The urine of a woman is administered to 5 immature mice (weighing 6-8 g): the first - 0.2 ml, the second - 0.25, the third and fourth - 0.3 ml, the fifth - 0.4 ml. On the first day, urine is administered 2 times, in the morning and in the evening, on the second day - 3 times and on the third day - 1 time. After 96-100 hours from the moment of the first injection, the mice are dissected and the genitals are examined microscopically. If there are multiple blood points or anretic yellow spots in the testicles, then in 98% there are clear data for pregnancy.
In frogs (males), the contents of the cloaca are examined before the reaction to exclude the possibility of spontaneous spermatorrhea. In the absence of the latter, 3-5 ml of the urine of a pregnant woman is injected into the lymphatic sac of the frog, located under the skin on the back, and after 30-60-90 minutes the cloacal fluid is re-examined. In the presence of pregnancy, a large number of motile spermatozoa are found in each field of view.
During pregnancy with twins, a depression is felt on the anterior surface of the uterus, which runs obliquely or along it and divides the uterus into 2 segments.
It consists in detecting a special rhythm of the fetal heartbeat, which appears as a result of the activity of two hearts and resembles the hooves of two galloping horses.
Excessive mobility of the uterus in the isthmus in the first months of pregnancy.
A characteristic and classic symptom of early pregnancy (2-3 months). It consists in a distinct difference in consistency between the body of the uterus (soft, loosened) and the still dense neck.
1. When examining 1-2 weeks after the delay of menstruation on the anterior surface of the uterine body along the midline in length, a protrusion in the form of a ridge is palpated.
2. With antiflexion of the uterus during pregnancy, due to softening of the isthmus, angiflexia increases sharply. It is a likely sign of pregnancy.
The area of the isthmus is easily displaced, due to its softening, while the rest of the isthmus of the uterus is still dense. It is a likely sign of pregnancy in 90-95% of cases.
Spherical uterus. It is a likely sign of pregnancy.
Slight mobility of the cervix in all directions, not transmitted to the body of the uterus. It is a sign of pregnancy.
In the presence of pregnancy, the cervix is \u200b\u200bsoft, in the absence of it - hard.
An increase in the anterior-posterior size of the uterus (large nodularity) compared to a normal uterus during pregnancy. It occurs in 96% already at the end of the first month of pregnancy. Similar to Gubarev's symptom.
An early symptom of pregnancy is a blue or wine-red color of the vaginal mucosa.
Changes in the cervix depending on the phase of the normal cycle of menstruation. Described by O. L. Golubeva. On the 8-9th day of the menstrual cycle, the external opening of the cervix expands and a vitreous, transparent mucus appears in it. Over the next 2-3 days, the cervical canal continues to expand and reaches a diameter of 1/4 or 1/3 cm, the external opening of the cervix becomes black, resembling a pupil. This condition lasts for several days, after which the pharynx closes.
Pregnancy symptom. The presence of an elastic layer on the anterior surface of the body of the uterus, in the isthmus, is best felt along the midline, the examining finger feels this layer as a site of fluctuation.
A catheter inserted into the bladder meets the resistance of the enlarged body of the pregnant uterus. A symptom of early pregnancy, little known.
Early pregnancy symptom. Sensation of fulfillment of the vaults of the vagina during vaginal examination.
Pregnancy symptom. Sensation of pulsation in the vagina. It has now lost its diagnostic value.
In the mucus dried on the glass, taken from the cervical canal, taken on the 7-18th day of the menstrual cycle, patterns resembling a fern leaf are visible under a microscope. After ovulation, this symptom is usually absent or only traces of it remain.
Early pregnancy symptom. Bulging of one of the sections of the uterus, usually the tubal angle, where the fetal egg is attached. This pronounced asymmetry of the uterus disappears by 11-12 weeks of pregnancy.
The appearance in early pregnancy of radiance in the form of strands around the nipples.
An enlarged uterus with an uneven consistency, under the influence of the study, it contracts and hardens. It is a likely sign of pregnancy.
Pregnancy symptom. Increased body hair during pregnancy.
Twin pregnancy symptom. Identification of two separately balloting formations in the pregnant uterus.
It is observed in pregnant women aged 20-30 years. The disease appears in the evening and at night in a sitting and lying position and manifests itself in the constant movement of the legs.
Early diagnosis of pregnancy, determination of its duration are important not only from an obstetric point of view, but also due to the fact that hormonal, physiological and anatomical changes caused by pregnancy can significantly affect the course of various extragenital diseases. An accurate knowledge of the gestational age is necessary for an adequate examination of patients and the management of pregnancy and childbirth.
