IMLE Preparatory Course

Lecture 52
Obstetrics and Gynecology

The Diagnosis of Pregnancy

 Definitions
 Gravida- A pregnant woman. This refers to any pregnancy
regardless of duration.
 Para- A woman who has delivered a viable young - >20-
week (not necessarily living at birth). Para is used with
numerals to designate the number of pregnancies that have
resulted in the birth of a viable offspring.
 Nulligravida- A woman who has never been pregnant.
 Nullipara- A woman who has not delivered a child who
reached viability.
 Primigravida- A woman pregnant for the first time.
 Primipara- A woman who has delivered one child after the
age of viability.
 Definitions
 Multigravida- A woman who has been pregnant more
than once.
 Multipara- A woman who has delivered two or more
fetuses past the age of viability. It does not matter whether
they are born dead or alive.
 Grandmultipara- A woman who has had six or more
births past the age of viability.
 Viability- Refers to the capability of a fetus to survive
outside the uterus after the earliest gestational age
(approximately 22 to 23 weeks gestation).
 In utero- Refers to within the uterus.
 5 Digit System
The information is abbreviated as parity/gravidity.
For example "0/1" means that a woman has not carried a pregnancy to
viability (nullipara) and is pregnant for the first time primigravida.
System using Five-Digit (GTPAL) system
Perinatal nomenclature by date
 Perinatal Diagnostic Testing

 β-hCG
 Quad Screening
 PAPP-A
 Chorionic Villus Sampling (CVS)
 Amniocentesis
 β-hCG
 The standard for diagnosing pregnancy.
 Produced by the placenta; peaks at 100,000
mIU/mL by 10 weeks of gestation.
 ↓ throughout the second trimester; levels off in
the third trimester.
 hCG levels double approximately every 48
hours during early pregnancy.
 This is often used to diagnose ectopic pregnancy
when doubling is abnormal.
Most state-of-the-art serum pregnancy tests
have a sensitivity for detection of β-human
chorionic gonadotropin (β-hCG) of 25 mLU/ mL.
Such tests would diagnose pregnancy as early as
which of the following?
a.5 days after fertilization
b.24 hours after implantation
c.day of the expected (missed) menses
d.5 weeks’ gestation age by menstrual dating
e.6 weeks’ gestation age by menstrual dating
Most state-of-the-art serum pregnancy tests
have a sensitivity for detection of β-human
chorionic gonadotropin (β-hCG) of 25 mLU/ mL.
Such tests would diagnose pregnancy as early as
which of the following?
a. 5 days after fertilization
b. 24 hours after implantation
c. day of the expected (missed) menses
d. 5 weeks’ gestation age by menstrual dating
e. 6 weeks’ gestation age by menstrual dating
 Quad Screening
 Maternal serum α-fetoprotein (MSAFP),
which is produced by the fetus, crosses the
placenta in small amounts and enters the
maternal circulation.

 Measurement results are reported as multiples of

the median (MoMs) and depend on accurate
gestational dating.
 Quad Screening
 Elevated MSAFP (> 2.5 MoMs): Associated with open
neural tube defects (anencephaly, spina bifida),
abdominal wall defects (gastroschisis, omphalocele),
multiple gestation, incorrect gestational dating, fetal
death, and placental abnormalities (e.g., placental
abruption).

 Decreased MSAFP (< 0.5 MoM): Associated with

trisomy 21 and 18, fetal demise, and inaccurate
gestational dating.
 Quad Screening
 MSAFP is now rarely performed alone because its
sensitivity for detecting chromosomal abnormalities is ↑
by adding inhibin A to estriol, β-hCG, and MSAFP
(quad screening) – weeks 15-20.

 Results of quad screening are as follows:

 Trisomy 18: All four are ↓.
 Trisomy 21: ↓ AFP and estriol; ↑ β-hCG and
inhibin A.
 PAPP-A
 Recommended at weeks 9–14.
 Pregnancy-associated plasma protein A (PAPP-
A) + ultrasound-determined nuchal
transparency (a measure of fluid in the fetal neck) +
free β-hCG can detect ~85% of cases of Down
syndrome and ~97% of cases of trisomy 18.

