Pregnancy diagnosis

JOHN LAMARTINA MD.

Family Practice Notebook Google search

AMENORRHEA
Primary Amenorrhea No menstrual period by:
Sixteen years old or One year beyond Family History

No secondary sexual characteristics by 14 years old Secondary Amenorrhea Previously regular cycles: 3 months of no Menses Previously irregular cycles: 6 months of no Menses MISSED MENSTURAL PERIOD!

POSITIVE HOME PREGNANCY TEST

HCG is a glycoprotein hormone with subunits a and b
HCG shares the same alpha subunit with other hormones Luteinizing hormone (LH) Thyroid Stimulating Hormone (TSH) Urine and Blood HCG tests are specific for beta subunit Serum half life of HCG: 24 to 36 hours

LUTEINIZING HORMONE

Normal Serum Levels

Male: <15 mIU/ml Female: <30 mIU/ml (higher in mid-cycle surge) Menopause: 30 to 200 mIU/ml

Detection: Urine LH
Urine LH dip-stick kit used to detect Ovulation Urine LH consistently surges 72 hours before Ovulation (for timing purposes) Most accurate kits (prescribed)
OvuQuick Clear Plan Easy

Interpretation: Levels of bHCG in pregnancy

Estimation in normal pregnancy for weeks 4 to 8

Anticipate HCG doubling every 48 to 72 hours

Chart of corresponding gestational age

Day 23 (3.3 weeks): 100 mIU/ml (9 DAYS AFTER OVULATION) ie.before missed period. Day 28 (4.0 weeks): 250 mIU/ml Day 35 (5.0 weeks): 1000 mIU/ml
bHCG 1800: Gestational Sac on Transvaginal U/S bHCG 3500: Gestational Sac on Transabdominal U/S

Day 42 (6.0 weeks): 4000 mIU/ml

bHCG in pregnancy
Day 49 (7.0 weeks): 15000 mIU/ml

bHCG 20,000: 5-10 mm Embryo with cardiac activity

Day 56 (8.0 weeks): 65000 mIU/ml Decreases gradually after 12.0 wks.

Ranges of bHCG over each Trimester

First Trimester: 30,000 to 100,000 mIU/ml Second Trimester: 10,000 to 30,000 mIU/ml Third Trimester: 5,000 to 15,000 mIU/ml

Elevated bHCG in non-pregnant state

HCG-producing tumors in women Hydatidiform Mole or Choriocarcinoma

Pathophysiology
Trophoblastic Neoplasia
Benign proliferation of chorionic villi Fetus absent

Choriocarcinoma no villi invassive

False positive hCG

Marijuana use

VAGINAL BLEEDING IN REPRODICTIVE AGE GROUP

RULE OUT COMPLICATION OF

Pregnancy

Ectopic Pregnancy
Incidence: 2% of all pregnancies Second most common cause of maternal mortality Accounts for 10-15% of maternal deaths Case fatality rate: 3.8 deaths per 10,000 ectopics BE AWARE !

Ectopic Pregnancy
Symptoms Onset occurs ~7 weeks after last menstrual period Abdominal Pain Vaginal Bleeding

Ectopic Pregnancy
Highest risk factors Pelvic or tubal surgery (e.g. FAILED Tubal Ligation) Prior ectopic pregnancy (11% of cases) Intrauterine Device (IUD) (14% of cases

Ectopic Pregnancy
Moderate risk factors Pelvic Inflammatory Disease or other tubal infection (PID) Infertility

Ectopic Pregnancy
Classic signs (15% of patients) Pelvic Pain or Abdominal Pain (97%)
Initially localized pain Pain later generalizes

Abdominal tenderness (91%) First Trimester Bleeding (79%)

Ectopic Pregnancy
Common associated findings Adnexal tenderness (54%) on pelvic pt. stands up Amenorrhea Shoulder Pain Tender pelvic or Adnexal Mass Cul-de-sac fullness

Ectopic Pregnancy
Culdocentesis Rarely performed now due to Transvaginal Ultrasound Yield of aspirate with >15% Hematocrit suggests bleed

