Transcript 1. Diagnosis of pregnancy

ASSOCIATE PROFESSOR
IOLANDA BLIDARU
MD, PhD
Diagnosis of pregnancy
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
The duration of pregnancy in humans
• 259 - 294 days =37-42 weeks
• medium= 280 days (40 weeks)
During the first half – maternal signs
During the second half – fetal signs
prezumptive diagnosis
diagnosis of certitude
Diagnosis of pregnancy in the first 16 weeks
(I-st trimester)
History
• general informations
amenorheea
• personal data
• family history
• personal medical history
• obstetrical history
• data about the partener
• contraceptive history
increased E2 and P secretion by
luteal corpus
Conditions
• previous regular, spontaneous, predictible menstruations
• absence of menstruation for min. 10 days
Diagnosis of pregnancy in the first 16 weeks
(I-st trimester)
 Breasts
symptoms
• enlargement
• heaviness or tension
• mastodinia, tenderness
History
 Neuro-vegetative symptoms
• nausea ( over 50%) and vomiting
Digestive
• sialoreea
• pyrozis
• alteration of apetite, taste, smell, food preferences
appeared during 4-6 weeks
disappeared spontaneously after 12-14 weeks
Urinary
Nervous
bladder irritability (compresion)
sleep difficulties, irritability, insomnia
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
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)
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
Diagnosis of pregnancy in the first 16 weeks
(I-st trimester)
Noble sign
Hegar
sign
Piscaceck
sign
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
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
hCG in plasma and urine
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.
Diagnosis of pregnancy in the first 4-5
weeks (I-st trimester)
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
Diagnosis of pregnancy between the 17- 28 weeks
(II-nd trimester)
Diagnosis of pregnancy between the 17- 28 weeks
(II-nd trimester)
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
Diagnosis of pregnancy between the 17- 28 weeks
(II-nd trimester)
Diagnosis of pregnancy between the 17- 28 weeks
(II-nd trimester)
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
Diagnosis of pregnancy between the 17- 28 weeks
(II-nd trimester)
Differential diagnosis
abdominal mass
 ovarian cyst with abdominal development
 uterine myoma
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.
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
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
Diagnosis of pregnancy between the 29 - 40 weeks
(III-rd trimester)
Diagnosis of pregnancy between the 29 - 40 weeks
(III-rd trimester)
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
Diagnosis of pregnancy between the 29 - 40 weeks
(III-rd trimester)
Diagnosis of pregnancy between the 29 - 40 weeks
(III-rd trimester)
Diagnosis of pregnancy between the 29 - 40 weeks
(III-rd trimester)
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
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
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?
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
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)
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