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DIAGNOSIS OF PREGNANCY AND
MATERNAL ASSESSMENT
Deepthy P.Thomas1st year MSc nursing Govt college of nursingAlappuzha.
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PRESUMPTIVE SIGNS OF THE PREGNANCY
• Breast changes.• Nausea and vomiting.• Amenorrhoea.• Frequent urination.• Fatigue and uterine
enlargement.• Quickening.• Linea nigra.• Melasma.• Striae gravidarum
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PROBABLE SIGNS OF PREGNANCY
Chadwick’s sign.Goodell’s sign.Hegar’s sign.Evidence on ultrasound of
gestational sac.Ballotment.Braxton’s hick contraction.Fetal outline felt by the examiner.
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POSITIVE SIGNS OF PREGNANCY
Demonstration of a fetal heart separate from the mother’s
heart.Fetal movements felt by an
examiner.Visualization of fetus by
ultrasound.
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FIRST TRIMESTER
SUBJECTIVE SYMPTOMS:
AmenorrhoeaMorning sicknessFrequency of micturitionBreast discomfortFatigue
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OBJECTIVE SIGNS
Breast changes: Per abdomenPelvic changes
Jacquemer’s sign 8th weekVaginal sign
osiander’s sign 8th week
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Cervical signsGoodell’s sign 6th week
Uterine signsSize shape and consisitency
piscacek’s signHegar’s sign between 6-10 weeksPalmer’s sign as early as 4-8 weeks
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IMMUNOLOGICAL TESTS FOR THE DIAGNOSIS OF PREGNANCY
Agglutination inhibition tests: Direct agglutination test: The sensitivity is 0.2 IU Hcg/ml. Enzyme-linked immunosorbent assay: It is based on one monoclonal antibody that binds the hCG in urine and serum. ELISA can detect hCG in serum upto 1-2 mIU/ml and as early as 5 days before the first missed period. Fluroimmuno assay:the fluroscence emitted is proportional to the amount of hCG. it can detect hCG as low as 1 Miu/ml. FIA takes 2-3 hours.
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Immune assays with radioisotopes:Radioimmunoassay: It is more sensitive and can detect β subunit of hCG upto 0.002 IU/ml in the serum. It can detect pregnancy as early as 8-9 days after ovulation. It requires 3-4 hours to perform. Immune-radiometric assay: Uses sandwich principle to detect whole hCG and require only 30 mts.SELECTION OF TIME: by 8-11 days after conception. The test is not reliable after 12 weeks
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ULTRASONOGRAPHY
Intra decidual gestational sac -29 -35 days of gestation. Fetal viability and gestational age is
determined by detecting the following structures by transvaginal ultrasonography.
Gestational sac and yolk sac by 5 menustral weeks.
Fetal pole and cardiac activity- 6 weeks. Embryo movements by 7 weeks. Fetal gestational age is measuring the
CRL the fetal heart reliably by 10 th week.
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SECOND TRIMESTER SYMPTOMS
Quickening at 16 to 18 weeks It denotes the perception of active fetal movements by the womenProgressive enlargement of the
lower abdomen GENERAL EXAMINATION
Cloasma Pigmentation over the forehead and cheek may appear at about 24th week.
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Breast changes:
Breasts are more enlarged with prominent veins under the skin.
Secondary areola specially demarcated in primigravidae, usually appears at about 20th week.
Montgomery’s tubercles are prominent and extent to the secondary areola.
Colustrum becomes thick and yellowish by 16th week.
Variable degree of striae may be visible with advancing weeks
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ABDOMINAL EXAMINATION:Inspection:
linea nigra as early as 20th week and Striae
PalpationFundal height
the height of the uterus is midway between the symphysis pubis and the umbilicus at 16th week.
At the level of umbilicus at 24th week.At the junction of the lower third and upper two-third of the distance between the umbilicus and ensiform cartilage at 28th week.
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ABDOMINAL EXAMINATION
The uterus feels soft and elastic Braxton’s-Hicks contraction Palpation of fetal parts Active fetal movements External ballotment
Auscultation:Fetal heart sound:Uterine souffle:Funic or fetal souffle:
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VAGINAL EXAMINATION:
The bluish discolouration:Internal ballotment
INVESTIGATIONS:Sonography: Routine sonography at 18-20 weeks permits a dilated survey of fetal anatomy, placental localization and the integrity of the cervical canalFetal organ anatomyMRI
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LAST TRIMESTERSYMPTOMS:
Amenorrhoea persists.Enlargement of the abdomenLighteningFrequency of micturitionFetal movements
SIGNS: Cutaneous changesUterine shape: it is changed from cylindrical to spherical beyond 36th week
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Fundal heightThe fundal height corresponds to the junction of the upper and middle third at 32 weeks. Upto the level of ensiform cartilage
at 36th week.It comes down to the level of 32
weeks at 40th week because of the engagement of the fetal head.
To determine whether the uterus height is correspond to 32 weeks or 40 weeks, engagement of the head should be tested.
