The Diagnosis of

Pregnancy
PRESUMPTIVE EVIDENCE OF PREGNANCY
PRESUMPTIVE SYMPTOMS
Nausea with or without vomiting (Morning sickness)
6-18 weeks (peak of hCG 8-10 weeks)
Disturbances in urination (increased in frequency)
1st and third trimester
Fatigue
Maternal perception of fetal movement (quickening)
16-18 weeks multigravida
18-20 weeks primigravid
Breast symptoms
PRESUMPTIVE SIGNS
Amenorrhea
Cessation of menses more than 10 days from
expected menses
Thermal signs
At 6 weeks: increased temperature =
increased progesterone
Anatomical breast changes
Engorgement starts at 6-8 weeks
Skin pigmentation changes
Chloasma or “mask of pregnancy”
Linea nigra- darkening of line alba
Striae gravidarum- collagen breakdown
Spider telangiectasia- increased in estrogen
Changes in the vaginal mucosa
Chadwick’s sign- violaceous discoloration of
the vaginal mucosa(congested vaginal mucosa)
which is evident at about the 6th weeks of gestation
Changes in cervical mucous
Starts at 6 weeks AOG
Elevated progesterone during pregnancy
lowers NaCl concentration that prohibits ferning
PROBABLE EVIDENCE OF PREGNANCY
Enlargement of the Abdomen
starts at 6 weeks AOG
at 12 weeks- fundus is felt by bimanual exam
Changes in the size, shape and consistency of the
uterus
1.) Hegar’s sign- softening of the uterine
isthmus which is observed on the the 6th-8th wk of
pregnancy
2.) Goodell’s sign- cyanosis and softening of
the cervix due to increased vascularity of the cervical
tissue; may occur as early as 4 wks
Anatomical changes in the cervix
Braxton – Hick’s Contraction
painless perception of irregular contractions
Ballottement
Physical Outlining of the fetus
Positive Results of Endocrine Tests- human chorionic
gonadotropin(hCG) which is detectable from the
maternal serum and urine as early as 8-9 days after
ovulation
(6 days after fertilization, 8-9 days post
implantation)
POSITIVE EVIDENCE OF PREGNANCY
Identification of Fetal Heart Tones (FHT)
heard by the stethoscope by the 18th wk on the
average; can be detected as early as 10-12 wks using
Doppler; transvaginal ultrasound at 6 weeks
Perception of Fetal Movement by the Examiner
usually at 20 weeks AOG
Recognition of the Embryo or the Fetus by Ultrasound
early ultrasound done at 12 weeks (most
accurate in establishing age of gestation)
Radiologic Methods
 DIFFERENTIAL DIAGNOSIS
1. Myoma
2. Hematometra
3. Adhesions or apparent enlargement attached to it.
4. Ovarian masses

PSEUDOCYESIS
-imaginary of spurious pregnancy occurring in women
nearing menopause, or in those who strongly desire
pregnancy
-patient may feel signs and symptoms of pregnancy
without being really pregnant at all
 IDENTIFICATION OF FETAL DEATH
-cause is unknown in about 50% of cases
-during the first few weeks of pregnancy, the demonstration of fetal
activity on ultrasound will confirm the diagnosis
-the uterine size has remained the same
(suggesting the fetus did not grow) or may have even
decreased in size
-cessation of fetal movements in the latter half of pregnancy
-patients with hyperemesis may not vomit anymore
- hypertensive patients may improve their blood pressure
- breasts may lose their turgor and engorgement
- patient’s weight may start to decrease
-absence of FHT by stethoscope or portable Doppler
 DEFINITION OF TERMS
PRIMIPARA is a woman who has been
delivered only once of a fetus or fetuses which
reached viability (beyond 20th week of pregnancy or
beyond the stage of abortion).

MULTIPARA is a woman who has completed two

or more pregnancies to viability. It is the number of
pregnancies reaching viability, and not the number
of fetuses delivered that determines parity
NULLIGRAVIDAis a woman who is not now and
never has been pregnant

GRAVIDA is a woman who is, or has been

pregnant irrespective of the pregnancy outcome

NULLIPARA is a woman who has never

completed a pregnancy beyond the stage of
viability or beyond an abortion.
PARTURIENT is a woman in labor

