2 Diagnosis and differential diagnosis of pregnancy . Flashcards
whenever you diagnose pregnancy what are the medical check ups we have to follow with ?
-where is the fetus located
intrauterine or extrauterine
position of the fetus inside the uterine
what is the gestational age of the fetus
does the gestational age match the development of the fetus
are there any discrepancies in the physical appearance of the fetus
is it a single or multiple birth
diagnosis of pregnancy is classified into which groups ?
early pregnancy - first trimester
second trimester
third trimester - late pregnancy
what are the early pregnancy diagnosis
obstetric amnesia
general/ physical examination
obstetric and gyencological examination
lab tests
basal temperatures
ultrasound
when diagnosing pregnancy what are certain terms we use ?
use the term GRAVIDA -
indicates the number of time the women has been PREGNANT
twin pregnancy is counted as 1.
nulligravida - 0 ,
primigravida - 1 time , multigravida - more than 1 time
Parity / para - idicates the number of birth given to fetus when it reaches viable gestational age (24 weeks). Even still births
nullipara, primipara , multipara
in the obstetric anamenesis what are the questions asked to the patient
change in appetite and certain smell
-we ask about the FIRST DAY of the last menstruation
(due date : subtract three months from the first day of your last period and add seven days)
- ask about the intensity and duration of the last menstruation
- ask about the menstruations in the last month generally the average interval and duration
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the absence of menstruation - AMENORRHEA - does not mean pregnancy - it can be due to thyroid hormonal imbalance , stress , other gynaecological disorders
may occur up to 12 weeks of pregnancy, until the decidual space is obliterated by the fusion of decidua vera with decidua capsularis = placental sign
should not be confused with the commonly met pathological bleeding, i.e. threatened abortion
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pseudomenorrhea -occur when the embryo inserts into the uterine wall causing some bleeding , also can be dut to ectopic pregnancies -but with that there will be strong pelvic pain , also can be due to cancer or uterine polyps.
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- ask about infertility problems / usage of contraceptives / previous pregnancy
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-ask about subjective complaints:
morning sickness (does not last beyond 16wks) due to hCG
salivation
fatigue
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Frequency of micturition - bad at 8-12th week
due to : exaggerated anteverted uterus position
maternal osmoregulation causing increased thirst and polyuria
As the uterus straightens up after 12th week, the symptom disappears.
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Breast discomfort:
evident at 6-8th wk
only valuable in primigravidae, in multiparae, the breasts are enlarged and often contain milk for years.
The nipple and the areola become more pigmented .
Montgomery’s tubercles are prominent. (sebaceous glands in the areola , giving a distinctive smell which the baby likes , also keeps the areola and nipple lubricated)
Thick yellowish secretion (colostrum) can be expressed as early as 12th week.
what is done in the physical and general examination
height , weight , gait
Per abdomen — Uterus remains a pelvic organ until 12th week, it may be just felt per abdomen as a suprapubic bulge.
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limbs
the limbs the upper limbs begin to swell - difficult to remove ring from finger
what is the obstetrical/ gynaecological examination
for the first half of pregnancy there is 2 key examinations - which is observation and palpation
what tools are used for observation in obstetrical/ gynaecological examination
observation is done with speculum and colposcopy
what do we observe for observation in obstetrical/ gynaecological examination
there is observation of the vulva , vaginal opening , perineum
check for inflammatory changes ,rashes, warts or anything dangerous for pregnancy
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speculum :
Chadwick’s sign: vestibule and anterior vaginal wall at about 8th week of pregnancy goes through the blue discoloration. It is due to local vascular congestion
cervix also blue
Copious non-irritating mucoid discharge appears at 6th week
check if there is any lacerations of vagina or cervix - may result in bleeding problems
what do we palpate for in obstetrical/ gynaecological examination
bring the ankles towards the bottom knees fall apart to both side and lubircate the index and middle finger
palpation begins in the introitus. Just posterior to the introitus is where the bartholin glands are located.Usually should not be palpable but if they can be this means cyst filled inflamed glands
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vagina : vaginal walls softened
Osiander’s sign : increased pulsation, felt through the lateral fornices at 8th week
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cervix -
Goodell’s sign : Cervix becomes soft as early as 6th week
tip of the nose in non pregnant women
and lips in pregnancy women
Gently move the cervix from side to side to check for cervical tenderness (important sign with ectopic pregnancy or pelvic inflammatory disease).
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uterus - bimanual examination
bladder and rectum needs to be empty
There may be asymmetrical enlargement of the uterus if there is implantation near the uterine tube. This is called Piskacek’s sign where one half is more firm than the other half. As pregnancy advances, symmetry is restored usually resolves around the 20th week
hegar sign
sign predominant between 6-10th week of pregnancy
two fingers in the anterior fornix and the abdominal fingers behind the uterus:
the uterine isthmus softens a lot when both the hands presses together they uterine isthmus feels thin as paper
the uterus and cervix seem to be two separate regions
the upper part if the uterus is enlarged by the growing fetus while the lower isthmus or cervix of the uterus is empty and softens
bimanual
cupped for 2-3 mins
palmer sign - regular uterine contraction = seen at 4-8 wks
During contraction uterus becomes firm and well defined but during relaxation,
becomes soft and ill defined. with increasing
duration of pregnancy, the relaxation phase increases . After 10th week, the relaxation phase is so much increased that the test is difficult to perform.
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shape non pregnant : pyriform early 4 wk= pyriform 12th wk = globular 28th wk = pyriform / ovoid 36th wk = spherical
what are the lab test we do to determine pregnancy ?
detect hCG in urine or blood is produced by synciotrophoblasts (fetal part of the placenta)
IMMUNOASSAYS:
1) positive : urine hcg and
hcg antiserum
agglutination inhibition test
hcg antibody added to hcg containing urine = neutralisation
then latex particle coated with hcg added = no agglutination
= pregnant
if agglutination present = not pregnant
2) direct agglutination test
Latex particles coated with anti-hCG monoclonal antibodies are mixed with urine.
3) ELISA
4) FLUROIMMUNOASSAY
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IMMUNOASSAYS WITH RADIOSIOTOPES
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ULTRASOUND -
intradecidual gestational sac
intradecidual gestational sac identified in 30 days
quantitive measures of hCG is only taken when
term of pregnancy and to diagnose trophoblastic tumors
how early can pregnancy be detected by hCG
sensitivity of the test can be upregulated to detect pregnancy on the 10th day after fertilisation of the egg
the first 7 gestational week what happens to hCG and there after
doubles every 2.5 days
after that it remains constant till the 12th week and declines
low hCG levels for gestational age can diagnose what ?
ectopic pregnancies
