Diagnosis of Pregnancy Shanghai OB/GYN Hospital Fudan University Yuan Lu 1

LMP: Last normal menstrual period Gestational age 280 days 40 weeks Duration of Pregnancy 2

Estimation of Gestation Age & Prediction of Excepted Date of Delivery Excepted Due Date (EDD) = LMP ﹣ 3/ ﹢ 9 month and ﹢ 7 days LMP: Sep 10, EDD: June 17. 3

FFirst trimester: first 12 weeks SSecond trimester: weeks LLast trimester: weeks 4

First trimester Symptoms Symptoms Signs Signs Immunological Tests Immunological Tests Ultra Sonograph Ultra Sonograph Pregnancy Diagnosis 5

Amenorrhoea Amenorrhoea Morning Sickness Morning Sickness Frequence of micturition Frequence of micturition Breast discomfort Breast discomfort Fatigue Fatigue Symptoms 6

Symptoms Amenorrhoea Amenorrhoea cardinal/most important sign of early pregnancy One or two episodes of bloody discharge 7

Morning Sickness Morning Sickness Usually appears soon following the missed period; Rarely lasts beyond 3 months 8

Frequence of micturition Frequence of micturition troublesome symptom during 8-12 weeks enlarged uterus congestion of bladder increased intravascular volume 9

Breast discomfort Breast discomfort Fullness Pricking sensation 10

Fatigue Fatigue Occur early in pregnancy 11

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

Uterus Fundus Height 6th week 8th week 12th week Uterine sign Uterine sign Uterus remains a pelvis organ until 12 weeks Size, shape and consistency 13

: Chadwick’s sign: darkening of the cervix, vagina, and vulva; Chadwick’s sign Goodell’s signGoodell’s sign: softening of the vaginal portion of the cervix Hegar’s signHegar’s sign: softening of the uters isthmus; Linea nigraLinea nigra: pigmentation of linea alba Medical Signs Non pregnant uterus Pregnant uterus The pregnant uterus feels soft and elastic 14

Immunological Test 15

Pregnancy test human chorionic gonadotropin (hCG): α/β-subunit produced in the syncytiotrophoblast Urine approximately 4 weeks following the first day of the last menstrual period All urine pregnancy tests are best performed on early-morning urine specimens, which contain the highest concentration of hCG Serum specific and sensitive by following serial quantitative hCG levels and comparing them to the expected rise derived from normative data for proven normal intrauterine pregnancies 16

the hCG usually doubles every HOURS it normally increases by at least 60% every 2 DAYS 17

Ultrasound examination Abdominal ultrasound: allowing visualization of a normal pregnancy gestational sac 5 to 6 weeks after the beginning of the last normal menstrual period (corresponding to β-hCG concentrations of 5000 to 6000 mIU/mL) Transvaginal ultrasound: often detects pregnancy at 3 to 4 weeks of gestation (corresponding to β-hCG concentrations of 1000 to 2000 mIU/mL) 18

Image of an early gestational sac containing a yolk sac and early embryo. The yolk sac is the circular hyperechoic structure adjacent to the embryo. Image of an early gestational sac demonstrating the early embryo. Calipers are placed at both ends of the embryo measuring the longest length from the "crown to the rump" giving the crown-rump length. This measurement is used for dating the pregnancy. 19

First Trimester Review The Whole Period of Pregnancy Can Be Divided Into Three Stages The first trimester (early pregnancy): 1-12w The first trimester (early pregnancy): 1-12w The second trimester (middle pregnancy): w The second trimester (middle pregnancy): w The third trimester (late pregnancy): 28-40w The third trimester (late pregnancy): 28-40w 20

1. History and symptoms Cessation of menstruation Nausea and Vomiting Urinary symptoms Mastodynia 21

2. Signs Breast changes Changes of the reproductive organs ( Vagina, Cervix, Uterus) 3. Supplementary examination Pregnancy test Basal body temperature (BBT) Progesterone test Ultrasonography 22

Second trimester: weeks 23

Symptoms Symptoms Abdominal examination Abdominal examination Vaginal examination Vaginal examination 24

