Post on 15-Jun-2015
description
Diagnosis of pregnancy
DR: MANAL BEHERY Zagazig University , Egypt
Principles of diagnosis
In the majority of women, the diagnosis of pregnancy is usually straightforward based on a history of amenorrhea and a positive pregnancy test.
women with irregular periods or irregular vaginal bleeding , the diagnosis of pregnancy is more complex.
Other symptoms of pregnancy may alert the clinician to the possibility of pregnancy.
Symptoms of pregnancy:
Amenorrhoea: HOWEVERPregnancy may occur during period of lactation
amenorrhea. Slight bleeding early in pregnancy (threatened
abortion) may be considered by the patient as menses .
Hartman's symptoms: slight bleeding occurs at time of menstruation
Symptoms of pregnancy:
Morning sickness: nausea, rarely vomiting confined to morning
Increased frequency of micturition.Enlargement of the breast and sensation
of heaviness. Easy fatiguability and tendency to sleep. Emotional changes e.g. change of the
appetite:
In the second and third trimesters
1-Abdominal enlargement2-Quickening -1st perception (sensation) of fetal
movements by the lady
-PG (18-20 weeks), MP (16-18 weeks)
Signs of pregnancy
Chloasma gravidarum
Butterfly face pigmentation
Breast signs
Increased pigmentation of the nipple and lry areola.
Appearance of Montgomery tubercle in the areola
dilated sebaceous glands
Abdominal stria
Linea nigra
- Abdominal signs Inspection:-
2- Palpation:
Auscultation:
Auscultation of FHS as early as 10-12 weeks by sonicade
Auscultation of FHS as early as 20-24 weeks by Pinard stethoscope
Auscultation of umbilical souffle as early as 20-24 weeks.
Auscultation of uterine souffl
Pregnancy tests:Principle:
Detection ofHCG in the urine or serum .
1- Urinary pregnancy test:
Classically it becomes +Ve 7- 10 day after 1st missed period
Commercial testing kits are available that are sensitive to 25 iu/L in urine.
By the time the mother has missed her first
menstrual period, her hCG levels are around 100 iu/L.
Serum pregnancy test:
Classically it becomes +Ve 5- 7 days before 1 st missed period
A quantitative serum HCG assay level of > 5 iu/L will usually denote a pregnancy.
With a normal intrauterine pregnancy, the hCG level doubles approximately every 36-48 hours.
Tran abdominal US
Transvaginal ultrasound ( TVS):
12 WEEKS GESTATION
CROWN RUMP LENGTH(CRL)
2ND TRIMESTER
Sure signs of pregnancy:
Inspection of fetal parts as early as 20th week. -Inspection of fetal movements as early as
20th week. Palpation of fetal movements as early as 20th
week. -Palpation of fetal parts as early as 20th
week.
Sure signs of pregnancy
-Auscultation of FHS at 10-12 weeks by sonicade
Investigations: Visualization of fetal parts by ultrasound
ANTENATAL CARE
Definition
Antenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of labor
It is a preventative cost effective service
GOALS
1-Ensure mother health.
2- Ensure delivery of a healthy infant.
3-Anticipate problem
4- Diagnose problem early.
Objectives
1-Early detection and if possible, prevention of
complications of pregnancy.
2-Educate women on danger and emergency signs
& symptoms.
3-Prepare the woman and her family for childbirth
4- Give education & counseling on
family planning
Schedual of antenatal care:
Medical check up every four weeks up to 28 weeks gestation,
Every 2 weeks until 36 weeks of gestation
Every week until delivery An average 7-11 antenatal visits/pregnancy
More frequent visits may be required if complications arise.
On first antenatal visit
1-First : Confirm pregnancy by pregnancy test or US.
2-History
3-Physical examination
4-investigation
HistoryPersonal history
Menstrual history Obstetrical history Family history Medical and surgical history History of present pregnancy
Menstrual history
- Ask about - 1-Last menstrual period (LMP).
- 2-Regularity and frequency of menstrual cycle.
- 3-Contraception method used .- 4-Calculate expected date of delivery
(EDD) as1st day of LMP −3 months +7 days, and change
the year.
Obstetric History
Gravidity? Parity? abortion, and living children.
Weight of infant at birth & length of gestation.
Type of delivery, location of birth, and type of anesthesia.
Maternal or infant complications.
1-Chronic conditions : as diabetes mellitus, hypertension, and renal disease ,cardiac disease.
2-Prior operation: as cesarean section, genital repair, and cervical cerclag.
3-Allergies, and medications.
4-Accidents involving injury of the bony pelvis
Medical and surgical history:
History of present pregnancy
History suggesting e.g. Diabetes,
hypertension and ante partum hemorrhage.
Ask about episodes of fever or chills
Ask about pain or burning sensation on urination.
Abnormal vaginal discharge, itching at the vulva or if partner has a urinary problem.
