DIAGNONSIS OF PREGNANCY AND

MATERNAL PHYSIOLOGICAL CHANGES OF PREGNANCY

BY

Dr : A/ ILLAH KUNNA

DIAGNOSIS OF

PREGNANCY Diagnosis in the first trimester (first 12 weeks)

Symptoms:

1- Cessation of menstruation

:(missed period):due to increased estrogen and progesterone

production by the corpus Luteum. However it

may be absent in cases of:

pregnancy during lactation amenorrhea.

Threatened abortion.

Slight bleeding at the expected time of

menstruation rarely occurs in the first 3 months

2- Morning sickness:- Nausea , vomiting especially in the

morning.

- Usually disappears after the third month.

- May be due to allergy to hCG.

3- Freguency of micturition:- Due to congestion. Irritation of the

bladder by the pregnant uterus.

- Usually disappears after the third month.

4- Breast symptoms:Enlargement , heaviness , discomfort and

tinling sensation.

5- Appetite changes:Craving for certain types of food and

refusal of other types.

Signs:1. Breast signs : ( evident in a

primigravida).

Increased size and vascularity.

Dilated visible veins.

Increased pigmentation of the nipple

and 1ry areola.

Appearance of 2ry areola.

Appearance of Montgomery

tubercles in the areola ( dilated

sebaceous glands).

Expression of colostrum.

2. Uterine sign ; felt by bimanual examination:

Size : enlarged.

consistency : soft.

Shape : globular.

Hegar sign : ( elicited between 6-10 weeks).

Two fingers in the anterior fornix, the fingers

of the other hand over the abdomen behind

the uterus . The fingers of both hands can be

approximated as the lower part of the uterine

body is soft and empty.

Palmer sign:

Uterine contractions felt on bimanual

examination.

3- Cervical and vaginal signs:

Leucorrhea :

Increased vaginal discharge.

Chadwick s sign:

Bluish discoloration of the vagina and

cervix.

Goodell s sign:

Cyanosis and softening of the cervix at 4

weeks

Investigations:1. Pregnancy test:

All depend on the detection of hCG either in

serum or in urine . Simple urine pregnancy

tests are now available to be used at home

giving an accurate result within 5 minutes.

A. Estimation of beta subunit of hCG in the

serum:

Using radioimmunoassay , sensitivity : 5

mIU/ml.

Positive I week BEFORE the expected

menstuation ( I week after fertilization ).

B. ELISA pregnancy slide test:

can detect pregnancy starting from 48

hours after the missed period.

C. Immunologic pregnancy tests:

Detect hCG in urine by an antigen

antibody reaction.

The sensitivity of these tests ranges

between 25-250 mIU/ ml. positive few

days AFTER the missed period.

Uses of pregnancy tests:Diagnosis of normal pregnancy.

Diagnosis of missed abortion.

Diagnosis of ectopic pregnancy (

see ectopic pregnancy) .

Diagnosis and follow – up of

vesicular mole and

choriocarcinoma .

2. Ultrasonography:Vaginal:

Gestational sac : 4 weeks.

One fetal pole : 5 weeks.

Two fetal poles : 6 weeks.

Fetal heart activity : 7 weeks.

Abdominal:

The previous findings can be detected one week later.

3. Auscultation of FHS :Using the Doptone (sonicaid ) starting from 10 weeks.

Diagnosis in the second trimester

( 13-28 weeks)

Symptoms: 1. Amenorrhea.

2. Morning sickness and urinary symptoms

gradually decrease .

3. “Quickening “ : perception of fetal

movements by the pregnant woman:

a. 18-20 weeks in primigravida.

b. 16-18 week s in multipara.

4. Abdominal enlargement.

Signs: 1. Breast changes become more evident.

2. The uterus is abdominally felt.

3. Braxton Hicks contractions; intermittent

painless contractions detected by abdominal

examination.

4. Internal ballottement : elicited at 16 week , it

can be demonstrated by by pushing the fetus

through the anterior fornix using 2 fingers.