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Braxton’s-Hick contractionFetal movements are easily felt
Palpation of fetal partsFHSSonography
Amniotic fluid assessment is done to detect oligohydramnios[AFI<5] or polyhydramnios[AFI>25].
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DIFFERENTIAL DIAGNOSIS OF PREGNANCY
PseudocyesisCystic ovarian tumor and fibroids
Encysted peritonitis
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MATERNAL ASSESSMENT
aims of maternal assessment are: To identify the high risk cases. To prevent and detect and treat at the
earliest any complications. To ensure continued risk assessment and to
provide ongoing primary prevention health care.
To educate the mother about the physiology of pregnancy, labour, newborn care and lactation.
To discuss with the couple about the place, time, and the mode of delivery.
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PROCEDURES AT THE FIRST VISIT
The initial interviewDemographic dataChief concernFamily profilePresent historyPast historyObstetric history
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Menstrual history Gynaecological history Personal history Family historyPHYSICAL EXAMINATION Baseline height and weight
measurement Vital signs Head and scalp Eyes Nose Ears Mouth and oral cavity
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NeckBreastsThoraxBackRectumExtremities and skinABDOMINAL EXAMINATIONPreliminaries InspectionPalpation
Height of the uterus Obstetric grips
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AuscultationThe relationship of the fetus to the uterus and pelvisLiePresentationAttitudeDenominatorPositionPresenting part
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PELVIC EXAMINATIONExternal genetaliaInternal genetaliaVaginal inspectionExamination of pelvic organs
Estimating pelvic sizeThe diagonal conjugateThe true conjugateThe ischial tuberosity
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LABORATORY METHODS:BLOOD STUDIES:
A complete blood count:Genetic screenSerologic test for syphyllisBlood typingMaternal serum alfa feta proteinIndirect coomb’s testAntibody titres for rubella and hepatitis B
HIV testingGlucose tolerance test
URINALYSIS
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ULTRASONOGRAPHY1ST TRIMESTER 2ND 3RD TRIMESTER
Confirm pregnancy
Confirm viability Determine
gestational age Rule out ectopic
pregnancy Detect multiple
gestation Use for
visualization during chori- onic villus sampling
Detect maternal abnormalities
Establish or confirm date
Confirm viability Detect
polyhydramnios, oligohy- dramnios
Detect congenital anomalies
Detect IUGR Confirm placenta placement
visualization during amnio- centesis
Confirm gestational age
Confirm viability Detect macrosomia Detect congenital
anomalies Detect IUGR Determine fetal
position Detect placenta previa
or abruptio placentae visualization during
amnio- centesis, external version
Biophysical profile Amniotic fluid volume
Detect placental maturity
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First Trimester Second and Third Trimester1. Gestational sac location 2. Embryo and/or yolk sac identification 3. Crown-rump length 4. Cardiac activity 5. Fetal number, including amnionicity and chorionicity of multiples when possible 6. Assessment of embryonic/fetal anatomy appropriate for the first trimester 7. Evaluation of the uterus, adnexa, and cul-de-sac 8. Assessment of the fetal nuchal region if possible
1. Fetal number; multifetal gestations: amnionicity, chorionicity, fetal sizes, amnionic fluid volume, and fetal genitalia, if visualized 2. Presentation 3. Fetal cardiac activity 4. Placental location and its relationship to the internal cervical os 5. Amnionic fluid volume 6. Gestational age 7. Fetal weight 8. Evaluation of the uterus, adnexa, and cervix 9. Fetal anatomical survey, including documentation of technical limitations
Components of Ultrasound Examination by Trimester
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SONOGRAPHIC EVALUATIONS The standard specialized examinations limited examination Nuchal Translucency Fetal Biometry Gestational Age Amnionic Fluid Fetal weight
Shepard’s formula:Log 10 EFW[gm]=1.2508+(0.166*BPD)
+0.046*AC)-(0.002646*AC*BPD). Hadlock’s formula:
Log 10 EFW[gm]= 1.3596-0.00386(AC*FL)+0.0064(AC)=0.00061 (BPD*AC)+0.0425(AC)
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SPECIAL INVESTIGATIONS IN HIGH RISK PREGNANCY
Maternal serum alpha fetoprotein Triple test Acetyl choline esterase (AChE) Amniocentesis Chorionic villous sampling Fetal movement count Cordocentesis Vibroacoustic stimulation (VAS) Fetal biophysical profile (BPP) Modified biophysical profile
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Fetal cardiotocography (CTG)Doppler ultrasound velocimetryPlacental gradingContraction stress test ( CST)Amniotic fluid volume assessment (AFV)
Amniocentesis in late pregnancy:Pulmonary maturity:Assessment of severity of Rh- isoimmunisation
Amnioscopy
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SIGNS INDICATING COMPLICATIONS OF PREGNANCY
Vaginal bleedingPersistent vomitingChills and feverSudden escape of clear fluid from vagina
Abdominal or chest painIncrease or decrease in fetal movement
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MINOR AILMENTS DURING PREGNANCY
Morning sicknessHeartburnVaricose veinsBackacheBreathlessnessPalpitationsVaginal dischargeConstipation
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