Cases of Pregnancy

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Cases of PregnancyQues. 1 How can pregnancy be diagnosed?

Ans.           Pregnancy is the condition of having a developing embryo of foetus in the body, after union of an ovum and spermatozoon.

The diagnosis of early pregnancy can usually be established with reasonable certainty by careful history and examination even as early as two weeks after first missed period. Difficulty in diagnosis may arise where the date is incorrect, the patient is unduly obese or difficult to examine or when pregnancy is not developing normally.

Ques. 2 Which are the important immunological and Biological tests for pregnancy?

Ans.           The important immunologic and Biological tests for pregnancy -

Immunologic tests for pregnancy

S.No.

Method

Materials

Results

(1)

Directcoagulation

Later particles coated with anti- HCG = (Serum of urine)

Coagulation if HCG is present (pregnant).

 

(2)

Inhibition of coagulation

Anti-HCG + Serum of urine +

(Sensitized red cells or Latex

Particles coated with HCG.)

Coagulation if HCG is absent (not pregnant)

Inhibition if HCG is present (pregnant).

 

 

Biological tests for pregnancy

S.No.

Name

Test animal

End point

Time of test

(1)

Ascheim Zondak

Mice

Corpus lutcum

5 days

(2)

Friedman

Rabbit

Corpus luteum

2 days

(3)

Ovarian hyperemia (beck)

Rat

Hyperemia

12-18 hours

(4)

Frog test (Hogben)

Female

Extrusion of eggs

24 hors

(5)

Toad test (Galli Mainini)

Male

Extrusion of sperm

2 – 5 hours

 

Pregnancy Causes both obvious and subtle changes which involve many organs, systems but are most pronounced in generative system. Because these subjective and objective alterations vary so widely, diagnostic criteria of pregnancy are classified as –

(a) probable, and (b) positive. (c) Presumptive,

Ques. 3 What are the presumptive signs of pregnancy?

Ans.          Presumptive, signs of pregnancy –

  1. Leucorrhoea- increased cervical mucus and pronounced exfoliation of vaginal epithelial cells.
  2. Breast changes –enlargement and vascular engorgement of the breast begin; colostrums is produced.
  3. Abdominal enlargement.
  4. Pelvic organ changes – softening of the cervix, cervico-uterine junction etc.
  5. Skin pigmentation and sriage.
  6. Epulis – hypertrophic gingival papillae are often seen after the first trimester of pregnancy.

Ques. 4 What are the probable signs of pregnancy?

Ans.           Probable symptoms of pregnancy – Same as presumptive symptoms. The Probable signs are – Enlargement of uterus; uterine soufflé (bruit); uterine contractions (Braxton Hicks sign), etc.

Ques. 5 What are the positive symptoms of pregnancy?

Ans.          Positive manifestations of pregnancy –

(A) Symptoms – There is no subjective evidence of pregnancy which can be accepted as diagnostic.

(B) Signs – Any one of the following signs is medical and legal proof of pregnancy; viz.

  1. Palpation of fetal outline.
  2. Recognition of fetal movements.
  • X-ray demonstration of fetal skeleton.
  1. Ultrasonography – ultrasound may have its greatest application in obstetrics.
  2. Fetal electrocardiography – can first be recorded about the 84th day of pregnancy.
  3. Auscultation of fetal heart beat; one must be able to hear distinctly and count the foetal heart beat.

The Symptoms & Signs of pregnancy

Appearance (in weeks)

Presumptive evidences : - 1. Amenorrhoea

2

(a)                   Morning sickness

6 to 10

(b)                   Bladder irritability

4 to 6

(c)                   Breast changes

3 to 6

(d)                   Discoloration of vagina

6

(e)                   Skin pigmentation and striae

-

(f)                    Quickening

18

Probable evidences

(i)  Hegar’s sign

8

(ii) Enlargement of uterus

8

(iii) Softening of cervix

8

(iv) Braxton-Hicks contraction

6

(v)  Ballotement

16 to 20

(vi) Fetal parts palpation

16

(vii) Endocrine tests (biological + immunological)

6

(viii) Fetal movement

20 to 24

(ix) FH beat hearing – 18 weeks. 3. Dopper

12 to 14

(x) X-ray of fctus – 16 weeks. 5. Sonographic

8

 

Ques. 6 What are the Evidences of Pregnancy?

