DIAGNOSIS OF

PREGNANCY
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.
PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY

• 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.
 PRESUMPTIVE SIGNS AND
SYMPTOMS OF PREGNANCY
1. Amenorrhea (Cessation of
Menstruation).
▪ One of the earliest clues of pregnancy.
2. Nausea and Vomiting (Morning
Sickness).
(1)Usually occurs in early morning during
the first 2 weeks of pregnancy.
(2) Usually spontaneous and subsides in 6
to 8 weeks or by the twelfth to sixteenth
week of pregnancy.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
2. Nausea and Vomiting (Morning Sickness).
(3) 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.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
3. Frequent Urination.
(1) Frequent urination is caused by pressure
of the expanding uterus on the bladder.
(2) It subsides as pregnancy progresses and
the uterus rises out of the pelvic cavity.
(3) The uterus returns during the last weeks
of pregnancy as the head of the fetus
presses against the bladder.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
4. Breast Changes.
(1) In early pregnancy, changes start with a slight,
temporary enlargement of the breasts, causing
a sensation of weight, fullness, and mild
tingling.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
4. Breast Changes (continued…)
(2) As pregnancy continues the patient may notice:
(a) Darkening of the areola--the brown part around the
nipple.
(b) Enlargement of Montgomery glands--the tiny
nodules or sebaceous glands within the areola.
(c) Increased firmness or tenderness of the breasts.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
4. Breast Changes (continued…)
(d) More prominent and visible veins due to the
increased blood supply.

(e) 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.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
5. Vaginal Changes
(1) 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.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
6. Quickening (Feeling of Life).
(1) 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.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
7. Skin Changes.
(1) 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 hormones during
pregnancy, not just weight gain.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
7. Skin Changes.
(2) 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.
 PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY
7. Skin Changes.
(3) 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.
PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY

8. Fatigue.
▪ This is a common complaint by most patients
during the first trimester.
▪ 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.
PROBABLE SIGNS OF PREGNANCY

a. Uterine Changes.
(1) 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.
PROBABLE SIGNS OF PREGNANCY
a. Uterine Changes.
(2) Size.
▪ The uterine increases in width and
length approximately five times its
normal size. Its weight increases from 50
grams to 1,000 grams.
 PROBABLE SIGNS OF PREGNANCY

a. Uterine Changes.
(3) 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.
 PROBABLE SIGNS OF PREGNANCY
a. Uterine Changes.
(4) 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.
 PROBABLE SIGNS OF PREGNANCY

b. Cervical Changes.
(1) 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.
PROBABLE SIGNS OF PREGNANCY
b. Cervical Changes.
(2) 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.
PROBABLE SIGNS OF PREGNANCY
c. 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.
 PROBABLE SIGNS OF PREGNANCY
d. 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).
e. 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.
 POSITIVE SIGNS OF PREGNANCY
a. Fetal Heart Sounds.
▪ 5 weeks
❖ echocardiography can demonstrate a
heartbeat
▪ 6th to 7th week
❖ An ultrasound can reveal a beating fetal
heart
▪ 10th to 12th week of gestation.
❖ able to detect fetal heart sounds thru doppler
▪ 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.
POSITIVE SIGNS OF PREGNANCY
b. 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.
 POSITIVE SIGNS OF PREGNANCY
c. 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.
d. Palpation of Fetal Movement.
• This is done by a trained examiner. It is easily
elicited at 20th – 24th week of pregnancy.
 End of
Diagnosis 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
 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
Local Changes
 Uterine changes
 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.
 Cervical Changes
 Goodell’s sign
 Softening of the cervix
 The cervix of the uterus becomes more
vascular and edematous than usual causing it
to soften in consistency (due to estrogen)
 Operculum
 A mucus plug forms to seal out bacteria and
help prevent infection in the fetus and
membranes.
 Vaginal Changes
 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.
 Leukorrhea
 increase in the activity of the epithelial cells
 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.
 Ovarian Changes
 Cessation of ovulation
 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
 Changes in the Breasts
 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.
 Systemic Changes
A. Integumentary System
 Striae gravidarum
 Diastasis
 Rectus muscles separate
 Abdominal wall unable to withstand the tension
created by the enlarging uterus.
 Linea nigra
 Brown line from umbilicus to symphysis pubis
 Melasma – “ mask of pregnancy “
 Due to melanocyte-stimulating hormone
 Vascular spiders
 due to increase of estrogen
B. Respiratory Changes

