DIAGNOSIS

OF
PREGNANCY
MENSTRUAL AGE

• Also known  GESTATIONAL AGE

• From the first day of the last menstrual period…
• 9 MONTHS AND 7 DAYS
• 280 DAYS
• 40 WEEKS
• FIRST TRIMESTER  1ST 12 weeks

• SECOND TRIMESTER  13 – 28 weeks

• THIRD TRIMESTER  29 – 40 weeks

Diagnosis in the first trimester (first 12
weeks)
Symptoms:

1- Cessation of
menstruation
(missed period):
due to increased estrogen and progesterone production by the corpus
Luteum. (Pregnancy during lactation amenorrhea).
• Slight bleeding at the expected time of menstruation rarely occurs in the
first 3 months (Hartman‘s sign / placental sign) – scanty.
• Shouldn’t get confused with Threatened abortion.
2- Morning sickness: 50% cases
- usually appears soon following the missed
period.
-Nausea , vomiting especially in the morning
on rising from the bed.
- Usually disappears after the third month.
3- Freguency of micturition:
-Due to congestion of bladder mucosa. Irritation of
the bladder by the pregnant uterus.
-resting of bulky uterus on the bladder (anteverted
position of the uterus).
-change in maternal osmoregulation  leads to
increased thirst and polyuria.
- Usually disappears after the third month.
4- Breast symptoms:
Enlargement , heaviness , discomfort and pricking sensation
 6th – 8th week specially in primigravidae.

5 Appetite changes:
Craving for certain types of food and refusal of other types.

6 Fatigue:
- frequent symptom that may occur in pregnancy
and tendency to sleep
1. Breast signs : ( evident in a primigravida).
– 6 - 8 weeks
– Increased size and
vascularityDilated visible veins.
– Increased pigmentation of the
nipple and 1ry areola.
Appearance of 2ry
areola.
– Appearance of Montgomery
tubercles in the areola ( dilated
sebaceous glands).
– Expression of colostrum (thick
Appearance of Montgomery tubercle in the
areola

• dilated sebaceous glands

• PER ABDOMEN:

– Uterus remains a pelvic organ until 12th week,it

may be just felt per abdomen a suprapubic bulge.

• PELVIC CHANGES:

– JACQUEMIER’S OR CHADWICK’S SIGN

– OSIANDER’S SIGN

– GOODELL’S SIGN
JACQUEMIER’S SIGN

• Also known as Chadwick’s sign

• Dusky hue of the vestibule and anterior vaginal wall
visible at 8th week
• More pronounced as pregnancy advances and is
more definitely present in multiparae.
• Due to local vascular congestion.
OSIANDER’S SIGN

• Increased pulsation , felt through the lateral fornices

at 8th week.
GOODELL’S SIGN

• Cervix becomes soft as early as 6th week

• Softening is more surrounding the external os and
also in the upper part.
• The pregnant cervix feels like the lips of the
mouth.
• On speculum examination. The bluish discolouration
of the cervix is visible  due to the increased
vascularity.
2. Uterine sign ; felt by bimanual examination:
– Size : enlarged.
– consistency : soft.
– Shape : globular.
– Hegar sign : ( elicited between 6-10
weeks). Two fingers in the anterior fornix, the
fingers of
the other hand over the abdomen behind the
uterus . The fingers of both hands can be
approximated as the lower part of the uterine
body is soft and empty.
– Palmer sign:
Uterine contractions felt on bimanual
examination.
•This hormone is only released by trophoblastic tissue produced
by a growing fetus and its associated placenta.

•hCG is present in the maternal circulation as either an intact

dimer, alpha or beta subunit, and degraded form, or beta core
fragment

• Detection of HCG in maternal serum and urine is evident

only 8-
10 days after conception
• hCG is detectable in the serum of approximately
5% of patients 8 days after conception and in
more than 98% of patients by day 11

• Diagnostic levels in Urine seen only about 23-

24
days after conception.

• Levels peak at 10-12 weeks' gestation and then

plateau before falling
In general, the HCG level will double every two to three days in early pregnancy
- Used only in special cases
( bad obstetric history, suspicion of ectopic,etc.)
- Require special labs and expertise.

