Diagnosis of pregnancy

obstetrical condition

1. DIAGNOSIS OF PREGNANCY BRITTO.V LECTURER IN NURSING

2. INTRODUCTION The total duration of pregnancy (38-40 weeks), is divided into 3 trimesters. These are 1 st trimester- 12 weeks 2 nd trimester – 13- 28 weeks 3 rd trimester – 29- 40 weeks The diagnosis of pregnancy is studied and made according to the changes occuring during these 3 trimesters. There are various signs and symptoms in these trimesters , which will be discussed below;

3. First trimesters A) subjective symptoms: Amenorrhea – it means missing of menses. Some women notice small blood discharge at the time of first missed period. It is known as placental (implantation )sign. Morning sickness – it is the feeling of nausea with or without vomiting. It is usually seen in 50% of women during second month. Mother feels loss of appetite, but it does not affect the health of the mother.

4. Frequency of micturation – mother feels the urges to pass urine again and again. It occurs mainly because of the anteverted position of the uterus, in which the gravid uterus puts pressure on the fundus of the bladder. There is also stretching of the bladder base due to the backward displacemnt of the cervix, which further irritates the bladder . After 12 weeks, the uterus straighten up, and the symptoms disappears. Breast discomfort – there is a feeling of fulness and pricking sensation in the breast, feel by the mother during 6-8 weeks. Fatigue – mother feels fatigued easily in the early pregnancy.

5. b) objective signs: Breast changes – the breast shows signs, such as enlargement of breast with vascular engorgement. This results in visualization of delicate veins under the skin, the areola becomes pigmented with appeareance of montgomerys tubercules ; a pale yellow secretion ( colostrum ) can be expressed from the nipple in third month. Per abdomen – fundus of uterus is not felt in earlier pregnancy . Till 12 weeks, it remains a pelvic organ at 12 weeks, a soft uterine fundus can be felt at superior border of symbysis pubis. Pelvic changes – 1. Jacquemiers sign or chadwicks sign – it is the dusky hue of the vestibule and anterior vaginal wall, occuring due to the local vascular congestion at about 8 weeks of pregnancy.

6. Cervical sign – or goodells sign – softening of ceervix , around 6 th week. Vaginal sign – the wall of the vagina become soft and during 6 th week , a non irritating mucous discharge appears. Around 8 th week , an increased pulsation is felt through the lateral fornices , called osianders sign. Uterine sign – with the advancement in pregnancy , uterus also keeps on increasing in size. Uterus is soft and elastic. It is the size of mens egg at 6 th week, size of cricket ball at 8 th week, size of fetal head by 12 th week. Hegars sign – it is between 6-10 weeks. According to this sign, when the uterus is palpated bimanually, the two vaginal fingers can almost meet the abdominal fingers, which shows that upper part of utreus is enlaeged by growing ovum and the lower part is soft and empty.

7. Palmers sign – it is bimanual examination regular and rhythmic contractions can be elicited as early as 4 – 6 weeks.

8. SECOND TRIMESTER A) subjective symptoms: Amenorrhoea Uterus enlargement Quickening - mother feels the active fetal movements at around 16 th week ( multigravida ), 18 th week ( primigravida ).

9. b) Objective signs Chloasma – pigmentation appears on face and forehead around 24 th week. Breast changes – from 20 th week, pigmenation appears around primary areola in breasts, which is called as secondary areola. Breasts are more enlarged and montomers tubercules are seen. Straiae become visible and colostrum becomes thick and yellowish.

10. Abdominal findings – 1. Inspection : after 20 th week, there is appeareance of a linear pigmentation in the middle of abdomen, extending from symphysis pubis to ensiform cartilage called as linea nigra . Various degree of straie also visible on the lower abdomen. 2. Palpation : uterus is ovoid in shape, enlargement of uterus, fundal height is also increased. Uterus is; at 16 th week – between symbsis pubis and umblicus . at 20 th week – 2.5 cm below umblicus at 24 th week – at the level of umblicus at 28 th week – between umblicus and xiphoid sternum. 3. Braxton hicks contractions : women cannot feel the contractions at this time , but these can be felt by placing a palm on the uterus.

