Diagnosis of Pregnancy Departmentment of ob & gyn Renmin Hospital of Wuhan University Zhuoni Xiao

Woman’s reproductive period Menarche Menopause 13-45 years

Duration of Pregnancy 10 lunar months ; 9 calendar months and 7 days ; 40 weeks The duration of pregnancy is calculated from the first day of the last cycle Menstrual or gestational age

280 days -14 days=266 days Fertilization or Ovulatory age

First trimester: first 12 weeks Second trimester: 13-28 weeks Last trimester: 29-40 weeks

Bladder Rectum

First trimester Subjective Symptoms Objective Signs Immunological Tests Ultra Sonograph Pregnancy Diagnosis

Subjective Symptoms Amenorrhoea Warning :cyclic bleeding may last up to 12 weeks; scanty and short time; pathological bleeding ,such as miscarriage

Usually appears soon following the missed period; Morning Sickness Usually appears soon following the missed period; Rarely lasts beyond 3 months

Frequence of micturition troublesome symptom during 8-12 weeks enlarged uterus congestion of bladder change in maternal osmoregulation

Breast discomfort Fullness Pricking sensation

Fatigue Occur early in pregnancy

Objective Signs Breast changes valuable only in primigravidae breast changes are evident between 6-8 weeks (vascular engorgement & nipple and areola pigment) Montgomery’s tubercle colostrum expressed as early as 12th weeks

Per Abdomen Uterus remains a pelvis organ until 12 weeks

Pelvic Changes Chadwick’ sign Vaginal sign Cervical sign Uterine sign

Chadwick’ sign is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in . It can be observed as early as 6-8 weeks after conception, and its presence is an early sign of pregnancy.

Vaginal sign (Osiander’s sign) Bluish discolouration of anterior vaginal wall Vaginal wall soften Mucoid discharge Increased pulsation

Cervical sign (Goodell’ sign) Become soft as early as 6th week Non pregnant uterus Pregnant uterus

Uterine sign Size, shape and consistency 6th week 8th week 12th week Asymmetric→Symmetric The pregnant uterus feels soft and elastic

Hegar’s sign demonstrated between 6-10 weeks Upper part of the body of the uterus is enlarged by growing fetus; Lower part of the body of the uterus is empty and extremely soft; The cervix is comparatively firm

The abdominal fingers behind the uterus The abdominal and vaginal fingers seem oppose below the body of uterus Two fingers in the anterior fornix

Palmer’s sign Regular and rhythmic uterine contraction can be elicited doring biomanual examination as early as 4-8 weeks

Immunological Test

Principle of pregnancy test detection of the antigen of HCG present in the maternal urine or serum Selectionn of time 8-10 days after conception Collection of urine the first voided urine in the morning in a clean container

Ultra Sonograph Gestation sac (GS) can be identified as early as 29-35 days of gestation

5 menstrual weeks

6 menstrual weeks

True and pseudo gestation sac Character True GS Pseudo GS Location Eccentrically Centrally Shape Round & regular Irregular Double ring sign Present Absent York sac and fetal pole Increase in sac size 1 mm/ day

First Trimester Review The Whole Period of Pregnancy Can Be Divided Into Three Stages The first trimester (early pregnancy): 1-12w The second trimester (middle pregnancy): 13-27 w The third trimester (late pregnancy): 28-40w

1. History and symptoms A. Cessation of menstruation This is the first frequent symptom of pregnancy, although a few women may have slight bleeding after conception. Amenorrhea is not only due to pregnancy but also other reasons. Women of breast feeding may be pregnant before the recovery of menses.

B. Nausea and Vomiting Also called morning sickness because they occur upon arising. These symptoms appear one or two weeks after the period is missed and last until 10th to 12th week, its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravidarum).

C. Urinary symptoms Increased frequency of urination is due to increased circulation associated with the effect of estrogen and progesterone on the bladder, combined with pressure by the gradually enlarged uterus on the bladder.

D. Mastodynia It may be present in early pregnancy and ranges in severity from a tingling sensation to frank pain.

2. Signs Breast changes Breast enlargement and vascular engorgement. Nipple and areola become blacker. Enlargement of the accumulated sebaceous glands of the areolas (Montgomery’s tubercles) may be noted.

Changes of the reproductive organs Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested. Cervix: Cyanosis and a gradual softening due to congestion.

Uterus: Enlargement and softening. The isthmus of the uterus is also soft and can be compressed between the fingers palpating vagina and abdomen (Hegar’s sign). After the 12th week, the fundus of the uterus is usually palpable above the symphysis pubis.

3. Supplementary examination Pregnancy test The laboratory test for pregnancy are based on the identification of human chorionic gonadotropin (hCG), which can be detected as early as 7-9 days after fertilization by high sensitive technique. The samples may be blood or urine.

