Diagnosis of pregnancy

1
Diagnosis of pregnancy

• First trimester (first 12 weeks)
• Symptoms
• 1. Amenorrhea
• 2. Morning sickness more often in the first
  pregnancy than in the subsequent one. It usually
  appears soon following the missed period and
  rarely lasts beyond the 3rd month
• Breast discomfort
• Frequency of micturition
• Constipation
• Enlargement of abdomen
• Fatigue

2
Diagnosis of pregnancy (contd)

• Signs
• Breast Engorgement of breast with dilatation of
  superficial veins
• Areola more pigmented
• Montgomerys tubercles are prominent
• Secretion as early as 8th week
• Per abdomen uterus remains a pelvic organ until
  at 12th week
• Pelvic changes
• Chadwicks sign It is the dusky blue of
  anterior vaginal wall visible at about 8th week
  of pregnancy. The discoloration is due to local
  vascularity.
• Uterine signs the pregnant uterus feels soft
  and elastic
• Hegars sign 6-10 weeks

3
Diagnosis of pregnancy (contd)

• Immunological test
• Depends on agglutination reaction of the antigen
  (b-HCG)
• Sonography
• Gestational ring
• Cardiac motion uniformly by 7th week
• Second trimester (13-28 weeks)
• Quickening
• Progressive enlargement of the lower abdomen
• General examination
• Chloasma

4
Diagnosis of pregnancy (contd)

• Abdominal examination
• Inspection
• Fundal height
• Palpation
• The uterus feels soft and elastic
• Braxton-Hicks contractions
• Palpation of fetal parts
• Active fetal movements
• Auscultation
• Last trimester (29-40 weeks)
• Enlargement of the abdomen
• Fetal movement
• Braxton-Hicks
• Fetal movements

5
Physiological changes during pregnancy

• Vulva
• Superficial varicosities may appear
• Labia minora are pigmented and hypertrophied
• Vagina
• Increased blood supply of the venous plexus
  surrounding the walls give the bluish coloration
  of the mucosa (Jacquemiers sign)
• Secretion
• The secretion becomes copious
• pH becomes acidic (3.5-6)
• Uterus
• The uterus which is non-pregnant state weighs
  about 50mg and measures about 7.5 cm in length,
  at term weighs 1000 gms and measures 35 cm in
  length. Hypertrophy and hyperplasia of the cells.

6
Physiological changes during pregnancy (contd)

• Cutaneous changes
• Face
• Chloasma gravidarum or pregnancy mask, extreme
  form of pigmentation around the cheek, forehead
  and around the eyes. It may be patchy or diffuse,
  disappears spontaneously after delivery
• Abdomen
• Linea nigra brownish black pigmented area in
  the midline stretching from the xiphisternum to
  the symphysis pubis
• Striae gravidarum represent the tissue in the
  deeper layer of the cutis, mechanical stretching
• Weight gain
• The total weight gain during the course of a
  singleton pregnancy in average is 10kgs.

7
Cardiovascular changes (1)

• Position and size of heart
• ECG changes
• Increased heart rate (15)
• 15-degrees left axis deviation
• Inverted T-waves in lead III
• Q in lead III and AVF
• Unspecific ST changes
• Appears larger on X-ray

8
Cardiovascular changes (2)

• Murmurs soft , transient
• Inferior vena cava syndrome
• In the supine position, the inferior vena
  cava is compressed by the enlarged uterus,
  resulting in decreased cardiac output. Some women
  may have symptoms that include dizziness,
  light-headedness, and syncope.

9
Cardiovascular changes (3)

• Stroke volume 30
• Heart rate 15
• Cardiac output 40
• Oxygen consumption 20
• SVR (systemic vascular resistance) -5
• Systolic BP -10mmHg
• Diastolic BP -15mmHg
• Mean BP -15mmHg

10
Cardiovascular changes (4)

• Blood volume 30
• Plasma volume 40
• Red blood cell volume 20

11
Cardiovascular changes(5)

• Venous pressure
• unchanged in the upper body
• Significantly increases in the lower
  extremities, esp. during supine, sitting or
  standing position, returns to near normal in
  lateral recumbent position

12
Hematologic system (1)

• Blood volume (polymorphonuclear) 40
• Dilutional anemia Hb 110 g/L
• Leukocytosis 15,000/ml
• Platelet no change
• Sedimentation rate increase, 100m/h

13
Hematologic system (2)

• Clotting factors hypercoagulable, throboembolism
• Fibrinogen (factor I) 50
  (4.5 vs 3 g/L)
• Factor VIII
  increase
• Factors VII, IX, X and XII
  increase
• Prothrombin time, PT
  shortened
• ATPP activated partial thromoplastin time
  shortened
• Fibrinolytic activity
  decrease

14
Hematologic system (3)

• Iron active transplacental transfer
• Requirement
  1000mg
• increase maternal red cell mass 500mg
• fetal development
  300mg
• compensate for normal iron loss 200mg

15
Physiological changes during pregnancy (contd)

• Leucocytes
• Neutrophilic leucocytosis occurs to the extent of
  10-15,000/cu.mm and even to 20,000/cu.mm
• Total proteins
• Supine hypotension syndrome (postural
  hypotension)
• Carbohydrate metabolism
• Glycosuria lowered renal threshold, increased
  glomerular filtration rate.