Diagnosis of pregnancy, especially early pregnancy, sometimes presents significant difficulties, since some endocrine diseases, stress, and medication can mimic the state of pregnancy. In the future, difficulties arise, as a rule, when determining the gestational age.
Signs of pregnancy, described in classic textbooks on obstetrics, have now lost their significance to a certain extent with the widespread introduction of ultrasound.
Signs of pregnancy, based on subjective or objective data, are divided into doubtful, probable and reliable.
To the dubious (presumably) signs of pregnancy include subjective data:
Nausea, vomiting, especially in the morning, changes in appetite, and food cravings;
Intolerance to certain odors (perfume, tobacco smoke, etc.);
Violations of the nervous system: malaise, irritability, drowsiness, mood instability, dizziness, etc .;
Increased urination;
Tension of the mammary glands;
Pigmentation of the skin on the face, along the white line of the abdomen, in the nipple area;
The appearance of stripes (scars) of pregnancy on the skin of the abdomen, mammary glands and thighs;
An increase in the volume of the abdomen.
Probable signs of pregnancy are determined mainly by objective changes in the genital organs, starting from the first trimester:
Cessation of menstruation (amenorrhea) in a healthy woman of reproductive age;
The appearance of colostrum in nulliparous with pressure on the nipples;
Cyanosis of the mucous membrane of the vagina and cervix;
An increase in the uterus, a change in its shape and consistency.
Detection of cyanosis of the vagina and cervix, as well as a change in the size, shape and consistency of the uterus is possible with a special gynecological examination: examination of the external genital organs and the entrance to the vagina, examination of the walls of the vagina and cervix using mirrors, as well as with a two-handed vaginal-abdominal examination.
The following signs are important for the diagnosis of pregnancy.
Enlargement of the uterus. The uterus becomes rounded, enlarged, softish, by the end of the 8th week the size of the uterus corresponds to the size of a goose egg, at the end of the 12th week the bottom of the uterus is at the level of the symphysis or slightly higher.
Horvitz-Hegar symptom. The uterus is soft on examination, softening is especially pronounced in the isthmus. With a two-handed examination, the fingers of both hands converge in the isthmus region with almost no resistance (Fig. 7.1). The symptom is clearly defined after 6-8 weeks from the beginning of the last menstruation.
Rice. 7.1. Horvitz-Geghara sign of pregnancyA sign of Snegi-roar. Changeable consistency of the pregnant uterus. During a two-handed examination, the soft pregnant uterus thickens and contracts. After the cessation of irritation, the uterus again acquires a soft texture.
Piskacek sign. The asymmetry of the uterus in early pregnancy is due to the protrusion of its right or left corner, which corresponds to the implantation of the ovum. As the fetal egg grows, this asymmetry gradually smoothes out (Fig. 7.2).
Sign of Gubarev and Gauss. Due to the significant softening of the isthmus, there is a slight mobility of the cervix in the early stages of pregnancy, which is not transmitted to the body of the uterus.
Genter's sign. Rib-like thickening along the midline of the anterior surface of the uterus. However, this thickening is not always determined (Fig. 7.3).
Chadwick's mark. In the first 6-8 weeks of pregnancy, cyanosis of the cervix.
The likely signs of pregnancy include a positive result of immunological pregnancy tests. In practice, the determination of the level of the b-subunit of hCG in the blood serum is widely used, which allows you to establish pregnancy a few days after the implantation of the fetal egg.
Credible, or undoubted, signs of pregnancy indicate the presence of an embryo / fetus in the uterine cavity.
The most reliable information for diagnosing pregnancy is obtained using ultrasound. With transabdominal scanning, pregnancy can be established from 4-5 weeks, and with transvaginal echography - 1-1.5 weeks earlier. In the early stages, pregnancy is established on the basis of the determination in the uterine cavity of the fetal egg, yolk sac, embryo and its heart contractions, at a later date - due to the visualization of the fetus (or fetuses in multiple pregnancies). The cardiac activity of the fetus with ultrasound can be detected from 5-6 weeks of pregnancy, the motor activity of the embryo from 7-8 weeks.
To determine the duration of pregnancy and childbirth, the date of the last menstruation (menstrual period) and information about the first movement of the fetus are important. Often, the gestational age is set according to the day of the alleged ovulation (ovulatory period), for which, in addition to the 1st day of the last menstruation, the duration of the menstrual cycle is taken into account and the countdown is from its middle.