 Congestion or “ Stuffiness “ of the nasopharynx

 Due to increased estrogen level

 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%
B. Respiratory Changes

 Mild hyperventilation
 to blow off excess CO2 being shifted to her by the fetus

 Temperature
 Slight increase due to progesterone
 C. Cardiovascular System
Assessment factor Prepregnancy Pregnancy
Cardiac output 25 – 50% increase
Heart rate (bpm) 70 – 80 bpm 80 – 90 bpm
Plasma volume 2,600 ml 3,600 ml
Blood volume 4,000 ml 5,250 ml
RBC mass 4.2 million/mm3 4.65 million/mm3
Leukocytes 7,000/mm3 20,500/mm3
Total protein 7 g/dl 5.5 – 6.0 g/dl
Fibrinogen 300 mg/dl 450 mg/dl
Bp Decreases in 2nd tri
At prepregnancy
level in 3rd trimester
C. Cardiovascular System
▪ 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.
C. Cardiovascular System
▪ 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. Cardiovascular System
▪ Increase in blood volume
▪ To provide for an adequate exchange of
nutrients in the placenta
▪ Pseudoanemia
▪ Plasma volume increase faster than RBC,
concentration of hemoglobin and
erythrocytes may decline.
C. Cardiovascular System
 Decreased Systemic Vascular Resistance due to:
 (1) vasodilation caused by the effects of
progesterone and prostaglandins;
 (2) the addition of the uteroplacental unit, which
provides low resistance and a greater area for
circulation;
 (3) fetal, maternal, and placental heat production,
which causes vasodilation;
C. Cardiovascular System
 Decreased Systemic Vascular Resistance due to:
 (4) decreased vascular sensitivity to angiotensin II;
and
 (5) endothelial prostacyclin and endothelial-derived
relaxant factors such as nitric oxide (Blackburn,
2013).
C. Cardiovascular System
▪ 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
C. Cardiovascular System
▪ Iron, Folic acid, Vitamin needs
▪ Lack of folic acid have been linked to
increased risk for neural tube disorder in
fetuses.
▪ Foods high in folic acid:
▪ Spinach, asparagus, legumes
C. Cardiovascular System
▪ 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
▪ Supine Hypotension Syndrome
▪ Weight of growing uterus presses the vena cava
against 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.
C. Cardiovascular System
 Increased fibrinogen (necessary for clotting)
 Due to increased estrogen
 Safeguard against major bleeding.
 Pre-pregnancy - 300 mg/dL
 Pregnancy - 450 g/dL
 Increased WBC
 Protective mechanism
 Reflection of the woman’s increased blood volume
 Protein level decreased
 Indicating amount of protein used by the fetus.
D. Gastrointestinal System

 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
 flatulence , constipation
 Slow emptying time of the stomach, slow intestinal peristalsis
 Due to relaxin and progesterone.
 nausea and vomiting
 due to:
 Increased hCG, estrogen and progesterone levels
 Decreased glucose levels (glucose being used by the
growing fetus) = FBS 95 mg/dL or lower
 Hyperptyalism
 increased in saliva formation
 A local response to increased levels of estrogen
 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.
 Hypertrophy of gumlines and bleeding of gingival
tissue when they brush their teeth.
E. Urinary System

 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.
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
E. Urinary System

 Ureter and Bladder function

 Due to progesterone during pregnancy, ureters
increase in diameter, bladder capacity increases to
1,500 ml
F. Skeletal System

▪ Gradual softening of pelvic ligaments and

joints due to:
▪ Ovarian hormone relaxin and placental
progesterone

▪ Lordosis (“pride of pregnancy”)

▪ Forward curve of the spine.
G. Endocrine System
▪ Placenta
▪ Estrogen
▪ (1) It stimulates uterine growth and increases
blood supply to uterine vessels;
▪ (2) it aids in developing the ductal system in
the breasts in preparation for lactation; and
▪ (3) 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.
▪ Causes palmar erythema (redness on palms)
G. Endocrine System
▪ Placenta
▪ Progesterone
 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
G. Endocrine System
▪ Placenta
▪ Progesterone
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
G. Endocrine System
▪ Placenta
▪ hCG
▪ Secreted by the trophoblast cells of the
placenta in early pregnancy
▪ 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).
G. Endocrine System
▪ Placenta
▪ hPL
▪ Antagonist to insulin which allows more glucose
to become available for fetal growth
▪ Relaxin
▪ Secreted primarily by corpus luteum
▪ Inhibit uterine activity
▪ Soften the cervix and collagen in joints
▪ Prostaglandins
▪ Affect smooth muscle contractility
▪ They may be the trigger that initiates labor at
term.
G. Endocrine System
▪ 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.
▪ Thyroid & Parathyroid
▪ Thyroid gland enlarges early in pregnancy
causing increased basal body metabolic rate
by 20%.
▪ Parathyroid glands necessary for calcium
metabolism.
G. Endocrine System
▪ 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.
▪ aldosterone aids in promoting sodium
reabsorption and maintaining osmolarity in the
amount of fluid retained.
G. Endocrine System
▪ 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
H. 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.