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Pregnancy Stages



Clinical symptoms, signs and diagnosis of pregnancy


<!--<h1>Clinical symptoms, signs and diagnosis of pregnancy </h1>--> <strong>Symptoms of pregnancy </strong> <ul> <li> 1.Amenorrhea.</li> <li> 2.Nausea and vomiting.</li> <li> 3.Breasts changes.</li> <li> 4.Quickening.</li> <li> 5.Urinary frequency.</li> </ul> <strong>1.Amenorrhoea: </strong> <ul> <li>This is the earliest symptoms of pregnancy.- which means cessation of menses.</li> <li>Amenorrhea is a fairly reliable symptom of pregnancy in women with regular menstrual cycles.</li> <li>In women with irregular cycles , amenorrhea is not a reliable sign.</li> </ul> *Spotting due to bleeding at implantation site may occur from the time of implantation (about 6 days after fertilization ) until 29-35 days after the LMP in many women.<br> *some women have unexplained cyclic bleeding throughout pregnancy.<br><br> <strong>2.Nausea and vomiting:</strong> <ul> <li> This common symptoms occurs in approximately 50% of pregnancies.</li> <li> It is most marked at 2-12weeks gestation </li> <li> It is usually most sever in the morning but can occur at any time. </li> <li> May be precipitated by cooking odors pungent smells.</li> </ul> <strong>3.Breasts changes:</strong><br><br> a.Mastodynia (or breast tenderness): <ul> <li>This may rang from tingling to frank pain. </li> <li>Caused by hormonal responses of the memory ducts and alveolar system.</li> <li>Circulatory increases results in breast engorgement and venous prominence </li> </ul> b. Enlargement of sebaceous gland of the areola(Montgomery s tubercle). <ul> <li>Enlargement of these glands occurs at 6-8 weeks gestation and is due to hormonal stimulation.</li> </ul> c.Colostrum secretion : <ul> <li>Colostrums secretion may begins at 16weeks gestation.</li> </ul> <strong>4.Quickening:</strong> <ul> <li>This is the first perception of fetal movement </li> <li>In primigravida felt at 18-20 weeks</li> <li>In multigravida it is felt at 16-18 weeks gestation.</li> <li>Intestinal peristalsis may be mistaken for fetal movement.</li> <li>Therefore, perceived fetal movement alone is not a reliable symptom of pregnancy ,but may be helpful in determining the duration of pregnancy.</li> </ul> <strong>5.Frequency of micturition and nocturia:</strong> <ul> <li>These conditions occur because of:</li> <ul> <li>increased bladder circulation </li> <li>pressure from enlarging uterus.</li> </ul> <li>Urinary tract infection must always be ruled out because pregnant women are more likely than non pregnant women to have significant bacteriuria which may be asymptomatic.</li> </ul> <strong>Signs of pregnancy </strong>: <ul> <li>1.increased body temperature.</li> <li>2.Skin changes.</li> <ul> <li>Chloasma.</li> <li>linea nigra. </li> <li>Stretch marks.</li> <li>Spider telangiectases.</li> </ul> <li>3.changes in pelvic organs.</li> <ul> <li>Chadwick s sign.</li> <li>Leukorrhoea.</li> <li>Goodell s sign.</li> <li>Hegar s sign.</li> </ul> <li>4.Abdominal enlargement.</li> <li>5.Uterine contractions.</li> <li>6.Ballottement of the uterus.</li> <li>7.Uterine souffle.</li> </ul> <strong>Signs of pregnancy </strong> :<br><br> <strong>1.Increased basal body temperature </strong> :<br> Persistent elevation of basal body temperature over a 3weeks period usually indicates pregnancy if temperature have been carefully charted.<br><br> <strong>2.Skin changes </strong> : <br> A.Chloasma (or the mask of pregnancy): <ul> <li>This is darkening of the skin over the forehead ,bridge of the nose ,or cheek bones. </li> <li>most marked in those with dark complexions </li> <li>intensified by exposure to sunlight.</li> </ul> B.Linea nigra: <ul> <li>Is darkening of the lower midline of the abdomen from the umbilicus to the pubis (linea alba).</li> <li>The basis of these changes is stimulation of the melanophores by an increase in melanocyte-stimulating hormone.</li> </ul> C.Stretch marks: <ul> <li>Striae of the breast and abdomen are caused by separation of the underlying collagen tissue and appear as irregular scars.</li> <li>It is probably an adrenocorticosteroid response.</li> <li>These marks appear later in pregnancy when the skin is under great tension.</li> </ul> D. Spider telangiectases: <ul> <li>These are common skin lesions that result from high levels of circulating estrogen.