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Diagnosis of Pregnancy Departmentment of ob & gyn Renmin Hospital of Wuhan University Zhuoni Xiao.

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Presentation on theme: "Diagnosis of Pregnancy Departmentment of ob & gyn Renmin Hospital of Wuhan University Zhuoni Xiao."— Presentation transcript:

1 Diagnosis of Pregnancy Departmentment of ob & gyn Renmin Hospital of Wuhan University Zhuoni Xiao

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4 Woman’s reproductive period Menarche Menopause years

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6 Duration of Pregnancy 10 lunar months ; 9 calendar months and 7 days ; 280 days ; 40 weeks Menstrual or gestational age

7 Fertilization or Ovulatory age 280 days -14 days=266 days

8 First trimester: first 12 weeks Second trimester: weeks Last trimester: weeks

9 Bladder Rectum

10 First trimester Subjective Symptoms Subjective Symptoms Objective Signs Objective Signs Immunological Tests Immunological Tests Ultra Sonograph Ultra Sonograph Pregnancy Diagnosis

11 Subjective Symptoms Amenorrhoea Amenorrhoea Warning :cyclic bleeding may last up to 12 weeks; Warning :cyclic bleeding may last up to 12 weeks; scanty and short time; scanty and short time; pathological bleeding,such as miscarriage pathological bleeding,such as miscarriage

12 Morning Sickness Morning Sickness Usually appears soon following the missed period; Usually appears soon following the missed period; Rarely lasts beyond 3 months Rarely lasts beyond 3 months

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14 Frequence of micturition Frequence of micturition troublesome symptom during 8-12 weeks troublesome symptom during 8-12 weeks enlarged uterus enlarged uterus congestion of bladder congestion of bladder change in maternal osmoregulation change in maternal osmoregulation

15 Breast discomfort Breast discomfort Fullness Fullness Pricking sensation Pricking sensation

16 Fatigue Fatigue Occur early in pregnancy Occur early in pregnancy

17 Objective Signs Breast changes Breast changes valuable only in primigravidae valuable only in primigravidae breast changes are evident between 6-8 weeks breast changes are evident between 6-8 weeks (vascular engorgement & nipple and areola pigment) (vascular engorgement & nipple and areola pigment) Montgomery’s tubercle Montgomery’s tubercle colostrum expressed as early as 12th weeks colostrum expressed as early as 12th weeks

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23 Per Abdomen Per Abdomen Uterus remains a pelvis organ until 12 weeks Uterus remains a pelvis organ until 12 weeks

24 Pelvic Changes Pelvic Changes Chadwick’ sign Chadwick’ sign Vaginal sign Vaginal sign Cervical sign Cervical sign Uterine sign Uterine sign

25 Chadwick’ sign is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in. It can be observed as early as 6-8 weeks after conception, and its presence is an early sign of pregnancy. Chadwick’ sign is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in. It can be observed as early as 6-8 weeks after conception, and its presence is an early sign of pregnancy.cervix vaginalabia conceptionpregnancycervix vaginalabia conceptionpregnancy

26 Vaginal sign (Osiander’s sign) Vaginal sign (Osiander’s sign) Bluish discolouration of anterior vaginal wall Bluish discolouration of anterior vaginal wall Vaginal wall soften Vaginal wall soften Mucoid discharge Mucoid discharge Increased pulsation Increased pulsation

27 Cervical sign (Goodell’ sign) Cervical sign (Goodell’ sign) Become soft as early as 6th week Become soft as early as 6th week Non pregnant uterus Pregnant uterus

28 Uterine sign Uterine sign Size, shape and consistency 6th week 8th week 12th week Asymmetric→Symmetric The pregnant uterus feels soft and elastic

29 Hegar’s sign demonstrated between 6-10 weeks Upper part of the body of the uterus is enlarged by growing fetus; Upper part of the body of the uterus is enlarged by growing fetus; Lower part of the body of the uterus is empty and extremely soft; Lower part of the body of the uterus is empty and extremely soft; The cervix is comparatively firm The cervix is comparatively firm

