Pregnancy Diagnosis

Peng Xuebing, M.D.

Dept of Obs/Gyn
Beijing Fu Xing Hospital
Capital Medical University
 Gestational Age
About 280 days, or 40 weeks, elapse on
average between the first day of the last
menstrual period and the birth of the
fetus.( 9 and 1/3 calender months)
 2 weeks

3 weeks

Menses Ovulation Fertilization Implantation

Gestational age 40 weeks

Menstrual age
(280 days)

Ovulation age
(Embryologist)
 The expected date of delivery (EDD)

Naegele’s rule:
calculate from the last menstrual period
(LMP)
add 1 year and 7 days to the LMP and
subtract 3 month ；
or add 7 days to the LMP and add 9 month.

for example:
LMP: Sep. 11th. 2015
the due date is 9(-3)/11(+7)=6/18( June 18th, 2016)

LMP: Jan. 6th, 2015

the due date is 1 (+9)/ 6 (+7)=10/13 (Oct. 13th, 2012)
 The periods of gestation :
• The first / early trimester: to extend from
conception through to 13 gestational weeks;
• The second / mid-trimester: to extend from 14
gestational weeks to the end of 27 gestational
weeks;
• The third/ late trimester: to extend from 28 to 40
gestational weeks.
 The first trimester
Pregnancy?
Site?
• Symptoms
• Signs
• Assessments

结束
 Symptoms
1. Cessation of menstruation
• Most obvious and most important symptoms;
• Should discriminate with endocrine disorder,
breast-feeding period and amenorrhoea due
to oral contraceptives or uterine/ uterine
adhesion……
 Symptoms
2. Morning sickness: nausea (80-85%), vomiting (52%),
• mostly occur at about 6 weeks and ease/disappear at 12
weeks;
• may sometimes persist throughout pregnancy;
• believed to be caused by hormones of pregnancy especially
hCG (human chorionic gonadotrophin);
• may be severe enough to warrant hospital admission:
hyperemesis gravidarum.
 Symptoms
3. Frequency of micturition:
↑plasma volume and ↑urine production;
pressure effect of the uterus on the bladder.

4. Excessive lassitude or fatigue

tends to disappear after 12 weeks gestation.

5. Breast tenderness or “heaviness”

often seen early in pregnancy, particularly in the
month after the first period is missed.
 Signs

1. Vaginal and cervix: Non-

have a bluish tinge due pregnancy
to blood congestion;

20

16
pregnancy 12
 Signs
2. Hegar sign: cervix may seem to separate from
uterine fundus. softening of the lower uterine
segment (cervix and isthmus);

3. The size of uterus:

double normal size at 8 weeks gestation,
triple normal size at 12 weeks gestation,
and after 12 weeks uterus is palpable abdominally
(above the symphysis pubis).
 Pregnancy Tests
1. The hormone hCG (human chorionic
gonadotropin) is secreted by trophoblastic tissue:
• ↑exponentially from ~8 days after ovulation,
peaks at 8-12 weeks gestation,
the rate of rise is important: ~ 66% (repeated 24
hrs later);
• be measured in blood or urine;
• test kits are available commercially ( home
pregnancy test): can show a positive result with
urinary hCG levels of > 50 IU/L;
• These tests can confirm pregnancy within 1 week
of a missed period.
HCG (serum) in Pregnancy Duration
Pregnancy weeks HCG (IU/L)
0.2-1 5-50
1-2 50-500
2-3 100-5,000
3-4 500-10,000
4-5 1,000-50,000
5-6 10,000-100,000
6-8 15,000-200,000
8-12 10,000-100,000
Pregnancy test strip (HCG test strip)
 Pregnancy Tests
2. Sonographic scan:
• B-mode ultrasound:
Gestational sac (GS): detect at 4-5 weeks gestation;
Embryo bud: ~ 5 weeks gestation;
Yolk sac: a membranous sac attached to an embryo, 5
weeks gestation;
Crown-rump length (CRL): 8-13 weeks, predict the
dating of pregnancy (the fetal CRL is 6 to 7 cm at 12
weeks gestation).
• Doppler ultrasound device: embryocardia/fetal heart
tone, 7 -8 weeks gestation.
 Abdominal sonogram
demonstrating a gestational
sac at 4 - 5 weeks’ gestational
age.
Vaginal sonogram demonstrating a gestational sac at
6 weeks’ gestational age

