Signs of Pregnancy
The diagnosis of early pregnancy in ordinary cases is by no means easy, especially before the third or fourth month of gestation; but to the medical jurist it is still more difficult, as he has to deal with cases where he can scarcely expect much candour. No opinion should, however, be given without taking into consideration the collective value of the signs, as no one sign will afford sufficient data on which to base an opinion. The signs furnished by auscultation are the most reliable, but the position of the fœtus may render the sounds of the fœtal heart and placental souffle difficult to detect.
The following may be taken as among the most important signs of pregnancy, given in the usual order of their occurrence:
Uncertain Signs
1. Cessation of Menstruation.—The non-appearance of the catamenia, though a most valuable sign, is by no means a conclusive one, as menstruation may be arrested by diseases of various kinds; while, on the other hand, there are many well-recorded cases of women who have menstruated regularly during the whole period of their pregnancy. There have been also cases in which the menses only occurred during pregnancy; and in a few still more curious cases, women who have never menstruated have been known to have borne several children. In cases of concealed pregnancy, the woman may smear her linen with blood to imitate the menstrual flow.
2. Morning Sickness.—Nausea, often ending in vomiting, generally occurs soon after rising in the morning, and may commence almost immediately, but more frequently not till the expiration of the fifth or sixth week after conception. It is not a reliable sign, and is often very irregular in its occurrence. When present, it varies in degree, from a feeling of nausea to the most violent vomiting, very distressing to the patient.
3. Salivation.—The excessive secretion of the salivary glands, due to the irritation caused by pregnancy, was first mentioned by Hippocrates as a sign of this condition. “It is to be distinguished from ptyalism induced by mercury, by the absence of sponginess and soreness of the gums, and of the peculiar fœtor, and by the presence of pregnancy.” It is oftener absent than present.
4. Mammary Sympathies.—As the breasts may enlarge from various causes—such, for instance, as the distension of the uterus from hydatids, or, as is the case with some women at each menstrual period, when the catamenia are suspended, or after they have ceased—this is by no means a sign on which much reliance should be placed. The change in the colour of the nipple and areola, more apparent in women of dark complexions, is more to be relied on as a diagnostic sign of pregnancy. The first observable alteration, which occurs about two months after conception, is “a soft and moist state of the integument, which appears raised, and in a state of turgescence, giving one the idea that, if touched by the point of the finger, it would be found emphysematous. This state appears, however, to be caused by infiltration of the subjacent cellular tissue, which, together with its altered colour, gives us the idea of a part in which there is going forward a greater degree of vital action than is in operation around it; and we not infrequently find that the little glandular follicles, or tubercles as they are called by Morgagni, are bedewed with a secretion sufficient to damp and colour the woman‘s dress.”
During the progress of the next two months, the changes in the areola are in general perfected, or nearly so, and then it presents the following characteristics: “A circle round the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion. The extent of the circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of colour. In the centre of the coloured circle, the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part which lies more immediately around the base of the nipple, is studded over and rendered unequal by the prominence of the glandicular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and, lastly, the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed at this period, especially in women with dark hair and eyes, numerous round spots or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all around, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part.” The value of the above changes in the nipple and areola as a diagnostic sign of pregnancy is greatly lessened by a previous pregnancy. It should also be remembered that milk may occur in the breasts of women who are not pregnant.
5. Enlargement of the Abdomen.—For the first four months of pregnancy the entire uterus is contained in the cavity of the pelvis; it then gradually rises, so that at about the fifth month it is midway between the pubes and umbilicus, which latter it reaches at the end of the sixth month; during the seventh month it may be felt half-way between the umbilicus and ensiform cartilage; at the end of the eighth month it is level with the cartilage, now quite filling the abdomen. Still increasing in size during the ninth month it does not ascend higher, the abdominal walls yielding to its increased weight, allowing it to fall somewhat forward. A caution is necessary with regard to this sign. The abdomen may enlarge from causes other than pregnancy. Pregnancy and ascites, or ovarian dropsy, may coexist in the same patient, and the diagnosis be rendered anything but easy. The enlargement of the abdomen may lead to unfounded suspicions detrimental to the happiness and health of the unfortunate object of them.
6. Condition of the Cervix Uteri.—The cervix softens during pregnancy, and the softening is present as early as the second or third week. It is an important sign. Hejar‘s sign or the softening at the junction of cervix and body and the lower uterine segment is valuable, but not always easily elicited. It is of most value from the second to the fifth months. At the sixth month it loses one-fourth of its length; at the seventh it is only half of its original length; at the eighth it loses another quarter; and at the ninth the neck is entirely obliterated. This shortening is more apparent than real, and its occurrence is denied by the late Dr. J. M. Duncan, except during the last few days of pregnancy.
