CHAPTER 3 - DIAGNOSIS OF PREGNANCY

Before a patient is admitted for termination of pregnancy it must be ascertained by the history and examination (1) that she is pregnant, (2) that she wants the termination herself and considered alternatives, (3) that her pregnancy is not too far advanced, and (4) that there are no conditions or diseases which make the operation difficult or contraindicated (Chapter ll). Although this seems obvious some common complications are caused by neglecting the examination.

To save time the examination is done first to find out if the patient can be treated. Then the anamnesis (history) is done. Some doctors prefer to do examination and treatment in different rooms. Schlebaum prefers to do the examination directly prior to the procedure in the same room. The patients mounts the operation table and after examination and anamnesis the procedure is explained to her and started at once.

Not every amenorrhoea is caused by pregnancy. A pregnancy test is not always reliable. It is fairly common that a woman has one or more 'periods' after the onset of pregnancy, and although such 'periods' are mostly lighter than a real period, the woman may accept the last one as her LMP. Often the woman deliberately gives false information desperately hoping that she will be treated. Some women are very inventive:

The patient states that her she is 14 weeks pregnant and she shows a recent ultrasound scan report as proof. In the clinic her pregnancy is diagnosed as 24 weeks. It appears that a friend, who is indeed 14 weeks pregnant, had the ultrasound scan made in the name of the patient.

To avoid problems, never accept the patients word and never accept another doctor's diagnosis, but always examine the patient yourself. Patients can be very persisting. We have seen several cases where the doctor yielded for the constant pressure of the patient who kept repeating that she could not be too far advanced so that he doubted his diagnosis and ended up meddling with a twenty week pregnancy. Also another doctor's diagnosis can be misleading:

1. The patient states that she is fourteen weeks pregnant. When we find a pregnancy of some 26 weeks she produces a doctor's letter stating that she is 22 weeks. When the the doctor was contacted he confesses that he got tired of the patient's demands and wrote the letter to get rid of her, trusting us to find the correct diagnosis.

2. A patient comes with a letter from her doctor who declares her about 10 weeks pregnant. A pregnancy, probably twins, of about 27 weeks was found. This doctor refers many patients and his integrity was never doubted. When asked by telephone he can not believe that he made such a mistake. Later he writes that he must have had an acute blackout and that he can only confirm the correct diagnosis: twin pregnancy in the 27th week.

3. A German nulliparous patient came to the Bloemenhove Clinic with a letter from her gynaecologist stating that she is in the 16th week. In the waiting room she got cramps and was brought into the theatre as an assistant diagnosed ablatio. Joeri van den Bergh thinks that she is in labour and prepares for a delivery . Ten minutes later the healthy baby is born (and later adopted by another couple)

1. BIMANUAL EXAMINATION

Ultrasound screening does not make this superfluous. First the fundus is sought by external examination. At 20 weeks it reaches till the umbilicus, at 13 weeks it may just be felt above the pubis. Two (or one, in nulliparous teenagers) finger(s) of the right hand are brought into the vagina, while the other hand supports the fundus by pushing gently into the abdominal wall, preferably standing on the right side of the patient. The internal finger(s) explore the cervix. The size of the uterus is estimated by mentally measuring the distance of both hands and subtracting the thickness of the layer of abdominal fat. It is convenient to express the size of the uterus in weeks amenorrhoea and not in different fruits. (applesize, grapefruit size etc..)

If the uterus is larger than normal (fibroma, multiple pregnancy, hydramnios) or if an ovarian cyst or tumour exists the pregnancy may be diagnosed to be too far advanced, or the condition may be mistaken for a pregnancy. In a very young pregnancy the diagnosis is uncertain. It is therefore advisable to do a pregnancy test of the urine in all cases of doubt. The following case demonstrates a particular tricky situation in which an ovarian tumour not only felt like a pregnancy but also caused amenorrhoea:

The patient arrives with a letter from her doctor stating that she has an amenorrhoea of some 10 weeks and that he found a positive pregnancy test. On ultrasound scan examination a small non-pregnant uterus is seen and a large multilocular ovarian tumour. Unfortunately the pregnancy test was not checked. The patient was advised to have her condition evaluated by a gynaecologist.

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