1. DIAGNONSIS OF PREGNANCY
AND
MATERNAL PHYSIOLOGICAL
CHANGES OF PREGNANCY
BY
Dr : A/ ILLAH KUNNA

2. DIAGNOSIS OF
PREGNANCY
 Diagnosis in the first trimester (first 12 weeks)
Symptoms:
1- Cessation of menstruation
:(missed period):
due to increased estrogen and progesterone
production by the corpus Luteum. However it
may be absent in cases of:
 pregnancy during lactation amenorrhea.
 Threatened abortion.
 Slight bleeding at the expected time of

3. 2- Morning sickness:
- Nausea , vomiting especially in the
morning.
- Usually disappears after the third month.
- May be due to allergy to hCG.
3- Freguency of micturition:
- Due to congestion. Irritation of the
bladder by the pregnant uterus.
- Usually disappears after the third month.

4. 4- Breast symptoms:
Enlargement , heaviness , discomfort and
tinling sensation.
5- Appetite changes:
Craving for certain types of food and
refusal of other types.

5. Signs:
1. Breast signs : ( evident in a
primigravida).
 Increased size and vascularity.
 Dilated visible veins.
 Increased pigmentation of the nipple
and 1ry areola.
 Appearance of 2ry areola.
 Appearance of Montgomery
tubercles in the areola ( dilated
sebaceous glands).

6. 2. Uterine sign ; felt by bimanual examination:
 Size : enlarged.
 consistency : soft.
 Shape : globular.
 Hegar sign : ( elicited between 6-10 weeks).
Two fingers in the anterior fornix, the fingers
of the other hand over the abdomen behind
the uterus . The fingers of both hands can be
approximated as the lower part of the uterine
body is soft and empty.
 Palmer sign:
Uterine contractions felt on bimanual
examination.

7. 3- Cervical and vaginal signs:
 Leucorrhea :
Increased vaginal discharge.
 Chadwick s sign:
Bluish discoloration of the vagina and
cervix.
 Goodell s sign:
Cyanosis and softening of the cervix at 4
weeks

8. Investigations:
1. Pregnancy test:
All depend on the detection of hCG either in
serum or in urine . Simple urine pregnancy
tests are now available to be used at home
giving an accurate result within 5 minutes.
A. Estimation of beta subunit of hCG in the
serum:
Using radioimmunoassay , sensitivity : 5
mIU/ml.
Positive I week BEFORE the expected
menstuation ( I week after fertilization ).

9. B. ELISA pregnancy slide test:
can detect pregnancy starting from 48
hours after the missed period.
C. Immunologic pregnancy tests:
 Detect hCG in urine by an antigen
antibody reaction.
 The sensitivity of these tests ranges
between 25-250 mIU/ ml. positive few
days AFTER the missed period.

10. Uses of pregnancy tests:
 Diagnosis of normal pregnancy.
 Diagnosis of missed abortion.
 Diagnosis of ectopic pregnancy (
see ectopic pregnancy) .
 Diagnosis and follow – up of
vesicular mole and
choriocarcinoma .

11. 2. Ultrasonography:
Vaginal:
 Gestational sac : 4 weeks.
 One fetal pole : 5 weeks.
 Two fetal poles : 6 weeks.
 Fetal heart activity : 7 weeks.
Abdominal:
The previous findings can be detected one
week later.
3. Auscultation of FHS :
Using the Doptone (sonicaid ) starting
from 10 weeks.

12. Diagnosis in the second trimester
( 13-28 weeks)
Symptoms:
1. Amenorrhea.
2. Morning sickness and urinary symptoms
gradually decrease .
3. “Quickening “ : perception of fetal
movements by the pregnant woman:
a. 18-20 weeks in primigravida.
b. 16-18 week s in multipara.
4. Abdominal enlargement.