Basal body temperature (BBT) A persistent elevation of BBT for longer than 18 days may be presumptive evidence of pregnancy.

Progesterone is given to a women with amenorrhea. Progesterone test Progesterone is given to a women with amenorrhea. If she is pregnant, no bleeding will follow, otherwise, bleeding should occur within 7-10 days of progesterone administration. This is reliable in the nonpregnant patient only if there is adequate estrogen stimulation of the endometrium.

Ultrasonography There are trans-vaginal and abdominal Ultrasonagraphys. A gestational sac can usually be identified at 5-6 weeks after the beginning of the last period. Fetal heart beating can be detected by about 7th week and the fetus itself can be seen by about the 8th week. Doppler is also an ultrasound technique, which diagnoses the pregnancy by revealing the heart beating.

Second trimester: 13-28 weeks

Symptoms General examination Abdominal examination Vaginal examination

Nausea, vomiting, frequency of micturition subside Symptoms Nausea, vomiting, frequency of micturition subside Amenorrhea continues Quickening: perception of active fetal movement by women (From 18th week) Progressive enlargement of lower abdomen by the growing uterus

General examination Pigmentation Chloasma 24th week Breast changes: more enlarged

Abdominal examination Inspection Palpation Auscultation

Inspection Linea nigra Striae

Ensiform Cartilage Symphysis Pubis Striae

Fundal height increases Palpation Fundal height increases Uterus soft and elastic, ovoid in shape Braxton-Hicks Contraction Palpation of fetal parts: 20th week Active fetal movements: 20th week External ballottement

Fundal height is increased with progressive enlargement of the uterus. Duration of pregnancy can be ascertained by noting the height of the uterus.

16th week: midway between symphysis pubis and umbilicus 22~24th week: at the level of umbilicus 28th week: at the junction of the lower 1/3 and upper 2/3 of the distance between the umbilicus and ensiform cartilage

Abnormal Fundal Height IUGR (intrauterine growth retardation) Multiple Pregnancy Polyhydramnios(CNS or Cardiovascular Disfunction) Oligohydramnios

Braxton-Hicks Contraction In 1872, John Braxton Hicks investigated the later stages of pregnancy and noted that many women felt contractions without being near birth. This process was usually painless but caused women confusion as to whether or not they were going into actual labor

Cause Braxton Hicks contractions are a tightening of the uterine muscles for one to two hours and are thought to be an aid to the body in its preparation for birth.

Alleviating factors Rhythmic breathing Lying down on the left side A slight change in movement Urination

Very early, the uterus undergoes spontaneous contraction Firmer at one moment and soft at another Can be excited by rubbing the uterus Irregular,infrequent, spasmodic, and painess Near term, frequent with increase in intensity, discomfort Merge with the labor

Palpation of fetal parts Diagnosis of pregnancy Identify the presentation and position of fetus

Active fetal movements Positive evidence of pregnancy & live fetus Faint flutter→stronger movement

External ballottement Be elicited as early as 20th week Obese women & scanty liquor amnii by a push to the foetal parts with one hand abdominally and the other hand receiving the impulse

Ballottement is a medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.

Ascutation

Fetal heart sound Most conclusive 18-20 weeks Location 140-160 bpm→120-140 bpm

The bluish discolouration of the vagina, cervix is much more evident; Vaginal Examination The bluish discolouration of the vagina, cervix is much more evident; Cervix softening

Investigation Sonograph: 12-20 weeks; a detailed survey of fetal anatomy, placenta localization, integrity of the cervical canal Fetal organ anatomy Radiologic examination

Biparietal diameter(BPD)

BPD First Trimester: < 3cm From 20th week: = pregnancy month(28th week=7cm; 32th week=8cm From 32th week = 8cm: 02.cm/week

FL( femur length) 2-3 cm less than the BPD For example: BPD=9.3cm ，FL=7.3cm； BPD=8.9cm，FL=6.9cm

Second Trimester Review Symptoms Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of gestation.

Signs The uterus continues to enlarge Fetal movement (quickening) can usually be seen or heard after 18th week of gestation

Height of the uterine top

Signs Fetal heart sound can be heard at rate varies from 120 to 160 beats per minute. The fetal body can usually be palpated by the 18th to 20th week of gestation unless the patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid.

(uterine souffle and umbilical souffle)

ballottement

Third trimester: 29-40 weeks

Symptoms: Amenorrhoea Enlargement of the abdomen Lightening: due to the engagement of the presenting part Frequency of micturition Fetal movement

Cutaneous changes: increased pigmentation and striae Sign: Cutaneous changes: increased pigmentation and striae Uterine shape: cylindrical to spherical beyond 36th week Fundal height Braxton-Hicks contraction Fetal movement Palpation of the fetal parts

32th week: the junction of the upper and middle third between the distance of umbilicus and ensiform cartilage 36th week: the level of the ensiform cartilage 40th week: down to the level of 32th

Symphysis fundal height (SFH)

After 24 weeks, the SFH measured in cm After 24 weeks, the SFH measured in cm. correspond to the number of the weeks up to 36 weeks. A variation of ± 2 is accepted as normal. Variation beyond the normal range needs further evaluation.