For the management of patients at various stages of pregnancy (examination, therapeutic measures), three trimesters are conventionally distinguished. I trimester lasts 12-13 weeks from the first day of the last menstruation, II - from 13 to 27 weeks, III - from 27 weeks to the end of pregnancy.
Due date is based on the assumption that a woman has a 28-day menstrual cycle with ovulation on days 14-15. In most cases, pregnancy lasts 10 obstetric (lunar, 28 days each) months, or 280 days (40 weeks), if we calculate its beginning from the 1st day of the last menstruation. Thus, in order to calculate the estimated due date, 9 calendar months and 7 days are added to the date of the 1st day of the last menstruation. Usually, the term of childbirth is calculated more simply: from the date of the 1st day of the last menstruation, 3 calendar months are counted back and 7 days are added. When determining the due date, it should be borne in mind that ovulation does not always occur in the middle of the cycle. The duration of pregnancy increases by approximately 1 day for each day of the menstrual cycle that exceeds 28 days. For example, with a 35-day cycle (when ovulation occurs on the 21st day), the due date will be shifted a week later.
The estimated due date can be calculated by ovulation: from the 1st day of the expected but not arrived menstruation, 14-16 days are counted back and 273-274 days are added to the date obtained.
When determining the term of childbirth, the time of the first movement of the fetus, which is felt by primiparas from the 20th week, is also taken into account, i.e. from the middle of pregnancy, and multiparous - about 2 weeks earlier (from 18 weeks). To the date of the first movement, 5 obstetric months (20 weeks) are added for primigravidas, 5.5 obstetric months (22 weeks) for multi-pregnant women and the estimated term of delivery is obtained. However, it should be remembered that this sign has only an auxiliary value.
For the convenience of calculating the gestational age for menstruation, ovulation and the first movement of the fetus, there are special obstetric calendars.
To determine the gestational age and date of birth, objective examination data are of great importance: the size of the uterus, the volume of the abdomen and the height of the fundus of the uterus, the length of the fetus and the size of the head.
The size of the uterus and the height of its standing at different stages of pregnancy At the end of the 1st obstetric month of pregnancy (4 weeks), the size of the uterus reaches approximately the size of a chicken egg. At the end of the 2nd obstetric month of pregnancy (8 weeks), the size of the uterus approximately corresponds to the size of a goose egg. At the end of the 3rd obstetric month (12 weeks), the size of the uterus reaches the size of the newborn's head, its asymmetry disappears, the uterus fills the upper part of the pelvic cavity, its bottom reaches the upper edge of the pubic arch (Fig. 7.4).
From the 4th month of pregnancy, the bottom of the uterus is palpated through the abdominal wall, and the duration of pregnancy is judged by the height of the standing of the bottom of the uterus. It should be remembered that the height of the uterine fundus can be affected by the size of the fetus, excess amniotic fluid, multiple pregnancies, abnormal position of the fetus and other features of the course of pregnancy. The height of the fundus of the uterus when determining the duration of pregnancy is taken into account in conjunction with other signs (the date of the last menstruation, the first movement of the fetus, etc.).
At the end of the 4th obstetric month (16 weeks) the bottom of the uterus is located in the middle of the distance between the pubis and the navel (4 transverse fingers above the symphysis), at the end of the 5th month (20 weeks) the bottom of the uterus is 2 transverse fingers below the navel; noticeable protrusion of the abdominal wall. At the end of the 6th obstetric month (24 weeks) the bottom of the uterus is at the level of the navel, at the end of the 7th (28 weeks) the bottom of the uterus is determined 2-3 fingers above the navel, and at the end of the 8th (32 weeks) the bottom of the uterus stands in the middle between the navel and the xiphoid process. The navel begins to smooth out, the abdominal circumference at the level of the navel is 80-85 cm. At the end of the 9th obstetric month (38 weeks), the fundus of the uterus rises to the xiphoid process and costal arches - this is the highest level of standing of the fundus of the pregnant uterus, the abdominal circumference is 90 cm, the navel is smoothed .
At the end of the 10th obstetric month (40 weeks), the fundus of the uterus descends to the level at which it was at the end of the 8th month, i.e. to the middle of the distance between the navel and the xiphoid process. The navel protrudes. The circumference of the abdomen is 95-98 cm, the fetal head descends, in primigravidas it presses against the entrance to the small pelvis or stands as a small segment at the entrance to the small pelvis.
