Pregnancy: Overview and Diagnosis.

Diagnoses of pregnancy :
Pregnancy is a physiological state. The importance
of the correct diagnosis of pregnancy is essential.
For physicians the medical management of
reproductive age , knowledge of the existence of
pregnancy is vital, to make proper diagnosis and
treatment of all disease processes. The physiological
changes of pregnancy are easily recognized. The
diagnosis of pregnancy is ordinarily easy to establish .
Pharmacological or pathophysiolgical processes may
cause endocrine or anatomical changes.
 Sometimes mistakes in diagnosis happens in the
first several weeks while the uterus a still a pelvic
organ. It is possible to mistake the enlarged uterus of
pregnancy even at term.
The endocrinological, physiological and anatomical
alterations gives symptoms and signs that provide
evidence that pregnancy exists.
These symptoms and signs are classified into 3 groups:
presumptive evidence
probable signs
positive signs of pregnancy.
 Presumptive Evidence of Pregnancy:
Presumptive evidence of pregnancy is based on
subjective symptoms and signs include:
-nausea with or without vomiting;
-disturbances in urination;
-fatigue and the perception of fetal movement.
The presumptive signs of pregnancy include: cessation
of menses
anatomical changes in the breasts
discoloration of the vaginal mucosa
increased skin pigmentation
development of abdominal striae .
 Symptoms of pregnancy:
Pregnancy is commonly characterized by
disturbances of the digestive system , manifested by
nausea with or without vomiting . The morning
sickness of pregnancy commences during the early
part of the day but passes off shortly. However it
persists longer and may occur at other times too. This
symptoms appears about 6 weeks after the
commencement of last menstrual period and
ordinarily disappears spontaneously 6-12 weeks later.
During the first trimester of pregnancy, the enlarging
uterus by exerting pressure on the urinary bladder
may cause frequent micturition.
The frequent urination diminishes as pregnancy
progresses and the uterus rises up on the abdomen.
Frequent urination reappears to the end of
pregnancy when the fetal head descends into the
maternal pelvis, impinging upon the volume capacity
of the bladder.
Sometime between 18 and 20 weeks (menstrual age)
gestation , the pregnant woman becomed conscious
of light fluttering movements in the abdomen. These
movements gradually increase in intensity. These
sensations are caused by fetal movements. The time
these are first recognized is designated as quickening
or the perception of life.
 Signs of pregnancy: [Cessation of menses ]
 In a healthy women who has experienced spontaneous, cyclic,
predictable menstruation, the abrupt cessation of menses is
highly suggestive. There is variation in the length of the ovarian
cycle among women. It is not until 10 days or more after the time of
expected onset of the menstrual period. The absence of menses is
a reliable indication of pregnancy. When a second menstrual
period is missed the probability of pregnancy is high.
 Cessation of menstruation is an early indication of pregnancy.
Gestation may begin without prior menstruation in a girl in whom
menarche has not occurred.
Nursing mothers who do not menstruate during lactation
sometimes ovulate and conceive.
Rarely women who believe they recently passed the menopause will
ovulate again and may become pregnant.
Uterine bleeding somewhat suggestive of menstruation, occurs
occasionally after conception.
During the first half of pregnancy, one or two episodes
of bloody discharge as menstruation are not
uncommon and such bleeding is brief and scant.
Bleeding during pregnancy is three times more frequent
among multiparas that primigravidas.
Some women menstruated every month throughout
pregnancy that is undoubtedly the result of abnormality
of the reproductive organs. Bleeding per vagina at any time
during pregnancy must be regarded as abnormal and
portends likelihood of serious pregnancy complications.
Cessation or absence of menstruation can be caused by
other conditions like: anovulation , emotional disorders,
fear of pregnancy , variety of chronic decease processes etc.
 Generally the anatomical changes in the breast that
accompany pregnancy are characteristic in primiparas. They
are less obvious in multiparas whose breasts may contain a
small amount of milky material.
Changes in the breast similar to those women with prolactin-
secreting pituitary tumors and in ones taking drugs induce
hyperprolactinemia.
During pregnancy the vaginal mucosa frequently appears
dark bluish or purplish-red and congested which is the
Chadwick sign.
Increased skin pigmentation and appearance of abdominal
striae are common but not diagnostic of pregnancy. These
signs may be absent during pregnancy , conversely.
These signs may be associated with the ingestion of estrogen-
progestin contraceptives.