More than ① Mistaken date of the last menstrual period; ② Twins; ③ Polyhydramnios; ④ Big baby; ⑤ Pelvic tumours; ⑥ Hydatidiform mole; ⑦ Concealed accidental haemorrhage

Twins

Hydatidiform mole

Less than ① Mistaken date of the last menstrual period; ② Scanty liquor amnii; ③ Fetal growth retardation; ④ Intrauterine fetal death

Upper part of the uterus Lateral part of the uterus Further confirmation Presentation; Engagement

broad, soft, irregular mass Fundal grip broad, soft, irregular mass smooth, hard, globular → breech → head

Lateral or umbilical grip smooth curved and resistant →black comparatively empty and small knob → limb

First pelvic grip Presentation: the part occupy the lower pole of the uterus Attitude: the relative position of the sincipital and occipital or different parts of the fetus to one another Engagement: convergence or divergence of the finger during palpation

Second pelvic grip mobility from one side to side is tested

Fetal lie & fetal Presentation Fetal lie: the relationship between the long axis of the mother and the long axis of the fetus. (longitudinal lie and transverse lie) Fetal presentation: the portion of the fetus that descends into pelvis first.

Head presentation Breech presentation Shoulder presentation

Occipital Presentation Bregma Presentation Brow Presentation Face Presentation

One foot Presentation Two feet Presentation Mixed breech Presentation Frank breech Presentation

Fetal position Fetal position: the relationship of some guiding point of fetal presentation to a fined area of the maternal pelvis. (LOA, left occipital anterior)

Presentation Occipital Presentation: Occipital, O Breech Presentation: Sacrum, S Face Presentation: Mentum, M Shoulder Presentation: Scapula, Sc

LOA ROA sacrum LOP ROP

Fetal Heart Sound

LSA RSA ROA LOA

Sonograph AC abdominal circumference HC head circumference BPD biparietal diameter FL femur length Amniotic Fluid volume oligohydramnios & polyhydramnios Placental anatomy: location, thickness, abnormalities

Differential Diagnosis of Pregnancy Pseudocyesis: psychological disorder, cessation of menstruation

Cystic ovarian tumour Amenorrhoea is absent; Swelling is slow; Amenorrhoea is absent; Feels cystic or tense cystic; Absence of Braxton-Hicks contraction; Absence of positive signs of pregnancy; Ultrasonograph show absence of fetus

Uterine fibroid: Amenorrhoea is absent; Slow growing; Amenorrhoea is absent; Feels firm , more towards hard; Absence of Braxton-Hicks contraction; Absence of positive signs of pregnancy; Ultrasonograph show absence of fetus

Summary of Diagnosis of Pregnancy Positive or absolute sign Persumptive symptoms and signs Probable signs

Positive or absolute sign Palpation; Auscutation; Ultrasound

Persumptive symptoms and signs Amenorrhoea; Frequence of micturition; Morning sickness; Fatigue; Breast changes; Skin changes; Quickening

Probable signs Abdominal enlargement; Braxton-Hicks contraction; External & internal ballotement; Uterus change; Vaginal sign; Immunological test

Chronological Appearance At 6-8 weeks At 16th week At 20th week

Estimation of Gestation Age & Prediction of Excepted Date of Delivery Excepted Due Date = LMP﹣3/﹢9 month and ﹢7 days LMP is 26th July, when is the EDD?

Patient’ statement Date of coitus Naegele’s Formula Date of quickening: adding 22 -24 weeks

add seven days subtract 3 months add one year Excepted Due Date = LMP﹣3/﹢9 month and ﹢7 days add seven days subtract 3 months add one year LMP is 26th July, when is the EDD?

Clinical : Size of the uterus Investigation: Ultrasonographic finding Previous record Clinical : Size of the uterus Palpation of fetal parts Investigation: Ultrasonographic finding GS - 5th week cardiac activity - 6th week Embryo movement – 7th week CRL in cm + 6.5 = week of pregnancy (Crown-rump length) BPD in cm = month of pregnancy (From 20th week)

Objective signs Height of the uterus Lightening Size of the fetus Vaginal examination

Hegar’s sign Question

Patient A, 24 years, irregular cycle, 30 days~90 days Amenorrhea: 6 months Morning sickness: > 3 months Fetal movement: for about a week Fundal height: midway of pubis and umbilicus