Sonographic determination of the gestational age. Echography is of great importance in determining the duration of pregnancy. The main parameter for accurate ultrasound determination of the gestational age in the first trimester is the coccygeal-parietal size (KTR) of the embryo. In the II and III trimesters, the gestational age is determined by various fetometric parameters: biparietal size and head circumference, average diameters of the chest and abdomen, abdominal circumference, and femur length. The longer the gestational age, the less accurate the determination of the gestational age of the fetus due to the variability of its size. Ultrasound is considered optimal for determining the gestational age before the 24th week of pregnancy.
Early diagnosis of pregnancy, as a rule, is established on the basis of presumptive and probable signs. Alleged signs of pregnancy are:
Change in appetite (aversion to meat, fish, etc.), nausea, vomiting in the morning;
Change in olfactory sensations (aversion to perfumes, tobacco smoke, etc.);
Changes in the nervous system, which is manifested by irritability, drowsiness, mood instability, etc.;
Pigmentation of the skin of the face, nipples or areola, along the white line of the abdomen.
Possible signs of pregnancy are:
Violation of menstrual function and changes in the genital organs;
Absence of menstruation.
This sign is likely because the cessation of menstruation can be associated with serious illnesses, endocrine pathology, with malnutrition, after stress and strong feelings. However, the cessation of menstruation in a healthy young woman is usually associated with the onset of pregnancy:
Cyanosis (cyanosis) of the mucous membrane of the vagina and cervix;
Change in the size, shape and consistency of the uterus;
The appearance of colostrum from the milk passages that open on the nipple when pressing on the mammary glands.
It is possible to diagnose probable signs of pregnancy after questioning the woman, feeling the mammary glands and squeezing out colostrum, examining the external and internal genital organs, and vaginal examination. By examining the cervix on the mirrors, it is possible to detect the presence of cyanosis of the cervix and vaginal mucosa (a likely sign of pregnancy), as well as to detect diseases of the cervix and vagina (inflammatory process, cervical erosion, polyp, cancer, etc.). Bimanual vaginal examination determines the following signs:
An increase in the size of the uterus, which becomes noticeable already at the 5-6th week of pregnancy. An increase in the uterus is initially noted in the anteroposterior size (becomes spherical), while later its transverse size also increases. The longer the gestation period, the clearer the increase in uterine volume. And by the end of the second month of pregnancy, the uterus increases to the size of a goose egg, at the end of the third month of pregnancy, the bottom of the uterus is at the level of the symphysis or slightly above it.
Horvitz-Gegar sign characterized by the fact that the consistency of the pregnant uterus is soft, and the softening is especially pronounced in the isthmus. As a result, in a two-handed vaginal examination, the fingers of both hands meet at the isthmus almost without resistance. This symptom is most characteristic of early pregnancy.
Piskacek sign characterized by the appearance of uterine asymmetry in early pregnancy. This is manifested by the appearance of a dome-shaped protrusion of the right and left corners of the uterus. The place of protrusion corresponds to the place of implantation of the fetal egg. In the future, as the fetal egg grows, the protrusion disappears.
Sign of Snegireva characterized by a change in the consistency of the uterus during pregnancy. The softened pregnant uterus during a two-handed examination under the influence of mechanical irritation becomes denser and shrinks in size. After the cessation of irritation, the uterus again acquires a soft texture.
Genter's sign characterized by the occurrence in the early stages of pregnancy of the inflection of the uterus in front as a result of a strong softening of the isthmus, as well as the appearance of a ridge-like thickening (protrusion) on the anterior surface of the uterus along the midline. The appearance of thickening, however, cannot always be determined.
Gubarev-Gauss sign characterized by the fact that the appearance of slight mobility of the cervix was noted. In early pregnancy, slight displacement of the cervix is associated with significant softening of the isthmus.
Today, a condition such as uterine rupture is extremely rare. This is ensured by the timely diagnosis of the threat of uterine rupture both in the maternity hospital and during pregnancy in the antenatal clinic.
A modern screening test that allows you to determine pregnancy already in the first days of the expected menstruation delay, based on determining the level of (i-subunit of human chorionic gonadotropin (hCG) in the blood or urine. 7 days after fertilization (4-5 days after implantation ) the level of hCG in the blood serum is 25 mIU / ml and can be determined by enzyme immunoassay.
Determination of hCG in urine (" pregnancy test”) has the same sensitivity (the test will be positive at a hCG level of 25 mIU / ml). Human chorionic gonadotropin is produced by syncytiotrophoblast and placenta, reaches a peak (100,000 mIU/ml) in blood serum at 10 weeks of gestation (60 days after fertilization), decreases during the second trimester (up to 5,000 mIU/ml after 100-130 days) and then rises slightly again to 20,000-30,000 mIU/ml in the third trimester.
