CHAPTER 07. DIAGNOSIS OF PREGNANCY

Early diagnosis of pregnancy and 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 influence the course of various extragenital diseases. Accurate knowledge of the gestational age is necessary for adequate examination of patients and management of pregnancy and childbirth.

Diagnosing pregnancy, especially in the early stages, sometimes presents significant difficulties, since some endocrine diseases, stress, and medications can mimic the state of pregnancy. In the future, difficulties arise, as a rule, when determining the duration of pregnancy.

SIGNS OF PREGNANCY

The signs of pregnancy described in classic textbooks on obstetrics have now, with the widespread introduction of ultrasound, lost their significance to a certain extent.

Signs of pregnancy, based on subjective or objective data, are divided into doubtful, probable and reliable.

To the doubtful (supposed) Signs of pregnancy include subjective data:

Nausea, vomiting, especially in the morning, changes in appetite, as well as food cravings;

Intolerance to certain odors (perfume, tobacco smoke, etc.);

Nervous system dysfunction: malaise, irritability, drowsiness, mood instability, dizziness, etc.;

Increased urination;

Breast tension;

Skin pigmentation on the face, along the white line of the abdomen, in the nipple area;

The appearance of pregnancy stripes (scars) on the skin of the abdomen, mammary glands and thighs;

Increased abdominal volume.

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 women when pressing on the nipples;

Cyanosis of the mucous membrane of the vagina and cervix;

Enlargement of the uterus, change in its shape and consistency.

Detection of cyanosis of the vagina and cervix, as well as changes in the size, shape and consistency of the uterus is possible with a special gynecological examination: examination of the external genitalia and the entrance to the vagina, examination of the walls of the vagina and cervix using mirrors, as well as with a two-manual vaginal-abdominal examination.

The following signs are important for diagnosing pregnancy.

Enlarged uterus. The uterus becomes round, enlarged, and 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 fundus of the uterus is at the level of the symphysis or slightly higher.

Horwitz-Hegar's sign. When examined, the uterus is soft, softening is especially pronounced in the isthmus area. During a two-handed examination, the fingers of both hands converge in the isthmus area with almost no resistance (Fig. 7.1). The sign is clearly identified 6-8 weeks after the start of the last menstruation.

Rice. 7.1. Horwitz-Geghar pregnancy sign

Sign of Snow-roar. Variable consistency of the pregnant uterus. During a two-handed examination, the soft pregnant uterus thickens and contracts. After the irritation stops, the uterus again acquires a soft consistency.

Piskacek's sign. Asymmetry of the uterus in early pregnancy is caused by protrusion of its right or left corner, which corresponds to implantation of the fertilized egg. As the fertilized egg grows, this asymmetry gradually smoothes out (Fig. 7.2).

Rice. 7.2. Piskacek's sign of pregnancy

Gubarev and Gauss test. Due to significant softening of the isthmus, there is slight mobility of the cervix in the early stages of pregnancy, which is not transmitted to the body of the uterus.

Genter's sign. Comb-like thickening along the midline of the anterior surface of the uterus. However, this thickening is not always detected (Fig. 7.3).

Rice. 7.3. Sign of pregnancy Gen-tera

Chadwick's sign. In the first 6-8 weeks of pregnancy, the cervix is ​​cyanotic.

Possible signs of pregnancy include a positive result of immunological pregnancy tests. In practice, determination of the level of hCG b-subunit in blood serum is widely used, which makes it possible to establish pregnancy a few days after implantation of the fertilized egg.

Reliable, 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 based on the detection of the fertilized egg, yolk sac, embryo and its heartbeat in the uterine cavity, in later stages - thanks to visualization of the fetus (or fetuses in multiple pregnancies). Cardiac activity of the fetus can be detected by ultrasound from 5-6 weeks of pregnancy, motor activity of the embryo from 7-8 weeks.

DETERMINING 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 determined by the day of expected 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 counting is carried out from its middle.

To manage patients at different stages of pregnancy (examination, treatment), three trimesters are conventionally distinguished. The first trimester lasts 12-13 weeks from the first day of the last menstruation, the second - from 13 to 27 weeks, the third - from 27 weeks until the end of pregnancy.

