DIAGNOSIS OFPREGNANCY

AND MATERNAL
ASSESSMENT
PRESUMPTIVE SIGNS OF THE PREGNANCY
• Breast changes.
• Nausea and vomiting.
• Amenorrhoea.
• Frequent urination.
• Fatigue and uterine
enlargement.
• Quickening.
• Linea nigra.
• Melasma.
• Striae gravidarum
 PROBABLE SIGNS OF PREGNANCY

 Chadwick’s sign.
 Goodell’s sign.
 Hegar’s sign.
 Evidence on ultrasound of gestational
sac.
 Ballotment.
 Braxton’s hick contraction.
 Fetal outline felt by the examiner.
 POSITIVE SIGNS OF PREGNANCY

 Demonstration of a fetal heart

separate from the mother’s
heart.
 Fetal movements felt by an
examiner.
 Visualization of fetus by
ultrasound.
 FIRST TRIMESTER

 SUBJECTIVE SYMPTOMS:

 Amenorrhoea
 Morning sickness
 Frequency of micturition
 Breast discomfort
 Fatigue
 OBJECTIVE SIGNS

 Breast changes:
 Per abdomen
 Pelvic changes
 Jacquemer’s
sign 8th week
 Vaginal sign
 osiander’s sign
8th week
 Cervical signs
 Goodell’s sign
6th week
 Uterine signs

 Size shape and consisitency

 piscacek’s sign

 Hegar’s sign
between 6-10 weeks
 Palmer’s sign
as early as 4-8 weeks
 IMMUNOLOGICAL TESTS FOR THE
DIAGNOSIS OF PREGNANCY

 Agglutination inhibition tests:

 Direct agglutination test:

The sensitivity is 0.2 IU Hcg/ml.

 Enzyme-linked immunosorbent assay:

It is based on one monoclonal antibody that binds

the hCG in urine and serum. ELISA can detect hCG
in serum upto 1-2 mIU/ml and as early as 5 days
before the first missed period.
 Fluroimmuno assay:

the fluroscence emitted is proportional to the amount

of hCG. it can detect hCG as low as 1 Miu/ml. FIA
takes 2-3 hours.
 Immune assays with radioisotopes:
 Radioimmunoassay:

It is more sensitive and can detect β

subunit of hCG upto 0.002 IU/ml in the
serum. It can detect pregnancy as early as 8-
9 days after ovulation. It requires 3-4 hours
to perform.
 Immune-radiometric assay:

Uses sandwich principle to detect whole

hCG and require only 30 mts.
 SELECTION OF TIME:

by 8-11 days after conception. The test is not

reliable after 12 weeks
 ULTRASONOGRAPHY

 Intra decidual gestational sac -29

-35 days of gestation.
 Fetal viability and gestational age is determined
by detecting the following structures by
transvaginal ultrasonography.
 Gestational sac and yolk sac by 5 menustral
weeks.
 Fetal pole and cardiac activity- 6 weeks.

 Embryo movements by 7 weeks.

 Fetal gestational age is measuring the CRL

 the fetal heart reliably by 10 th week.

 SECOND TRIMESTER
 SYMPTOMS
 Quickening at 16 to 18 weeks
It denotes the perception of active fetal
movements by the women
 Progressive enlargement of the lower
abdomen
 GENERAL EXAMINATION
 Cloasma
Pigmentation over the forehead
and cheek may appear at about 24th
week.
 Breast changes:

 Breasts are more enlarged with prominent

veins under the skin.
 Secondary areola specially demarcated in
primigravidae, usually appears at about 20th
week.
 Montgomery’s tubercles are prominent and
extent to the secondary areola.
 Colustrum becomes thick and yellowish by 16th
week.
 Variable degree of striae may be visible with
advancing weeks
 ABDOMINAL EXAMINATION:
 Inspection:
linea nigra as early as 20th
week and Striae
 Palpation
 Fundal height
 the height of the uterus is midway between

the symphysis pubis and the umbilicus at 16th

week.
 At the level of umbilicus at 24th week.

 At the junction of the lower third and upper

two-third of the distance between the

umbilicus and ensiform cartilage at 28th week.
 ABDOMINAL EXAMINATION

 The uterus feels soft and elastic

 Braxton’s-Hicks contraction

 Palpation of fetal parts

 Active fetal movements

 External ballotment

 Auscultation:
 Fetal heart sound:

 Uterine souffle:

 Funic or fetal souffle:

 VAGINAL EXAMINATION:

 The bluish discolouration:

 Internal ballotment

INVESTIGATIONS:
 Sonography:

Routine sonography at 18-20 weeks permits a

dilated survey of fetal anatomy, placental
localization and the integrity of the cervical canal
 Fetal organ anatomy

 MRI
 LAST TRIMESTER
SYMPTOMS:
 Amenorrhoea persists.
 Enlargement of the abdomen

 Lightening

 Frequency of micturition

 Fetal movements

SIGNS:

Cutaneous changes
 Uterine shape: it is changed from

cylindrical to spherical beyond 36th week

 Fundal height
 The fundal height corresponds
to the junction of the upper and middle
third at 32 weeks.
 Upto the level of ensiform cartilage at
36th week.
 It comes down to the level of 32
weeks at 40th week because of the
engagement of the fetal head.
 To determine whether the uterus
height is correspond to 32 weeks or
40 weeks, engagement of the head
should be tested.
 Braxton’s-Hick contraction
 Fetal movements are easily felt

