INTRODUCTION

Diagnosis of pregnancy and knowledge of normal findings associated with early pregnancy are common issues in the medical care of reproductive age women. More than 6 million women are diagnosed with pregnancy each year in the United States, and millions more have sought diagnostic testing [1]. Early diagnosis of pregnancy may prompt women to seek prenatal care earlier and to take measures that can benefit the foetus, such as improving glucose control (in women with diabetes), or avoiding alcohol and potentially harmful drugs. Early diagnosis also provides the best opportunity for accurate estimation of gestational age and delivery rate. The diagnosis of early pregnancy is based primarily upon laboratory assessment of human chorionic gonadotropin (hCG). Characteristic findings on history and physical examination are not highly sensitive for diagnosis, but are important to help the clinician distinguish normal pregnancy from coexistent disorders.

FIRST TRIMESTER
Subjective symptoms The following are presumptive symptoms of early months of pregnancy. Amenorrhea During the reproductive period in an otherwise healthy individual having previous normal periods, likely due to pregnancy unless proved otherwise. However, cyclic bleeding may occur up to 12 weeks of pregnancy, until the decidual space is obliterated by the fusion of deciduas capsularis. Such bleeding is usually scanty, lasting for a shorter duration than her usual and roughly corresponds with the date of the expected period. This is termed as a placental sign. This type of bleeding should not be confused with the commonly met the pathological bleeding i.e., threatened abortion.

Morning sickness It is inconsistently present in about 50% cases, more often in first pregnancy than in the subsequent one. It appearly soon following the missed period and rarely last beyond the third month. Its intensity varies from nausea on rising from the bed to loss of appetite or even vomiting. But it usually does not affect the health status of the mother. Frequency of micturition It is quite troublesome symptom during 8th to 12th week of pregnancy. It is due to 1) Resting the bulky uterus on the fundus of the bladder because of exaggerated anteverted position of the uterus. 2) Congestion of the bladder mucosa 3) Change in maternal osmoregulation causes increased thirst and polyuria. As the uterus straightens up after 12th week, the symptom disappears. Breast discomfort in the form of feeling of fullness and pricking sensation is evident as early as 6_ 8th week especially in primygravidae. Fatigue is a frequent symptom which may occur early in pregnancy. OBJECTIVE SIGNS Breast changes are valuable only in primigravidae, as in multiparae, the breast are enlarged and often contain milk for years. The breast changes are evident between 6-8 weeks. There is enlargement with vascular engorgement evidenced by the delicate veins visible under the skin The nipple and the areola become more pigmented specially in dark women. Montgomerys tubercles are prominent. Thick yellowish secretion can be expressed as early as 12th week. Per abdomen- Uterus remains a pelvic organ until 12th week, it may be just felt for abdomen as a suprapubic bulge. Pelvic changes- The pelvic changes are diverse and appear at different period.
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Jacquemiers or Chadwicks sign: It is the dusky hue of the vestibule and anterior vaginal wall visible at about 8th week of pregnancy. It is more pronounced as pregnancy advances and is more definitely present in multiparae. The discolouration is due to local vascular congestion and as such, it may be brought about by pelvic tumour such as uterine fibroid. Vaginal sign a) b) c) d) Apart from the bluish discolouration of the anterior vaginal wall. The walls become softened and Copious nonirritating mucoid discharge appears at 6th week. There is increased pulsation, felt through the lateral fornics at the 8th week called Osianders sign.

