Diagnosis Of Pregnancy: Cheng Guomei

Chapter

4:

Diagnosis of Pregnancy Cheng Guomei Department of Gynecology and Obstetrics the Third Affiliated Hospital of ZhengZhou University

Diagnosis of pregnancy the first trimester

the second and third trimester

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fetal lie and presentation position

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The gestational period is the interval from LMP(Last menstrual period ) to delivery. Although obviously conception can not occur until 2 weeks after the beginning of this calculation. Fertilization (LMP) 

Fetus born

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The average duration is about 280 days or 40 weeks. It can be devided into 3 stages:

1. early pregnancy (the first trimester). Before 12 weeks of pregnancy 2. middle pregnancy (the second trimester) From 13 weeks to 27 weeks 3.late pregnancy (the third trimester) After 28 weeks

Section 1: diagnosis of early pregnancy 1 symptoms: ⑴amenorrhea: Is the earliest symptoms of pregnancy. ⑵ morning sickness: It is usually appears about 6 weeks and disappeared spontaneously 12 weeks later. ⑶ frequency of micturition : enlarging uterus presses on the bladder slightly.

2 signs: ⑴ changes on the breasts: The breasts is enlarged nipple area pigmentation occurs and appears the small nodules called Montgomery’s tubercles.  

Montgomer y’s tubercles

⑵ changes of the genital organs: The mucosa of the cervix and vagina appears purplish-red and congested. At about 6 to 8weeks after LMP, The softening at the isthmus is so marked that the cervix and the body of uterus seem to be separate organs, this is so called Hegar’s sign. The uter us is become bigger and bigger.

3 accessory examination:   ⑴ultrasonography: By B-mode ultrasonography,The gestational ring can be found after 6 weeks to identified the intrauterine pregnancy

⑵ pregnant test: The detection of HCG in urine or serum by immunological test is by far the most common test. HCG levels increase shortly after implantation,reach a peak at 50-75 days, and fall to lower levels later.

Section 2. diagnosis of the second and third trimester. 1. Symptoms: abdominal enlargement and presence of fetal movement.

2. Signs:

enlargement of uterus

e rth u s a m 12 周末 3 个月末 耻骨联合上 2~3 横指 th e ig trb e m y ig h 12th week later ） 3th month later 2~3 fingers ahead of pubic symphys e k m o n th fu rs b y 16 周末 w 4 个月末 脐耻之间 a h n d 16th week later)4th month later midpoint between umbilicus and pubic ymphy 20 周末 5 个月末 脐下 1 横指 18(15.3~21.4 20th week later 5th month later 1 finger under umbilicus 24 周末 6 个月末 脐下 1 横指 24(22.0~25.1 24th week later) 6th month later 1 finger ahead of umbilicus 28 周末 7 个月末 脐上 3 横指 26(22.4~29.0 28th week later) 7th month later 3 fingers ahead of umbilicus 32 周末 8 个月末 脐与剑突之间 29(25.3~32.0 32th week later) 8th month later midpoint between umbilicus and xipho poce 36 周末 9 个月末 剑突下 2 横指 32(29.8~34.5 36th week later) 9th month later 2fingers under xiphoid process 40 周末 10 个月末 脐与剑突之间或稍高 33(30.0~35.3) 40th week later) 10th month later midpoint between umbilicus and xiph process or more e g s ta io n lm e s u r

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36w later 32.40w later 28w later 24w later 20w later 16w later 12w later

the gestational age and the height of uterus vertex

⑵ fetal movement. From 18-20 weeks, fetal movement can be felt. The more weeks, the more active. ⑶ fetal heart sound. The fetal heart sound can be heard after 18 weeks. The rate about 120-160 bpm.(beats per minute)

⑷ fetal parts. Fetal parts are palpable after 20 weeks of preganacy.

3 accessory examination: ⑴ B-type ultrasonography: Can show the number of fetus. Fetal position. fetal heart beats. the position of placenta. 1. ⑵ fetal electrocardiogram: After 12 weeks, a regular ECG can be recorded.     

Section 3. fetal lie, fetal presentation and fetal position 1 fetal lie: means the relationship of longitudinal axis of fetus to that of mother. It has 3 type:

n tio a e s rh p d l~ u g L

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⑴ longitudinal lie: The most common.The longitudinal axis of fetus and mother are parallel

b re c h p s n ta io

⑵ transverse lie: The axis of fetus and mother are as at angle of 90 degree

n tio a e s rp ld u h ~ v T

⑶ oblique lie: Is a temporary situation

2 fetal presentation: Is the part of fetus first entering inlet of pelvis. Accordingly in longitudinal lies, The presenting part is either the fatal head or the breech. In transverse lies, A shoulder presentation is present.

c e a F w ro B tig m u p O n io ta e rs p n o ip ta s re 

fo e p y th T n o ita e s rp d a h

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The type of breech presentation

Compound presentation

e s rp d n u o m C n o ita

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Ordinarily the head is reflected sharply so that the chin is in contact with the thorax. In this circumstance, the presentation is usually referred to as a vertex or occiput presentation.

c o ip u tre s n a

Much less commonly, the fetal neck may be sharply extended. So that the occiput and back in contact and the face is foremost called face presentation.

fa c e p rs n tio

.

  3  fetal position: refers to the relation of an fixed point in presenting part to the maternal pelvis.    