11. 4.Active fetal movements : can also be felt by placing the palms on the sides of the uterus. 5. Palpation of fetal movements: by 20 th week, fetal parts can be palpated. 6. External ballotment : around 20th week, by keeping the mother in dorsal position, with one hand tapping of uterus is done from one side, while the other hand, which is kept outstrched on the other side feels the impulse. 7 . Ascultation : by 20 th week , one can hear the fetal sound with the stethoscope.normally – FHS is 140- 160 /min. There are other 2 sounds, uterine souffle and fetal souffle .

12. Uterine souffle – soft blowing systolic murmur which is heard low down at the sides of the uterus. Fetal souffle – soft blowing murmur with the fetal heart sound . It is due to rush of blood through the umblical arteries.

13. Internal ballotment – around 16- 28 weeks , internal ballotment can be elicited , as the fetus is too small before 16 th weeks to elicit sign. Clinical manifestation – ultrasonography – with the help of sonography , gestational age is determined.

14. THIRD TRIMESTER A) subjective symptoms: Amenorrhea Enlargement of the abdomen Pressure symptoms Fetal movements Lightening – it is the sense of relief felt by the mother from the pressure symptoms due to the engagement of the presenting part into the pelvis.

15. Objective signs: Skin changes Uterine shape – become cylindrical to spherical Fundal height – increases Braxton hicks contractions Fetal movements and palpation of fetal parts can more easily. ultrasonography

16. Signs of pregnancy 1. presumptive signs 2. probable signs 3. positive signs Presumptive signs: this include maternal physiological changes, which the women experiences, indicating that she is pregnant. Amennorhea Nausea and vomiting in 1 st trimester Frequency of micturation in 1 st trimester

17. Fatique of mother Enlargement of breast Appeareance of montgomerys tubercles Expression of colostrum from nipples Pigmentation of skin ( cholasma , linea nigra , striae ) Quickening

18. Probable sign: these are maternal physiological changes, which are detected upon examination by the examiner. Changes in shape of uterus and enlargement in the size. Positive pregnancy test through presence of HCG in urine. Hegar’s sign Chadwick’s sign Osciander’s sign Goodell’s sign Ballotment of fetus . Braxton hicks contractions.

19. Positive sign: these signs directly tell about the presence of the fetus and are detected by the examiner. Visualization of the fetus by ultrasound Visualization of fetal skeleton by x-ray F.H.S by ultrsound and later on by fetoscope Fetal movements palpable by examiner Visualization of fetal movements in late pregnancy. Palpation of fetal parts.

20. DIFFERENTIAL DIAGNOSIS Emotional stress, illness, imbalance in hormones. Contrceptive pills Gastrointestinal disorders Urinary tract infection Intestinal movement Choriocarcinoma Hydatidiform mole Tumors Pelvic congestion Increased blood flow to uterus.

21. CONFIRMATORY TEST The confirmatory test carried during pregnancy are: Urinary immunological tests Latex agglutination slide test Immunochromatographic test 2.ELISA or radioimmunoassay (RIA) 3.Biological test, achhein and zondek test

22. Urinary immunological tests: it includes 2 test latex aggultination slide test: in slide test, when HCG antesera is combined with urine with HCG , if no agglutination appears, then the pregnancy is positive. If there is visible agglutination there is no pregnancy. This test comes positive after 2 weeks of missed menses. Immunochromatogrphic test: these test are available in market as pregcolor card or asccutest HCG . This test is more sensitive than the former test and comes positive after 1 week of missed menses.

23. Elisa or radioimmunoassay (RIA): this test is specially indicated in patients with trophoblastic diseases. It can detect HCG on the 8 th day of fertilization, before menses is missed. Biological test, achheim and zondek test : as there is problem of available animals , this test is no more used.

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