Normal hCG levels double every 48-60 hours for the first 8 weeks. With an ectopic (ectopic) pregnancy, the level of hCG rises more slowly and to a lesser extent. With the threat of miscarriage, the level of hCG decreases before the expulsion of the fetal egg. The accuracy of this method is reduced by the fact that in 15% of cases during normal pregnancy, hCG increases more slowly, and in 17% of cases of ectopic pregnancy, its level increases adequately.
Pregnancy diagnosis supported by data ultrasound. With the help of modern endovaginal ultrasound, it is possible to determine the fetal egg with cardiac activity at a hCG level of 1000-1500 mIU / ml, which corresponds to 24 days after fertilization. The fetal egg (gestational sac) should be clearly visible in the uterus from 5 weeks of gestational age (corresponding to the level of r-hCG from 1500 to 2000 mIU / ml), and the heartbeat of the embryo - from 6 weeks (corresponding to the level of r-hCG from 5000 to 6000 mIU / ml). ml).
A false positive pregnancy test may be in the presence of hCG-producing tumors, hemolysis, lipidemia, or laboratory error. False-negative test results are usually associated with a shorter expected pregnancy, at which the hCG level is still beyond the diagnostic capabilities of the method.
The fetal heartbeat is determined by auscultation from 20 weeks (with a stethoscope, or fetoscope), electronic methods (ultrasound Doppler) - from 10 weeks of pregnancy.
A pregnant woman begins to feel fetal movements between 16 (pregnant women again) and 18-20 weeks (pregnant women for the first time).
The expected date of delivery (ODP) is calculated using the Naegele formula:
ODP \u003d OM + 7 days - 3 months + 1 year,
where OM is the first day of the last menstrual period.
The average pregnancy lasts 280 days from the first day of the last menstruation. If the date of ovulation is known (when assisted reproductive technologies are used), the ADP is calculated by adding 266 days. This date must be set, and the size of the uterus must be determined at the first visit of the pregnant woman to the doctor (first visit).
When the date of the first day of the last menstrual period is uncertain (unknown), the gestational age and the expected date of delivery are determined by ultrasound. The error in determining the gestational age according to ultrasound can be 7-8% and increases with increasing fetal age. The error in ultrasonic determination of the gestational age of the fetus is approximately 1 week in the first trimester, 2 weeks in the second trimester and 3 weeks in the third trimester of pregnancy (“finger rule”). Measurement of the coccygeal-parietal size of the embryo in the first half of the first trimester of pregnancy can reduce the error in determining the gestational age to 3-5 days.
The expected date of delivery can be roughly determined by the date of the sensation of fetal movements. In women giving birth for the first time, 22 weeks are added to this date, again - 24 weeks. The expected date of delivery is also calculated from the date of the first visit to the doctor (establishment of pregnancy according to clinical data - the size of the uterus). The error will be less when a pregnant woman is treated before 12 weeks of gestation. And, finally, the expected date of delivery can be determined by the start of the prenatal leave, adding 10 weeks to this date. Special obstetric calendars make it easier for a doctor to determine the date of birth.
The endocrine, physiological, and anatomical changes that accompany pregnancy form the basis of its classic supposed, probable, and credible symptoms and signs.
Pregnancy is often characterized by disorders of the digestive system, especially the development of nausea and vomiting. The so-called "morning sickness and vomiting" usually appear in the morning, but disappear after a few hours. Sometimes this condition lasts longer and occurs at other times. This symptom appears around the 6th week of gestational age, spontaneously disappears after 6-12 weeks.
The cause of this condition is not exactly known, but it is thought to be related to elevated levels of estrogen and progesterone; greater sensitivity to hCG, or with a special isoform of hCG (reduced sialic acids), which has greater thyroid-stimulating activity and acts through thyroid-stimulating hormone receptors, or that causes a condition similar to iodine attack. According to another hypothesis, such women have subclinical adrenal hypofunction, which normalizes in the second trimester.
Alleged
Probable
1. Changes in the shape, size and consistency of the uterus
2. Belly enlargement
3. Anatomical changes in the cervix
4. Braxton Hicks Contraction
5. Balloting
Credible
In the first trimester, the enlargement of the uterus leads to an increase in pressure on the bladder, which can cause frequent urination. With the progression of pregnancy, the frequency of urination is normalized due to the fact that the uterus rises into the abdominal cavity. Frequent urination may reappear at the end of pregnancy due to the descent of the fetal head into the pelvic cavity, which reduces the capacity of the bladder.
