DIAGNOSIS OF PREGNANCY AND

MATERNAL ASSESSMENT

Deepthy P.Thomas1st year MSc nursing Govt college of nursingAlappuzha.

PRESUMPTIVE SIGNS OF THE PREGNANCY

• Breast changes.• Nausea and vomiting.• Amenorrhoea.• Frequent urination.• Fatigue and uterine

enlargement.• Quickening.• Linea nigra.• Melasma.• Striae gravidarum

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.

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.

FIRST TRIMESTER

SUBJECTIVE SYMPTOMS:

AmenorrhoeaMorning sicknessFrequency of micturitionBreast discomfortFatigue

OBJECTIVE SIGNS

Breast changes: Per abdomenPelvic changes

Jacquemer’s sign 8th weekVaginal sign

osiander’s sign 8th week

Cervical signsGoodell’s sign 6th week

Uterine signsSize shape and consisitency

piscacek’s signHegar’s sign between 6-10 weeksPalmer’s sign as early as 4-8 weeks

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.

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

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.

SECOND TRIMESTER SYMPTOMS

Quickening at 16 to 18 weeks It denotes the perception of active fetal movements by the womenProgressive enlargement of the

lower abdomen GENERAL EXAMINATION

Cloasma Pigmentation over the forehead and cheek may appear at about 24th week.

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 16th week.

Variable degree of striae may be visible with advancing weeks

ABDOMINAL EXAMINATION:Inspection:

linea nigra as early as 20th week and Striae 

PalpationFundal height

the height of the uterus is midway between the symphysis pubis and the umbilicus at 16th week.

At the level of umbilicus at 24th week.At the junction of the lower third and upper two-third of the distance between the umbilicus and ensiform cartilage at 28th week.

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:

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 canalFetal organ anatomyMRI

LAST TRIMESTERSYMPTOMS:

Amenorrhoea persists.Enlargement of the abdomenLighteningFrequency of micturitionFetal movements

SIGNS:  Cutaneous changesUterine shape: it is changed from cylindrical to spherical beyond 36th week

Fundal heightThe fundal height corresponds to the junction of the upper and middle third at 32 weeks. Upto the level of ensiform cartilage

at 36th week.It comes down to the level of 32

weeks at 40th 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.

Braxton’s-Hick contractionFetal movements are easily felt

Palpation of fetal partsFHSSonography

Amniotic fluid assessment is done to detect oligohydramnios[AFI<5] or polyhydramnios[AFI>25].

DIFFERENTIAL DIAGNOSIS OF PREGNANCY

 PseudocyesisCystic ovarian tumor and fibroids

Encysted peritonitis

 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.

PROCEDURES AT THE FIRST VISIT

The initial interviewDemographic dataChief concernFamily profilePresent historyPast historyObstetric history

Menstrual history Gynaecological history Personal history Family historyPHYSICAL EXAMINATION Baseline height and weight

measurement Vital signs Head and scalp Eyes Nose Ears Mouth and oral cavity

NeckBreastsThoraxBackRectumExtremities and skinABDOMINAL EXAMINATIONPreliminaries InspectionPalpation

Height of the uterus Obstetric grips

AuscultationThe relationship of the fetus to the uterus and pelvisLiePresentationAttitudeDenominatorPositionPresenting part

PELVIC EXAMINATIONExternal genetaliaInternal genetaliaVaginal inspectionExamination of pelvic organs

Estimating pelvic sizeThe diagonal conjugateThe true conjugateThe ischial tuberosity

LABORATORY METHODS:BLOOD STUDIES: 

A complete blood count:Genetic screenSerologic test for syphyllisBlood typingMaternal serum alfa feta proteinIndirect coomb’s testAntibody titres for rubella and hepatitis B

HIV testingGlucose tolerance test

URINALYSIS

ULTRASONOGRAPHY1ST TRIMESTER 2ND 3RD 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

First Trimester Second and Third Trimester1. 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

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)

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

Fetal cardiotocography (CTG)Doppler ultrasound velocimetryPlacental gradingContraction stress test ( CST)Amniotic fluid volume assessment (AFV)

Amniocentesis in late pregnancy:Pulmonary maturity:Assessment of severity of Rh- isoimmunisation

Amnioscopy

SIGNS INDICATING COMPLICATIONS OF PREGNANCY

Vaginal bleedingPersistent vomitingChills and feverSudden escape of clear fluid from vagina

Abdominal or chest painIncrease or decrease in fetal movement

MINOR AILMENTS DURING PREGNANCY

Morning sicknessHeartburnVaricose veinsBackacheBreathlessnessPalpitationsVaginal dischargeConstipation