3 pregnancy monitoring

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HuYan ([email protected])Department Of Obstetrics & Gynecology ZhongDa Hospital

PREGNANCY MONITORING

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prenatal interval

• A physiological process

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PRENATAL CARE

• the primary method for pregnancy monitoring

• identification and special treatment • to ensure an normal pregnancy and the

delivery • lower risk of complication

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high-risk pregnancyAge<16y or ≥35yObesity or <50kgBody height< 145cmPregnancy compliationsChronic diseasesInfectionBleeding…

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Initial Office Visit

• Identify all risk factors• Medical history, general examination, o

bstetric examination• High-risk pregnancies - individualized s

pecialized care

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1.History

First interview :Age, Occupation, menstrual, etc

LMP normal cycle (28d)EDC 40w or 280d Naegele’s rule: Naegele’s rule: EDC = LMP-3 months + 7daysEDC = LMP-3 months + 7dayse.g. LMP:2012-04-01 EDC:2013-01-08 LMP (last menstrual period)EDC (expected date of confinement)

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1.HistoryA. Maternal Age • <16y – dystocia (Macrosomia, position of the fetus, pelvis immaturity… )• ≧35y -pregnancy-induced hypertension, diabete

s, obesity, chromosomal abnormalitiesB. Modality of Conception • ART (test-tube baby)- multiple gestation, pregna

ncy-induced hypertension, preterm birth

ART (assisted reproductive technologies )

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C. Pastmedical History• DM ， hypertension, seizure disorder, cardiac c

onditions• Previous blood transfusion (blood group antibod

y, infection virus ) • Drug sensitivitiesD. Family History• Inherited diseases, retardation, birth defects, perin

atal deaths

1.History

DM (Diabetes mellitus)

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E. Lifestyle alcohol, tobacco, poor nutrition, eating d

isorder (folic, calcium, iron…)F. Teratogenic exposure x-rays, toxins, chemicals, medications

1.History

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1.HistoryE. Past Obstetric Historya. Habitual abortionb. Previous stillbirth or fetal deathc. Previous preterm deliveryd. isoimmunization （ Rh or ABO ） e. Previous preeclampsia-eclampsiaf. Previous infant with genetic disorder or congenital a

nomalyg. artificial abortion operation

app:ds:artificial

app:ds:abortion

app:ds:operation

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2.Physical Examination

A. General Examination Signs Vital: 　　 T temperature P pulse HR heart rate R respiratation BP blood pressure

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B. Obstetric examination

• abdominal examination • pelvic examination • check the birth canal• anal examination

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Leopold maneuvers

• First: What fetal part occupies the fundus?• Second: On what side is the fetal back?• Third: What fetal part lies over the pelvic inlet?• Fourth: On which side is the cephalic promine

nce?

Leopold maneuvers can describe : fetal lie, presentation, position, attitude

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step 1

step 4step 3

step 2

four maneuvers of leopold

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fetal heart tone auscultation sites

RSA

ROA LOA

LSAnavel

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C. Pelvic examination External pelvimetry:

Internal pelvimetry:

IS (interspinal diameter):23-26cmIC (intercristal diameter):25-28cmEC (external conjugate):18-20cm

DC (diagonal conjugate) :12.5-13cmTC (true conjugate): DC-1.5cm

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IS: interspinal diameter

EC:External conjugate

IC: intercristal diameter

4th/5th lumbar

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External conjugate External conjugate

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Pelvic measurements

C. Pelvic Examination a. Pelvic soft tissue b. Bony pelvis (inlet, midpelvis, outlet) c. cervical length:3-4cm

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Pelvic inlet

• Pelvic inlet: DC (diagonal conjugate) true conjugate=DC-1.5cm

Measurement of the DC

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Midpelvis

• Midpelvis – pelvis wall , sacrum curve sacrosciatic notches Ischial spine diameter 10cm

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Pelvic outlet

Subpubic angle>90°IT (intertuberal diamet

er)>8.5cmPS (Posterior sagittal

diameter)

• PS + IT > 15cm• outlet is adequate

Measurement of the BI

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internal pelvimetry item Pelvic inlet midpelvis Pelvic outlet

transverse diameter

13cm 10cm(ischial spine diameter )

8.5-9.5cmIT or TO

anteroposterior diameter

11.5cm(DC-1.5)

11.5cm 11.5cm

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Laboratory TestsA. Blood screening

hematocrit/ hemoglobin/ WBC/blood type/ serologic test for syphilis/ rubella/hepatitis B/HIV

HCG/ unconjugated estriol/AFP-- trisomy 21 and 18

early 1-hour post glucose Glucose level is checked after ingestion of 50g of glu (GDM)24-28w

15-20w

the first visit

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3.Laboratory Tests

B. Genetics Testing: age >35/ abnormal pedigrees

at 10-12w: CVS (chorionic villus sampling) at 16-18w: standard amniocentesisC. Urine Testing: urinary protein, glucose, and

ketones

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Subsequent Visits the standard schedule :• 0-32w: Once every 4 weeks• 32-36w: Once every 2 weeks• 36w-delivery: Once each week

