DIAGNOSIS MODALITIES OF PREGNANCY.pptx

diagnosis modalities of preganancy:obg

1. Diagnosis modalities of pregnancy

2. DIAGNOSTIC MODALITIES OF PREGNANCY Introduction: Many changes occur in woman’s body during pregnancy. These changes although most apparent in the reproductive organs, involve other body systems as well. Weeks may pass before the family realizes she has become pregnant or she may learn upon a visit to a doctor for other reasons Confirmation of her pregnancy is most important for the health & welfare of herself & the baby. In this lesson, we will cover the tests used to determine pregnancy

3. Risk Approach Screening: Blood testing Excessive weight gain of the mother due to fluid retention. Falling weight also poses risk as there can be intrauterine growth retardation. Pre-existing hypertension or PIH Excess amount or decreased amount of amniotic fluid is another risk factor. Other approaches, which should be followed for high-risk cases, are: non-invasive & invasive methods are used

4. Non - Invasive Methods: Examination of the woman’s uterus from outside the baby. Listening to the fetal heart sound External fetal monitoring It includes: 1) Ultrasonography  2) Non Stress Test  3) Contraction Stress Test (CST)  4) Amniotic Fluid Index (AFI) 5) Cardiotocography 

5. Invasive Methods: 1.Chorionic villus sampling 2. Amniocentesis 3. Fetoscopy  4. MSAFP: Maternal Serum Alpha Feto Protein. 5. Cordocentesis 6. Amnioscopy .

6. Objectives of Invasive & Non - Invasive: Diagnosis: To reduce maternal and fetal mortality rate.  To check fetal growth and development. To enable timely medical or surgical treatment of a condition before or after birth To give the parents the chance to abort a fetus with the diagnosed condition To give parents the chance to "prepare" psychologically, socially, financially, and medically for a baby with a health problem or disability, or for the likelihood of a stillbirth

7. Non - Invasive Methods:  1. ULTRASONOGRAPHY (USG) An ultrasonography is a diagnostic technique, which uses high-frequency sound waves to create an image of the internal organs. A screening ultrasound is sometimes done during the course of a pregnancy to check normal fetal growth and verify the due date. It is a safe , non invasive, accurate and cost effective investigation Hard tissues such as bone appear white on the image and soft tissues appear grey.

8. USG Indications: In the first trimester: To establish the dates of a pregnancy To determine the number of fetuses and identify placental structures To diagnose an ectopic pregnancy or miscarriage To examine the uterus and other pelvic anatomy In some cases to detect fetal abnormalities as anencephaly

9. Mid - Trimester:  To determine the number of fetuses and examine the placental structures To assist in prenatal tests such as an amniocentesis, Cordocentesis . To examine the fetal anatomy for presence of abnormalities To check the amount of amniotic fluid by measuring AFI. To examine blood flow patterns To check on the location of placenta; to see if its covering cervix To observe fetal behavior and activity

10. Third Trimester:  To monitor fetal growth, to check IUGR Detailed anatomical survey.  To check the amount of amniotic fluid to determine the position of a fetus To assess the placenta

11. Types of ultrasounds performed during pregnancy  Abdominal ultrasound Transvaginal ultrasound

12. Abdominal ultrasound:  In an abdominal ultrasound, gel is applied to the abdomen and the ultrasound transducer glides over the gel on the abdomen to create the image

13. Procedure: Trans Abdominal USG: Explain the procedure to the patient.  Provide privacy  Provide supine position to the patient. Apply gel

14. Nursing responsibility before procedure: Explain the purpose of procedure and how it will be done. Advise for drink lots of water so that full bladder to capture clearer images Provide privacy. Provide supine position (dorsal position). The abdominal wall is prepared and draped. Check USG 

15. Transvaginal Ultrasound: A smaller ultrasound transducer is inserted into the vagina and rests against the back of the vagina to create an image. A transvaginal ultrasound produces a sharper image and is often used in early pregnancy.

16. Indication of Transvaginal ultrasound: Early month of pregnancy In this high frequency of sound waves used so greater resolution is possible Typical gynaecological indication includes uterine size, evaluation of endometrium, myometrium, cervix.

17. The confirmation of lung maturation is done to minimize the chances of respiratory distress syndrome of the baby.  In this test, specifically we are looking for Lecithin : Sphingomyelin ratio and identification of phosphatidyl glycerol.  Fetal movement count- In the later pregnancy, fetal well-being is assessed by having the fetal movement count.  In Cardif 'count 10' formula , the patient is told to count the 10 fetal movements, starting from a particular time.  She should report to the physician, if she feels less than 10 movements in 12 hours, on two consecutive days.   In Daily fetal movement count (DFMC), mother is told to count the fetal movements for one hour, three times a day (say, morning, afternoon and evening).  Later, the total count is multiplied by 4, which gives DFMC.  Mother should report if she feels less than 10 movements in 12 hours.

