1. ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

2. The importance of the problem avoiding exposure to teratogens (e.g. drugs) solving abnormal situations (e.g. ectopic pregnancy, hydatidiform mole) initial assessment and monitoring through prenatal care Diagnosis history clinical examination laboratory tests Diagnosis of pregnancy The duration of pregnancy in humans 259 - 294 days =37-42 weeks medium= 280 days (40 weeks) During the first half – maternal signs prezumptive diagnosis During the second half – fetal signs diagnosis of certitude

3. History amenorheea amenorheea increased E2 and P secretion by luteal corpus Conditions previous regular, spontaneous, predictible menstruations absence of menstruation for min. 10 days general informations personal data family history personal medical history obstetrical history data about the partener contraceptive history Diagnosis of pregnancy in the first 16 weeks (I-st trimester)

4.  Breasts symptoms enlargement heaviness or tension mastodinia, tenderness Digestive nausea ( over 50%) and vomiting sialoreea pyrozis alteration of apetite, taste, smell, food preferences appeared during 4-6 weeks disappeared spontaneously after 12-14 weeks Urinary bladder irritability (compresion) Nervous sleep difficulties, irritability, insomnia  Neuro-vegetative symptoms Diagnosis of pregnancy in the first 16 weeks (I-st trimester) History

5. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Clinical signs Inspection Breasts - increase in size - venous network (Haller) - Montgomery tubercules (sebaceus glands) - minute hyper-pigmentation of the areola and the nipple Abdomen - linea nigra - progressive deformation upward symfizis pubis (after 12 weeks) Perineum – accentuation of pigment

6. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Clinical signs Palpation Breasts - specific consistency - colostrum (occasionally) – thick, yellowish fluid, expressed from the nipples Abdomen - pregnant uterus – the upper margin of a globulous, soft mass - the height of the uterine fundus becomes measurable (cm)

7. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Clinical signs Obstetrical examination Cervix, vagina and perineum (speculum examination) - increased vascularity and hyperemia - characteristic violet-bluish color of the mucosa – Chadwick sign - increased size of the cervix Uterus (bimanual examination) - softening of the cervix, isthmus (Hegar sign) and uterine corpus - enlargement of the uterus (4cm per month) - irregular, painless uterine contractions – Braxton-Hicks contractions

8. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Noble sign Hegar sign Piscaceck sign

9. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Differential diagnosis - abdominal mass: ovarian cyst, uterine myoma, trophoblastic disease, ectopic pregnancy, bladder globus - amenorrhea: in the emotional stress, endocrine disfunctions, lactation, anorexia, certain treatments (e.g. antidepressants, metyldopa, haloperidol), pseudocyesis

10. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Laboratory diagnosis Principle: presence of hCG in plasma and urine - produced by syncytiotrophoblast - peak at 60-70 days - biological tests (laboratory animals) - immunological tests – β-hCG (monoclonal anti-HCG antibody serum assays); home test kit (ELISA, RIA, etc) - detection and quantification

11. hCG in plasma and urine

12. Diagnosis of pregnancy in the first 16 weeks (I-st trimester) Ultrasound imaging - abdominal sonography - vaginal sonography can detect an uterine pregnancy 1 week after the missed menstruation AIMS - assessment of the amnionic sac dimensions (4-5 weeks) - visualize the fetus and the placenta (position, aspect) - measure fetal crown-rump length (FCR) - detects twins, ectopic pregnancy, missed abortion, hydatidiform mole.

13. Diagnosis of pregnancy in the first 4-5 weeks (I-st trimester)

14. Diagnosis of pregnancy between the 17- 28 weeks (II-nd trimester) Clinical signs - amenorrhea (> 16 weeks) - progressive enlargement of the abdomen - perception of the fetal movements by the mother beginning with 17-18 weeks (multiparas) up to 19-20 weeks (primiparas) = quickening Inspection Face: chloasma (melasma gravidarum) = mask of pregnancy Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola Abdomen: enlargement, linea nigra, stria (reddish, slightly depressed streaks), protruded umbilicus, pigmented scars Perineum – accentuation of pigment

