Diagnosis In Pregnancy
FIRST TRIMESTER FIRST (12 WEEKS):
SUBJECTIVE SYMPTOMS:
Amenorrhea:
- placental sign:scanty & shorter duration of cyclic bleeding may occur up to 12 weeks of pregnancy
- Hartman’s symptoms: slight bleeding occurs at time of menstruation
Morning sickness (Nausea and vomiting):
- Appears soon following the missed period
- Rarely lasts beyond 16 weeks
Frequency of micturition:
- 8–12th week
- Due to resting of the bulky anteverted uterus on the fundus of the bladder
- Congestion of the bladder mucosa
- Maternal osmoregulation changes
Breast discomfort:
- Fullness & pricking sensation
- 6–8th week
- Fatigue
OBJECTIVE SIGNS:
Breast changes:
- 6 and 8 week
- Enlargement with vascular engorgement
- ↑ Pigmentation of nipple and areola
- Montgomery’s tubercles are prominent
- Terminal lobular units more affected
- Colostrum at 12th week.
- Per abdomen:Uterus is felt per abdomen after 12th week
Pelvic changes:
- Jacquemier’s or Chadwick’s sign:(8th week) Dusky hue of vestibule and anterior vaginal wall
- Vaginal sign: ↑ed number of lactobacilli, bluish discoloration,pH 4- 6, softening of anterior vaginal wall with Copious non-irritating mucoid discharge
- Osiander’s sign:increased pulsation in lateral fornices at 8th week
- Goodell’s sign:Cervix becomes soft(6th week)
- Bluish discoloration of the cervix
Uterine signs:
- Size increase(hypertrophy and hyperplasia )
- Piskacek’s sign:Asymmetrical enlargement of uterus in lateral implantation
- Hegar’s sign:(6 -10weeks)Softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions.
Palmer’s sign:
- On bimanual examination :uterus is cupped between the internal fingers and the external fingers for 2–3 minutes
- Regular and rhythmic uterine contraction(4–8 weeks)
SECOND TRIMESTER (13-28 WEEKS):
SYMPTOMS:
- Except amenorrhea other subjective symptoms subsides
Quickening:
-
- (18th week) About 2 weeks earlier in multiparae
- The perception of active fetal movements by the women.
- Useful guide to calculate the expected date of delivery with reasonable accuracy
- Progressive enlargement of the lower abdomen by the growing uterus.
- Chloasma:Pigmentation over the forehead and cheek ( 24th week)
Breast changes:
- Enlarged with prominent veins under skin
- Secretory changes are well developed
- Cuboidal luminal epithelial cells show evidence of vacuolization.
- Secondary areola specially demarcated in primigravidae(20th week)
- Montgomery’s tubercles are prominent and extend to the secondary areola
- Colostrum:thick and yellowish(16th week)
- Variable degree of striae
Abdominal Changes:
- Linear pigmented zone (linea nigra):Symphysis pubis to ensiform cartilage(20th week)
- Striae (both pink and white)
- Fundal height is increased
- Uterus feels soft and elastic and becomes ovoid
- Braxton-Hicks contractions
- Palpation of fetal parts(20th week)
- Active fetal movements(20th week)
External ballottement:
- 20th week when the fetus is relatively smaller than the volume of the amniotic fluid
- Best elicited in breech presentation with the head at the fundus.
- Diffcult to elicit in obese patients and in cases
Fetal heart sound (FHS) :
- Definitive clinical sign of pregnancy
- 110–160 beats/minute
Uterine souffle:
- Soft blowing and systolic murmur
- Lower left sides of the uterus
- Synchronous with the maternal pulse
- Increase in blood flow through dilated uterine vessels
- Heard in big uterine fibroid
Funic or fetal souffle:
- Soft, blowing murmur synchronous with the fetal heart sounds
- Due to rush of blood through the umbilical arteries
Vaginal changes:
- Bluish discoloration:vulva, vagina and cervix
- Internal ballottement(16–28th week)
Fundal height:
| Height of the uterus | Fetal age |
| Midway betweensymphysis pubis and umbilicus | 16th week |
| At level of umbilicus | 24th week |
| At junction of lower third and upper 2/3rd between umbilicus and ensiform cartilage | 28th week |
LAST TRIMESTER(29-40 WEEKS):
SYMPTOMS:
- Amenorrhea persists
- Enlargement of the abdomen with palpitation or dyspnea following exertion
- Lightening(38th week):sense of relief of the pressure symptoms is obtained due to engagement of the presenting part
- Frequency of micturition reappears
- Fetal movements are more pronounced.
- Supine hypotension
SIGNS:
- Cutaneous changes:Melasma over face
- Uterine shape:cylindrical to spherical beyond (36th week)
Fundal height:
- Distance between the umbilicus and the ensiform cartilage is divided into three equal parts
| Height of the uterus | Fetal age |
|
Junction of the upper and middle third
(head is floating) |
32 weeks |
| Up to the level of ensiform cartilage | 36th week |
|
comes down to 32 week level
(Head is engaged) |
40th week |
Symphysis fundal height (SFH):
- Upper border of the fundus is located by the ulnar border of left hand & upper border of the symphysis
- 24 weeks to 36 weeks
- Braxton-Hicks contractions are more evident.
- Fetal movements are easily felt.
Breast changes:
- Fat droplets accumulation occur in the cytoplasm of epithelium
- FHS is heard distinctly
- Fetal AC at the level of the umbilical vein is used to assess gestational age and fetal growth
Exam Important
- Supine hypotension is characteristic of 3rd trimester of pregnancy
- Signs positive in early pregnancy are Hegar’s sign, Palmer’s sign & Goodell’s sign and Osiander’s sign
- Braxton-Hicks contraction, Amenorrhea both are seen in 2nd trimester of pregnancy
- An expectant mother feels quickening at 16-20 weeks
- Hegar’s sign is feeling the cervix and the body of bulky uterus separated because of softened isthmus at 6 – 10 weeks of gestation
- Osiander’s sign means Pulsation in the lateral vaginal fornix
- Chadwick’s sign is Bluish discoloration of vagina
- Fetal movements, Fetal heart sounds & Fetal skeleton seen an X-ray are the definitive signs of pregnancy
- Braxton — Hicks contractions Occur during most of the months of pregnancy
- In normal pregnancy ↑ed number of lactobacilli is seen in vagina
- Fat droplets occur in the cytoplasm of the epithelium in breast at pregnancy
- Cuboidal luminal epithelial cells of breast show vacuolization
- The terminal lobular units of breast are most affected during pregnancy
- In Pregnancy uterus shows both hypertrophy and hyperplasia at the same time
- Palmer’s sign indicate Rhythmic contraction of uterus
- Hegar’s sign be elicited at 8 weeks
- pH of vagina in pregnancy is is 4-6
- Uterus reaches up to umbilical level at 24 weeks
- During pregnancyMelasma over face is seen
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