APMC Ch.

9 The Diagnosis of Pregnancy

PRESUMPTIVE EVIDENCE OF PREGNANCY

Presumptive Symptoms:
1. Nausea with or without Vomiting
During 1st 2-3 months of pregnancy, 50% of women
experience distaste for food, food idiosyncracies, &
other digestive tract disturbances
Morning Sickness
Emotional tension
Associated with hyperplacentosis (multiple gestations
or molar pregnancies)
Persistent vomiting aggravated by inability to take in
food results in dehydration & ketonuria (hyperemesia
gravidarium)
Symptoms usually appear at 6 weeks, peat at around
60-70 days; correlated with amount of circulating
hCG
Management:
i. Small feedings, avoid fatty foods
ii. Light, dry, low fat diet
iii. Ice chips may help
iv. Hospitalization for hydration & correction of
fluid & electrolyte imbalances
2.

Disturbances in Urination
Enlarging uterus causes direct pressure on the urinary
bladder, results in:
a.
Irritability
b.
Dribbling
c.
Nocturia
d.
Frequent UTIs
Most marked during 2nd & 3rd month when uterus is
still a pelvic organ & adjacent to bladder
Symptoms disappear as uterus rises as an abdominal
organ but reappear near term

3.

Fatigue
Especially during the 1st few weeks of pregnancy
Attributed to increased metabolism

4.

5.

Perception of Fetal Movement (Quickening)

Primigravidas- experienced in 18-20 weeks
Multigravidas- experienced in 14-16 weeks
Intensity and frequency increases as pregnancy
progresses
Breast Symptoms
Mastodynia- tenderness; from tingling to frank pain
during 1st few weeks of pregnancy
Described as tightness or heaviness that results from
engorgement
Due to effects of estrogen(stimulate mammary ducts)
& progesterone(stimulates alveolar components)

Presumtive Signs:
1.

Cessation of Menstruation

Delay of 10 or more days is highly suspect; 2nd missed

period enhances suspicion
Amenorrhea is not always a reliable indicator; delays
may be caused by factors such as:
a. Irregular cycles
b. Emotional stress
c. Chronic disease
d. Drugs
e. Endocrine disorders
f. Lactation
g. Genitourinary tumors
Implantation bleeding may occur & resolves
spontaneously

2.

Anatomical Breast Changes (6-8 weeks after conception)

Montgomerys tubercles (circumlacteal sebaceous
glands) of the areola become prominent
Areola become darker & more prominent
Increased erectility of nipples
16th Week- colostrums may be expressed

3.

Changes in Vaginal Mucosa (6th Week)

Chadwicks Sign- congested & violaceous, bluish or
purplish color of vaginal mucosa

4.

Skin Pigmenation Changes

Chloasma (mask of pregnancy) - darkening of skin
over the forehead, bridge of nose or cheekbones
Linea Negra darkening of linea alba due to
stimulation of melanophores by increased MSH; also
included are areola, nipples, lower abdominal midline,
axilla, neck, groin
Striae Gravidarum (stretch marks)- caused by
separation of underlying collagen tissue; appears in
later pregnancy; may be reddish or purplish (recent
rupture of muscle fibers) but may turn silvery white
Spider Telangiectasia- vascular, stellate marks
resulting from high levels of estrogen; blanch when
compressed; palmar erythema is an associated sign

5.

Thermal Signs
Elevation in body temp for longer than 3 weeks
Attributed to thermogenic effect of progesterone
Basal body temp is higher during luteal phase

PROBABLE EVIDENCE OF PREGNANCY

Probable Signs:
1. Enlargement of Abdomen
Progressive from 6 weeks on
By 12th week- uterine fundus felt at level of symphis
pubis
At 16-22 weeks- growth is more rapid as uterus rises
Fundic Health Measurement is a useful tool in
estimating the AOG:
a.
Linear measurement from symphis pubis to
uterine fundus on an empty bladder
b.
Correlated with AOG from 16-32 weeks

2.

3.