A delay in menstruation in a woman of reproductive age for more than 10 days requires a mandatory pregnancy test. Delayed menstruation can also be caused by anovulation or persistence of the corpus luteum. Sometimes in women during the implantation of the blastocyst in the endometrium (1 week after ovulation and fertilization, there are 3-3.5 days after the last menstruation), slight bleeding occurs - a sign of Hartmann, which can lead to an inaccurate determination of gestational age. Such bloody discharge is more typical for pregnant women again than for pregnant women for the first time.
From the 7th to the 18th day of the ovulatory menstrual cycle, cervical mucus is abundant, transparent, well stretched and, when dried on a glass slide, forms a picture of a “fern leaf”. This is due to the high content of sodium chloride in the mucus (estrogenic effect). After the 21st day of the cycle, under the influence of progesterone, the content of sodium chloride decreases, and the mucus becomes denser, whitish and does not form a “fern leaf” pattern.
Changes in the mammary glands during pregnancy are more typical for women who give birth for the first time and are manifested by coarsening and increased sensitivity or soreness of the mammary glands.
Changescolor of the lining of the uterus (Chadwick's sign)) - the appearance of a cyanotic or purple-red hue of the mucous membrane of the vagina and cervix.
Increaseskin pigmentation. In pregnant women, there is increased pigmentation of the midline of the abdomen from the symphysis to the navel, areola. The appearance of pregnancy stripes is associated with the structural features of the skin.
Changessize, shape and consistency of the uterus. During the first few weeks, the uterus increases mainly in the anteroposterior diameter (starting from 5-6 weeks), later it becomes spherical and in the period of 12 weeks has a diameter of about 8 cm. Therefore, with a bimanual examination, an increase in the uterus can be detected from the 5-6th weeks of pregnancy. At 6-8 weeks of gestation, changes in the consistency of the cervix appear: it softens, the cervical canal opens up somewhat and can pass a fingertip; the neck becomes more mobile (a sign of Gubarev - Gauss).
signGeghara. At a period of 6-8 weeks of pregnancy, a bimanual gynecological examination can detect softening of the isthmus.
signGentera I - the appearance of a comb-like protrusion on the anterior surface of the uterine body along the midline, which does not extend to the fundus, posterior surface of the uterus and cervix.
signGenther II- hyperanteflexia of the uterus associated with softening of its isthmus; appears from 7-8 weeks of pregnancy.
signSnegirev- contraction of the uterus "under the fingers" during a bimanual gynecological examination.
signPiskachek- an increase in the area of the uterine fundus on the side of implantation (noticeable from the 5-6th week of pregnancy).
Abdominal enlargement. At 12 weeks, the uterus is usually palpated above the symphysis through the anterior abdominal wall. With the progression of pregnancy, the height of the uterine fundus above the symphysis (in cm) approximately corresponds to the gestational age (in weeks).
ReductionBraxton - Hicks. During pregnancy, contractions of the uterine muscles occur in the uterus, usually painless, which can be aggravated by palpation or massage of the uterus - the so-called Braxton-Hicks contractions (a sign of uterine pregnancy, as opposed to abdominal). The frequency of such contractions increases in the last days of pregnancy, especially at night. Braxton-Hicks contraction at the end of pregnancy is a sign of the preparation of the uterus for childbirth.
balloting. In the middle of pregnancy, the volume of the fetus is smaller compared to the volume of amniotic fluid (amniotic fluid), therefore, with increasing pressure on the uterus (during palpation), the fetus “repels” again returns to its previous position. In the second half of pregnancy, the outer contours and parts of the fetus can be palpated, especially at the end of the third trimester, and balloting of the fetal head can be determined.
CHAPTER 07. DIAGNOSTICS OF PREGNANCY
Early diagnosis of pregnancy, determination of its duration are important not only from an obstetric point of view, but also due to the fact that hormonal, physiological and anatomical changes caused by pregnancy can significantly affect the course of various extragenital diseases. An accurate knowledge of the gestational age is necessary for an adequate examination of patients and the management of pregnancy and childbirth.
Diagnosis of pregnancy, especially early pregnancy, sometimes presents significant difficulties, since some endocrine diseases, stress, and medication can mimic the state of pregnancy. In the future, difficulties arise, as a rule, when determining the gestational age.
SIGNS OF PREGNANCY
Signs of pregnancy, described in classic textbooks on obstetrics, have now lost their significance to a certain extent with the widespread introduction of ultrasound.
Signs of pregnancy, based on subjective or objective data, are divided into doubtful, probable and reliable.
