DIAGNOSIS OF

PREGNANCY

 The

reproductive period of a woman begins

at menarche and ends in menopause, and
it usually extends from 13-45 years
Pregnancy dating the estimated date
of confinement (EDC), or due date, is
based on the assumption that a woman
has a 28-day cycle, with ovulation on day
14 or 15
Pregnancy lasts for 280 days (40 weeks)
from the LMP. The EDC is therefore 9
months plus 7-10 days from the start of
the LMP

First trimester (first 12 weeks)

Subjective symptoms presumptive symptoms
Cessation of menses (amenorrhoea) during the
reproductive period in an otherwise healthy
individual having previous normal periods is
strongly suggestive of pregnancy
Breast changes (discomfort) in very early
pregnancy, women complain of tenderness and
tingling in the breasts, breast enlargement and
nodularity
Morning sickness nausea with or without
vomiting is inconsistently in about 50% cases.
It usually appears soon following the missed
period and rarely lasts beyond the 3rd month

 Disturbances

in urination - frequency of
micturition early in pregnancy, the
enlarging uterus puts pressure on the
bladder, causing frequent urination. This
condition improves as the uterus grows
and moves up into the abdomen but
returns late in pregnancy when the fetal
head settles into the pelvis against the
bladder
Fatigue (tiredness)

Objective signs (clinical evidence)

Breast

changes there is
enlargement with vascular
engorgement evidenced by the
delicate veins visible under the
skin (increased vascularity). The
nipple and the areola (primary)
become more pigmented and the
secondary areola appears.
Montgomerys tubercles are
prominent. There are variable
degree of striae
Enlargement of the abdomen
uterus remains a pelvic organ until
12th week, it may be just felt per
abdomen as a suprapubic bulge

Pelvic changes
Bluish discolouration of the vestibule, vagina
and cervix is due to local vascular
congestion (increased vascularity) visible
on speculum examination
Cervix becomes soft the pregnant cervix
feels like the lips of the mouth, while in the
non pregnant state, like that of tip of the
nose. Nulliparous cervix is conical with a
round external os; in parous women, it
becomes cylindrical and the external os is a
transverse slit

 Uterine

signs changes in
the size, shape and
consistency. The uterus
enlarges and softens. The
pyriform shape of the non
pregnant uterus becomes
globular by 12 weeks
There may be asymmetrical
enlargement of the uterus if
there is lateral implantation.
This is called Piskaceks sign
where one half is more firm
than the other half. As
pregnancy advances,
symmetry is restored

 Endocrine

tests for pregnancy depend on

human chorionic gonadotropin (hCG) levels
in maternal plasma and excretion of hCG in
the urine
Urine pregnancy tests detect the presence
of hCG and luteinizing hormone (LH)
Serum pregnancy tests quantify the subunit of hCG, which differs from the subunit of LH, thus providing greater
sensitivity than the urine tests

Second trimester (13-28 weeks)

The subjective symptoms (nausea, vomiting,
frequency of micturition) usually subside,
while amenorrhoea continues. The new
features that appears are quickening and
progressive enlargement of the lower
abdomen by a mass
Quickening (feeling of life) denotes the
perception of active fetal movements by the
women. It is usually felt about the 18th week
in the first pregnancy, about 2 weeks earlier in
multiparae. Its appearance is an useful guide
to calculate the expected date of delivery

General examination
Chloasma
pigmentation over
the forehead and
cheek
Abdominal
examination
Inspection
Linea nigra (linear
pigmented zone)
Striae (pink or white)
of varying degree are
visible in the lower
abdomen, more
towards the flanks

Palpation

Fundal height is increased with progressive enlargement

of the uterus. Approximate duration of pregnancy can be
ascertained by noting the height of the uterus in relation
to different levels in the abdomen
The height of the uterus is midway between the
symphysis pubis and umbilicus at 16th week; at the level
of umbilicus at 24th week and at the junction of the
lower third and upper two-third of the distance between
the umbilicus and ensiform cartilage at 28th week
The uterus feels soft and elastic and becomes ovoid in
shape
Braxton-Hicks contractions are evident
Palpation of fetal parts can be made distinctly by 20th
week
Active fetal movements

External ballottement the test is elicited with the

patient in dorsal position; one hand taps the uterus on
the side to displace the fetus; the other hand which is
placed on the other side to steady the uterus can
perceive the impulse
Ascultation
Fetal heart sounds (FHS) is the most conclusive
clinical sign of pregnancy. It can be detected between
18-20 weeks. The sounds resemble the tick of a watch
under the pillow. Its location varies with the position of
the fetus. The rate varies from 120-160 per minute
Two other sounds are confused with fetal heart sounds
uterine souffle (the sound is synchronous with the
maternal pulse) and funic or fetal souffle (the sound is
synchronous with the fetal heart sounds) and it is due
to rush of blood through the umbilical arteries

Last trimester (29-40 weeks)

Symptoms amenorrhoea; enlargement of the

abdomen; frequency of micturition reappears; fetal
movements; lightening (at about 38th week, specially
in primigravida, a sense of relief of the pressure
symptoms is obtained due to engagement of the
presenting part)
Signs
Cutaneous changes increased pigmentation and
striae
Uterine shape is change from cylindrical to spherical
beyond 36th week
Fundal height
Braxton-Hicks contractions
Fetal movements
Palpation of the fetal parts
F.H.S.
Sonography

Differential diagnosis of
pregnancy
Pseudocyesis (false pregnancy)
Cystic ovarian tumour with abdominal
development
Fibroids
Distended urinary bladder
Gastro-intestinal diseases