Emergency symptomsVaginal bleeding
Severe abdominal ,epigastric, or pelvic pain
Severe headache with visual disturbance
Persistent vomiting
Unconscious/Convulsion
Severe difficulty in breathing
Fever, chills , dysurea
Absent fetal movement
Assessment and physical examination
Weight measurement
Maternal height and weight measurements to determine body mass index(BMI).
Maternal weight should be measured at each antenatal visit
Check for pallor or anemia.
1-Look for palmar pallor.
2-Look for conjunctival pallor
3-Count respiratory rate
in one minute.
Blood pressure measurement
Measure BP in sitting position.
If diastolic BP is 90 mm Hg or higher repeat measurement after 6 hour rest.
If diastolic BP is still 90 mm Hg or higher ask the woman if she has:
• Severe headache• Blurred vision • Epigastric pain
Check urine for protein.
Get baseline on the first or following the first visit.
Hemoglobin, blood typeUrine analysisVDRL or RPR to screen for syphilisHepatitis B surface antigen To detect carrier status or active disease
Investigations
At each visit
At each visit
1-Questions about fetal movement
2-Ask for danger signs during this pregnancy
3-Ask patient if she has any other concerns
Symphysis Fundal hieght
• LMP plus 280 days
• Add 7 days, subtract 3 months
• MacDonald's Rule (cm = weeks)
At third trimester
Do Leopold’s exam
Provide advice on
1.Diet and weight gain 2.Medication3.Avoid Radiation exposure 4.Self-care during pregnancy5.Minor complaints.6.Family planning Breastfeeding7.Birth place preparation and anticipation of
complication& Emergency situations.
Diet in pregnancy:
Total caloric intake increase to 300 kcal /day
due to 15% increase in BMR .Diet show contain 20%Protein(better from
animal source), 30% fat ,and 50% carbohydrates .
Sufficient fluids should be available.
Supplementation
1-Folic acid 0.4 mg tab daily 2- iron (ferrous sulphate or gluconate )300
mg/daily 3- Ca 1200mg /daily 4-
• -Those with a normal balanced diet • probably don’t need extra vitamins
Weight gain in pregnancy:
There is a slight loss of pounds during early pregnancy if the patient experiences much nausea and vomiting.
Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of the first trimester.
Gain of 1 lb(0.5)/ per wk is expected during the second and third trimesters.
Monitoring of weight gain should be done in
conjunction with close monitoring of BP.
Medications During Pregnancy
• Antibiotics - some OK, some not
• Local anesthetics - OK
• Local with epinephrine - not OK
• Aspirin - not OK
• Immunizations - some are OK, some are not
• Antimalarial - some OK, some are not
• Narcotics - OK except for addiction issue
Case Study
Case Study
A 35-year-old G2 P1+0 woman is seen for her first prenatal visit.
Based on her LMP, she is at 15 weeks’ gestation.
She has no complaints, and no significant medical history.
She denies dysuria or urinary urgency.Her surgical history is remarkableHer last delivery was a vaginal delivery and
was uncomplicated
On examination
Her blood pressure (BP) is 100/65 mm Hg
heart rate (HR)90 (bpm),
respiratory rate (RR) 12,temperature 98°F (36.6°C),
weight 70KG.
general physical examination is normal
Abdominal examination
Her abdomen is non tender Fundal height is at the level ofthe umbilicus. Fetal heart tones are 140 bpm. Her extremities are without edema.
Prenatal laboratories
CBC: Hgb 10.0 g/dL ,Plt 150,000 WBC 8,000Rubella: nonimmune Hepatitis B surface antigen: positiveBlood type: O, Rh negative UC&S: 10,000 cfu/mL of group
BstreptococcusGonorrhea assay: negative Chlamydia assay:
negative
Questions
➤ What items should be listed on the problems list?
➤ What is your next step for the problems listed?
➤ What other testing should be recommended to the patient?
Problem List:
Advanced maternal age 35 Y or greater at EDD
fundal height at umbilicus corresponds to 20 weeks)
Mild microcytic anemia (Hgb < 10.5) Hepatitis B surface antigen (HBsAg) positive Rh-negative blood type Urine culture with GBS 10,000 cfu/mL,Rubella nonimmune
Next Steps:
1. AMA—genetic counseling
2. Size/dates—fetal ultrasound to assess GA, multiple gestation
3. Anemia—therapeutic trial of iron
4. HBsAg positive—check liver function tests, and hepatitis B serology toassess for active hepatitis versus chronic carrier status
Next step
5. Rh negative Rhogam at 28 weeks and at delivery if the baby proves to be Rh positive
6. Urine culture with GBS—treat with ampicillin and re-culture urine, peni-cillin IV prophylaxis in labor
7. Rubella status—vaccinate postpartum
Other tests recommended to patient
consider early diabetic screen
Thank you