To the dubious (presumably) signs of pregnancy include subjective data:
Nausea, vomiting, especially in the morning, changes in appetite, and food cravings;
Intolerance to certain odors (perfume, tobacco smoke, etc.);
Violations of the nervous system: malaise, irritability, drowsiness, mood instability, dizziness, etc .;
Increased urination;
Tension of the mammary glands;
Pigmentation of the skin on the face, along the white line of the abdomen, in the nipple area;
The appearance of stripes (scars) of pregnancy on the skin of the abdomen, mammary glands and thighs;
An increase in the volume of the abdomen.
Probable signs of pregnancy are determined mainly by objective changes in the genital organs, starting from the first trimester:
Cessation of menstruation (amenorrhea) in a healthy woman of reproductive age;
The appearance of colostrum in nulliparous with pressure on the nipples;
Cyanosis of the mucous membrane of the vagina and cervix;
An increase in the uterus, a change in its shape and consistency.
Detection of cyanosis of the vagina and cervix, as well as a change in the size, shape and consistency of the uterus is possible with a special gynecological examination: examination of the external genital organs and the entrance to the vagina, examination of the walls of the vagina and cervix using mirrors, as well as with a two-handed vaginal-abdominal examination.
The following signs are important for the diagnosis of pregnancy.
Enlargement of the uterus. The uterus becomes round, enlarged, soft; by the end of the 8th week, the size of the uterus corresponds to the size of a goose egg; at the end of the 12th week, the bottom of the uterus is at the level of the symphysis or slightly higher.
Horvitz-Hegar symptom. The uterus is soft on examination, softening is especially pronounced in the isthmus. With a two-handed examination, the fingers of both hands converge in the isthmus region with almost no resistance (Fig. 7.1). The symptom is clearly defined after 6-8 weeks from the beginning of the last menstruation.
Rice. 7.1. Horvitz-Geghara sign of pregnancy
A sign of Snegi-roar. Changeable consistency of the pregnant uterus. During a two-handed examination, the soft pregnant uterus thickens and contracts. After the cessation of irritation, the uterus again acquires a soft texture.
Piskacek sign. The asymmetry of the uterus in early pregnancy is due to the protrusion of its right or left corner, which corresponds to the implantation of the ovum. As the fetal egg grows, this asymmetry gradually smoothes out (Fig. 7.2).
Rice. 7.2. Piskacek pregnancy sign
Sign of Gubarev and Gauss. Due to the significant softening of the isthmus, there is a slight mobility of the cervix in the early stages of pregnancy, which is not transmitted to the body of the uterus.
Genter's sign. Rib-like thickening along the midline of the anterior surface of the uterus. However, this thickening is not always determined (Fig. 7.3).
Rice. 7.3. Sign of pregnancy Gen-tera
Chadwick's mark. In the first 6-8 weeks of pregnancy, cyanosis of the cervix.
The likely signs of pregnancy include a positive result of immunological pregnancy tests. In practice, the determination of the level of the b-subunit of hCG in the blood serum is widely used, which allows you to establish pregnancy a few days after implantation of the fetal egg.
Credible, or undoubted, signs of pregnancy indicate the presence of an embryo / fetus in the uterine cavity.
The most reliable information for diagnosing pregnancy is obtained using ultrasound. With transabdominal scanning, pregnancy can be established from 4-5 weeks, and with transvaginal echography - 1-1.5 weeks earlier. In the early stages, pregnancy is established on the basis of the determination in the uterine cavity of the fetal egg, yolk sac, embryo and its heart contractions, at a later date - due to the visualization of the fetus (or fetuses in multiple pregnancies). The cardiac activity of the fetus with ultrasound can be detected from 5-6 weeks of pregnancy, the motor activity of the embryo from 7-8 weeks.
DETERMINATION OF THE DATE OF PREGNANCY AND DELIVERY
To determine the duration of pregnancy and childbirth, the date of the last menstruation (menstrual period) and information about the first movement of the fetus are important. Often, the gestational age is set according to the day of the alleged ovulation (ovulatory period), for which, in addition to the 1st day of the last menstruation, the duration of the menstrual cycle is taken into account and the countdown is from its middle.
For the management of patients at various stages of pregnancy (examination, therapeutic measures), three trimesters are conventionally distinguished. I trimester lasts 12-13 weeks from the first day of the last menstruation, II - from 13 to 27 weeks, III - from 27 weeks to the end of pregnancy.
