Diagnosis of

pregnancy
DR RENU SHARMA
A S S O C I AT E P R O F E S S O R
D E PA RT M E N T O F O B S T E T R I C S & G Y N A E C O L O G Y
A I I M S , V I J AY P U R , J A M M U
Reproductive period
•From menarche to menopause- 13 to 45 years
• Youngest women to have pregnancy-Lina Medina-5 years 7months
•Oldest- Dawn Brooke -59 years –spontaneous conception
• Maria del Carmen Bousada Lara-55 years –IVF conception
•Erramati Mangayamma- India – 74 years- IVF conception

American Society for Reproductive Medicine in 2016 discouraged physicians from "providing
donor oocytes or embryos to women over 55 years of age, even when they have no underlying medical
problems." The committee noted concerns about maternal and fetal safety, longevity and "the need for
adequate psychosocial supports for raising a child to adulthood."
Duration of pregnancy
Menstrual age/gestational age- Naegele “s Formula
•10 lunar months
•9 calender months 7 days
•40 weeks
•280 days
Fertilization age/ovulatory age –
266 days
Division of pregnancy
Traditionally

NOW as –
Early pregnancy- 0 to14 weeks
Mid pregnancy- 15 to 28 weeks
Late pregnancy- 29 to 40 weeks
First trimester (0-12 weeks)
Symptoms
Amenorrhoea –cessation of periods (presumptive symptom)
Occasionally
Implantation bleeding can occur as Placental sign /Hartman’s sign-28-35 days
Cyclical bleeding can occur in bicornuate/didelphys uterus till 8-12 weeks
Bleeding occurs when pregnancy is abnormal
Morning sickness (Emesis gravidarum)
•Starts early in pregnancy (4-8 weeks)
•Mostly settles by 12-14 weeks
•Doesnot restrict daily activities
•Due to high levels of HCG, oestrogen and altered
Immunological ,psychological states.
Frequency of micturation
•Troublesome in 8 to 12 weeks
• Causes-
•Bulky uterus presses on fundus of bladder.
•Congestion of bladder mucosa
•Changes in maternal osmoregulation
Breast discomfort
•Fullness & prickling sensation in breast
•Common in primigravida
•More evident at 6-8 weeks

Fatigue
Salivation
Feeling of warmth & sweating
Mood changes
Pica-craving for abnormal/non food items
 Signs of pregnancy in First Trimester
Breast Changes
• Prominent in Primgravida
• Evident by 6-8 weeks
• Increased Pigmentation of nipple
and primary areola
• Appearance of secondary areola
• Montogomery tubercles appear
• Increased vascularity
• Colostrum secretion by 12 weeks
 Pelvic organ changes

Per Abdomen Examination- Till 12 weeks, uterus remains pelvic organ .It may
be just felt as a Suprapubic bulge at 12 weeks
Per speculum examination-

Pelvic Changes
Per Speculum Exami

Cusco’s bivalved speculum

Pelvic findings
PER SPECULUM EXAMINATION_ Changes appear at 6-8 weeks
• Chadwick’s or Jacquemier’s Sign- Bluish discolouration of vestibule & vagina
• Bluish discolouration of cervix
• Copious ,non- irritating mucoid discharge

Non-pregnant Pregnant
(Chadwick’s sign)
 Per vaginal examination (Bimanual Exam)

Osiander’s sign-
pulsations felt through lateral vaginal fornices.-8 weeks

Goodell’s sign-
Pregnant cervix feels like lips of the mouth due to softening -6 weeks
Non-pregnant cervix feels like tip of the nose.
Uterine signs
Piskacek’s sign-Asymmetrical enlargement of uterus due to lateral implantation.
Size of uterus-
6weeks-hen’s egg

8 weeks-cricket ball

12 weeks-fetal head
6weeks 8weeks 12 weeks
Hager’s sign
• On bimanual examination,abdominal and vaginal fingers seem to appose below the body
of the uterus.
• Due to variation in consistency of uterus (soft) and cervix (comparatively firm).
• 6-10 weeks

Palmer’s sign-
•Rhythmic & regular uterine contractions
•4-8 weeks
 Immunological tests
•Based on detection of Human chorionic gonadotrotropin (HCG) in serum or urine.
•HCG-Glycoprotein with 2 subunits-alpha & beta
•Beta subunit is more specific.
•HCG is secreted by syncytiotrophoblast of the placenta.
Urine Tests For HCG detection

Latex agglutination inhibition test-

•Positive on 2 days after missed periods
•Detects 0.5-1IU/ml of HCG
•Takes 2 minutes
Urine Card tests
•Home tests(DIY )tests
•Rapid chromatographic immunoassay (Two-site sandwich)
•Utiizes a combination of monoclonal and polyclonal antibodies
•Detects upto 25 mIU/ml
•Come positive 2 days after missed periods
Blood tests for detection of HCG

Enzyme- linked immunosorbent tests (ELISA) - Uses one monoclonal antibody

and second antibody tagged with alkaline phosphatase to sandwich the HCG
Detection is by colour change.
Can detect 1 -2 mIU/ml of serum HCG
Takes 2 to 4 hours
Comes positive 5 days before missed periods