 Palpation of fetal parts

 FHS

 Sonography

Amniotic fluid
assessment is done to detect
oligohydramnios[AFI<5] or
polyhydramnios[AFI>25].
DIFFERENTIAL DIAGNOSIS OF
PREGNANCY

 Pseudocyesis

Cystic ovarian tumor and

fibroids
 Encysted peritonitis
 MATERNAL ASSESSMENT
aims of maternal assessment are:
 To identify the high risk cases.
 To prevent and detect and treat at the earliest
any complications.
 To ensure continued risk assessment and to
provide ongoing primary prevention health
care.
 To educate the mother about the physiology of
pregnancy, labour, newborn care and
lactation.
 To discuss with the couple about the place,
time, and the mode of delivery.
PROCEDURES AT THE FIRST VISIT

 The initial interview

 Demographic data
 Chief concern
 Family profile
 Present history
 Past history
 Obstetric history
 Menstrual history
 Gynaecological history
 Personal history
 Family history

PHYSICAL EXAMINATION
 Baseline height and weight
measurement
 Vital signs
 Head and scalp
 Eyes
 Nose
 Ears
 Mouth and oral cavity
 Neck

 Breasts

 Thorax

 Back

 Rectum

 Extremities and skin

ABDOMINAL EXAMINATION
 Preliminaries

 Inspection

 Palpation

 Height of the uterus

 Obstetric grips
 Auscultation
 The relationship of the fetus to the
uterus and pelvis
 Lie
 Presentation
 Attitude
 Denominator
 Position
 Presenting part
 PELVIC EXAMINATION
 External genetalia
 Internal genetalia
 Vaginal inspection
 Examination of pelvic organs
 Estimating pelvic size
 The diagonal conjugate

 The true conjugate

 The ischial tuberosity

 LABORATORY METHODS:
 BLOOD STUDIES:
 A complete blood count:

 Genetic screen

 Serologic test for syphyllis

 Blood typing

 Maternal serum alfa feta protein

 Indirect coomb’s test

 Antibody titres for rubella and hepatitis B

 HIV testing

 Glucose tolerance test

 URINALYSIS
 ULTRASONOGRAPHY
1ST TRIMESTER 2ND 3RD TRIMESTER
Confirm pregnancy Establish Confirm gestational age

or
Confirm viability confirm date Confirm viability
Determine gestational Confirm viability Detect macrosomia
age Detect Detect congenital
Rule out ectopic polyhydramnios, anomalies
pregnancy oligohy- dramnios Detect IUGR
Detect multiple Detect congenital Determine fetal position
gestation anomalies Detect placenta previa or
Use for visualization Detect IUGR abruptio placentae
during chori- onic Confirm placenta visualization during
villus sampling placement amnio- centesis, external
Detect maternal visualization version
abnormalities during amnio- Biophysical profile
centesis Amniotic fluid volume
Detect placental maturity
Components of Ultrasound Examination by Trimester
First Trimester
1. Gestational sac location
2. Embryo and/or yolk sac
identification 3. Crown-rump
length
4. Cardiac activity
5.Fetal number, including
amnionicity and chorionicity of
multiples when possible
6.Assessment of
embryonic/fetal anatomy
appropriate for the first
trimester 7. Evaluation of the
uterus, adnexa, and cul-de-sac
8. Assessment of the fetal
nuchal region if possible
Second and Third Trimester
1.Fetal number; multifetal
gestations: amnionicity, chorionicity,
fetal sizes, amnionic fluid volume,
and fetal genitalia, if visualized
2. Presentation
3. Fetal cardiac activity
4.Placental location and its
relationship to the internal cervical
os
5. Amnionic fluid volume
6. Gestational age
7. Fetal weight
8.Evaluation of the uterus, adnexa,
and cervix
9.Fetal anatomical survey,
including documentation of
technical limitations
 SONOGRAPHIC EVALUATIONS
 The standard
 specialized examinations
 limited examination
 Nuchal Translucency
 Fetal Biometry
 Gestational Age
 Amnionic Fluid
 Fetal weight
 Shepard’s formula:
 Log 10 EFW[gm]=1.2508+(0.166*BPD)
+0.046*AC)- (0.002646*AC*BPD).
 Hadlock’s formula:
 Log 10 EFW[gm]= 1.3596-
0.00386(AC*FL)+0.0064(AC)=0.00061
(BPD*AC)+0.0425(AC)
SPECIAL INVESTIGATIONS IN HIGH RISK
PREGNANCY
 Maternal serum alpha fetoprotein
 Triple test

 Acetyl choline esterase (AChE)

 Amniocentesis

 Chorionic villous sampling

 Fetal movement count

 Cordocentesis

 Vibroacoustic stimulation (VAS)

 Fetal biophysical profile (BPP)

 Modified biophysical profile

 Fetalcardiotocography (CTG)
 Doppler ultrasound velocimetry
 Placental grading
 Contraction stress test ( CST)
 Amniotic fluid volume assessment
(AFV)
 Amniocentesis in late pregnancy:
 Pulmonary maturity:
 Assessment of severity of Rh-
isoimmunisation
 Amnioscopy
 SIGNS INDICATING COMPLICATIONS OF
PREGNANCY

 Vaginal bleeding
 Persistent vomiting
 Chills and fever
 Sudden escape of clear fluid from
vagina
 Abdominal or chest pain
 Increase or decrease in fetal
movement
 MINOR AILMENTS DURING
PREGNANCY
 Morning sickness
 Heartburn
 Varicose veins
 Backache
 Breathlessness
 Palpitations
 Vaginal discharge
 Constipation