Transcript Document

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 ;
280 days ;
40 weeks
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

Rectum
Bladder
First trimester
Subjective Symptoms
 Objective Signs
 Immunological Tests
 Ultra Sonograph

Pregnancy Diagnosis
Subjective Symptoms
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Amenorrhoea
Warning :cyclic bleeding may last up to 12 weeks;
scanty and short time;
pathological bleeding ,such as miscarriage
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Morning Sickness
Usually appears soon following the missed period;
Rarely lasts beyond 3 months
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Frequence of micturition
troublesome symptom during 8-12 weeks
enlarged uterus
congestion of bladder
change in maternal osmoregulation
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Breast discomfort
Fullness
Pricking sensation
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Fatigue
Occur early in pregnancy
Objective Signs
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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
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Per Abdomen
Uterus remains a pelvis organ until 12 weeks
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Pelvic Changes
Chadwick’ sign
Vaginal sign
Cervical sign
Uterine sign
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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.
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Vaginal sign (Osiander’s sign)
Bluish discolouration of anterior vaginal wall
Vaginal wall soften
Mucoid discharge
Increased pulsation
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Cervical sign (Goodell’ sign)
Become soft as early as 6th week
Non pregnant
uterus
Pregnant uterus
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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
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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
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Selectionn of time
8-10 days after conception
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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 2935 days of gestation
5 menstrual weeks
6 menstrual weeks
True and pseudo gestation sac
Character
True GS
Pseudo GS
Eccentrically
Centrally
Round & regular
Irregular
Double ring sign
Present
Absent
York sac and fetal pole
Present
Absent
1 mm/ day
Absent
Location
Shape
Increase in sac size
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 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
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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
Chloasma 24th week
Breast changes: more enlarged
Pigmentation

Abdominal examination
Inspection
Palpation
Auscultation

Inspection
Linea nigra
Striae
Ensiform Cartilage
Symphysis Pubis
Striae

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
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
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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.
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Alleviating factors
Rhythmic breathing
Lying down on the left side
A slight change in movement
Urination
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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
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Vaginal Examination
The bluish discolouration of the vagina, cervix is
much more evident;
Cervix softening
Investigation
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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
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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

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)
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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
 Fundal
grip
broad, soft, irregular mass → breech
smooth, hard, globular → 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
Bregma
Brow
Face
Presentation Presentation Presentation Presentation
Mixed breech
Frank breech
One foot
Two feet
Presentation
Presentation
Presentation
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
LOP
ROA
sacrum
ROP
Fetal Heart Sound
RSA
LSA
ROA
LOA
Sonograph
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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
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:
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


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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
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?

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
Question
Hegar’s sign
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
