Diagnostic evaluation of pregnancy presentation.pptx

Verification of zygote formation

1. DIAGNOSIS OF PREGNANCY Submitted to: Respected Dr. Harleen Kaur [ Professsor OBG Nursing] Respected Mrs. Ashmeen Kaur [ Nursing tutor OBG] Subitted by: Sarvan Singh BSC[NSG] 4 th YEAR

2. MENSTRUAL AGE Also known  GESTATIONAL AGE From the first day of the last menstrual period… 9 MONTHS AND 7 DAYS 280 DAYS 40 WEEKS

3. TRIMESTERS

4. FIRST TRIMESTER  1 ST 12 weeks SECOND TRIMESTER  13 – 28 weeks THIRD TRIMESTER  29 – 40 weeks

5. Diagnosis in the first trimester (first 12 weeks) Symptoms: 1- Cessation of menstruation :(missed period): due to increased estrogen and progesterone production by the corpus Luteum . (Pregnancy during lactation amenorrhea). Slight bleeding at the expected time of menstruation rarely occurs in the first 3 months (Hartman ‘ s sign / placental sign) – scanty. Shouldn’t get confused with  Threatened abortion.

6. 2- Morning sickness : 50% cases - usually appears soon following the missed period. - Nausea , vomiting especially in the morning on rising from the bed. - Usually disappears after the third month.

7. 3- Freguency of micturition : - Due to congestion of bladder mucosa. Irritation of the bladder by the pregnant uterus. - resting of bulky uterus on the bladder ( anteverted position of the uterus). - change in maternal osmoregulation  leads to increased thirst and polyuria . - Usually disappears after the third month.

8. 4- Breast symptoms: Enlargement , heaviness , discomfort and pricking sensation  6 th – 8 th week specially in primigravidae . 5- Appetite changes: Craving for certain types of food and refusal of other types. 6- Fatigue: - frequent symptom that may occur in pregnancy and tendency to sleep

9. OBJECTIVE SIGNS

10. Breast signs : ( evident in a primigravida ). 6 - 8 weeks Increased size and vascularity  Dilated visible veins. Increased pigmentation of the nipple and 1ry areola. Appearance of 2ry areola. Appearance of Montgomery tubercles in the areola ( dilated sebaceous glands). Expression of colostrum (thick yellowish secretion) – as early as 12 th week

11. Appearance of Montgomery tubercle in the areola dilated sebaceous glands

12. PER ABDOMEN: Uterus remains a pelvic organ until 12 th week,it may be just felt per abdomen a suprapubic bulge. PELVIC CHANGES: JACQUEMIER’S OR CHADWICK’S SIGN OSIANDER’S SIGN GOODELL’S SIGN

13. JACQUEMIER’S SIGN Also known as Chadwick’s sign Dusky hue of the vestibule and anterior vaginal wall visible at 8 th week More pronounced as pregnancy advances and is more definitely present in multiparae . Due to local vascular congestion.

14. OSIANDER’S SIGN Increased pulsation , felt through the lateral fornices at 8 th week.

15. GOODELL’S SIGN Cervix becomes soft as early as 6 th week Softening is more surrounding the external os and also in the upper part. The pregnant cervix feels like the lips of the mouth. On speculum examination. The bluish discolouration of the cervix is visible  due to the increased vascularity .

16. 2. Uterine sign ; felt by bimanual examination: Size : enlarged. consistency : soft. Shape : globular. Hegar sign : ( elicited between 6-10 weeks). Two fingers in the anterior fornix, the fingers of the other hand over the abdomen behind the uterus . The fingers of both hands can be approximated as the lower part of the uterine body is soft and empty. Palmer sign : Uterine contractions felt on bimanual examination.

17. Immunological tests

18. This hormone is only released by trophoblastic tissue produced by a growing fetus and its associated placenta. hCG is present in the maternal circulation as either an intact dimer , alpha or beta subunit, and degraded form, or beta core fragment Detection of HCG in maternal serum and urine is evident only 8-10 days after conception HCG

19. hCG is detectable in the serum of approximately 5% of patients 8 days after conception and in more than 98% of patients by day 11 Diagnostic levels in Urine seen only about 23-24 days after conception. Levels peak at 10-12 weeks' gestation and then plateau before falling

20. In general, the HCG level will double every two to three days in early pregnancy

21. Currently, 4 main hCG assays are used, radioimmunoassay, immunoradiometric assay, enzyme-linked immunosorbent assay (ELISA), fluoroimmunoassay . Blood tests for HCG Used only in special cases ( bad obstetric history, suspicion of ectopic,etc.) Require special labs and expertise .

22. Radioimmunoassay Sensitivity - 5 mIU / mL Time to complete - 4 hours Postconception age when first positive - 10-18 days Gestational age when first positive - 3-4 weeks Immunoradiometric assay (more sensitive) Sensitivity - 150 mIU / mL Time to complete - 30 minutes Postconception age when first positive - 18-22 days Gestational age when first positive - 4 weeks Blood tests for HCG...

