Fertility

Things to ask.
• Age
Menstruation History
• Last Menstrual Period – first day of the last menstrual flow
• Menstrual cycle – (28 days cycle or 35 days cycle) from the first day of menstrual flow to the first day of the next
menstrual flow
• MIDAS acronym in history taking
• M – age of MENARCHE (first menstrual period)
• I – Interval of menstrual cycle (regular or irregular)
• D – Duration of Menstruation (5 days – 9 days)
• A – Amount (number of pads used per day)
• S – Symptoms felt during menstruation (dysmenorrhea)
 Things to ask.
Sexual History
• Age of first coitus (sexual intercourse)
• Current/Past sexual partner
• Number of sexual partner
• Sexual Preference (ex. homosexual, bisexual)
• Date of last sexual activity
• Contraceptive used
• Medical history of STI or pregnancy
Fertilization and Implantation
 PREGNANCY
SIGNS OF PREGNANCY
 SIGNS OF PREGNANCY
1. PRESUMPTIVE SIGNS

2. PROBABLE SIGNS

3. POSITIVE SIGNS
 PRESUMPTIVE SIGNS

The subjective signs the mother experiences

during pregnancy.
Presumptive signs

• Presumptive symptoms are those

which, when taken as single
entities, could easily indicate other
conditions

• Experienced by the woman but

cannot be documented by an
examiner
1. AMENORRHEA
- Absence of menses
- usually the first sign a woman notices that may cause
her to think she is pregnant
Other Causes:
hormone imbalance, stress, menopause or tumors
2. NAUSEA AND VOMITING

- Usually occur in the morning, but could occur anytime.

- Sometimes called as “ MORNING SICKNESS”
- Usually experienced during early pregnancy
3. BREAST CHANGES

- tenderness, tingling, enlargement of the breast

- Occur in early pregnancy
- Many women also experience these changes with the monthly
period
4. URINARY FREQUENCY

- Occurs because of the enlarging uterus presses on the bladder,

giving the woman the feeling of needing to urinate often.
- Other disorders:
Urinary infection
Abdominal tumor
5. FATIGUE

- Is most often noted in the first few months of pregnancy

6. ABDOMINAL ENLARGEMENT

- Is noted by the 12th weeks but may be earlier in the very thin
women or later in the large woman
7. QUICKENING

- Is a fluttering sensation felt as the fetus moves . The sensation

begins at 16 to 20 weeks and gradually becomes stronger and
more frequent
 PROBABLE SIGNS

Objective signs that could indicate

pregnancy
 Probable signs
• Objective and so can be verified by an
examiner.

• More reliable than presumptive

symptoms, they still do not positively
diagnosis a pregnancy
 Laboratory test

• Use of a venipuncture or a urine specimen to detect the presence of human chorionic gonadotropin (hCG), a
hormone created by the chorionic villi of the placenta, in the urine or blood serum of the pregnant woman

• Because these tests are only accurate 95% to 98% of the time, positive results from these tests are considered
probable rather than positive signs

• In the pregnant woman, trace amounts of hCG appear in her serum as early as 24 to 48 hours after
implantation and reach a measurable level (about 50 milli-International Unit/ml 7 to 9 days after
conception.

• Levels peak at about 100 milli-International Unit/ml between the 60th and 80th day of gestation. After
that point, the concentration of hCG declines again so, at term, it is again barely detectable in serum or urine.
 Home pregnancy test
Best time to conduct pregnancy test is 2 weeks after a delayed menses.

• Take only 2 to 3 minutes to complete, and have a high degree of accuracy (97% to 99%) if the instructions are followed
exactly because they can detect as little as 35 milliInternational Unit/ml of hCG

• A concentrated urine sample such as a first urine in the morning tests best. Don’t drink a large quantity of water
beforehand because this can dilute a urine sample

• Most manufacturers suggest a woman wait until at least the day of the missed menstrual period to test. If a woman thinks
she is pregnant but gets a negative result, she could repeat the test 1 week later if she still has not had a menstrual flow.

