Diagnosis of pregnancy &antenal care for undergraduate

1. Diagnosis of pregnancy DR: MANAL BEHERY Zagazig University , Egypt

2. Principles of diagnosis • In the majority of women, the diagnosis of pregnancy is usually straightforward based on a history of amenorrhea and a positive pregnancy test. • women with irregular periods or irregular vaginal bleeding , the diagnosis of pregnancy is more complex. • Other symptoms of pregnancy may alert the clinician to the possibility of pregnancy.

3. Symptoms of pregnancy: • Amenorrhoea: HOWEVER • Pregnancy may occur during period of lactation amenorrhea. • Slight bleeding early in pregnancy (threatened abortion) may be considered by the patient as menses . • Hartman's symptoms: slight bleeding occurs at time of menstruation

4. Symptoms of pregnancy: • Morning sickness:nausea, rarely vomiting confined to morning • Increased frequency of micturition. • Enlargement of the breastand sensation of heaviness. • Easy fatiguability and tendency to sleep. • Emotional changes e.g. change of the appetite:

5. In the second and third trimesters • 1-Abdominal enlargement • 2-Quickening -1st perception (sensation) of fetal movements by the lady • -PG (18-20 weeks), MP (16-18 weeks)

6. Signs of pregnancy

7. Chloasma gravidarum • Butterfly face • pigmentation

8. Breast signs • Increased pigmentation of the nipple and lry areola.

9. Appearance of Montgomery tubercle in the areola • dilated sebaceous glands

10. Abdominal stria

11. Linea nigra

12. - Abdominal signs Inspection:-

13. 2- Palpation:

14. Auscultation: • Auscultation of FHS as early as 10-12 weeks by sonicade • Auscultation of FHS as early as 20-24 weeks by Pinard stethoscope • Auscultation of umbilical souffle as early as 20-24 weeks. • Auscultation of uterine souffl

15. Pregnancy tests:Principle: • Detection of • HCG in the • urine or • serum .

16. 1- Urinary pregnancy test: • Classically it becomes +Ve 7- 10 day after 1st missed period • Commercial testing kits are available that are sensitive to 25 iu/L in urine. • By the time the mother has missed her first menstrual period, her hCG levels are around 100 iu/L.

17. Serum pregnancy test: • Classically it becomes +Ve 5- 7 days before 1 st missed period • A quantitative serum HCG assay level of > 5 iu/L will usually denote a pregnancy. • With a normal intrauterine pregnancy, the hCG level doubles approximately every 36-48 hours.

18. Tran abdominal US

19. Transvaginal ultrasound ( TVS):

20. 12 WEEKS GESTATION • CROWN RUMP • LENGTH(CRL)

21. 2ND TRIMESTER

22. Sure signs of pregnancy: • Inspection of fetal parts as early as 20th week. • -Inspection of fetal movements as early as 20th week. • Palpation of fetal movements as early as 20th week. • -Palpation of fetal parts as early as 20th week.

23. Sure signs of pregnancy • -Auscultation of FHS at 10-12 weeks by sonicade • Investigations: Visualization of fetal parts by ultrasound

24. ANTENATAL CARE

25. Definition • Antenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of labor • It is a preventative cost effective service

26. GOALS • 1-Ensure mother health. • 2- Ensure delivery of a healthy infant. • 3-Anticipate problem • 4- Diagnose problem early.

27. Objectives • 1-Early detection and if possible, prevention of complications of pregnancy. • 2-Educate women on danger and emergency signs & symptoms. • 3-Prepare the woman and her family for childbirth • 4- Give education & counseling on family planning

28. Schedual of antenatal care: Medical check up every four weeks up to 28 weeks gestation, Every 2 weeks until 36 weeks of gestation Every week until delivery An average 7-11 antenatal visits/pregnancy More frequent visits may be required if complications arise.