Cervical signs a) Cervix becomes soft as early as 6th week (Goodells sign), a later earlier in multiparae. The softening is pronounced surrounding the external os and also in the upper part. The pregnant cervix feels like the lips of the mouth, while in nonpregnant state, like that of tip of the nose. Such degree of softening may be evident in cases who are using combination pill for contraception. b) On speculum examination, the bluish discolouration of the cervix is visible. It is due to increased vascularity. Uterine signs Size, shape and consistency-The uterus is enlarged to the size of hens egg at the 6th week. The pyriform shape of the non pregnant uterus becomes globular by 12th weeks. The uterus becomes acutely anteverted between 6-8 weeks. There may be asymmetrical enlargement of the uterus if there is lateral manipulation. This is called Piskaceks sign where one half is more firm than the other half. As pregnancy advances, symmetry is restored. The pregnant uterus feels soft and elastic. Hegars signs: It is present in two thirds of cases. It can be demonstrated between 6-10 weeks, a little earlier in multiparae. This sign is based on the fact that 1) upper part of the body of the uterus is
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enlarged by the growing fetus, 2) lower part of the body is empty and extremely soft and 3) the cervix is comparatively firm. Because of variation in consistency, on bimanual examination, the abdominal and vaginal fingers seem to appose below the body of the uterus. Examination must be gentle to avoided the risk of abortion. Palmers sign: Regular and rhythmic uterine contraction can be elicited during bimanual examination as early as 4-8 weeks. Palmer in 1949 first described it. IMMUNOLOGICAL TEST FOR DIAGNOSIS OF PREGNANCY Pregnancy tests depend on the detection of the antigen (HCG) present in the maternal urine or serum with antibody either polyclonal available commercially. SCHEMATIC PRESENTATION OF THE PRINCIPLES IMMUNOLOGICAL TESTS FOR DIAGNOSIS OF PREGNANCY EMPLOYED IN

PREGNANT Urine + HCG antiserum Urine

NON PREGNANT + HCG antiserum

Neutralization of the antibody + HCG coated latex particles

HCG antibody not neutralis + HCG coated latex particles

NO VISIBLE AGGLUTINATION AGGLUTINATION

Agglutination inhibition test- The materials for these tests are supplied in kits containing all the reagents needed to do a test.

Principles of agglutination inhibition tests: One drop of urine is mixed with one drop of solution that contain HCG is not present in the urine sample (e.g.: the women is not pregnant) the antibody remains free .Now one drop of another solution that contain latex particle coated with hCG is added. Agglutination of the latex particles can be observed easily this time. Therefore the pregnancy test is negative if there is agglutination. On the other hand if HCG were present in the urine sample (eg: woman was pregnant), it would bind the available antibody. There would be no further agglutination when the solution containing HCG coated latex particles was addeded. Therefore, pregnancy test is positive if there is no agglutination. DIRECT AGGLUTINATION TEST ( hCG direct test) Latex particles coated with anti HCG monoclonal antibodies are mixed with urine. An agglutination react indicates a positive result when the urine sampile contains hCG. Absence of agglutination indicates a negative one. The sensitivity is o.2 IU HCG/ M ENZYME LINKED IMMUNOSOBENT ASSAY (ELISA) It is based on one monoclonal antibody that bind the hCG and a second antibody that is linked with enzyme alkaline phosphate to sandwich the HCG. It is detected by colour change after binding. This is more sensitive and specific. Elisa can detect HCG in serum up to 1-2 mIU/ ml and as early as 5 days before the first missed period. Fluroimmuno assay (FIA) It is a highly precise sandwich assay. It uses a second antibody tagged with a fluorescent level. The fluorescence emitted is proportional to the amount of hCG. It can detect hCG as low as 1 mlU/ FIA takes 2-3 hours. It is used to detect hCG and for follow up hCG concentrations. B. Immuno assays with radioisotopes RADIOIMMUNO ASSAY

Using 1215 ido hcg antibodies .It is more sensitive and can detect beta subunit of Hcg up to o.oo2 IU/ ml in the serum. It can detect pregnancy as early as 8-9 days after ovulation ( day of blastocyst implantation). Radio receptor assay give highest sensitivity o.oo1 iu/ ml in the serum. RIA are quantitative so can be used for determining the doubling time of Hcg. IMMUNO RADIO METRIC ASSAY (IRMA) Uses sandwich principle to detect whole hCG molecule. IRMAs use 125 levelled hCG as low as 0.05 m lU/ ml. Selection of time Diagnosis of pregnancy by detecting Hcg in maternal serum or urine can be made by 8 to 11 days after conception. The test is not reliable after 12 weeks. Collection of urine The patient is advised to collect the first voided urine in the morning in a clean container (not to wash with soap) Kits to perform the test at home are also available. ULTRASONOGRAPHY Intra decidual gestational sac is defined as early as29 to 35 days of gestation. Fetal viability and gestational age is determined by detecting the following structures by transvaginal ultrasonography. Gestational sac and yolk sac by 5 menstrual weeks, Fetal pole and cardiac activity-6 weeks. Embryonic movement by 7 weeks. Fetal gestational age is just determined by measuring the CRL between 7 and 12 weeks. Doppler Effect of ultrasound can pick up the heart rate reliably by the 10th week. The instrument is small, handy and cheep.