30 Two fingers in the anterior fornix The abdominal fingers behind the uterus The abdominal and vaginal fingers seem oppose fingers seem oppose below the body of uterus

31 Palmer’s sign Palmer’s sign Regular and rhythmic uterine contraction can be elicited doring biomanual examination as early as 4-8 weeks Regular and rhythmic uterine contraction can be elicited doring biomanual examination as early as 4-8 weeks

32 Immunological Test

33 Principle of pregnancy test Principle of pregnancy test detection of the antigen of HCG present in the maternal urine or serum detection of the antigen of HCG present in the maternal urine or serum Selectionn of time Selectionn of time 8-10 days after conception 8-10 days after conception Collection of urine Collection of urine the first voided urine in the morning in a clean container the first voided urine in the morning in a clean container

34 Ultra Sonograph Gestation sac (GS) can be identified as early as days of gestation Gestation sac (GS) can be identified as early as days of gestation

35 5 menstrual weeks

36 6 menstrual weeks

37 True and pseudo gestation sac Character True GS Pseudo GS LocationEccentricallyCentrally Shape Round & regular Irregular Double ring sign PresentAbsent York sac and fetal pole PresentAbsent Increase in sac size 1 mm/ day Absent

38 First Trimester Review The Whole Period of Pregnancy Can Be Divided Into Three Stages The first trimester (early pregnancy): 1-12w The second trimester (middle pregnancy): w The third trimester (late pregnancy): 28-40w

39 1. History and symptoms A. Cessation of menstruation This is the first frequent symptom of pregnancy, although This is the first frequent symptom of pregnancy, although a few women may have slight bleeding after conception. Amenorrhea is not only due to pregnancy Amenorrhea is not only due to pregnancy but also other reasons. but also other reasons. Women of breast feeding may be pregnant Women of breast feeding may be pregnant before the recovery of menses before the recovery of menses.

40 B. Nausea and Vomiting Also called morning sickness because they occur upon arising. These symptoms appear one or two weeks after the period is missed and last until 10th to 12th week, its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravidarum). Also called morning sickness because they occur upon arising. These symptoms appear one or two weeks after the period is missed and last until 10th to 12th week, its severity varies from mild nausea to persistent vomiting (e.g. Hyperemesis gravidarum).

41 C. Urinary symptoms Increased frequency of urination is due to increased circulation associated with the effect of estrogen and progesterone on the bladder, combined with pressure by the gradually enlarged uterus on the bladder. Increased frequency of urination is due to increased circulation associated with the effect of estrogen and progesterone on the bladder, combined with pressure by the gradually enlarged uterus on the bladder.

42 D. Mastodynia It may be present in early pregnancy and ranges in severity from a tingling sensation to frank pain. It may be present in early pregnancy and ranges in severity from a tingling sensation to frank pain.

43 2. Signs Breast changes Breast enlargement and vascular engorgement. Nipple and areola become blacker. Enlargement of the accumulated sebaceous glands of the areolas (Montgomery’s tubercles) may be noted.

44 Changes of the reproductive organs Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested. Vagina: The vaginal wall become discoloration as the pelvic blood vessel becomes congested. Cervix: Cyanosis and a gradual softening due to congestion. Cervix: Cyanosis and a gradual softening due to congestion.

45 Uterus: Uterus: Enlargement and softening. The isthmus of the uterus is also soft and can be compressed between the fingers palpating vagina and abdomen (Hegar’s sign). After the 12th week, the fundus of the uterus is usually palpable above the symphysis pubis.

46 3. Supplementary examination Pregnancy test The laboratory test for pregnancy are based on the identification of human chorionic gonadotropin (hCG), which can be detected as early as 7-9 days after fertilization by high sensitive technique. The samples may be blood or urine.

47 Basal body temperature (BBT) A persistent elevation of BBT for longer than 18 days may be presumptive evidence of pregnancy.

