Diagnosis of Pregnancy

Diagnosis of Pregnancy

First Trimester

Presumptive signs:

·  Amenorrhoea-Absence of menstruation.

·  Morning sickness- Nausea, vomiting on rising from bed, loss of appetite.

·  Frequency of micturition due to congestion of the bladder mucosa.

·  Breast discomfort- feeling of fullness and ‘Pricking sensation’ is present.

·  Darkening of the nipples, primary and secondary areolar change.

·  Fatigue or tiredness.

Probable signs

·  Breast changes: The breasts are enlarged, evident between 6 to 8 weeks.

·  Vaginal Sign- The walls become softened and looks bluish in colour. Copious non irritating mucoid discharge appears at 6th week.

·  Osiander’s sign- There is increased pulsation, felt through the laternal fornices at 8th week.

·  Jacquemier’s or Chadwick’s sign - a bluish discoloration of the cervix, vagina and labia. This is due to local vascular congestion.

·  Hegar’s Sign- Upper part of the uterus is enlarged by the growing fetus, and lower part of the body of the uterus is empty and extremely soft.

Positive signs

·  Fetal heart sounds.

·  Fetal movements.

·  Fetal parts.

Diagnostic test:

·  Blood/urine test for Beta HCG (Human Chorionic Gonadotropin)

·  Ultrasonogram

Second Trimester (13-28 Weeks)

·  Quickening(feeling of life): The perception of active fetal movement by the woman. Usually felt during 18-20 weeks of pregnancy.

·  Progressive enlargement of the lower abdomen by a mass(fetus)

·  chloasma-Pigmenation over the forehead and cheek, appear at 24th week.

·  Braxton-Hicks contraction: Braxton-Hicks contraction-Irregular, Infrequent, spasmodic painless uterine contraction without any effect on dilation of cervix.

·  Ballottment of the uterus.

·  Fetal heart sound (FHS) is elicited around 20th weeks by fetoscope with doppler by 16th weeks.

Third Trimester (29-40 Weeks)

Symptoms

·  Amenorrhea continues

·  Enlargement of the abdomen

·  Lightening(fetal head sink in to the pelvic brim)

·  Frequency of micturition

Signs

·  Skin changes are more prominent

·  Uterine shape is changed from cylindrical to spherical

·  Fundal height up to the level of ensiform cartilage

·  Braxton Hicks contraction

·  Fetal movement are easily felt.

·  Fetal parts are Palpable.

·  Fetal heart rate

Calculation of Expected Date of Delivery [EDD]

EDD is calculated from first day of the Last Menstural Period [LMP] by using Naegle’s formula. For calculation, 9 calendar months and 7 days are added in the LMP

Gestational age – It is to be calculated as completed weeks of gestation

1. Antenatal Care

Antenatal care refers to the care given to an expectant mother from the time of conception to the beginning of labour. It includes,

·  Maternal health check ups.

·  Evaluation of fetal health and development

·  Detection of high risk pregnancies e.g GDM, PIH

·  Prompt intervention to prevent complications.

·  Health education. e.g Diet, exercise and follow up

Aims

·  To achieve a healthy mother and baby.

·  To provide psychological support to the women and her family.

·  To educate the women regarding health care during pregnancy.

·  To monitor progress of pregnancy and the baby.

·  To recognize deviation from the normal and provide treatment as required.

·  To prepare women physically and emotionally for the child birth, lactation and care of the baby.

·  To prevent congenital deformities by educating the mother to avoid smoking, substance abuse and self medications.

Antenatal Visits

Routine prenatal visits has been followed as convention and not an evidence based benefits.

·  Initial visits at early pregnancy (when a women missed her first period.

·  Every 4 weeks until 28 weeks

·  Every 2 weeks until 36 weeks

·  Every week until delivery

Antenatal visits should cover the following

·  History collection

·  Examination

·  Investigation

History Collection

a) Socio economic status

Low socio-economic status increases the risk of perinatal morbidity and mortality.

b) Age

Maternal age younger than 20 years increases the risk of premature births, late prenatal care, low birth weight, uterine dysfunction, fetal death, neonatal death

Maternal age older than 35 years increases the risk of first trimester miscarriage, genetically abnormal fetus, medical complication (Hypertension, Diabetes, Eclampsia), multiple gestation, fetal morbidity and mortality.

c)  Menstrual history

•  Age of menarche

•  Cycle : regular/irregular

•  Amount and duration of blood flow

• LMP- date is counted from the first day of the last menstrual period

•  EDD- calculate from LMP

d)  Contraceptive history

Use of contraceptives copper T, or oral pills.

e)  Past obstetric history

•  Previous miscarriage

•  Previous viable pregnancies

•  Still births or neonatal deaths

•  Method of delivery

•  Gestational age, sex and weight of infants

• Previous antenatal or postnatal complications

d)  Previous medical history

•  Diabetes

•  Cardiac diseases

•  Hypertension

•  Renal diseases

·  Infectious diseases such as HIV, Hepatitis B or C

e)  Personal history

•  Smoking

•  Alcohol

•  Substance abuse

f)  Family history

·  Diabetes

·  Hypertension

·  Tuberculosis

·  Twins

Examination

General state of health:

·  Build - obese, average, thin

·  Nutritional status - good, average, poor

·  Gait - normal, with a limp,

·  Postures - Kyphosis, Scoliosis, Lordosis

·  Personal hygiene

Height – A short stature women (<145cm) may have a small pelvis leading to difficulty in labour.