PUERPERAis a woman who had just given birth

 Height of the Fundus
-the fundus can usually be felt above the pubic symphysis
12 wks after LMP
-at 16 wks- halfway between the symphysis and the
umbilicus
-at 20wks – at the level of the umbilicus
-at 36wks – fundus is just below the ensiform cartilage,
where it may remain until the onset of labor in the
multipara. In primigravidas, the fundic height drops
slightly at the time of lightening.
-method used to measure fundic height: A tape calibrated in cms. Was applied over
the abdominal curvature to measure the distance between the symphysis pubis and
the highest level of the uterine fundus measured off from a vertical line drawn at the
level of the greatest thickness of the fundus.
*Johnson’s rule: used to clinically correlate fundic height with fetal
weight by using the following formula by R.W. Johnson:
estimated fetal weight(gms) = K (x-n)
where: x=fundic height (cms)
n=12 if the station of the fetal head is below
the ischial spines (engaged)
= 11 if the presenting part is above the
ischial spines (unengaged)
K= 155 (constant)
 Ultrasound
-Transvaginal Ultrasound can detect a pregnancy at
4-5 wks AOG

Timing by Trimesters
-most spontaneous abortions occur during the first
trimester
- pregnancy-induced hypertension becomes clinically
evident during the third trimester
INITIAL COMPREHENSIVE
EVALUATION

HISTORY
PHYSICAL EXAMINATION
Leopold’s Maneuvers
PELVIC EXAMINATION
RECTAL & RECTOVAGINAL
EXAMINATIONS
Leopold’s Maneuver 1

FIGURE.10.3. Leopold’s first maneuver.

Determines what fetal parts occupied the fundus.
Leopold’s Maneuver 2

FIGURE 10.4. Leopold’s second maneuver.

Determines on which side is the fetal back
Leopold’s Maneuver 3

FIGURE.10.5. Leopold’s third maneuver.

Determines what fetal parts lies over the pelvic inlet.
 Leopold’s Maneuver 4

FIGURE.10.6. Leopold’s fourth maneuver. FIGURE.10.7. Leopold’s fourth maneuver. Determines on

Determines on which side is the cephalic prominence. In which side is the cephalic prominence. In extension
flexion attitude, cephalic prominence is on the same side attitude, cephalic prominence is on the same side as the
as the small parts. small parts.
 Nutrition During Pregnancy
Fat Soluble Vitamins Pregnant Lactating
Vit A 770ug 1300ug
Vit D 15ug 15ug
Vit E 15mg 19ug
Vit K 90ug 90ug
• Water Soluble Vitamins Pregnant Lactating
Vit C 85mg 120mg
Vit B6 (Pyridoxine) 1.9mg 2mg
Folate 600ug 500ug
Vit B12(Cyanocobalamine) 2.6ug 2.8ug
• Minerals Pregnant Lactating
Iron 27mg 9mg
Zinc 11mg 12mg
Calcium 1000mg 1000mg
Protein 71g 71g
Carbohydrates 175g 210g
Fiber 28g 29g
General Hygiene

Exercise
Bathing
Clothing
Bowel Habits
Sexual Relations
Douches
Care of teeth
• Travel
– Air: can safely fly if less than 36 weeks
• Coitus
– Not harmful in pregnancy but should be avoided if with
risk of miscarriage or preterm labor
• Caffeine intake
– 300mg/day or 3-5 cups of coffee
• Alcohol
– Causes fetal alcohol syndrome and growth restrictions
• Cigarette smoking
 ROUTINE OBSTETRIC TESTS

TEST DISCUSSION
1. Complete blood count To determine hematologic status;
To rule out anemia
2. Urinalysis and urine culture To evaluate for UTI and renal function
and sensitivity
3. Blood group, Rh To determine blood type, Rh status, and
risk of isoimmunization

4. Serologic test for syphilis To detect previous/current infection;

(RPR, VDRL) if positive-- specific treponemal test
(eg FTA-ABS or MHA – TP)
 ROUTINE OBSTETRIC TESTS
TEST DISCUSSION
5. Hepatitis B surface antigen To detect carrier status or active
disease;
If positive, further testing indicated
6. Rubella titer Approximately 85% of mothers have evidence of
prior infection; if patient is seronegative, special
precautions are needed to avoid infection, which
can severely affect the fetus; vaccination is then
required postpartum

7. Cervical pathology To screen for cervical dysplasia.cancer

(Pap smear)

8.Cervical culture for To screen for infection both cause neonatal and
chlamydia trachomatis conjunctivitis; association
Neiserria gonorrhea with premature labor and postpartum
endometritis.
 ROUTINE OBSTETRIC TESTS
TEST DISCUSSION
9. Hemoglobin electrophoresis To detect sickle-cell trait (HbSA). Associated with
higher risk for UTI, and sickle-cell disease (HbSS),
thalassemias at risk for multiple fetal and maternal
complications

10. HIV titer by ELISA; Should be offfered to all patients at risk

(multiple sexual partners, drug use, or sexual contact
Western blot if HIV + ELISA with drug users); may be offered to all patients at
physicians discretion