18. Contraindication: Allergy to latex.  Vaginal infection

19. PROCEDURE A probe is placed into the vagina instead of over the abdomen. Provide dorsal lithotomy position with empty bladder. Vaginal probe should be lubricated with gel and the probe should be inserted into an appropriate covering sheeth such as condom The sheath covered probe is gently advanced up the vaginal canal If ultrasound is done before the week 11, it would be transvaginal

20. Safety of USG: Ultrasounds bring no long term or short-term harm to both mother and baby. In fact, it is a useful scanning tool. Because the waves are of very low intensity, there is no danger in repeating the scans, if your condition merits it. However if pregnancy is normal, then 2 routine scans as part of antenatal care. More scans are only necessary if any medical condition

21. 2. NON  - STRESS TEST Definition: A nonstress test (NST) is a screening test used in pregnancy to assess fetal status by means of the fetal heart rate and its responsiveness.

22. Purpose: To assess the fetal wellbeing To measure the heart rate in response to its own movements Concept of NST:  Oxygen is required for fetal activity and heart rate to be with in normal ranges. Time to Perform NST: After 28 weeks of gestation. Between 38-42 weeks. As early as beginning of third trimester.

23. Indications: 1.Post dated mothers 2.GDM 3.IUGR 4.Placental and cord abnormalities 5.Absence of fetal movements  6. As a precaution 

24. Non - Stress Test: Findings depends upon the following components: Fetal Heart rate Fetal movement Fetal Heart Rate Ranges Normal Baseline FHR 110–160 bpm Moderate bradycardia 100–109 bpm Moderate tachycardia 161–180 bpm Abnormal bradycardia < 100 bpm Abnormal tachycardia > 180 bpm

25. Interpretation

26. Non - Stress Test: Advantages: Non invasive. Painless. Lack of risk to mother and fetus . immediate results

27. Disadvantages: False positive results during fetal sleep. 40 min gives most sleeping fetus time to awaken. Awaiting acceleration prolong

28. 3. CONTRACTION STRESS TESTS CST is done to see whether fetus remains healthy during reduced oxygen levels (contraction). Definition: CST or oxytocin challenge test evaluates FHR in the presence of spontaneous or oxytocin-induced contractions.

29. Purpose: To assess fetal placental functioning. Fetus ability to cope up with continuation of high risk pregnancy and stress of labor

30. Indications: a) In abnormal biophysical profile. b) Gives better picture of your baby than NST c) Contractions , fetal breathing movements, fetal muscle tone, and AFI can be checked. Risks: False positive results Prolonged contractions Labor starts before EDD

31. Sl.no Steps Rationale 1. Take client to prenatal testing unit. Ensures that qualified personnel conducts test. 2. Explain the client the procedure. Gain co-operation.   3. Position the client in semi-fowlers position. Eliminates supine hypotension. 4. Place client on an external monitor. An USG to record FHR and CTG for contractions

32. 5. Record client BP initially and at 5-10 min intervals. To determine supine hypotension. 6. Obtain atleast 10 min base line recording (FHR AND contractions) To test fetal well being. 7. Prepare and begin oxytocin infusion.  a)start oxytocin infusion.  b)client is evaluated by physician when dose is 10 mu/mt Can discontinue the infusion in hyperstimulation. To test adequate uterine contractions and FHR.

33. Advantages: Follow up of non reactive NST. More informative. Disadvantages: Contra-indicated in placenta praevia,LSCS,PROM . Utero placental perfusion reduced due to hyperstimulation. Time consuming.

34. 4. AMNIOTIC FLUID INDEX    Amniotic fluid index (AFI) is a rough estimate of the amount of amniotic fluid and is an index for the fetal well-being. AFI is the score (expressed in cm) given to the amount of amniotic fluid seen on pregnant uterus and calculated by a ultrasonograph ( ultrasound). To determine the AFI, doctors may use a four-quadrant technique , when the deepest, unobstructed, vertical length of each pocket of fluid is measured in each quadrant and then added up to the others , or the so called "Single Deepest Pocket" technique.

35. Method to evaluate amniotic fluid volume: Most popular method to evaluate amniotic fluid volume is four quadrant technique to calculate Amniotic Fluid Index (AFI). AFI is obtained by measuring the vertical diameter of largest pocket of amniotic fluid in 4 quadrants of uterus by USG and the sum of the result is AFI AFI :    <5cm - Oligohydromnios  5 - 10cm - Decreased amniotic fluid volume 10 - 19cm - Nomal 20 - 25cm - Increased amniotic fluid volume >25cm - Polyhydromnios     

36. Cardiotocography:

37. 5. Cardiotocography: Introduction: Cardiotocography (CTG) is a test used in pregnancy to monitor both the fetal heart pattern as well as the uterine contractions. It should only used in the 3rd trimester when fetal neural reflexes are present. Its purpose is to monitor fetal well-being & allows early detection of fetal distress antenatal or intra-partum.