FIA- Flourescent immunoassay- Uses other antibody tagged with fluorescent level
Detection by measuring amount of flourescence emitted
Detects upto 1miu/ml
Takes 3-4 hours
Radioimmunoassay(RIA)
Uses I125 ido HCG antibodies
Can detect β-HCG upto 2 mIU/ml
Can detect pregnancy 8-9 days after ovulation
Takes 3-4 hours

Immuno-radiometric assay (IRMA)

Uses sandwich principle to detect whole HCG molecule.
Requires 30 minutes
Can detect HCG as low as 0.05 mIU/ml
ULTRASONOGRAPHY
Timing for appearance of various parameters on TVS
Gestational sac-41/2 weeks
Yolk sac-5 weeks
Fetal node-51/2 weeks
Fetal heart-6 weeks

Critical value of Serum β-HCG for detection of IU pregnancy

For TVS-2000IU/l
For TA-6500IU/l
Doppler USG for cardiac activity
Second trimester 13-28 weeks
Symptoms
•Amenorrhoea continues.
•Progressive enlargement of lower abdomen
•Nausea,vomiting,frequency of micturition subsides.
•Quickening-perception of fetal movements by the
women for the first time.
Primigravida- 18 weeks
Multigravida- 16 weeks
SIGNS
Chloasma-Pigmentation over the forehead & cheeks.
Appear around 24 weeks
Breast changes
•Enlargement with prominent veins under the skin.
•Secondary areola -20 weeks
•Montogomery’s tubercles extend to secondary areola
•Colostrum becomes thick and yellowish -16 weeks
•Stria may be visible
Abdominal examination

Linea Nigra-linear pigmented zone extending

from the symphysis pubis to ensiform cartilage-
20 weeks

Stria-Visible in the lower abdomen,

& more towards the flanks.
Fundal height

•Midway between umbilicus and symphysis

pubis-16 weeks
•Level of umbilicus-20—24 weeks
•Junction of lower 1/3rd and upper 2/3rd between
umbilicus and ensiform cartilage-28 weeks
•At ensiform cartilage-36 weeks
Braxton –Hick’s Contractions
•.Spontaneous but can be induced by rubbing

•.Irregular,infrequent,spasmodic,and painless contractions without any effect on

dilatation of the cervix.
•.Can be felt during bimanual exam/abdominal exam
•.The woman is not conscious about these contractions.
•.Intrauterine pressure remains below 8 mmhg.
•.Absent in abdominal pregnancy
UTERINE SIGNS
•Uterus becomes ovoid in shape.
•Uterus feels soft, elastic.
•Fetal parts can be palpated by 20 weeks
•Fetal movements can be appreciated by 20 weeks
• by placing hand over the uterus
External Ballotement-
• Elicited by giving a push to the fetal parts
abdominally and feeling an implulse with
other hand.
• -By 20 weeks when fetus is relativeluy
smaller than the amniotic fluid
• Difficult to elicit in obese &
Oligihydroamnios
• Best elicited in breech presentation.

Internal Ballotement
• Elicited by pushing the fetus by two
fingers in anterior fornix.
• From 16 to28 weeks
• Not elicited in oligohydroamnios or
transverse lie
Auscultation
Fetal heart sounds are ascultated by fetal doppler by 10-12 weeks
by Pinard’s fetoscope or stethoscope by 20-24 weeks
Confusing sounds-
Uterine souffle- soft blowing systolic murmur synchronous with the maternal pulse.
due to increased blood flow through the dilated uterine vessels.
Fetal souffle or funic souffle-soft blowing murmer synchronous with fetal heart sounds
due to blood flow through the dilated umblical vessels
Ultrasound in second trimester
 Third trimester(29-40 weeks)
Symptoms
•Amenorrhoea continues
•Progressive enlargement of abdomen
•Fetal movements become more pronounced
•Frequency of micturition reappears
•Lightening-Sense of relief of pressure symptoms due to engagement of the
presenting part-38 weeks ,in primigravida
Signs
•Increased pigmentation and stria
•Uterine shape-Cylindrical to spherical
•Fundal Height-
 Symphysiofundal height (SFH)
• Distance between the upper border of the left hand and point at upper border of
the fundus
•After 24 weeks ,it corresponds ( in centimetres) +/- 2 cms to the number of weeks
upto 36 weeks .
• Braxton –Hick’s Contractions –more evident

• Fetal movements- felt easily

• Palpation of fetal parts –Easily identifiable

• FHS- heard in distinct areas corresponding to presentation &

position of fetus
USG in third trimester
Summary of Signs & Symptoms of pregnancy
•Presumptive Signs lead a woman to believe that she is
pregnant
•Probable Signs are highly suggestive of the diagnosis of the
pregnancy
•Positive signs ascertain the presence of pregnancy
 Presumptive Symptoms & Signs
•Amenorrhoea
•Morning sickness
•Frequency of micturition
•Fatigue
•Breast changes
•Skin changes
•Quickening
Probable signs
•Abdominal enlargement
•Braxton- Hick’s contractions
•External ballottement
•Outlining the fetus
•Changes in size, shape and consistency of the uterus
•Jacquemier’s sign, osiander’s sign
•Internal ballottement
•Immunological tests
Positive/Absolute signs
•Palpation of fetal parts &Perception of active fetal movements by the examiner
•Auscultation of fetal heart sounds
•Ultrasound evidence of embryo
•Radiological demonstration of the fetal skeleton at 16th week and onwards