16
Physiological changes during pregnancy (contd)

• Systemic changes

Change
Respiration rate/min Unaffected
Vital capacity (ml) Almost unaffected
Tidal volume (ml) 40
Residual volume (ml) -20

• Nervous system
• May be generalized neuritis probably due to
  vitamin B1 deficiency
• Compression of the lumbosacral trunk by the fetal
  head or by features of sciatica
• Compression of the median nerve (Carpal tunnel
  syndrome)

17
Hemodynamic changes during pregnancy

• Decreased peripheral vascular resistance
• Decreased pulmonary vascular resistance
• Decreased colloid oncotic pressure
• Increased cardiac output
• Increased pulse rate

18
Changes in the kidneys and the urinary system

• Anatomical changes
• Dilatation of the collecting system
• The renal calices, the renal pelvis and the
  ureters starts to dilate and remain enlarged for
  several weeks after delivery
• Causes
• Progesterone
• Compression of the ureter
• Physiological changes
• The most important consequence of the increased
  RPF is a 50 increase in the GFR
• The serum creatinine and urea nitrogen
  concentration below lower than in the
  non-pregnant situation

19
Endocrinology in relation to reproduction

• Hormones of placenta
• Protein hormones
• Human chorionic gonadotrophin (HCG)
• Human placenta lactogen (HPL)
• Human chorionic thyrotrophin (HCT)
• Human chorionic corticotrophin (HCC)
• Pregnancy specific b-1 glycoprotein (PS b G)
• Steroid hormones
• Estrogens estriol, estradiol and estrone
• Progesterone

20
Endocrinology in relation to reproduction (contd)

• Estrogen and progesterone
• 100 folds increase in progesterone concentration
• Estrogen levels are also very high
• The level of SHBG increases
• Adrenal cortical hormones
• Increased level of plasma cortisol
• There is increase in adrenal androgens helps in
  protein anabolism
• Increase in aldosterone secretion

21
Endocrinology in relation to reproduction (contd)

• Thyroid gland
• Moderate enlargement with hyperplasia
• Increased secretion of thyroid hormones
• Parathyroid gland
• Enlarged with increase secretion of parathyroid
  hormone to facilitate mobilization of ionic
  calcium and phosphorus for fetal bone development
• Calcitonin level slightly increased just to
  counter the effect of PTH on maternal skeleton
• Pancreas
• Hypertrophy and hyperplasia of beta cells of
  Langerhans
• Pregnancy has diabetogenic effect

22
Endocrinology in relation to reproduction (contd)

• Diabetogenic effects of pregnancy
• Insulin resistance
• Production of placental somatomammotropin
• Increased production of cortisol, estriol, and
  progesterone
• Increased insulin destruction by kidney and
  placenta

23
Endocrinology in relation to reproduction (contd)

• Human chorionic gonadotrophin (HCG)
• Functions
• Secretion of progesterone by the corpus luteum of
  pregnancy
• HCG stimulates Leydig cells of the male fetus to
  produce testosterone in conjunction with fetal
  pituitary gonadotropins. It is thus indirectly
  involved in the development of male external
  genitalia
• It has got immuno-suppressive activity which may
  inhibit the maternal processes of immunorejection
  of the fetus as a homograft

24
Endocrinology in relation to reproduction (contd)

• Steroidal hormones
• Functions
• Estrogen causes hypertrophy and hyperplasia of
  the uterine myometrium, thereby increasing the
  accommodation capacity, vascularity and blood
  flow of the uterus.
• Progesterone in conjunction with estrogen
  stimulates growth of the uterus
• Development and hypertrophy of the breasts.
  Hypertrophy and proliferation of the ducts are
  due to estrogen
• Both the steroids are required for the adaptation
  of the maternal organs to the constantly
  increasing demands of the growing fetus
• The steroids are involved in the complex pathway
  in initiation of normal labor

25
Metabolic changes

• Carbohydrate metabolism
• Fetus drives its energy almost totally from
  glucose, passed through placenta by facilitated
  diffusion
• Lipid metabolism
• Increased mobilization of lipids from maternal
  adipose tissue to raise plasma FFA level
• HPL has glucose sparing effect by mobilizing free
  fatty acids for mothers skeletal and cardiac
  muscles and diverting the glucose to placenta and
  fetus

26
Metabolic changes (contd)

• Salt and water metabolism
• Marked water retention is found in pregnancy with
  the decrease in plasma osmolarity
• Edema of legs seen because of increased venous
  pressure due to compression by gravid uterus
• Increase in blood volume causes decreased oncotic
  pressure causes leakage of water in the tissue
  bed.
• The reduction in serum, sodium is caused by
  increased GFR. However, sodium and fluid balance
  is maintained by increase in plasma aldosterone
  and increase level of estrogen and
  deoxycorticosterone prevents sodium loss