Yolk sac

Embryo
bud

Gestational
Sac
 Pregnancy Tests
3. Cervical mucus examination (Dried cervical
mucus examined microscopically):
• The endocervical mucosal cells produce copious
amounts of a tenacious mucus that obstruct the
cervical canal soon after conception;
• progesterone secretion—even without a reduction
in estrogen secretion—acts promptly to lower
sodium chloride concentration to levels that
prohibit ferning;
• a beaded or cellular appearance.
• Photomicrograph of cervical
mucus obtained on day 11 of
the menstrual cycle.
(a ferning appearance)

• Photomicrograph of dried
cervical mucus obtained
from the cervical canal of a
woman pregnant at 32 to 33
weeks. The beaded pattern
is characteristic of
progesterone action on the
endocervical gland mucus
composition. (a beaded or
cellular appearance)
 Pregnancy Tests
4. Basal body temperature (BBT):
higher for 18 days, possible pregnancy;
higher for 21 days, probable pregnancy.

5. Progesterone test:
20mg/day im. for 3 days;
be possible pregnancy if no vaginal bleeding
7 days later.
 Notice:
• For the woman who is in reproductive age,
we should always concern about whether
she has got pregnancy or not.
 The periods of gestation :
• The first / early trimester: to extend from
conception through to 13 gestational weeks;
• The second / mid-trimester: to extend from 14
gestational weeks to the end of 27 gestational
weeks;
• The third/ late trimester: to extend from 28 to 40
gestational weeks.
 The second- and the third-trimester

History and signs:

• Uterus enlarged;
• Fetal movement;
• Fetal heart beats;
• Fetal body.
 Uterus size

Symphysis-fundal height
36 (SFH):
Xiphi sternum
Be estimated to be the
32,40number of weeks
28 gestation in centimetres
umbilicus 24 (at 30 wks the SFH
20 shoultd be 30cm±2cm):
16 ±2cm for 20-36 wks
Symphysis 12
±3cm for 36-40 wks
pubis
±4cm at 40 wks
 Fetal movement

• Perception of Fetal Movements.

Maternal perception of fetal movement may
depend on factors such as parity and habitus;
In general, after a first successful pregnancy,
a woman may first perceive fetal movements
between 16 and 18 weeks. A primigravida may
not appreciate fetal movements until
approximately 2 weeks later (18 to 20 weeks).
At approximately 20 weeks, depending on
maternal habitus, an examiner can begin to
detect fetal movements.
 Fetal movement

• The mean number of weekly movements

calculated from 12-hour daily recording periods
increases from approximately 200 at 20 weeks to a
maximum of 575 movements at 32 weeks.
• Fetal movements then decline to an average of
282 at 40 weeks.
 Fetal movement

• Maternal Counts of fetal movements:

after 28 gestational weeks;
counts fetal movement 3 times everyday;
normal: ≥30 /12 hrs or ≥ 4/ every hour;
abnormal: ≤ 3/ hour for 2 days.
 Fetal heart
• Can be heard fetal heart tones by Doppler
after 10-12 weeks gestation;
• Can be heard by stethoscopes about 24
weeks gestation;
• 120-160 beat per minute
 Fetal body
• Abdominally palpate fetal body after 20 weeks.
• Differentiate fetal head, back, breech and limbs.
head: like as a hard ball (ballottement)
breech: wide and soft, irregular shape
back: wide and plain
limbs: small, irregular shapes and movements.
 Ultrasound Assessment of fetal growth

• Biparietal diameter (BPD) :

the greatest transverse diameter of the head,
which extends from one parietal boss to the other;

• Abdominal circumference (AC);

be the single most important measurement in
assessing fetal size and growth;
be measured where the image of the stomach
and the portal vein is visualized in a tangential
section.
 Ultrasound Assessment of fetal growth
• Femur length (FL):
by convention, measurement of the FL is
considered accurate only when the image shows
two blunted ends.
FL can be underestimated if the correct plane
is not obtained.