Ectopic Pregnancy
Quantitative hCG
Normally will increase by at least 53% every day
Usually will double in 48 hours

bHCG with inadequately increase may suggest ectopic

Ectopic Pregnancy
Findings suggestive of ectopic pregnancy Absence of gestational sac at bHCG 1800 mIU/ml Free fluid present (71% likelihood of ectopic) Echogenic mass at adnexa (85% likelihood) Moderate to large free fluid (95% likelihood) Echogenic mass with free fluid (100% likelihood)

Management Ectopic Pregnancy

Expectant Management indications Minimal pain or bleeding in reliable patient bHCG less than 1000 mIU/ml and falling No signs of tubal rupture Adnexal Mass <3 cm No Embryonic heart beat

Management Ectopic Pregnancy

Medical Management: Methotrexate Stable vital signs with normal LFTs, CBC, platelets Unruptured ectopic pregnancy without cardiac activity Ectopic mass <4 cm bHCG <5000 mIU/ml

Management Ectopic Pregnancy

Surgical Management / Indications
Failed or contraindicated non-surgical management Nondiagnostic Transvaginal Ultrasound and bHCG >1500 (lap) Hemoperitoneum Diagnosis unclear (lap) Advanced ectopic pregnancy Unstable vital signs

Methotrexate Ectopic Protocol

Quantitative bhCG < 5,000 mIU/ml Ectopic Pregnancy fully visualized on ultrasound Embryo size under 3 cm Tubal serosa intact (no rupture No fetal heart activity) Normal lab testing

No active bleeding

Methotrexate Ectopic Protocol

Contraindications White Blood Cell Count <3000 Platelet Count <100,000 Liver disease or Elevated Aspartate Aminotransferase Renal Disease or elevated Serum Creatinine History Peptic Ulcer Disease Fetal cardiac activity noted on ultrasound

Methotrexate Ectopic Protocol

Protocol 1: Single Dose Contraception until bHCG returns to 5 mIU/ml or less Methotrexate 50 mg/m2 BSA PO or IV for 1 dose bHCG monitoring as below (days 4, 7 and then weekly)
Repeat dose if bHCG does not drop 15% from days 4-7

Consider Leucovorin rescue Outcomes

Success rate: 88.1% (>1 dose needed in 14% of cases) Adverse effects: 31.3%

Methotrexate Ectopic Protocol

Protocol 2: Multiple Dose (preferred for better efficacy) Contraception until bHCG returns to 5 mIU/ml or less bHCG monitoring as below Alternate agents up to 4 doses of each drug
Methotrexate 1 mg/kg PO or IV on days 1, 3, 5, and 7 Leucovorin 0.1 mg/kg on days 2, 4, 6, and 8

Outcomes
Success rate: 92.7% Adverse effects: 41.2%

Methotrexate Ectopic Protocol monitoring

Quantitative bhCG First Week: Draw bHCG days 4 and 7
Anticipate 15% bHCG decrease between days 4 and 7

Subsequent Weeks: Draw bHCG weekly

Anticipate drop to 5 mIU/ml by 3-4 weeks

Serum Progesterone may also be followed Anticipate drop to 1.5 mg/ml by 2-3 week

Methotrexate Ectopic Protocol monitoring

Inadequate bHCG response

consider possible surgical intervention

Pregnancy Symptoms
Week 4 Symptoms
Amenorrhea Nausea ( Morning Sickness) Fatigue

Pregnancy Symptoms
Week 6-8
Urinary frequency onset at 6 weeks

Week 10 to 12
Irregular contractions start

Week 15 to 20
Quickening in multiparous patients by 15 to 17 weeks Quickening in nulliparous patients by 18 to 20 weeks

Pregnancy Signs
Areola darkens by 6-8 weeks Breasts engorge by 6-8 weeks Uterus is size of Orange by 10 weeks Uterus is size of Grapefruit by 12 weeks Fetal Heart Tones auscultated by Doppler (12 WKS) Fetal Heart Tones by Fetoscope by 16 to 20 weeks Irregular Contractions palpable by 20 weeks

Pregnancy Signs
Chadwick's Sign Darkened vulva and vagina Chloasma (Mask of pregnancy) Dark under eyes, bridge nose Linea Nigra Dark midline low abdomen Hegar's Sign Softened low uterine segment on bimanual exam

Pregnancy Signs

Pregnancy Signs

Chloasma (Mask of pregnancy)

Pregnancy Dating
Naegele's Rule for calculating EDC Start with the First Day of LMP Add 7 days Subtract 3 months

