Diagnosis of Pregnancy in First Trimester

Subject: Midwifery I (Theory)

Overview

Pregnancy signs and symptoms are classified into three stages: presumptive, probable, and positive. Early breast changes, amenorrhea, morning sickness, bladder irritation, and quickening are all suspect signs. Women report heaviness, tingling, and discomfort/tenderness in their breasts early in pregnancy. As the pregnancy progresses and the breast enlarges and becomes nodular, the areola and nipple enlarge and become more deeply pigmented. Morning sickness is the most prevalent symptom encountered by women who suffer nausea, usually in the early hours of the day. During early pregnancy, the pyriform shape of the uterus changes to globular. At 6 weeks, it is about the size of an egg, a cricket ball at 8 weeks, and the size of the fetal head at 12 weeks.

The following factors are used to determine pregnancy:

  1. Presumptive/ subjective symptoms
  2. Clinical examination findings
  3. Investigation

Presumptive Symptoms:

  1. Cessation of menses (amenorrhea): The abrupt termination of spontaneously cyclic and regular periods in a normal menstrual woman is extremely predictive of pregnancy. Allowing for the possibility of ovulation delays, it is prudent to wait at least 10 days after the estimated date of menstruation before considering the possibility of pregnancy.
  2. Breast changes: Women report heaviness, tingling, and discomfort/tenderness in the breasts early in pregnancy. The areola and nipple grow and become more deeply pigmented as the pregnancy progresses and the breast enlarges and feels nodular. A clear or thin milky fluid is frequently released, and tiny protuberances known as 'Montgomery tubercles' form around the nipples.
  3. Morning sickness: Most women (about 70%) suffer some nausea, mainly in the early hours of the day. It is possible that vomiting will occur. This symptom usually goes away by the end of the first trimester.
  4. A frequency of micturition: Early in pregnancy, the growing gravid uterus exerts pressure on the bladder base, generating frequent urine. This symptom is eased when the expanding uterus transforms into abdominal organs, but it returns when the fetal head engages in the pelvis.
  5. Fatigue: Tiredness as an initial symptom Some women complain of drowsiness and a lack of motivation to work; these symptoms frequently last until mid-pregnancy.
  6. Feeling of worth: Some women complain of a feverish feeling and heavy sweating. This is the outcome of altered skin circulation.

Clinical Examination Findings

Only around 12 weeks is the growing gravid uterus perceptible above the pubic symphysis, and it reaches the level of the umbilicus by around 22 weeks.

  1. Early changes in the uterus and cervix:
    • The cervix and uterus feel softened, according to Goodell's sign.
    • Hegar's sign (softened uterus): On bimanual examination, the cervix and bulky uterus feel separated between the 6th and 10th weeks of gestation due to a softened isthmus.
    • Jacquemier's sign and Chadwick's sign: the cervix and vagina appear to have a bluish or purplish discoloration on speculum examination.
  2. Changes in the uterus: The uterus of a pregnant woman is delicate and stretchy.
  • Palmer’s sign: During early pregnancy, bimanual examination reveals frequent mild rhythmic contractions.
  • Braxton hick’s contraction: As the pregnancy advances, painless uterine contractions are felt. During the third trimester, the gap between contractions increases greater and maybe every 6-8 minutes or longer.

The pyriform shape of the uterus changes to globular during early pregnancy. At 6 weeks, it is roughly the size of an egg, a criket ball at 8 weeks, and about the size of the fetal head at 12 weeks. If the implantation is asymmetrical (lateral), the consistency of the two portions of the uterus may differ, producing the appearance of an extrauterine mass (Pickacek's sign).

Investigation

  1. Immunological test: HCG hormone detection in a urine test (antigen body agglutination). It is most commonly noticed 8 days after a missed period.
  2. Ultrasonography: This is a trustworthy test. The gestational sac can be identified as early as the fifth week of intrauterine life. The fetal node can be seen by the sixth week and the fetal heart pulse by the eighth.

