DIAGNOSIS OF PREGNANCY

1. DIAGNOSIS OF PREGNANCY ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

2. The importance of the problem • avoiding exposure to teratogens (e.g. drugs) • solving abnormal situations (e.g. ectopic pregnancy, hydatidiform mole) • initial assessment and monitoring through prenatal care • history • clinical examination • laboratory tests Diagnosis The duration of pregnancy in humans • 259 - 294 days =37-42 weeks • medium= 280 days (40 weeks) prezumptive diagnosis During the first half – maternal signs During the second half – fetal signs diagnosisof certitude Diagnosis of pregnancy

3. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) • personaldata • family history • personalmedical history • obstetricalhistory • data about the partener • contraceptive history • generalinformations increased E2 and P secretion by luteal corpus • amenorheea History • Conditions • previous regular, spontaneous, predictible menstruations • absence of menstruation for min. 10 days

4. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) • enlargement • heaviness or tension • mastodinia, tenderness • Breasts symptoms History • Neuro-vegetative symptoms • nausea ( over 50%) and vomiting • sialoreea • pyrozis • alteration of apetite, taste, smell, food preferences Digestive • appeared during 4-6 weeks • disappeared spontaneously after 12-14 weeks Urinary bladder irritability (compresion) Nervous sleep difficulties, irritability, insomnia

5. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Clinical signs Inspection • Breasts - increase in size - venous network (Haller) - Montgomery tubercules (sebaceus glands) - minute hyper-pigmentation of the areola and the nipple • Abdomen - linea nigra - progressive deformation upward symfizis pubis (after 12 weeks) • Perineum– accentuation of pigment

6. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Clinical signs Palpation • Breasts - specific consistency - colostrum (occasionally) – thick, yellowish fluid, expressed from the nipples • Abdomen - pregnant uterus – the upper margin of a globulous, soft mass - the height of the uterine fundus becomes measurable (cm)

7. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Clinical signs Obstetrical examination Cervix, vagina and perineum (speculum examination) - increased vascularity and hyperemia - characteristic violet-bluish color of the mucosa – Chadwick sign - increased size of the cervix Uterus (bimanual examination) - softening of the cervix, isthmus (Hegar sign) and uterine corpus - enlargement of the uterus (4cm per month) - irregular, painless uterine contractions – Braxton-Hicks contractions

8. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Noble sign Hegar sign Piscaceck sign

9. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Differential diagnosis - abdominal mass: ovarian cyst, uterine myoma, trophoblastic disease, ectopic pregnancy, bladder globus - amenorrhea: in the emotional stress, endocrine disfunctions, lactation, anorexia, certain treatments (e.g. antidepressants, metyldopa, haloperidol), pseudocyesis

10. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Laboratory diagnosis Principle: presence of hCG in plasma and urine - produced by syncytiotrophoblast - peak at 60-70 days - biological tests (laboratory animals) - immunological tests – β-hCG (monoclonal anti-HCG antibody serum assays); home test kit (ELISA, RIA, etc) - detection and quantification

11. hCG in plasma and urine

12. Diagnosis ofpregnancy in the first 16 weeks (I-sttrimester) Ultrasound imaging - abdominal sonography - vaginal sonography can detect an uterine pregnancy 1 week after the missed menstruation AIMS - assessment of the amnionic sac dimensions (4-5 weeks) - visualize the fetus and the placenta (position, aspect) - measure fetal crown-rump length (FCR) - detects twins, ectopic pregnancy, missed abortion, hydatidiform mole.

13. Diagnosis ofpregnancy in the first 4-5 weeks (I-sttrimester)

14. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester) Clinical signs - amenorrhea (> 16 weeks) - progressive enlargement of the abdomen - perception of the fetal movements by the mother beginning with 17-18 weeks (multiparas) up to 19-20 weeks (primiparas) = quickening Inspection • Face: chloasma (melasmagravidarum) = mask of pregnancy • Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola • Abdomen: enlargement, linea nigra, stria (reddish, slightly depressed streaks), protruded umbilicus, pigmented scars • Perineum– accentuation of pigment

15. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester)

16. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester) Clinical signs Palpation • Breasts:specific consistency, colostrum expressed from the nipples • Abdomen: - pregnant uterus – a globulous, soft, contractile, painless mass - irregular, painless uterine contractions – Braxton-Hicks contractions - the height of the uterine fundus becomes measurable (16cm – 20 weeks, 20cm – 24 weeks) - ballottement sign Ascultation • fetal heart sounds (110-160 b/min), with obstetrical stethoscope, near umbilicus

17. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester)

18. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester) Clinical signs Obstetrical examination – cont. Speculum examination (cervix, vagina and perineum) - hyperemia - Chadwick sign (violet-bluish color of the mucosa) - increased size of the cervix Bimanual examination (uterus) - softening of the vagina, cervix, lower segment and upper segment - enlargement of the uterus - Braxton-Hicks contractions - vaginal ballottement

19. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester) Differential diagnosis abdominal mass • ovarian cyst with abdominal development • uterine myoma

20. Diagnosis ofpregnancy between the 17- 28 weeks (II-ndtrimester) Laboratory diagnosis - biological tests – no more - immunological tests – β-hCG (detection and quantification) Ultrasound imaging abdominal sonography / vaginal sonography AIMS - gestational age (BPD, FL, AC) - fetal morphology and biometry - multiple pregnancy - fetal heart movements - placental insertion, a.f.

21. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester) Clinical signs - amenorrhea (> 29 weeks) - progressive enlargement of the abdomen - perception of the fetal movements by the mother/examinator Inspection • Face: chloasma (melasmagravidarum) = mask of pregnancy • Breasts: increased vascularity, Montgomery tubercules, pigmented primary areola and the nipple, secondary areola • Abdomen: enlargement, linea nigra, striaegravidarum, protruded umbilicus, pigmented previous surgical scars • Perineum– accentuation of pigment

22. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester) Clinical signs Palpation • Breasts:specific consistency, colostrum expressed from the nipples • Abdomen (Leopold manoevers): Superficial palpation - pregnant uterus(a globulous, soft, contractile, painless mass, Braxton-Hicks contractions - measurement of the height of the uterine fundus

23. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester)

24. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester) Clinical signs • Abdomen: Deep palpation - identification of the presenting part (if the head, it is firm, rounded, large, regulated) - lateral palpation – on the sides of the uterus (the back is an elongated firm mass; the limbs are small, irregular parts) Ascultation • fetal heart sounds (110-160 b/min) in vertex presentation – below the umbilicus

25. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester)

26. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester)

27. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester) Clinical signs Obstetrical examination Speculum examination (cervix, vagina and perineum) - hyperemia - Chadwick sign (violet-bluish color of the mucosa) - increased size of the cervix - external cervical os - slit-like or round, with mucous plug Bimanual examination - softening of the vagina, cervix, lower segment and upper segment (patulous cervix admits a fingertip) - fetal presenting part, membranes

28. Diagnosis ofpregnancy between the 29 - 40 weeks (III-rdtrimester) Ultrasound imaging abdominal sonography / vaginal sonography AIMS - fetal morphology and biometry (BPD, Fl, AC) - fetal heart movements, - breathing movements - evaluation of the amniotic fluid - placental insertion and maturation degree

29. Presumptive evidence of pregnancy • Subjective symptoms - nausea +/- vomiting - disturbances in urination - fatigue - the perceptions of fetal movements • Presumptive signs - cessation of menses - changes in the breast - changes in the cervical mucus - discoloration of the vaginal mucosa - increased skin pigmentation and development of abdominal striae - does the woman believe that she is pregnant?

30. Probable evidence of pregnancy • Enlargement of the abdomen • Changes in the shape, size and consistency of the uterus • Anatomical changes in the cervix • Braxton-Hicks contractions • Ballottement • Physical outlining of the fetus • Presence of β-hCG in serum or urine

31. Positive signs of pregnancy • Identification of fetal heart activity separately and distinctly (from mother) • Perception of fetal movements by the examiner • Recognition of the embryo / the fetus throughout imagistic methods (ultrasound)

32. Gestational age assessment • First day of the last menstrual period (LMP) + no. of weeks • The day when the mother has felt the first fetal movements (quickening) + 22 weeks in multiparas, or 20 weeks in primiparas • The uterine height (UH) in cm + 4 =the number of gestational weeks • Ultrasound examination during the first 12 weeks of amenorrhea