5. External ballottement : elicited at 20 week

through abdominal examination.

6. Palpation of the fetal parts and palpation of fetal

movements by the obstetrician at 20 weeks.

7. Auscultation of the F.H.S. at 20- 24 weeks by

pinard s fetal stethoscope.

MATERNAL PHYSIOLOGICAL

CHANGES OF PREGNANCY

pregnancy is a peculiar physiologicalstate in which many changes take place; mostly due to the effect of pregnancyhormones. These changes helpadaptation of the woman s body topregnancy . Understanding thesechanges is essential for the followingreason: to discriminate betweensymptoms related to pregnancy andthose of pathological conditions, tounderstand the effect of pregnancy onpre-existing diseases e.g diabetes andheart diseases.

1. Genital organs: A. The uterus :

Increase in : size : 7.5 to 35 cm.

weight : 50 to 1000 gms.

Due to:

Effect of pregnancy hormones leading to hypertrophy

( mainly ) and hyperplasia.

Stretching by the growing fetus.

Shape :

Globular until 14 weeks then pyrifrom.

Ligament:

Hypertrophy .

Dextro rotation : ( 80 % of cases).

The uterus is tilted and twisted to the right .

Braxton Hicks contractions:

Irregular , usually painless, with no effect on cervical

dilatation. Promoting placental circulation.

The lower uterine segment:

Is formed from the isthmus , starting from the fourth

month to reach 10 cm by full term.

Upper segment Lower segment

-Active -Passive

-Contracts and retracts

to become shorter and

thicker

- Dilates , stretches to

become thinner and

longer

- Thick wall:

Outer longitudinal

Middle oblique ( main

bulk – most important for

hemostasis ).

Inner circular ( especially

around orifices)

- thin wall, the oblique

layer is poorly

developed.

- Covered by adherent

pertoneum

- Covered by loose

peritoneum

- Membranes are firmly

attached

-Membranes are loosely

attached.

Obstetric singnificance of

L.U.S.:1. Site of lower segment cesarean

section (LSCS).

2. Site of rupture in obstructed labor.

3. Site of implantation of placenta previa.

B. The cervix: Edema.

Increased vascularity.

Hypertrophy of glands.

The cervix becomes soft and bluish ;

the secretions from the mucus plug in

the cervical canal.

Hormonal erosion sometimes occurs.

Near term , prostaglandins induce

changes in collagen fibers and ground

substances making the cervix softer

and easily dilatable.

C. The vulva:Varicosities may develop.

D. The vagina:Increased vascularity makes it

soft, moist, bluish and warm.

E. The ovaries:Edema , increased vasceularity . One

of the ovaries contains the corpus

luteum which may reach up to 5-6 cm

then in starts to degenerate by the 10 th

week.

2. Breasts:changes are induced by estrogen and

progesterone:

1. Early in pregnancy , breasts show increased size and vascularity , become warm, tense, nodular and slighty tender.

2. Increased pigmentation of nipple and 1 ryareola.

3. Secondary areola appears later: a lightly pigmented area around the (1ry) areola.

4. Montgomery s tubercles appear on the areola ( dilated sebaceous glands).

5. colostrum may be expressed at the end of the third month.

3. Skin:1. pigmentation : may be due to MSH or estrogen:

Linea nigra:

pigmentation appears in the midline of the

abdomen , more evident below the umbilicus.

Chloasma :

pigmentation of the face with butterfly

distibution.

2. Striae gravidarum : ( stretch marks).

Pink line in the flanks due to stretch of the

abdominal wall which causes rupture of the

subcutaneous elastic tissue, and also due to

increased cortisol. After labor , the color turns to

white ; “ striae albicans” due to fibrosis.

3. Signs of malnutrition and vitamin deficiency

may be evident , sometimes loss of hair.

4. Cardiovascular system:

1) Blood volume :

Increased by about 45% , half of

this rise is achieved by 8 week and

the maximum increased in blood

volume is mainly due to expansion

of plasma volume more than the

increase in R.B.Cs . Volume

resulting in physiological hydremia

and drop of hemoglobin level.

