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Diagnosis of Pregnancy in three trimesters

Diagnosis of Pregnancy contains the signs and symptoms obtained during first, second and third trimester along with general examination and investigation.

AFTER READING DIAGNOSIS OF PREGNANCY, READ POLYCYSTIC OVARIAN SYNDROME (PCOS).

Duration of Pregnancy= 280 days or 40 weeks, calculated from the first day of last menstrual period. This is called Menstrual / Gestational age.

Fertilization generally occurs 14 days prior to the expected missed period. Thus, true gestation period is 266 days.

First trimester (First 12 weeks)

1. Subjective Symptoms:-

  • Amenorrhoea= However, cyclic bleeding may occur upto 12 weeks of pregnancy.
  • Morning sickness in about 50% cases. It occurs soon following the missed period. Nausea on rising from the bed to loss of appetite or even vomiting may occur.
  • Frequency of micturition decreased during 8th-12th week of pregnancy. It is generally due to anteverted position of uterus, that straightens after 12th week.
  • Breast discomfort= Feeling of fullness and pricking sensation.
  • Fatigue

2. Objective signs:-

  • Breast changes= Observed in primigravidae. Evident between 6-8 weeks. The nipple and areola become more pigmented, specially in dark women. Montgomery’s tubercle are prominent. Colostrum is expressed.
Montgomery's tubercle
Montgomery’s tubercle
  • Per Abdomen= Uterus can be felt as a suprapubic bulge until 12th week.
  • Pelvic changes=
    • Jacquemier ‘s / Chadwick’s sign- Discolouration of the vestibule and anterior vaginal wall at about 8th week of pregnancy.
    • Vaginal sign- Walls soften, copious mucoid discharge at 6th week and increased pulsation at lateral fornices. (Osiander’s sign)
    • Cervical signs- Cervix softens at around 6th week. Pregnant cervix feels like lips of mouth
  • Uterine signs=
    • Change in size, shape and consistency.
    • Hegar’s sign–
    • Palmer’s sign- Regular and rhythmic uterine Contraction can be elicited during bimanual examination as early as 4-8 weeks.
Hegar's sign
Hegar’s sign

Immunological test for Diagnosis of Pregnancy :-

Principle:

It depends on detection of the antigen (hCG) present in the maternal urine or serum with antibody.

Test used:
  1. Agglutination inhibition test= Pregnancy test is negative, if there is Agglutination.
  2. Direct agglutination test (hCG direct test)
  3. Enzyme-linked immunosorbent assay (ELISA)
  4. Fluoroimmuno assay (FIA)
  5. Radioimmunoassay (RIA)

Second trimester (13-28 weeks)

Symptoms:

Amenorrhoea continues. Other features:

  • Quickening (feeling of life)= Perception of active foetal movements by the women. Usually felt at about 18th week.
  • Progressive enlargement of the lower abdomen.
General Examination:
  • Chloasma= Pigmentation over the forehead and cheek may appear at about 24th week.
  • Breast changes= Breasts are more enlarged with prominent veins under the skin. Secondary areola specially in primigravidae, colostrum becomes thick and variable degree of striae may be visible.
Abdominal examination:

1. Inspection:-

  • Linear pigmented zone extending from symphysis pubis to ensiform cartilage may be visible at around 20th week.
  • Striae (both pink and white) are visible in the lower abdomen.

2. Palpation:-

  • Fundal height is increased with progressive enlargement of the uterus.
Diagnosis of pregnancy
Level of fundus uteri at different weeks
  • Uterus feels soft and elastic.
  • Palpation of fetal parts can be felt distinctly by 20th week.
  • Active fetal movements as early as 20th week.
  • External ballottement is usually elicited as early as 20th week when the fetus is relatively smaller than the volume of the amniotic fluid.
Diagnosis of pregnancy
The first image shows external ballottement and other 2 images show internal ballottement

3. Auscultation:-

Foetal heart sound (FHS) most conclusive clinical sign of pregnancy. It can be detected between 18-20 weeks. The rate varies between 110-160 beats per minute. Other 2 sounds confused with fetal heart sounds are:- Uterine souffle and fetal souffle.

Vaginal Examination:
  • Bluish discolouration of the vulva, vagina and cervix and softening of cervix.
  • Internal ballottement can be elicited between 16-28th week
Investigations:
  • Sonography
  • Fetal organ anatomy
  • Magnetic Resonance Imaging (MRI)

Last / Third trimester (29-40 weeks)

Symptoms:
  • Amenorrhoea persists
  • Enlargement of the abdomen is Progressive
  • Lightening= At about 38th week, specially in primigravidae, a sense of relief of pressure symptoms is obtained
  • Frequency of micturition reappears
  • Fetal movements are more.
Signs:
  • Cutaneous changes are more prominent.
  • Uterine shape= changed from cylindrical to spherical beyond 36th week
  • Fundal height= Symphysis fundal height (SFH)
  • Braxton= Hicks contractions are more evident
  • Fetal movements are easily felt.
  • Palpation of the Fetal parts and their identification becomes easier.
  • FHS is heard distinctly in areas corresponding to presentation and position of fetus
Investigations:
  • Sonography
  • Fetal AC (at the level of umbilical vein to assess gestational age and fetal growth profile)
  • Amniotic fluid volume assessment
  • Placental anatomy

Other information:- Fetal life, number, presentation and organ anatomy are surveyed again.

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