Diagnosis of Pregnancy and Prenatal

Care During the First Trimester

Jose Augusto L. Genio , MD, FPOGS, FPSUOG

San Beda College of Medicine
 Presumptive Evidence of
Pregnancy
◼ PRESUMPTIVE SYMPTOMS :
▪Nausea with or without vomiting
▪Disturbances in urination
▪Fatigue
▪Perception of Fetal Movement
▪Breast tenderness
 Nausea and Vomiting
◼ Experienced by ~ 50 % of pregnant pxs
◼ Onset at 6 weeks and peaks at about 60-70 days
◼ Peculiar distaste for food and food idiosyncrasies
◼ “Morning sickness”
◼ Emotional tension may be contributory
◼ Hyperemesis gravidarum : extreme nausea and vomiting
sometimes associated with hyperplacentosis and molar
pregnancies
◼ Mgt : small frequent feedings , avoidance of fatty food , ice
chips , emotional support . Hospitalization for dehydration
and correction of electrolyte problems.
 Disturbances in Urination
◼ Caused by direct
pressure by the
enlarging uterus on the
urinary bladder
◼ Irritability , frequency ,
nocturia , and UTI
◼ Most marked during
the 2nd and 3rd month
and near term
 Fatigue
◼ First few weeks of
pregnancy
◼ Due to increased
metabolic rate
 Perception of Fetal Movement
◼ “Quickening”
◼ Primigravidas : 18th to
20th week AOG
◼ Multigravidas : 14th -16th
week AOG
Breast Symptoms
◼ Breast tenderness or
mastodynia
◼ Tingling to frank pain during
the first few weeks of
gestation
◼ Tightness or heavyness due
to engorgement
◼ Due to estrogenic
stimulation of mammary
duct system and
progesterone stimulation of
alveolar components
◼ PRESUMPTIVE SIGNS :
▪Cessation of menses
▪Anatomical breast changes
▪Changes in the vaginal mucosa
▪Skin pigmentation changes
▪Thermal signs
 Cessation of menses
◼ Delay of 10 or more days
◼ Not a reliable indicator
◼ Other causes :
▪ Irregular cycles
▪ Emotional stress
▪ Chronic disease
▪ Endocrine disorders
▪ Lactation
▪ Genitourinary tumors
◼ Uterine bleeding may occur in 25% of
pregnancies : “ Implantation bleeding”
 Anatomical Breast Changes
◼ Enlargement and
engorgement
◼ 6-8 weeks after
conception
◼ Areola becomes darker
◼ Montgomery’s glands
become prominent
◼ Increased erectability of
nipples
◼ Colostrum may be
expressed early at 16th
week AOG
 Changes in Vaginal Mucosa
◼ Chadwick’s sign
◼ 6th week AOG
◼ Vaginal mucosa
becomes congested ,
violaceous and bluish or
purplish in color
 Skin Pigmentation Changes
◼ Chloasma
◼ “ Mask of pregnancy”
 Skin Pigmentation Changes
◼ Linea Negra

◼ Caused by increase in
melanocyte stimulating
hormone

◼ May cause darkening of

areola , nipples , axilla ,
neck , and groin
 Skin Pigmentation Changes
◼ Striae gravidarum

◼ Separation of
underlying collagen
tissue
 Thermal signs

◼ Elevation of body temperature for > 3 weeks

◼ BBT rises ~0.3 – 0.5 C over temp during the
follicular phase
Probable Evidence of Pregnancy

◼ Enlargement of the abdomen

◼ Changes in the size , shape , consistency of
the uterus
◼ Anatomical changes in the cervix
◼ Braxton-Hicks contraction
◼ Ballotement
◼ Physical outlining of the fetus
◼ Positive HCG test
 Enlargement of the Abdomen

◼ Progressive
enlargement from 6
weeks AOG - term
Changes in Uterine Shape , Size , and
Consistency
◼ Hegar’s sign
◼ Softening of the uterine
isthmus
◼ 6-8 weeks AOG
Changes in Uterine Shape , Size , and
Consistency
◼ Goodell’s sign
◼ Cyanosis and softening of the cervix
◼ 4 weeks AOG
 Changes in the cervix