 Advantages: Screen of low-risk pregnant women (< 35

years of age). Available earlier and less invasive than
chorionic villus sampling.
 Chorionic Villus Sampling (CVS)
 Recommended at weeks 10–12.
 Involves transcervical or transabdominal aspiration of
placental (chorionic villi) tissue.
 Advantages: Has a diagnostic accuracy comparable to
that of amniocentesis; available at 10–12 weeks’
gestation.
 Disadvantages: Carries a risk of fetal loss (1–2%);
cannot detect open neural tube defects.
 Limb defects have been associated with CVS
performed at ≤ 9 weeks.
 Amniocentesis
 Recommended at 15–20 weeks.
 Consists of transabdominal aspiration of amniotic fluid
using an ultrasound-guided needle and evaluation of fetal
cells for genetic studies.
 Advantages: Detects ~80% of open neural tube defects,
~85% of cases of Down syndrome, and ~60% of cases of
trisomy 18.
 Disadvantages: Risks include premature rupture of
membranes (PROM), chorioamnionitis, and fetal-
maternal hemorrhage, which can result in fetal loss
(0.5%).
 Amniocentesis Indications
 In women who will be > 35 years of age at the
time of delivery.
 In conjunction with an abnormal quad
screen.
 In Rh-sensitized pregnancy to obtain fetal
blood type or to detect fetal hemolysis.
 To evaluate fetal lung maturity via a lecithin-
to-sphingomyelin ratio ≥ 2.5 or to detect the
presence of phosphatidylglycerol (done
during the third trimester).
Prenatal Diagnostic Testing Schedule
 Diagnosis of Pregnancy

Positive Probable Presumptive

 Presumptive signs and
symptoms of pregnancy
 Are those signs and symptoms that are usually
noted by the patient.

 These signs and symptoms are not proof of

pregnancy but will suspicious of pregnancy.
 Amenorrhea
 Amenorrhea is one of the earliest clues of
pregnancy.

 The majority of patients have no periodic

bleeding after the onset of pregnancy.

 At least 20 % of women have some slight,

painless spotting during early gestation for no
apparent reason and a large majority of these
continue to term and have normal infants.
 Other causes of amenorrhea

 Menopause.
 Stress (severe emotional shock, tension, fear, or a
strong desire for a pregnancy).
 Chronic illness (tuberculosis, endocrine disorders,
or central nervous system abnormality).
 Anemia.
 Excessive exercise.
 Nausea and Vomiting (Morning Sickness)

 Usually occurs in early morning during the first weeks of

pregnancy.

 Usually spontaneous and subsides in 6 to 8 weeks or by the

twelfth to sixteenth week of pregnancy.

 Hyperemesis gravidarum: Nausea and vomiting that

is severe and lasts beyond the fourth month of pregnancy. It
causes weight loss and upsets fluid and electrolyte balance of
the patient.
 Frequent Urination
 Is caused by pressure of the expanding uterus on
the bladder.

 It subsides as pregnancy progresses and the uterus

rises out of the pelvic cavity.

 The uterus returns during the last weeks of

pregnancy as the head of the fetus presses against
the bladder.
 Breast Changes
 Enlargement of the breasts, causing a sensation of weight,
fullness, and mild tingling.
 Darkening of the areola--the brown part around the nipple.
 Enlargement of Montgomery glands--the tiny nodules or
sebaceous glands within the areola.
 Increased firmness or tenderness of the breasts.
 More prominent and visible veins.
 Presence of colostrum.
 Vaginal Changes
 Chadwick's sign: The vaginal walls have taken on a
deeper color caused by the increased vascularity because of
increased hormones.
It is noted at the sixth week when associated with
pregnancy. It may also be noted with a rapidly growing
uterine tumor or any cause of pelvic congestion.

 Leukorrhea: This is an increase in the white or slightly

gray mucoid discharge that has a faint musty odor. It is due
to hyperplasia of vaginal epithelial cells of the cervix
because of increased hormone level from the pregnancy.
Leukorrhea is also present in vaginal infections.
In pregnancy, what is the Chadwick sign?

a. bluish discoloration of the hyperemic vaginal mucosa

b. lower uterine segment softening
c. tenderness of the breasts with enlargement
d. uterus palpable above the pubic symphysis
In pregnancy, what is the Chadwick sign?

a. bluish discoloration of the hyperemic vaginal

mucosa
b. lower uterine segment softening
c. tenderness of the breasts with enlargement
d. uterus palpable above the pubic symphysis
 Quickening (feeling of life)
 This is the first perception of
fetal movement within the
uterus. It usually occurs toward
the end of the fifth month
because of spasmodic flutter.

 A multigravida can feel

quickening as early as 16 weeks.

 A primigravida usually cannot

feel quickening until after 18
weeks.
 Quickening (feeling of life)

 Once quickening has been established, the

patient should be instructed to report any
instance in which fetal movement is
absent for a 24-hour period.

