Women’s Hospital School of Medicine Diagnosis of pregnancy and routine prenatal care Ai-Xia Liu Women’s Hospital School of Medicine Zhejiang University

Part I Pregnancy: defined as the maternal condition of having a developing embryo or fetus in the body.

A pregnancy is defined as the maternal condition of having a developing embryo or fetus in the body.

Oocyte and sperms Millions of sperm entering the vagina and swim towards the opening of the cervix. Lennart Nilsson (born 1922) is a Swedish photographer and scientist. He is noted for his photographs of in vivo human embryos in 1965.

Egg and sperms and Sperm in the Fallopian tube.

fertilization Only one sperm can penetrate through the zona pellucida of oocyte 8 days after fertilization, the blastocyst has landed and sinks slightly into its foundation Implantation

11w fetal 20w old fetal is sucking his thumb 这是长到。进入妊娠的第四个月后，胎儿从5厘米长到10厘米 20w old fetal is sucking his thumb

Embryo: 0-8weeks Fetus: 9-40weeks

The duration of pregnancy Gestational age: It is calculated from the first day of the last menstrual period (LMP, assuming a 28 day cycle) and expressed in completed age Fertilization age: the age of the offspring calculated from the time of fertilization

Gravidity: the total number of pregnancies (normal and abnormal) Parity: the state of having given birth to an infant or infants weighing ≥500g, alive or dead. (A multiple birth is a single parous experience) Live birth: the complete expulsion or extraction of a product of conception from the mother, which shows evidence of life

Pregnancy diagnosis Pregnancy is divided into three phases, called trimesters First trimester: 0 - 12 weeks Second trimester: 13 - 27 weeks Third trimester: 28 - 40 weeks Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time. The first 12 weeks of pregnancy are considered to make up the first trimester . Weeks 13 to 27 of the pregnancy are called the second trimester .

First trimester pregnancy Symptoms Amenorrhea: strongly suggestive of pregnancy Nausea morning sickness of pregnancy (4-12W) results from rapidly rising serum levels of HCG Fatigue: one of the earliest symptoms of pregnancy Frequent urination Most pregnant women experience a number of symptoms which can signify pregnancy. The symptoms can include missed menstruation, nausea and vomiting, excessive tiredness and fatigue, cravings for certain foods that are not normally sought out, and frequent urination particularly during the night.

Signs Increased basal body temperature Breast tenderness Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the uterus isthmus), A number of early medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. increased basal body temperature sustained for over 2 weeks after ovulation, Breast tenderness is common during the first trimester

Skin change: increased pigmentation including chloasma, linea nigra, stretch marks chloasma or the mask of pregnancy when present in pregnant women is a tan or dark skin discoloration . pigmentation of linea alba – Linea nigra, (darkening of the skin in a midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy). Stretch marks are the result of the rapid stretching of the skin associated with rapid fetal growth (common in puberty) or weight gain during pregnancy, and they also are influenced by hormonal changes associated with pregnancy chloasma linea nigra stretch marks

First trimester pregnancy Bleeding (25%) Spontaneous abortion (25-50%) Uterine cramping with bleeding in the first trimester is suggestive of impending abortion

Pregnancy test Urine pregnancy test Human chorionic gonadotropin (HCG) is produced by trophoblasts from 8 days after fertilization Urine pregnancy test Serum pregnancy test: more sensitive HCG may be detected in maternal serum in 9 days Pregnancy detection can be accomplished using one or more various pregnancy tests, which detect hormones generated by the newly formed placenta. Clinical blood and urine tests can detect pregnancy 12 days after implantation. Home pregnancy tests are urine tests, and normally cannot detect a pregnancy until at least 12 to 15 days after fertilization. Blood pregnancy tests are more accurate than urine tests. A quantitative blood test can determine approximately the date the embryo was conceived.

Positive manifestations Fetal heart tone (120-160 BPM) Doppler device can detect at 10 weeks

Positive manifestations Ultrasound examination of fetus is one of the most useful technical way

Second trimester pregnancy Symptoms General well-being: the most comfortable time for a pregnant woman Pain: stretching of pelvic structures Uterine contraction (Braxton hicks contractions) Braxton Hicks contractions also known as false labor or practice contractions, are sporadic uterine contractions that sometimes start around 6 weeks. However, they are not usually felt until the second trimester or third trimester of pregnancy. They are a tightening of the uterine muscles for one to two minutes and are thought to be an aid to the body in its preparation for birth. Not all expectant mothers feel these contractions. They are not thought to be part of the process of effacement [i‘feismənt] 子宫颈展平of the cervix.

Second trimester pregnancy Abdominal enlargement: quickening: primigravida 16-20 w multigravidas 14-16 w Fetus: attains a size of almost 1000g by 28w Motion: begin at 16-20w Viability Quickening: means the day that the pregnant woman recognized fetal movement for the first time. Sensation of fetal movement occurs at 16-20 weeks in primigravida and at 14-16 weeks in multigravidas.

Positive manifestations Palpation of fetus (22 weeks) Leopold Maneuver to determine the fetal presentation

In obstetrics, the presentation of a fetus about to be born refers to which anatomical part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal. According to the leading part, this is identified as a cephalic, breech, or shoulder presentation.

Longitudinal lie Transverse lie A cephalic presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput [‘ɔksipʌt 】枕后is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means. Cephalic presentation means head first. This is the normal presentation. Breech presentation means the fetal butt is coming out first. means the fetus is oriented from one side of the mother to the other and neither the head nor the butt is coming out first. Compound presentation means that a fetal hand is coming out with the fetal head. Shoulder presentation means that the fetal shoulder is trying to come out first.