SECOND TRIMESTER
SYMPTOMS The subjective symptoms- such as nausea, vomiting and frequency of micturition usually subside, while amenorrhea continues. The new features that appear are:

Quickening(feeling of life) denote the perception of active fetal movements by the women. It is usually felt about the 18th week, about 2 weeks earlier in multipare. Its appearance is an usual guide to calculated the expected date of delivery with reasonable accuracy. Progressive enlargement of the lower abdomen by growing uterus. GENERAL EXAMINATION Chloasma: Pigmentation over the forehead and cheek my appear at about 24th week Breast changes Breasts are more enlarged with prominent veins under the skin. b) Secondary areola specially demarcated in primygravidae, usually appear about 12th week c) Montgomerys tubercles are prominent and extend to the secondary areola d) Colostrums becomes thick and yellowish by 16th week. e) Variable degree of straie may be visible with advancing weeks. ABDOMINAL EXAMINATION Inspection 1) Linear pigmented zone (linea nagra) extending from the symphysis pubis to ensiform cartilage may be visible as early as 20th week 2) Striae ( both pink and white) of varying degree are visible in the lower abdomen, more towards the flanks. Palpation Fundal height is increased with progressive enlargement of the uterus. Approximate duration of pregnancy can be ascertained by noting the height of the uterus in relation to the different levels in the abdomen. The following formula is an useful guide for the purpose. The height of the uterus is midway between the symphysis pubis and umbilicus at 16th week, at the level of the umbilicus at 24th week and at the junction of the lower third and upper two third of the distance between the umbilicus and ensiform cartilage at the 28th week.
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The uterus feels soft and elastic and become ovoid in shape. Braxton- Hicks contractions are evident Palpation of the fetal parts can be made distinctly by the 20th week. Active fetal movements can be felt at intervals by placing the hand over the uterus early as 20th week. It not only gives positive evidence of pregnancy but of a live fetus. The intensity varies from a faint flutter in early months to stronger movements in later months. External ballotment- is usually elicited as early as 20th week when the fetus is relatively smaller than the volume of the amniotic fluid. It is difficult to elicit in obese patients and in cases with scanty liquor amni. It is best elicited in breech presentations with the head at the fundus. Auscultation Fetal heart sound is the most clinical sign of pregnancy. With an ordinary stethoscopes, it can be detected between 18- 20 weeks. The sound resemble the tic of a watch under a pillow. It location varies with the position of the fetus. The rate vary from 140-160 per minute but gradually settles down to 120-140 per minute as the pregnancy advances. Two other sounds are confused with fetal heart sounds. Those are: Uterine souffl is a soft blowing and systolic murmur heard low down at the sides of the uterus, best on the left side. The sound is synchronous with the maternal pulse and is due to increase in blood flow through the dilated uterine vessels. It can be heard in bid uterine fibroid. Funic or fetal souffl is due to rush of blood through the umbilical artery. It is a soft, blowing murmur synchronous with the fetal heart sounds. VAGINAL EXAMINATIONS The bluish discolouration of the vulva, vagina and cervix. Internal ballottement can be elicited between 16-28th week. The fetus is too small before 16th week and too large to displace after 18th week. INVESTIGATIONS Sonography: routine Sonography at 18-20 weeks permits a detailed survey of fetal anatomy, placental localization and the integrity of the cervical canal.
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Gestational age is determined by measuring the biparietal diameter (BPD), head circumference (HC) abdominal circumference (AC) and femur length (FL). It is most accurate when done between 12 and 20 weeks. BPD is measured at the level of the thalami cavum septum pellucidum. BPD is measured is measured from the outer edge of the skull to the inner edge of the opposite side. Fetal organ anatomy Are survived to detect any malformation. Fetal viability is determined by real time ultrasound. Absence of fetal cardiac motion, confirms fetal death. Radiological evidence of fetal skeletal shadow may be visible as early as 16th week.