References

  • Medscape. 1994. 2017 http://emedicine.medscape.com/article/262591-overview#a3
  • GFMER. 22 September 2016 http://www.gfmer.ch/Obstetrics_simplified/Diagnosis_of_pregnancy.htm
  • BabyMed. 2001. 2017. http://www.babymed.com/tag/early-pregnancy-diagnosis#
  • WHO, UNFPA, UNICEF, 2003. Pregnancy, childbirth, Postpartum and Newborn care (PCPNC): A guide for essential practice, “IMPAC” World bank.
  • Web MD. 2005. 2017 http://www.webmd.com/baby/guide/first-trimester-tests#1
  • Tuitui R. 2002, A textbook of Midwifery A (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu
  • PinkWhaleHealthCare.  02 August 2015. http://pinkwhalehealthcare.com/blog/diagnosis-of-pregnancy-first-trimester/
  • Tuitui R. 2002, A textbook of Midwifery B (Intranatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu
  • Midwifery manual for a certificate level nursing student, 2000, 2nd edition. HLMC, TUIOM, P.O. Box2533
Things to remember
  • The signs and symptoms of pregnancy are classified into three stages: presumptive, probable, and positive.
  • Early breast changes, amenorrhea, morning sickness, bladder irritation, and quickening are all presumptive signs.
  • The abrupt termination of spontaneously cyclic and regular periods in a normal menstrual woman is extremely predictive of pregnancy.
  • Women report heaviness, tingling, and discomfort/tenderness in the breasts early in pregnancy. The areola and nipple grow and become more deeply pigmented as the pregnancy progresses and the breast enlarges and feels nodular.
  • Morning sickness is the most prevalent symptom experienced by women (about 70% suffer nausea, mainly in the early hours of the day).
  • Only around 12 weeks is the growing gravid uterus perceptible above the pubic symphysis, and it reaches the level of the umbilicus by around 22 weeks.
  • The pyriform shape of the uterus changes to globular during early pregnancy. At 6 weeks, it is roughly the size of an egg, a cricket ball at 8 weeks, and about the size of the fetal head at 12 weeks.
Questions and Answers

The diagnosis of pregnancy is based on:

  • Hypothetical or subjective symptoms
  • Results of a clinical examination
  • Investigation

Presumptive symptoms:

  • Cessation of menses(amenorrhea):The abrupt cessation of spontaneously cyclic and regular periods in a woman who is normally menstruating is strongly suggestive of pregnancy. It is advisable to wait at least 10 days after the anticipated menstrual cycle to consider the possibility of pregnancy, with the possibility of an occasional ovulation delay taken into account.
  • Breast changes: Women feel heavy, tingly, and uncomfortable or painful in their breasts early in pregnancy. The areola and nipple grow bigger and more deeply pigmented as the pregnancy goes on, and the breasts grow bigger and feel nodular. The nipples frequently produce a clear or thin milky secretion, and tiny protuberances known as "Montgomery tubercles" surround them.
  • Morning sickness: 70% of women report having some nausea at some point, usually in the morning. Vomiting could accompany it. Usually, this symptom disappears by the end of the first trimester.
  • Frequency of micturition: Early in pregnancy, the expanding gravid uterus places pressure on the base of the bladder, causing frequent urination. When the expanding uterus develops abdominal organs, this symptom is alleviated, but it returns as the pregnancy nears full term when the fetal head engages with the pelvis.
  • Fatigue: fatigue as a preliminary symptom. Some women complain of being tired and not wanting to work; these symptoms frequently last until the middle of pregnancy.
  • Feeling of worth: Some women report feeling feverish and perspiring excessively. This is the outcome of altered skin circulation.

Clinical examination findings

It usually takes 12 weeks for the expanding gravid uterus to become well palpable above the pubic symphysis and 22 weeks or so to reach the level of the umbilicus..

  • Early changes in the uterus and cervix:
    • Goodell’s sign
      • The uterus and cervix feel softer.
    • Hegar’s sign (softened uterus)
      • On bimanual examination, the cervix and large uterus feel separated between the sixth and tenth weeks of gestation due to the softened isthmus.
    • Jacquemier’s sign of Chadwick’s sign
      • The speculum examination reveals that the cervix and vagina appear to have a bluish or purplish discoloration.
  • Changes in the uterus
    • The uterus during pregnancy is flexible and soft.
  • Palmer’s sign
    • Early pregnancy is observed to experience regular, painless rhythmic contractions during bimanual examination.
  • Braxton hick’s contraction
    • As the pregnancy advances, the uterus begins to contract painlessly. During the third trimester, the time between contractions lengthens and may reach every 6 to 8 minutes or longer.

The uterus's pyriform shape changes to a globular one in the early stages of pregnancy. At six weeks, it is roughly the size of an egg, a criket bell at eight weeks, and roughly the size of the fetal head at twelve weeks. The consistency of the two halves of the uterus may differ if there is an asymmetrical implantation (lateral), giving the appearance of an additional uterine mass (Pickacek's sign).

Investigation

  • Immunological test
    • HCG hormone detection in a urine test The best time to see it is eight days after a missed period.
  • Ultrasonography
    • This test is trustworthy. The gestational sac can be seen as early as the fifth week of intrauterine life. By the sixth week, the fetal node can be seen, and by the eighth, the fetal cardiac pulsation.

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