otherwise healthy individual having previous normal regular cycles is likely due to pregnancy, unless proved otherwise Morning sickness
Frequency of micturition : 8- 12th week
Breast discomfort : 6- 8th week
Fatigue Objective signs Breast changes (primigravidae) : 6- 8 weeks Enlargement with vascular engorgement Nipple and the primary areola become more pigmented Colustrum can be expressed as early as 12th week
Per Abdomen Uterus remains a pelvic organ till 12 weeks Pelvic Changes Vaginal changes Jacquemier’s or Chadwick’s sign : dusky hue of the vestibule and the anterior vaginal wall (at about 8th week) Osiander’s sign : increased pulsations felt through the lateral fornices (at 8th week)
Cervical changes Goodell’s sign : cervix becomes soft (as early as 6th week) Bluish discoloration of the cervix Uterine changes Size, shape and consistency of the uterus (Piskacek’s sign : In a case of lateral implantation of the embryo, one half of the uterus becomes more firm than the other) Hegar’s sign : 6- 10 weeks On bimanual examination, the abdominal and vaginal fingers seem to appose below the body of the uterus Palmer’s sign : 4- 8 weeks Regular and rhythmic uterine contractions elicited during bimanual examination Immunological tests Principle : detection of hCG antigen present in the maternal urine or serum with antibody Selection of time : diagnosis by detecting hCG in maternal urine or serum can be made by 8 to 11 days after conception. The test is not reliable after 12 weeks Collection of urine : first voided urine in the morning Test Sensitivity Time taken Inference Positive on Agglutination 0.5- 1 IU/ml 2 min Absence of 2 days after inhibition test (Urine) agglutination missed period Direct latex 0.2 IU/ml 2 min Presence of 2- 3 days after agglutination (Urine) agglutination missed period test Two-site 30- 50 4- 5 min Colour bands On the fist day sandwich mIU/ml in the control of the missed immunoassay/ (Urine) as well as in period (28th Membrane ELISA test windows day of cycle) test (Card test) ELISA 1- 2 mIU/ml 2- 4 hours 5 days before (Serum) the first missed period Fluoroimmuno 1 mIU/ml 2- 3 hours “ assay (FIA) (Serum) Radioimmuno 0.002 mIU/ml 3- 4 hours 25th day of assay (RIA) (Serum) cycle Immuno 0.05 mIU/ml 30 min 8 days after radiometric (Serum) conception assay (IRMA) Ultrasonography Intradecidual gestational sac is identified as early as 29- 35 days of gestation Embryonic structures identified by TVS
Menstrual/ Fetal structures
gestational age (weeks) 4 Choriodecidual thickness, chorionic sac 5 Gestational sac, embryo yolk sac 6 Fetal pole, cardiac activity 7 Lower limb buds, midgut herniation 8 Upper limb buds, stomach 9 Spine, choroid plexus Symptoms Amenorrhea continues Quickening : about 18th week in primi and 16th week in multi Progressive enlargement of the lower abdomen by the growing uterus General examination Chloasma : pigmentation over the forehead and cheek (at about 24th week)
Breast changes: Breasts are more engorged with prominent veins Secondary areola appears at about 20th week Montgomery’s tubercles are prominent and extend upto secondary areola Variable degree of striae Abdominal examination Inspection: Linea nigra as early as 20th week Striae on the flanks
Palpation: Fundal height Braxton- Hicks contractions are evident Palpation of the fetal parts (by 20th week) Active fetal movements (by 20th week) External ballotment (by 20 th week) Ausculatation: Fetal heart sounds (most conclusive clinical sign of pregnancy): detected by 18- 20 weeks with a stethoscope Differential diagnosis: Uterine souffle – synchronous with maternal pulse Funic or fetal souffle – synchronus with fetal heart souds Vaginal examination Bluish discoloration of the vulva, vagina and cervix is more evident, so is softening of the cervix Internal ballotment: 16- 28th week Imaging studies Sonography Gestational age is determined by measuring BPD, HC, AC and FL and is most accurate between 12- 20 weeks Detailed survey of fetal anatomy at 18- 20 weeks MRI Radiological evidence of fetal skeletal shadow by 16th week Symptoms Amenoorhea persists Enlargement of the abdomen Lightening Frequency of micturition Fetal movements Signs Cutaneous signs Fundal height: increases and decreases back to 32 week size with head engaged and flank fullness Symphysiofundal height: measured in cms (corresponds to gestational age from 24 weeks to 36 weeks) Braxton- Hicks contractions Fetal parts and fetal movements Fetal Heart Sounds Sonography Gestational age estimation is less accurate (variation of 3 weeks) Fetal growth profile by AC (IUGR or macrosomia) Amniotic fluid volume assessment Uterine fibroid Hematometra Cystic ovarian tumour Encysted tubercular peritonitis Distended urinary bladder Pseudocyesis (false/ spurious/ phantom pregnnacy) Psychological disorder where the woman has the false but firm belief that she is pregnant although no pregnancy exists Conspicuous feature is cessation of menstruation Gradual enlargement of abdomen because of deposition of fat Secretions from breast Intestinal movements, interpreted as fetal movements Eventually spurious labour Obstetric examination, imaging and the immunological tests for pregnancy negate the presence of any pregnancy Positive or absolute signs: Palpation of feta parts and perception of active fetal movements by the examiner Ausculation of fetal heart sounds Ultrasound evidence of embryo and fetus Radiological demonstration of fetal skeleton Probable signs: Abdominal enlargement Braxton- Hicks contractions External and internal ballotment Outlining of fetus Changes in the size, shape and consistency of the uterus Vaginal and cervical changes Immunological test Presumptive signs and symptoms Amenorrhea Frequency of micturition Morning sickness Fatigue Breast changes Skin changes Quickening