LAST TRIMESTER
SYMPTOMS (1) Amenorrhea persists (2) Enlargement of the abdomen is progressive which produces some mechanical discomfort to the patient such as palpation or dysponea following exertion. (3) Lightening- At about 38th week, especially in primigravidae, a sense of relief of the pressure symptom is obtained due to engagement of the presenting part. (4) Frequency of micturition reappears (5) Fetal movements are more pronounced SIGNS # cutaneous changes are more prominent with increased pigmentation and straiae # Uterine shape is changed from cylindrical to beyond 36th week. # Fundal height: The distance between the umbilicus and the ensiform cartilage is divided in to two equal parts. The Fundal height corresponds to the junction of the upper and middle third at the 13th weeks, up to the level of ensiform cartilage at 36th week and it come down to 32 week level at the 40th
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week because of engagement of the presenting part. To determine whether the height of the uterus corresponds to 32 weeks, engagement of the head should be tested. If the head is floating, it is of 32 weeks pregnancy and if the head is engaged, it is 40th weeks of pregnancy. Symphysis Fundal height (SFH) The upper border of the fundus is located by the ulnar border of the left hand this point is marked. The distance between the upper borders of the symphysis pubis up to the marked point is measured by a tape in centimeter. After 24th weeks, the SFH measured in cm corresponds to the number of weeks up to 36 weeks. A variation of+ or 2 cm. is accepted as normal. Variation, beyond the normal range needs further evaluation. # BRAXTON-HICKS CONTRACTIONS are more evident. # FETAL MOVEMENTS are easily felt. # PALPATION OF THE FETAL PARTS and there identification become much easier. Lie, presentation and position of the fetus are determined. # F.H.S is heard distinctly in areas corresponding to the presentation and position of the fetus. F. H.S may not be audible in cases of maternal obesity, polyhydramnios, and occipito posterior position and certainly in I U D. # Sonography- gestational age estimation by BPD, HC, AC and FL is less accurate. Fetal growth assessment can be made provided accurate dating scan has been done in first or second trimester. FETAL AC at the level of the umbilical vein is used to assess gestational age and fetal growth profile PLACENTAL ANATOMY location (fundus or praevia), thickness (placentomegaly I diabetes) or other abnormalities are noted. OTHER INFORMATION: Fetal life, number, presentation and organ anatomy as done in the first and second trimester are surveyed again. DIFFERENTIAL DIAGNOSIS OF PREGNANCY While the clinical diagnosis of pregnancy at times, become easy, but there are occasions where the diagnosis poses a problem. The enlargement of the uterus caused by pregnancy may have to be differentiated from abdomino- pelvic
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swellings, such as uterine fibroid, cystic ovarian tumor, encysted tubercular peritonitis, haematometra or even distended urinary bladder. PSEUDOCYESIS It is a psychological disorder where the women have the false but firm belief that she is pregnant although no pregnancy exists. The women often are infertile who has an intense desire to have a baby. The conspicuous feature of cessation of menstruation. Other confusing manifestations are gradual enlargement of the abdomen because of deposition of fat, secretion from the breasts and intestinal movement, imagining it to be a fetal movement. In some cases the condition continuous until eventually spurious labour sets in. Obstetric examination reveals absence of positive signs of pregnancy. Cystic ovarian tumors: The diagnostic points are 1) 2) 3) 4) 5) 6) The swelling is slow growing, usually takes to month to grow Amenorrhea is usually absent It feels cystic or tense cystic Absence of Braxton Hick contractions Absence of positive signs of pregnancy Ultrasonography shows absence of fetus

FIBROID 1) The tumors is slow growing, often take years 2) Amenorrhea is usually absent 3) The feel is firm, more towards hard but may be cystic in cystic degeneration 4) Positive signs of pregnancy are absent 5) Ultrasonography or immunological test for pregnancy gives negative results

REVIEW OF LITERATURE Prenatal diagnosis, pregnancy terminations and prevalence of Down syndrome in Atlanta.