The 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) months, or 280 days (40 weeks), if we calculate its beginning from the 1st day of the last menstruation. Thus, to calculate the expected due date, 9 calendar months and 7 days are added to the date of the 1st day of the last menstruation. Usually, the due date is calculated more simply: from the date of the 1st day of the last menstruation, count 3 calendar months ago and add 7 days. When determining the due date, it should be taken into account 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 exceeding 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 expected due date can be calculated by ovulation: from the 1st day of expected but not occurring menstruation, count back 14-16 days and add 273-274 days to the resulting date.

When determining the due date, the time of the first movement of the fetus is also taken into account, which is felt by first-time mothers from the 20th week, i.e. from the middle of pregnancy, and for multiparous women - 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 multigravidas, and the estimated due date is obtained. However, it should be remembered that this sign has only an auxiliary meaning.

For the convenience of calculating the duration of pregnancy by menstruation, ovulation and the first movement of the fetus, there are special obstetric calendars.

To establish 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 uterine fundus, the length of the fetus and the size of the head.

The size of the uterus and its height 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. Height of the uterine fundus at different stages of pregnancy

From the 4th month of pregnancy, the fundus of the uterus is palpated through the abdominal wall, and the duration of pregnancy is judged by the height of the fundus 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. When determining the duration of pregnancy, the height of the uterine fundus is taken into account in conjunction with other signs (date of last menstruation, first fetal movement, etc.).

At the end of the 4th obstetric month (16 weeks), the fundus 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 fundus of the uterus is 2 transverse fingers below the navel; protrusion of the abdominal wall is noticeable. At the end of the 6th obstetric month (24 weeks) the uterine fundus is at the level of the navel, at the end of the 7th (28 weeks) the uterine fundus is determined 2-3 fingers above the navel, and at the end of the 8th (32 weeks) the uterine fundus stands midway 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 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 drops 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 abdominal circumference is 95-98 cm, the fetal head descends, in primigravidas it is pressed against the entrance to the small pelvis or stands as a small segment at the entrance to the small pelvis.

Ultrasound determination of gestational age. Echography is of great importance in determining the duration of pregnancy. The main parameter for accurate ultrasound determination of gestational age in the first trimester is the coccygeal-parietal size (CPR) of the embryo. In the II and III trimesters, the gestational age is determined according to various fetometric parameters: biparietal size and head circumference, average diameters of the chest and abdomen, abdominal circumference, femur length. The longer the gestation period, the lower the accuracy of determining the gestational age of the fetus due to the variability of its size. Ultrasound before 24 weeks of pregnancy is considered optimal for determining the duration of pregnancy.

Organization of obstetric care

Questions for the lesson

QUESTIONS FOR THE CLASS:

The main tasks of the antenatal clinic

Legislation on labor protection for pregnant women and mothers

Specialized assistance in antenatal clinic

Clinical examination

Risk groups for perinatal and obstetric pathology

Consultation "Marriage and family". Work organization.

Medical and genetic assistance in antenatal clinics.

What are the generally accepted methods used to examine pregnant women?

What obstetric history data should be found out in pregnant women?

Why is it important to find out fertility issues in the anamnesis?

The significance of previous extragenital diseases for the course of pregnancy and childbirth.

Questionable signs of pregnancy.

Research using mirrors.

Vaginal two-manual examination.

Possible signs of pregnancy.

Biological methods for diagnosing pregnancy.

Diagnosis of late pregnancy.

Position of the fetus in the uterus.

Determination of the articulation, position, position, type and presentation of the fetus.

Techniques for palpation of the pregnant abdomen.

Assessment of fetal cardiac activity.

Auscultation of the pregnant woman's abdomen.

Reliable signs of pregnancy.

Determining the duration of prenatal leave.

The size of the uterus and the height of its fundus at different stages of pregnancy.

The main tasks of the antenatal clinic.

The work of the antenatal clinic is based on a territorial-precinct principle.

The purpose of the antenatal clinic is to protect the health of mothers and children by providing qualified outpatient obstetric and gynecological care before, during pregnancy, and in the postpartum period, family planning and reproductive health services.

