OBSTETRICS

Diagnosis of Pregnancy
Lecturer: Dr. Mercado | August 7, 2017
Transcribed by: AAG l JBG l ECL l ABL l RAM

OUTLINE
1. Presumptive Evidence of Pregnancy
Management:
i. Nausea with or without vomiting
ii. Disturbances in urination - Small, frequent feedings
iii. Fatigue - Avoidance of fatty foods
iv. Perception of fetal movement - Light, dry, low fat diet is recommended
v. Breast Symptoms - Ice chips to relieved heartburn, which is the
2. Presumptive Signs of Pregnancy most common cause of vomiting
i. Cessation of Menstruation
ii. Anatomical Breast changes
iii. Changes in Vaginal Mucosa Hyperemesis gravidarum
iv. Skin pigmentation - Severe nausea and vomiting that might lead to
v. Thermal Signs severe dehydration
3. Probable Evidence of Pregnancy - Might require hospitalization
i. Abdominal Enlargement - Intractable vomiting - secondary to gestational
ii. Changes in the uterine size, shape and
thyrotoxicosis, request for FSH and monitor up to
consistency
iii. Changes in the cervix 3 months.
iv. Braxton Hicks Contraction
v. Ballottement Disturbances in urination
vi. Outlining the fetus - Enlarging uterus causes direct pressure on the
vii. Endocrine Test bladder
4. Positive Signs of Pregnancy
- Frequent urination, dribbling, bladder irritability,
5. Differential Diagnosis
i. Pseudocyesis nocturia and urinary tract infection
6. Identification of Fetal Life or Death - UTI - compressed bladder retained urine
7. Radiologic Evidences of fetal demise bacterial growth
- Bacteruria - >100,000 microorganism
Molar Pregnancy (-) pregnancy test (PT) result d/t high levels - Proper urine collection
of -hCG. Midstream
Shifting of hormones reason for (+) PT prior to menstruation Separate labia
- (+) epithelial cells means not properly
Diagnosis of Pregnancy collected
The manifestations of pregnancy have been classified into 3 - Asymptomatic patient request for urine culture
groups: to check before treating
1. Presumptive - Most marked during the second and third months
2. Probable of pregnancy and recur during late trimester
3. Positive evidences of pregnancy - 1st trimester uterus - pelvic organ
- 2nd trimester (mid) uterus abdominal organ
Presumptive Evidence of Pregnancy - Nocturia sign of good renal perfusion
- Based on signs and symptoms that may involve - Sleep more on left lateral best position because
different organs it will release the compression of major blood
- Most prominent in the reproductive tract vessel.

Nausea with or without vomiting Fatigue

- About 50% - Increased metabolism in pregnancy
- cravings or pica
- Occurs in the morning Perception of fetal movement
- Correlates significantly with the amount of serum - quickening part of knowing the gestational age
hCG. especially those px who doesnt remember their
- Usually appears at 6 weeks, reaches a peak at LMP
about 60 70 days - Primigravids 18th 20th weeks of gestation
- Multigravids 14th 16th weeks of gestation