• If symptoms of pregnancy persist after two tests, she needs to see her healthcare provider as she might have another
condition causing the amenorrhea; she would need appropriate diagnosis and therapy for this.
1.POSITIVE PREGNANCY TEST

- Pregnancy tests screen for the presence of hCG in the urine or

blood.
- A test may be positive 8 to 14 days after conception
2. BALLOTEMENT

-
Is the test for pregnancy in which the examiner puts two fingers
into the vagina and pushes upward on the uterus. If the woman is
pregnant, the fetus will rebound against the fingers.
3. UTERINE CHANGES
-Physical signs that can be
checked to assess the
probability of pregnancy:
• HEGARS SIGN-
a softening of the lower
uterine segment
• GOODELL’S SIGN-
A softening of the cervix
• CHADWICK’S SIGN
- A bluish purple discoloration
of the cervix and vagina
 POSITIVE SIGNS OF PREGNANCY

- Diagnostic of pregnancy
- No other condition can cause this sign
 Positive signs of Pregnancy
• There are only three documented or positive signs of pregnancy:
1. Demonstration of a fetal heart separate from the mother’s
• Ordinary stethoscope - 18 to 20 weeks of pregnancy,
• An echocardiography can demonstrate a heartbeat as early as 5 weeks.
• An ultrasound can reveal a beating fetal heart as early as the 6 th to 7th week of pregnancy.
• Doppler instrumentation detect fetal heart sounds as early as the 10th to 12th week of gestation.
• 2. Fetal movements felt by an examiner
• Fetal movements may be felt by a woman as early as 16 to 20 weeks of pregnancy.
• An objective examiner can discern fetal movements at about the 20th to 24th week of pregnancy unless the woman is extremely obese.

• 3. Visualization of the fetus by ultrasound

• If a woman is pregnant, a characteristic ring, indicating the gestational sac, will be revealed on an oscilloscope screen as early as the 4th to 6th
week of pregnancy.
• By the 8th week, a fetal outline can be seen so clearly that the crown-to-rump length can be measured to establish the gestational age of the
pregnancy
1. FETAL HEART TONES (FHT)

- The normal fetal heart rate is 120-160 bpm

- UTERINE SOUFFLE- the sound occurring at the same rate as the
maternal pulse, is caused by increased maternal blood flow to the uterus.
- FUNIC SOUFFLE- the sound occurring at the FHR, is caused by fetal
blood flowing through the umbilical cord.
2. ULTRASOUND (UTZ)