29. On first antenatal visit • 1-First : Confirm pregnancy by pregnancy test or US. • 2-History • 3-Physical examination • 4-investigation

30. History • Personal history • Menstrual history • Obstetrical history • Family history • Medical and surgical history • History of present pregnancy

31. Menstrual history • Ask about • 1-Last menstrual period (LMP). • 2-Regularity and frequency of menstrual cycle. • 3-Contraception method used . • 4-Calculate expected date of delivery (EDD)as 1st day of LMP −3 months +7 days, and change the year.

32. Obstetric History • Gravidity? Parity? abortion, and living children. • Weight of infant at birth & length of gestation. • Type of delivery, location of birth, and type of anesthesia. • Maternal or infant complications.

33. Medical and surgical history: 1-Chronic conditions : as diabetes mellitus, hypertension, and renal disease ,cardiac disease. 2-Prior operation: as cesarean section, genital repair, and cervical cerclag. 3-Allergies, and medications. 4-Accidents involving injury of the bony pelvis

34. History of present pregnancy • History suggesting e.g. Diabetes, hypertension and ante partum hemorrhage. • Ask about episodes of fever or chills • Ask about pain or burning sensation on urination. • Abnormal vaginal discharge, itching at the vulva or if partner has a urinary problem.

35. Emergency symptoms • Vaginal bleeding • Severe abdominal ,epigastric, or pelvic pain • Severe headache with visual disturbance • Persistent vomiting • Unconscious/Convulsion • Severe difficulty in breathing • Fever, chills , dysurea • Absent fetal movement

36. Assessment and physical examination

37. Weight measurement • Maternal height and weight measurements to determine body mass index(BMI). • Maternal weight should be • measured at each • antenatal visit

38. Check for pallor or anemia. 1-Look for palmar pallor. 2-Look for conjunctival pallor 3-Count respiratory rate in one minute.

39. Blood pressure measurement • Measure BP in sitting position. • If diastolic BP is 90 mm Hg or higher repeat measurement after 6 hour rest. • If diastolic BP is still 90 mm Hg or higher ask the woman if she has: • Severe headache • Blurred vision • Epigastricpain • Check urine for protein.

40. Investigations Get baseline on the first or following the first visit. • Hemoglobin, blood type • Urine analysis • VDRL or RPR to screen for syphilis • Hepatitis B surface antigen To detect carrier status or active disease

41. At each visit

42. At each visit • 1-Questions about fetal movement • 2-Ask for danger signs during this pregnancy • 3-Ask patient if she has any other concerns

43. Symphysis Fundalhieght • LMP plus 280 days • Add 7 days, subtract 3 months • MacDonald's Rule (cm = weeks)

44. At third trimester Do Leopold’s exam

45. Provide advice on • Diet and weight gain • Medication • Avoid Radiation exposure • Self-care during pregnancy • Minor complaints. • Family planning Breastfeeding • Birth place preparation and anticipation of complication& Emergency situations.

46. Diet in pregnancy: • Total caloric intake increase to 300 kcal /day due to 15% increase in BMR . • Diet show contain 20%Protein(better from animal source), 30% fat ,and 50% carbohydrates . • Sufficient fluids should be available.

47. Supplementation • 1-Folic acid 0.4 mg tab daily • 2- iron (ferrous sulphate or gluconate )300 mg/daily • 3- Ca 1200mg /daily • 4- • -Those with a normal balanced diet • probably don’t need extra vitamins

48. Weight gain in pregnancy: • There is a slight loss of pounds during early pregnancy if the patient experiences much nausea and vomiting. • Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of the first trimester. • Gain of 1 lb(0.5)/ per wk is expected during the second and third trimesters. • Monitoring of weight gain should be done in conjunction with close monitoring of BP.

49. Medications During Pregnancy • Antibiotics - some OK, some not • Local anesthetics - OK • Local with epinephrine - not OK • Aspirin - not OK • Immunizations - some are OK, some are not • Antimalarial - some OK, some are not • Narcotics - OK except for addiction issue

50. Case Study