Udergraduate course lectuers in OB&GYNE,Faculty of medicine ,Zagazig University

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 breast and 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
• Epigastric pain
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 Fundal hieght
• 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
1.Diet and weight gain
2.Medication
3.Avoid Radiation exposure
4.Self-care during pregnancy
5.Minor complaints.
6. Family planning Breastfeeding
7.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

51. Case Study
A 35-year-old G2 P1+0 woman is seen for her first
prenatal visit.
Based on her LMP, she is at 15 weeks’ gestation.
She has no complaints, and no significant medical
history.
 She denies dysuria or urinary urgency.
Her surgical history is remarkable
Her last delivery was a vaginal delivery and was
uncomplicated

52. On examination
Her blood pressure (BP) is 100/65 mm Hg
heart rate (HR)90 (bpm),
 respiratory rate (RR) 12,temperature 98°F (36.6°C),
weight 70KG.
general physical examination is normal

53. Abdominal examination
 Her abdomen is non tender
Fundal height is at the level ofthe umbilicus.
 Fetal heart tones are 140 bpm.
Her extremities are without edema.

54. Prenatal laboratories
CBC: Hgb 10.0 g/dL ,Plt 150,000 WBC 8,000
Rubella: nonimmune
Hepatitis B surface antigen: positive
Blood type: O, Rh negative
UC&S: 10,000 cfu/mL of group Bstreptococcus
Gonorrhea assay: negative Chlamydia assay:
negative

55. Questions
➤ What items should be listed on the problems list?
➤ What is your next step for the problems listed?
➤ What other testing should be recommended to the
patient?

56. Problem List:
Advanced maternal age 35 Y or greater at EDD
fundal height at umbilicus corresponds to 20 weeks)
 Mild microcytic anemia (Hgb < 10.5)
 Hepatitis B surface antigen (HBsAg) positive
 Rh-negative blood type
 Urine culture with GBS 10,000 cfu/mL,
Rubella nonimmune

57. Next Steps:
1. AMA—genetic counseling
2. Size/dates—fetal ultrasound to assess GA,
multiple gestation
3. Anemia—therapeutic trial of iron
4. HBsAg positive—check liver function tests, and
hepatitis B serology toassess for active hepatitis
versus chronic carrier status

58. Next step
5. Rh negative Rhogam at 28 weeks and at delivery if
the baby proves to be Rh positive
6. Urine culture with GBS—treat with ampicillin and
re-culture urine, peni-cillin IV prophylaxis in labor
7. Rubella status—vaccinate postpartum

59. Other tests recommended to patient
consider early diabetic screen

60. Thank you