DIAGNOSIS OF

PREGNANCY
DIAGNOSIS OF PREGNANCY BY
TRIMESTERS
 Calculated from the first day of the last menstrual period.
 9 MONTHS AND 7 DAYS i.e. 280 DAYS i.e. 40 WEEKS
 FIRST TRIMESTER: 0 TO 12 weeks
 SECOND TRIMESTER:12 TO 28 weeks
 THIRD TRIMESTER: 29 TO 42 weeks

Diagnosis in each trimester is based on

1. Subjective symptoms
2. Objective signs and examination
3. Blood investigations
4. Ultrasonography
DIAGNOSIS IN THE FIRST TRIMESTER
Symptoms:
1. AMENORRHEA
- Amenorrhea in a healthy reproductive aged woman who has previously
experienced spontaneous, cyclical and predictable menses is highly suggestive
of pregnancy.
- Due to negative feedback mechanism caused by increased estrogen and
progesterone production by the Corpus Luteum.
- Reliable after at least 10 days after missed periods.
- Hartman‘s sign
Uterine bleeding that mimics menses, that is noted after conception.
Likely due to blastocyst implantation.
Similar to Threatened abortion.
Altered blood is usually seen.
2. NAUSEA AND VOMITING
- 70% cases
- Usually appears soon following the missed period and disappears after 12 weeks of
gestation.
- More common in primigravidae.
- When severe and unrelenting- hyperemesis gravidarum (weight loss, dehydration,
ketosis, alkalosis, dyselectrolemia.

3. FREQUENCY OF MICTURITION
- Due to i. congestion of bladder mucosa
ii. anteverted position of the uterus
iii. change in maternal osmoregulation
- Seen in 20% of women in first trimester and in 40% of women in the third trimester.
4. BREAST SYMPTOMS
- Enlargement, heaviness, pricking sensation, tenderness.
- Seen more at 6 to 8 weeks - especially in primigravidae.
- Due to estrogen.
5. APPETITE CHANGES (Pica)
- Craving for certain types of food and refusal of other types.
6. FATIGUE
- Frequent symptom that may occur in pregnancy and tendency to sleep
7. Skin changes:
- Striae gravidarum (reddish, slightly depressed streaks; multipara- white,
cicatrised
- Linea nigra
- Diastasis recti
- Chloasma (10% have pigmentation - more prominent in dark women; butterfly
shaped, over face and cheeks- mask of pregnancy/melisma gravidarum)
- Vascular spiders (face, neck, upper chest and arms)
- Palmar erythema (due to hyperestrogenemia)
- Increased anagen phase of hair follicle during pregnancy and increased telogen
phase in puerperium (TELOGEN EFFLUVIUM).
 SIGNS
1. Breast signs
- Usually more evident in a primigravidae.
- Seen between 6 to 8 weeks.
- Enlargement of breast along with vascular engorgement.
- Increased pigmentation of the nipple and primary areola and appearance of
secondary areola.
- Appearance of Montgomery tubercles in the areola (hypertrophied sebaceous
glands).
- Expression of colostrum as early as 12th week.
2. PER ABDOMEN
- Uterus remains a pelvic organ until 12th week (hypertrophy is more evident at fundus and near
placental attachment).
- Till 12 weeks- by action of estrogen and progesterone; after 12 weeks- by pressure effect
exerted by products of conception.

