Introduction

 The diagnosis of pregnancy requires a 3multifaceted

approach using 3 main diagnostic tools, history and
physical examination, hormonal assays, and ultrasound
(US).
 Currently, physicians may utilize all of these tools to
diagnose pregnancy at early gestation and to help rule
out other pathologies
• Presumptive (subjective )signs

•Objective (probable) signs

 Diagnostic (positive/sure) signs of pregnancy
I- Presumptive (subjective )signs of
pregnancy:

These signs are least indicative of pregnancy; they

could easily indicate other conditions. signs lead a
woman to believe that she is pregnant
Diagnosis of pregnancy

 The diagnosis of pregnancy is based on

 A. Presumptive signs
 B. Probable signs
 C. Positive signs
PRESUMPTIVE SIGNS
( Possible signs )
 Those maternal and physiological changes that
the women experience
 Most cases these dictate a positive preg
 A. Amenorrhoea 3- 4 weeks
 B. 70% of – experience nausea accompanied by
vomiting – btw 4- 16 week
 C. Tingling , heaviness, tenderness and pricking
sensation in the breast – felt in early pregnancy .
Gradually nodular formation , enlargement of
breast areolar tissue and nipple changes are
noticeable at 6 week onwards
 Frequency of mituration increases btw 6 and
12 week . Bladder irritability is more pronuced
in case of UTI and pelvic tumors
 Quickening 016 – 20 week – the first fetal
movement felt by the mother
 II-Objective (probable) signs:
An examiner can perceive the objective changes

that occur in pregnancy. They are more diagnostic

than the subjective symptoms; however, their
presence does not offer a definite diagnosis of
pregnancy.
Changes in the pelvic organs:
These changes caused by increased vascularity
and congestion during the first three months of
pregnancy.
 1- Hegar's sign:
 It is the softening of the isthmus of the uterus, the

area between the cervix and body of the uterus,

which occur at 6 to 8 weeks of pregnancy. This
area may become so soft that on bimanual
examination the anterior fornix fingers and
abdominally fingers meet each other.
 2- Chadwick's sign:
 Is the deep red to purple or bluish coloration of

the mucous membranes of the cervix, vagina

and vulva due to vasocongestion of the pelvic
vessels.
 McDonald's sign :
 It is an ease in flexing the body of the uterus

against the cervix.

 Osiander's sign:
 It is increase pulsation in lateral fornix due to

increase vascularity resulted in pelvic

congestion.
 Enlargement of the abdomen:
 During the childbearing years is usually regarded

as evidence of pregnancy, especially if the

enlargement is progressive and is accompanied
by a continuing amenorrhea.
 Braxton Hicks contractions:
 Are ordinary painless that occur at irregular

intervals throughout pregnancy but are felt

with abdominal palpation after 28 weeks. As
the pregnancy progresses these contractions
become uncomfortable and are often called"
false labor ".
 
 Uterine Soufflé:
 May be heard when auscultating the
abdomen over the uterus. It is a soft blowing
sound at the same rate as the maternal pulse
and is due to the increased uterine
vascularization and the pulsation through the
placenta.
  
PROBABLE SIGNS
These maternal physiological changes are
detected by physical examination
 1. PRESENCE of HCG hormone in the blood on 9
th or 10 th day . This hormone is also found in
the mothers urine – detected by the 14 day
 2.Softening of the isthmus ( HEGARS SIGN)- is
marked btw 6- 12 week of pregnancy
 3. CHADWICKS SIGN / OSIANDERS – bluish
discoloration of the vagina, ( increased
vascularity , causes congestion ,hence purple
discolouration ) , along with pulsation in the
lateral fornices – noticed at 8 th week onwards
 Production of hCG begins as early as the day of
implantation
 a) Urine. This test can be performed accurately 42 days
(

