diagnosis of pregnancy shanghai ob/gyn hospital fudan university yuan lu 1
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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