Gynecological examination
Pelvic ultrasound scan
Early pregnancy essentials
- Diagnosis of pregnancy is made on the basis of presumptive and definitive symptoms.
- It is crucial to diagnose pregnancy as soon as possible in order to initiate appropriate prenatal care, avoid teratogen exposure, and diagnose nonviable or ectopic pregnancies.
Presumptive symptoms & signs
- Amenorrhea of sudden onset is highly suggestive of pregnancy in reproductive age.
- Nausea & vomiting affects 50% of women between 2-16 weeks. Extreme forms (hyperemesis gravidarium) require hospitalization.
- Breast changes include tenderness (mastodynia), enlargement, colostrum secretion, and development of secondary breast tissue across the nipple line and in the axillae.
- Elevated basal body temperatue (0.5 C) persists after missed menses.
- Skin changes include chloasma (darkening of forehead and cheek), linea nigra (darkening of nipples and midlien down from umbilicus), striae (breast and abdomen), spider teleangiectasia.
- Pelvic organ changes include the Chadwick's sign (bluish discoloration of vagina and cervix); Hegar's sign (softening of uterine isthmus); leukorrhea; relaxation of pelvic ligaments; abdominal enlargement; Braxton Hick's contractions (painless, intermittent at 28 weeks onward).
- Pregnancy tests detect secretion of human chorionic gonadotropin by the embryonic trophoblast. Although typically indicative of pregnancy, hCG can be also increased in malignancies. More on hCG
Definitive signs
- Fetal heart activity is detectable by M-mode ultrasonography by 6 weeks.
- Fetal movements are first perceived at 18–20 weeks' gestation in primigravida and as early as 14 weeks' gestation in multiparous women.
- Fetal palpation is possible through the abdominal wall after 22 weeks.
Essentials of infertility workup
A couple is subfertile if they fail to conceive after one year of unprotected regular sexual intercourse.
Flowchart
Early investigation
Early investigation is warranted if
- her age > 35 years
- previous ectopic pregnancy
- history of pelvic inflammatory disease
- oligo- or amenorrhoea
- substantial fibroids
- testicular maldescensus
- chemotherapy
- STD
Key questions
- Does the woman ovulate?
- If not, why not?
- Is the semen quality normal?
- Is there tubal damage or uterine abnormality?
Eligibility for assisted reproduction
In Norway, married or cohabitating couples (heterosexual or lesbian) and single women have access to assisted reproduction treatment. Medical, psychological, or social conditions of the parents must not weaken the ability for care and support of the future child.
Ovulation
Elevated midluteal phase progesterone concentration will indicate recent ovulation. Urine LH-test will detect the LH-surge.
Further endocrine assays (day 3 FSH, LH, estradiol, PRL, testosterone, SHBG, and AMH) are often useful. Transvaginal ultrasonography is useful to estimate the ovarian size and detect ovarian follicles or cysts.
Semen analysis
The test should be performed in a dedicated andrology laboratory. In case of abnormal results, repeated analysis is recommended after 3 months.
Tubal damage
Imaging by X-ray hysterosalpingography or ultrasound with contrast is indicated to test tubal patency and the uterine cavity. Laparoscopy can be useful to diagnose or treat tubal damage, endometriosis, or pelvic adhesions.
Scrotal ultrasound scan