3. PELVIC CHANGES:
i. JACQUEMIER’S OR CHADWICK’S SIGN
Dusky hue (violet color) of the vestibule and anterior vaginal wall most visible at 8th week of
pregnancy
More present in multipara.
Due to increased vascularity and edema of vagina and cervix.
Increased risk of candidiasis in 2nd and 3rd trimester.
ii. OTHER VAGINAL CHANGES
1. OSIANDER’S SIGN:
Increased pulsation, felt through the lateral fornices at 8th week.
2. Softened vaginal walls.
3. Copious non-irritating mucoid discharge after 6th week- acts as an
immunological barrier to protect uterine contents from infection- seen as bloody
show at term.
iii. CERVICAL CHANGES
1. GOODELL’S SIGN:
Cervix becomes soft as early as 6th week. The pregnant cervix feels like the lips of the
mouth.
2. P/S shows bluish discoloration of the cervix- visible due to the increased vascularity and
edema, from changes in the collagen network and from hyperplasia and hypertrophy of the
cervical glands.
3. In pregnancy, as a result of progesterone, when cervical mucus is spread and dried on a glass
slide, its is characterised by poor crystallization, or beading.
4. Hypersecretory appearance and hyperplasia of endocervical glands – the Arias Stella
reaction.
5. Cervical glands undergo marked proliferation and by the end of pregnancy, they occupy up
to one half of the entire cervical mass. This is known as extension or eversion of the
proliferating columnar endocervical glands.
iv. Uterine sign
1. Size, consistency, shape:
Enlarged, globular by 12 weeks.
Asymmetrical enlargement of uterus due to lateral implantation is known as
PISKACHEK’S SIGN.
Pregnant uterus feels soft and elastic.
2. Palmer sign:
Regular rhythmic uterine contractions felt on bimanual examination.
As early as 4 to 8 weeks.
3. Hegar sign:
Elicited between 6-10 weeks.
Upper part of the uterus is enlarging, lower part is empty and soft and
cervix is firm.
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.
HORMONES IN PREGNANCY
1. BETA HCG

 This glycoprotein hormone is produced by syncytiotrophoblasts in amounts that increase

exponentially during the first trimester following implantation.
 hCG is present in serum as alpha and beta subunits of which alpha subunit is identical to LH,
FSH and TSH but beta subunit is structurally distinct.
 Detection of HCG in maternal serum and urine is evident only 8- 10 days after conception
and a detection limit of 12.5mIU/ml is required for home pregnancy tests to diagnose 95% of
pregnancies at the time of missed menses.
 Detectable 7 to 9 days after LH surge.
 Maternal urine will show degradation products.
 Beta HCG 1. maintains corpus luteum for production of progesterone
2. stimulates fetal testicular testerone
3. stimulates maternal thyroid- hyperthyroidism
4. Increases relaxin produced by corpus luteum
 Beta hCG can be detected in serum or urine by 8 to 9 days after ovulation.
 Doubling time of Beta hCG is 1.4 to 2 days.
 Serum levels range widely and increase from the day of implantation.
 Discriminatory cutoff is 1500 mIU/ml, by which time an intrauterine
gestational sac can usually be seen in 99% of cases.

DETECTION 8 TO 9 DAYS
PEAK 60 TO 70 DAYS
PLATEAU 16 WEEKS
 DETECTION OF BETA HCG LEVELS:

A. Immunoassays without radioisotopes:

1. Agglutination inhibition test:

• 1 drop of urine is mixed with 1 drop of solution containing hCG antibody.
• If hCG is not present, antibody remains free and agglutination occurs when
another drop of solution with latex particles coated with hCG is added.
• Sensitivity – 0.5 to 1IU/ml (urine)
• Time taken to completion - 2 minutes
• Post conception age when first positive – 2 days
2. Direct agglutination test:
• Latex particles coated with anti-hCG antibodies are mixed with urine.
• Agglutination occurs in positive test.
• Sensitivity – 0.2IU/ml (urine)
• Time taken to completion – 2 minutes
• Post conception age when first positive – 2 to 3 days
3. Enzyme-linked immunosorbent assay:
• One monoclonal antibody binds Beta hCG in urine and serum and a second
antibody that is linked with alkaline phosphatase is used to ‘sandwich’ the
bound hCG.
• Sensitivity – 1 to 2 mIU/mL (serum)
• Time for completion - 80 minutes
• Post conception age when first positive - 14-17 days
• Gestational age when first positive - 3.5 weeks
4. Fluoroimmuno assay:
• Utilizes a second antibody tagged with a fluorescent label.
• Can be used for hCG detection and follow up of hCG levels.
• Sensitivity - 1 mIU/mL
• Time for completion - 2-3 hours
• Post conception age when first positive - 14-17 days
• Gestational age when first positive - 3.5 weeks
B. Immunoassays with radioisotopes:
1. Immunoradiometric assay:
• Uses sandwich principle to detect whole hCG molecules.
• Uses I125.
• Sensitivity – 0.005 IU/mL (serum)
• Time for completion - 30 minutes
• Post conception age when first positive - 18-22 days
• Gestational age when first positive - 4 weeks
2. Radioimmuno assay:
• Uses I125 ido-hCG antibodies.
• Can be used to detect doubling time as they are highly sensitive.
• Sensitivity – 0.002 IU/mL (serum)
• Time for completion - 4 hours
• Post conception age when first positive – 8-10 days
• Gestational age when first positive - 3-4 weeks
TEST TEST SENSITIVITY TIME TAKEN INFERENCE POSITIVE ON
IMMUNOLOGICAL TESTS (URINE)
Agglutination 0.5 – 1 IU/ml (urine) 2 minutes Absence of agglutination 2 days after missed
inhibition test (latex period
test)
Direct latex 0.2 IU/ml (urine) 2 minutes Presence of agglutination 2 – 3 days after
agglutination test missed period
Two-site sandwich 30 – 50 mIU/ml 4 – 5 minutes Color bands in the control as On the first day of
immunoassay (urine) 1.0mIU/ml well as in test window the missed period
(membrane (serum) (28th day of cycle)
ELISA/card test)
Various kits in card forms are available + Pregnant (card test) - Not Pregnant (card
test)
S CT
CT S

