Diagnosis of pregnancy By Dr/Ayat Masoud Omar

Introduction The diagnosis of pregnancy requires a 3multifaceted approach using 3 main diagnostic tools, history and physical examination, hormonal assays, and ultrasound (US). Currently, physicians may utilize all of these tools to diagnose pregnancy at early gestation and to help rule out other pathologies

Presumptive (subjective )signs Objective (probable) signs Diagnostic (positive/sure) signs of pregnancy

I- Presumptive (subjective )signs of pregnancy: These signs are least indicative of pregnancy; they could easily indicate other conditions. signs lead a woman to believe that she is pregnant

D.D( others )? (1)Amenorrhea: It is the earliest symptoms of pregnancy. In healthy women whose menstrual cycles are regular, missing one or more menstrual periods leads to consideration of pregnancy. D.D( others )?

(2) Nausea and Vomiting Are experienced by almost half of all pregnant women during the first three months of pregnancy and result from elevated HCG level .The symptoms frequently occur in the early part of the day, and disappear within few hours and commonly called Morning Sickness. These symptoms disappear spontaneously from 6 to 12 wks

3)Excessive fatigue: May be noted within a few weeks after the first missed menstrual period and may be persisted throughout the first trimester.

4-Frequent urination • Is caused by pressure of the expanding uterus on the bladder. • It subsides as pregnancy progresses and the uterus rises out of the pelvic cavity. • The uterus returns during the last weeks of pregnancy as the head of the fetus presses against the bladder.

4)Engorgement of the breasts due to the hormone-induced growth of the secretary ductal system results in subjective symptoms of tenderness and tingling, especially of the nipple area. Montgomery's tubercles: from 12-30 nodules appear on primary areola, opening of sebaceous glands and keeps the nipple soft.  

Secondary areola: appears from 16 weeks, covering half of breast, persist year after delivery.  More prominent and visible veins due to the increased blood supply.

5) Quickening: It is the first perceptible fetal movement felt by the pregnant mother, occurs about 18-20 wks after the last menstrual period in a primigravida, but may occur as early as 16 wks. in a multigravida. Quickening is the fluttering sensation in the abdomen that gradually increases in intensity and frequency.

II-Objective (probable) signs: An examiner can perceive the objective changes that occur in pregnancy. They are more diagnostic than the subjective symptoms; however, their presence does not offer a definite diagnosis of pregnancy.

Changes in the pelvic organs: These changes caused by increased vascularity and congestion during the first three months of pregnancy.

1- Hegar's sign: It is the softening of the isthmus of the uterus, the area between the cervix and body of the uterus, which occur at 6 to 8 weeks of pregnancy. This area may become so soft that on bimanual examination the anterior fornix fingers and abdominally fingers meet each other.

2- Chadwick's sign: Is the deep red to purple or bluish coloration of the mucous membranes of the cervix, vagina and vulva due to vasocongestion of the pelvic vessels.

McDonald's sign : It is an ease in flexing the body of the uterus against the cervix. Osiander's sign: It is increase pulsation in lateral fornix due to increase vascularity resulted in pelvic congestion.

Enlargement of the abdomen: During the childbearing years is usually regarded as evidence of pregnancy, especially if the enlargement is progressive and is accompanied by a continuing amenorrhea.

Braxton Hicks contractions: Are ordinary painless that occur at irregular intervals throughout pregnancy but are felt with abdominal palpation after 28 weeks. As the pregnancy progresses these contractions become uncomfortable and are often called" false labor ".  

Uterine Soufflé: May be heard when auscultating the abdomen over the uterus. It is a soft blowing sound at the same rate as the maternal pulse and is due to the increased uterine vascularization and the pulsation through the placenta.  

Uterine soufflé is sometimes confused with the funic soufflé which is a soft blowing sound of blood pulsating through the umbilical arteries. The funic soufflé is as the same rate as the fetal heart rate

Skin changes: Changes as pigmentation of the skin and the appearance of abdominal stria gravidarium are common manifestation in pregnancy. Facial cholasma occurs in varying degrees after 16 weeks. Also linea nigra also appear in the abdomen. The pigmentation of the nipple and areola may darken, especially in primigravidas. - Fingernails. Some patients note marked thinning and softening by the sixth week.

Ballottement: Is a passive fetal movement elicited by pushing up against the cervix with two fingers. This pushes the fetal body up and down as it falls back, the examiner feels a rebound.

Pregnancy test: Are based on analysis of maternal blood or urine for the detection of human chorionic gonadotrophins(hcG).   Pregnancy tests: All depend on the detection of hCG either in urine or in serum. HCG levels peak between 50 to 90 days after the last menstrual period.

Production of hCG begins as early as the day of implantation (a) Urine. This test can be performed accurately 42 days after the last menstrual period or 2 weeks after the first missed period. The first urine specimen of the morning is the best one to use. (b). Blood. Radioimmunoassays (RIA) can detect HCG in the blood 2 days after implantation or 5 days before the first menstrual period is missed.

III -Diagnostic (positive/sure) signs of pregnancy The positive signs of pregnancy are completely objective, cannot be confused with pathological states, and offer conclusive proof of pregnancy, but they are usually not present until after the fourth month of pregnancy.

1-The fetal heart beats: The fetal heart begins beating by the 24th day following conception. It is audible with a doppler by 10 weeks of pregnancy and with a fetoscope after the 16th week . It is not to be confused with uterine souffle or swishlike tone from pulsating uterine arteries. The normal fetal heart rate is 120 to 160 beats.

2-Fetal movements: Are actively palpable by a trained examiner after about 20weeks of gestation. They vary form a faint flutter in the early months to more vigorous movements late in pregnancy.

3-Ultra sound: Is a technique that can be used for a positive diagnosis as early as the fourth to fifth week of pregnancy. The earliest structure identified is the gestational sac (GS). The GS can be seen on TVUS by 4-5 weeks' gestation and grows at a rate of 1 mm/d in early gestation

4-Fetal Parts: Can be palpated through the abdominal wall 5-Radiological (x-ray): An x-ray will identify the entire fetal skeleton by the 12th week. In utero, the fetus receives total body radiation that may lead to genetic or gonadal alterations. An x-ray is not a recommended test for identifying pregnancy.