Diagnosis of pregnancy and maternal assessment

diagnosis of pregnancy,,,,

1. Diagnosis of pregnancy and maternal assessment Deepthy P.Thomas 1 st year MSc nursing Govt college of nursing Alappuzha.

2. Presumptive signs of the pregnancy Breast changes. Nausea and vomiting. Amenorrhoea. Frequent urination. Fatigue and uterine enlargement. Quickening. Linea nigra . Melasma . Striae gravidarum

3. Probable signs of pregnancy   Chadwick’s sign. Goodell’s sign. Hegar’s sign. Evidence on ultrasound of gestational sac. Ballotment . Braxton’s hick contraction. Fetal outline felt by the examiner .

4. Positive signs of pregnancy Demonstration of a fetal heart separate from the mother’s heart. Fetal movements felt by an examiner. Visualization of fetus by ultrasound.

5. FIRST TRIMESTER SUBJECTIVE SYMPTOMS : Amenorrhoea Morning sickness Frequency of micturition Breast discomfort Fatigue

6. OBJECTIVE SIGNS Breast changes : Per abdomen Pelvic changes Jacquemer’s sign 8 th week Vaginal sign osiander’s sign 8 th week

7. Cervical signs Goodell’s sign 6 th week Uterine signs Size shape and consisitency piscacek’s sign Hegar’s sign between 6-10 weeks Palmer’s sign as early as 4-8 weeks

8. IMMUNOLOGICAL TESTS FOR THE DIAGNOSIS OF PREGNANCY Agglutination inhibition tests : Direct agglutination test: The sensitivity is 0.2 IU Hcg /ml. Enzyme-linked immunosorbent assay : It is based on one monoclonal antibody that binds the hCG in urine and serum. ELISA can detect hCG in serum upto 1-2 mIU /ml and as early as 5 days before the first missed period. Fluroimmuno assay : the fluroscence emitted is proportional to the amount of hCG . it can detect hCG as low as 1 Miu /ml. FIA takes 2-3 hours.

9. Immune assays with radioisotopes : Radioimmunoassay: It is more sensitive and can detect β subunit of hCG upto 0.002 IU/ml in the serum. It can detect pregnancy as early as 8-9 days after ovulation. It requires 3-4 hours to perform . Immune-radiometric assay: Uses sandwich principle to detect whole hCG and require only 30 mts . SELECTION OF TIME : by 8-11 days after conception. The test is not reliable after 12 weeks

10. ULTRASONOGRAPHY Intra decidual gestational sac - 29 - 35 days of gestation. Fetal viability and gestational age is determined by detecting the following structures by transvaginal ultrasonography. Gestational sac and yolk sac by 5 menustral weeks. Fetal pole and cardiac activity- 6 weeks. Embryo movements by 7 weeks. Fetal gestational age is measuring the CRL the fetal heart reliably by 10 th week.

11. SECOND TRIMESTER SYMPTOMS Quickening at 16 to 18 weeks It denotes the perception of active fetal movements by the women Progressive enlargement of the lower abdomen GENERAL EXAMINATION Cloasma Pigmentation over the forehead and cheek may appear at about 24 th week.

12. Breast changes: Breasts are more enlarged with prominent veins under the skin. Secondary areola specially demarcated in primigravidae , usually appears at about 20th week. Montgomery’s tubercles are prominent and extent to the secondary areola. Colustrum becomes thick and yellowish by 16 th week. Variable degree of striae may be visible with advancing weeks

13. ABDOMINAL EXAMINATION : Inspection : linea nigra as early as 20 th week and Striae   Palpation Fundal height the height of the uterus is midway between the symphysis pubis and the umbilicus at 16 th week. At the level of umbilicus at 24 th week. At the junction of the lower third and upper two-third of the distance between the umbilicus and ensiform cartilage at 28 th week.

14. ABDOMINAL EXAMINATION The uterus feels soft and elastic Braxton’s-Hicks contraction Palpation of fetal parts Active fetal movements External ballotment Auscultation : Fetal heart sound: Uterine souffle : Funic or fetal souffle :

15. VAGINAL EXAMINATION :   The bluish discolouration: Internal ballotment INVESTIGATIONS : Sonography : Routine sonography at 18-20 weeks permits a dilated survey of fetal anatomy, placental localization and the integrity of the cervical canal Fetal organ anatomy MRI

16. LAST TRIMESTER SYMPTOMS : Amenorrhoea persists . Enlargement of the abdomen Lightening Frequency of micturition Fetal movements SIGNS :   Cutaneous changes Uterine shape: it is changed from cylindrical to spherical beyond 36 th week

17. Fundal height The fundal height corresponds to the junction of the upper and middle third at 32 weeks. Upto the level of ensiform cartilage at 36 th week. It comes down to the level of 32 weeks at 40 th week because of the engagement of the fetal head. To determine whether the uterus height is correspond to 32 weeks or 40 weeks, engagement of the head should be tested .

