DIAGNOSIS OF PREGNANCY

Dr. K. Bharathi

Professor

P.G. Dept. of Prasutitantra and Striroga

Sadhyo grihita garbha lakshana

• तत्र सद्योगृहीतगर्भाया लिङ्गानि- श्रमो ग्लानिः पिपासा सक्थिसदनं शुक्रशोणितयोरवबन्धः स्फुरणं च योनेः || (Su. Sha. 3/ 13)
• परिहार्यपरिहारार्थं सद्योगृहीतगर्भलक्षणं निर्दिशन्नाह- तत्र सद्योगृहीतेत्यादि| श्रमः खेदः| ग्लानिः क्लमः| सक्थिसदनमूरुग्लानिः| अवबन्धोऽप्रवृत्तिः|स्फुरणं कम्पनम्|| (Dalhana on Su. Sha. 3/ 13) � �

• निष्ठीविका गौरवमङ्गसादस्तन्द्राप्रहर्षौ हृदये व्यथा च| �तृप्तिश्च बीजग्रहणं च योन्यां गर्भस्य सद्योऽनुगतस्य लिङ्गम्|| (ca. sha. 2/23)
• बीजग्रहणं शुक्रस्य योनौ निषिक्तस्यानिःसरणम्| (Cakrapano on ca. sha. 2/23)

Vyaktagarbha Garbhini Linga

• स्तनयोः कृष्णमुखता रोमराज्युद्गमस्तथा | �अक्षिपक्ष्माणि चाप्यस्याः सम्मील्यन्ते विशेषतः ||१४|| �अकामतश्छर्दयति गन्धादुद्विजते शुभात् | �प्रसेकः सदनं चापि गर्भिण्या लिङ्गमुच्यते ||१५|| (Su. Sha. 3/14-15)
• उत्तरकालीनं गृहीतगर्भाया लक्षणमाह- स्तनयोरित्यादि| प्रसेकः थूत्करणम्|| (Dalhana on Su. Sha. 10/14-15) ��

• आर्तवादर्शनमास्यसंस्रवणमनन्नाभिलाषश्छर्दिररोचकोऽम्लकामता च विशेषेण श्रद्धाप्रणयनमुच्चावचेषु भावेषुगुरुगात्रत्वं चक्षुषोर्ग्लानिः स्तनयोः स्तन्यमोष्ठयोः स्तनमण्डलयोश्च कार्ष्ण्यमत्यर्थं श्वयथुः पादयोरीषल्लोमराज्युद्गमोयोन्याश्चाटालत्वमिति गर्भे पर्यागते रूपाणि भवन्ति|| (ca. sha. 4/16) 
• अम्लकामता विशेषेणेति च्छेदः| श्रद्धाइच्छा| उच्चावचेष्विति उच्चनीचेषु, भक्षणीयत्वेन कृतेषु चाकृतेषु चेत्यर्थः| ईषत् पादयोः श्वयथुः| चाटालत्वं विवृतत्वम्| एतानि च लक्षणानि स्वरूपेणगर्भस्य भवन्ति, तृतीयमासयुक्तानि तु द्वैहृदय्यस्य च लिङ्गानि भवन्तीति ज्ञेयम्|| (Cakrapani on 4/16) 

Diagnosis of pregnancy

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History

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Conditions

• previous regular, spontaneous, predictible menstruations
• absence of menstruation for min. 10 days

Diagnosis of pregnancy in the first 16 weeks

(I-st trimester)

Digestive

• nausea ( over 50%) and vomiting
• sialoreea
• pyrozis
• alteration of apetite, taste, smell, food preferences

• appeared during 4-6 weeks
• disappeared spontaneously after 12-14 weeks

Urinary bladder irritability (compresion)

Nervous sleep difficulties, irritability, insomnia

• Neuro-vegetative symptoms

Diagnosis of pregnancy in the first 16 weeks

(I-st trimester)