◼ Softening of the cervix : same consistency as

your lips
◼ Non-pregnant state : same consistency as
your nasal cartilage
◼ Cervical mucus :
▪ “beaded” pattern during pregnancy
▪ “Ferning “ pattern during non-pregnant state
 Cervical Mucus
NON-PREGNANT : PREGNANT :
FERNING PATTERN BEADED PATTERN
 Ballotement

◼ 20th week
◼ Sensation by an examiner that something is
floating / bouncing inside when moving the
abdomen from side to side
 Outlining the fetus
◼ Examiner is able to feel
the fetal parts

◼ Huge masses like

myomas or ovarian
tumors may be
mistaken for the fetal
head.
 Endocrine tests
◼ Beta HCG

◼ Can be detected in serum

and urine as early as 8-9
days after missed menses

◼ Pregtest : depends on
sensitivity
▪ <5 miU/ml : negative
▪ 5-24 miU/ml : equivocal
▪ >25 miU/ml : positive
 Positive Signs of Pregnancy

◼ Presence of Fetal heart tones separately and

distinctly from the mother
◼ Perception of fetal movement by an
independent examiner
◼ Ultrasound or radiographic documentation
1st Trimester Ultrasound

6 WEEKS 12 WEEKS
 Pseudocyesis
◼ Imaginary or spurious
pregnancy
◼ Menopausal
◼ Strongly desirous of
pregnancy
◼ Px actually feels signs
and symptoms of
pregnancy
 Prenatal Care during the First
Trimester
◼ Major Goals :
▪ Define the health status of the mother and fetus
▪ Estimate the gestational age
▪ Initiate a plan for continuing obstetrical care
 Definitions
◼ Nulligravida: a woman who currently is not pregnant,
nor has she ever been pregnant.
◼ Gravida: a woman who currently is pregnant or she
has been in the past, irrespective of the pregnancy
outcome. With the establishment of the first
pregnancy, she becomes a primigravida, and with
successive pregnancies, a multigravida.
◼ Nullipara: a woman who has never completed a
pregnancy beyond 20 weeks' gestation. She may or
may not have been pregnant or may have had a
spontaneous or elective abortion(s) or an ectopic
pregnancy.
 Definitions
◼ Primipara: a woman who has been delivered only
once of a fetus or fetuses born alive or dead with
an estimated length of gestation of 20 or more
weeks.
◼ Multipara: a woman who has completed two or
more pregnancies to 20 weeks or more. Parity is
determined by the number of pregnancies
reaching 20 weeks and not by the number of
fetuses delivered. Parity is the same (para 1) for a
singleton or multifetal delivery or delivery of a live
or stillborn infant.
 Obstetrical Score

◼ G_P_ (FPAL)
▪ G=total number of pregnancies
▪ P=total number of births
▪ F = full term births
▪ P= preterm births
▪ A = abortion (less than 20 weeks)
▪ L = living children
 Practice

◼ Ob Hx :
▪ 5 full term births ; all currently alive
▪ 1 premature birth ; baby died after 2 days
▪ 2 miscarriages

What is the OB score ?

Answer : G8P6 (5125)
 Practice
◼ OB Hx :
▪ 1st pregnancy = full term live birth
▪ 2nd pregnancy = ectopic pregnancy
▪ 3rd pregnancy = full term live birth
▪ 4th pregnancy = abortion
▪ 5th pregnancy = currently at 12 weeks AOG

What is the OB score ?

Answer : G5P2 (2022)
 Estimation of the AOG
◼ Naegele’s rule
▪ LMP = Month , Day , Year
▪ EDD = -3 , +7 , Year
▪ AOG in weeks = count total number of days from Day 1 of
LMP and divide by 7

◼ Timing from ovulation

▪ EDD = + 267 days from ovulation date

◼ Quickening
▪ 16-18 weeks in multipara
▪ 18-20 weeks in primigravida
 Practice

◼ LMP = April 21 , 2022

Calculate AOG and EDD ?

