Diagnosis of Diagnosis of PregnancyPregnancy

Shanghai OB/GYN HospitalShanghai OB/GYN Hospital

Fudan UniversityFudan University

Yuan LuYuan Lu

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LMP: Last normal menstrual period Gestational age 280 days 40 weeks

Duration of PregnancyDuration of Pregnancy 2

Estimation of Gestation AgeEstimation of Gestation Age& &

Prediction of Excepted Date of Prediction of Excepted Date of DeliveryDelivery

Excepted Due Date (EDD) = LMP 3/ 9 month and 7 days﹣ ﹢ ﹢

LMP: Sep 10, EDD: June 17.

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

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First trimesterFirst trimester

SymptomsSymptoms

SignsSigns

Immunological TestsImmunological Tests

Ultra SonographUltra Sonograph

Pregnancy DiagnosisPregnancy Diagnosis

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AmenorrhoeaAmenorrhoea

Morning SicknessMorning Sickness

Frequence of micturitionFrequence of micturition

Breast discomfortBreast discomfort

FatigueFatigue

SymptomsSymptoms

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SymptomsSymptoms

AmenorrhoeaAmenorrhoea

cardinal/most important sign of early pregnancy

One or two episodes of bloody discharge

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Morning SicknessMorning Sickness Usually appears soon following the missed

period; Rarely lasts beyond 3 months

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

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Breast discomfortBreast discomfort• Fullness• Pricking sensation

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FatigueFatigue Occur early in pregnancy

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SignsSigns Breast Breast

changeschanges 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

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Uterus Fundus HeightUterus Fundus Height

6th 6th weeweekk

8th week8th week 12th week12th week

Uterine signUterine signUterus remains a pelvis organ until 12 weeksSize, shape and consistency

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Chadwick’s sign: : darkening of the cervix, vagina, and vulva;Goodell’s sign: softening of the vaginal portion of the cervixHegar’s sign: softening of the uters isthmus;Linea nigra: pigmentation of linea alba

Medical SignsMedical Signs

Non pregnant Non pregnant uterusuterus

Pregnant Pregnant uterusuterusThe pregnant uterus feels The pregnant uterus feels softsoft and and elasticelastic14

Immunological Immunological TestTest

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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

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the hCG usually doubles every 48-72 HOURS

it normally increases by at least 60% every 2 DAYS

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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)

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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.

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First Trimester First Trimester ReviewReview

The Whole Period of Pregnancy Can The Whole Period of Pregnancy Can Be Divided Into Three StagesBe Divided Into Three Stages

The first trimester (early pregnancy): The first trimester (early pregnancy): 1-12w1-12w

The second trimester (middle The second trimester (middle pregnancy): 13-27 wpregnancy): 13-27 w

The third trimester (late pregnancy): The third trimester (late pregnancy): 28-40w28-40w

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1. History and symptoms1. History and symptoms

• Cessation of menstruation• Nausea and Vomiting• Urinary symptoms• Mastodynia

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2. Signs2. Signs• Breast changes• Changes of the reproductive organs (Vagina, Cervix, Uterus)

3. Supplementary examination3. Supplementary examination• Pregnancy test• Basal body temperature

(BBT) • Progesterone test• Ultrasonography

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Second trimester: 13-28 weeksSecond trimester: 13-28 weeks

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SymptomsSymptoms

Abdominal examinationAbdominal examination

Vaginal examinationVaginal examination

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SymptomsSymptoms• 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

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Abdominal examinationAbdominal examination

Inspection

Palpation

Auscultation

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Symphysis Pubis

Ensiform Cartilage

Striae

InspectionInspection• Linea nigra• Striae

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PalpationPalpation• 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

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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 heightFundal height

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Abnormal Fundal HeightAbnormal Fundal Height

IUGR (intrauterine growth retardation)

Multiple Pregnancy

Polyhydramnios(CNS or Cardiovascular

Disfunction)

Oligohydramnios

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Braxton-Hicks ContractionBraxton-Hicks Contraction

