Based on the Department lecture (Dr Ritho). The point on the ward: confirm the pregnancy, say how far along it is, and be sure where it is.
The reasoning chain: symptoms and signs raise the suspicion → a pregnancy test confirms → ultrasound shows it is in the uterus, alive, and how many weeks → think of what else can look like pregnancy.
1. Trimesters
- First trimester: the first 12 weeks
- Second trimester: 13 to 28 weeks
- Third trimester: 29 to 40 weeks
2. First trimester: symptoms
| Symptom | Notes |
|---|---|
| Amenorrhoea | The commonest symptom: a sudden stop of regular periods. It can also occur in lactation, illness, stress or endocrine disease; and bleeding can occur in early pregnancy (threatened abortion, or slight bleeding at the expected period in the first 12 weeks, Hartman's sign) |
| Morning sickness | Nausea with or without vomiting, about 6 weeks after the LMP, usually gone by about 12–14 weeks |
| Frequency of micturition | From congestion and pressure on the bladder; it returns late in pregnancy when the head descends |
| Breast symptoms | Enlargement, fullness, tingling and tenderness |
| Appetite changes, sleepiness, fatigue | Common |
3. First trimester: signs
Breast signs
Increased size and vascularity, increased pigmentation of the nipple and primary areola, a secondary areola, Montgomery's tubercles, and colostrum that can be expressed. Breast signs are only diagnostic in a first pregnancy, because earlier pregnancies leave similar changes.
Pelvic and uterine signs
| Sign | What you find |
|---|---|
| Uterine enlargement | Enlarged, globular, soft; remains a pelvic organ until 12 weeks, when it can just be felt above the symphysis |
| Hegar's sign | On bimanual examination, the two fingers in the anterior fornix can nearly touch the abdominal hand behind the softened lower uterine segment (6–10 weeks) |
| Palmer's sign | Rhythmic uterine contractions felt on bimanual examination |
| Jacquemier's (Chadwick's) sign | Bluish or violet discolouration of the vestibule and anterior vaginal wall, from vascular congestion (about 8 weeks) |
| Osiander's sign | Increased pulsation felt through the lateral fornices |
| Goodell's sign | Softening of the cervix from about 6 weeks ("like the lips of the mouth", not "the tip of the nose") with bluish colour on speculum examination |
| Vagina | Violet, moist and warm with more discharge and increased acidity |
4. Investigations: pregnancy tests
Human chorionic gonadotrophin (hCG) is made by the trophoblast only, so it appears only in pregnancy (and in trophoblastic disease). It is detectable in maternal serum about 8 to 11 days after conception, rises, peaks at 8 to 12 weeks, then falls to a plateau.
| Test | Notes |
|---|---|
| Urine pregnancy test (dipstick) | Rapid, simple, based on enzyme-labelled monoclonal antibodies; detects low hCG from about the time of the missed period. False negatives (too early, dilute urine, hook effect in very high hCG) and false positives (some drugs, hCG-secreting tumours, recent miscarriage) occur |
| Latex agglutination (inhibition) tests | The older form |
| Serum β-hCG (quantitative) | More sensitive and can follow the rise (doubling about every 48 hours early in a normal pregnancy). Essential for ectopic pregnancy, molar pregnancy and threatened miscarriage |
| ELISA and radio-immunoassay | Laboratory methods |
Ultrasound: what you see and when
Counted from the last menstrual period (weeks of amenorrhoea):
| Finding | When |
|---|---|
| Gestational sac | About 4 to 5 weeks (transvaginal) |
| Yolk sac | About 5 weeks |
| Fetal pole and cardiac activity | About 6 weeks |
| Embryonic movements | About 7 weeks |
| Fetal heart by Doppler | About 10 weeks |
Ultrasound also tells you where the pregnancy is (excluding ectopic), how many embryos there are, how old the pregnancy is (crown-rump length in the first trimester) and whether it is alive.
5. Second trimester (13 to 28 weeks)
- Symptoms: continued amenorrhoea, morning sickness and urinary frequency settle, quickening (the mother first feels the baby move) at 18–20 weeks in a first pregnancy and 16–18 weeks if she has delivered before, and abdominal enlargement.
- Skin signs: chloasma (melasma), linea nigra and striae gravidarum.
- Breast signs become obvious.
- Uterine signs: the uterus is felt through the abdomen; Braxton Hicks contractions (painless, intermittent, irregular tightening) are felt on palpation.
- Fetal signs: internal ballottement at about 16 weeks (tap the fetal part through the anterior fornix and feel it rebound) and external ballottement at about 20 weeks; fetal movements and fetal parts are felt; the fetal heart is heard with a Pinard stethoscope at about 20 weeks and by Doppler from about 10–12 weeks.
6. Third trimester (29 to 40 weeks)
The fundus rises to the xiphisternum at term (36 weeks) and may drop (lightening) as the head engages in a first pregnancy. Leopold's manoeuvres show lie, presentation and position; fetal movements and heart sounds are clear; ultrasound estimates growth and well-being. Reduced fetal movement is an urgent symptom.
7. Summary of the signs
| Type | Examples |
|---|---|
| Presumptive (felt by the woman; many causes) | Amenorrhoea, nausea and vomiting, breast changes, frequency, fatigue, quickening, skin changes |
| Probable (found by the examiner; other causes possible) | Enlarged uterus, Hegar's, Goodell's, Chadwick's signs, Braxton Hicks contractions, ballottement, positive pregnancy test |
| Positive (certain) | Fetal heart heard or seen, fetal movements felt by the examiner, fetal parts palpated, and ultrasound of the fetus |
8. What else can mimic pregnancy?
- Pseudocyesis (false pregnancy): amenorrhoea, a swollen abdomen and the belief of being pregnant, with a negative test.
- Hydatidiform mole and other trophoblastic disease (positive test, but the uterus is larger than dates and the scan shows no fetus).
- Fibroids, ovarian tumours, ascites, a full bladder and obesity.
- Secondary amenorrhoea from PCOS, thyroid disease, hyperprolactinaemia, premature ovarian failure, stress or weight change.
Examiner questions
- List the presumptive, probable and positive signs of pregnancy.
- Describe Hegar's, Goodell's, Chadwick's and Osiander's signs.
- When is hCG first detectable, and why can a urine test be falsely negative?
- At what gestation can ultrasound show the gestational sac, the yolk sac and cardiac activity?
Practice questions
1. Bluish discolouration of the vestibule and anterior vaginal wall in early pregnancy is: A. Hegar's sign · B. Goodell's sign · C. Jacquemier's (Chadwick's) sign · D. Osiander's sign · E. Palmer's sign Answer: C.
2. Softening of the cervix from about 6 weeks is: A. Chadwick's sign · B. Goodell's sign · C. Hegar's sign · D. Piskacek's sign · E. Ladin's sign Answer: B.
3. Which of the following is a POSITIVE (certain) sign of pregnancy? A. Amenorrhoea · B. Positive urine test · C. Breast tenderness · D. Fetal heart seen on ultrasound · E. Enlarged uterus Answer: D.
4. Quickening in a woman in her first pregnancy occurs at about: A. 8–10 weeks · B. 12–14 weeks · C. 18–20 weeks · D. 24–26 weeks · E. 30 weeks Answer: C.
5. A woman has amenorrhoea, a large uterus for dates and a very high hCG with no fetus on ultrasound. The diagnosis is: A. Twin pregnancy · B. Hydatidiform mole · C. Ectopic pregnancy · D. Pseudocyesis · E. Missed abortion Answer: B.