ANTEPARTUM CARE (ANTENATAL CARE)

Pregnancy is a normal physiologic state, not a
disease state. The objective of prenatal care is
the delivery of a healthy infant and maintenance
of the health of the mother
Components of antepartum care
Periodic assessment, which begins with a
comprehensive history and physical examination
to identify risk factors and abnormalities, should
continue at regular interval
Patient education fosters optimal health, good
dietary, and proper hygiene
Psychosocial support is very important during an
emotional experience as profound as pregnancy

Terminology
A

nulligravida is a woman who is not and has

never been pregnant
A nullipara is a woman who has never completed
a pregnancy to the stage of viability; she may or
may not have aborted previously
A primipara is a woman who has completed one
pregnancy (single or multiple gestation) to the
stage of viability
A multipara is a woman who has completed two
or more pregnancies to the stage of viability
A parturient is a woman in labour
A puerperal is a woman who has just given birth

History taking
Vital statistics name, date of examination,
address, age (a woman having her first
pregnancy at the age of 30 or above is called
elderly primigravida), gravida, parity,
occupation, menstrual history (cycle, duration,
amount of blood flow, and the first day of the
last menstrual period LMP), past medical
history, past surgical history (previous surgery
general or gynaecological), family history
(hypertension, diabetes, tuberculosis,
malignancy, mental retardation, blood
dyscrasia, known hereditary disease, multiple
births) , personal history (contraceptive
practice prior to pregnancy, smoking or alcohol
habits), obstetrical history (number of living
children, boys, girls, health status of the baby,
immunization)

 Calculation

of the expected date of

delivery (EDD)
Identification of risk factors - maternal
health problems, alcohol consumption,
cigarette smoking, hypertension, and
exposure to environmental and
occupational hazards
History of present pregnancy the
important complications in different
trimesters of the present pregnancy

Physical examination
General examination
Build obese/average/thin; nutrition
good/average/poor; height, weight,
pallor, pulse, blood pressure (B.P.), heart,
lungs, liver and spleen, breasts
Edema normal (edema of the feet and
ankles during the day is normal);
abnormal (generalized edema of the face,
hands, abdomen, and ankles is abnormal)

Obstetrical examination
Abdominal

tone of the abdominal muscles,

presence of any incisional scar or presence
of herniation and skin condition of the
abdomen. Fundus of the uterus is just
palpable above the symphysis pubis at 12
weeks. Fetal heart tones. Ultrasonography
Pelvic examination
Vagina and cervix speculum examination
(bluish dicolouration, discharges normal or
abnormal, evaluation of cervical and vaginal
lesions)
Pelvis and uterus bimanual examination

Antepartum management
In each visit the following are recorded: weight,
pallor, edema legs, blood pressure
Routine investigations laboratory tests
Initial screening hemoglobin or hematocrit
levels, blood group and Rh type, urinanalysis
for protein and glucose, urine culture, cervical
cytology, serologic testing for syphilis
Additional screening (special investigations)
serological tests for rubella and hepatitis B
virus, maternal serum alpha feto protein
(MSAFP) estimation or triple test at 16-18
weeks for mother at risk of carrying a fetus
with neural tube defect, Downs syndrome or
other chromosomal anomaly

Ultrasound examination
First trimester scan either transabdominal
(TAS) or transvaginal (TVS) helps to detect
early pregnancy, accurate dating, number of
fetuses, gross fetal anomalies, any uterine
or adnexal pathology
Ultrasound examination at 18-20 weeks is
performed for detailed fetal anatomy survey
Repetition of investigations
Haemoglobin estimation is repeated at 28th
and 36th week
Urine is tested for protein and sugar at
every antenatal visit

Frequency of visits
In an uncomplicated pregnancy, a woman
should be seen every 4 weeks for the first
28-30 weeks of pregnancy, every 2
weeks until 36 weeks, and weekly
thereafter until delivery
High-risk pregnancies women with
medical or obstetrical problems require
close surveillance at intervals determined
by the nature and severity of the
problems

Monitoring
Mother blood pressure, weight,
presence of headache, altered vision,
abdominal pain, nausea, vomiting,
bleeding, dysuria, vaginal discharge;
height of the uterine fundus above the
symphysis pubis; position, consistency,
effacement and dilatation of the cervix
(late in pregnancy)
Fetus fetal heart rate, size of the fetus,
amount of amniotic fluid, fetal activity,
presenting part and station (late in
pregnancy)

Special instructions
Patients are instructed about the
following danger signals, which should
be reported immediately whenever
they occur: any vaginal bleeding,
swelling of the face or fingers, severe
or continuous headache, blurring of
vision, abdominal pain, persistent
vomiting, fever, dysuria, escape of
fluid from the vagina

Nutrition

Weight gain 0.5 Kg per month (first trimester), 1 Kg

per month (second trimester), 1.5 kg per month (third
trimester); total 10-12 Kg during pregnancy
The pregnancy diet ideally should be light, nutritious,
easily digestible and rich in protein, minerals and
vitamins
Supplementary nutritional therapy iron therapy is
needed from 20 weeks onwards. The practice of
prescribing supplemental vitamins is common among
obstetricians, even though there is little evidence that
vitamins benefit either the mother or the fetus.
Vitamins should not be regarded as a substitute for food
Antenatal hygiene - rest and sleep, dental care, care of
the breasts; to avoid constipation (due to
progesterone), smoking and alcohol, drugs (medications
which cross the placenta and reach the fetus)