The main tasks of the antenatal clinic:

Providing obstetric care to women during pregnancy, in the postpartum period, preparation for pregnancy and childbirth;

Providing qualified obstetric and gynecological care to women of the assigned territory with gynecological diseases;

Providing counseling and services on family planning, prevention of abortion, sexually transmitted infections, introduction of modern methods of contraception;

Introduction into practice of modern diagnostic and treatment technologies at the outpatient stage;

providing women with medical, social and legal protection in accordance with the current legislation on the protection of motherhood and childhood;

Implementation of sanitary, hygienic and anti-epidemic measures to ensure the safety of medical personnel and patients and prevent the spread of infections;

Carrying out activities to improve the knowledge of sanitary culture of the population in the field of reproductive health.

According to the main objectives, the antenatal clinic carries out:

Providing outpatient obstetric and gynecological care, identifying women in the labor reserve group, preparing them for pregnancy and childbirth;

Dispensary observation of pregnant women;

Identification of pregnant women in need of timely hospitalization in day hospitals, pathology departments of pregnant maternity hospitals and other departments;

Psychoprophylactic preparation of pregnant women for childbirth;

Patronage of pregnant and postpartum women;

Family planning counseling and services;

Organization and conduct of preventive examinations of the female population, starting from adolescence, with the aim of early detection of pathology of the reproductive system and secondary prevention of malignant neoplasms of the reproductive system;

Medical examination of gynecological patients;

Performing minor gynecological operations (hysteroscopy, etc.);

Examination of temporary disability for pregnancy and childbirth, in connection with gynecological diseases;

Carrying out activities in the field of improving the sanitary culture of the population on various aspects of a healthy lifestyle;

Analysis of performance indicators, efficiency and quality of medical care.

Legislation on labor protection for pregnant women and mothers.

Legislation on labor protection for pregnant women and mothers.

The state pays special attention to the working conditions of women, which is reflected in Chapter 19 of the Labor Code of the Republic of Belarus “Features of regulating the labor of women and workers with family responsibilities.”

According to Article 262 of the Labor Code, the use of women in heavy work is prohibited; at work associated with lifting and moving heavy loads manually, exceeding the maximum standards established for them; at work with hazardous working conditions, as well as at underground work, except for non-physical underground work or work on sanitary and consumer services.

The Labor Code of the Republic of Belarus regulates the following guarantees for women in connection with maternity:

prohibition of engaging pregnant women and women with children under three years of age to work at night, to work overtime, to work on public holidays, holidays and weekends, and to send pregnant women on business trips; women with children aged from three to fourteen years (disabled children up to eighteen years old) can be involved in night work, overtime work, work on public holidays and public holidays, work on weekends and sent on business trips only with their consent ;

reduction in production standards, standards of care for pregnant women in accordance with a medical report, or transfer to another job, easier and excluding the impact of adverse production factors, while maintaining the average earnings for the previous job; until the issue of providing a pregnant woman, in accordance with a medical report, with another job that is easier and excludes the impact of adverse production factors is decided, she is subject to release from work with the preservation of average earnings for all working days missed as a result at the expense of the employer;

if it is impossible to perform the previous job, women with children under the age of one and a half years are transferred to another job while maintaining the average earnings for the previous job until the child reaches the age of one and a half years;

a mother raising a disabled child under the age of eighteen, upon her request, is given one day off from work every month with payment in the amount of the average daily earnings at the expense of state social insurance funds and one day off from work per week with payment in the amount of the average daily earnings in the manner and on the terms determined by the Government of the Republic of Belarus;

a mother raising two or more children under the age of sixteen, upon her application, is given one day off from work every month with payment in the amount and on the terms provided for in the collective agreement;

a mother raising three or more children under the age of sixteen, a single mother raising two or more children under the age of sixteen, is given one day off from work per week with payment in the amount of average daily earnings in the manner and on the terms determined by the Government The Republic of Belarus;

women who have adopted a child under the age of three months are granted leave of 70 calendar days from the date of adoption with payment of state social insurance benefits for this period; at the request of a woman who has adopted a child, she is granted parental leave in the manner and under the conditions provided for in Article 185 of this Code;

women with children under the age of one and a half years are provided, in addition to the general break for rest and nutrition, with additional breaks for feeding the child at least every three hours, lasting at least 30 minutes each; if there are two or more children under the age of one and a half years, the duration of the break is set at least one hour; at the request of the woman, breaks for feeding the child can be added to the break for rest and nutrition, or in aggregate form transferred both to the beginning and to the end of the working day (work shift) with a corresponding reduction; they are included in working hours and paid according to average earnings;

