DR. S. RAMYA MD (OG) 2008 – 09 DIAGNOSIS OF PREGNANCY

Pregnancy occurs between puberty and menopause Duration: 9 months and 7 days from 1st day of last menstrual cycle (280 days / 40 wks) Trimesters: duration of pregnancy is divided into 3 periods called trimesters each comprising 13 weeks or 3 months.

Why to diagnose a Pregnancy? Gives absolute joy Gives absolute joy Crucial diagnosis in treating a female of reproductive age group Crucial diagnosis in treating a female of reproductive age group

Failure to diagnose may lead to Failure to diagnose may lead to –incorrect diagnosis –inappropriate treatment –medico legal problems Some pregnancy changes gives clue to verify the gestational age of fetus. Some pregnancy changes gives clue to verify the gestational age of fetus.

Presumptive evidence Presumptive evidence Probable evidence Probable evidence Positive signs Positive signs

Presumptive Evidence Symptoms Signs 1. Nausea and vomiting1. Ceseation of menses 2. Urinary disturbance2. Breast changes 3. Fatigue3. Discoloration of Vaginal mucosa 4. Perception of 4. Skin Changes fetal movements

Probable Evidence Probable Evidence Enlargement of abdomen Enlargement of abdomen Change of size, shape of consistency of Change of size, shape of consistency of the uterus the uterus Changes in cervix Changes in cervix Braxton Hicks contraction Braxton Hicks contraction Ballottement Ballottement Outlining the fetus Outlining the fetus Detection of HCG Detection of HCG

Positive Pregnancy Sings  Identifying FHS separately and distinctly  Perception of active fetal movements by the examiner  Recognition of embryo and fetus any time in pregnancy by USG.

1 st TRIMESTER  Symptoms:  Amenorrhoea best method in calculating EDD  Morning Sickness from 6 to 12 wks due to  levels of hCG

3. Urinary disturbance: due to pressure of enlarging gravid uterus on the bladder. 4. Breast discomfort: due to  vascularity and enlargement 5. Fatigue

on examination 1.Breast changes Valuable only in primi evident between 6 – 8 weeks enlargement with vascular engorgement more pigmented nipple of aerola Montgomery tubercles thick yellowish secretion (colostrum) can be expressed as early as 12th week

2. Skin Changes Cloasma 3. Per abdomen Uterus remains pelvic organ till 12th week 4. Pelvic changes: a. Vagina - Jacquemier’s or Chadwick’s sign - Osiander’s sign - Copious non irritating mucoid discharge

 b. Cervix - Goodell’s sign - bluish discolouration of cervix  c. Uterus - Soft, enlarged of globular - Piskacek’s sign - Hegar’s sign - Palmer’s sign

Investigations: 1. Hormonal tests 2. USG Hormonal tests: Principle: Detection of antigen (hCG) present in the maternal urine or serum with either polyclonal or monoclonal antibody.

Tests used: A. Immuno assays without radioisotopes Agglutination inhibition tests Direct agglutination test ELISA Fluoroimmuno assay B. Immunoassays with radioisotopes: Radioimmunoassay Immuno – radiometric assay

Pregnant Non Pregnant Urine + HCG antiserum (containing HCG) (No HCF) Neutralisation of Antibody HCG Antibody not neutralised HCG coated latex particle HCG coated latex particle No Agglutination Visible Agglutination

Chemical or Preclinical Pregnancy Pregnancy can be recognised early by estimating serum beta hCG at the time of implantation, before amenorrhea occurs (day 20 of gestation) Beta hCG level is more than 25 IU/L

USG  Gestational Sac : 5th wk.  Fetal pole, cardiac activity : 6th wk.  Embryonic movements : 7th wk.  CRL : 7 to 12 wk. (+/- 5 days)  Doppler – FHS : 10th wk.

also diagnoses  blighted ova  ectopic pregnancy  multiple pregnancy  Hydatiform mole

II Trimester Symptoms :Symptoms : 1. Amenorrhoea continues 2.morning sickness, bladder symptoms clears up 3.Breast & abdomen continues to enlarge 4.Quickening (feeling of life)

ON EXAMINATION  Chloasma  Breast changes  Linea nigra  Stria gravidarum  Uterus palpable per abdomen

Braxton Hicks contractionsBraxton Hicks contractions External BallottementExternal Ballottement Fetal parts palpableFetal parts palpable Active fetal movementActive fetal movement Fetal heart soundsFetal heart sounds Internal BallottementInternal Ballottement

Investigations 1. Pregnancy tests : not useful 2. USG - 18 to 20 weeks - to determine - Gestational age - Anomalies - Integrity of cervical canal - Placental localisation

III Trimester Symptoms : 1.Amenorrhoea continues 2.Enlargement of abdomen 3.Frequency of micturition 4.Fetal movements 5.Dyspnoea & Palpitations 6.Varicose Veins

ON EXAMINATION Cutaneous changes Braxton Hicks contractions Fetus-Lie, position & Parts identified Fetal movements & FHS Fundal Height

Investigation USGGestation age Growth AFI Placenta

Important functions of routine USG 1. Confirms gestational age 2. Diagnose anomalies 3. Diagnose multiple pregnancy 4. Doppler study 5. Reassuring to the couple 6. Integrity of cervical canal

DD’s of Pregnancy 1.Pseudocyesis 2.Ovarian tumour 3.Fibroid uterus 4.Encysted TB peritonitis 5.Haematocolpos & Haematometra 6.Distended urinary bladder

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