2) Cardiac output: ( = SV X HR)Increases by 30 – 50 % to reach a maximum at 32-34 weeks and then it is maintained up to full term. The increased CO is mainly due to increased SV as the HR increases only by 15%.

3) Leucocytes : increase to about 16.000/cc.

4) Platelets , fibrinogen : increase , fibrinogen reaches 600 mg %.

5) Venous stasis : in the lower half of the body due to compression of the pelvic veins by the gravid uterus and to relaxation of the venous wall by the effect of progesterone , this may lead to varicose veins, ankle edema and hemorrhoids.

6) Blood pressure :

Decreases slightly during the second trimester due to opening of A-V shunts in the placenta.

Any rise to 140/90 or 30 mm Hg systolic or 15 mm Hg diastolic (above the base line reading before pregnancy or during the first trimester) is considered abdominal .

“ Supine hypotension syndrome”:

Hypotension may develop in supine position especially during late pregnancy due to pressure by the gravid uterus on the in inferior vena cava with subsequent reduction in cardiac output.

7) The apex:

Is displaced upwards in late pregnancy by elevation of the diaphragm(ECG changes).

5. Urinary system:1. Frequency of micturition : Early in pregnancy : due to congestion and

pressure on the bladder by the enlarged uterus .

Late in pregnancy : due to pressure by the presenting part

2. Dilatation of the ureters due to: pressure against the pelvic brim by the uterus

especially on the right side. Effect of progesterone and relaxin hormone. Hypertrophy of the wall of the lower end of

the ureters caused by estrogen .* Dilatation leads to stasis of urine which in turn

predisposes to infection.

6. Respiratory system:

Dyspnea is common due to:

Hyperventilation ( progesterone

effect).

Elevation of the diaphragm (

especially during the 8th month ).

7. Gastrointestinal tract:

Increased salivation with increased aciditypredisposing to dental caries.

Hypertrophy of the gums ( sometimes bleedinggums)

Morning sickness in early pregnancy.

decreased gastric acidicity ( by 50% ) and motilitythat may cause flatulence and interference with irona bsorption.

Heart burn due to reflux esophagitis.

Tendency to constipation due to relaxation of thesmooth muscles by progesterone .

Slight impairment of liver functions.

Relaxation of the wall of gallbladder (cholestasis, predisposing to stone formation).

8. Musculoskeletal system: Increased lumbar lordosis.

Relaxation of pelvic joints and ligaments

( progesterone and relaxin).

9. Endocrine system:1) pituitary :

Anterior pituitary increases in size and activity butthe blood supply is NOT increased. Posteriorpituitary produces oxytocin thus stimulating onsetof labor.

1) Thyroid :

Increased size and activity ; physiological goitermay occur. Total T3 and T4 are increased .

1) parathyroid:

Increased size and activity ; to regulate theincreased calcium metabolism.

4) Adrenals:

Increased activity ; total cortisol is increased but thefree portion calcium metabolism.

5) Placental hormones :

10. Metabolic changes:1. Proteins:

Tendency to nitrogen retention.

2. Carbohydrates:Carbohydrates metabolism is slightly DISTURBED.

- Anti – insulin : are increased .

* HPL ( human placental lactogen) favors transfer of glucose to the fetus.

* Cortisol. Estrogen.

* progesterone Insulinaseenzyme

All , except cortisol , are produced by the plasenta.

Alimentary glycosuria : due to rapid absorption of glucose .

Renal glycosuria : due to lowering of renal thrshold.

3. Fats:

Fats metabolism is disturbed secondary to disturbance of carbohydrate metabolism.

3. Minerals:

Increased requirements of : iron , calcium , phosphorus and Iodine . Tendency to NaClretention ( effect of pregnancy hormones).

3. Water :

Tendency to salt and water retention.

11. Weight :

The average total weight gain is

11- 16 kg, most of it occurs during

the 3rd trimester.

THANK

U