13. Signs:
1. Breast changes become more evident.
2. The uterus is abdominally felt.
3. Braxton Hicks contractions; intermittent
painless contractions detected by abdominal
examination.
4. Internal ballottement : elicited at 16 week , it
can be demonstrated by by pushing the fetus
through the anterior fornix using 2 fingers.
5. External ballottement : elicited at 20 week
through abdominal examination.
6. Palpation of the fetal parts and palpation of fetal
movements by the obstetrician at 20 weeks.
7. Auscultation of the F.H.S. at 20- 24 weeks by

14. MATERNAL PHYSIOLOGICAL
CHANGES OF PREGNANCY
pregnancy is a peculiar physiological
state in which many changes take place
; mostly due to the effect of pregnancy
hormones. These changes help
adaptation of the woman s body to
pregnancy . Understanding these
changes is essential for the following
reason: to discriminate between
symptoms related to pregnancy and
those of pathological conditions, to
understand the effect of pregnancy on
pre-existing diseases e.g diabetes and

15. 1. Genital organs:
A. The uterus :
Increase in : size : 7.5 to 35 cm.
weight : 50 to 1000 gms.
Due to:
 Effect of pregnancy hormones leading to hypertrophy
( mainly ) and hyperplasia.
 Stretching by the growing fetus.
Shape :
Globular until 14 weeks then pyrifrom.
Ligament:
Hypertrophy .

16. Dextro rotation : ( 80 % of cases).
The uterus is tilted and twisted to the right .
Braxton Hicks contractions:
Irregular , usually painless, with no effect on cervical
dilatation. Promoting placental circulation.
The lower uterine segment:
Is formed from the isthmus , starting from the fourth
month to reach 10 cm by full term.

17. Upper segment Lower segment
-Active -Passive
-Contracts and retracts - Dilates , stretches to
to become shorter and become thinner and
thicker longer
- Thick wall: - thin wall, the oblique
Outer longitudinal layer is poorly
Middle oblique ( main developed.
bulk – most important for
hemostasis ).
Inner circular ( especially
around orifices)
- Covered by adherent - Covered by loose
pertoneum peritoneum
- Membranes are firmly -Membranes are loosely
attached attached.

18.  Obstetric singnificance of
L.U.S.:
1. Site of lower segment cesarean
section (LSCS).
2. Site of rupture in obstructed labor.
3. Site of implantation of placenta previa.

19. B. The cervix:
 Edema.
 Increased vascularity.
 Hypertrophy of glands.
 The cervix becomes soft and bluish ;
the secretions from the mucus plug in
the cervical canal.
 Hormonal erosion sometimes occurs.
 Near term , prostaglandins induce
changes in collagen fibers and ground
substances making the cervix softer
and easily dilatable.

20. C. The vulva:
Varicosities may develop.
D. The vagina:
Increased vascularity makes it
soft, moist, bluish and warm.
E. The ovaries:
Edema , increased vasceularity . One
of the ovaries contains the corpus
luteum which may reach up to 5-6 cm
then in starts to degenerate by the 10 th
week.

21. 2. Breasts:
changes are induced by estrogen and
progesterone:
1. Early in pregnancy , breasts show
increased size and vascularity , become
warm, tense, nodular and slighty tender.
2. Increased pigmentation of nipple and 1 ry
areola.
3. Secondary areola appears later: a lightly
pigmented area around the (1ry) areola.
4. Montgomery s tubercles appear on the
areola ( dilated sebaceous glands).
5. colostrum may be expressed at the end of
the third month.

22. 3. Skin:
1. pigmentation : may be due to MSH or estrogen:
Linea nigra:
pigmentation appears in the midline of the
abdomen , more evident below the umbilicus.
Chloasma :
pigmentation of the face with butterfly
distibution.
2. Striae gravidarum : ( stretch marks).
Pink line in the flanks due to stretch of the
abdominal wall which causes rupture of the
subcutaneous elastic tissue, and also due to
increased cortisol. After labor , the color turns to
white ; “ striae albicans” due to fibrosis.
3. Signs of malnutrition and vitamin deficiency

23. 4. Cardiovascular system:
1) Blood volume :
Increased by about 45% , half of
this rise is achieved by 8 week and
the maximum increased in blood
volume is mainly due to expansion
of plasma volume more than the
increase in R.B.Cs . Volume
resulting in physiological hydremia
and drop of hemoglobin level.

