop exponentially.
 Normally, serum and urine hCG levels return to nonpregnant value (<5 mIU/mL)
21 -24 days after delivery.
 The higher the level at pregnancy termination (first trimester abortion or molar
pregnancy), the longer the time until the return to baseline values.
 Different types of pregnancy tests are available (further reading).
 The different types of tests detect hCG at different serum levels (variable
sensitivity).
 Tests can be quantitative or qualitative.
 Precise quantification of hCG level is important in some conditions like in
pregnancy monitoring to exclude ectopic pregnancy and to evaluate the course
and treatment of GTD.
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 Fetal heart beats
 Fetoscope - 18 -20 weeks
 Doppler – 10 weeks
 Echocardiography – as early as 48 days from NLMP.
 Sonography – as early as 5- 6weeks.
Other sounds, some of which should be differentiated
from FHB, include:
1. The funic (umblical cord) souffle
2. The uterine souffle
3. Sounds resulting from fetal movement

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 Cont.
4. Maternal pulse
5. Gurgling sounds produced by gas or liquid propulsion
through the maternal intestine.
 Funic soufflé –sharp, whistling sound that is
synchronous with the fetal pulse.
 Caused by a rush of blood through the umbilical arteries
 Uterine soufflé – soft blowing sound that is
synchronous with the maternal pulse.
 Caused by the passage of blood through the dilated
uterine vessels, occurs in any condition in which the
blood flow to the uterus is increased.

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 Ultrasound

Used for diagnosis of early pregnancy.

Gestational sac - 4 to 5 weeks
FHB- 5 to 6 weeks
Also used to estimate GA, follow growth and development of
the embryo/fetus.
The confirmatory test of pregnancy
X-ray of the fetus
The ossified fetal bones appear at 12-14 weeks.
Before 16 weeks, bowel shadows and pelvic bone configuration
often conceal a pregnancy in the AP view.
Diagnostic radiation of less than 10 rads is considered by some
authorities to have minimal teratogenic risks.
Generally, x –ray should be avoided during pregnancy.

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 Minor disorders of Pregnancy

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 Nausea and Vomiting
• Nausea and vomiting in pregnancy is extremely common( morning
sickness)
• 50-90% of the pregnant women suffer some degree of nausea and
vomiting during the first trimester
• The nausea and vomiting associated with pregnancy usually begins

by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in

most cases by 12-14 weeks.
 In 1-10% of pregnancies symptoms may continue beyond 20-22
weeks.
 Begins within few weeks of conception and continues through
weeks 12 and 14 of gestation
• Most often in the morning
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• Some women suffer during day time
 ….
Normal nausea and vomiting may be an evolutionary
protective mechanism
It may protect the pregnant woman and her embryo
from harmful substances in food, such as pathogenic
microorganisms in meat products and toxins in plants,
with the effect being maximal during embryogenesis
(the most vulnerable period of pregnancy).
This is supported by studies showing that women who
had nausea and vomiting were less likely to have
miscarriages and stillbirth.

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 Hyperemesis gravidarum (HEG) is the most severe form of
nausea and vomiting in pregnancy.
Hyperemesis gravidarum is characterized by persistent
nausea and vomiting associated with ketosis and weight loss
(>5% of prepregnancy weight).
Hyperemesis gravidarum may cause volume depletion,
electrolytes and acidbase imbalances, nutritional deficiencies,
and even death.
 Severe hyperemesis requiring hospital admission occurs in
0.3-2% of pregnancies.

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 Heartburn
2/3 of pregnant women in the later pregnancy
Due to relaxation of the esophageal sphincter and
increased pressure on the stomach caused by
enlarged uterus, allowing regurgitation of the
stomach contents into the lower esophagus

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 Treatment
1. Elevating the head when sleep

2. Avoid eating 3 hrs before sleep

3. Avoid acidic food

4. Small more frequent meals

5. Antacids for whom not responding to non drug therapy

6. Mg and Al hydroxide is effective

7. Calcium carbonate is used but with Na bicarbonate has a

short duration
8. Sucralfate is poorly absorbed from GIT and used as
alternative
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 Constipation
 Due to decreased peristalsis b/c of the effect of progestrone

 Drink plenty of fluids and bulk forming laxatives

 Mineral oil should be avoided due to possibility of impairment of

vitamin K absorption
 Stool softeners

Hemorrhoids “Piles”
 Due to constipation and increased venous pressure below the uterus

