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

4. Woman’s reproductive period
Menarche
Menopause
13-45 years

6. Duration of Pregnancy 10 lunar months ; 9 calendar months and 7 days ;
40 weeks
The duration of pregnancy is calculated from the first day of the last cycle
Menstrual or gestational age

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

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

9. Bladder
Rectum

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

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

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

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

15. Breast discomfort
Fullness
Pricking sensation

16. Fatigue
Occur early in pregnancy

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

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

24. Pelvic Changes
Chadwick’ sign
Vaginal sign
Cervical 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.

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

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

28. 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;
Lower part of the body of the uterus is empty and extremely soft;
The cervix is comparatively firm

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

31. Palmer’s sign
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
detection of the antigen of HCG present in the maternal urine or serum
Selectionn of time
8-10 days after conception
Collection of urine
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

35. 5 menstrual weeks

36. 6 menstrual weeks

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

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
a few women may have slight bleeding after conception.
Amenorrhea is not only due to pregnancy
but also other reasons.
Women of breast feeding may be pregnant
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).

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.

42. D. Mastodynia
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.
Cervix: Cyanosis and a gradual softening due to congestion.

45. 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 is given to a women with amenorrhea.
Progesterone test
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: 13-28 weeks

51. Symptoms
General examination
Abdominal examination
Vaginal examination

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

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

57. Abdominal examination Inspection
Palpation
Auscultation

58. Inspection
Linea nigra
Striae

59. Ensiform Cartilage
Symphysis Pubis
Striae

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

63. 16th week: midway between symphysis pubis and 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

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

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

66. 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.

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

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

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

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

72. External ballottement
Be elicited as early as 20th week
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.

74. Ascutation

75. Fetal heart sound Most conclusive 18-20 weeks Location
bpm→ bpm

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

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

80. Biparietal diameter(BPD)

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

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

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

88. Signs
The uterus continues to enlarge
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.
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

94. Third trimester: 29-40 weeks

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

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

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

99. Symphysis fundal height (SFH)

100. After 24 weeks, the SFH measured in cm
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.
Variation beyond the normal range needs further evaluation.

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

102. Twins

103. Hydatidiform mole

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

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

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

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

108. First pelvic grip
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
Engagement: convergence or divergence of the finger during palpation

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

110. 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 presentation: the portion of the fetus that descends into pelvis first.

111. Head presentation
Breech presentation
Shoulder presentation

112. Occipital Presentation
Bregma Presentation
Brow Presentation
Face Presentation

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

114. 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)

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

116. LOA
ROA
sacrum
LOP
ROP

117. Fetal Heart Sound

118. LSA
RSA
ROA
LOA

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

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

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

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

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

124. Positive or absolute sign
Palpation; Auscutation; Ultrasound

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

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

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

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

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

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

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

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

133. Hegar’s sign
Question

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