48 Progesterone test Progesterone Progesterone is given to a women with amenorrhea. If she is pregnant, no bleeding will follow, otherwise, bleeding should occur within 7-10 days of progesterone administration. This is reliable in the nonpregnant patient only if there is adequate estrogen stimulation of the endometrium.

49 Ultrasonography   There are trans-vaginal and abdominal Ultrasonagraphys.   A gestational sac can usually be identified at 5-6 weeks after the beginning of the last period.   Fetal heart beating can be detected by about 7th week and the fetus itself can be seen by about the 8th week.   Doppler is also an ultrasound technique, which diagnoses the pregnancy by revealing the heart beating.

50 Second trimester: weeks

51 Symptoms Symptoms General examination General examination Abdominal examination Abdominal examination Vaginal examination Vaginal examination

52 Symptoms Symptoms Nausea, vomiting, frequency of micturition subside Nausea, vomiting, frequency of micturition subside Amenorrhea continues Amenorrhea continues Quickening: perception of active fetal movement by women Quickening: perception of active fetal movement by women (From 18th week) (From 18th week) Progressive enlargement of lower abdomen by the growing uterus Progressive enlargement of lower abdomen by the growing uterus

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56 General examination General examination Chloasma 24th week Chloasma 24th week Breast changes: more enlarged Breast changes: more enlarged Pigmentation

57 Abdominal examination Abdominal examination Inspection Palpation Palpation Auscultation Auscultation

58 Inspection Inspection Linea nigra Striae Striae

59 Symphysis Pubis Ensiform Cartilage Striae

60 Palpation Palpation Fundal height increases Uterus soft and elastic, ovoid in shape Uterus soft and elastic, ovoid in shape Braxton-Hicks Contraction Braxton-Hicks Contraction Palpation of fetal parts: 20th week Palpation of fetal parts: 20th week Active fetal movements: 20th week Active fetal movements: 20th week External ballottement External ballottement

61 Fundal height is increased with progressive enlargement of the uterus. Duration of pregnancy can be ascertained by noting the height of the uterus. Duration of pregnancy can be ascertained by noting the height of the uterus. Fundal height Fundal height

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63 16th week: midway between symphysis pubis and umbilicus 16th week: midway between symphysis pubis and umbilicus 22~24th week: at the level of umbilicus 22~24th week: at the level of umbilicus 28th week: at the junction of the lower 1/3 and upper 2/3 of the distance between the umbilicus and ensiform cartilage 28th week: at the junction of the lower 1/3 and upper 2/3 of the distance between the umbilicus and ensiform cartilage

64 Abnormal Fundal Height IUGR (intrauterine growth retardation) IUGR (intrauterine growth retardation) Multiple Pregnancy Multiple Pregnancy Polyhydramnios(CNS or Cardiovascular Disfunction) Polyhydramnios(CNS or Cardiovascular Disfunction) Oligohydramnios Oligohydramnios

65 Braxton-Hicks Contraction Braxton-Hicks Contraction In 1872, John Braxton Hicks investigated the later In 1872, John Braxton Hicks investigated the laterJohn Braxton HicksJohn Braxton Hicks stages of pregnancy and noted that many women felt contractions without being near birth. This process was usually painless but caused women confusion This process was usually painless but caused women confusion as to whether or not they were going into actual labor labor

66 Cause Cause Braxton Hicks contractions are a tightening of the uterine muscles for one to two hours and are thought to be an aid to the body in its preparation for birth. Braxton Hicks contractions are a tightening of the uterine muscles for one to two hours and are thought to be an aid to the body in its preparation for birth. uterinemusclesbirth uterinemusclesbirth

67 Alleviating factors Alleviating factors Rhythmic breathing Rhythmic breathing Lying down on the left side Lying down on the left side A slight change in movement A slight change in movement Urination Urination