15. Diagnosis of pregnancy between the 17- 28 weeks (II-nd trimester)

16. Clinical signs Palpation Breasts: specific consistency, colostrum expressed from the nipples Abdomen: - pregnant uterus – a globulous, soft, contractile, painless mass - irregular, painless uterine contractions – Braxton-Hicks contractions - the height of the uterine fundus becomes measurable (16cm – 20 weeks, 20cm – 24 weeks) - ballottement sign Ascultation fetal heart sounds (110-160 b/min), with obstetrical stethoscope, near umbilicus

17. Diagnosis of pregnancy between the 17- 28 weeks (II-nd trimester)

18. Clinical signs Obstetrical examination – cont. Speculum examination (cervix, vagina and perineum) - hyperemia - Chadwick sign (violet-bluish color of the mucosa) - increased size of the cervix Bimanual examination (uterus) - softening of the vagina, cervix, lower segment and upper segment - enlargement of the uterus - Braxton-Hicks contractions - vaginal ballottement

19. Diagnosis of pregnancy between the 17- 28 weeks (II-nd trimester) Differential diagnosis abdominal mass ovarian cyst with abdominal development uterine myoma

20. Diagnosis of pregnancy between the 17- 28 weeks (II-nd trimester) Laboratory diagnosis - biological tests – no more - immunological tests – β-hCG (detection and quantification) Ultrasound imaging abdominal sonography / vaginal sonography AIMS - gestational age (BPD, FL, AC) - fetal morphology and biometry - multiple pregnancy - fetal heart movements - placental insertion, a.f.

21. Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester) Clinical signs - amenorrhea (> 29 weeks) - progressive enlargement of the abdomen - perception of the fetal movements by the mother/examinator Inspection Face: chloasma (melasma gravidarum) = mask of pregnancy Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola Abdomen: enlargement, linea nigra, striae gravidarum, protruded umbilicus, pigmented previous surgical scars Perineum – accentuation of pigment

22. Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester) Clinical signs Palpation Breasts: specific consistency, colostrum expressed from the nipples Abdomen (Leopold manoevers): Superficial palpation - pregnant uterus (a globulous, soft, contractile, painless mass, Braxton-Hicks contractions - measurement of the height of the uterine fundus

23. Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester)

24. Clinical signs Abdomen: Deep palpation - identification of the presenting part (if the head, it is firm, rounded, large, regulated) - lateral palpation – on the sides of the uterus (the back is an elongated firm mass; the limbs are small, irregular parts) Ascultation fetal heart sounds (110-160 b/min) in vertex presentation – below the umbilicus

25. Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester)

27. Clinical signs Obstetrical examination Speculum examination (cervix, vagina and perineum) - hyperemia - Chadwick sign (violet-bluish color of the mucosa) - increased size of the cervix - external cervical os - slit-like or round, with mucous plug Bimanual examination - softening of the vagina, cervix, lower segment and upper segment (patulous cervix admits a fingertip) - fetal presenting part, membranes

28. Diagnosis of pregnancy between the 29 - 40 weeks (III-rd trimester) Ultrasound imaging abdominal sonography / vaginal sonography AIMS - fetal morphology and biometry (BPD, Fl, AC) - fetal heart movements, - breathing movements - evaluation of the amniotic fluid - placental insertion and maturation degree

29. Presumptive evidence of pregnancy Subjective symptoms - nausea +/- vomiting - disturbances in urination - fatigue - the perceptions of fetal movements Presumptive signs - cessation of menses - changes in the breast - changes in the cervical mucus - discoloration of the vaginal mucosa - increased skin pigmentation and development of abdominal striae - does the woman believe that she is pregnant?

30. Probable evidence of pregnancy Enlargement of the abdomen Changes in the shape, size and consistency of the uterus Anatomical changes in the cervix Braxton-Hicks contractions Ballottement Physical outlining of the fetus Presence of β-hCG in serum or urine

31. Positive signs of pregnancy Identification of fetal heart activity separately and distinctly (from mother) Perception of fetal movements by the examiner Recognition of the embryo / the fetus throughout imagistic methods (ultrasound)

32. Gestational age assessment First day of the last menstrual period (LMP) + no. of weeks The day when the mother has felt the first fetal movements (quickening) + 22 weeks in multiparas, or 20 weeks in primiparas The uterine height (UH) in cm + 4 =the number of gestational weeks Ultrasound examination during the first 12 weeks of amenorrhea