History

Diagnosis of pregnancy in the first 16 weeks (I-st trimester)

Clinical signs

Inspection

• Breasts

- increase in size

- venous network (Haller)

- Montgomery tubercules (sebaceus glands)

- minute hyper-pigmentation of the areola and the nipple

• Abdomen

- linea nigra

- progressive deformation upward symfizis pubis (after 12 weeks)

• Perineum – accentuation of pigment

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Diagnosis of pregnancy in the first 16 weeks �(I-st trimester)

Clinical signs

Palpation

• Breasts

- specific consistency

- colostrum (occasionally) – thick, yellowish fluid, expressed from the nipples

• Abdomen

- pregnant uterus – the upper margin of a globulous, soft mass

- the height of the uterine fundus becomes measurable (cm)

Diagnosis of pregnancy in the first 16 weeks �(I-st trimester)

Clinical signs

Obstetrical examination

Cervix, vagina and perineum (speculum examination)

- increased vascularity and hyperemia

- characteristic violet-bluish color of the mucosa – Chadwick sign

- increased size of the cervix

Uterus (bimanual examination)

- softening of the cervix, isthmus (Hegar sign) and uterine corpus

- enlargement of the uterus (4cm per month)

- irregular, painless uterine contractions – Braxton-Hicks contractions

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Diagnosis of pregnancy in the first 16 weeks (I-st trimester)

Noble sign

Hegar sign

Piscaceck sign

Diagnosis of pregnancy in the first 16 weeks �(I-st trimester)

Differential diagnosis

- abdominal mass: ovarian cyst, uterine myoma, trophoblastic disease, ectopic pregnancy, bladder globus

- amenorrhea: in the emotional stress, endocrine disfunctions, lactation, anorexia, certain treatments (e.g. antidepressants, metyldopa, haloperidol), pseudocyesis

Diagnosis of pregnancy in the first 16 weeks �(I-st trimester)

Laboratory diagnosis

Principle: presence of hCG in plasma and urine

- produced by syncytiotrophoblast

- peak at 60-70 days

- biological tests (laboratory animals)

- immunological tests – β-hCG (monoclonal anti-HCG antibody serum assays); home test kit (ELISA, RIA, etc)

- detection and quantification

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hCG in plasma and urine

Diagnosis of pregnancy in the first 16 weeks �(I-st trimester)

Ultrasound imaging

- abdominal sonography

- vaginal sonography can detect an uterine pregnancy 1 week after the missed menstruation

AIMS

- assessment of the amnionic sac dimensions (4-5 weeks)

- visualize the fetus and the placenta (position, aspect)

- measure fetal crown-rump length (FCR)

- detects twins, ectopic pregnancy, missed abortion, hydatidiform mole.

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Diagnosis of pregnancy in the first 4-5 weeks (I-st trimester)

Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Clinical signs

- amenorrhea (> 16 weeks)

- progressive enlargement of the abdomen

- perception of the fetal movements by the mother beginning with 17-18 weeks (multiparas) up to 19-20 weeks (primiparas) = quickening

Inspection

• Face: chloasma (melasma gravidarum) = mask of pregnancy
• Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola
• Abdomen: enlargement, linea nigra, stria (reddish, slightly depressed streaks), protruded umbilicus, pigmented scars
• Perineum – accentuation of pigment

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Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Clinical signs

Palpation

• Breasts: specific consistency, colostrum expressed from the nipples
• Abdomen:

- pregnant uterus – a globulous, soft, contractile, painless mass

- irregular, painless uterine contractions – Braxton-Hicks contractions

- the height of the uterine fundus becomes measurable (16cm – 20 weeks, 20cm – 24 weeks)

- ballottement sign

Ascultation

• fetal heart sounds (110-160 b/min), with obstetrical stethoscope, near umbilicus

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Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Clinical signs

Obstetrical examination – cont.