Enzyme-linked 1 -2 mIU/ml (serum) 2 – 4 hours 5 days before the

immunosorbent assay first missed period
RADIOIMMUNOASSAY
Beta subunit 0.002IU/ml 3 – 4 hours 25th day of cycle
Immunoradiometric 0.05mIU/ml (serum) 30 minutes 8 days after
 Other uses of Beta HCG testing:
1. Monitoring pregnancy post IVF and embryo transfer.
2. Follow up of hydatifiorm mole and choriocarcinoma (Beta HCG seen in
millions- UPT may show false negative- HOOK EFFECT- excessive beta HCG will
oversaturate antibodies in test and show low levels in urine- serum Beta HCG
should always be done) .
3. Follow up for ectopic pregnancies.
4. As part of First Trimester Screening ( Beta HCG, PAPP-A) and Quadruple
testing ( Beta HCG, AFP, Estriol, Inhibin) – raised HCG is more specific for
Trisomy 21.
 HIGH BETA HCG LEVELS:
1. Women having heterophile antibodies
2. Women taking exogenous HCG injections
3. Delayed HCG clearance due to renal failure
4. Presence of physiological pituitary HCG
5. Neoplasms producing HCG
6. Multifetal pregnancy
7. Erythroblastosis fetalis

 LOW BETA HCG LEVELS:

1. Ectopic pregnancy
2. Abortions
2. HUMAN PLACENTAL LACTOGEN (hPL)
 Similar to pituitary growth hormone and prolactin and produced by
syncytiotrophoblasts.
 Detected during 3rd week of gestation.
 Progressively increases from 5 to 25 mcg/ml till 36 weeks.
 Half life is 10 to 30 minutes.
 Plasma concentration is proportional to placental mass.

3. PREGNANCY SPECIFIC BETA-1 GLYCOPROTEIN

 Produced by trophoblasts and detectable 18 to 20 days after ovulation.
 Potent immunosuppressant.
4. EARLY PREGNANCY FACTOR
 Produced by activated platelets and other maternal tissue.
 Detectable 6 to 24 hours after conception.
 Potent immunosuppressant.

5. PAPP-A
 Produced by syncytiotrophoblasts.
 Immunosuppressant.
 Low levels are associated with increased risk of IUGR and preeclampsia.
6. PROGESTERONE
 Till 6 to 7 weeks of gestation, progesterone production is maintained by
corpus luteum.
 After 8 weeks, placenta takes over progesterone secretion causing a gradual
increase throughout pregnancy (10 to 5000 times that of non-pregnant
woman).
 Daily production of progesterone in late, normal, singleton pregnancy is
250mg. (multifetal pregnancies >600mg)
 Placental progesterone are not relative to fetal well-being.

PROGESTERONE LEVEL
NON PREGNANT < 1 – 20 ng/ml
FIRST TRIMESTER 8 – 48 ng/ml
SECOND TRIMESTER 17 – 146 ng/ml
THIRD TRIMESTER 99 – 342ng/ml
ULTRASOUND
 Fetal viability and gestational age is determined by TVS.
 By the end of 4th week of pregnancy, gestational sac can be visualized.
 The first definitive sonographic sign of early pregnancy is the presence of a
GESTATIONAL SAC, which is a small anechoeic fluid collection in the
endometrial cavity.
 Size threshold for sac detection is 2 to 3mm, corresponding to gestational age
of 4 weeks and 2 to 3 days.
 Gestational sac grows at a rate of 1mm per day during early pregnancy.
 Sac of 5mm can be seen by TAS.
 PSEUDOSAC is seen in ectopic pregnancies in the endometrial cavity.
 Embryo should be visible when sac reaches 25mm – otherwise,
anembryonic.
 DOUBLE DECIDUAL SIGN:

