1. Diagnosis of Pregnancy
Akmal Abbasi, M.D.

2. Diagnosis of Pregnancy
Presumptive Signs
Probable Signs
Positive

3. Presumptive Signs: cessation of menses/missed period
nausea and/or vomiting
breast changes
urinary frequency
Fatigue continued elevation of BBT in absence of infection
Excessive salivation
Chadwick’s sign
Quickening, skin pigment changes

4. Probable Signs First Trimester: Goodell’s Sign Hegar’s Sign
Chadwick’s Sign

5. Probable Signs Second Trimester: uterine enlargement
Braxton-Hicks contractions
uterine souffle
pregnancy tests
palpation of fetal outline

6. Positive (diagnostic)
Fetal heartbeat
Palpation of fetal movement
Ultrasound
X-ray

7. Diagnosis In The First Trimester--Symptoms:
Amenorrhea: Sudden cessation of previously regular menstruation is often the first indication that conception has occurred.
Absence of menstruation may be due to conditions other than pregnancy.
Pregnancy may occur during a period of amenorrhea as lactation amenorrhea.

8. Diagnosis In The First Trimester--Symptoms:
Morning Sickness: Nausea and vomiting are common symptom which usually starts in the early weeks of pregnancy and rarely lasts for more than three months.
Easy fatigability, lassitude and sleepiness are fairly common.
Emotional Changes: Craving for certain foods, odors and particular objects, and disinclination to others may also be present.

9. Diagnosis In The First Trimester--Symptoms:
Frequency and urgency of micturation: These are due to irritability of the bladder caused by pressure of the enlarged pregnant uterus and the congestion bladder mucosa. After the third month the symptoms become less severe and commonly disappear.

10. Diagnosis In The First Trimester--Symptoms:
Enlargement of the breasts: This is often noticed early in pregnancy.
There is increased heaviness, tingling sensation and there may be discomfort or actual pain in the breasts.

11. Diagnosis In The First Trimester--Signs:
Breast Signs:
Increased size and sensitivity of the breasts and nipples, Increased vascularity and the appearance of subcutaneous veins.
Dark pigmentation of the nipples and areola.
Development of the second areola, Increased prominence of the tubercles of Montgomery.
Secretion of colostrum.

12. Diagnosis In The First Trimester--Signs:
Uterine Signs:
The uterus becomes large in size, globular in shape and soft in consistence. By the end of the third month the fundus of the uterus can be felt just above the symphysis pubis.
Palmer’s sign: Uterine contractions can be elicited by bimanual examination.

13. Diagnosis In The First Trimester--Signs:
3) Hegar’s sign: bimanual examination with two fingers in the anterior fornix and the fingers of the other hand on the abdomen behind the uterus, the internal and external fingers can be approximated due to the fact that the lower segment is soft and empty. The sign can be elicited between the 6th and 10th week of pregnancy, after which the sign becomes negative as the ovum has now filled the whole uterine cavity.

14. Diagnosis In The First Trimester--Signs:
Cervical Signs:
The cervix is soft (Goodell’s sign), and shows a purplish or violet coloration (Chadwick’s sign).
Vaginal and Vulval Signs: The vulva and vagina are violet in color, particularly the vestibule. The vagina becomes moist, warm and lax. There is increased acidity of the vaginal discharge.

15. Diagnosis In The First Trimester--Signs:
Although none of the early clinical features of pregnancy is reliable yet they are very suggestive when taken collectively. In cases of doubt the diagnosis can be established with a high degree of accuracy by carrying out one of the pregnancy test.

16. Diagnosis of pregnancy in The second trimester--Symptoms:
The amenorrhea continues while the morning sickness and the urinary symptoms either becomes less marked or completely disappear.
The breast changes become more obvious.
Quickening which is the first perception of the fetal movements by the pregnant woman is usually experienced about the 16thweek in the multipara and the 18th week in the primipara.
From the fourth month onwards the patient notices the abdominal enlargement.

17. Diagnosis of pregnancy in The second trimester--Signs:
AbdominalSwelling: The uterus is felt abdominally as an elastic median swelling with a convex upper border. The gravid uterus undergoes contractions which are now evident on abdominal palpation (Braxton Hicks Contractions).
Ballottement: Internal ballottement which is elicited bimanually is evident from the 16th week. Repercussion is felt when the fetus is given a push with two fingers in the anterior fornix. External ballottement can be elicited from the abdomen as early as the 20th week.)     
Palpation of the fetal parts and active fetal movements is experienced as early as the 20thweek·         

18. Diagnosis of pregnancy in The second trimester--Signs:
Fetal heart sounds. These are usually heard by the 24th week. Their presence is a sure sign of pregnancy· The rate of the fetal heart sounds is between 120 to 140 under normal conditions.
UterineSouffle. This is a soft blowing murmur synchronous with the maternal pulse. It is due to the rush of blood in the dilated uterine vessels.
Umbilical or Funic Souffle. It is due to the rush of blood in the umbilical arteries. It is only occasionally heard when the cord happens to be adjacent to the anterior wall of the uterus.
The appearance of the stria gravidarum and the linea nigra which are evident in the second half of pregnancy.    

19. Diagnosis of pregnancy In The Third Trimester
all signs of pregnancy have become more apparent and more convincing. 
The Sure Signs of Pregnancy
Active fetal movements detected by the obstetrician.
Palpation of the fetal parts.
Auscultation of the fetal heart sounds. 
The occasional hearing of the umbilical souffle.
Detection of the fetal skeleton by ultrasound.         

20. Pregnancy Testing Type of tests: urine and blood (serum)
Tests based on production of chorionic gonadotrophin (hCG) by the syncitiotrophoblastic cells during early pregnancy (hCG secreted into maternal bolldstream (plasma) then is excreted in mother’s urine.

21. Pregnancy Testing
hCG levels increase rapidly between days of pregnancy • peak levels days • levels decrease to a low between days • low level maintained throughout remaining weeks of pregnancy • hCG first detectable in urine days after conception • a positive pregnancy test is possible when the concentration of hCG in urine is at 25 mIU’s

22. Home/office pregnancy tests
use enzymes to detect hCG beta subunit (the most accurate) – referred to as “ELISA” tests – has good sensitivity and specificity – quick – inexpensive – 99% accurate

23. Pregnancy Testing
Serum beta hCG – detectable earlier than urine – positive if over 5 mIU – detected by 7-11 days after conception – doubles every 2 days until about 10 weeks

24. Gravidity and Parity
Gravida (G) = total # of pregnancies, including current.
Parity (P) = # of previous pregnancies >20wks
TPAL is a statement of the obstetric hx
T = term pregnancies >37 wks
P = premature preg >20 <37 wks
A = abortions <20 wks
L = living children

25. Nagele’s Rule To determine EDC:
From 1st day of LNMP subtract 3 months and add 7 days