- Visualization of the fetus

 ABDOMINAL UTZ- detect
pregnancy by 6th weeks
 TRANSVAGIVAL UTZ- can
detect a trophoblast by the 10th
days after conception.
 MATERNAL
CHANGES DURING
PREGNANCY
 Uterine Changes
Over the 10 lunar months of pregnancy, the uterus increases in length, depth, width, weight, wall thickness, and volume.
•
• Length grows from approximately 6.5 cm to 32 cm. •
• Depth increases from 2.5 cm to 22 cm. •
• Width expands from 4 cm to 24 cm. •
• Weight increases from 50 g to 1,000 g. •
• Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the end of pregnancy, the wall
thins to become supple and only about 0.5- cm thick. •
• The volume of the uterus increases from about 2 ml to more than 1,000 ml.
• This makes it possible for a uterus to hold a 7-lb (3,175-g) fetus plus 1,000 ml of amniotic fluid for a total of about
4,000 g.
 Uterine Changes
• By the end of the 12th week of pregnancy, the
uterus is large enough that it can be palpated as
a firm globe under the abdominal wall, just
above the symphysis pubis.
• By the 20th or 22nd week of pregnancy, it
typically reaches the level of the umbilicus.
• By the 36th week, it usually touches the xiphoid
process and can make breathing difficult.
• About 2 weeks before term (the 38th week) for a
primigravida, a woman in her first pregnancy,
the fetal head settles into the pelvis and the
uterus returns to the height it was at 36 weeks.
 Uterine Changes
• This settling of the fetus into the midpelvis is termed lightening
because a woman’s breathing is so much easier that she feels as
if her load is lightened. The point at which lightening will occur
is not predictable in a multipara (a woman who has more
children). In such women, it may not occur until labor begins
• Uterine height is measured from the top of the symphysis
pubis to over the top of the uterine fundus
• The exact shape of the expanding uterus can be influenced by
the position of the fetus. As the uterus grows larger, it pushes
the intestines to the sides of the abdomen, elevates the
diaphragm and liver, compresses the stomach, and puts pressure
on the bladder. It usually remains in the midline during
pregnancy, although it may be pushed slightly to the right side
because of the larger bulk of the sigmoid colon on the left.
 Uterine Changes
• Becomes so soft when it is
compressed between
examining fingers on
bimanual examination that
the wall feels as thin as
tissue paper. This extreme
softening of the lower
uterine segment is known as
Hegar’s sign
 Uterine Changes
• During the 16th to 20th week of pregnancy, when the fetus is still small in relation to the amount of
amniotic fluid present, if the lower uterine segment is tapped sharply during a pelvic exam, the fetus
can be felt to bounce or rise in the amniotic fluid up against a hand placed on the abdomen.
• This phenomenon, termed ballottement (from the French word ballotter, meaning “to quake”)
• “practice” contractions, termed Braxton Hicks contractions, serve as warm up exercises for labor
and also play a role in ensuring the placenta receives adequate blood. They may become so strong
in the last month of pregnancy that a woman mistakes them for labor contractions (i.e., false labor).
• One way they can be differentiated from true contractions is that true contractions cause cervical
dilation, and Braxton Hicks contractions do not
 Breast Changes
• By the 16th week, colostrum—the thin, watery,
high-protein fluid that is the precursor of breast
milk—can be expelled from the nipples. As
vascularity of the breasts increases, blue veins
may become prominent over the surface of the
breasts. The sebaceous glands of the areola
(Montgomery’s tubercles), which keep the
nipple supple and help to prevent nipples from
cracking and drying during lactation, enlarge
and become protuberant.
Systemic Changes
 Systemic Changes
Immune system - Immunoglobulin G (IgG) production is
particularly decreased, which can make a woman more prone to
infection during pregnancy. A simultaneous increase in the white
blood cell count may help to counteract this decrease in the IgG
response.
Integumentary - stretching (plus possibly increased adrenal
cortex activity) can cause rupture and atrophy of small segments
of the connective layer of the skin, leading to streaks (striae
gravidarum) on the sides of the abdominal wall and sometimes
on the thighs. During the months after birth, striae gravidarum
lighten to a silvery color (striae albicantes or atrophicae), and,
although permanent, they become barely noticeable.
 Systemic Changes
• Respiratory system - A local change that often occurs in the respiratory
system is marked congestion, or “stuffiness,” of the nasopharynx, a
response, again, to increased estrogen levels.
• Musculoskeletal system - As pregnancy advances, a gradual softening of
a woman’s pelvic ligaments and joints occurs to create pliability and to
facilitate passage of the baby through the pelvis at birth. This softening is
probably caused by the influence of both the ovarian hormone relaxin and
placental progesterone
Systemic Changes
Systemic Changes
Systemic Changes
 Systemic Changes
• Metabolic Changes - Metabolism accelerates 20% during pregnancy
• average weight gain during pregnancy is 25 to 35 lb, which is composed of:
a. fetus – 7.5 lb
b. placenta and membrane – 1.5 lb
c. amniotic fluid – 2 lb
d. uterus – 2.5 lb
e. breasts – 3 lb
f. increased blood volume – 2 to 4 lb
g. extravascular fluid and fat – 5 to 10 lb