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Source Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. csiffel@cdc.gov Abstract BACKGROUND: The impact of prenatal diagnosis on the live birth prevalence of Down syndrome (trisomy 21) has been described. This study examines the prevalence of Down syndrome before (1990-1993) and after inclusion of prenatally diagnosed cases (1994-1999) in a population-based registry of birth defects in metropolitan Atlanta. METHODS: We identified infants and spontaneous fetal deaths with Down syndrome (n = 387), and pregnancies electively terminated after a prenatal diagnosis of Down syndrome (n = 139) from 1990 to 1999 among residents of metropolitan Atlanta from a population-based registry of birth defects, the Metropolitan Atlanta Congenital Defects Program (MACDP). Only diagnoses of full trisomy 21 were included. Denominator information on live births was derived from State of Georgia birth certificate data. We compared the prevalence of Down syndrome by calendar period (1990-1993, 1994-1999), maternal age (<35 years, 35+ years), and race/ethnicity (White, Black, other), using chi-square and Fisher's exact tests. RESULTS: During the period when case ascertainment was based only on hospitals (19901993), the prevalence of Down syndrome was 8.4 per 10,000 live births when pregnancy terminations were excluded and 8.8 per 10,000 when terminations were included. When case ascertainment also included perinatal offices (19941999), the prevalence of Down syndrome was 10.1 per 10,000 when terminations were excluded and 15.3 when terminations were included. During 1990-1993, the prevalence of Down syndrome was 24.7 per 10,000 among offspring to women 35+ years of age compared to 6.8 per 10,000 among offspring to women <35 years of age (rate ratio [RR] = 3.65, 95% confidence interval [CI] = 2.53-5.28). During 1994-1999, the prevalence of Down syndrome was 55.3 per 10,000 among offspring to women 35+ years compared to 8.5 per 10,000 among offspring to women <35 years (RR = 6.55, 95% CI = 5.36-7.99). There was no statistically significant variation in the prevalence of Down syndrome by race/ethnicity within maternal age and period of birth strata. During 1994-1999, the proportion of cases that were electively terminated was greater for women 35+ years compared to women
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<35 years (RR = 5.10, 95% CI = 3.14-8.28), and lower for Blacks compared to Whites among women 35+ years of age (RR = 0.33, 95% CI = 0.16-0.66). CONCLUSIONS: In recent years, perinatal offices have become an important source of cases of Down syndrome for MACDP, contributing at least 34% of cases among pregnancies in women 35+ years of age. Variation in the prevalence of Down syndrome by race/ethnicity, before or after inclusion of cases ascertained from perinatal offices, was not statistically significant. Among Down syndrome pregnancies in mothers 35+ years we found a lower proportion of elective termination among Black women compared to White women. We suggest that future reports on the prevalence of Down syndrome by race/ethnicity take into account possible variations in the frequency of prenatal diagnosis or elective termination by race/ethnicity. Prenatal diagnosis, pregnancy terminations and prevalence of Down syndrome in Atlanta. Siffel C, Correa A, Cragan J, Alverson CJ. Source Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. csiffel@cdc.gov Abstract BACKGROUND: The impact of prenatal diagnosis on the live birth prevalence of Down syndrome (trisomy 21) has been described. This study examines the prevalence of Down syndrome before (1990-1993) and after inclusion of prenatally diagnosed cases (1994-1999) in a population-based registry of birth defects in metropolitan Atlanta. METHODS: We identified infants and spontaneous fetal deaths with Down syndrome (n = 387), and pregnancies electively terminated after a prenatal diagnosis of Down syndrome (n = 139) from 1990 to 1999 among residents of metropolitan Atlanta from a population-based registry of birth defects, the Metropolitan Atlanta Congenital Defects Program (MACDP). Only diagnoses of full trisomy 21 were included. Denominator information on live births was derived from State of Georgia birth certificate data. We compared the prevalence of Down syndrome by calendar period (1990-1993, 1994-1999), maternal age (<35