 Probable Evidence of Pregnancy:
The probable signs of pregnancy include : enlargement of
the abdomen, changes in the shape, size and consistency
of the uterine, anatomical changes in the cervix, Braxton
Hicks contraction( sporadic contractions and relaxation
of the uterine muscle), ballottement, physical outlining
of the fetus and positive results of endocrine tests for the
presence of hCG in urine or cerum.
Endocrine Tests of Pregnancy.
The presence of chorionic gonadotropin (hCG) in
maternal plasma and its excretion in urine provides the
basis for the endocrine tests for pregnancy.
This hormone can be identified in body fluids of
immunoassay or bioassay techniques.
 Detection of Chorionic Gonadotropin:
One constituent of the fetal-induced maternal
recognition of pregnancy system arises in the
production of the glycoprotein hormone , hCG. The
production of hCG by fetal trophoblast is important
because hCG acts to rescue the corpus luteum, the
principal site of progesterone formation in the first 6-
8 weeks of pregnancy by preventing its involution.
The detection of hCG in biological fluids in urine or
serum of the woman is tasted by the most common
test of pregnancy.
 Levels of hCG in pregnancy:
hCG is produces in placenta exclusively by
syncytiotrophoblast , not by cytotrophoblasts. The
synthesis of hCG constitutes an important function
of the differentiated trophoblast. The production of
hCG in trophoblasts begins in very early pregnancy,
almost certainly on the day of implantation. The
levels of hCG in maternal plasma and urine rise very
rapidly. With a sensitive test as a radioimmunoassay
using antibodies directed against the β-subunit of
hCG, pregnancy hormone can be demonstrated in
maternal plasma or urine by 8-9 days after ovulation.
The levels of hCG in blood and urine increase from
the day of implantation until about 60-70 days of
pregnancy. The concentration of hCG declines slowly
until a nadir is reached at about 100-130 days of
pregnancy. The hCG level in urine closely parallel to
levels in serum; peak level are attained if the
amount of hCG contained in 1 liter of maternal plasma
is equivalent to that contained in 24 hour of urine. If
the urine excreted per 24 hours were 1 liter, the
concentration of hCG in serim and in urine would be
similar.
 Pregnancy tests:
When radio-receptor assays are common, as are
radioenzumatic asseys and the use of monoclonal
antibodies we used bioassays for the detection and
quantification of hCG in biological fluids for nearly 4
decades. Was necessary to establish the general
principles of immunoassay before these could be
applied to the measurement of hCG as a means of
sensitive and accurate testing for pregnancy. It is
impressive to recall several of the bioassays for hCG,
especially in the development of ovarian hyperemia in
the immature rat was used as the end-point were
insensitive, remarkably accurate by 4-5 weeks after
ovulation or of the second missed menses.
 This attests to the specific bioaction of hCG and the
amount of glycoprotein produced in pregnancy.
Nowadays there are inexpensive kits available. They
can be used for pregnancy testing and be completed
in 3-5 minutes or less with high accuracy. The
chemical detection of pregnancy involves the
demonstration of hCG in blood or urine to be tested.
Many different test systems are available however
each is dependent upon the: recognition of hCG by an
antibody to the hCG molecule or the β-subunit.
 Positive signs of pregnancy:
Three positive signs of pregnancy are identification of
fetal heart action separately and distinctly from the
pregnant . Perception of active fetal movements by an
examiner, recognition of the embryo and fetus at any
time in pregnancy by sonographic techniques or fetus
radiographically in the latter half of pregnancy.
 Identification of fetal heart action:
Observing the pulsation of fetal heart assures the diagnosis
of pregnancy. Fetal heart’s contractions can be identified by
auscultation with a special fetoscope by use of the Doppler
princip0le with ultrasound and by of sonogrphy.
The fetus heartbeat can be detected by auscultation with a
stethoscope by 17 weeks gestation , on nonobese women .
Generally the fetal heart rate at this stage of gestation and
beyond ranges from 120-160 beats per minute. It is heard as
double sound resembling the tick of a watch under a pillow.
To establish the diagnosis of pregnancy is not sufficient
merely/ just to hear the fetal heart , it must be different
from the maternal pulse. During much of pregnancy the
fetus moves freely in the amnionic fluid where the fetal
heart sounds can be heard best as the positions of the fetus
changes.