24. 2) Cardiac output: ( = SV X HR)
Increases by 30 – 50 % to reach a
maximum at 32-34 weeks and then it is
maintained up to full term. The increased
CO is mainly due to increased SV as the
HR increases only by 15%.
3) Leucocytes : increase to about
16.000/cc.
4) Platelets , fibrinogen : increase
, fibrinogen reaches 600 mg %.
5) Venous stasis : in the lower half of the
body due to compression of the pelvic
veins by the gravid uterus and to
relaxation of the venous wall by the effect
of progesterone , this may lead to
varicose veins, ankle edema and

25. 6) Blood pressure :
Decreases slightly during the second trimester
due to opening of A-V shunts in the placenta.
 Any rise to 140/90 or 30 mm Hg systolic or 15
mm Hg diastolic (above the base line reading
before pregnancy or during the first trimester) is
considered abdominal .
 “ Supine hypotension syndrome”:
Hypotension may develop in supine position
especially during late pregnancy due to
pressure by the gravid uterus on the in inferior
vena cava with subsequent reduction in cardiac
output.
7) The apex:
Is displaced upwards in late pregnancy by
elevation of the diaphragm(ECG changes).

26. 5. Urinary system:
1. Frequency of micturition :
 Early in pregnancy : due to congestion and
pressure on the bladder by the enlarged
uterus .
 Late in pregnancy : due to pressure by the
presenting part
2. Dilatation of the ureters due to:
 pressure against the pelvic brim by the uterus
especially on the right side.
 Effect of progesterone and relaxin hormone.
 Hypertrophy of the wall of the lower end of
the ureters caused by estrogen .
* Dilatation leads to stasis of urine which in turn
predisposes to infection.

27. 6. Respiratory system:
Dyspnea is common due to:
 Hyperventilation ( progesterone
effect).
 Elevation of the diaphragm (
especially during the 8th month ).

28. 7. Gastrointestinal tract:
 Increased salivation with increased acidity
predisposing to dental caries.
 Hypertrophy of the gums ( sometimes bleeding
gums)
 Morning sickness in early pregnancy.
 decreased gastric acidicity ( by 50% ) and motility
that may cause flatulence and interference with iron
a bsorption.
 Heart burn due to reflux esophagitis.
 Tendency to constipation due to relaxation of the
smooth muscles by progesterone .
 Slight impairment of liver functions.
 Relaxation of the wall of gallbladder (
cholestasis, predisposing to stone formation).

29. 8. Musculoskeletal system:
 Increased lumbar lordosis.
 Relaxation of pelvic joints and ligaments
( progesterone and relaxin).

30. 9. Endocrine system:
1) pituitary :
Anterior pituitary increases in size and activity but
the blood supply is NOT increased. Posterior
pituitary produces oxytocin thus stimulating onset
of labor.
1) Thyroid :
Increased size and activity ; physiological goiter
may occur. Total T3 and T4 are increased .
1) parathyroid:
Increased size and activity ; to regulate the
increased calcium metabolism.
4) Adrenals:
Increased activity ; total cortisol is increased but the
free portion calcium metabolism.
5) Placental hormones :

31. 10. Metabolic changes:
1. Proteins:
Tendency to nitrogen retention.
2. Carbohydrates:
Carbohydrates metabolism is slightly
DISTURBED.
- Anti – insulin : are increased .
* HPL ( human placental lactogen) favors
transfer of glucose to the fetus.
* Cortisol. Estrogen.
* progesterone Insulinase
enzyme
All , except cortisol , are produced by the plasenta.

32.  Alimentary glycosuria : due to rapid absorption of
glucose .
 Renal glycosuria : due to lowering of renal thrshold.
3. Fats:
Fats metabolism is disturbed secondary to
disturbance of carbohydrate metabolism.
3. Minerals:
Increased requirements of : iron , calcium
, phosphorus and Iodine . Tendency to NaCl
retention ( effect of pregnancy hormones).
3. Water :
Tendency to salt and water retention.

33. 11. Weight :
The average total weight gain is
11- 16 kg, most of it occurs during
the 3rd trimester.

34. THANK
U