23. Immunoradiometric assay (less sensitive ) Sensitivity - 1500 mIU / mL Time to complete - 2 minutes Postconception age when first positive - 25-28 days Gestational age when first positive - 5 weeks Enzyme-linked immunosorbent assay (more sensitive) Sensitivity - 25 mIU / mL Time to complete - 80 minutes Postconception age when first positive - 14-17 days Gestational age when first positive - 3.5 weeks

24. Enzyme-linked immunosorbent assay (less sensitive) Sensitivity - Less than 50 mIU / mL Time to complete - 5-15 minutes Postconception age when first positive - 18-22 days Gestational age when first positive - 4 weeks Fluoroimmunoassay Sensitivity - 1 mIU / mL Time to complete - 2-3 hours Postconception age when first positive - 14-17 days Gestational age when first positive - 3.5 weeks

25. ULTRASOUND Intra decidual gestational sac is identified as early as 29 – 35 days of gestation Gestational sac & yolk sac -5 menstrual weeks Fetal pole and cardiac activity – 6 weeks Embryonic movements -7 weeks Doppler effect of US can pick heart rate reliably by 10 th week.

26. Diagnosis in the second trimester ( 13-28 weeks) Symptoms: Amenorrhea . Morning sickness and urinary symptoms gradually decrease . “ Quickening “ : perception of fetal movements by the pregnant woman: 18-20 weeks in primigravida . 16-18 week s in multipara . Abdominal enlargement .

27. ABDOMINAL EXAMINATION… INSPECTION: Linea nigra extending from symphysis pubis to ensiform cartilage  20 th week …

28. STRIAE ( both pink and white) visible in the lower abdomen more towards the flanks…

29. PALPATION: Fundal height – increased with progressive enlargement of the uterus.

30. The uterus is abdominally felt (ovoid). The uterus feels soft and elastic Braxton Hicks contractions; intermittent painless contractions detected by abdominal examination. Active fetal movements can be felt at intervals by placing the hand over the uterus as early as 20 th week. External ballottement : elicited at 20 week through abdominal examination. Palpation of the fetal parts and palpation of fetal movements by the obstetrician at 20 weeks.

31. Auscultation : Auscultation of FHS as early as 20-24 weeks by Pinard stethoscope Auscultation of funic /fetal souffle  due to rush of blood through the umblical artery Auscultation of uterine souffle (soft blowing and systolic murmur heard low own at the sides of the uterus)  synchronous with the maternal pulse

32. INVESTIGATIONS… SONOGRAPHY: Routine sonography at 18 – 20 weeks permits a detailed survey of fetal anatomy, placental localisation and the integrity of the cervical canal. FETAL ORGAN ANATOMY : To detect any malformation. FETAL VIABILITY RADIOLOGIC: 16 TH WEEK – FETAL SKELETAL SHADOW.

33. Diagnosis in the third trimester (29 - 40weeks) SYMPTOMS: Amenorrhoea persists Enlargement of the abdomen  leading to discomfort to the patient ( palpitaion or dyspnoea following exertion) LIGHTENING: 38 th week  sense of relief of the pressure symptoms due to engagement of the presenting part.

34. Frequency of micturition reappears Fetal movements are more pronounced.

35. SIGNS: Cutaneous changes are more prominent with increased pigmentation and striae . Uterine shape – from cylindrical to spherical beyond 36 th week FUNDAL HEIGHT (distance between the umbilicus and ensiform cartilage) Junction of the upper and middle third at 32 weeks. Level of ensiform cartilage at 36 th week Comes down to 32 weel level at 40 th week because of the engagement of the presenting part.

36. SYMPHYSIS FUNDAL HEIGHT: Upper border of the fundus located by ulnar border of the left hand and point is marked. Distance between the upper border of the symphysis pubis upto the point marked is measured in centemetre After 24 weeks, the SFH in cm corresponds to the number of weeks upto 36 weeks. Braxon -Hicks contraction – more evident Fetal movements – easily felt

37. Palpation of the fetal parts and their identification become much easier. F.H.S – heard distinctly SONOGRAPHY: Fetal growth assessment can be made more accurate. Amniotic fluid volume assessment – for oligo / poly.

38. DIFFERENTIAL DIAGNOSIS

39. UTERINE FIBROID CYSTIC OVARIAN TUMOUR ( Amenorrhoea absent firm, hard, positive sign absent, USG) ENCYSTED TUBERCULAR PERITONITIS (H/O Koch’s infection, swelling ill defined, positive signs absent, USG) HAEMATOMETRA DISTENDED URINARY BLADDER ( Catheterisation solves the problem) PSEUDOCYESIS