Engidaw Ambelu

1. Diagnosis Of pregnancy and Physiologic
Change during Pregnancy
Ashete (MD)
April 2018

2. Presentation Outline
• Definition of pregnancy
• How to diagnosis pregnancy
• Differential diagnosis of pregnancy
• Effect of pregnancy on specific organs(local)
• Effect of pregnancy on systems (Systemic)

3. Definition ……..
• Pregnancy ; is the maternal condition of having a
developing fetus in maternal body.
• This is during reproductive period of women which is
between menarche to menopause, usually 13-45 years of
age.
• Gestational age Vs fertilization( ovulatory) age
Gravidity, parity, grand multiparity, great grand multi.

4. Cont.
• Normal duration of gestation is 280 days ( 40 completed weeks) or 10
lunar months.
 Preterm: < 37 weeks
 Term : 37-42 weeks
 Post term: > 42 weeks
• Normal pregnancy is divided into three equal trimesters
 1st Trimester: 1- 14 weeks
 2nd Trimester: 14-28 weeks
 3rd Trimester: 28- 42 weeks

5. Diagnosis Of Pregnancy
• Important because;
 assure couples
 prevent exposure
 to start ANC follow up
• Diagnosis of pregnancy usually begins when the women
present with symptoms and/ or positive home urine
pregnancy test
• Manifestation of pregnancy can be;
1. presumptive,
2. probable, and
3. positive.

6. 1. Presumptive Manifestation
1.1 Presumptive Symptoms
• Amenorrhea: is a fairly reliable sign of conception in
women with regular menstrual cycles.
 In women with irregular cycles, it is not a reliable sign
• Nausea and Vomiting :
 occurs in approximately 50% of pregnancies and is most
marked at 2–12 weeks' gestation.
 The nausea is probably related to rapidly rising serum
levels of human chorionic gonadotropin (HCG), although
the mechanism is not understood

7. Cont..
 Extreme nausea and vomiting may be a sign of multiple
gestation or molar pregnancy.
• Fatigue: Due to the soporific effects of progesterone
• Mastodynia; may range from tingling to frank pain caused
by hormonal responses of the mammary ducts and
alveolar system.
 Circulatory increases result in breast engorgement and
venous prominence.
 Similar tenderness may occur just before menses.

8. Cont…
• Montgomery's Tubercles; enlargement of Circum
lacteal Sebaceous Glands of the Areola
 Enlargement of these glands occurs at 6–8 weeks'
gestation and is a result of hormonal stimulation.
• Colostrum secretion; may begin after 16 weeks'
gestation.
• Quickening:
 First perception of fetal kick by the mother
 Prim ; 18-20 weeks , Multi: 14-16 weeks
• Urinary frequency
 Because of increased bladder circulation and pressure
from the enlarging uterus.

9. Cont..
1.2 Presumptive Signs
• Increased Basal Body Temperature
 Persistent elevation over a 3-week period usually indicates
pregnancy if temperatures have been carefully charted
• Chloasma; darkening of the skin over the forehead, nose
bridge and cheekbones
 It usually occurs after 16 weeks' gestation and is intensified
by exposure to sunlight.
• Linea Nigra; is darkening of skin over the nipples and lower
midline of the abdomen from the umbilicus to the pubis.
 It is due to stimulation of the melanophores by an increase
in melanocyte-stimulating hormone.

10. Cont..
• Stretch Marks
 or striae gravidarum are caused by separation of the
underlying collagen tissue and appear as irregular scars.
 and usually occurs over abdomen, breast and thigh
 probably an adrenocorticosteroid response.
• These marks generally appear later in pregnancy when
the skin is under greater tension.
• Spider Telangiectasias
 common skin lesions that result from high levels of
circulating estrogen
 blanchable when compressed.
 Palmar erythema is often an associated sign.

11. 2. Probable Manifestation
2.1 Probable Symptoms; these the same as presumptive
manifestation
2.2 Probable Signs; these are pelvic organ changes, like;
• Chadwick's Sign:
 Congestion of the pelvic vasculature causes bluish or
purplish discoloration of the vagina and cervix.
• Hegar's Sign:
 is widening of the softened area of the isthmus,
resulting in compressibility of the isthmus on bimanual
examination.
 occurs by 6–8 weeks.