• When mean sac diameter is about 10mm, 2 concentric echogenic lines

surround it.
• The inner line is the chorion along with the decidua capsularis and the outer
line is decidua parietalis.
• This is the double decidual sign.
• Differentiates between ectopic and intrauterine pregnancy.
• INTRADECIDUAL SIGN is when an anechoic centre is surrounded by a single
echogenic rim.
STRUCTURE TAS TVS

GESTATIONAL SAC 5 Weeks End of 4th week

(5mm) (2-3mm)
YOLK SAC Week 7 Beginning of 5th week
(20mm) (5mm)

EMBYRONIC DISC 5 to 6 weeks

CARDIAC ACTIVITY 6 weeks

Yolk Sac: 1. Confirms intrauterine pregnancy.

2. Helps in dating pregnancy.
3. Helps locate embryonic disc.
4. Abnormal yolk sac is associated with early pregnancy failure.
 DATING A PREGNANCY
• Parameters used to date a pregnancy are:
1. GESTATIONAL SAC SIZE
2. EMBRYONIC SIZE.

• Gestational sac size is measured by mean sum of three diameters:

1. Craniocaudal
2. Anteroposterior
3. Transverse.

• Between 5 to 11 weeks, gestational age can be calculated by adding 30 to mean

sac diameter.
• Between 6 to 12 weeks, CROWN RUMP LENGTH is measured- MOST ACCURATE
METHOD OF DATING PREGNANCIES (not accurate beyond 14 weeks- 84mm).
• Measured in the midsagittal plane with the embryo or fetus in neutral,
nonflexed position so that length can be measured as a straight line.
• Measurement should not include yolk sac nor a limb bud.
• Mean of three measurements is used.
• Until 13+6 weeks of gestation, CRL is accurate to within 5 to 7 days.
• Gestational age in weeks = CRL in cm + 6.5
DIAGNOSIS IN THE SECOND TRIMESTER

Symptoms:
1. Continued Amenorrhea.
2. Morning sickness and urinary symptoms gradually decrease.
3. “Quickening “ : first perception of fetal movements by the
pregnant woman in utero.
a. 18-20 weeks in primigravida.
b. 16-18 weeks in multipara.
4. Abdominal enlargement
General examination:
1. Chloasma (melasma gravidarum)- pigmentation over forehead and cheeks at
20 weeks (the mask of pregnancy)
2. Breast changes:
• Enlarged, prominent veins
• Secondary areola more prominent by 20 weeks
• Montgomery’s tubercles more prominent and extending to secondary areola
• Colostrum by 16 weeks
• Striae
ABDOMINAL EXAMINATION
INSPECTION:
Linea nigra extending from symphysis pubis to ensiform cartilage from 20
weeks.
 STRIAE (both pink and white) visible in the lower abdomen more towards
the flanks
PALPATION:
 Fundal height – increases with progressive enlargement of the uterus.
 Uterus abdominally felt
 Braxton Hicks contractions: intermittent painless contractions detected by abdominal
examination without any cervical changes.
- unpredictable, sporadic, nonrhythmic contractions
- Intensity 5 to 25mm
- More common near term, lasting 10 to 20 minutes.
 Active fetal movements can be felt at intervals by placing the hand over the uterus
as early as 20th week.
 SYMPHYSIO 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 up to the point
marked is measured in centimeter.
• After 18 weeks, the SFH in cm corresponds to the number of weeks up to 32
weeks.
• Around umbilicus is 20 weeks.
• Considerations to be noted: Full bladder, Uterine contraction, Patient
position.
• MacDonald’s rule:
Period of gestation in months = Fundal Height in cm x 2/7
Period of gestation in weeks = Fundal Height in cm x 8/7
 External ballottement : elicited at 20 week through abdominal examination.
Palpation of the fetal parts and palpation of fetal movements at 20 weeks
Auscultation:
 Most conclusive clinical sign of pregnancy.
 Auscultation of FHS by 18 to 20 weeks
 Rate of 110 to 160beats/min
 Auscultation of funic/fetal souffle:
due to rush of blood through the umbilical artery (soft blowing murmur in tune
with fetal heart rate)
 Auscultation of uterine soufflé:
soft blowing and systolic murmur; heard low own at the sides of the uterus, best
on the left and is synchronous with the maternal pulse
Vaginal examination:
 Bluish discoloration of vulva, vagina and cervix is more evident
 Internal ballottement done between 16 to 28 weeks.
 INVESTIGATIONS
SONOGRAPHY:
• Routine sonography at 18 – 20 weeks permits a detailed survey of fetal
anatomy, placental localisation and the integrity of the cervical canal
• Gestational age calculated by BPD, HC, AC, FL and is most accurate between
12 to 20 weeks.
• Fetal organ anatomy is studied to detect any malformations.
• Viability of the fetus is checked.
• BPD is measured at the transthalamic view, at the level of thalami and cavum
septum pellucidum, perpendicular to midline falx.
- Measured from the outer edge of the skull in the near field and the inner edge
of the skull in the far filed.
• HC is also measured in transthalamic view.
- An ellipse is placed around the outer edge of the skull and circumference is
calculated using BPD and OFD.
CEPHALIC INDEX: BPD divided by OFD and is normally 70 to 86 %.
• Femur length (FL) correlates with BPD and HC.
- Measured with the beam perpendicular to long axis of shaft and length taken by
including the calcified diaphysis and excluding the epiphysis.
• Abdominal circumference (AC) is most affected by fetal growth.
- Measured by placing a circle outside the fetal skin in a transverse image
containing the stomach and the confluence of the umbilical vein with the
portal sinus.
- Kidneys should not be visualised.
- Image should not contain more than 1 rib on either side.
GESTATIONAL AGE PARAMETER THRESHOLD TO REVISE