7. Quickening.—The period at which quickening occurs varies from the fourth to the fifth month; and the term is understood to imply the first perception of the movements of the fœtus experienced by the mother. Nervous women, anxious to have children, sometimes complain of sensations which they ascribe to quickening, pregnancy being absent. Pregnancy may occur without quickening.
8. Kiesteine.—This is no test of pregnancy, as it may be found in women not pregnant.
9. Jacquemier‘s Test.—A violet or port-wine colour of the vagina and inner surface of the vulva, due to venous congestion of the parts from pressure of the gravid uterus.
A flattening of the upper wall of the vagina, produced by the enlargement and anteversion of the uterus, which, forcing the os towards the sacrum, makes the anterior wall of the vagina tense, has been added by Dr. Barnes as a sign of pregnancy.
Certain Signs
1. Ballottement.—This test of pregnancy is applied by causing the patient to stand upright; the finger of the right hand is then passed into the vagina and placed in the anterior fornix, the other hand being placed lightly over the abdomen in order to steady the uterine tumour. If the finger be now jerked upwards against the head of the child, it will be felt to float upwards in the liquor amnii, and then by its own weight gradually to return to its former position. Tumours in the uterus, attached to its walls by a pedicle, may give the same sensation. Scanty supply of liquor amnii, or malposition of the child, may sometimes prevent the adoption of the test.
2. Uterine Souffle.—Under this head are included the placental bruit, and the pulsations of the umbilical cord. Both these sounds require a skilled auscultator to detect them. The uterine murmur, or bruit placentaire, is heard best at the lower and lateral portions of the uterus, just above Poupart‘s ligament. It is isochronous with the pulse of the mother, and is heard most distinctly about the fourth or fifth month of utero-gestation; in some cases, however, it may be heard as early as the tenth week. The sound is intermittent, and varies in character, being sometimes hissing, whirring, or cooing, at others rasping.
3. Pulsation of the Fœtal Heart.—The sounds of the fœtal heart were first noticed by Mayar in 1818, and those of the placenta, or placental souffle, by Kergaradec in 1822. The sound of the fœtal heart is composed of a rapid succession of short, regular double pulsations, differing from that of the adult heart in rhythm and frequency. It can be heard more or less over the whole of the abdomen about the middle of the fourth month, and is not unlike the muffled ticking of a watch. In frequency it varies from 100 to 140. The auscultator should be careful not to hang his head down, or he may be apt to mistake the throbbing of his own arteries for sounds communicated from the patient.
4. Intermittent Contraction of the Uterus.—From the fourth to the tenth month of pregnancy, the uterus may be felt by the palpating hand to alternately contract and relax; the period of contraction and relaxation varies. It is present in pregnancy whether the fœtus be alive or dead.
Pregnancy may be simulated by ascites, by fibrous tumours of the uterus, by ovarian dropsy, and by enlargement of the uterus from retention of the catamenia due to an imperforate hymen, &c. The breasts may also become affected by uterine tumours.
Diagnosis of Pregnancy
1. Pseudo-Pregnancy.—In the examination of cases of alleged pregnancy, the medical jurist should bear in mind the possibility of enlargement of the uterus and abdomen from the presence of tumours. The probable occurrence of pseudo-pregnancy should also be considered. Tumours and pseudo-pregnancy may occur in the married and unmarried; and as the latter is not infrequently accompanied with many of the signs and symptoms of pregnancy, an early diagnosis is of the utmost importance.
The diagnosis will consist in—
(a) A careful examination of all the symptoms present, when, in most cases, a break in their order of sequence may be observed, or certain signs may be added which do not occur in true pregnancy.
(b) Presence or absence of the hymen.
(c) If the patient be placed well under the influence of chloroform, the tumour, if the result of pseudo-pregnancy, will subside, gradually returning as the effects of the anæsthetic pass off. Whilst the patient is under the influence of the anæsthetic, the hand may be pressed on the abdomen at each expiration, and there retained, the pressure being continued during the inspirations.
2. Dropsy.—Use of the stethoscope; examination of the breasts for milk, and the urine for albumen.
3. Fibrous Tumours.—Absence of fœtal movements and other signs of pregnancy.
4. Ovarian Dropsy.—Tumour on one side of the abdomen; breasts unaffected, and auscultation giving negative results.
5. Retention of the Catamenia.—On examination, the hymen found perfect and bulging. This condition cured by a crucial incision.