It is prohibited to deny women an employment contract and reduce their wages for reasons related to pregnancy or the presence of children under the age of three, and for single mothers - with a child under the age of fourteen (a disabled child - up to eighteen years).

for pregnant women, activities associated with wet clothes and shoes are excluded; working in a draft, under conditions of sudden changes in barometric pressure - this applies to flight crews, flight attendants, etc.

the work processes and equipment used in which a pregnant woman is employed should not be a source of elevated levels of physical, chemical, biological and psychophysical factors.

the workplace should not expose pregnant women to harmful chemicals; industrial aerosols; vibrations; ultrasound.

a woman should not constantly stand in one position; the total distance she covers per shift should not exceed 2 km. Constant work in a sitting, standing position or associated with continuous movement (walking) is excluded. In addition, pregnant women should not be assigned work performed in a squatting, kneeling, bending position, with emphasis on the stomach and chest.

Special workplaces should be equipped for pregnant women, which provide for the performance of work duties in a free mode, allowing for a change of position at will.

women should not perform production operations related to lifting objects of labor from the floor; above the level of the shoulder girdle; with a predominance of abdominal muscle tension.

Permissible load values ​​for pregnant women:

when lifting and moving heavy objects in alternation with other work (up to 2 times per hour) - no more than 2.5 kg;

with continuous lifting and moving heavy objects during a work shift - no more than 1.25 kg;

the total mass of goods moved during each hour of a work shift at a distance of up to 5 m is no more than 60 kg;

the total mass of goods moved during an 8-hour work shift is no more than 480 kg.

Thus, the current legislation of the country makes it possible to provide a reliable system of social protection for the mother, which includes economic, social and labor guarantees and rights and creates specific conditions for their implementation.

Specialized assistance in antenatal clinics. Clinical examination.

Specialized assistance in antenatal clinics. Clinical examination.

In large antenatal clinics serving an area with a population of 40 thousand or more inhabitants (with 8 or more obstetric and gynecological departments), specialized obstetric and gynecological care rooms are organized:

prenatal diagnostic room;

cancer prevention room (cervical pathology);

cabinet of endocrine disorders and pathology of menopause;

family planning office;

miscarriage room.

If conditions exist, antenatal clinics organize a day hospital for pregnant and gynecological patients in accordance with current regulatory documents.

Risk groups for obstetric and perinatal pathology.

Risk groups for obstetric and perinatal pathology.

Determining the risk of perinatal pathology in the antenatal clinic is carried out according to the system developed by O.G. Frolova and E.I. Nikolaeva (1980). Risk factors for perinatal pathology are divided into five groups:

socio-biological;

anamnestic (data from obstetric and gynecological history);

extragenital pathology;

complications of this pregnancy;

condition of the fetus.

Each factor is assessed in points, the points are summed up, and if the sum is 10 or higher, there is a high risk of perinatal pathology; 5-9 points indicate average, 4 or less - low risk.

Consultation "Marriage and family".

Consultation "Marriage and family".

The main task is to provide specialized treatment, preventive and advisory assistance on medical aspects of family relationships.

Includes cabinets:

teenage gynecology office

barren marriage office

family planning office

psycho-somatic and psychological support room

gynecological endocrinology office

miscarriage room

menopause pathology room

medical genetic consultation

Medical and genetic assistance in antenatal clinics.

Medical and genetic assistance in antenatal clinics.

Medical genetic consultations are organized in regional centers. Their activities are aimed at prevention, timely detection and treatment of hereditary diseases, prevention of miscarriage and related complications for mother and child.

Pregnant women are subject to mandatory consultation at the medical genetic center if they have the following indications:

The pregnant woman is 35 years of age or more.

The presence of a chromosomal rearrangement or developmental defect in one of the spouses.

A history of children with hereditary diseases, congenital malformations, mental retardation.

The presence of the above pathology among relatives.

Consanguineous marriage.

