- Dr.

Neelesh Bhandari
M.B.B.S (AFMC), M.D. (Path)
P.G.P in Human Rights.
Early pregnancy detection allows

• the commencement of prenatal care,

• potential medication changes,

• lifestyle changes to promote a healthy

pregnancy (appropriate diet; avoidance of
alcohol, tobacco, and certain medications),

• early pregnancy termination if so desired.

Pregnancy can be diagnosed by 3
approaches.
1. Physical examination

3. Laboratory evaluation

5. Ultrasonography
Early Physical signs of pregnancy
• Blue discoloration of the cervix and vagina (
Chadwick's sign)

• Softening of cervix (Goodell's sign)

• Softening of uterus (Ladin's sign and Hegar's sign)

• Darkening of the nipples

• Unexplained pelvic or abdominal mass

Physical signs of pregnancy…

• Breast and nipple tenderness

• Nausea

• Urinary frequency
 Laboratory Investigations

• The most commonly used assays are for the beta

subunit of hCG

Other hormones that have been used for diagnosis-

• progesterone

• early pregnancy factor (EPF).

• This hormone is only released by trophoblastic
tissue produced by a growing fetus and its associated
placenta.

• hCG is present in the maternal circulation as either

an intact dimer, alpha or beta subunit, and degraded
form, or beta core fragment

• Detection of HCG in maternal serum and urine is

evident only 8-10 days after conception
• hCG is detectable in the serum of approximately
5% of patients 8 days after conception and in
more than 98% of patients by day 11

• Diagnostic levels in Urine seen only about 23-24

days after conception.

• Levels peak at 10-12 weeks' gestation and then

plateau before falling
In general, the HCG level will double every two to three days in early pregnancy
Detects presence of HCG in Urine sample.
• Easy to perform.
• Inexpensive compared to Blood tests

Most current pregnancy tests have sensitivity to

approximately 25 to 35 mIU/mL
(ranges from 25 to 100mIU/mL).

After 3 drops of urine are placed in the "S" basin,

a sold line appears at the "C" area. After a minute,
another line appears at the "T" area, indicating that
this patient is pregnant.
 Home Pregnancy Tests

kits available for hCG detection in urine via

- Direct Latex agglutination and/or
- Indirect Agglutination inhibition tests.

• HPTs are most commonly used in the week after

the missed menstrual period
(fourth completed gestational week).

• Urine hCG values are extremely variable at this

time and can range from 12 to 2500 mIU/mL.
- Used only in special cases
( bad obstetric history, suspicion of ectopic,etc.)
- Require special labs and expertise.
Currently, 4 main hCG assays are used,

(3) radioimmunoassay,

(5) immunoradiometric assay,

(7) enzyme-linked immunosorbent assay

(ELISA),

(9) fluoroimmunoassay.
Radioimmunoassay
Sensitivity - 5 mIU/mL
Time to complete - 4 hours
Postconception age when first positive - 10-18 days
Gestational age when first positive - 3-4 weeks

Immunoradiometric assay (more sensitive)

Sensitivity - 150 mIU/mL
Time to complete - 30 minutes
Postconception age when first positive - 18-22 days
Gestational age when first positive - 4 weeks

Immunoradiometric assay (less sensitive)

Sensitivity - 1500 mIU/mL
Time to complete - 2 minutes
Postconception age when first positive - 25-28 days
Gestational age when first positive - 5 weeks
Enzyme-linked immunosorbent assay (more sensitive)
Sensitivity - 25 mIU/mL
Time to complete - 80 minutes
Postconception age when first positive - 14-17 days
Gestational age when first positive - 3.5 weeks

Enzyme-linked immunosorbent assay (less sensitive)

Sensitivity - Less than 50 mIU/mL
Time to complete - 5-15 minutes
Postconception age when first positive - 18-22 days
Gestational age when first positive - 4 weeks

Fluoroimmunoassay
Sensitivity - 1 mIU/mL
Time to complete - 2-3 hours
Postconception age when first positive - 14-17 days
Gestational age when first positive - 3.5 weeks
Failure to achieve the projected rate of rise
(slow rise) may suggest an ectopic
pregnancy or spontaneous abortion.

On the other hand, an abnormally high level

or accelerated rise can prompt investigation
into the possibility of
• molar pregnancy,
• multiple gestations,
• chromosomal abnormalities.
 False-positive hCG
• Phantom hCG - Rule out with sensitive urine assay, as
these antibodies do not cross into urine

• Pituitary hCG - Diagnosed by administering oral

contraceptive pills, which should suppress hCG levels

• Exogenous administration of hCG

• Trophoblastic neoplasm – e.g. Choriocarcinoma

• Nontrophoblastic neoplasm - Can be secreted by different

cancers, (e.g., testicular, bladder, uterine, lung, liver,
stomach)

Most false-positive results are characterized by serum levels that are

generally less than 1000 mIU/mL and usually less than 150 mIU/mL
 False-negative hCG
usually involve urine and are due to the qualitative
nature of the test. Reasons include –

• an hCG concentration below the sensitivity

threshold of the specific test being used.
• a miscalculation in the onset of the missed
menses,
• delayed menses from early pregnancy loss.
• Delayed ovulation or delayed implantation.
• Measurement of serum progesterone is inexpensive

• Done by Radioimmunoassay and Fluoroimmunoassay

• Can reliably predict pregnancy prognosis.

A dipstick ELISA that can determine a S.Progesterone

level of less than 15 ng/mL is also on the market.
ELISA is helpful as a screening tool for at
risk populations because progesterone
levels of greater than 15 ng/mL make
ectopic pregnancy unlikely.

• Serum progesterone levels greater than

25 ng/mL Viable Intrauterine Pregnancy

• Serum progesterone levels of less than

5 ng/mL Nonviable pregnancy.
Early pregnancy factor

• Earliest available marker to indicate fertilization

(detectable 36-48 hours after fertilization).

• Peaks early in first trimester, almost undetectable

at term.

• Appears within 48 hours of successful

IVF embryo transfers.

• Vanishes 24 hours after delivery

(or at the termination of pregnancy)

• Detected by rosette inhibition test.

 Ultrasound

The identification of gestational structures

by US correlates with specific levels of hCG, termed
discriminatory levels.

• A discriminatory level is the level of hCG at which

the structure in question should always be identified.

• Most experienced TVUS operators should visualize

the GS when levels are approximately 1000 mIU/mL.

• The discriminatory level for the GS is approximately

3600 mIU/mL, and if it is not seen at this point,
other pathology must be excluded.
GS – Gestational Sac
• The yolk sac is commonly observed with
an hCG level of approximately 2500 mIU/mL,

• The embryonic pole usually becomes evident

at a level of approximately 5000 mIU/mL,

• Fetal heartbeat can be seen in the vast

majority of normal gestations when the hCG
level reaches 10,000 mIU/mL.