17Objective Signs Breast changes valuable only in primigravidae breast changes are evident between 6-8 weeks(vascular engorgement & nipple and areola pigment)Montgomery’s tuberclecolostrum expressed as early as 12th weeks
25Chadwick’ sign is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in . It can be observed as early as 6-8 weeks after conception, and its presence is an early sign of pregnancy.
27Cervical sign (Goodell’ sign) Become soft as early as 6th week Non pregnant uterusPregnant uterus
28Uterine sign Size, shape and consistency 6th week 8th week 12th week Asymmetric→SymmetricThe pregnant uterus feels soft and elastic
29Hegar’s sign demonstrated between 6-10 weeks Upper part of the body of the uterus is enlarged by growing fetus;Lower part of the body of the uterus is empty and extremely soft;The cervix is comparatively firm
30The abdominal fingers behind the uterus The abdominal and vaginalfingers seem opposebelow the body of uterusTwo fingers in the anterior fornix
31Palmer’s signRegular and rhythmic uterine contraction can be elicited doring biomanual examination as early as 4-8 weeks
33Principle of pregnancy test detection of the antigen of HCG present in the maternal urine or serumSelectionn of time8-10 days after conceptionCollection of urinethe first voided urine in the morning in a clean container
34Ultra SonographGestation sac (GS) can be identified as early as days of gestation
37True and pseudo gestation sac CharacterTrue GSPseudo GSLocationEccentricallyCentrallyShapeRound & regularIrregularDouble ring signPresentAbsentYork sac and fetal poleIncrease in sac size1 mm/ day
38First Trimester Review The Whole Period of Pregnancy Can Be Divided Into Three StagesThe first trimester (early pregnancy): 1-12wThe second trimester (middle pregnancy): wThe third trimester (late pregnancy): 28-40w
391. History and symptoms A. Cessation of menstruation This is the first frequent symptom of pregnancy, althougha few women may have slight bleeding after conception.Amenorrhea is not only due to pregnancybut also other reasons.Women of breast feeding may be pregnantbefore the recovery of menses.
40B. Nausea and VomitingAlso called morning sickness because they occur upon arising. These symptoms appear one or two weeks after the period is missed and last until 10th to 12th week, its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravidarum).
41C. Urinary symptomsIncreased frequency of urination is due to increased circulation associated with the effect of estrogen and progesterone on the bladder, combined with pressure by the gradually enlarged uterus on the bladder.
42D. MastodyniaIt may be present in early pregnancy and ranges in severity from a tingling sensation to frank pain.
432. Signs Breast changes Breast enlargement and vascular engorgement. Nipple and areola become blacker.Enlargement of the accumulated sebaceous glandsof the areolas (Montgomery’s tubercles) may be noted.
44Changes of the reproductive organs Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested.Cervix: Cyanosis and a gradual softening due to congestion.
45Uterus: Enlargement and softening. The isthmus of the uterus is also soft and can be compressed between the fingers palpating vagina and abdomen (Hegar’s sign).After the 12th week, the fundus of the uterus is usually palpable above the symphysis pubis.
463. Supplementary examination Pregnancy testThe laboratory test for pregnancy are based on theidentification of human chorionic gonadotropin (hCG),which can be detected as early as 7-9 days after fertilizationby high sensitive technique.The samples may be blood or urine.
47Basal body temperature (BBT) A persistent elevation of BBT for longer than 18 daysmay be presumptive evidence of pregnancy.
48Progesterone is given to a women with amenorrhea. Progesterone testProgesterone is given to a women with amenorrhea.If she is pregnant, no bleeding will follow, otherwise,bleeding should occur within 7-10 days of progesteroneadministration.This is reliable in the nonpregnant patient only ifthere is adequate estrogen stimulation of the endometrium.
49UltrasonographyThere are trans-vaginal and abdominal Ultrasonagraphys.A gestational sac can usually be identified at 5-6 weeksafter the beginning of the last period.Fetal heart beating can be detected by about 7th week andthe fetus itself can be seen by about the 8th week.Doppler is also an ultrasound technique,which diagnoses the pregnancy by revealing the heart beating.
52Nausea, vomiting, frequency of micturition subside SymptomsNausea, vomiting, frequency of micturition subsideAmenorrhea continuesQuickening: perception of active fetal movement by women(From 18th week)Progressive enlargement of lower abdomen by the growing uterus
6316th week: midway between symphysis pubis and umbilicus 22~24th week: at the level of umbilicus28th week: at the junction of the lower 1/3 and upper 2/3 of the distance between the umbilicus and ensiform cartilage
65Braxton-Hicks Contraction In 1872, John Braxton Hicks investigated the laterstages of pregnancy and noted that many women feltcontractions without being near birth.This process was usually painless but caused women confusionas to whether or not they were going into actual labor
66CauseBraxton Hicks contractions are a tightening of the uterine muscles for one to two hours and are thought to be an aid to the body in its preparation for birth.