Third trimester pregnancy Symptoms Contraction: more apparent Pain in the lower back and legs: pressure on muscles and nerves by the uterus and fetal head Lightening: descent of the fetal head weight gain: fetal grows rapidly Fetal movement: regularly, strong This period of her pregnancy can be uncomfortable, causing symptoms like weak bladder control and backache. which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28 g per day . The fetus begins to move regularly, and is felt by the woman. Fetal movement can become quite strong and be disruptive to the woman

Part II Routine Prenatal care Pregnancy is a normal physiologic event that is sometimes complicated by pathologic processes dangerous to the health of the mother and fetus. The abnormalities during pregnancy should be recognized so that their effects can be minimized. The principle aim of prenatal care is identification and special treatment of high-risk pregnancy, and to ensure as much as possible an uncomplicated pregnancy and the delivery of healthy baby. Prior to modern medicine, many mothers and their babies did not survive pregnancy and the birth process. Today, good prenatal care can significantly improve the quality of the pregnancy and the outcome for the infant and mother. Prenatal care (also known as antenatal care) refers to the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc.), and to direct the woman to appropriate specialists, hospitals, etc. if necessary. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable infant problems.

Prenatal care Preconception care Routine prenatal care Women who contemplate pregnancy should be evaluated for the conditions that could affect a future pregnancy Routine prenatal care Every 4 weeks during the first 28 weeks of gestation Every 2 weeks from 28 to 36 weeks Weekly from 36 weeks to delivery Contemplate. [‘kɔntem.pleit] 打算

The first prenatal visit Usually at the first trimester, most thorough History Physical examination Laboratory tests A healthy first trimester is crucial to the normal development of the fetus. The mother-to-be may not be showing much on the outside, but inside her body all the major body organs and systems of the fetus are forming. It is during this first trimester that the fetus is most susceptible to damage from substances such as alcohol, drugs, certain medications, and illnesses such as rubella (German measles).

History Obstetrical history Medical history Family history Social history

Complete obstetric history Present pregnancy and menstrual history Estimated gestational age(EGA), EDC The length and duration of menstruation Past pregnancies EGA at the time of delivery or abortion Fetal outcome Mode of delivery: vaginal or cesarean section Complications: GDM, preeclampsia

Medical history Previous and current medical disease Diabetes, chronic hypertension Medication Previous surgeries Blood transfusion history

General history Family history Social history and education Diabetes Mental retardation Genetic disorders Social history and education

Physical examination Physical examinations generally consist of: Checking (mother's) blood pressure (Mother's) height and weight Pelvic exam Doppler fetal heart rate monitoring (Mother's) blood and urine tests

Physical examination Pelvic examination Clinical pelvimetry： Evaluation for abnormal vaginal discharge Performance of cervical culture Assessment of pelvic soft tissue: cervix and uterine Bony pelvis Clinical pelvimetry： pelvic inlet, midpelvis and pelvic outlet Pelvic soft tissue: to note any pelvic mass, evaluation of the uterus (the size and position of the uterus, cervical length) and to determine the age of the fetus. Bony pelvis: pelvic inlet, midpelvis and pelvic outlet. Pelvimetry [pel'vimitri

Laboratory Tests Blood screening Blood routine test Blood type (ABO and RH) Detect diseases: rubella, syphilis, hepatitis B, HIV Screening test for certain diseases according family history Diabetes screen: glucose challenge test (GCT) All pregnant women are tested for the Rh factor during the early weeks of pregnancy. A mother and fetus may have incompatible blood types. The most common is Rh incompatibility. Rh incompatibility occurs when the mother's blood is Rh-negative and the father's blood is Rh-positive and the fetus' blood is Rh-positive. The mother may produce antibodies against the Rh-positive fetus, which may lead to anemia in the fetus. Incompatibility problems are monitored and appropriate medical treatment is available to prevent the formation of Rh antibodies during pregnancy.

Laboratory tests Urinalysis: bacteria, sugar, and protein Pap smear :detection abnormal cells Infectious disease: gonorrhea, chlamydia, group B streptococcus, et al Stool test when indicated Tuberculin skin test for high risk patients Urine testing - to screen for bacteria, sugar, ketones and protein. Pap smear - to detect the presence of abnormal cells To detect infectious diseases – gonorrhea[.gɔnə'ri:ə ], chlamydia[klə'midiə] , Group B streptococcus[.streptəu'kɔkəs ], et al.

Laboratory tests Neural tube defects screening testing First trimester screening (10w3d-13w6d) Nuchal translucency(NT) measurement+serum analytes Second trimester screening(15-20w) Serum analyses: AFP+HCG+estriol (uE3) Diagnostic genetic testing Chorionic villus sampling (CVS) (10-12w ) Amniocentesis ( 16-18w ) Age>35 or abnormal pedigrees first trimester screening (combination of maternal serum analytes [PAPPA+βhCG] and fetal nuchal translucency measurement) screening for neural tube defects and chromosomal abnormalities (blood test for hCG + estriol +AFP, 15-20w), Genetic testing –including chorionic villus sampling (CVS) at 10-12w and amniocentesis at 16-18w. It is indicated for women over age 35 and those with abnormal pedigrees家系 to detect inherited diseases (i.e., sickle-cell anemia, Tay-Sachs disease).

Subsequent Visit Every 4w until 28(32)w Every 2w until 36w After 36 weeks, every 1 w until delivery Complicated pregnancies require closer surveillance

Subsequent Visit fetal size and position Weight gain Blood pressure Fundal height Abdominal examination Fetal heart tones Edema Urine test fetal size and position Each visit including weight gain, blood pressure, fundal height, abdominal examination, fetal heart tones, urine test, edema and fetal size and position.