Speculum examination (cervix, vagina and perineum)

- hyperemia

- Chadwick sign (violet-bluish color of the mucosa)

- increased size of the cervix

Bimanual examination (uterus)

- softening of the vagina, cervix, lower segment and upper segment

- enlargement of the uterus

- Braxton-Hicks contractions

- vaginal ballottement

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Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

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Differential diagnosis

abdominal mass

• ovarian cyst with abdominal development
• uterine myoma

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Diagnosis of pregnancy between the 17- 28 weeks �(II-nd trimester)

Laboratory diagnosis

- biological tests – no more

- immunological tests – β-hCG (detection and quantification)

Ultrasound imaging

abdominal sonography / vaginal sonography

AIMS

- gestational age (BPD, FL, AC)

- fetal morphology and biometry

- multiple pregnancy

- fetal heart movements

- placental insertion, a.f.

Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Clinical signs

- amenorrhea (> 29 weeks)

- progressive enlargement of the abdomen

- perception of the fetal movements by the mother/examinator

Inspection

• Face: chloasma (melasma gravidarum) = mask of pregnancy
• Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola
• Abdomen: enlargement, linea nigra, striae gravidarum, protruded umbilicus, pigmented previous surgical scars
• Perineum – accentuation of pigment

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Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Clinical signs

Palpation

• Breasts: specific consistency, colostrum expressed from the nipples
• Abdomen (Leopold manoevers):

Superficial palpation

- pregnant uterus (a globulous, soft, contractile, painless mass, Braxton-Hicks contractions

- measurement of the height of the uterine fundus

Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Clinical signs

• Abdomen:

Deep palpation

- identification of the presenting part (if the head, it is firm, rounded, large, regulated)

- lateral palpation – on the sides of the uterus (the back is an elongated firm mass; the limbs are small, irregular parts)

Ascultation

• fetal heart sounds (110-160 b/min) in vertex presentation – below the umbilicus

Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester)

Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Diagnosis of pregnancy between the 29 - 40 weeks �(III-rd trimester)

Clinical signs

Obstetrical examination

Speculum examination (cervix, vagina and perineum)

- hyperemia

- Chadwick sign (violet-bluish color of the mucosa)

- increased size of the cervix

- external cervical os - slit-like or round, with mucous plug

Bimanual examination

- softening of the vagina, cervix, lower segment and upper segment (patulous cervix admits a fingertip)

- fetal presenting part, membranes

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Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester)

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Ultrasound imaging

abdominal sonography / vaginal sonography

AIMS

- fetal morphology and biometry (BPD, Fl, AC)

- fetal heart movements,

- breathing movements

- evaluation of the amniotic fluid

- placental insertion and maturation degree

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Presumptive evidence of pregnancy

• Subjective symptoms

- nausea +/- vomiting

- disturbances in urination

- fatigue

- the perceptions of fetal movements

• Presumptive signs

- cessation of menses

- changes in the breast

- changes in the cervical mucus

- discoloration of the vaginal mucosa

- increased skin pigmentation and development of abdominal striae

- does the woman believe that she is pregnant?

Probable evidence of pregnancy

• Enlargement of the abdomen
• Changes in the shape, size and consistency of the uterus
• Anatomical changes in the cervix
• Braxton-Hicks contractions
• Ballottement
• Physical outlining of the fetus
• Presence of β-hCG in serum or urine

Positive signs of pregnancy

• Identification of fetal heart activity separately and distinctly (from mother)
• Perception of fetal movements by the examiner
• Recognition of the embryo / the fetus throughout imagistic methods (ultrasound)

Gestational age assessment

• First day of the last menstrual period (LMP) + no. of weeks
• The day when the mother has felt the first fetal movements (quickening) + 22 weeks in multiparas, or 20 weeks in primiparas
• The uterine height (UH) in cm + 4 =the number of gestational weeks
• Ultrasound examination during the first 12 weeks of amenorrhea