18. Braxton’s-Hick contraction Fetal movements are easily felt Palpation of fetal parts FHS Sonography Amniotic fluid assessment is done to detect oligohydramnios [AFI<5] or polyhydramnios [AFI>25].

19. DIFFERENTIAL DIAGNOSIS OF PREGNANCY   Pseudocyesis Cystic ovarian tumor and fibroids Encysted peritonitis

20.   MATERNAL ASSESSMENT aims of maternal assessment are: To identify the high risk cases. To prevent and detect and treat at the earliest any complications. To ensure continued risk assessment and to provide ongoing primary prevention health care. To educate the mother about the physiology of pregnancy, labour, newborn care and lactation. To discuss with the couple about the place, time, and the mode of delivery.

21. PROCEDURES AT THE FIRST VISIT The initial interview Demographic data Chief concern Family profile Present history Past history Obstetric history

22. Menstrual history Gynaecological history Personal history Family history PHYSICAL EXAMINATION Baseline height and weight measurement Vital signs Head and scalp Eyes Nose Ears Mouth and oral cavity

23. Neck Breasts Thorax Back Rectum Extremities and skin ABDOMINAL EXAMINATION Preliminaries Inspection Palpation Height of the uterus Obstetric grips

24. Auscultation The relationship of the fetus to the uterus and pelvis Lie Presentation Attitude Denominator Position Presenting part

25. PELVIC EXAMINATION External genetalia Internal genetalia Vaginal inspection Examination of pelvic organs Estimating pelvic size The diagonal conjugate The true conjugate The ischial tuberosity

26. LABORATORY METHODS : BLOOD STUDIES :   A complete blood count: Genetic screen Serologic test for syphyllis Blood typing Maternal serum alfa feta protein Indirect coomb’s test Antibody titres for rubella and hepatitis B HIV testing Glucose tolerance test URINALYSIS

27. ULTRASONOGRAPHY 1 ST TRIMESTER 2 ND 3 RD TRIMESTER Confirm pregnancy Confirm viability Determine gestational age Rule out ectopic pregnancy Detect multiple gestation Use for visualization during chori - onic villus sampling Detect maternal abnormalities Establish or confirm date Confirm viability Detect polyhydramnios , oligohy - dramnios Detect congenital anomalies Detect IUGR Confirm placenta placement visualization during amnio - centesis Confirm gestational age Confirm viability Detect macrosomia Detect congenital anomalies Detect IUGR Determine fetal position Detect placenta previa or abruptio placentae visualization during amnio - centesis , external version Biophysical profile Amniotic fluid volume Detect placental maturity

28. First Trimester Second and Third Trimester 1. Gestational sac location 2. Embryo and/or yolk sac identification 3. Crown-rump length 4. Cardiac activity 5. Fetal number, including amnionicity and chorionicity of multiples when possible 6. Assessment of embryonic/ fetal anatomy appropriate for the first trimester 7. Evaluation of the uterus, adnexa, and cul-de-sac 8. Assessment of the fetal nuchal region if possible 1. Fetal number; multifetal gestations: amnionicity , chorionicity , fetal sizes, amnionic fluid volume, and fetal genitalia, if visualized 2. Presentation 3. Fetal cardiac activity 4. Placental location and its relationship to the internal cervical os 5. Amnionic fluid volume 6. Gestational age 7. Fetal weight 8. Evaluation of the uterus, adnexa, and cervix 9. Fetal anatomical survey, including documentation of technical limitations Components of Ultrasound Examination by Trimester

29. sonographic evaluations The standard specialized examinations limited examination Nuchal Translucency Fetal Biometry Gestational Age Amnionic Fluid Fetal weight Shepard’s formula : Log 10 EFW[ gm ]=1.2508+(0.166*BPD)+0.046*AC)-(0.002646*AC*BPD). Hadlock’s formula : Log 10 EFW[ gm ]= 1.3596-0.00386(AC*FL)+0.0064(AC)=0.00061 (BPD*AC)+0.0425(AC)

30. SPECIAL INVESTIGATIONS IN HIGH RISK PREGNANCY Maternal serum alpha fetoprotein Triple test Acetyl choline esterase ( AChE ) Amniocentesis Chorionic villous sampling Fetal movement count Cordocentesis Vibroacoustic stimulation (VAS) Fetal biophysical profile (BPP) Modified biophysical profile

31. Fetal cardiotocography (CTG) Doppler ultrasound velocimetry Placental grading Contraction stress test ( CST) Amniotic fluid volume assessment (AFV) Amniocentesis in late pregnancy : Pulmonary maturity : Assessment of severity of Rh- isoimmunisation Amnioscopy

32. SIGNS INDICATING COMPLICATIONS OF PREGNANCY Vaginal bleeding Persistent vomiting Chills and fever Sudden escape of clear fluid from vagina Abdominal or chest pain Increase or decrease in fetal movement

33. MINOR AILMENTS DURING PREGNANCY Morning sickness Heartburn Varicose veins Backache Breathlessness Palpitations Vaginal discharge Constipation