diagnosis of pregnancy
TRANSCRIPT
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