DIAGNOSIS OF PREGNANCY

Dx of pregnancy
Sign and Symptom of pregnancy may appear as
early as 6 weeks
Manifestations of pregnancy may be: PRESUMPTIVE,
PROBABLE
POSITIVE

Dx of pregnancy
1. Presumptive symptoms
Amenorrhea,
Nausea and vomiting
Breast changes
tenderness ,enlargement, colostrum
Montgomery Tubercles
2 breasts prominence

Quickening(18 -20 wks primis, 16- 18wk multis)

Frequency+ nocturia ( bladder irritation)
UTI ( bacteruria in preg. woman ~7% vs 3% in nonpreg)*
*Bacteruria may be asymptomatic but leads to serious complications
(pyelonephritis, which is associated with miscarriage, preterm birth,
and intrauterine fetal demise) if left untreated

Dx of pregnancy
Presumptive Signs
Skin changes
Chloasma ( mask of pregnancy),
is darkening of the skin over the forehead, bridge of the
nose, or cheekbones .
It usually occurs after 16 weeks' gestation and is
intensified by exposure to sunlight.

Linea Nigra
is darkening of the nipples and lower midline of the
abdomen from the umbilicus to the pubis (darkening of
the linea alba)
due to stimulation of the melanophores by an
increase in melanocyte SH.

Presumptive signs- contd.

Stretch Marks
striae of the breast and abdomen are caused by
separation of the underlying collagen tissue and
appear as irregular scars.
This is probably an adrenocorticosteroid response.
These marks generally appear later in pregnancy
when the skin is under greater tension.

Spider Telangiectases
are common skin lesions that result from high levels
of circulating estrogen.
These vascular stellate marks blanch when
compressed.
Palmar erythema is often an associated sign.
Both of these signs are also seen in patients with
liver failure.

2.Probable Manifestations
Probable Symptoms are the same as the Presumptive
ones, above.
Probable Signs (Pelvic organ changes)
Chadwicks sign:Congestion of the pelvic vasculature causes bluish or
purplish discoloration of the vagina and cervix.
Leukorrhea
Hegars sign
this is widening of the softened area of the isthmus,
resulting in compressibility of the isthmus on
bimanual examination. This occurs by 68 weeks.
Relaxation of pelvic joints(pronounced on SP)

2.Probable Manifestations..
Abdominal Enlargement
There is progressive abdominal enlargement
from 728 weeks.
At 1622 weeks, growth may appear more rapid
as the uterus rises out of the pelvis and into the
abdomen
Painless uterine contractions (Braxton Hicks
contractions)
are felt as tightening or pressure usually
disappear with walking or exercise.
They usually begin at about 28 weeks' gestation
and increase in regularity.

3.Pregnancy Positive manifestations

The various signs and symptoms of pregnancy are
often reliable, but none is diagnostic.
A positive diagnosis must be made on objective
findings, many of which are not produced until after
the first trimester.
However, more methods are becoming available to
diagnose pregnancy at an early stage. These are: Fetal Heart Tones (FHTs); detected by: hand held Doppler as early as 10 weeks' and
fetoscope at 1820 weeks'.
The normal fetal heart rate is 120160 bpm.

Palpation of Fetus:
Fetal outline after 22 wks
Fetal movement after 18 wks

Positive manifestations-US
A Gestational Sacthe first sonographic
evidence of pregnancy;
a small anechoic fluid collection within the
endometrial cavity seen by TVUS at 4 to 5 Wks GA.

A normal GS implants eccentrically in the

endometrium, whereas a pseudosac is seen in
the midline of the endometrial cavity.
Other potential indicators of early intrauterine
pregnancy are: The Intradecidual Sign;
an anechoic center surrounded by a single echogenic
rim or of GA within 4 days.

Others +ve US findings of px dx

Double Decidual Sign

two concentric echogenic rings surrounding the

gestational sac ( D. parietalis and D .Capsularies)

yolk sac
a brightly echogenic ring with an anechoic center and
can normally be seen by the middle of the 5th week.
confirms with certainty an Iux pregnancy.

Embryo
is seen after 6 weeks, an as a linear structure
immediately adjacent to the yolk sac, and cardiac
motion is typically noted at this point.

Up to 12 weeks gestation, the CRL is predictive

Positive manifestations-US
Ultrasound Examination of Fetus
Cardiac activity- -----------------5-6 wks
limb buds- ------------------------7-8wks
Fingers & limbs movt----- ----9-10 wk
Human appearance after--- -10 wk

Positive manifestations-US
pregnancy of unknown location
equivocal Sonography finding
With PUL -serial serum hCG levels can help
differentiate a normal intrauterine
pregnancy from an extrauterine pregnancy
or an early miscarriage

Pregnancy-positive manifestations..
Urine Pregnancy Test (the level of hCG detection ranging
between 5 and 50 mIU/mL, depending on the kit used.)
Home Pregnancy tests first voided morning urine (low
sensitivity)
Serum Pregnancy test: hCG can be detected in the serum as
early as a week after conception.
The serum pregnancy test can be quantitative or
qualitative with a threshold as low as 24 mIU/mL,
depending on the technique used.
The serum pregnancy test is a reliable method to
diagnose an early pregnancy; it is widely used in the
evaluation of threatened abortion, ectopic pregnancy,
and other conditions