< 9 weeks CRL >5d

9 to <14 weeks CRL >7d

14 to <16 weeks BPD,HC,AC,FL >7d

16 to <22 weeks BPD,HC,AC,FL >10d

22 to <28 weeks BPD,HC,AC,FL >14d

> 28 weeks BPD,HC,AC,FL >21d

THIRD TRIMESTER
 SYMPTOMS:

1. Amenorrhea
2. Enlargement of abdomen
3. Lightening (pressure symptoms relieved due to
engagement of presenting part- more evident in primi)
4. Frequency of micturition
5. Fetal movements
 SIGNS:
• Cutaneous changes are more prominent with increased pigmentation and
striae.
• 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 week level at 40th week because of the engagement of the
presenting part.
• Braxton-Hicks contraction – more evident
• Fetal movements – easily felt
• Palpation of the fetal parts and their identification become much easier.
• FHS – heard distinctly.
• Ultrasound- Fetal growth assessment can be made more accurately.
• Amniotic fluid volume assessment – for oligo or polyhydramnios.
DIFFERENTIAL DIAGNOSIS
 DISTENDED URINARY BLADDER (Catheterisation solves the problem)
 UTERINE FIBROID
 CYSTIC OVARIAN TUMOUR (Amenorrhoea absent, cystic mass, no contractions,
no fetus on USG)
 ENCYSTED TUBERCULAR PERITONITIS (H/O Koch’s infection, swelling ill
defined, positive signs absent, USG)
 HAEMATOMETRA
 PSEUDOCYESIS (psychological disorder)
 PRESUMPTIVE PROBABLE CONFIRMATORY

IST TRIMESTER AMENORRHEA, BREAST

SYMPTOMS
CERVICAL & VAGINAL
CHANGES
BETA HCG
USG – GESTATIONAL SAC,
CRL, CARDIAC ACTIVITY

IIND TRIMESTER AMENORRHEA, BREAST

SYMPTOMS
QUICKENING, ABDOMINAL
ENLARGEMENT
AUSCULTATION OF FHS,
USG – FETAL PARAMETERS

IIIRD TRIMESTER AMENORRHEA, BREAST

SYMPTOMS
FETAL MOVEMENTS,
ABDOMINAL ENLARGEMENT
AUSCULTATION OF FHS
USG – FETAL PARAMETERS
REFERENCES

 Williams Obstetrics 25th edition.

 Gabbe- Obstetrics- Normal and Problem pregnancies
 Obstetrics and gynecology for PGs- 3rd edition (Dr.Arulkumaran)
 Dutta’s Textbook of Obstetrics
THANK YOU