Symptoms 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 25

Abdominal examination Abdominal examination Inspection Palpation Auscultation 26

Symphysis Pubis Ensiform Cartilage Striae Inspection Inspection Linea nigra Striae 27

Palpation 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 28

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 Fundal height 29

Abnormal Fundal Height IUGR (intrauterine growth retardation) Multiple Pregnancy Polyhydramnios(CNS or Cardiovascular Disfunction) Oligohydramnios 30

Braxton-Hicks Contraction Cause Cause 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 Alleviating factors Rhythmic breathing Lying down on the left side A slight change in movement Urination 31

Very early, the uterus undergoes spontaneous contraction Very early, the uterus undergoes spontaneous contraction Firmer at one moment and soft at another Firmer at one moment and soft at another Can be excited by rubbing the uterus Can be excited by rubbing the uterus Irregular, infrequent, spasmodic, and painless Irregular, infrequent, spasmodic, and painless Near term, frequent with increase in intensity, discomfort Near term, frequent with increase in intensity, discomfort Merge with the labor Merge with the labor 32

Palpation of fetal parts Palpation of fetal parts Diagnosis of pregnancy Identify the presentation and position of fetus 33

Active fetal movements Active fetal movements Positive evidence of pregnancy & live fetus Faint flutter→stronger movement 34

Ascutation Fetal heart sound Fetal heart sound Most conclusive weeks Location bpm→ bpm 35

Vaginal Examination Vaginal Examination The bluish discolouration of the vagina, cervix is much more evident; Cervix softening 36

Sonograph: weeks; a detailed survey of fetal anatomy, placenta localization, integrity of the cervical canal 37 Ultrasound examination

Biparietal diameter(BPD) 38

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Second Trimester Review Symptoms Symptoms  Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of gestation. 41

Signs Signs The uterus continues to enlarge Fetal movement (quickening) can usually be seen or heard after 18th week of gestation 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. 42

Third trimester: weeks 43

Symptoms Symptoms Amenorrhoea Amenorrhoea Enlargement of the abdomen Enlargement of the abdomen Lightening: due to the engagement of the presenting part Lightening: due to the engagement of the presenting part Frequency of micturition Frequency of micturition Fetal movement Fetal movement 44

Sign 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 45

32th week 32th week: the junction of the upper and middle third between the distance of umbilicus and ensiform cartilage 36th week: 36th week: the level of the ensiform cartilage 40th week: 40th week: down to the level of 32th 46

Symphysis fundal height (SFH) 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. 47

Upper part of the uterus Lateral part of the uterus Presentation; Engagement Further confirmation Four steps of obstetric palpation 48

The first step-Fundal grip The first step-Fundal grip broad, soft, irregular mass- head smooth, hard, globular – breech The second step The second step smooth curved and resistant-black comparatively empty and small knob -limb Four steps of obstetric palpation 49

The third step The third step confirm the present The fourth step The fourth step determine its engagement degree Four steps of obstetric palpation 50

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. 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. 51

Head presentation Breech presentation Shoulder presentation Fetal presentation 52

Face Presentation Brow Presentation Occipital Presentation Bregma Presentation 53

Mixed breech Presentation Frank breech Presentation One foot Presentation Two feet Presentation 54

Fetal position 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) 55

Presentation Occipital Presentation: Occipital, O Occipital Presentation: Occipital, O Breech Presentation: Sacrum, S Breech Presentation: Sacrum, S Face Presentation: Mentum, M Face Presentation: Mentum, M Shoulder Presentation: Scapula, Sc Shoulder Presentation: Scapula, Sc 56

sacrum ROP LOA ROA LOP 57

Differential Diagnosis of Pregnancy Pseudocyesis: Pseudocyesis: psychological disorder, cessation of menstruation 58

Cystic ovarian tumour Cystic ovarian tumour 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 59

Uterine fibroid: Uterine fibroid: 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 60

Persumptive symptoms and signs Persumptive symptoms and signs Amenorrhoea; Frequence of micturition; Morning sickness; Fatigue; Breast changes; Skin changes; Quickening Summary 61

Probable signs Probable signs Abdominal enlargement; Braxton-Hicks contraction; External & internal ballotement; Uterus change; Vaginal sign; Immunological test Summary 62

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