Positive manifestations-contd.
Pregnancy Tests
Sensitive, early pregnancy tests measure changes in
levels of B hCG.
hCG is produced by the Syncytiotrophoblast 8 days
after fertilization and may be detected in the maternal
serum after implantation occurs, 1011 days after
conception.
hCG levels peak at approximately 1012 weeks of
gestation.
Levels gradually decrease in the second and third
trimesters and increase slightly after 34 weeks.
The doubling time of hCG is 1.5 days.
Normally, serum and urine hCG levels return to
nonpregnant values (<5mIU/mL) 2124 days after
delivery.

hCG Tests
Several Immunoassays
Sandwitch Immunoassay Immunometric assay- all comm assays
Monoclonal Ab against B subunit
2 antibodies
capture (1st)bound and immobilize hCG
tracer (2nd) -lable the immobilized hCG by radioactive or Enzyme label
hCG is sandwithced b/n Abs ( 1st on solid phase support, second added
subsequently)
Amount of immobilized label measured proportional to the amount of
hCG in the sandwitch
Enzyme linked
2nd Ab is E linked (e.g, ALPase)
After 2nd Ab, E substrate is added, bind to E and color change is produced
Intense color high E conc High amount of bound 2nd Ab High hCG
conc
Can detect as low as 1miu/ml hCG

hCG tests-Home Pregnancy tests

HPTs are Less accurate than advertisement
Only 1 brand detected 95% of hCG +ves at
12mu/ml
44% of brands +VE at 100Miu/ml
only 15% are dxed at time of missed
menses
Cole and ASS 2011

hCG Test.
Although all assays detect regular hCG, they do
not necessarily detect all hCG variants .
For example, many over-the-counter pregnancy
tests do not measure hyperglycosylated hCG,
which accounts for most of the total hCG at the
time of missed menses when these tests are
typically performed.
At a minimum, testing for total hCG should detect
both regular and hyperglycosylated hCG.
The hCG variants detected depends upon the
only commercial assay used;

HCG test

the only commercial assay that detects all hCG

variants is the Siemen's Immulite Series.
It is also important to know the sensitivity of the
test.
Clinical tests for pregnancy may only detect total
hCG levels 20 mIU/mL.
Therefore, when following hCG levels to negative
(<1 mIU/mL) in women with GTD, it is important
to use a sensitive hCG test that detects both
regular and hCG-H.
Testing for pregnancy
The clinical use of this test for diagnosis of pregnancy
(intrauterine or ectopic) is reviewed separately

False negative test - hook effect

At levels of hCG > 500,000 mIU/mL, a "hook effect" can

occur resulting in an artifactually low value for hCG (ie,
1 to 100 mIU/mL)
This is because the sensitivity of most hCG tests is set
to the pregnancy hCG range (ie, 27,300 to 233,000
mIU/mL at 8 to 11 weeks of gestation);
therefore, when an extremely high hCG concentration
is present, both the capture and tracer antibodies used
in immunoradiometric assays become saturated,
preventing the binding of the two to create a sandwich
Since the nonsandwiched tracer antibodies are washed
away with the excess material, the test result will be
negative.
For this reason, a suspected diagnosis of GTD must be
communicated to the laboratory so that the hCG assay
will also be performed at 1:1000 dilution.

False-positive hCG values

phantom hCG, a false +ve serum hCG result due to nonspecific
heterophilic antibodies in the serum and this often results in
inappropriate intervention (chemorx, Hysterectomy).
Seen in people who are close to animals
Abs against Ags of animal origin bind to the animal derived
test abs
These false-positive levels are usually low (10 mIU/mL) but have
been reported at levels > 300 mIU/mL.
This situation should be suspected when hCG levels plateau at a low
concentration and do not respond to further therapeutic attempts,
such as methotrexate for a persistent EP or molar gest.
Since the H Abs are not secreted in the urine, one should measure a
urinary hCG level if suspicious.
Also, a serial dilution of the patients serum can be performed, as
the false-positive test is not affected by the dilution

How to exclude Phantom hCG?

Urinary test VE
Hetrophilic Abs are not excreted by the kidney

Serial dilution of serum sample

True hCG conc. decreases with dilution while that
of the phantom is not affected

Alternate assay which blocks hetrophilic Abs

False hCG +VES

Exogenous hCG-Injection for wt loss
Tumors like;
GI, Ovary, Bladder, Lung
hCG may hve angiogenic role for the tumors

Renal Failure;impaired clearance

Physiologic Pituitary hCG
One possible explanation is that a small amount of hCG
is produced along LH because the single LH beta-subunit
gene is buried among the seven back-to-back hCG betasubunit gene
Usually 1-32mu/ml
Pituitary production of hCG is most notable around the
time of menopause (natural or surgical) and prior to
ovulation, which are times when LH levels peak

The end !!!