</li> <li>Palmar erythema is often an associated sign.</li> <li>Both of these signs are also seen in patients with liver failure.</li> </ul> <strong>3. Signs due to changes in the pelvic organs </strong> :<br> a. Chadwick's sign: <ul> <li>Congestion of the pelvic vasculature causes bluish or purplish discoloration of the vagina and cervix.</li> </ul> b.Leukorrhea: <ul> <li>An increase in vaginal discharge consisting of epithelial cells and cervical mucus is due to hormone stimulation.</li> <li>Cervical mucus when spread on slide and left to dry no longer forms a fernlike pattern but has a granular appearance</li> </ul> c.Goodell s sign <ul> <li>cyanosis and softening of the cervix is due to increased vascularity of the cervical tissue.</li> <li>This sign is seen as early as 4weeks.</li> </ul> d. Hegar's sign: <ul> <li>This is widening of the softened area of the isthmus , resulting in compressibility of the isthmus on bimanual examination.</li> <li>This occur at 6-8weeks.</li> </ul> <strong>4. Abdominal enlargement </strong>: <br> There is progressive abdominal enlargement from 7-28 weeks.<br> At 16-22 weeks growth may appear more rapid as the uterus rise out of the pelvis into the abdomen.<br><br> <strong>5. Uterine contractions </strong>:<br> As the uterus enlarges, it becomes globular and often rotates to the right.<br> Painless uterine contractions (Braxton Hicks contractions) are felt as tightening or pressure.<br> They usually begin at about 28 weeks gestation and increase in regularity .<br> These contractions usually disappear with walking or exercise whereas true labor contractions become more intense.<br><br> <strong>6. Ballottement of the uterus </strong>: <br> At 16-20 weeks, ballottement of the uterus on bimanual examination may give the impression that a floating object occupies the uterus.<br> It is a valuable sign but not diagnostic<br> Similar sign may also be elicited with uterine leiomyomas, ascites or ovarian cysts<br><br> <strong> 7.Uterine souffle </strong>: <br> Auscultation of the abdomen after 16 weeks often elicits a rushing sound synchronous with the pulse (caused by the movement of maternal blood filling the placental vessels and sinuses).<br> The intensity may vary from a whisper to a loud rush.<br> With anterior placenta this sound may mask the fetal heart sounds for several months<br><br> <strong> Positive manifestations </strong>: <ul> <li> The various signs and symptoms of pregnancy are often reliable but none is diagnostic.</li> <li> A positive diagnosis must be made upon objective findings, many of which are not produced until after the first trimester.</li> <li> However, more methods are becoming available to diagnose pregnancy at an early stage.</li> </ul> <strong>1. Fetal heart tones (FHTs)</strong>: <ul> <li>It is possible to hear FHTs with a fetoscope in a slender woman at 17-18 weeks.</li> <li>The normal fetal heart rate is 120-160 beats per minute .</li> <li>It is best to palpate the maternal pulse for comparison.</li> <li>Doppler devices detect FHTs as early as 10 weeks.</li> </ul> <strong>2. Palpation of the fetus </strong>: <ul> <li>After 22 weeks, the fetal outline can be palpated through the maternal abdominal wall.</li> <li> Fetal movements may be palpated after 18 weeks. </li> </ul> <strong>3. Ultrasound examination of the fetus</strong>: <ul> <li> Sonografy is one of the most useful aid in diagnosing and monitoring pregnancy.</li> <li> Cardiac activity is seen at 5-6weeks.</li> <li> Limb buds at 7-8 weeks.-</li> <li> Finger and limb movement at 9-10 weeks.</li> <li> At the end of the embryonic period (10 weeks by LMP), the embryo has a human appearance.</li> </ul> <strong>4. x-ray of the fetus <strong>: <ul> <li> X-ray films should be avoided in pregnancy to protect the mother and fetus from possible genetic or oncogenic risk.</li> <li> However, if the potential benefit outweighs the risk, radiographs may be of value.</li> <li> The ossified fetal bones appear at 12-14 weeks.</li> <li> Radiation of less than 10 rads is considered to have minimal teratogenic risk.</li> </ul> <strong>Pregnancy tests <strong>: <br><br> Sensitive early pregnancy tests measure changes in the levels of hCG.<br> hCG is produced by the syncytiotrophoblast 8days after fertilization and may be detected in the maternal serum as early as 9days.