CauseCause

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 factorsAlleviating factors • Rhythmic breathing • Lying down on the left

side • A slight change in

movement • Urination 31

Very early, the uterus undergoes spontaneous Very early, the uterus undergoes spontaneous

contractioncontraction

Firmer at one moment and soft at anotherFirmer at one moment and soft at another

Can be excited by rubbing the uterusCan be excited by rubbing the uterus

Irregular, infrequent, spasmodic, and painlessIrregular, infrequent, spasmodic, and painless

Near term, frequent with increase in intensity, Near term, frequent with increase in intensity,

discomfortdiscomfort

Merge with the labor Merge with the labor

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Palpation of fetal partsPalpation of fetal parts Diagnosis of pregnancy

Identify the presentation and position of fetus

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Active fetal movementsActive fetal movements

Positive evidence of pregnancy & live fetus

Faint flutter→stronger movement

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AscutationAscutation

Fetal heart Fetal heart soundsound

• Most conclusive• 18-20 weeks• Location• 140-160 bpm→120-

140 bpm

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Vaginal ExaminationVaginal Examination• The bluish discolouration of the vagina,

cervix is much more evident;

• Cervix softening

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• Sonograph: 12-20 weeks; a detailed survey of fetal anatomy, placenta localization, integrity of the cervical canal

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Ultrasound examinationUltrasound examination

Biparietal diameter(BPD)Biparietal diameter(BPD)38

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Second Trimester ReviewSecond Trimester Review

SymptomsSymptoms Abdominal enlargement and fetal Abdominal enlargement and fetal

movement generally occurs after the movement generally occurs after the 18th to 20th week of gestation.18th to 20th week of gestation.

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SignsSigns

• 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.

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Third trimester: 29-42 weeks

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SymptomsSymptoms• AmenorrhoeaAmenorrhoea

• Enlargement of the abdomen Enlargement of the abdomen

• Lightening: due to the engagement of the Lightening: due to the engagement of the

presenting partpresenting part

• Frequency of micturitionFrequency of micturition

• Fetal movementFetal movement

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SignSign• 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

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32th week32th week: the junction of the upper and middle third between the distance of umbilicus and ensiform cartilage

36th week36th week: : the level of the ensiform cartilage

40th week40th week: : down to the level of 32th

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Symphysis fundal height (SFH)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.

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Upper part of the uterus

Lateral part of the uterus

Presentation;

EngagementFurther

confirmation

Four steps of obstetric Four steps of obstetric palpationpalpation

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The first step-Fundal The first step-Fundal gripgrip

broad, soft, irregular mass- head

smooth, hard, globular – breech

The second stepThe second step smooth curved and

resistant-black comparatively empty and

small knob -limb

Four steps of obstetric Four steps of obstetric palpationpalpation

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The third stepThe third step confirm the present

The fourth stepThe fourth stepdetermine its engagement

degree

Four steps of obstetric Four steps of obstetric palpationpalpation

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Fetal lie & fetal PresentationFetal 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.

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Head Head presentationpresentation

Breech Breech presentationpresentation

Shoulder Shoulder presentationpresentation

Fetal presentationFetal presentation

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Face Presentatio

n

Brow Presentatio

n

Occipital Presentatio

n

Bregma Presentatio

n

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Mixed breech Presentation

Frank breech Presentation

One foot Presentation

Two feet Presentation

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Fetal positionFetal position

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

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PresentationPresentation

• Occipital Presentation: Occipital, Occipital Presentation: Occipital,

OO

• Breech Presentation: Sacrum, S Breech Presentation: Sacrum, S

• Face Presentation: Mentum, M Face Presentation: Mentum, M

• Shoulder Presentation: Scapula, Shoulder Presentation: Scapula,

Sc Sc

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sacrumsacrum ROPROP

LOALOA ROAROA

LOPLOP

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Differential Diagnosis of Differential Diagnosis of PregnancyPregnancy

Pseudocyesis: Pseudocyesis: psychological disorder,

cessation of menstruation

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Cystic ovarian tumourCystic 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

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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

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

Summary

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

Summary

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Thanks