ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD. The importance of the problem avoiding exposure to teratogens (e.g. drugs) solving abnormal situations (e.g

ASSOCIATE PROFESSOR IOLANDA BLIDARU

MD, PhD

The importance of the problemThe 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

DiagnosisDiagnosis• history• clinical examination• laboratory tests

Diagnosis of pregnancyDiagnosis of pregnancy

The duration of pregnancy in humansThe duration of pregnancy in humans• 259 - 294 days =37-42 weeks• medium= 280 days (40 weeks)

During the first half – maternal signs prezumptive diagnosis

During the second half – fetal signs diagnosis of certitude

History

amenorheeaamenorheea increased E2 and P secretion by luteal corpus

Conditions• previous regular, spontaneous, predictible menstruations • absence of menstruation for min. 10 days

• general informations

• personal data• family history• personal medical history• obstetrical history• data about the partener• contraceptive history

Diagnosis ofDiagnosis of pregnancypregnancy in the first 16 weeks in the first 16 weeks (I-st(I-st trimester)trimester)

Breasts symptoms• enlargement• heaviness or tension• mastodinia, tenderness

Digestive• nausea ( over 50%) and vomiting• sialoreea • pyrozis • alteration of apetite, taste, smell, food preferences

appeared during 4-6 weeksdisappeared spontaneously after 12-14 weeks

Urinary bladder irritability (compresion)

Nervous sleep difficulties, irritability, insomnia

Neuro-vegetative symptoms

Diagnosis ofDiagnosis of pregnancypregnancy in the first 16 weeks in the first 16 weeks (I-st(I-st trimestertrimester))

History

Diagnosis ofDiagnosis of pregnancypregnancy in the first 16 weeks (I-st in the first 16 weeks (I-st trimestertrimester))

Clinical signsInspection 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


Clinical signs Palpation Breasts - specific consistency - colostrum (occasionally) – thick, yellowish fluid, expressed

from the nipplesAbdomen- pregnant uterus – the upper margin of a globulous, soft

mass - the height of the uterine fundus becomes measurable

(cm)


Clinical signs Obstetrical examinationCervix, vagina and perineum (speculum examination)- increased vascularity and hyperemia- characteristic violet-bluish color of the mucosa – Chadwick

sign- increased size of the cervixUterus (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

Diagnosis ofDiagnosis of pregnancypregnancy in the first 16 weeks in the first 16 weeks (I-st(I-st trimester)trimester)

Noble sign

Hegar sign

Piscaceck sign


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


Laboratory diagnosisPrinciple: 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

hCG in plasma and urine


Ultrasound imagingabdominal 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.

Diagnosis ofDiagnosis of pregnancypregnancy in the first 4-5 in the first 4-5 weeks (I-stweeks (I-st trimestertrimester))

Diagnosis ofDiagnosis of pregnancypregnancy between the 17- 28 weeks between the 17- 28 weeks (II-nd(II-nd trimestertrimester))

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

InspectionFace: chloasma (melasma gravidarum) = 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 scarsPerineum – accentuation of pigment



Clinical signs Palpation Breasts: specific consistency, colostrum expressed from the

nipplesAbdomen: - 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 signAscultationfetal heart sounds (110-160 b/min), with obstetrical

stethoscope, near umbilicus



Clinical signs Obstetrical examination – cont.

Speculum examination (cervix, vagina and perineum) - hyperemia- Chadwick sign (violet-bluish color of the mucosa) - increased size of the cervixBimanual examination (uterus)- softening of the vagina, cervix, lower segment and upper segment- enlargement of the uterus- Braxton-Hicks contractions- vaginal ballottement


Differential diagnosis

abdominal mass

ovarian cyst with abdominal development

uterine myoma


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.

Diagnosis ofDiagnosis of pregnancypregnancy between the 29 - 40 weeks between the 29 - 40 weeks (III-rd(III-rd trimestertrimester))

Clinical signs- amenorrhea (> 29 weeks)- progressive enlargement of the abdomen- perception of the fetal movements by the mother/examinatorInspectionFace: chloasma (melasma gravidarum) = mask of pregnancy Breasts: increased vascularity, Montgomery tubercules,

pigmented primary areola and the nipple, secondary areola Abdomen: enlargement, linea nigra, striae gravidarum,

protruded umbilicus, pigmented previous surgical scarsPerineum – accentuation of pigment


Clinical signs Palpation Breasts: specific consistency, colostrum expressed

from the nipplesAbdomen (Leopold manoevers): Superficial palpation - pregnant uterus (a globulous, soft, contractile, painless

mass, Braxton-Hicks contractions - measurement of the height of the uterine fundus


Diagnosis ofDiagnosis of pregnancypregnancy between the 29 - 40 weeks between the 29 - 40 weeks (III-rd(III-rd trimestertrimester))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)Ascultationfetal heart sounds (110-160 b/min) in vertex presentation –

below the umbilicus




Clinical signs Obstetrical examinationSpeculum 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


Ultrasound imagingabdominal 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

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?

Probable evidence of pregnancyEnlargement 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

Positive signs of pregnancyIdentification 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)

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

Documents

ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD. The importance of the problem avoiding exposure to teratogens (e.g. drugs) solving abnormal situations (e.g