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Breast Symptoms
- mastodynia
- Effects of estrogen which stimulate the mammary
duct system and by progesterone which stimulate
the alveolar component
Presumptive Signs of Pregnancy
Cessation of Menstruation
- Not all cessation of menstruation is secondary to
pregnancy
- Earliest sign of pregnancy
- Abrupt cessation of menstruation in a healthy
reproductive aged women who previously has
experienced spontaneous, cylindrical, predictable
menses is highly suggestive of pregnancy
- Usually delay of 10 days
- others: delay of 3 days (+) PT
- Amenorrhea is not always a reliable indicator as
delay may cause by other factors like:
o Irregular menstrual cycles
o Emotional stress
o Chronic disease
o Drugs
o Endocrine disorders
o Lactation
o Genitourinary tumors
- 25% of cases implantation bleeding as the
blastocyst implants in the uterus
- Implantation bleeding
1 day bleeding
- Usually mistaken as menstruation
- spotting
- to establish the age of gestation check past 3
months of menstrual cycle
Anatomical Breast Changes
- 6 to 8 weeks after conception
- Breast enlargement
- Vascular engorgement
- Montgomery tubercles become hypertrophied
and very prominent
- 16th weeks colostrum may be expressed from
the breast by gentle massage
- Breast size before pregnancy does not
necessarily correlate with volume of milk
production during lactation
Changes in the Vaginal Mucosa
- 6th week of pregnancy Chadwicks Sign
OBSTETRICS Diagnosis of Pregnancy
Skin Pigmentation Changes
- Chloasma, linea nigra, striae gravidarum, spider
telangiectasia
- d/t increased melanocyte stimulating factors and
estrogen production
- very prominent in the cheek bone
- mask of pregnancy
- Linea nigra d/t stimulation of melanophores by
the increased melanocyte stimulating hormone
- Striae gravidarum secondary to separation of
underlying collagen
- Spider telangiectasia vascular sellate marks d/t
increased estrogen
- Palmar Erythema
Thermal Signs
- Perceptible elevation of body temperature for
longer than 3 weeks
- Thermogenic effect of progesterone.
Probable Evidence of Pregnancy
Abdominal enlargement
- Linear measurement from the symphysis pubis to
the uterine fundus on an empty bladder correlates
vis--vis with the age of gestation from 16 to 32
weeks.
- In actual practice it doesnt follow this theory.
- In Asian at 36weeks of gestation usually fundic
height measures 28-30cm, if its >35-36 cm big
baby
BIMANUAL EXAM
12 weeks uterus palpable at the level of symphysis
16 weeks between symphysis and umbilicus
18 weeks below the umbilicus
20 weeks at the level of umbilicus
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 OBSTETRICS Diagnosis of Pregnancy

Changes in the Cervix

- Softening of the cervix occurs at about 6-8weeks
- Cervical mucus during pregnancy has a
characteristic beaded cellular pattern when seen
under the microscope
- Progesterone
- beading cervical mucus, progesterone
- ferning amniotic fluid , estrogen

Braxton Hicks Contraction

- Painless, irregular contractions
- Usually occurs at 3rd trimester, after fetal
FUNDIC HEIGHT: movement
36 weeks fundus at below the ensiform cartilage - false contractions
remain until the onset of labor in multipara
40 weeks descend engagement Ballottement
- Description of fetal head
- before 20 weeks : bimanual examination - Leopolds maneuver
- beyond 20 weeks: fundic height (upper border of - bounce back
symphysis up to the level of the fundus) - Fetal head round, ballottable
- Breech large, irregular, nodular and not
ballottable
- Abdominal enlargement is more pronounced in
multigravida patients Outlining the fetus
LEOPOLDS MANEUVER

Changes in the Uterine size, shape and consistensy LEOPOLDS MANEUVER I

1. Hegars sign - To check the fetal
presentation
- Softening of the uterine isthmus
- 6th to 8th week of pregnancy

LEOPOLDS MANEUVER II
- To check the fetal heart
tone
- Fetal back hard and
convex
2. Goodells sign - Extremities small and
nodular
- Cyanosis and softening of the cervix due to the
increased vascularity of the cervical tissue
- May occur as early as 4 weeks

- 12th week uterus is a globular with an average

diameter of about 8cm all around.