 Fetal movement early in pregnancy is

frequently thought to be gas.
 Skin Changes
 Striae gravidarum (stretch marks) Marks noted on
the abdomen and/or buttocks caused by increased
production or sensitivity to adrenocortical hormones
during pregnancy.

 Chloasma Called the "Mask of pregnancy." A

bronze type of facial coloration seen more on dark-
haired women. Seen after the sixteenth week of
pregnancy.

 Fingernails Some patients note marked thinning and

softening by the sixth week.
 Striae gravidarum

Chloasma
 Linea Nigra
 Linea nigra. A black line
in the midline of the
abdomen that may run from
the sternum or umbilicus to
the symphysis pubis.

 Appears on the
primigravida by the third
month.

 The entire line may appear

on the multigravida before
the third month.
 Probable Signs of Pregnancy
 Probable signs of pregnancy are those signs
commonly noted by the physician upon
examination of the patient.

 These signs include uterine changes,

abdominal changes, cervical changes,
basal body temperature, positive
pregnancy test by physician, and fetal
palpation.
 Uterine Changes
 Position: By the twelfth week, the uterus rises above the
symphysis pubis and it should reach the xiphoid process by the
36th week of pregnancy. These guidelines are fairly accurate
only as long as pregnancy is normal and there are no twins,
tumors, or excessive amniotic fluid.

 Size: The uterine increases in width and length approximately

five times its normal size. Its weight increases from 50 grams to
1,000 grams.
 Hegar’s Sign
 Softening of the lower
uterine segment just
above the cervix.
 When the uterine is
compressed between
examining fingers, the wall
feels tissue paper thin.
 The physician will use
bimanual maneuver
simultaneously and will cause
the uterus to tilt forward
 Noted by the sixth to
eighth week of
pregnancy.
 Ballottement
Demonstrated during the bimanual exam at the 16th to 20th week.
Ballottement is when the lower uterine segment or the cervix is tapped by
the examiner's finger and left there, the fetus floats upward, then sinks back
and a gentle tap is felt on the finger.
 Abdominal changes
 This corresponds to changes that occur in the uterus,
as the uterus grows the abdomen gets larger.

 Abdominal enlargement alone is not a sign of

pregnancy.

 Enlargement may be due to uterine or ovarian

tumors, or edema.

 Striae gravidarum may also be classified as a

probable sign of pregnancy by the physician.
 Cervical Changes

 Goodell's sign. The cervix is normally firm like the

cartilage at the end of the nose. The Goodell's sign is when
there is marked softening of the cervix. This is present at
6 weeks of pregnancy.

 Formation of a mucous plug. This is due to hyperplasia

of the cervical glands as a result of increased hormones. It
serves to seal the cervix of the pregnant uterus and to
protect it from contamination by bacteria in the vagina. The
mucous is expelled at the end of pregnancy near or at the
onset of labor.
 Braxton-Hick's contractions
 This involves painless uterine contractions occurring
throughout pregnancy.
 It usually begins about the 12th week of
pregnancy and becomes progressively stronger.
 These contractions will, generally, cease with
walking or other forms of exercise.
 The Braxton-Hick's contractions are distinct from
contractions of true labor by the fact that
they do not cause the cervix to dilate and
can usually be stopped by walking.
 Basal Body Temperature
 A good indication if the patient has been recording
for several cycles previously.

 A persistent temperature elevation spanning over 3

weeks since ovulation is noted.

 Basal body temperature (BBT) is 97 percent

accurate.
 Positive Pregnancy test by the Clinician
 May be misread by doing it too early or too late

 Even if the test is positive, it could be the result of

ectopic pregnancy or a hydatidiform mole (an
abnormal growth of a fertilized ovum)

 Hydatidiform Mole
 Fetal Palpation
 A probable sign in early pregnancy.

 The physician can palpate the abdomen and

identify fetal parts.

 It is not always accurate, a mass in the

abdomen may be palpated and mistakenly
identified as an infant.
 Positive signs of pregnancy
 Positive signs of pregnancy are those signs that
are definitely confirmed as a pregnancy.

 They include fetal heart sounds, ultrasound

scanning of the fetus, palpation of the entire
fetus, palpation of fetal movements, x-ray, and
actual delivery of an infant.
 Fetal Heart Sounds

 The fetal heart begins beating by the 24th day

following conception.

 It is audible with a doppler by 10 weeks of

pregnancy and with a fetoscope after the
16th week.