0 32w

36w

delivery 4w 1w2w

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Visit

• Weight• Blood pressure• fundal height• abdominal examination • fetal heart tones• urine PR and GLU

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Nutrition In Pregnancy

• A balanced diet- calorie, protein, carbohydrate

• Special needs vitamin, folic acid, iron, calcium, and zinc

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FETAL ASSESSMENT

A. Assessment of prenatal diagnosis

a. Ultrasoundb. Amniocentesisc. Chorionic villus samplin

gd. Fetal blood sampling

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Assessment Of Prenatal Diagnosis

Ultrasound 2-D image: fetal number/ anatomy

/presentation /GA[placenta previa , placental mature, amniotic fluid, biparietal diameter (BPD), Cord around neck, fetal anomaly…]

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3-D image: certain anatomical anomalies4-D image: 3-D real time

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Amniocentesis (15-20w)• cytology for detection of infection• AFP (alpha-fetoprotein) evaluation for neural

tube defect assessment• Karyotype or DNA assaysRisks: Pain/Cramping Vaginal spotting Fetal loss(≤0.5%)

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Fetal Blood Sampling (2-3trimester) chromosomal or metabolic analysis of the fetus

assessment and treatment of certain fetal conditions (Rh sensitization and alloimmune thrombocytopenia)

Risk: fetal death

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Chorionic Villus Sampling (10-12w)• transcervically or transabdominally• availability earlier in pregnancy• allows for chromosomal status, fetal karyotype, a

nd DNA assays

Risks: 0.5% rate of complication Preterm delivery PROM (premature rupture of membranes) Fetal injury

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Assessment Of Fetal Well-being

1. Fetal Monitoring Techniques A. External Fetal Monitoring a continuous beam of ultrasound waves B. Internal Fetal Monitoring an electrode attached to the fetal scalp

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C. Sonographic Fetal Monitoring Biophysical profile• fetal breathing movements• fine motor movement • gross fetal tone• amniotic fluid volume

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2. Fetal Heart Rate Interpretation NST (nonstress test) Normocardia： 120-160bpm Tachycardia： >160bpm Mild=161-180bpm Severe≧181bpm Bradycardia： <120bpm

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NST

NST

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Fetal Heart Rate

• Periodic FHR changes : accelerations decelerations • Decelerations: different meaning depending

on when then occur in relation to contractions

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Early Decelerations

Early Decelerations: normal head compression during contractions no intervention

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late Decelerations

• late Decelerations: abnormal uteroplacental insufficiency intervention:

Change maternal positionGive oxygen by face maskStop oxytocin infusion, etc

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Variable Decelerations

Variable Decelerations: abnormalcord compression or head compression occur anytimeIntervention:

Amnioinfusionchange maternal positiondeliver fetus

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OCT (oxytocin challenge test)OCT positive

oxytocin challenge test

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Fetal distress

• Undulating Baseline• Severe bradycardia• Tachycardia with diminished variability un

related to drugs• Tachycardia associated with additional no

nreassuring periodic patterns

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Fetal Maturity Tests

1. L:S (Lecithin: Sphingomyelin Ratio) >22. PG (Phosphatidylglycerol)3. FSI (Foam Stability Index)4. CR (creatinine) 176.8mmol/L: renal maturit≧

y5. Bilirubin substances < 0.02: liver maturity6. The rate of fat-containing cells 20%: skin mat

urity

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AFI :the vertical depths of the largest pocketin each of four eaual uterine quadrants

DISORDERS OF AMNIONIC FLUID VOLUME

•AFI (amnionic fluid index) •Maximum amniotic fluid is at 28w – 800ml•After 28w, amniotic fluid decreases•At 40w, amniotic fluid is at 500ml

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DISORDERS OF AMNIONIC FLUID VOLUME

• Oligohydramnios: <300ml AFI < 8cm Suspected Oligohydramnios AFI < 5cm Oligohydramnios• Hydramnios (polyhydramnios): >2000ml AFI > 24cm

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First visit 6-8w 16-18w 26-28w

1.History and physical(H&P)

H&P H&P H&P

2.Labs test 2. Fetal exam(FHR)

2. FHFundal height

2. FHFundal heightFetal position

3. Genetic screen 3. Urine analysis and culture

3. Pelvic sonogram

3. Labs: DM

4. Patient education 4. HIV testing 4. Amniocentesis

4. Give Rho-GAM if nonsensitized RH(-)

5. MSAFP/estriol6. Urine analysisand culture

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32w 36w 38w 39w 40w

1.H&P 1.H&P 1.H&P 1.H&P 1.H&P






3. Urine analysis /culture





4.Cervical exam

4.Fetoplacental functional tests

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Question&Answer

1. What is prenatal period Ⅰ2. If an LMP =Nov 1st,2009; LMP=Feb,27th,2010, When is the EDC? 3.What is high risk pregnancy?4. What is the function of Leopold maneuvers?5. How to measure the DC and TC?6. What is the FHR deceleration? 7. What kinds of FHR deceleration is divided into?8. What are the indicators of lung maturity?9. How much is a normal amniotic fluid volume?

3 pregnancy monitoring

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