38. Difference Between NST & CTG: A Nonstress test (NST) is a screening test used in pregnancy to assess fetal status by means of the fetal heart rate and its responsiveness. A Cardiotocograph (CTG) is used to monitor the fetal heart rate and presence or absence of uterine contractions.

39. Indications for CTG: Maternal indications Fetal indications A. Maternal medical disorders: Pregnancy induced hypertension Diabetes mellitus Anemia and other hematolog.dis . Chronic hypertension Cardiac disease Collagen disease Renal disease Thyroid disease B. Bad obstetric history C. Post-date pregancy 1. Reduced fetal movements 2. Suspected IUGR 3. Abnormal FHR by auscultation 4. Multiple pregnancy 5. Rhesus iso- immunisation 6. Before induction

40. Parts of CTG: It involves the placement of 2 transducers on the abdomen of a pregnant woman: one transducer records the fetal heart rate using ultrasound beam , the other transducer records uterine contractions

41. Findings depends upon the following components 1. Baseline fetal heart rate 2. Baseline variability 3. Accelerations 4. Decelerations

42. Baseline fetal heart rate: The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm. Baseline variability: The minor fluctuations in baseline FHR occurring at three to five Cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of  fluctuation in a one-minute segment of the trace

43. D ecelerations: Early: Head compression Late : Utero-Placental Insufficiency Variable: Cord compression and Primary CNS dysfunction

44. Interpretation: Negative:No late deceleration with adequate contractions  Positive  : late deceleration with adequate contractions  Equivocal :No positive or negative window occurs Hyper stimulation Excessive uterine activity is present in association with deceleration of FHR Unsatisfactory: Inadequate FHR record or contractions. Test should be repeated with in 24 hours 

45. Tachycardia: Hypoxia Chorioamnionitis Maternal fever B-Mimetic drugs Fetal anaemia, Sepsis Heart Failure  Arrhythmias

46. Categorization of fetal heart rate traces:   Category Definition Normal All four reassuring Suspicious 1 non-reassuring  Rest reassuring Pathological 2 or more non-reassuring  1 or more abnormal

47. Suspicious CTG: CTG Pattern  Cause Clinical Management Early  2nd stage None Late Uterine hypercontractily Stop oxytocin Consider terbutaline sc Oxygen @ 8-10 l/min Left lateral decubitus Variable Cord compression Consider amnioinfusion (mild/mod v.d.) Tachycardia Maternal fever,tachycardia,dehydration Infection screen Hydrate - crystalloids Stop tocolysis if pulse>120

48. Invasive methods     Maternal Alpha- Fetop protein Amniocentesis Chorionic Villus Sampling (CVS)  Cordocenthesis or Percutaneous Umblical cord Blood sampling  (PUBS) Fetoscopy  Amnioscopy

49. 1. Maternal Alpha - Fetoprotein Screening (MAFP): A blood test that measures the level of alpha- fetoprotein in the mothers' blood during pregnancy. AFP is a fetal protein normally produced by the fetal liver and is present in the fluid surrounding the fetus (amniotic fluid), and crosses the placenta into the mother's blood. The AFP blood test is also called MSAFP (maternal serum AFP)Maternal Alpha-Fetoprotein screening (MAFP) 

50. Indication: All pregnant women are usually offered the AFP test. But, the doctor may recommend the test, especially if : Mother is 35 or older Have a family history of birth defects Have diabetes Have taken certain drugs or medication during pregnancy Time of performing test:- 15-18 weeks

51. Abnormal levels of AFP may signal the following: MSAFP level high indicates: 1. Open neural tube defects (ONTD) such as spina bifida 2. Other chromosomal abnormalities lead to IUFD 3. Defects in the abdominal wall of the fetus 4. Twins more than one fetus is making the protein 5. A miscalculated due date 6. Renal anomalies.

52. MSAFP level low indicates: Down’s syndrome Gestational trophoblastic disease

53. 2. Amniocentesis: It is a medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections. In which a small amount of amniotic fluid, which contains fetal tissues, is extracted from the amniotic sac surrounding a developing fetus , and the fetal DNA is examined for genetic abnormalities.

54. Amniocentesis: Definition : It is deliberate puncture of the fluid sac per abdomen. Indication :- Diagnostic Early and later therapeutic procedure Time of performing: It is performed between the 15th-20th weeks of pregnancy. Mostly during the 18th week.