67Alleviating factors Rhythmic breathing Lying down on the left side A slight change in movementUrination
68Very early, the uterus undergoes spontaneous contraction Firmer at one moment and soft at anotherCan be excited by rubbing the uterusIrregular,infrequent, spasmodic, and painessNear term, frequent with increase in intensity, discomfortMerge with the labor
69Palpation of fetal parts Diagnosis of pregnancyIdentify the presentation and position of fetus
71Active fetal movements Positive evidence of pregnancy & live fetusFaint flutter→stronger movement
72External ballottement Be elicited as early as 20th weekObese women & scanty liquor amniiby a push to the foetal parts with one hand abdominallyand the other hand receiving the impulse
73Ballottement is a medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.
90SignsFetal heart sound can be heard at rate varies from 120 to 160 beats per minute.The fetal body can usually be palpated by the 18th to 20th week of gestation unless the patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid.
95Symptoms: Amenorrhoea Enlargement of the abdomen Lightening: due to the engagement of the presenting partFrequency of micturitionFetal movement
96Cutaneous changes: increased pigmentation and striae Sign:Cutaneous changes: increased pigmentation and striaeUterine shape: cylindrical to spherical beyond 36th weekFundal heightBraxton-Hicks contractionFetal movementPalpation of the fetal parts
100After 24 weeks, the SFH measured in cm After 24 weeks, the SFH measured in cm. correspond to the number of the weeks up to 36 weeks.A variation of ± 2 is accepted as normal.Variation beyond the normal range needs further evaluation.
101More than ① Mistaken date of the last menstrual period; ② Twins; ③ Polyhydramnios;④ Big baby;⑤ Pelvic tumours;⑥ Hydatidiform mole;⑦ Concealed accidental haemorrhage
104Less than ① Mistaken date of the last menstrual period; ② Scanty liquor amnii;③ Fetal growth retardation;④ Intrauterine fetal death
105Upper part of the uterus Lateral part of the uterusFurther confirmationPresentation; Engagement
106broad, soft, irregular mass Fundal gripbroad, soft, irregular masssmooth, hard, globular→ breech→ head
107Lateral or umbilical grip smooth curved and resistant →black comparatively empty and small knob → limb
108First pelvic gripPresentation: the part occupy the lower pole of the uterusAttitude: the relative position of the sincipital and occipital or different parts of the fetus to one anotherEngagement: convergence or divergence of the finger during palpation
109Second pelvic gripmobility from one side to side is tested
110Fetal lie & fetal Presentation Fetal lie: the relationship between the long axis of the mother and the long axis of the fetus. (longitudinal lie and transverse lie)Fetal presentation: the portion of the fetus that descends into pelvis first.
119Sonograph AC abdominal circumference HC head circumference BPD biparietal diameterFL femur lengthAmniotic Fluid volumeoligohydramnios & polyhydramniosPlacental anatomy:location, thickness, abnormalities
120Differential Diagnosis of Pregnancy Pseudocyesis: psychological disorder,cessation of menstruation
121Cystic ovarian tumour Amenorrhoea is absent; Swelling is slow;Amenorrhoea is absent;Feels cystic or tense cystic;Absence of Braxton-Hicks contraction;Absence of positive signs of pregnancy;Ultrasonograph show absence of fetus
122Uterine fibroid: Amenorrhoea is absent; Slow growing;Amenorrhoea is absent;Feels firm , more towards hard;Absence of Braxton-Hicks contraction;Absence of positive signs of pregnancy;Ultrasonograph show absence of fetus
123Summary of Diagnosis of Pregnancy Positive or absolute signPersumptive symptoms and signsProbable signs
124Positive or absolute sign Palpation; Auscutation; Ultrasound
125Persumptive symptoms and signs Amenorrhoea;Frequence of micturition;Morning sickness;Fatigue;Breast changes;Skin changes;Quickening
127Chronological Appearance At 6-8 weeksAt 16th weekAt 20th week
128Estimation of Gestation Age & Prediction of Excepted Date of Delivery Excepted Due Date= LMP﹣3/﹢9 month and ﹢7 daysLMP is 26th July, when is the EDD?
129Patient’ statement Date of coitus Naegele’s Formula Date of quickening: adding weeks
130add seven days subtract 3 months add one year Excepted Due Date = LMP﹣3/﹢9 month and ﹢7 daysadd seven dayssubtract 3 monthsadd one yearLMP is 26th July, when is the EDD?
131Clinical : Size of the uterus Investigation: Ultrasonographic finding Previous recordClinical : Size of the uterusPalpation of fetal partsInvestigation: Ultrasonographic findingGS - 5th weekcardiac activity - 6th weekEmbryo movement – 7th weekCRL in cm = week of pregnancy(Crown-rump length)BPD in cm = month of pregnancy(From 20th week)
132Objective signs Height of the uterus Lightening Size of the fetus Vaginal examination