There are several instruments available to use the
Doppler principle to detect the action of the fetal
heart. Because of the difference in heart rates,
pulsatile flow in the fetus is easily differentiated from
the mother unless there is severe fetal bradycardia or
significant maternal tachycardia. Fetal cardiac
action can always be detected by the 10th week of
gestation with the Doppler. Echocardiography can be
used to detect fetal heart action as early as 48 days
after the first day of the last normal menses. Real-
time sonography can be used to detect fetal heart
action and fetal movement after the second month
of pregnancy.
 Upon auscultation of the abdomen of the pregnant woman in
the later months of pregnancy, the examiner may often hear
sounds other than those produced by fetal heart action
which are :
1. the funic / umbilical cord soufflé,
2. 2. the uterine soufflé,
3. 3. sounds resulting from movement of the fetus,
4. 4. the maternal pulse ,
5. 5. the gurgling of gas in the intestines of the pregnant
woman.
The funic soufflé in soused by the rush of blood through the
umbilical arteries. It is shart, whistling sound that is
synchronous with the fetal pulse and can be heard in 15% of
pregnancies. It is inconstant, being recognizable distinctly at
the time of one examination but not found in the same
pregnancy on other occasions.
The uterine soufflé is heard as a soft , blowing sound.
It is synchronous with the maternal pulse and usually
heard most distinctly during auscultation of the
lower portion of the uterus. The sound is produced by
the passage of blood through the dilated uterine
vessels and in characteristic of any condition in which
the blood flow to the uterus is highly increased . A
uterine soufflé may be heard in nonpregnant
women with large uterine myomas or large tumors of
the ovaries.
 Frequently the maternal pulse can be heard distinctly
by auscultation of the abdomen, and in women where
the pulsation of the aorta is unusually loud.
Occasionally during examination the mother’s pulse
may become rapid to simulate the fetal heart sounds.
It is not unusual to hear other sounds that are
produced by the passage of gases or liquids through
the intestines of the pregnant woman.
 Perception of Fetal Movements:
The positive sign of pregnancy is the detection of
movements of fetus by the examiner. After 20 weeks’
gestation, active fetal movements can be felt, at
indeterminate intervals, by placing the examination
hand on the woman’s abdomen. These movements
vary in intensity from a faint flutter early in
pregnancy to brisk motions at a later period that are
sometimes visible and palpable. Sometimes
somewhat similar sensations may be produced by
contractions of the intestines or the muscles of the
abdominal wall of the pregnant woman.
 Up to 12 weeks, the crown-rump length is predictive
of gestational age within 4 days. In early
identification of normal pregnancy the findings of
sonographpy may permit the identification of
gestation. When the embryo is dead there is a
blighted ovum and an abortion will ultimately.
The characteristic features of blighted ovum are:
1. loss of definition of the gestational sac,
2. an unusually small gestational sac,
3. the absence of echoes emanating from the fetus
after 8 weeks’ gestation.
 By the 14th week, the fetal heard and thorax can be
identified and soon thereafter the placental site can
be visualized by ultrasound techniques.
Subsequently, ultrasonopraphy can be used to identify
the number of fetuses, the presenting pars , various
fetal anomalies , hydramnios and to assess the rate of
fetal growth by measuring , serially, the biparietal
diameter of fetal head, the circumference of the fetal
abdomen and other fetal structures.
 Vaginal Sonography in Early Pregnancy:
Ultrasonic scanning , using a vaginal probe provides a
number of methodological advantages for selected diagnostic
purposes in obstetrics and gynecology.
A gestational sac in the uterine cavity - 2mm small in
diameter can be identified .
This shows a time about 16 days after ovulation or 10 days
after implantation. Visualization of the chorionic cavity is
possible by 2 weeks after conception.
The yolk sac at 3 weeks and cardiac activity is readily
recognized at 4 postconceptional weeks by vaginal
sonography.
The findings of sonography almost always provide more
information than those of radiographpy without the risks of
irradiation.
 Differential Diagnoses of Pregnancy:
The uterus of pregnancy is mistaken for other tumors
occupying the pelvis or abdomen. The uterine
changes of early weeks of pregnancy may be
simulated through enlargement of uterus caused by
myomas, hematometra, adenomyosis or by apparent
enlargement, due to a contiguous but extrauterine
mass or masses. As a rule the enlarged uterus in
these situations is firmer than in pregnancy and is
less elastic and boggy.
 Spurious Pregnancy:
Imaginary pregnancy or pseudocyesis usually occurs
in women nearing the menopause or in women with
an intense desire to be pregnant. Such women may
present all the subjective symptoms of pregnancy in
association with a considerable increase in the size of
their abdomen. It may be caused by deposition of fat ,
by gas in the intestinal tract or by abdominal fluid. In
these women the menses do not as a rule disappear.