55. Contraindication: Acute skin infections near the site of needle placement. Maternal fever Allergies to material used like skin preparation materials, local anesthesia. May be difficulty in-patient with multiple pregnancies

56. Amniocentesis: Maternal complication Infection Allo immunisation of the mother Preterm labor and delivery Hemorrhage Fetal complication Miscarriage Respiratory distress, Postural deformities Fetal trauma. Oligo hydramnions due to leakage of Amniotic fluid

57. Nursing responsibility before procedure: Before procedure, take written consent. Explain the purpose of procedure Emptying the bladder AND Provide privacy. Provide supine position with elevated head

58. The abdominal wall is prepared aseptically and draped. Check the vital sign and FHR to obtain base line data. Check USG. Prophylactic administration of 100 mg of anti –D immunoglobulin in Rh negative mother. The proposed site of puncture is unfiltered with 2 ml of 1% lignocainE

59. Nursing responsibility after procedure: Fetus should be monitored for short period after procedure, check FHR every 30 minutes. Tell patient, to report physician if uterine cramping, vaginal bleeding or leakage of fluid or fever. Strenuous activities should be avoided for 24 hours following an amniocentesis

60. Chorionic Villus Sampling CVS:

61. 3. Chorionic Villus Sampling CVS: Chorionic villous sampling a form of prenatal diagnosis to determine chromosomal or genetic disorders in the fetus . It entails getting a sample of the chorionic villus (placental tissue) and testing it. It can be performed in a transvaginally or transabdominal manner Performing time: Before 15 weeks, usually performed between the 10th and 12th weeks of pregnancy.

62. Indications: Abnormal first trimester screen results Increased AFP or other abnormal ultrasound findings Family history of a chromosomal abnormality or other genetic disorder Parents are known carriers for a genetic disorder maternal age above 35 Contraindication: Active vaginal bleeding Infection Multiple gestation HIV infection

63. Complications: Miscarriage in CVS in about 0.5 - 1%. Infection and amniotic fluid leakage. The resulting amniotic fluid leak can develop into a condition known as oligohydramnions Mild risk of Limb Reduction Defects associated with CVS, especially if the procedure is carried out in earlier terms (before 12th week of pregnancy). Fetal loss. Infection Vaginal bleeding

64. Nursing responsibility after procedure: • Fetus should be monitored for short period after procedure, check FHR every 30 minutes. • Tell patient, to report physician if uterine cramping, vaginal bleeding or leakage of fluid or fever. • Strenuous activities should be avoided for 24 hours following a CVS. • Anti –D immunoglobulin 50 ug IM should be administered following the procedures to the Rh negative women’s

65. 4. Cordocentesis or Percutaneous Umbilical Cord: Blood Sampling (PUBS): It is a diagnostic genetic test that examines blood from the fetal umbilical cord to detect fetal abnormalities. PUBS provides a means of rapid chromosome analysis and is useful when information cannot be obtained through amniocentesis, CVS, or ultrasound Time of performance:-18 weeks of gestation

66. Cordocentesis: Procedure: PUBS is similar to amniocentesis, but instead of sampling the amniotic fluid which surrounds the fetus, PUBS examines fetal blood Before the start of the procedure, a local anesthetic is given to the mother. After the local is in effect, a 25 gauze spinal needle 13 cm in length is usually inserted through the mother's abdominal wall An advanced imaging ultrasound determines the location for needle insertion, and the needle is guided through the mother's abdomen and uterine wall into the fetal vein of the umbilical cord, approximately 1-2 cm from the placenta. The sample can then be sent for chromosomal analysis.

67. Complications: Miscarriage is the primary risk associated with PUBS Blood loss at the puncture site, Infection, and Premature rupture of membranes. During the procedure, the mother may feel discomfort similar to a menstrual cramp. Cord hematoma formation Preterm labor

68. 5. Fetoscopy:

69. 5. Fetoscopy: A fibreoptic instrument that can be passed through the abdomen of a pregnant woman to enable examination of the fetus and withdrawal of blood for sampling in prenatal diagnosis. Definition: Examination of the pregnant uterus by means of a fiber-optic tube. Time of performing: 18th week of pregnancy.

70. Complication: Miscarriage, as high as 12%. Excessive bleeding, infection, or excessive leakage of the amniotic fluid. Preterm rupture of the membranes which may require early delivery of your baby . Mixing your blood with babys blood

71. 6. Amnioscopy: Definition: Direct observation of the foetus and the colour and amount of the amniotic fluid by means of a specially designed endoscope inserted through the uterine cervix. Contraindication Cervix is in insufficiently dilated

72. Amnioscopy:

73. Complication: Sepsis Rupture of membrane