12. Cont..
• Goodell’s sign:
 cyanosis and softening of the cervix is due to increased
vascularity of cervical tissue.
 can occur as early as 4 weeks.
• Leukorrhea
• Relaxation of ligaments
• Abdominal enlargement
• Braxton- Hicks contraction

13. 3. Positive Evidence
• Fetal heart tones
 Fetoscope: 18-20 weeks
 Doppler: 10-12 weeks
• Perception of fetal movements & Outlining of the fetus
• Ultrasound demonstration of fetus
• Radiological demonstration of fetal skeleton
 Usually at 16 weeks as primary ossification centers appear
at 12-14 weeks
 Replaced by ultrasound.

14. Cont..
• Pregnancy Tests:
 Test accuracy ranges from 98.6-99%.
• Causes of false positive results:
 Proteinuria.
 Hematuria.
 At time of ovulation (cross reaction with LH).
 HCG injection for infertility treatment within the previous 30
days.
 Thyrotoxicosis (high TSH).
 Premature menopause (high LH & FSH).
 Early days after delivery or abortion.
 Trophoblastic diseases.
 hCG secreting tumours.

15. Cont…
• Causes of false negative results:
 Missed abortion.
 Ectopic pregnancy.
 Too early pregnancy.
 Urine stored too long in room temperature.
 Interfering medications.
• The pregnancy test becomes negative about:
 one week after labor,
 2 weeks after abortion, and
 4 weeks after evacuation of vesicular mole.

16. Differential Diagnosis of Pregnancy
 Uterine fibroids
 Ovarian cysts
 Hematometra
 Ascites
 Full baldder
 Pseudocyesis; assuming as pregnant:
amenorrhea, abd. distension, nausea and vomiting

17. Physiologic change during pregnancy
• Is a change that occur during pregnancy to support
ongoing fetal growth
• Aim is to prepare and make ready for fetal expulsion and
control the bleeding during delivery
• It is mainly on reproductive organs and systemic

18. Local Changes
• Uterus; one of unique features of the uterus is its
remarkable capacity to increase in size in a few months
and then to return essentially to its original state within a
very few weeks.
 Capacity; from about 10ml almost solid organ to about 5L
thin walled muscular container
 Size; from 7x5x3cm35x25x22cm, about 5-6 times
increase
 Weight: Undergoes a 20-fold : from 50-70 g1-1.1kg
 Position; usually dextrorotation to the right caused by
rectosigmoid on the left side of the pelvis

19. Local cont..
• Uterine growth is through:
 almost entirely by hypertrophy of the muscle cells
 there is an increase in the amount of elastic
connective tissue
 there is a remarkable increase in the size and number
of blood vessels and lymphatics
 hypertrophy of the nerve supply of the uterus takes
place

20. Cont..
• Initially stimulated by hormone which latter on by
pressure effect of expanding product of conception;
usually after 12 weeks of gestation
• Braxton Hick contractions
• Uteroplacental blood flow; delivery of most substances
essential for the growth and metabolism of the fetus and
placenta, as well as removal of most metabolic wastes, is
dependent upon adequate perfusion of the placenta by
maternal blood, which depends upon blood flow to the
uterus through uterine and ovarian arteries
• Estimated to be 450 to 650mL/min near term.
•  50 ml/min in the nonpregnant state

21. Local cont…
Cervix; pronounced softening and cyanosis of the cervix
occurs.
•These changes are apparent 5th-6th week due to increased
vascularity and edema of the cervix
• hypertrophy and hyperplasia of the cervical glands
• mucus secretion is greatly increased
•Vagina; It becomes deeply congested and cyanotic because
of the greatly  vascularity (characteristic violet color of the
vagina).
 mucosa thickens
 connective tissue becomes less dense
 muscular coat hypertrophies in preparation for labour

22. Systemic Change
Weight; hormonal changes are responsible for a considerable  in
weight during pregnancy.
• Women gain an average of approximately 12.5 kg, and it may be
approximated as follows
Fetus 3.5 kg
Placenta 0.5 kg
Amniotic fluid 0.8 kg
Uterus 1.0 kg
Increase in blood volume 1.5 kg
Breasts 0.5 kg
Extracellular fluid 1.5 kg
Fat and protein storage 3.3 kg

23. Mucocutaneous
• Striae gravidarum (striae distensae or stretch marks)
 White in multi
 Red/brown in primi
• linea nigra:
 brownish-black color of
 the midline of the abdominal skin