Pregnancy Dating
Actual Fetal age dated from time of conception Menstrual Age (gestational age) = Conception + 14 days

Transvaginal Ultrasound
Gestational Sac
Day: 35 to 37 Gestational Sac size over 9 mm: Yolk Sac present Gestational Sac size over 16 mm: Fetal pole present (Thickening on margin of yoke sac) Day: 40 Fetal pole flutter)

size over 5 mm

(fetal ht. beat -irregular

Day: 45 Fetal Heart Movement

Abdominal Ultrasound
Gestational Sac
Day: 42

Embryo 5-10 mm with cardiac activity

Day: 49-50

Transvaginal Ultrasound
Gestational Sac (5 weeks gestation,)
Round sac with echogenic ring located in fundus

Transvaginal Ultrasound
Yolk Sac (6 weeks gestation) Echogenic, round sac within gestational sac May appear more as '=' sign rather than circle

Transvaginal Ultrasound
Embryo (7 weeks gestation) Onset as dot at yolk sac edge Grows at 1 mm per day Fetal heart activity by crown-rump length 5 mm

Table of menstrual ages per crownrump length

6.1 Weeks: 0.4 cm 7.2 Weeks: 1.0 cm 8.0 Weeks: 1.6 cm 9.2 Weeks: 2.5 cm 9.9 Weeks: 3.0 cm 10.9 Weeks: 4.0 cm 12.1 Weeks: 5.5 cm 13.2 Weeks: 7.0 cm 14.0 Weeks: 8.0 cm

Routine Obstetric Visit

Routine Obstetric and Prenatal EXAM

Prenatal Lab
Initial Labs: General Complete Blood Count
Hemoglobin Platelets Urine sample Urinalysis Urine Culture

Prenatal Lab
Blood Type
ABO and Rh Antibody screen (Coombs test)

Rubella antibody
MMR contraindicated during pregnancy

Administer postpartum MMR if negative Screen prior to pregnancy and immunize if negative

Prenatal Lab
Syphilis Serology (RPR) Hepatitis B Surface Antigen (HBsAg)
If at risk, Hepatitis B Vaccine (safe in pregnancy)

Pelvic Exam Initial Labs

Gonorrhea Culture or Gonorrhea Antigen Chlamydia Antigen Pap Smear

Prenatal Lab
HIV Test Consider Thyroid Stimulating Hormone (TSH) in all women

Prenatal Lab Specific risk factor directed tests

Group B Streptococcus Culture

Culture both vagina and anus

Sickle Cell Anemia or Sickle Cell Trait screen

Predisposes to Pyelonephritis

Prenatal Lab Specific risk factor directed tests

Glucose Challenge Test (50 g Glucola drink) Hepatitis C Antibody If no maternal history of Varicella infection
Obtain varicella zoster IgG , if negative
Avoid Varicella exposure If exposed, consider varicella Immunoglobulin Offer postpartum Varicella Vaccine
Wait 3 months after last RhoGAM shot

Varicella Vaccine is contraindicated in pregnancy

Screen prior to pregnancy and immunize if negative

Congenital defect screening

1. Alpha-fetoprotein (AFP) Increased with Neural Tube Defects Decreased in Trisomy 21 and Trisomy 18 2. Human chorionic gonadotropin (Free bHCG) Increased in Trisomy 21 and decreased in Trisomy 18 3. Unconjugated Estriol (uE3) Decreased in Trisomy 21 and Trisomy 18 4. Inhibin A Increased in Trisomy 21 and normal in Trisomy 18 (Quad screen)

Vaccination in Pregnancy
Class C: Small risk in controlled animal studies Td (Tetanus Toxoid and Diphtheria Toxoid)
Give after first trimester if none in last 10 years

Hepatitis A Vaccine
Give if travel to endemic area or IV DRUG ABUSE in pregnancy

Vaccination in Pregnancy
Hepatitis B Vaccine
Administer in pregnancy for Hepatitis B risk factor

Influenza Vaccine
Indicated if pregnant in Influenza season Immunize after first trimester

Meningococcal Vaccine
Standard indications (dormitory, barracks, travel)

Vaccination in Pregnancy
Plague Vaccine Polyvalent Pneumococcal Vaccine
Vaccinate high risk women before pregnancy ACIP recommends avoiding during pregnancy