Changes in shape, size, consistency of uterus

12 Weeks- uterus is somewhat globular with an
average diameter of 8 cm
Hegars Sign (6th-8th week)- softening of the uterine
isthmus; compressible on bimanual examination
Goodells Sign (as early as 4 weeks)- cyanosis and
softening of the cervix due to increased vascularity of
tissue
Anatomical changes in cervix
Softening occurs at 6-8 weeks, likened to consistency
of lips
Mucus has beaded cellular pattern; characterizes
progestational effect on mucus which replaces
ferning pattern of estrogen predominance seen in 1st
half of menstrual cycle

4.

Braxton-Hicks contraction
Painless, irregular contractions which may be palpable
and visible
Begin early in pregnancy but become more
perceivable towards the 28th week

5.

Ballottement
By 20th Week, volume of fetus is small compared to
amniotic fluid
When uterus is moved from side to side, feels like
something is floating or bouncing
Internal ballottement feels bounce back

6.

Physical outlining of the fetus

Huge masses as myomas or ovarian newgrowths often
mistaken for fetal head

7.

Positive results of endocrine tests

hCG (detected as early as 8-9 days after ovulation)
a. in serum & urine
b. increase from day of implantation; peak
levels about 60-70 days
c. decline slowly till plateau is reached at 100120 days of pregnancy
agglutination-inhibition; radioimmunoassay, ELISA,
immunochromatography

POSITIVE RESULTS OF PREGNANCY

1.

Abdominal enlargement is more pronounced in

multigravida then primigravida
a.
More so if history of multifetal pregnancies,
polyhydramnios, fetal macrosomia

Identification of Fetal Heart Action Separately and

Distinctly from the Mother
Fetal Heart Tones (FHT) 18th week with stethoscope,
can be detected as early as 10-12 weeks with more
sensitive stethoscope using Doppler principle
FHT is faster than mothers, usual rate 110-115 bpm
Fever, drugs (tocolytics), thryotoxicosis cause inc
FHT

Fetal echocardiography demonstrates FHT as early as

48 days from 1st day of menstruataion (6-8 weeks
AOG)
Real time sonography demonstrates FHT & movement
by 2nd month of pregnancy
Other sounds heard through abdominal wall:
a. Funic Souffle or umbilical cord souffl
b. Uterine souffl
c. Sound from movements of fetus
d. Maternal pulse
e. Gurgling Gas in Mothers GIT

2.

Perception of Active Fetal Movement by the Examiner

After 20th Week- active fetal movement seen and felt
by examiner

3.

Recognitionof the Embryo or Fetus by Ultrasound or

Radiological Methods
At 6-12 weeks, CRL is accurate to 4 days of AOG
Info from Ultrasound
Presence of Blighted Ovum
Number of Fetuses
Ectopic Gestation
Presenting Part
Fetal Anomalies
Hydramnios
Detection of Intrauterine Growth Retardation (IUGR)
Vaginal probe gives opportunity to assess early
pregnancy with more accuracy
Gestational sac as small as 2 mm corresponds to 16
days from ovulation or 10 days after implantation

Differential Diagnosis
Pregnancy often mistaken for myoma, hematometra,
or
Adhesions
Pseudocyesis
Imaginary or spurious pregnancy, may occur in
women nearing menopause or those strongly desiring
pregnancy
IDENTIFICATION OF FETAL LIFE OR DEATH
50% of cases are of unknown cause
Pregnancy tests are not reliable because trophoblasts of the
placent continue producing hCG for several days or weeks
after fetal demise
Hyperemesis, hypertension, breast, and weight return to
normal
Decrease in uterine size
Soft, collapsible fetal skull may be felt
Tobacco stained amniotic fluid, seen either on
amniocentesis or amniotomy is highly suggestive
Ultrasound may show oligohydramnios or particulate
matter
Radiographic Evidence include:

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Spaldings Sign- overlapping of fetal skull bones

due to liquefaction of the brain
Exaggeration of fetal spine curvature
Roberts Sign- gas bubbles in the fetus