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years, 35+ years), and race/ethnicity (White, Black, other), using chi-square and Fisher's exact tests. RESULTS: During the period when case ascertainment was based only on hospitals (19901993), the prevalence of Down syndrome was 8.4 per 10,000 live births when pregnancy terminations were excluded and 8.8 per 10,000 when terminations were included. When case ascertainment also included perinatal offices (19941999), the prevalence of Down syndrome was 10.1 per 10,000 when terminations were excluded and 15.3 when terminations were included. During 1990-1993, the prevalence of Down syndrome was 24.7 per 10,000 among offspring to women 35+ years of age compared to 6.8 per 10,000 among offspring to women <35 years of age (rate ratio [RR] = 3.65, 95% confidence interval [CI] = 2.53-5.28). During 1994-1999, the prevalence of Down syndrome was 55.3 per 10,000 among offspring to women 35+ years compared to 8.5 per 10,000 among offspring to women <35 years (RR = 6.55, 95% CI = 5.36-7.99). There was no statistically significant variation in the prevalence of Down syndrome by race/ethnicity within maternal age and period of birth strata. During 1994-1999, the proportion of cases that were electively terminated was greater for women 35+ years compared to women <35 years (RR = 5.10, 95% CI = 3.14-8.28), and lower for Blacks compared to Whites among women 35+ years of age (RR = 0.33, 95% CI = 0.16-0.66). CONCLUSIONS: In recent years, perinatal offices have become an important source of cases of Down syndrome for MACDP, contributing at least 34% of cases among pregnancies in women 35+ years of age. Variation in the prevalence of Down syndrome by race/ethnicity, before or after inclusion of cases ascertained from perinatal offices, was not statistically significant. Among Down syndrome pregnancies in mothers 35+ years we found a lower proportion of elective termination among Black women compared to White women. We suggest that future reports on the prevalence of Down syndrome by race/ethnicity take into account possible variations in the frequency of prenatal diagnosis or elective termination by race/ethnicity. .

CONCLUSION
The diagnosis of pregnancy can be made by several methods. Normocyclic women who present with amenorrhea and typical history and physical examination findings have the classic presentation and can be diagnosed with
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a viable intrauterine pregnancy if they progress appropriately. Currently, most women are diagnosed with pregnancy after a missed menstrual cycle and a positive urine or serum hCG finding. The pregnancy is diagnosed as viable with serial examinations and normal pregnancy development, a normal result after dating ultrasonography, or a positive finding of fetal heart tones using Doppler studies. Women who are considered high-risk or those who present with abdominal pain or vaginal bleeding in early gestation are more likely to be evaluated with ultrasonography and additional hormonal assays. A number of different combinations can aid in the diagnosis of a viable intrauterine pregnancy. The physician must ascertain what is most appropriate at the time of patient presentation.

BIBLIOGRAPHY
# Diane. M. Fraser, Margaret. A. Cooper. Myles text books for midwives. 14th edition. Churchil living stone; 2003 # Diane. M. Frasher. Margaret A. Cooper. Mylws text book for midwives 15th edition. Elsever publication 2009 # D.C Dutta, Text book of gynecology. 6th edition. New central book agency (p) LTD. Culcutta 2006 # Kamini. A. Raw, Text book of midwifery and obstrtics for nurses. Elsever publication 2011 # Michael. D. Benson. OB/ GYN Mentior edition J P Brothers medical publishers New delhi # Neville.F. Hacker, Joseph C Cambone, Calvin. J. Hobel. Essential of obstetrics and gynecology, Elsever publications # Richa Saxena, Bedside obstetrics and gynacologyf first edition. Jaypee brothers 2010 Shirish N Daffary, Sudip Chakravarti. 2nd edition. Manual pf obstetricus. Lseveier publications
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# Sudha Salhan. Text book of obstetrics. 1st edition Jaypee brothers medical publishers. New Delhi # Shirish N Daftary Second ediyion manual of onstetricus. Elsevier publications # http/www/ Female pelvis edu/bw -10 # American journal of obstetrics and Gynacology 2019 march

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