68 Very early, the uterus undergoes spontaneous contraction Very early, the uterus undergoes spontaneous contraction Firmer at one moment and soft at another Firmer at one moment and soft at another Can be excited by rubbing the uterus Can be excited by rubbing the uterus Irregular,infrequent, spasmodic, and painess Irregular,infrequent, spasmodic, and painess Near term, frequent with increase in intensity, discomfort Near term, frequent with increase in intensity, discomfort Merge with the labor Merge with the labor

69 Palpation of fetal parts Palpation of fetal parts Diagnosis of pregnancy Diagnosis of pregnancy Identify the presentation and position of fetus Identify the presentation and position of fetus

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71 Active fetal movements Active fetal movements Positive evidence of pregnancy & live fetus Faint flutter→stronger movement

72 External ballottement External ballottement Be elicited as early as 20th week Be elicited as early as 20th week Obese women & scanty liquor amnii Obese women & scanty liquor amnii by a push to the foetal parts with one hand abdominally and the other hand receiving the impulse

73 Ballottement is a medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand. Ballottement is a medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.medical signpatellakneemedical signpatellaknee

74 Ascutation

75 Fetal heart sound Fetal heart sound Most conclusive Most conclusive weeks weeks Location Location bpm→ bpm bpm→ bpm

76 Vaginal Examination Vaginal Examination The bluish discolouration of the vagina, cervix is much more evident; The bluish discolouration of the vagina, cervix is much more evident; Cervix softening Cervix softening

77 Investigation Sonograph: weeks; a detailed survey of fetal anatomy, placenta localization, integrity of the cervical canal Sonograph: weeks; a detailed survey of fetal anatomy, placenta localization, integrity of the cervical canal Fetal organ anatomy Fetal organ anatomy Radiologic examination Radiologic examination

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80 Biparietal diameter(BPD)

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82 BPD First Trimester: < 3cm First Trimester: < 3cm From 20th week: = pregnancy month(28th week=7cm; 32th week=8cm From 20th week: = pregnancy month(28th week=7cm; 32th week=8cm From 32th week = 8cm: 02.cm/week From 32th week = 8cm: 02.cm/week

83 FL ( femur length ) 2-3 cm less than the BPD 2-3 cm less than the BPD For example: For example: BPD=9.3cm , FL=7.3cm ; BPD=8.9cm , FL=6.9cm

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87 Second Trimester Review Symptoms Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of gestation. Abdominal enlargement and fetal movement generally occurs after the 18th to 20th week of gestation.

88 Signs The uterus continues to enlarge The uterus continues to enlarge Fetal movement (quickening) can usually be seen or heard after 18th week of gestation Fetal movement (quickening) can usually be seen or heard after 18th week of gestation

89 Height of the uterine top

90 Signs Fetal heart sound can be heard at rate varies from 120 to 160 beats per minute. Fetal heart sound can be heard at rate varies from 120 to 160 beats per minute. The fetal body can usually be palpated by the 18th to 20th week of gestation unless the patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid. The fetal body can usually be palpated by the 18th to 20th week of gestation unless the patient is too fat, the abdomen is tender or there is an excessive amount of amniotic fluid.

91 (uterine souffle and umbilical souffle)

92 ballottement

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94 Third trimester: weeks

95 Symptoms: Symptoms: Amenorrhoea Enlargement of the abdomen Enlargement of the abdomen Lightening: due to the engagement of the presenting part Lightening: due to the engagement of the presenting part Frequency of micturition Frequency of micturition Fetal movement Fetal movement

96 Sign: Sign: Cutaneous changes: increased pigmentation and striae Uterine shape: cylindrical to spherical beyond 36th week Uterine shape: cylindrical to spherical beyond 36th week Fundal height Fundal height Braxton-Hicks contraction Braxton-Hicks contraction Fetal movement Fetal movement Palpation of the fetal parts Palpation of the fetal parts

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98 32 th week: the junction of the upper and middle third between the distance middle third between the distance of umbilicus and ensiform cartilage of umbilicus and ensiform cartilage 36 th week: the level of the ensiform cartilage 40 th week: down to the level of 32th

99 Symphysis fundal height (SFH)

100 After 24 weeks, the SFH measured in cm. correspond to the number of the weeks up to 36 weeks. After 24 weeks, the SFH measured in cm. correspond to the number of the weeks up to 36 weeks. A variation of ± 2 is accepted as normal. A variation of ± 2 is accepted as normal. Variation beyond the normal range needs further evaluation. Variation beyond the normal range needs further evaluation.