Currently, 4 main hCG assays are used,

(1) radioimmunoassay,

(2) immunoradiometric assay,

(3) enzyme-linked immunosorbent assay (ELISA),

(4) fluoroimmunoassay.
ULTRASOUND
• Intra decidual gestational sac is identified
as early as 29 – 35 days of gestation
• Gestational sac & yolk sac -5 menstrual
weeks
• Fetal pole and cardiac activity – 6
weeks
• Embryonic movements -7 weeks
• Doppler effect of US can pick heart rate
reliably by 10th week.
Diagnosis in the second trimester
( 13-28 weeks)
Symptoms:
1. Amenorrhea.
2. Morning sickness and urinary symptoms
gradually decrease .
3. “Quickening “ : perception of fetal
movements by the pregnant woman:
a. 18-20 weeks in primigravida.
b. 16-18 week s in multipara.
4. Abdominal enlargement.
 ABDOMINAL EXAMINATION…
• INSPECTION:
– Linea nigra extending
from symphysis pubis
to ensiform cartilage
 20th week…
– STRIAE ( both pink and white) visible in the
lower abdomen more towards the flanks…
• PALPATION:
– Fundal height – increased with progressive
enlargement of the uterus.
1. The uterus is abdominally felt (ovoid).
The uterus feels soft and elastic
2. Braxton Hicks contractions; intermittent
painless contractions detected by abdominal
examination.
3. Active fetal movements can be felt at
intervals by placing the hand over the uterus
as early as 20th week.
4. External ballottement : elicited at 20
week through abdominal examination.
5. Palpation of the fetal parts and palpation of
fetal movements by the obstetrician at 20 weeks.
 Auscultation:
• Auscultation of FHS as early as 20-24 weeks by Pinard
stethoscope
• Auscultation of funic/fetal souffle  due to rush of
blood through the umblical artery
• Auscultation of uterine souffle (soft blowing and
systolic murmur heard low own at the sides of the
uterus)  synchronous with the maternal pulse
INVESTIGATIONS…
• SONOGRAPHY:
– Routine sonography at 18 – 20 weeks permits a
detailed survey of fetal anatomy, placental
localisation and the integrity of the cervical canal.
• FETAL ORGAN ANATOMY :
– To detect any malformation.
• FETAL VIABILITY
• RADIOLOGIC:
– 16TH WEEK – FETAL SKELETAL SHADOW.
 Diagnosis in the third trimester
(29 - 40weeks)
• SYMPTOMS:
– Amenorrhoea persists
– Enlargement of the abdomen  leading to
discomfort to the patient (palpitaion or dyspnoea
following exertion)
– LIGHTENING: 38th week  sense of relief of the
pressure symptoms due to engagement of the
presenting part.
– Frequency of micturition reappears
– Fetal movements are more pronounced.
• SIGNS:
– Cutaneous changes are more prominent with
increased pigmentation and striae.
– Uterine shape – from cylindrical to spherical
beyond 36th week
– FUNDAL HEIGHT (distance between the umbilicus
and ensiform cartilage)
• Junction of the upper and middle third at 32 weeks.
• Level of ensiform cartilage at 36th week
• Comes down to 32 weel level at 40th week because of
the engagement of the presenting part.
• SYMPHYSIS FUNDAL HEIGHT:
– Upper border of the fundus located by ulnar
border of the left hand and point is marked.
– Distance between the upper border of the
symphysis pubis upto the point marked is
measured in centemetre
– After 24 weeks, the SFH in cm corresponds to the
number of weeks upto 36 weeks.
• Braxon-Hicks contraction – more evident
• Fetal movements – easily felt
• Palpation of the fetal parts and their identification
become much easier.
• F.H.S – heard distinctly
• SONOGRAPHY:
– Fetal growth assessment can be made more
accurate.
• Amniotic fluid volume assessment – for oligo /
poly.
 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
• UTERINE FIBROID
• CYSTIC OVARIAN TUMOUR (Amenorrhoea absent
firm, hard, positive sign absent, USG)
• ENCYSTED TUBERCULAR PERITONITIS (H/O Koch’s
infection, swelling ill defined, positive signs absent,
USG)
• HAEMATOMETRA
• DISTENDED URINARY BLADDER (Catheterisation
solves the problem)
• PSEUDOCYESIS