 It is not to be confused with uterine souffle or

swishlike tone from pulsating uterine arteries.

 The normal fetal heart rate is 120 to 160 beats.

 Positive signs of pregnancy
 Palpation of the Entire Fetus: Palpation must include the fetus
head, back, and upper and lower body parts. This is a positive sign after
the 24th week of pregnancy if the woman is not obese.

 Palpation of Fetal Movement: This is done by a trained examiner.

It is easily elicited after 24 weeks of pregnancy.

 X-ray: An x-ray will identify the entire fetal skeleton by the 12th
week. In utero, the fetus receives total body radiation that may lead to
genetic or gonadal alterations. An x-ray is not a recommended test for
identifying pregnancy.

 Actual Delivery of An Infant: Self-explanatory.

 Changes of the Reproductive
System during Pregnancy
 Uterus.
 By the time the pregnancy has reached term, the
uterus will have increased five times its normal
size:
 In length from 6.5 to 32 cm.
 In depth from 2.5 to 22 cm.
 In width from 4 to 24 cm.
 In weight from 50 to 1000 grams.
 In thickness of the walls from 1 to 0.5 cm.
 The Uterus
 The capacity of the uterus must expand to normally
accommodate a seven-pound fetus and the placenta, the
umbilical cord, 500 ml to 1000 ml of amniotic fluid, and
the fetal membranes.

 The abdominal contents are displaced to the sides as the

uterus grows in size, which allows for ample space for the
uterus within the abdominal cavity.

 Growth of the uterus occurs at a steady, predictable pace.

 Measurement of the fundal height during pregnancy is an

important factor that is noted and recorded.
The Uterus Changes
 Fundal Height
 Growth that occurs too fast or too slow could be an
indication of problems.

 The size of the uterus usually reaches its peak at 38

weeks gestation.

 The uterus may drop slightly as the fetal head settles

into the pelvis, preparing for delivery, referred to as
"lightening."
 The Cervix
 The cervix undergoes a marked softening which is
referred to as the Goodell's sign.

 Operculum: A mucus plug is formed in the

cervical canal.

 The mucus plug is expelled at the end of the

pregnancy. This may occur at the onset of labor or
precede labor by a few days. When the mucus is
blood-tinged, it is referred to as a "bloody show."
 Other changes
 Softening of the cervix occur prior to the
beginning of labor.

 Vagina. Increased circulation to the vagina early

in pregnancy changes the color from normal light
pink to a purple hue which is known as the
"Chadwick's sign."
 The Ovaries

 Follicle-stimulating hormone (FSH) ceases its

activity due to the increased levels of estrogen and
progesterone secreted by the ovaries and corpus
luteum.

 The FSH prevents ovulation and menstruation.

 The corpus luteum enlarges during early pregnancy

and may even form a cyst on the ovary.
 The Corpus Luteum
 The corpus luteum produces progesterone to
help maintain the lining of the endometrium in
early pregnancy.

 It functions until about the 10th to 12th week of

pregnancy when the placenta is capable of
producing adequate amounts of progesterone and
estrogen.

 It slowly decreases in size and function after the

10th to 12th week.
 The Integumentary System
 Alterations in hormonal balance and mechanical stretching are
responsible for several changes.

 Linea Nigra: Is a dark line that runs from the umbilicus to the
symphysis pubis and may extend as high as the sternum. After
delivery, the line begins to fade, though it may not ever
completely disappear.

 Sweat Glands. Activity of the sweat glands throughout the body

usually increases which causes the woman to perspire more
profusely during pregnancy.
 The Circulatory System
 Blood volume
increases gradually
by 30% to 50%.
 This results in decrease
concentration of red
blood cells and
hemoglobin iron is
so important during
pregnancy.
 By the time pregnancy
reaches term, the body
has usually compensated
for the decrease resulting
in an essentially normal
blood count.
 Blood Circulation changes
 Increased blood volume compensates for hypertrophied vascular
system of enlarged uterus.
 It improves the placental performance.
 Blood lost during delivery, less than 500 cc is normal (300 to 400
cc is average).
Cardiovascular Changes
 Changes in the Respiratory System
during Pregnancy
 The respiratory rate
rises to 18 - 20 to
compensate for increased
maternal oxygen
consumption, which is
needed for demands of the
uterus, the placenta, and
the fetus.
 Body Temperature
 A slight increase in body temperature in early
pregnancy is noted. The temperature returns
to normal at about the 16th week of
gestation.