Ans.          The Evidences of Pregnancy are -

  1. Recognition of the fetus by X-ray and sonography.
  2. Enlargement of the abdomen.
  3. Changes in size, shape and consistency of the uterus.
  4. Changes in cervix.
  5. By Braxton-Hicks contractions test.
  6. Outlining the fetus, by endocrine test, etc.
  7. Indentification of the fetal heart beat.
  8. Perception of active fetal movements.

Ques. 7 What is the Differential Diagnosis of Pregnancy.

Ans.          All of the presumptive and probable symptoms and signs of pregnancy, as well as positive clinical and laboratory test results indicative of pregnancy, can be caused by other conditions.

The Differential diagnosis of Symptoms –

(A) Amenorrhoea –

  1. Metabolic factors – Anaemia, malnutrition, climatic changes, diabetes mellitus, & degenerative disorders.
  2. Obliteration of the endometrial cavity by infection.
  3. Systemic disease (e.g. infection such as tuberculosis, malignancy etc.)
  4. Psychic factors – emotional shock, fear of pregnancy or venereal disease, intense desire for pregnancy.
  5. Endocrine factors – Ealy menopause: lactation; pituitary, thyroid, adrenal, or ovarian dysfunction.

(B) Nausea and vomiting –

  1. Gastrointestinal disorders (e.g. enteritis ulcer, hiatus hernia, appendicitis, intestinal obstruction, food poisoning etc.)
  2. Acute infections (influenza, encephalitis etc.) Breast tenderness (due to premenstrual tension, hyper-estinism, chronic cystic mastitis etc.) Urinary frequency (e.g. urinary tract infection, cystocele, emotional tension etc.) Quickening (increased peristalsis, abdominal muscles contractions, shifting abdominal contents etc.)
  3. Emotional disorders.

Differential Diagnosis of Signs –

  1. Lactiferous secretion – Persistent manual breast stimulation, residual fluid from a previous pregnancy etc.
  2. Abdominal enlargement –obesity of rapid onset, relaxation of abdominal muscles etc.
  • Leucorrhoea- infection and tumors of the vagina and cervix etc.
  1. Vaginal and cervical color chages – premenstrual turgescence, pelvic congestion syndrome, vinous obstruction etc.
  2. Change of consistency, size, shape of cervix and uterus – premenstrual engorgement, uterine hypertrophy, uterine tumors, tubo-ovarian cysts etc.
  3. Epulis – local infection, dental calculus, Vit. C.deficiency.

For the sake of convenience the description of sign and symptoms of pregnancy can be diviled into 3 periods.

  1. Early Pregnancy (1st 12th weeks) First Trimester.
  2. Mid Pregnancy (13th to 28th week) Second Trimester.
  • Late Pregnancy (29th to 40th weeks) Third Trimester.

Ques. 8 What are the clinical features of first trimester of pregnancy?

Ans.           Clinical Features of First Trimester –

(I) Amenorrhoea – sudden stoppage of menstruation in woman of child bearing are who has previously menstruated regularly must be considered due to pregnancy until disproved.

(II) Morning sickness – between 2nd to 12th week almost 50% of pregnant women suffer from anorexia, nausea & vomiting esp. in early morning. Giddiness. Frequency of micturation. Breast (discomfort) full-ness, tingling, enlarged. Constipation, sleepiness, excessive salivation, loss of appetite craving for unusual articles or food.