101 More than More than ① Mistaken date of the last menstrual period; ② Twins; ② Twins; ③ Polyhydramnios; ③ Polyhydramnios; ④ Big baby; ④ Big baby; ⑤ Pelvic tumours; ⑤ Pelvic tumours; ⑥ Hydatidiform mole; ⑥ Hydatidiform mole; ⑦ Concealed accidental haemorrhage ⑦ Concealed accidental haemorrhage

102 Twins

103 Hydatidiform mole

104 Less than Less than ① Mistaken date of the last menstrual period; ② Scanty liquor amnii; ② Scanty liquor amnii; ③ Fetal growth retardation; ③ Fetal growth retardation; ④ Intrauterine fetal death ④ Intrauterine fetal death

105 Upper part of the uterus Lateral part of the uterus Presentation; Engagement Further confirmation

106 → breech → head Fundal grip Fundal grip broad, soft, irregular mass broad, soft, irregular mass smooth, hard, globular smooth, hard, globular

107 Lateral or umbilical grip Lateral or umbilical grip smooth curved and resistant →black smooth curved and resistant →black comparatively empty and small knob → limb comparatively empty and small knob → limb

108 First pelvic grip First pelvic grip Presentation: the part occupy the lower pole of the uterus Presentation: the part occupy the lower pole of the uterus Attitude: the relative position of the sincipital and occipital or different parts of the fetus to one another Attitude: the relative position of the sincipital and occipital or different parts of the fetus to one another Engagement: convergence or divergence of the finger during palpation Engagement: convergence or divergence of the finger during palpation

109 Second pelvic grip Second pelvic grip mobility from one side to side is tested mobility from one side to side is tested

110 Fetal lie & fetal Presentation Fetal lie & fetal Presentation Fetal lie: the relationship between the long axis of the mother and the long axis of the fetus. (longitudinal lie and transverse lie) Fetal lie: the relationship between the long axis of the mother and the long axis of the fetus. (longitudinal lie and transverse lie) Fetal presentation: the portion of the fetus that descends into pelvis first. Fetal presentation: the portion of the fetus that descends into pelvis first.

111 Head presentation Breech presentation Shoulder presentation

112 Face Presentation Brow Presentation Occipital Presentation Bregma Presentation

113 Mixed breech Presentation Frank breech Presentation One foot Presentation Two feet Presentation

114 Fetal position Fetal position Fetal position: the relationship of some guiding point of fetal presentation to a fined area of the maternal pelvis. (LOA, left occipital anterior) Fetal position: the relationship of some guiding point of fetal presentation to a fined area of the maternal pelvis. (LOA, left occipital anterior)

115 Presentation Occipital Presentation: Occipital, O Breech Presentation: Sacrum, S Face Presentation: Mentum, M Shoulder Presentation: Scapula, Sc

116 sacrum ROP LOA ROA LOP

117 Fetal Heart Sound

118 LOA RSA LSA ROA

119 Sonograph AC abdominal circumference AC abdominal circumference HC head circumference HC head circumference BPD biparietal diameter BPD biparietal diameter FL femur length FL femur length Amniotic Fluid volume Amniotic Fluid volume oligohydramnios & polyhydramnios oligohydramnios & polyhydramnios Placental anatomy: Placental anatomy: location, thickness, abnormalities location, thickness, abnormalities

120 Differential Diagnosis of Pregnancy Pseudocyesis: psychological disorder, Pseudocyesis: psychological disorder, cessation of menstruation cessation of menstruation