 The patient may feel warmer or experience

"hot flashes" caused by increased hormonal
level and basal metabolic rate.
 The Urinary System
 The kidneys must work extra hard excreting the
mother's own waste products plus those of the fetus.
 There is an increase in urinary output and a
decrease in the specific gravity.
 The patient may develop urine stasis and
pyelonephritis in the right kidney.
 This is due to pressure on the right ureter resulting
from displacement of the uterus slightly to the
right by the sigmoid colon.
 Urinary changes
 Frequent urination is a
complaint during the first
through third trimester.

 As the uterus rises out of the

pelvic cavity in early
pregnancy, pressure on the
bladder decreases and
frequency diminishes.

 When lightening occurs

during the final weeks of
pregnancy, pressure on the
bladder returns to cause
frequency.
 The Skeletal System
 There is a realignment of the spinal curvatures
during pregnancy to maintain balance.
 The patient walks with head and shoulders thrust
backward and chest protruding outward to
compensate.
 This gives the patient a "waddling" gait.
 There is a slight relaxation and increased
mobility of the pelvic joints, which allows
stretching at the time of delivery of the infant.
 Changes in the Gastrointestinal System
 The uterus enlarges and rises up into the pelvic
cavity, which displaces the stomach, intestines,
and other adjacent organs.

 Peristalsis is slowed because of the

production of the hormone progesterone,
which decreases tone and mobility of
smooth muscles.

 This slowing enhances the absorption of

nutrients and slows the rate of secretion
of hydrochloric acid and pepsin.
 GI Changes
 Flare-up of peptic ulcers is
uncommon in pregnancy.
 Slow emptying may increase
nausea and heartburn.

 Relaxation of the cardiac

sphincter may increase
regurgitation and chance for
heartburn.

 Movement through the large

intestines is also slowed due to an
increase in water consumption.

 Increased chance for constipation.

 Nursing Implications
 If the mother has difficulty with nausea and/or
heartburn, advise her to eat small, frequent
meals.

 The patient should eat a well- balanced diet high in

protein, iron, and calcium for fetal growth; high
fiber and fluids to prevent constipation.

 The mother should not lie flat for 1 to 2 hours

after eating because this may cause heartburn and/or
regurgitation.
The Endocrine System During Pregnancy
 Parathyroid Gland. Increases in size slightly. It
meets the increased requirements for calcium
needed for fetal growth.

 Posterior Pituitary. Near the end of term, the

posterior pituitary will begin to secrete oxytocin
that was produced in the hypothalamus and stored
there. It will serve to initiate labor.
 Endocrine changes
 Anterior Pituitary. At birth, It will begin to
secrete prolactin. This stimulates the production
of breast milk.

 Placenta. Acts as a temporary endocrine gland

during pregnancy. It produces large amounts of
estrogen and progesterone by 10 to 12 weeks
of pregnancy.
 It serves to maintain the growth of the uterus, helps
to control uterine activity, and is responsible for
many of the maternal changes in the body.
Severe maternal hypothyroidism has been linked to
which:
A. Cretinism
B. Dwarfism
C. Hypogonadism in children
D. Limb reduction deformity
Severe maternal hypothyroidism has been linked to
which:
A. Cretinism
B. Dwarfism
C. Hypogonadism in children
D. Limb reduction deformity
 Changes in body weight during Pregnancy
 There is a slight loss of pounds
during early pregnancy if the
patient experiences much nausea
and vomiting.
 Weight gain of 2 to 4 lbs by the end
of the first trimester.
 A gain of a 1 lb. per wk is expected
during the second and third
trimesters.
 Monitoring of weight gain should
be done in conjunction with close
monitoring of BP.
Which of the following is the most substantial component
for the maternal weight gain during pregnancy?

a. maternal fat
b. fetus
c. placenta
d. amniotic fluid
e. intra and extra cellular fluid
Which of the following is the most substantial component
for the maternal weight gain during pregnancy?

a. maternal fat
b. fetus
c. placenta
d. amniotic fluid
e. intra and extra cellular fluid
 Body weight changes during pregnancy
 A lack of significant weight gain may be an indication
of intrauterine growth retardation (IUGR) of the
infant.
 Twin pregnancy: will require a higher caloric diet
and expect a higher weight gain than a single
pregnancy.
 Adequate protein intake emphasized to the patient
for development of the healthy fetus and proper diet
reviewed at each prenatal visit.
 Normal weight gain is about 24 to 30 pounds
(lbs) during pregnancy.
Standard Prenatal Care