<br> hCG level peaks approximately 65days after conception.<br> Gradually decreases in the 2nd and 3rd trimester and increase slightly after 34 weeks.<br> Urine values are usually proportionate to serum values if maternal renal function is normal.<br> The half life of hCG is 1.5 days.<br> Normally serum and urine hCG levels return to non pregnant values (less than 5mIU/ml) 21-24 days after delivery.<br><br> Types of pregnancy tests: <strong>A. immunologic tests <strong>: <br><br> Immunologic test are based on antigenic properties of the polypeptide protein hCG.<BR> The tests available are direct and indirect agglutination of sensitized red blood cells or latex particles.<BR> Testing time is 2minutes -2hours.<BR> Sensitivities varies from 250-3500mIU/ml.of hCG,depending on the product used. <BR> Most tests are positive 4-7 days after the first missed period. <BR> Tests accuracy may be altered by: <br><br> 1. Protienuria,which inactivate anti-hCG agglutination.<br> 2. Immunologic disease, which cause false positive reactions because of IgM inter-action with test reagent.<br> 3. LH levels (the similarity of LH and hCG subunits causes cross-reactivity). <ul> <li> Any condition that stimulates release of LH from the anterior pituitary may result in a false-positive reaction. </li> <li> Women with oophorectomy, menopausal women ,who have renal failure or have hypothyroidism may also have false-positive tests.</li> </ul> <strong>Immunologic test of pregnancy</strong><br> <table border= 1 width=90% align=center> <tr> <td align=center><strong>Results </strong></td> <td align=center><strong>Materials</strong></td> <td align=center><strong>method</strong></td> </tr> <tr> <td cellspacing="2" cellpadding="4"> &nbsp;&nbsp;Coagulation if hCG is present (pregnant)</td> <td cellspacing="2" cellpadding="4">&nbsp;&nbsp;Latex particles coated with anti-hCG+serum or urine.</td> <td cellspacing="2" cellpadding="4"> &nbsp;&nbsp;Direct coagulation</td> </tr> <tr> <td cellspacing="2" cellpadding="4">&nbsp;&nbsp;Coagulation if hCG is absent (not pregnant) inhibition if hCG is present (pregnant)</td> <td cellspacing="2" cellpadding="4"> &nbsp;&nbsp;Anti-hCG+serum or urine plus sensitized red cells or latex particles coated with hCG.</td> <td cellspacing="2" cellpadding="4">&nbsp;&nbsp;Inhibition of coagulation.</td> </tr> </table> <strong>B. Radioimmunoassay for hCG </strong>: <ul> <li>Radioimmunoassay for hCG is a sensitive and specific test for early pregnancy </li> <li>LH cross- reactivity does not occur when the reagent used are sensitive to the B-sub-unit of the glycoprotein.</li> <li>Laboratories can detect serum levels as low as 2-4mIU/ml</li> <li>This test requires scintillation counting and 24-48 hours of incubation time.</li> <li>A quantitative analysis of hCG can be obtained and used to determine the normality and viability of early pregnancy.</li> </ul> <strong>c. Radio-receptor assay </strong>: <ul> <li>This measures receptor sites by a competitive binding mechanism and is capable of measuring levels as low as 200mIU.</li> <li>This test may be completed in 2-4 hours .</li> <li>This test also cross-react with LH. </li> </ul> <strong>d. Home pregnancy tests </strong>: <ul> <li>Home pregnancy tests are immunologic tests and have the same problems mentioned above in addition to the possibility of interpretation.</li> <li>hCG is detected in a first-voided morning urine sample.</li> <li>A positive test is indicated by a color change or confirmation mark in the test well.</li> <li>If negative should repeated in 2 weeks or radioimmunoassay done .</li> </ul> <strong>Calculation of the gestational age.</strong><br> Normally, human pregnancy lasts 280 days or 40weeks from the last menstrual normal period (LNMP).<br> It may also be calculated as 266 days or 38 weeks from the last ovulation in a normal 28 day cycle.<br><br> <strong>The estimated date of delivery(EDD)</strong> :<br> The EDD cam be calculated mathematically using Nagele's rule by subtracting 3months from the month of the LNMP and add 7 days to the first day of the LNMP.<br> In women with longer cycle we add to the 1st day of the LNMP the usual 7 days plus the number of days that the cycle extends beyond 28 days.


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