11. Glucose screening To screen for glucose intolerance in high-risk

patients; usually at 24- 28 weeks in low risk patients.
(usually 1 – hr Glucose)

12. MSAFP at 15- 18 wks Elevated levels seen with Neural Tube Defects,
gastroschisis, omphalocoele; Downs syndrome
(usually with hCG, estriol)
• Rectovaginal culture should be done between 35
to 37 weeks
• First trimester Aneuploidy may be offered
between 11-14 weeks
– Test at 28 weeks if indicated
– high risk women should be tested at first visit and re-
tested at the start of 3rd trimester
Recommendations for total weight
gain
Underweight 12.5-18 kg 28-40 lbs
Normal weight 11.5-16 kg 25-35 lbs
Overweight 7-11.5 kg 15-25 lbs
Obese 5-9 kg 11-20 lbs
Recommendations of Weight Gain
in Twin Pregnancy
Normal 37-54 lbs
Overweight 31-50 lbs
Obese 25-42 lbs
 Immunization during Pregnancy
• Tetanus Diptheria (Td)/ Tetanus Diptheria
Acellular Pertussis (Tdap)
– 1st dose- after 14th week
– 2nd dose- around 28th week
– 3rd dose 6 months after the first dose
• Influenza
– One dose every year
– All pregnant women regardless of trimester
• Hepatitis A
– 2 doses 6 months apart
• Hepatitis B
– 3 doses at 0,1 and 6 months
 High Risk Pregnancy
• Maternal Age <17 yo
• Primigravidas >35 yo
• Poor OB History
– 2 consecutive spontaneous miscarriages
– 3 or more repeated spontaneous miscarriages
– Premature delivery
– Fetal death in utero/ Neonatal death
– Previous birth with congenital anomalies
• Problems in Fetal aging, structure and size
– Beyond 41 weeks
– Growth restrictions (IUGR)
– Macrosomia
– Unsure LMP
– Fetal congenital anomalies
– Multiple gestation
• Placenta Previa/ Abruptio placenta
• Medical conditions
• Reproductive tract disorders
• Malignancy
• Trophoblastic disease
• Oligo/Polyhydramnios
• Psychiatric conditions/ Mental Retardation
 10 Danger signs of Pregnancy
• Headache
• Blurring of vision
• Prolonged vomiting
• Fever
• Epigastric/ right upper quadrant pain
• Decreased in fetal movement
• Uterine contractions
• Dysuria
• Vaginal bleeding/ discharge
• Edema (face/ fingers/lower extremities)
 COMMON COMPLAINTS
DURING PREGNANCY
NAUSEA AND VOMITING
 4TH to 12th wk of pregnancy
 ETIOLOGY : Hormonal –hCG levels are high
at the same time that nausea and vomiting are most
common

 MANAGEMENT : small frequent feedings

anti-nausea medications
 COMMON COMPLAINTS
DURING PREGNANCY
BACKPAIN
 LOCATION : region of the buttocks
thighs

 MANAGEMENT : analgesics (Paracetamol)

heat (warm compress,
bath)
rest
 COMMON COMPLAINTS
DURING PREGNANCY
VARICOSITIES
 Increased venous pressure in the lower
extremities and the vulva
 MANAGEMENT : elevation of the feet
support stockings
belly belt for support
 COMMON COMPLAINTS
DURING PREGNANCY
HEMORRHOIDS
 Increased pressure in the rectal vein
caused by obstruction of venous return
by the large uterus
 MANAGEMENT : topical anesthetics
stool softeners
** Hemorrhoidectomy postponed until
after childbearing
 COMMON COMPLAINTS
DURING PREGNANCY
HEARTBURN
 Burning sensation in the epigastrium accompanied
by feeling of fullness
 Reflux of acid gastric contents into the lower
esophagus
 Upward displacement of the stomach by the uterus
and progesterone mediated relaxation of
esophageal sphincter
 MANAGEMENT: antacids
aluminum hydroxide
magnesium trilicate/ hydroxide
avoidance of large meals
 COMMON COMPLAINTS
DURING PREGNANCY
PICA
 bizarre carving for strange foods and
materials hardly considered edible
PTYALISM
Profuse salivation
FATIGUE
 desire for excessive periods of sleep
 usually disappears by the 4th month of
pregnancy
 COMMON COMPLAINTS
DURING PREGNANCY
HEADACHE
Treatment is symptomatic

LEUKORRHEA
Increased vaginal discharge
Secondary to increased mucus
formation by cervical glands in response
to hyperestogenemia