As of 11/14/2022
◼ AOG = 29 weeks and 4 days
◼ EDD =January 28 , 2023
 Estimation of the AOG
◼ Fundic height
◼ Above symphysis pubis
at 12 weeks
◼ Between symphysis
pubis and umbilicus at
16 weeks
◼ Level of umbilicus = 20
weeks
◼ Linear correlation in
cms from 16 weeks to
32 weeks
 Ultrasound
◼ TVS can detect a
pregnancy at 4-5 weeks
AOG

◼ Accuracy = +/- 3 to 5
days using Crown-
Rump length (CRL)

◼ Most accurate at 7-9

weeks AOG
 Trimesters

◼ 1st trimester : up to 14 weeks

◼ 2 trimester : through 28 weeks

nd

◼ 3rd trimester : up to 42 weeks

 History
◼ Same as other medical history but with more detailed
information concerning past obstetrical history is crucial
because many prior pregnancy complications tend to
recur in subsequent pregnancies

◼ Menstrual history is extremely important

▪ Without a history of regular, predictable, cyclic, spontaneous
menses that suggest ovulatory cycles, accurate dating of
pregnancy by history and physical examination is difficult

◼ Contraceptive history
 Psychosocial Screening
◼ Non-biomedical factors that affect mental and physical well-
being
◼ Done at least once each trimester
◼ Goal : identify important issues and reducing adverse
pregnancy outcomes.
◼ Screening for barriers to care includes lack of transportation,
child care, or family support; unstable housing; unintended
pregnancy; communication barriers; nutritional problems;
cigarette smoking; substance abuse; depression; and safety
concerns that include domestic violence
 Cigarette Smoking

◼ twofold risk of placenta previa, placental

abruption, and premature membrane rupture

◼ Increase incidence of low birthweight ,

abortion , fetal death , limb anomalies and
sudden infant death syndrome (SIDS)

◼ Use of nicotine patch is allowed during

pregnancy
 Illicit Drug Use
◼ Agents may include heroin and other opiates,
cocaine, amphetamines, barbiturates, and
marijuana.

◼ Chronic use of large quantities is harmful to

the fetus

◼ sequelae include fetal distress, low

birthweight, and drug withdrawal soon after
birth
 Domestic Violence Screening

◼ Violence against adolescent and adult

females within the context of family or
intimate relationships

◼ prevalence rate : 4 - 8 %

◼ increased risk of a preterm delivery, fetal-

growth restriction, and perinatal death
 Pelvic Examination during the 1st
trimester
◼ Internal Examination :
▪ Determine the absence
or presence of uterine or
adnexal pathology
◼ Speculum exam :
▪ Inspect character of any
vaginal discharge
▪ Collect specimen for culture
or gram staining
▪ Pap smear : routine
cervical cancer screening
 Prenatal Visits
◼ Traditionally :
▪ Every 4 weeks until 28 weeks then
▪ Every 2 weeks until 36 weeks then
▪ Every week until delivery

◼ WHO :4 visits
▪ 1st visit by end of 4th month
▪ 2nd visit by end of 6th or 7th month
▪ 3rd visit by the end of 8th month
▪ 4th visit at 9 months
Routine Antepartal Tests during the 1st
trimester
◼ Complete Blood Count and blood typing
▪ Hematologic status
▪ Rule out anemia
▪ Rh status
▪ Risk of isoimmunization

◼ Urinalysis
▪ Evaluate for UTI and renal function
Routine Antepartal Tests during the 1st
trimester
◼ Serologic test for Syphillis (RPR/VDRL)
▪ Detect previous/current infection
▪ If (+) : request for FTA-ABS or MHA-TP

◼ Hepatitis B surface Antigen (HbsAg) and

Antibody (Anti –HbS)
▪ Detect carrier status or active disease
▪ If HbsAg reactive : do complete Hep profile and liver
function tests
▪ If anti-Hbs non-reactive : vaccinate
Routine Antepartal Tests during the 1st
trimester
◼ Rubella titer
▪ ~85% of patients have evidence of prior infection
▪ If seronegative : advice special precaution to avoid
infection ; vaccinate POSTPARTUM only