The occiput vertex Is the Chin determining presentations,respectively part in Sacrum breech

With each presentation there may be two position, right or left.

face

Presentation Occiput ~ Face ~ Shoulder ~ Breech ~

Fixed point Expressed by Occiput ~ (O) Mentum ~ (M) Scapula ~ (Sc) Sacrum ~ (S)

the part of pelvis that the fixed point touched Left (L) right (R)

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Anterior (A) Post (P) Transverse (T)

O L A

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Right Occipito post R.O.P

Left Occipito-post L.O.P.

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The type and relationof presentation,fetal position Head presentation

O c ip u t

fa c e

L o n g itu d in a le

B re c h p re s n ta io

re d lu o h S

T ra n s v e lie

the

fetal

lie,

fetal

Affecting factors placenta

maternal

Fetal

fluid

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Placenta previa

Chapter FIVE : .

Prenatal

care

Perinatal period is the time from pre-to post-labor. There are 4 kinds of definition of perinatal period

⑴ From the full 28 weeks of gestation (fetal body weight>1000g, or height>35cm) to 1 week after labor . ⑵ From full 20 weeks of gestation (fetal body weight>500g, or height>25cm) to 4 weeks after labor.

⑶ From full 28 weeks of gestation weeks after labor.

to 4

⑷ From the formation of embryo to 1 week after labor. In China, the first one is adopted in the clinic.

Time for antenatal care 

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As early as possible and maintain a regular prenatal visits: At intervals of 4 weeks until 28 weeks Every 2 weeks until 36 weeks Weekly thereafter High-risk be examined more frequently

Initial visit 

Case history age occupation estimation for EDC menstrual and past pregnancy-delivery history past history the course of this pregnancy family history condition of the husband

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Physical examinations systemic examinations obstetrical examinations

1 prenatal visits. prenatal care should begin early and 0-28:every 4weeks High-risk pregnancy woman should be examined frequently

2 Estimation for EDC (expected date of confinement). By adding 7 days to the date of the first day of LMP and forward 9 months. For example: LMP Is January first 1999 EDC : October eighth 1999

3 Obstetrical examination. Palpation: The four maneuvers should be used. This can provide information about the presentation and position of the fetus.

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(1)The first maneuver :Put hands on the uterine fundus, to define which fetal pole is present.

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(2)The second maneuver:The palms are placed on either side of the abdomen gentle but deep pressure is exerted. On one side, a hard resistant structure is felt , It is the back.And on the other,the small parts.

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(3) The third maneuver:Employ the thumb and other fingers of one hand, the examiner grasps the lower portion of abdomen. If the presenting part is not engaged, a moveable body will be felt,if it is deeply engaged, the lower pole is fixed in the pelvic

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(4)The fourth maneuver:The examiner faces the mother,s feet,make deep pressure in the direction of the pelvic inlet. Gain information about the extent to which the presenting part has descended into the pelvis

R S A

A S L

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Auscultation: the fetal heart sounds are transmitted through the convex portion of the fetus, that is the nearest to the uterine wall, so fetal heart sounds are heard best through the fetal back in cephalic or breech presentation.

A o R

Transverse Lie

L O A

4 Pelvic measurement: The size and the shape of pelvic are very important for determining whether the fetus can be delivered through vagina.Therefore,pelvic measurement are essential for antenatal

tn e m rs u a lx E A: Interspinal diameter, IS: refers to the distance between the left and right anterior superior spine of ilium. The normal value is 23-26cm.

m e s a rth u e in rs p ld a m t

B: Intercristal diameter, IC: It refers to the widest distance from one outer fringe of iliac crest to the other. The normal range is 2528cm.

e h tru s a m la tis rc e n .re tm ia d

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C: External conjugate, EC: The distance between the interior part of the 5th lumber spine and the mid-point of superior margin of symphysis pubis. The normal range is 18-20cm. Be used to estimate the length of anterior posterior inlet diameter indirectly.

measure the external conjugate

D: Intertuberal diameter or transverse outlet TO: Measure the distance between the internal margin of ischial tuberosities. The normal value is 8.5-9.5cm.

m e a s u rth in b e a ld m tr

Internal measurement: A: The normal value of the distance between ischial spires is about 10cm. The examiner introduces two fingers into the vagina, reaching one ischial spine and then the other, estimate the distance between the two spines

m e a u s rth d in c e b tw n is c h a lp .

B: Width of incisura ischiadic: The distance between ischial spine and the lower part of sacrum is the width of incisura. Also the width of sacrospinous ligament.

Put the fingers on the ligament to see whether it has the capacity of 3 fingers side by side. If it has, there is no obvious narrow in midpelvis.

M e a s u rth w id o fin c s u ra h id c

Supplementary examination       

Lab Test for blood and urine routine Blood group, Rh type Test of hepatic funtion Examination of ECG HbsAg evaluation HIV screening Serologic test for syphilis

Return visit   

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Ask special conditions Weight ,blood pressure, urine Check fetal position and heart sounds Publicizing the knowledge of pregnancy health Predetermining the date of next visit

Advice to pregnant woman    

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Prenatal visits Eat a balanced diet Expect to gain 20~40 lb Abstain from alcohol, tobsacco and other drugs. Do not take medications unless prescribed by your physician. Avoid x-rays and noxious exposures.