Diagnosis of Pregnancy

Diagnosis of Pregnancy first trimester

A. Presumptive symptoms
1. Amenorrhea
- abrupt cessation of spontaneous, cyclic, and predictable
menstruation
- the menses should be at least 10 days late before their absence
is considered a reliable indication
2. Breast changes
- women report tenderness in the breasts and breast enlargement
3. Nausea (with or without vomiting) (so-called morning sickness of
pregnancy)
- gastrointestinal disturbances begin at 4 to 6 weeks' gestation
and usually last no longer than the first trimester
4. Disturbances in urination

- early in pregnancy, the enlarging uterus puts pressure on the

bladder, causing frequent urination

Diagnosis of Pregnancy first trimester

from the LMP through the first 12 to 13 weeks of pregnancy
B. Clinical evidence
Uterine and cervical changes
- uterus enlarges and softens early in pregnancy, by 12 weeks, the body
of the uterus is almost globular
- during pregnancy, the vaginal mucosa usually appears dark bluish and
congested - Chadwick sign
- the softening between the cervix and the uterine fundus causes a
sensation of separateness between these two structures - Hegar sign

C. Calculating the Estimated Date of Confinement (EDC)

The mean duration of pregnancy is 280 days or 40 weeks.
The EDC is therefore 9 calendar months plus 7 days from the start of the
LMP; it is customary to estimate the EDC by counting back 3 calendar
months and adding 7 days to the LMP (Naegele rule)

Diagnosis of Pregnancy first trimester

C. Confirming the diagnosis of pregnancy
1. Endocrine tests for pregnancy
- depend on human chorionic gonadotropin (hCG) levels in maternal
plasma and excretion of hCG in the urine, which are identified by a
number of immunoassays and bioassays.
- the presence of hCG can be demonstrated in maternal plasma by 8
to 9 days after ovulation. The serum test is more sensitive than the
urine test

2. Ultrasonographic recognition of the fetus

- after 5 weeks of amenorrhea, an early chorionic (gestational) sac is
visible as a small, fluid-filled structure surrounded by an echogenic rim
of tissue on transvaginal ultrasound.
- the embryo is apparent within the gestational sac after 6 weeks of
amenorrhea.
- fetal heart activity is seen by real-time ultrasonography after 6 weeks
of gestation

Diagnosis of Pregnancy second trimester

A. Symptoms
1. Amenorrhea
2. Sensation of fetal movement
- between the 16th and 20th week after the last menstrual period (LMP), a
woman begins to feel movement in the lower abdomen
B. Clinical evidence
1. Enlargement of the abdomen
- By the end of the 12th week of pregnancy, the uterus can be felt above the
symphysis pubis. By the 20th week, the uterus should be at the level of the
umbilicus
2. Palpation of Fetus
- the fetus and fetal movements may be palpated after 18 weeks. This may
be more easily accomplished by a vaginal examination
3. The fetal heartbeat
- can be detected by auscultation with a standard nonamplified stethoscope
by 18 - 20 weeks

Diagnosis of Pregnancy third trimester

from 28 weeks of pregnancy until term, or 40 weeks' gestation
A. Symptoms
1. Braxton Hicks contractions
- palpable uterine contractions that are mild and irregular, can begin
during the second trimester
2. Sensation of fetal movement
B. Clinical evidence

Diagnosis of Pregnancy third trimester

1. Lie of the fetus
- the relation of the long axis of the fetus to the long axis of the uterus
a. Longitudinal lie - in most labors (more than 99%) at term, the fetal head is
either up or down in a longitudinal lie.
b. Transverse lie - the fetus is crosswise in the uterus in a transverse lie.
c. Oblique lie - this indicates an unstable situation that becomes either a
longitudinal or transverse lie during the course of labor.

2. Fetal presentation
- is determined by the portion of the fetus that can be felt through the cervix.
a. Cephalic presentations the presenting part is fetal head
b. Breech presentations classified according to the position of the legs and
buttocks

3. Fetal Position
- refers to the relationship of the fetal back the right or left side of the
maternal birth canal (two positions: right or left)

Leopold Maneuvers

First Maneuver - permits identification

of which fetal polethat is, breech or
headoccupies the uterine fundus
Second Maneuver - indicates the fetal
back to be on one side of the abdomen
and the small parts on the other
Third Maneuver - using the thumb and
fingers of one hand, the lower portion of
the maternal abdomen is grasped just
above the symphysis pubis
(differentiation between head and
breech, movable/engaged
Fourth Maneuver - the presenting part
is engaged or not

Antepartum Care

Antepartum Care
Prenatal care should be initiated as soon as there is a reasonable
likelihood of pregnancy.
The purpose of prenatal care is to ensure, as much as possible,
an uncomplicated pregnancy and the delivery of a live,
healthy infant

Initial Prenatal Evaluation

The major goals are:
- to define the health status of the mother and fetus.
- to estimate the gestational age of the fetus.
- to initiate a plan for continuing obstetrical care.