24. Cont..
• Chloasma/ melasma or mask of pregnancy:
irregular pigmentation of the face and neck

25. Cont..
 palmar erythema
 mild degrees of hirsutism
 alopecia
 skin tags (polypoid lesions)
 gingivitis

26. Breast
 Become enlarged by the 8th week of pregnancy
 As they  in size, delicate veins become visible beneath the
skin
 Nipples become considerably ,deeply pigmented &
erectile
 The primary areola deepens in color and lightly pigmented
secondary areola develops at the periphery
 Montgomery’s tubercles appears (hypertrophy sebaceous
glands located in the primary areola)
 Colostrum (a thick & yellowish fluid) often can be expressed
from the nipples >10th week
 Until delivery and during puerperium there are histological and
functional changes that permit synthesis and secretion of milk

27. Cont..
• Rarely, breast enlargement may become
So pathologically extensive and
Referred to as gigantomastia

28. HEMATOLOGIC CHANGES
1.Change in Fluid Balance; retention of sodium and
water has important hemodynamic consequences:
 Total body water  steadily: 6-8 l accumulate in a
normal pregnancy, most being located in the
extracellular space
 Excess sodium retention reaches 500-900 mEq by the
time of delivery
• Maternal blood volume  40–50% above
nonpregnant levels (the main contribution to this
expansion is plasma volume).

29. Cont..
2. Total red cell volume and Fe metabolism;
- begins to rise at 10wks rises until term, average
450ml(increase by 33%)
 Compared with total red cell volume, plasma volume
Increase greater  hemodilution with a Hct termed
“the physiologic anemia of pregnancy”.

30. Cont…
• IMPORTANCE OF INCREASED BLOOD VOLUME
 Protects the mother from the possibility of haemorrhage during
pregnancy.
 Helps fill the expanded vascular system created by vasodilatation
and large low -resistance vascular pool with in the uteroplacental
unit.
 Protect the mother and fetus against the deleterious effects of
impaired VR in the supine and erect positions.

31. Cont..
• Iron requirements: In normal pregnancy 1 g (200 mg is
excreted + 300 mg is transferred to fetus + 500 mg is
needed for the mother).
 Daily average requerment is 6-7 mg/day

32. Coagulation and fibrinolysis
• Normal pregnancy is accompanied by major changes in the
coagulation system:  in the level of all except Factors xi
and xiii
 Particularly markedofplasma fibrinogen(inc.50%).average
450mg late in pregnancy
 fibrinolytic activity is  during pregnancy
 Net effect = produce hypercoagulable state

33. Cont..
The alterations in the coagulation and fibrinolytic systems
+
blood volume
+
myometrial contraction

=>help to combat the hazard of hemorrhage during and after
placental separation.

34. CIRCULATORY SYSTEM
• Heart; position and size: It is a little  and pushed by the
elevation of the diaphragm and rotated forwards, so that the
apex beat is moved upwards and laterally
 Heart rate: Its average  about 10-15 beats/min to  the
cardiac output
 Heart sounds: The 1st and 3rd sounds become louder. The
2nd sound is not notably affected
 Murmurs: Systolic ejection murmurs develop in most of
the women; . In some women a diastolic murmur may
occur

35. Cont..
• Cardiac output; it’s the most significant
hemodynamic change during pregnancy
 Begins to  5th week and  40% 20-24 weeks (the
highest levels). The cardiac output fluctuates markedly
with changes in body position
 Lowest in sitting or supine position=enlarged uterus
compress IVC
 Highest in Rt and Lt lateral and knee chest position.

36. Cont..

37. Cont..
• BLOOD PRESSURE; arterial BP:  during 2nd trimester & 
thereafter.
 Venous pressure in the femoral venous: there is a tendency
toward stagnation in the lower extremities
• SYSTEMIC VASCULAR RESISTANCE DECREASE;
 smooth muscle relaxing effect of progesterone
 presence of circulating substances exerting a vasodilatory
effect on arterial and venous vasculature (NO,PG,ANP).