Polio Vaccine (live and inactivated) Avoid during pregnancy in most cases Rabies Vaccine Tularemia Vaccine Typhoid Vaccine

Very high risk to fetus

BCG vaccine (Bacille Calmette-Guerin Vaccine)TB Measles Vaccine Yellow Fever Vaccine Mumps Vaccine

Very high risk to fetus

Rubella Vaccine Small Pox Vaccine TC-83 Venezuelan Equine Encephalitis Vaccine Varicella Vaccine (Varivax)
Risk if vaccinated within 4 weeks of conception Theoretic risk only; not an indication for EAB

Schedule of Clinic Visits

Confirmation of intrauterine pregnancy First Obstetric Visit at 8 weeks gestation Routine Obstetric Visit
Prenatal visit every 4 weeks to 28 weeks gestation Prenatal visit every 2 weeks to 36 weeks gestation Prenatal visit every 1 week until delivery

MONITOR
Blood Pressure Weight Hemoglobin / Hematocrit Perform at 26-28 weeks Fetal Heart Activity by doptone (after 10-12 weeks)

MONITOR
Fundal height (after 20 weeks) Abdominal palpation for Fetal Presentation >35 weeks Edema
Lower extremity edema Face and hand edema (more suggestive of Preeclampsia)

Weight Gain in Pregnancy

Normal conception weight (BMI = 19.8 - 26)
Total weight gain: 11.25 - 15.75 kg (25 - 35 lb) Gain 1st trimester: 1.35-2.25 kg (3-5 lb) per month Gain 2nd/3rd: 0.45-0.90 kg (1-2 lb) per week

Overweight at conception (BMI 27-29)

Total weight gain: 6.75 - 11.25 kg (15 - 25 lb) Gain 1st trimester: 0.90-1.80 kg (2-4 lb) per month Gain 2nd/3rd: 0.45 kg (1 lb) per week

Weight Gain in Pregnancy

Morbidly overweight at conception (BMI >29)
Total weight gain: 6.8 kg (15 lb)

Low weight at conception (BMI < 15)

Total gain: 15.75 - 18 kg (35 - 40 lb)

Daily caloric intake

Pregnant Women: First Trimester Daily caloric intake 2300 KCals Pregnant Women (Second and third trimester) Daily caloric intake: 2500 KCals Daily Protein intake: 60 grams

Lactating Women Daily caloric intake: 2600 KCals Daily Protein intake: 65 grams

Prenatal Vitamin
Folate 400 ug
Most important component in prenatal vitamins Reduces Neural Tube Defects by 50% at conception
Spina bifida Anencephaly

Reduced fetal risk of Cleft Lip and palate by 25-50% Reduces conotruncal heart defects by 43%

Calcium 250 mg
Diet needs supply 750 mg/day to total 1000 mg/day

Iron Supplementation (30 mg iron)

Prenatal Vitamin

Magnesium Supplementation (320 mg Magnesium) Vitamin C 65 mg Zinc 25 mg

Increases birth weight and Head Circumference Results in birth at later gestational age Results in shorter hospital stay

Vitamin A 800 mcg (8,000 IU)

Should not exceed 1000 mcg (10,000 IU)

Teratogen at higher doses

Vitamin D 10 mcg Vitamin E 10 mcg B Vitamins

Vitamin B6 2.2 mcg Thiamine Riboflavin

Pelvimetry
Gynecoid Pelvis (50%)
Pelvic brim is a transverse ellipse (nearly a circle) Most favorable for delivery Pelvic brim is triangular Convergent Side Walls (widest posteriorly) Prominent ischial spines Narrow subpubic arch More common in white women

Android Pelvis (Male type)

Pelvimetry
Anthropoid Pelvis
Pelvic brim is an anteroposterior ellipse
Gynecoid pelvis turned 90 degrees

Narrow ischial spines Much more common in black women

Platypelloid Pelvis (3%)

Pelvic brim is transverse kidney shape Flattened gynecoid shape

Determination of an Adequate Pelvis

Diagonal conjugate
Distance from sacral promontory to symphysis pubis Approximate length of fingers introitus to sacrum Adequate diagonal conjugate > 11.5cm Images