Due date is based on the assumption that a woman has a 28-day menstrual cycle with ovulation on days 14-15. In most cases, pregnancy lasts 10 obstetric (lunar, 28 days each) months, or 280 days (40 weeks), if we calculate its beginning from the 1st day of the last menstruation. Thus, in order to calculate the estimated due date, 9 calendar months and 7 days are added to the date of the 1st day of the last menstruation. Usually, the term of childbirth is calculated more simply: from the date of the 1st day of the last menstruation, 3 calendar months are counted back and 7 days are added. When determining the due date, it should be borne in mind that ovulation does not always occur in the middle of the cycle. The duration of pregnancy increases by approximately 1 day for each day of the menstrual cycle that exceeds 28 days. For example, with a 35-day cycle (when ovulation occurs on the 21st day), the due date will be shifted a week later.
The estimated due date can be calculated by ovulation: from the 1st day of the expected but not occurring menstruation, 14-16 days are counted back and 273-274 days are added to the date obtained.
When determining the term of childbirth, the time of the first movement of the fetus, which is felt by primiparas from the 20th week, is also taken into account, i.e. from the middle of pregnancy, and multiparous - about 2 weeks earlier (from 18 weeks). To the date of the first movement, 5 obstetric months (20 weeks) are added for primigravidas, 5.5 obstetric months (22 weeks) for multi-pregnant women and the estimated term of delivery is obtained. However, it should be remembered that this sign has only an auxiliary value.
For the convenience of calculating the gestational age for menstruation, ovulation and the first movement of the fetus, there are special obstetric calendars.
To determine the gestational age and date of birth, objective examination data are of great importance: the size of the uterus, the volume of the abdomen and the height of the fundus of the uterus, the length of the fetus and the size of the head.
The size of the uterus and the height of its standing at different stages of pregnancy At the end of the 1st obstetric month of pregnancy (4 weeks), the size of the uterus reaches approximately the size of a chicken egg. At the end of the 2nd obstetric month of pregnancy (8 weeks), the size of the uterus approximately corresponds to the size of a goose egg. At the end of the 3rd obstetric month (12 weeks), the size of the uterus reaches the size of the newborn's head, its asymmetry disappears, the uterus fills the upper part of the pelvic cavity, its bottom reaches the upper edge of the pubic arch (Fig. 7.4).
Rice. 7.4. The height of the fundus of the uterus at various stages of pregnancy
From the 4th month of pregnancy, the bottom of the uterus is palpated through the abdominal wall, and the duration of pregnancy is judged by the height of the standing of the bottom of the uterus. It should be remembered that the height of the uterine fundus can be affected by the size of the fetus, excess amniotic fluid, multiple pregnancies, abnormal position of the fetus and other features of the course of pregnancy. The height of the fundus of the uterus when determining the duration of pregnancy is taken into account in conjunction with other signs (the date of the last menstruation, the first movement of the fetus, etc.).
At the end of the 4th obstetric month (16 weeks) the bottom of the uterus is located in the middle of the distance between the pubis and the navel (4 transverse fingers above the symphysis), at the end of the 5th month (20 weeks) the bottom of the uterus is 2 transverse fingers below the navel; noticeable protrusion of the abdominal wall. At the end of the 6th obstetric month (24 weeks) the bottom of the uterus is at the level of the navel, at the end of the 7th (28 weeks) the bottom of the uterus is determined 2-3 fingers above the navel, and at the end of the 8th (32 weeks) the bottom of the uterus stands in the middle between the navel and the xiphoid process. The navel begins to smooth out, the abdominal circumference at the level of the navel is 80-85 cm. At the end of the 9th obstetric month (38 weeks), the fundus of the uterus rises to the xiphoid process and costal arches - this is the highest level of standing of the fundus of the pregnant uterus, the abdominal circumference is 90 cm, the navel is smoothed .
At the end of the 10th obstetric month (40 weeks), the fundus of the uterus descends to the level at which it was at the end of the 8th month, i.e. to the middle of the distance between the navel and the xiphoid process. The navel protrudes. The circumference of the abdomen is 95-98 cm, the fetal head descends, in primigravidas it presses against the entrance to the small pelvis or stands as a small segment at the entrance to the small pelvis.
Sonographic determination of the gestational age. Echography is of great importance in determining the duration of pregnancy. The main parameter for accurate ultrasound determination of the gestational age in the first trimester is the coccygeal-parietal size (KTR) of the embryo. In the II and III trimesters, the gestational age is determined by various fetometric parameters: biparietal size and head circumference, average diameters of the chest and abdomen, abdominal circumference, and femur length. The longer the gestational age, the less accurate the determination of the gestational age of the fetus due to the variability of its size. Ultrasound is considered optimal for determining the gestational age before the 24th week of pregnancy.