38. RESPIRATORY SYSTEM
• The major influence in the phenomenon of over breathing
is a change in central respiratory control but alterations in
the subdivision of lung volume are largely due to
anatomical changes:
 the level of the diaphragm rises about 4 cm
 the subcostal angle widens
 the transverse diameter of the thoracic cage increases
about 2 cm
 the circumference of the thoracic cage increases about
6 cm

39. Cont..
• Respiratory functions:
 vital capacity=unchanged.
 FRC,RV,ERV decreased –due to elevated diaphragm

 tidal volume: increased ( 40%)
 respiratory rate: no changes
 minute ventilation  from 7ml/min to 10,5 ml/min in
late pregnancy.

40. Cont..

41. URINARY SYSTEM
• kidneys: size increase because vasculature & Interstitial
volume, urinary dead space.
• ureters: dilatation of the calyces, renal pelvis and ureters,
they are prominent on the right side & can be seen as
early as the 1st trimester and are present in 90% of
women by the 3rd trimester.
Causes; hormonal effect–smooth Ms relaxation by
progestrone

42. Causes of hydronephrosis and hydroureter
 obstruction-by the enlarged uterus
 pressure from a dilated ovarian venous plexus
 Hyperplasia of smooth MS in the distal 1/3 of the ureter –
decrease in luminal size
 dilatation in upper 2/3 of the ureter
• Rt ureter dilated more than Lt. b/c
 greater compression of the Rt ureter due to
dextrorotation of the uterus
 Rt ovarian vein complex, dilated more during pregnancy,
lies obliquely over the Rt ureter

43. Cont..
•Increase GFR(50%) and RPF(25%-50%).
• Plasma conc. of creatinine and urea decreased due to
increased GFR.
 In early pregnancy, water excretion by the kidney is ,
that’s why frequency of micturition is often present
 The frequency of micturition in late pregnancy is due to
the pressure of the uterus upon the bladder
 the dilation of ureters may led to urinary stasis and may
consequently give rise to renal infection

44. ALIMENTARY SYSTEM
  of appetite and  thirst.
 Gums are often swollen and bleed easily(epulis
gravidarum).
 Ptyalism can be found, almost always associated with
nausea.
 Heartburn because of reflux esophagitis resulting from
regurgitation of gastric acid.

46. Cont..
 Gastric tone, secreting activity, and motility are ed.
 Besides, stomach and intestine are displaced.
 The colon may share in the general relaxation of smooth
muscle structures and constipation is a common complaint
 Hemorrhoids are common
 Gallbladder is distended but hypotonic and bile is quite
thick.
 Pregnancy predisposes to formation of gallstones

47. ENDOCRINE SYSTEM
Pituitary gland
 Enlarges by 135% -proliferation of prolactin producing cells
in the ant. pituitary.
 Makes it susceptible to alterations in blood supply –risk of
postpartum infarction- sheehan’s syndrome.

48. Thyroid Gland
• Modification in the regulation of thyroid hormone
 Increase in circulating TBG-in response to high estrogen
 Thyroid stimulating factors of placental origin are
produced e.g. hcG
• Decreased availability of iodide for maternal thyroid;
 increase renal loss of iodide
 transfer of iodide to the foetus
 Results in a relative iodine deficiency state
 Causes alteration in thyroid morphology ,histology, and lab
indices

49. Cont..
 Moderate enlargement of thyroid due to hyperplasia of
glandular tissue
 and increased vascularity but doesn’t cause significant
thyromegally
 Any goiter in pregnancy should be evaluated.

50. Carbohydrate Metabolism
 Normal pregnancy is x-zed by mild fasting
hypoglycaemia, hyperinsulinemia, postprandial
hyperglycaemia.
 Allows for the continuous transport of nutrients to the
fetus and placenta
 To accommodate the increased demand for Insulin –
hypertrophy and hyperplasia of the B-cells of the
pancreas

51. Cont..
• Conversion from predominantly CHO to predominantly fat
utilization b/se of;
 earlier depletion of liver glycogen store during maternal fasting
 constant drain of maternal glucose by fetomaternal unit
 FBS is 10mg/dl less than non pregnant.
• Factors responsible for the diabetogenic effects of
pregnancy;
 Human placenta lactogen
 Cortisol
 PRL
 Estrogen
 progestrone

52. Cont..
• Progressivelordosis;ed mobility of the sacroiliac,
sacrococcygeal & the pubic joints.
• During the last trimester: aching, numbness, and
weakness in the upper extremities

53. References
• Williams Obstetrics 24th edition
• Simplified Obstetrics

54. THANK YOU