 Correct constipation

 Use stool softeners

 Avoid anesthetics and corticosteroids

 Taking site bath

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 Coagulation Disorders
Uncommon
Avoid warfarin because of 30% of the development of fetal
malformation, stillbirth, and hemorrhage
SC heparin or LMWH is the drug of choice
Anticoagulation effect of heparin can be suppressed by
protamine sulfate when needed especially in emergency labor
Heparin is considered safe for the mother and fetus
Osteoporosis may reults from heparin due to effect on vtamin
D metabolism, and thrombocytopnia
LMWH is better than heparin because of the low
thrombocytopenia, once daily, no monitoring, and less risk of
osteoporosis

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 Headache and Backache
 Common
 Due to intracranial vascular changes mediated by progesterone and estrogen
 Migraine attacks often improves during pregnancy due to the lack of estrogen
 Worse during 2nd trimester and 3rd trimester
 Backache caused by strain on the muscle of the back as the uterus enlarges and
grows forward
 In the 3rd trimester, the hormone relaxin softens the muscles and ligaments in
readiness for labor, making them more able to stretch but this can make them
ache
 Weight gain can cause backache
 Paracetamol is the safest analgesic
 Aspirin and ibuprofen should be avoided
 Teratogenisity of codeine with paracetamol is not evident but they depress

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 Massage is helpful
 Vaginal Thrush (Candidiasis)
10 times more common in pregnant than non
pregnant women
Vagina rich in glycogen which promotes candida
Imidazole can be given by doctor
Candida does not harm babies but can be passed to
baby when the baby pass through the birth canal

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 Varicose Vein and Muscle Cramps
>80% of pregnant women suffer from leg edema
1/3 of pregnant women suffer from calf muscle
cramps in the lat pregnancy
Support hosiery is usually recommended for
varicose vein
Rest is the treatment of edema with their legs
elevated

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 Pruritus
Pruritus gravidarum; the most common during pregnancy
It is a generalized mild itching without rash that affects up to 20% of
pregnant women
It occurs from the 3rd month upwards
Due to estrogen induced cholestasis
Oily calamine lotion is effective
Sometime papular rash happens and it needs investigation
Wearing tight clothes should be avoided
Increase intake of calcium and potassium is recommended to
decrease muscle cramp
Avoid high heeled shoe
Put a pillow at the foot of the bed to prevent stretching the foot
forward from the ankle while lying on the back, which often triggers
cramps
Massage and stretching the affected muscle is helpful
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 Stretch Marks & Hyperpigmentation
 Hyperpigmentation is due to increased level of MSH, while estrogen makes
veins more noticeable
 Melasma; brown, clearly defined patches on the face

 Darkening of the nipples

 All these fade after delivery

• Stretch marks are caused by the overstretching of the elastic tissue in the skin as
the abdomen and breasts enlarge and the replacement of collagen by scar tissue
• They appear as a red bands or lines during pregnancy

• Usually fade afterwards to white or silvery colour

• They may never disappear completely

• Exercise during pregnancy may help prevent the development of stretch marks

• Vitamin E topical products, cocoa butter, collagen and elastin products can be
used
38• After pregnancy, tretinoin can be used in severe cases to remove scarring
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 Urinary Tract Infection
• Asymptomatic bacteriuria occurs in approximately 6% of pregnant women, and
up to 30% of them will go on to develop symptomatic urinary tract infection
(UTI)
• 40% of UTIs experienced during pregnancy progress to pyelonephritis
• Because of the increased risk for the development of pyelonephritis, the first
symptom of UTI may be fever
• Any woman presenting with unexplained fever in pregnancy should be screened
for UTI
• Two subgroups of women, those with sickle cell trait and diabetes, are
at increased risk for asymptomatic bacteriuria and should be screened
frequently for UTI during pregnancy
• Pathogens causing UTIs are unchanged in pregnancy; 80% of
infections involve Escherichia coli
Normal UTI avoidance measures;
• adequate fluids
39 • voiding after intercourse 02/20/2024
 ….
• Treatment should continue for 7-10 days because
of the mild immunosuppression associated with
pregnancy
• In an uncomplicated UTI, Fitzgerald recommended
considering treatment with nitrofurantoin
(category B)
• For treatment of pyelonephritis, treatment with
third-generation cephalosporins or amoxicillin
with clavulanate (Augmentin) was recommended
because of their coverage of gram-negative
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