after the last menstrual period or 2 weeks after the first

missed period. The first urine specimen of the morning is
the best one to use.
 (b). Blood. Radioimmunoassays (RIA) can detect HCG in
the blood 2 days after implantation or 5 days before the
first menstrual period is missed.
 4.JACQUEMIERS SIGNS- Violet discolouration of
the of the vaginal and vulva mucosa membrane –
seen positive at 8 week onwards
 Palmer’s sign: Uterine contractions can be elicited
by bimanual examination.
 5. Changes in shape and size of the uterus – found
from 8 week onwards . Its consistency is soft and
shape is globular than pear shaped
 6. changes in the skin pigmentation – cholasma ,
linea nigra , darkening of primary areolar and
formation of secondary areolar
 7. UTERINE SOUFFLE – 16 week onwards – soft
blowing sound heard on auscultation at the side of
the uterus , best heard on the left side. This sound is
heard due to increase in the blood flow through the
dilated uterine vessels and is synchronous with the
maternal pulse
 THE FUNIC SOUFFLE – the sound of blood
rushing through the umbilical arteries , it is a
soft blowing murmur synchronous with the
fetal heart sounds.
 8. braxton – hicks contraction – PAINLESS
uterine contraction felt on abdominal
palpation , occurring every 15 minutes at 16
week are noticed . They increase in instensity
after 35 week . They facilitate blood
circulation at the placental site in a healthy
pregnancy
 9 . GOODELL’S sign- the cervix and the
uterus is softened
 10. External Ballottment – Around 20 week , the
uterus between the palpating hand reveals the
feeling of ballotment .
 11. INTERNAL BALLOTTMENT – 16 week
onwards , vaginal examination reveals , the
presence of a body that moves away on tapping
and later returns with a thud .
 In this a sudden tap on the uterus cause the fetus
to sink into the amniotic fluid and rebound to
strike gently against the fingers of the examiner .
EXTERNAL BALLOTTMENT
INTERNAL BALLOTTMENT
 Skin changes:
 Changes as pigmentation of the skin and the appearance
of abdominal stria gravidarium are common
manifestation in pregnancy. Facial cholasma occurs in
varying degrees after 16 weeks. Also linea nigra also
appear in the abdomen. The pigmentation of the nipple
and areola may darken, especially in primigravidas.

- Fingernails. Some patients note marked thinning and

softening by the sixth week.

 III -Diagnostic (positive/sure) signs of
pregnancy

 The positive signs of pregnancy are completely

objective, cannot be confused with pathological

states, and offer conclusive proof of pregnancy,
but they are usually not present until after the
fourth month of pregnancy.
 1-The fetal heart beats:

 The fetal heart begins beating by the 24th day

following conception. It is audible with a doppler by
10 weeks of pregnancy and with a fetoscope after the
16th week . It is not to be confused with uterine
souffle or swishlike tone from pulsating uterine
arteries. The normal fetal heart rate is 120 to 160
beats.
 2-Fetal movements:

 Are actively palpable by a trained examiner

after about 20weeks of gestation. They vary

form a faint flutter in the early months to more
vigorous movements late in pregnancy.
 3-Ultra sound:
 Is a technique that can be used for a positive
diagnosis as early as the fourth to fifth week of
pregnancy.
 The earliest structure identified is the gestational
sac (GS). The GS can be seen on TVUS by 4-5
weeks' gestation and grows at a rate of 1 mm/d
in early gestation
 4-Fetal Parts:
 Can be palpated through the abdominal wall
 5-Radiological (x-ray):
 An x-ray will identify the entire fetal skeleton by

the 12th week. In utero, the fetus receives total

body radiation that may lead to genetic or
gonadal alterations. An x-ray is not a
recommended test for identifying pregnancy.
POSITIVE SIGNS
Positive or sure signs – AS DOCUMENTED BY THE
PHYSICAIN or examiner
1. ULTRASONOGRAPHY -Visualization of the
gestational sac by Transvaginally usg( by 4.5
weeks ) AND TRANS ABDOMINAL( 5.5 weeks )
usg –
2. VISUALISATION of heart pulsation by trans
vaginal usg( 5week) and trans abdominal usg (6
week)
3. Fetal heart sounds by doppler or usg ( 11- 12
weeks ), fetal stethoscope ( 20 + weeks )
Contd

 4. Fetal movements – palpable by 22weeks

and later , visible – ( in late pregnancy)
 5. Fetal parts palpated – (24 + weeks)
 6. x- ray – visualisation of fetus by xray –
( 16week + )
OTHER SIGNS
 BMR - initially falls during early pregnancy – it
accounts for the period of fatigue experienced
by the women , following which the BMR rises
to meet the growing metabolic demands of
pregnancy .
 Nausea and vomiting is present in the first
trimester
 Excessive salivation – rarely present , because
of increased acidity in stomach or by the intake
of starch stimulating salivary glands
 HORMONAL PREGNANCY TEST
 By the detecting of HCG hormone – in urine by
the 26 th day after conception
 Abnormally low in case of ectopic pregnancy
 Abnormally high in multiple pregnancy ,
hydatidiform mole or choriocarncinoma
DIFFERENTIAL DIAGNOSIS

 AMENORRHOEA- hormonal imbalance ,

emotional stress, or illness
 MORNING SICKNESS- gastroinstenstinal
disorders , pyrexia illness , cerebral irritation
 Bladder irritability – uti or pelvic tumors
 Quickening – intestinal movements “ wind “
 Breast changes – contraceptive pills
 Presence of HCG in the blood – Hydatidiform
mole
 Presence of HCG in the urine
Choriocarcinoma
 Pulsation of the fornices – pelvic congestion
 Uterine enlargement – uterine tumors
 Uterine souffle – increased blood flow to
uterus as in a large uterine myomas or
ovarian tumors