BPD
AC Fetal weight
FL
 Ultrasound Assessment
• Fetal lie,
fetal presentation,
fetal position
• Placenta
• Fetal heart
• Amniotic fluid volume
• Genetic screen: 18-20 weeks gestation
 Ultrasound Assessment
• The uterus may measure small for dates:
Wrong dates;
Oligohydramnios;
Intrauterine growth restriction;
Abnormal lie of the fetus.
• The uterus may measure large for dates:
Wrong dates;
Macrosomia;
Polyhydramnios;
Multiple pregnancy;
Presence of fibroids.
 Fetal electrocardiography (FECG)

• After 20 weeks gestation

• Fetal intrauterine hypoxia: ST-segment
elevation;
• Congenital heart disease: obviously
abnormal heart rate, conduction block,
arhythmia, QRS complex widen.
 Fetal Attitude
(the 3rd trimester)
Fetal certain
position and
posture in
uterus:
Fetal lie
Fetal presentation
Fetal position
 Fetal lie
The relationship of longitudinal axis of fetus to that of
the uterus
• Longitudinal lie: fetal head or breech is palpable
over pelvic inlet, 99.75%;
• Transverse lie: fetal poles felt in flanks 0.25%;
• Oblique lie: the head or breech is palpable in the iliac
fossa, temporary.
 Fetal lie
Causes and associations of abnormal fetal lie:
• Multiparity with lax uterus,
• Poly hydramnios,
• Uterine abnormalities (fibroids, Mullerian duct
abnormalities),
• Placenta praevia and obstructions to the pelvis;
• Fetal abnormalities
• Multiple pregnancy
 Fetal presentation
The part of the fetus that lies closest to or has
entered the true pelvis.
• Head (cephalic) presentation;
• Breech presentation;
• Shoulder presentation: rare and require caesarean
section (C/S) or turning before vaginal birth;
• Compound presentation: the entry of more than
one part in the true pelvis, most commonly a hand
next to the head.
 Head presentation

Occiput --- Bregma Brow

Face ---
--- ---
 Breech presentation

Frank--- Single
Complete --- Double
footling ---
footling ---
Fetal presentations
 Fetal position
• The relationships of the fetal
presenting parts and the maternal
pelvis.
• Presenting parts:
Posterior
head presentation --- occiput
breech presentation --- sacrum transverse
face presentation --- mentum anterior
shoulder presentation --- scapular
• The relationship of the part of
the fetus that presents in the
pelvis to the four quadrants of the
maternal pelvis, identified by
initial L (left), R (right), A
(anterior) and P (posterior);
• The presenting part is also
identified by initial O (occiput),
M (mentum), S(sacrum) and Sc
(scapular).
Fetal positions
Fetal attitude variations
 fetal lie, fetal presentation and fetal position

occipital LOA, LOT, LOP

head （95.5%~97.5%） ROA, ROT, ROP
longitudinal lie (95.7% face LMA, LMT, LMP
(99.7%） ~97.7%） （0.2%） RMA, RMT, RMP
breech LSA, LST, LSP
（2%~4%） RSA, RST, RSP
transverse lie shoulder LScA, LScP
(0.25%） （0.25%） RScA, RScP
 Summary
• Gestational age, EDD, and 3 trimesters;
• First trimester:
whether and where be pregnant;
• Second and third trimester:
fetal development
fetal movement
• Third trimester: fetal lie, fetal presentation,
fetal position
The End