Signs –

  1. Per vagina : Vagina-bluish, moist, soft. Cervix-bluish, soft. Uterus Pyriform, enlarged, soft, elastic.
  2. Hegar’s sign – It is the appreciation of softness of the isthmus by bimanual examination during first trimester.
  3. Palmer’s sign – intermittent firmness and softness of the uterus may be detected during the bimanual examination from the 6th week onwards.
  4. McDonald’s sign – this occurs simultaneously with Hegar’s sign and is due to localized softening when uterine body & cervix can be easily flexed against one another.
  5. Basal body temperature – Persistence of the raised basal body temperature found in the second half anovulatory cycles is one of earliest signs of pregnancy.
  6. Breasts (significant in a primigravida only) – Pigmented primary areola with appearance of Montgomer’s tubercle. Nodular, tense, tender, watery pale yellow secretion may present. Dilatation of superficial veins on chest and breasts.

Laboratory Test – 1. Biological 2. Immunological.

All pregnancy tests depend upon fact that 14th days after fertilization, the chorionic tissues – the cytotrophoblastic cells start secreting chorionic gonadotrophic hormones. A peak is reached by about 70th to 100th days and hormone is excreted in the mother’s urine.

Biological Tests – (i) Friedman test – Here rabbit is used and result can be obtained in 2 day. (ii) Hogben test or Male toad test – 2.5 cc. of urine unjected into dorsal lymph sac of a toad. The animal passes ova when it hops. Positive within 6th to 12th weeks. (iii) Aschheim-Zondek test – Mother’s urine is injected into a mouse which is killed after 5 days. A positive reaction is presence of corpus luteum and haemorrhagic follicle in mouse ovary.

Immunological tests – (i) Gravindex test – 6 drops of anti H.C.G. serum urine (.25 ml.) Latex particles: if agglutination – woman is non-pregnant and if no agglutination – woman is pregnant. (ii) R.B.C. test – 6 drops of anti H.C.G. – serum plus urine (.25 ml.) plus Sheep’s R.B.C. sensitized to H.C.G. – if agglutination: no pregnancy and if no agglutination – pregnancy, (positive test).

Withdrawal Bleeding Test (Hormonal) – Here some hormonal preparation, for e.g., Cumorit, Oreasecron forte, Euogynon in used. 2 tablets are orally given to women – if bleeding occurs within 7 to 10 days –woman is non-pregnant should be suspected.

Ultrasonic detection of Pregnancy – With this sophisticated technique pregnancy can be detected 10 days after first missed period and twin pregnancy as early as 5 and half weeks of amenorrhoea. The apparatus is costly and not yet universally available.

Ques. 9 What is the clinical features and Diagnosis of Pregnancy during the Second Trimester of Gestation.

Ans.           Clinical features of Second Trimester (13th to 28th weeks)

Symptoms – 1. Progressive enlargement of abdomen. 2. Enlargement of breast, pricking sensation. 3. Quickening – fluttering sensation felt due to foetal movement. 4. Pain in groin may be present. 5. History of amenorrhoea (3rd to 8th weeks).

Signs –

  1. Breasts – (a) enlarged veins, (b) by about 16 week colostrums secreted (a clear fluid secreted by the breast). By 20 weeks secondary areola becomes prominent. (c) Enlarged, pigmented,
  2. Per abdomen – Inspecton – (a) abdomen enlarged Palpation – uterus felt soft elastic mass and from height of fundus the gestational age can be calculated. Braxton- Hicks Signs – Painless intermittent uterine contraction at intervals of every 15 minutes. (b) a linear pigmentation in the middle appears from symphysis pubes so ensiform cartilage,
  3. Pigmentation – ‘Chloasma’ on face and forehed.

External Ballottement sign – This can be elicited from 20th weeks. One hand taps the abdomen and sends foetus across the uterine cavity. The other hand lying on the uterus on the opposite side receives impulse. This is due to the fact the foetus is relatively smaller in size that amount of liquor amnii. Percussion – Dull.