Changes in the breasts including enlargement, the
appearance of galastorrhea and increased areolar
pigmentation sometimes occur.
 In a majority of these women , there is morning
sickness, probably of psychogenic origin. The
ingestion of a variety of phenothiazines can lead to
amenorrhea, hyperprolactinemia, breast enlargement
and galastorrhea. The supposed fetal movements can
usually be ascribed to intestinal peristalsis or
muscular contractions of her abdominal wall. Such
women’s careful examination usually leads to a
correct diagnosis without difficulty because the
small uterus can be palpated on bimanual
examination. These women need correct diagnosis.
 Distinction Between First and Subsequent Pregnancies :
It is important to ascertain whether a woman is pregnant for
the first time or has previously borne children. Ordinarily
there are indelible traces of a former term pregnancy.
In a nullipara the abdomen is usually tense and firm. The
uterus is felt through it with difficulty.
The old abdominal striae and the distinctive changes in the
breasts ate absent.
The labia majora are usually in close apposition and the
frenulum is intact.
The vagina is usually narrow with well-developed rugae. The
cervix is softened but does not admit the tip of the
examiner’s finger until the end of the pregnancy.
 In multiparas, the abdominal wall is lax and pendulous.
Through it the uterus is palpated readily. In addition to
the pink abdominal striae, the silvery cicatrices of past
pregnancies may be present. The breast are not so firm
as in women during their first pregnancy. There are striae
in the skin over the breast tissue similar to the abdomen.
The previously has delivered virginally vulva gapes open to
some extent, the frenulum has disappeared and the
hymen is transformed into the myrtiform caruncles. In
multiparas who previously have delivered vaginally , the
external os of the cervix even in the early months of
pregnancy, may admit the tip of the examiner’s finger,
which can be extended up to the internal os.
 Identification of Fetal Life or Death:
The occurrence of fetal death comes utterly without
warning in a pregnancy that has previously seemed
entirely normal. Woman has not felt fetal
movement for hours or for several days, the fetal heart
is not heard by auscultation or identified by real-
time ultrasound examination. Failure to detect heart
wall motion after 10-12 weeks gestation by real-time
ultrasonography is reliable evidence of fetal death.
Ancillary findings of sonography in the case of fetal
death include scalp edema and sequelae of
maceration.
 In early months of pregnancy, the diagnosis of fetal death may
present difficulty. Ultrasonic techniques are employed to diagnose
of fetal death. It can be shown by repeated examination whether
the uterus has remained constant in size or there has been a
decrease in size over a number or weeks. Because of placenta
trophoblasts may continue to produce hCG for several weeks
after death of the embryo or fetus, a positive endocrine test for
pregnancy is not necessarily indicate the fetus is alive.
In the latter half of pregnancy ,by cessation of fetal movements
usually alerts woman. If fetal cardiac action can still be
identified distinct form the mother’s , the fetus is certainly alive.
If by auscultation, the fetal heart tones are not heard, the fetus
probably is dead.
Of course there is a possibility of error , especially in
pregnancies where the fetal heart is remote from the examiner
when the woman is obese or if hydramnios exists.
 Doppler ultrasonic examinations are valuable in the
evaluation of pregnancies, where the fetal heart
cannot be heard by auscultation with a stethoscope.
The use of Doppler ultrasound is valuable when
fetal death is suspected but fetal heart action can be
identified. If fetal heart action is not demonstrated
after careful checking it can probably be stated as
dead . Real-time ultrasonic examination will serve to
identify the presence or absence of fetal heart
motion. By vaginal ultrasonography, an enlarged
amnionic cavity is indicative of embryonic death.
If the fetus has been dead for some time, it can be
shown by careful examination when the uterus does
not correspond in size to the estimated duration of
pregnancy or when the uterus has become smaller
than previously observed. With death fetus ,
maternal weight gain usually ceases and there is a
slight decrease in her weight. At the same time
retrogressive changes have occurred in the breasts
too. Occasionally a positive diagnosis of fetal death
can be established by palpating the collapsed fetal
skull through the partially dilated cervix. In that
event the fetal’s head loose bones are contained in
a flabby bag.
In cases which the fetus has been dead for several
days to weeks the amnionic fluid is red to brown and
turbid rather than nearly colorless and clear. Prior
hemorrhage into the amnionic sac, rarely occurs
during amniocentesis, may lead to similar
discoloration of the amnionic fluid even if the fetus is
alive.