Weight - Monitor for weight gain regularly

·  Inadequate weight gain may indicate low birth weight baby,Intra Uterine Growth Retardation( IUGR )and poor perinatal outcome.

·  Excessive weight gain may be due to fluid retention, pre-eclampsia, multiple pregnancies, polyhydramnios.

Pallor – It is a indicative of anemia, examine conjunctiva, tongue and nails for pallor.

Jaundice – Yellowish discoloration of the sclera, palate and skin.

Oedema – Examine for pitting oedema over the legs above the medial malleolus.

Breast and nipple – Observe the skin changes over the breast, gently palpate the breast for any tumor or nodule, look for any crack or retracted nipple.

Teeth and gums – women with dental carries, gingivitis or poor oral hygiene should be reported.

Varicosities – Note the presence of varicose vein and their distribution.

Vital signs – Record pulse, respiration, temperature and blood pressure and report any abnormality.

Abdominal Examination should be performed in each visit.

Steps of Abdominal Examination:

·  Inspection

·  Palpation

Auscultation

Inspection

·  Abdomen

·  Size

·  shape

·  Contour – spherical, cylindrical, pendulous, flattened anteriorly, unduly enlarged or small.

·  Skin – Striaegravidarum and lineanigra

·  Scar of previous operations

·  Prominent veins, evidence of skin infections

·  Umbilicus - Flat and dimple

Uterus Size

12 Weeks-at the level of symphysis pubis

16 weeks- Half way between symphysis pubis

22 weeks- at the level of umbilicus

28 weeks- between umbilicus and Xiphoid process

32 weeks- below the xiphoid process

38 weeks- level of the xiphoid process

48 weeks- below the xiphoid process (if lightening occurs).

Palpation

·  Measure symphysis pubis - fundal height

·  Between 18-34 weeks measurements from pubis symphysis to the top of the uterus in cm correlates well with the weeks of gestation

Abdominal –palpation

·  Measuring fundal height (Leopold maneuver).

·  Fundal palpation(first maneuver)

·  lateral palpation(second maneuver)

·  Pelvic grip-I

·  Pelvic grip-II(Pawlik’s grip)

Feel for presenting part

·  Determine lie

·  Determine position of the presenting part

·  Engagement

Auscultation

Fetal heart rates can be identified by Doppler ultrasound by 12 – 24 weeks and by fetoscope at 18– 20 weeks.

Investigations

·  Urine test for confirmation of pregnancy, albumin and sugar

·  Blood test for

1.            grouping

2.            Rh-typing

3.            Blood sugar

4.            Haemoglobin

5.            HIV Antigen.

6.            VDRL

7.            HbsAg.

2. Antenatal Advice

Nutrition

·  Weight gain - the recommended weight gain in a normal pregnancy is 11.5 to 16 kg. Failure to weight gain may lead to IUGR, Low birth weight babies and poor perinatal outcome. Excessive weight gain may be due to fluid retention pre-eclampsia.

·  Calories & proteins – The pregnant women require 300 kcal/day protein promotes growth of the fetus, placenta, uterus, breast, red cells and production of milk. During pregnancy 1 g of protein is deposited half to the fetus and half to mothers.

·  Fats – Fats are important sources of energy. Phospholipids lower the surface tension in the lungs of the newborn.

·  Iron – Recommended iron intake is 30 – 60 mg of elemental iron per day. During pregnancy iron stores are depleted, supplementary iron is needed for both mother and fetus.

·  Calcium – Recommended calcium intake is 1200 mg per day.

·  Vitamins – Folic acid is required for the formation of heme. Deficiency of folic

acid may cause megaloblastic anaemia and neural tube defect in fetus.

Life Style Modification

·  Exercise– It is not necessary for a pregnant mother to limit her exercise but restriction may require in Placenta previa, Cervical incompetence, Pregnancy induced hypertension, Premature labour and multiple gestation.

·  Travel – No harmful effects have been identified. A pregnant woman should move around every 2 hours to prevent venous stasis and thrombus formation.

·  Bowel habit in pregnancy due to progesterone induced GI smooth muscle relaxes lead to increased transit time. Late in pregnancy compression on the bowel by the presenting part may cause constipation. Women may avoid constipation by liberal fluid intake, exercise and stool softner, bulking agents & mild laxatives.

·  Nausea & vomiting are common in the first and second trimesters, usually in the morning. Small frequent meals and avoidance of strong odours.

·  Sexual intercourse does no harm but should be avoided if there is pregnancy complication such as placenta praevia, rupture of membrane, preterm labour.

·  Smoking– women who smoke often have smaller infants with increased perinatal morbidity. Mothers are encouraged to quit smoking completely during pregnancy.

·  Alcohol should not be consumed during pregnancy. The fetal abnormalities associated with drinking (fetal alcoholic syndrome) include craniofacial defects, limb and CVS defects, prenatal and postnatal growth restriction and mental retardation.

Caffeine has no increase in teratogenic or reproductive risk.