Initial Prenatal Visit: History

A. Complete obstetric history
Definitions:

Gravida: describes the number of pregnancies

Nulligravida: describes a woman who is not now and never
has been pregnant
Parity: describes a woman who has delivered a fetus
Nulliparous: describes a woman who has never delivered a
fetus
Primipara: describes a woman who has delivered only once
Multipara: describes a woman who has delivered more than
once

Initial Prenatal Visit: History

B. For each prior pregnancy, the following information should be

obtained: time of delivery, weight of infant, anesthesia, mode of

delivery (spontaneous vaginal delivery, forceps-assisted vaginal
delivery, cesarean section

C. Identification of prior pregnancy complications

- History of prior preterm birth or preterm premature rupture of
membrane
- History of gestational diabetes, preeclampsia, shoulder dystocia

D. Complete medical, surgical, and gynecologic history

- women with medical diseases such as pregestational diabetes and
chronic hypertension require additional counseling, laboratory
evaluation, and fetal surveillance.
- a history of any medications taken and any possible exposures in
the first trimester should be obtained.

E. Thorough family history of both parents

F. Social history (including screening for substance abuse)

Initial Prenatal Visit: Physical Examination

A. A complete physical examination should be performed at
the initial visit.
- height,
- weight
- blood pressure should be recorded.

B. Pelvic examination should include:

- evaluation for abnormal vaginal discharge
- performance of cervical cultures and Pap smear
- assessment of cervix and uterine size
- assessment of the bony pelvis

Initial Prenatal Visit: Lab Examination

Blood Screening
- hematocrit, hemoglobin
- glucose level
- blood type group, Rh factor (antibodies if Rh-)
- serologic test for syphilis (VDRL or RPR),
- hepatitis B
- HIV
- rubella, toxoplasmosis

Urine Testing
Papanicolaou Smear

Subsequent Prenatal Visits

A.Frequency
In uncomplicated pregnancies, visits occur every 4 weeks
until 24 to 28 weeks, and then the frequency increases to
every 2 to 3 weeks. After 36 weeks, visits occur every week
until delivery.
Complicated pregnancies require closer surveillance.

B. Each visit includes:

- maternal weight
- blood pressure
- assessment of uterine size, and
- assessment of fetal heart tones

Nutrition
A. Weight gain
The recommended weight gain during pregnancy is 10- 12 kg.
B. Calories
Recommended diet should be 2500 kcal/day for pregnant women
C. Dietary composition
- Protein: requirement is ~ 60 g/day (best sources: meat, milk, eggs,
poultry, cheese)
- Iron: recommended intake is 30 mg elemental iron /day (usually
found in prenatal vitamins, some women may require still more iron
supplementation.
- Calcium: recommended intake is 1200 mg daily from diet or with
addition of calcium supplement.
- Folic acid: recommended intake is 400 - 1000 g/day to prevent
neural tube defects (a history of an infant with a neural tube defect - 4
mg/day)

Lifestyle Modifications
A. Exercise
- It is necessary to limit exercise, the level of intensity should be
decreased
B. Travel
- does not have harmful effects (long flights - to move around the
cabin every 2 hours to prevent deep vein thrombosis.
C. Coitus
- In uncomplicated pregnancies, sexual intercourse does not pose
harm to the pregnancy
D. Smoking
- low-birth-weight infants, preterm birth, placental abruption, and
sudden infant death syndrome

Lifestyle Modifications
E. Alcohol
- fetal alcohol syndrome (craniofacial defects, growth
restriction, and mental retardation)
F. Caffeine
- no teratogenic effects, associated with spontaneous abortion
at very high levels (more than 5 cups per day).
H. Medications
Most drugs administered during pregnancy cross the placenta
and reach the fetus. The Food and Drug Administration (FDA)
created five categories based on risk to the fetus (should be
consulted when prescribing medication in pregnancy)