Determination of an Adequate Pelvis

Intertuberous Diameter Distance between Ischial tuberosities Approximately width of fist Adequate intertuberous diameter > 10 cm Images

Assess Fundal Height

Fundal height (cm) approximates weeks of gestation
Assess Fetal Lie
Longitudinal (Normal) Transverse Oblique Breech Presentation Cephalic Presentation
Vertex Presentation (Normal attitude: Full flexion) Face Presentation (Abnormal attitude: Head extends)

Assess Fetal Presentation

Assess Fundal Height

Assess Fetal Vertex Position
Left Occiput Lateral (LOL) 40% Left Occiput Anterior (LOA) 12% Left Occiput Posterior (LOP) 3% Right Occiput Lateral (ROL) 25% Right Occiput Anterior (ROA) 10% Right Occiput Posterior (ROP) 10%

Assess Fetal Descent

Is Vertex engaged?

Leopold's Maneuvers
First Maneuver (Upper pole)
Examiner faces woman's head Palpate uterine fundus Determine what fetal part is at uterine fundus

Second Maneuver (Sides of maternal abdomen)

Examiner faces woman's head Palpate with one hand on each side of abdomen Palpate fetus between two hands Assess which side is spine and which extremities

Leopold's Maneuvers
Third Maneuver (Lower pole)
Examiner faces woman's feet Palpate just above symphysis pubis Palpate fetal presenting part between two hands Assess for Fetal Descent

Fourth Maneuver (Presenting part evaluation)

Examiner faces woman's head Apply downward pressure on uterine fundus Hold presenting part between index finger and thumb Assess for cephalic versus Breech Presentation

Bishop Score
Scoring
Cervical Dilation Cervix dilated < 1 cm: 0 Cervix dilated 1-2 cm: 1 Cervix dilated 2-4 cm: 2 Cervix dilated > 4 cm: 3

Bishop Score
Cervical Length (Effacement)
Cervical Length > 4 cm (0% effaced): 0 Cervical Length 2-4 cm (0 to 50% effaced): 1 Cervical Length 1-2 cm (50 to 75% effaced): 2 Cervical Length < 1 cm (>75% effaced): 3

Bishop Score
Cervical Consistency
Firm cervical consistency: 0 Average cervical consistency: 1 Soft cervical consistency: 2

Cervical Position
Posterior cervical position: 0 Middle or anterior cervical position: 1

Bishop Score
Zero Station Notation (presenting part level)
Presenting part at ischial spines -3 cm: 0 Presenting part at ischial spines -1 cm: 1 Presenting part at ischial spines +1 cm: 2 Presenting part at ischial spines +2 cm: 3

Modifiers
Add 1 point to score for:
Preeclampsia Each prior vaginal delivery

Subtract 1 point from score for:

Postdates Pregnancy Nulliparity Premature or prolonged Rupture of Membranes

Interpretation
Indications for Cervical Ripening with prostaglandins
Bishop Score <5 Membranes intact No regular contractions

Indications for Labor Induction with Pitocin

Bishop Score >= 5 Rupture of Membranes

Cervical Ripening
Medications: Standard Dinoprostone (PGE2 Gel, Cervidil, Prepidil) Misoprostol

Membrane Stripping (Membrane Sweeping )

Stimulates prostaglandin release Reduces the need for Labor induction Useful as adjunct in Labor Induction Allows for lower overall Oxytocin dose

Technique
Examining finger inserted into cervix Finger moved in circular fashion inside endocervix Press against internal cervical os Separates membranes from lower uterine segment

Non-Pharmacologic Methods
Breast stimulation
Theoretical benefit
Breast stimulation stimulates Oxytocin release Fetal Heart Rate response similar to OCT

Technique
Gentle massage or warm compresses applied to breast Done for one hour or repeated three times daily

Non-Pharmacologic Methods
Sexual Intercourse
Benefits in cervical ripening or induction unclear Theoretical benefit
Female orgasm induces uterine contraction Semen contain prostaglandins

Alternative Medications: Herbals

General
Used by some nurse-midwives in United States Anecdotal use in some cultures as long tradition No current rigorous studies on safety and efficacy

Alternative Medications: Herbals

Herbals historically used for cervical ripening
Evening Primrose Oil Black Haw Black Cohosh Blue Cohosh Red raspberry leaves