Auscultation – Foetal heart sound – detected (from 24th weeks) Rate at 24th weeks – 120 to 160 per minute. It is usually heard, at this time, in the midline below level of umbilicus.

Ques. 10 What is the clinical features and Diagnosis of Pregnancy during the Third Trimester of Gestation.

Ans.           Clinical Feature of Third Trimester –

Symptoms –

  1. Progressive enlargement of abdomen.
  2. Oedema of ankles and feet; breathlessness, palpitation; leg cramp, acidity, heart burn.
  3. Frequency of micturition may be present.
  4. Lightening sensation towards the later weeks of pregnancy.
  5. History of amenorrhoea for 7 to 9 months is present.

Signs –

  1. Per Abdomen – Linea nigra, Striae gravidarum – present. Fundal height – usually corresponds with period of the gestation. The foetal head, breech, back, limbs and foetal movements. Braxton-Hicks contraction is distinctly palpable. F.H.S. – audible near middle of one or other spino-umbilical line.
  2. Per vagina – Cervix is soft, directed usually posteriorly and gradually comes anteriorly in last days of pregnancy or during labour. Vagina is moist. Foetal presenting part is palpable. Internal ballottement – cannot be elicited.
  3. X-Ray – Demonstration of foetal bone rediologically.
  4. Slight ankle oedema (physiological swelling) may be present.
  5. Breast signs are prominent.

Diagnosis –Diagnosis of pregnancy is made on several important evidences. The symptom of amenorrhoea is usually present, but in some cases, first 2 or 3 months regular menstruation – like bleeding can be found. During early pregnancy, the positive breast changes and also uterine changes detected by bimanual palpation. Also urinary pregnancy tests help in diagnosis. In late pregnancy, breast changes, abdominal uterine enlargement. Presence of foetal parts and foetal heart sounds are diagnostic.

The first sign of pregnancy – strictly speaking of conception, is individual rather than general: and consists in certain peculiar thrill of voluptuous sensation, which is felt by some women during prolific coition, - who by experience leam to regard this unusually profound erethism as certain evidence of conception in their own case. Nearly connected with this is certain sense of chilliness subsequent to coition, which is found, by those who experience it, to be invariably followed by pregnancy. These sensations, which experience has taught some individuals to regard as decisive in their own case, can therefore be considered as possessing some value when reported by primiparae).

Ques. 11 Which are the important Homoeopathic remedies useful in pregnancy?

Ans.           Homoeopathic Remedies (useful during pregnancy)

  1. Pulsatilla – Frequent eructation, tasting of ingesta. Vomiting after every meal. Bad taste in mouth every morning on waking. No kind of food tastes good. Diarrhoea, mostly at night. Mild, teaful disposition.
  2. Berberis – She dreads all downward motions. Bitter taste of everything, even of the saliva, distension with flatulence after every meal.
  3. Colchicum – Loathing and disgust is esp. repugnant. All attempts to eat cause violent nausea and vomiting.
  4. Ipecac – Nausea and vomiting, with great uneasiness in the stomach. Continual nausea all time, not a moment’s relief. Vomiting large quantities of mucous. Bilious vomiting and tendency to relaxation of bowels.
  5. Antim Crud – Eructation tasting of ingesta. Nausea, with vertigo. Frightful and persistent vomiting, with convulsion; after overloading stomach.
  6. Sepia – Nausea in morning as if all the viscera were turning inside out. Sensation of emptiness in stomach. The thought of food sickness her. Painful feeling of hunger.

Ques. 12 Which are the Biochemic remedies for pregnancy?

Ans.           Biochemic Remedies –

  1. Natrum Phos – Morning sickness, with vomiting of sour, acid fluids.
  2. Natrum Sulph : Vomiting in pregnancy of bilious matter, and with bitter taste in the mouth.
  3. Natrum Mur – Morning sickness of pregnancy, with watery, frothy vomiting.
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