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LEOPOLDS MANEUVER III
- to check if there is engagement
of unengaged
Engangement
fetal head is not palpable
because the fetal head is now
located below the symphysis
pubis
fundic height: descend
LEOPOLDS MANEUVER IV
- to check fetal attitude
- either hyperextended or well
flexed fetal head
- Check cephalic prominence if
at the same level of the fetal
back hyperextended fetal
head
- cephalic prominence at the
level of small nodularities
well flexed fetal head
Endocrine Tests
- Presence of the glycoprotein hCG produced by
fetal trophoblasts is the basis of most commonly
used tests.
- The hCG supports early pregnancy by preventing
involution of the corpus luteum, which is the
principal site of progesterone formation
Human chrorionic gonadotrophin (hCG)
- Can be detected from maternal biological fluids
as early as 8 to 9 days after ovulation
- Levels increased from the day of implantation
- 60 to 90 days serum levels of approximately
50,000mIU
- During gestational sac 1500 2000 mIU hCG
- 14 to 16 weeks of pregnancy nadir is reached
- Decreased symptoms (nausea/ vomiting) after 3
months because of the decreased level of hCG
Positive Signs of Pregnancy
1) Identification of fetal heart action
2) Perception of active fetal movement by the
examiner
3) Recognition of the embryo or fetus by ultrasound
Fetal Heart Action
- 110 to 160 bpm
- Ordinary stethoscope 18th week on the average
OBSTETRICS Diagnosis of Pregnancy
- Doppler 10 to 12 weeks
- Fetal echocardiography can demonstrate as early
as 48 days from the last normal menstruation
- Real time sonography can demonstrate fetal heart
action and movement by the second month of
pregnancy
- Other sounds:
o Funic souffl or umilical cord souffl
produced by the sound of the blood
rushing through the umbilical arteries
- sharp, whistling sound, synchronous with
the fetal heart beat.
o Uterine souffl
soft blowing sound that is synchronous
with the maternal pulse
- appreciate near both hypogastric areas
of the abdomen
- due to maternal blood rushing through
the dilated uterine vessels
- can be heard with conditions resulting
from increases flow through the uterine
vessels
o Sound from movement of the fetus
o Maternal pulse
o Gurgling gas in the mothers
gastrointestinal tract
Funic souffl Uterine souffl
Sharp, whistling sound Soft, blowing sound
Synchronous w/ fetal heart beat Synchronous w/ maternal pulse
Passage of blood in umbilical Passage of blood in dilated
arteries uterine vessel
Perception of Fetal Movement by the Examiner
- After 20th week active fetal movement may be
seen and actually felt by the examiner
Recognition of Embryo or Fetus by Ultrasound
- 4th week thickened endometrium
- 5th week gestational sac may be demonstrated by
transvaginal sonography
- 6th week fetal heart beat
- 12th week CRL should be predictive of gestational
age
CRL most accurate measurement of age of gestation
For the age of gestation:
If UTZ < 1 week difference with the LMP follow LMP
If UTZ > 1week follow first UTZ
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 OBSTETRICS Diagnosis of Pregnancy

Radiographic evidences of fetal demise:

1. Spaldings sign
- overlapping of the fetal skill due to liquefaction of
the brain
2. Exaggeration of the fetal spine curvature
3. Roberts sign
- demonstration of gas bubbles in the fetus

Summary
Diagnosis of Pregnancy
- availability of commercially over the counter do it
yourself pregnancy kits
- Advent of ultrasound
The threshold level identifies the earliest we can visualize - Good history taking and physical exams including a well
the gestational sac : 4weeks + 3days
done pelvic evaluation are important tools on hand
- Proper management and monitoring
- Assure a good healthy fetus to be borne at the most
appropriate

The earliest sign of an intrauterine pregnancy by

transvaginal ultrasound is the double decidual sac sign
- (+) gestational sac + yolk sac

Differential Diagnosis
Pseudocyesis
- imagery pregnancy or spurious pregnancy
- Women nearing menopause or strongly desirous of
pregnancy

Identification of Fetal Life or Death

- diagnosis of fetal demise is unexplainable in about
50%
- Uterus ceases to grow
- Cessation of fetal movement
- Decrease in fundic height
- On IE - soft, collapsible fetal skull
- Efforts to hear fetal heart rate through doppler are
unsuccessful
- Tobacco stained amniotic fluid
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