DIAGNOSIS OF PREGNANCY AND PRENATAL CARE potx

103

The correct early diagnosis of pregnancy is often urgent. For ex￾ample, a diagnosis is essential to institute studies or treatment of

problems that may jeopardize the life or health of mother or off￾spring. Today this is usually accomplished by early beta-subunit

hCG testing or ultrasonic scanning because a definite clinical di￾agnosis of pregnancy before the second missed period is possible

in only about two thirds of patients. However, the practitioner must

be familiar with the signs and symptoms of pregnancy to properly

test for and treat the early pregnancy.

CLINICAL DIAGNOSIS

OF PREGNANCY

Traditionally, the clinical criteria for the diagnosis of pregnancy

have been categorized into presumptive, probable, and positive

(Table 5-1).

The differential diagnosis of the common signs and symptoms

of pregnancy involves other conditions associated with similar com￾plaints or alteration (Table 5-2).

PELVIC FINDINGS OF

EARLY PREGNANCY

Critical to the diagnosis of pregnancy by physical examination are

the pelvic findings. The presumptive indications of pregnancy

include the following.

Cyanosis of the vagina (Chadwick’s sign, Jacquemier’s sign) is

present by about 6 weeks.

5

DIAGNOSIS OF PREGNANCY

AND PRENATAL CARE

CHAPTER

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BENSON & PERNOLL’S

104 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

TABLE 5-1

PRESUMPTIVE OR PROBABLE SIGNS AND SYMPTOMS

OF PREGNANCY*

Symptoms Signs

Amenorrhea Leukorrhea

Nausea, vomiting Changes in color

Breast tingling, mastalgia consistency, size, or

Urinary frequency, urgency shape of cervix or

Quickening uterus

Temperature elevation

(usually by BBT)

Enlargement of abdomen

Breasts enlarged, engorged,

nipple discharge

Pelvic souffle (bruit)

Uterine contractions (with

enlarged corpus)

*

Although these may be suggestive, even 2 are not diagnostic of

pregnancy.

Softening of the tip of the cervix (Fig. 5-1) occasionally is noted

by the 4th–5th week of pregnancy. However, infection or scar￾ring may prevent softening until late pregnancy.

Softening of the cervicouterine junction often occurs by 5–6

weeks. A soft spot may be noted anteriorly in the middle of

the uterus near its junction with the cervix (Ladin’s sign) (Fig.

5-2). A wider zone of softness and compressibility in the lower

uterine segment (Hegar’s sign) is the most valuable sign of early

pregnancy and can usually be noted at
6 weeks (Fig. 5-3).

Ease in flexing the fundus on the cervix (McDonald’s sign) gen￾erally appears by 7–8 weeks.

Irregular softening and slight enlargement of the fundus at

the site of or on the side of implantation (Von Fernwald’s

sign) occur by
5 weeks. Similarly, if implantation is in the re￾gion of a uterine cornu, a more pronounced softening and sug￾gestive tumor like enlargement may occur (Piskacek’s sign)

(Fig. 5-4).

Generalized enlargement and diffuse softening of the uterine

corpus usually occur 8 weeks of pregnancy (Fig. 5-5).

CHAPTER 5

DIAGNOSIS OF PREGNANCY 105

TABLE 5-2

COMPARATIVE DIFFERENTIAL DIAGNOSIS

OF PRESUMPTIVE SYMPTOMS AND SIGNS

OF PREGNANCY

Cause(s) if Differential Diagnosis

Pregnant (Not Pregnant)

Symptoms

Amenorrhea hCG, etc. Pseudocyesis or

other

psychoneurosis,

endocrinopathies

(including

premature

menopause),

metabolic

disorders (e.g.,

anemia,

malnutrition),

obliteration of

the uterine

cavity, systemic

disease (e.g.,

acute or chronic

infection),

malignancy

Nausea, hCG, etc. Emotional

vomiting disorders (e.g.,

pseudocyesis,

anorexia

nervosa), GI

disorders

(gastroenteritis,

peptic ulcer,

hiatal hernia,

appendicitis,

intestinal

obstruction, food

poisoning),

acute infections

(e.g., influenza,

encephalitis)

(Continued)

BENSON & PERNOLL’S

106 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

TABLE 5-2

(Continued)

Cause(s) if Differential Diagnosis

Pregnant (Not Pregnant)

Mastalgia, Estrogen Estrogen with

breast tingling (duct anovulation,

stimulation), fibrocystic

progesterone breast disease

(alveolar

stimulation)

Urinary urgency, Estrogen Urinary tract

frequency (cystourethral infection (UTI),

turgescence) cystourethritis or

cystocele,

anxiety,

diabetes,

pelvic tumors,

emotional

tension

Quickening Fetal movements Increased

14 weeks peristalsis, free

(approx.) adnexal cyst,

pseudocyesis,

gas, contractions

Constipation Altered diet; Low fluid, low

hypoperistalsis fiber diet

Fatigue Progesterone Overwork

effect

Weight gain Gestational Overeating

anabolism

Signs

Leukorrhea Estrogen Vaginitis,

cervicitis,

genital foreign

body, tumor

Pelvic organ

alterations

Cyanosis of Hormones Vascular anomaly

cervix or of pregnancy or tumor of

Chadwick’s cervix or uterus

sign (
6 weeks)

CHAPTER 5

DIAGNOSIS OF PREGNANCY 107

Softening of Hormones Chronic cervicitis

cervix of pregnancy

(
4–5 weeks)

Softening of Hormones Vascular uterine

lower uterine of pregnancy anomaly or

segment (
5–6 tumor

weeks), Landin,

Hegar’s sign

Irregular Hormones Myoma

fundal of pregnancy

softening,

enlargement

(
5 weeks)

Generalized Hormones Adenomyosis or

corpus of pregnancy myomata

softening,

enlargement

(
8 weeks)

Temperature Progesterone Infection, corpus

elevation basal luteum cyst,

body temperature hCG or

(BBT)
2 weeks progestogen

therapy, faulty

thermometer

Abdominal Uterine size Obesity, pelvic or

enlargement abdominal

tumor, ascites,

obesity,

relaxation of

abdominal

muscles,

pelvic and

abdominal

tumors, ascites,

or ventral

hernia

(Continued)

TABLE 5-2

(Continued)

Cause(s) if Differential Diagnosis

Pregnant (Not Pregnant)