Young Woman in Vibrant Good Health
A healthy 33-year-old woman is seen in the office of her primary careclinician.
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HISTORY
A healthy 33-year-old woman is seen in the office of her primary care clinician.
PHYSICAL EXAMINATION
Comfortable normotensive woman who has had easy fatigability just for a short time.
WHAT'S YOUR DIAGNOSIS?
ANSWER: NORMAL PREGNANCY
This case should not represent a diagnostic puzzle even without our specifying that she missed 2 menstrual periods and had been trying to conceive. The history and demographics accord with recognition that pregnancy must be considered in any choice of testing, and specifically in regard to imaging and to any drug therapy, even if pregnancy is not the diagnosis in question. This woman’s breasts show an early physical sign of her pregnancy: increased vascularity compared with baseline (Figures 1 and 2). We do not yet recognize even the very beginning of increased abdominal girth as a further corroborating sign (Figure 3).
COLOR CHANGE: MUCOSAE
In the search for confirmatory physical signs of pregnancy over the years prior to laboratory testing,1 many characteristics of the gravid uterus were described. Some sound as though they were extremely unpleasant and uncomfortable for the patient, such as “flexibility at the junction of the corpus and the cervix,” and have rightly fallen into obscurity. Others may be highly examinerdependent, such as palpation of uterine artery pulsations in the lateral fornices.2-4
Still others have reflected presumably vascular changes in the squamous mucosa and skin of cervix, vagina, and vulva. The most prominent and enduring of this group is Jacquemin sign5 (often known as Chadwick sign), a blue-purple discoloration of the cervix but not the corpus uteri; the sign occurs commonly in early pregnancy (Figure 4). The precise basis of this sign may include both increased blood flow and increased oxygen extraction from the tissue. Why this phenomenon would occur in the vagina and vulva, that presumably do not have an increased metabolic burden especially early in pregnancy, remains unsolved; likewise why the endometrium, which should be more metabolically active than any other reproductive tissue, does not become blue.
CHANGES OVER THE COURSE OF PREGNANCY
Sequential enlargement of the abdomen and often of the breasts is familiar to most human beings and not just those who are health care workers. We were presented a unique opportunity to document these serially on an every-4-weeks’ basis from the time of the photos shown above, through delivery at term, and postpartum (Figures 5 through 23). A uniquely skilled professional medical photographer took images of this normal, healthy pregnancy with extreme attention to consistent lighting, color, and placement.