◼ Pap smear
▪ Screen for CIN / cervical cancer
 Other Antepartal Tests : depends on
History and PE
◼ Culture of cervical discharge
▪ Neiserria gonorrhea and Chlamydia trachomatis
▪ Risk of preterm labor , neonatal infection , and
postpartum endometritis

◼ Hemoglobin electrophoresis
▪ Detect sickle cell disease , thalasemia

◼ HIV titer : for high risk pxs

Other Antepartal Tests : depends on
History and PE
 Ultrasound
◼ Routine ultrasound
screening generally not
recommended
◼ Indications :
▪ Presence of vaginal bleeding
▪ Discrepancy between uterine
size and menstrual dates
▪ Absent fetal heart tones by
Doppler by 10 weeks
▪ Pelvic pain
▪ Previous infertility / pregnancy
losses
▪ Previous fetal congenital
anomalies
Recommendations For Weight gain
during Pregnancy
 Caloric intake

◼ pregnancy requires an additional 80,000 kcal

—most are accumulated in the last 20 weeks

◼ caloric increase of 100 to 300 kcal per day is

recommended during pregnancy (AAP and
ACOG 2007)
 RDA during Pregnancy (ACOG 2007)

◼ Protein
▪ 71 gms
▪ Ideally should come from
animal resources (meat ,
dairy , eggs, poultry
except fish due to
mercury toxicity)
◼ Carbohydrates
▪ 175 gms
◼ Fiber
▪ 28 gms
 Minerals

◼ Iron

◼ The WHO currently recommends preventive

iron supplementation at a dose of 30-60 mg
elemental iron per day plus 0.4 mg (400 ug)
per day of Folic acid as part of antenatal care
of pregnant women .
 Vitamins
◼ Folic Acid
▪ Pxs with previous hx of
birth to a child with
neural tube defects
should take 4 mg/ day
one month prior to
conception and throught
1st trimester
▪ 70% decrease in 2-5%
recurrence risk
 Common Concerns
◼ Employment
▪ any occupation that subjects the pregnant woman to
severe physical strain should be avoided

◼ Exercise
▪ In general, pregnant women do not need to limit
exercise, provided they do not become excessively
fatigued or risk injury

◼ Sex
▪ Generally permitted as long as there is no undiagnosed
vaginal bleeding or threatened abortion
Absolute and Relative Contraindications to
Aerobic Exercise during Pregnancy
◼ Absolute Contraindications
▪ Hemodynamically significant heart disease
▪ Restrictive lung disease
▪ Incompetent cervix/cerclage
▪ Multifetal gestation at risk for preterm labor
▪ Persistent second- or third-trimester bleeding
▪ Placenta previa after 26 weeks
▪ Preterm labor during the current pregnancy
▪ Ruptured membranes
▪ Preeclampsia/pregnancy-induced hypertension
Absolute and Relative Contraindications to
Aerobic Exercise during Pregnancy
◼ Relative Contraindications
▪ Severe anemia
▪ Unevaluated maternal cardiac arrhythmia
▪ Chronic bronchitis
▪ Poorly controlled type 1 diabetes
▪ Extreme morbid obesity
▪ Extreme underweight (BMI <12)
▪ History of extremely sedentary lifestyle
▪ Fetal-growth restriction in current pregnancy
▪ Poorly controlled hypertension
▪ Orthopedic limitations
▪ Poorly controlled seizure disorder
▪ Poorly controlled hyperthyroidism
▪ Heavy smoker
Immunizations during Pregnancy
 Caffeine

The American College of Obstetricians and

Gynecologists (ACOG) recommends that
pregnant women limit their caffeine
consumption to less than 200 mg (about
two, six-ounce cups) per day.

The recommendations are based on

studies that suggest potential associations
with pregnancy loss and fetal growth at
higher caffeine levels.

However, there remains limited data on the

link between caffeine and maternal health
outcomes
End of Lecture
Thank You