121 Cystic ovarian tumour Cystic ovarian tumour Swelling is slow; Swelling is slow; Amenorrhoea is absent; Amenorrhoea is absent; Feels cystic or tense cystic; Feels cystic or tense cystic; Absence of Braxton-Hicks contraction; Absence of Braxton-Hicks contraction; Absence of positive signs of pregnancy; Absence of positive signs of pregnancy; Ultrasonograph show absence of fetus Ultrasonograph show absence of fetus

122 Uterine fibroid: Uterine fibroid: Slow growing; Amenorrhoea is absent; Amenorrhoea is absent; Feels firm, more towards hard; Feels firm, more towards hard; Absence of Braxton-Hicks contraction; Absence of Braxton-Hicks contraction; Absence of positive signs of pregnancy; Absence of positive signs of pregnancy; Ultrasonograph show absence of fetus Ultrasonograph show absence of fetus

123 Summary of Diagnosis of Pregnancy Positive or absolute sign Positive or absolute sign Persumptive symptoms and signs Persumptive symptoms and signs Probable signs Probable signs

124 Positive or absolute sign Positive or absolute sign Palpation; Auscutation; Ultrasound

125 Persumptive symptoms and signs Persumptive symptoms and signs Amenorrhoea; Amenorrhoea; Frequence of micturition; Frequence of micturition; Morning sickness; Morning sickness; Fatigue; Fatigue; Breast changes; Breast changes; Skin changes; Skin changes; Quickening Quickening

126 Probable signs Probable signs Abdominal enlargement; Braxton-Hicks contraction; Braxton-Hicks contraction; External & internal ballotement; External & internal ballotement; Uterus change; Uterus change; Vaginal sign; Vaginal sign; Immunological test Immunological test

127 Chronological Appearance At 6-8 weeks At 6-8 weeks At 16th week At 16th week At 20th week At 20th week

128 Estimation of Gestation Age & Prediction of Excepted Date of Delivery Excepted Due Date Excepted Due Date = LMP ﹣ 3/ ﹢ 9 month and ﹢ 7 days = LMP ﹣ 3/ ﹢ 9 month and ﹢ 7 days LMP is 26th July, when is the EDD? LMP is 26th July, when is the EDD?

129 Patient’ statement Patient’ statement Date of coitus Date of coitus Naegele’s Formula Naegele’s Formula Date of quickening: adding weeks Date of quickening: adding weeks

130 Excepted Due Date = LMP ﹣ 3/ ﹢ 9 month and ﹢ 7 days = LMP ﹣ 3/ ﹢ 9 month and ﹢ 7 days add seven days add seven days subtract 3 months subtract 3 months add one year add one year LMP is 26th July, when is the EDD? LMP is 26th July, when is the EDD?

131 Previous record Previous record Clinical : Size of the uterus Clinical : Size of the uterus Palpation of fetal parts Palpation of fetal parts Investigation: Ultrasonographic finding Investigation: Ultrasonographic finding GS - 5th week GS - 5th week cardiac activity - 6th week cardiac activity - 6th week Embryo movement – 7th week Embryo movement – 7th week CRL in cm = week of pregnancy CRL in cm = week of pregnancy (Crown-rump length) (Crown-rump length) BPD in cm = month of pregnancy BPD in cm = month of pregnancy (From 20th week) (From 20th week)

132 Objective signs Objective signs Height of the uterus Height of the uterus Lightening Lightening Size of the fetus Size of the fetus Vaginal examination Vaginal examination

133 Question Hegar’s sign

134 Patient A, 24 years, irregular cycle, 30 days~90 days Patient A, 24 years, irregular cycle, 30 days~90 days Amenorrhea: 6 months Amenorrhea: 6 months Morning sickness: > 3 months Morning sickness: > 3 months Fetal movement: for about a week Fetal movement: for about a week Fundal height: midway of pubis and umbilicus Fundal height: midway of pubis and umbilicus


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