Diagnosis of pregnancy &antenatal care for undergraduate

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