Habitual miscarriage of unknown origin.

Adverse effects in early pregnancy (diseases, diagnostic or therapeutic procedures, medications).

Complicated course of pregnancy (threat of miscarriage from an early stage, not amenable to therapy, polyhydramnios).

Fetal pathology detected by ultrasound examination.

Changes in indicators of screening factors: alpha-fetoprotein, human chorionic gonadotropin, estriol, 17-hydroxyprogesterone.

The spouses have harmful occupational hazards.

Primary amenorrhea, menstrual irregularities of unknown origin.

It is preferable to refer patients for medical genetic consultation before pregnancy or in its early stages (6-8 weeks) with a detailed statement about the course of previous pregnancies, childbirth, the health status of the newborn, and the results of his examination.

Common methods of examining pregnant women.

What are the generally accepted methods used to examine pregnant women? What obstetric history data should be found out in pregnant women. Why is it important to find out in the anamnesis issues of reproductive function. The significance of previous extragenital diseases for the course of pregnancy and childbirth.

SURVEY– the main purpose of the survey is to identify factors that can negatively affect the course of pregnancy and fetal development. During the survey, the following information is revealed:

Age. For primigravidas, the age group is determined: young primigravida - up to 18 years, old primigravida - over 30 years.

Working and living conditions, profession, presence of occupational hazards.

Living conditions: number of people living with the pregnant woman, material security, living conditions, presence of animals in the apartment.

Previous somatic and infectious diseases: childhood infections, diseases of the cardiovascular, endocrine, genitourinary, respiratory systems, gastrointestinal tract, viral hepatitis, STIs, cancer, etc.

Previous blood transfusions, allergic reactions, surgeries, injuries.

Epidemiological anamnesis.

Bad habits(smoking tobacco, drinking alcohol, drugs).

Menstrual and sexual function. Reproductive function: number of previous pregnancies (duration, course, multiple pregnancies), number of births and abortions, intervals between pregnancies, complications during childbirth, complications after childbirth and abortion, weight of newborns.

Obstetric history provides valuable information for predicting obstetric complications, features of the course of pregnancy and childbirth. Complications from previous pregnancies and births, a short interval between births increases the risk of complications. In the case of a scar on the uterus after a CS, enucleation of a myomatous node, or suturing of a perforation, it is necessary to clarify the timing of the operation, the type of cesarean section (corporal or in the lower uterine segment), and the nature of the postoperative period.

Past diseases of the genital organs: inflammatory processes, infertility, menstrual dysfunction, operations on the uterus, fallopian tubes, ovaries; STI.

Family history: the health status of family members living with the pregnant woman (tuberculosis, alcoholism, sexually transmitted diseases, smoking, etc.); heredity (multiple pregnancies, diabetes, oncological and mental diseases, hypertension, the presence of children in the family with congenital and hereditary diseases, etc.); the age and health status of the husband, the type and Rhesus of his blood, as well as the presence of occupational hazards and bad habits.

OBJECTIVE EXAMINATION

A pregnant woman is examined by an obstetrician-gynecologist, dentist, otolaryngologist, ophthalmologist, and, if necessary, by an endocrinologist, urologist, surgeon, and cardiologist. If indicated, medical genetic counseling is carried out.

An objective examination of a pregnant woman includes:

thermometry;

anthropometry (measurement of height, determination of body weight);

measuring blood pressure to diagnose hypertension;

determination of physique and pelviometry;

examination of the skin;

examination and palpation of the mammary glands;

examination and palpation of the abdomen;

palpation of the symphysis pubis;

study of the circulatory, respiratory, digestive, excretory, nervous and endocrine systems;

routine studies performed by doctors of other specialties.

• Doubtful, probable, reliable signs of pregnancy.

Doubtful, probable, reliable signs of pregnancy. Biological methods for diagnosing pregnancy. Diagnosis of late pregnancy.

Doubtful signs: changes in taste and olfactory sensations, changes in appetite, as well as objective signs in the form of changes in the nervous system (irritability, drowsiness, vegetative reactions), the appearance of pigmentation on the face, along the white line of the abdomen, on the nipples and in the peripapillary area, nausea, vomiting in the morning, etc.

Possible signs: cessation of menstruation; enlargement of the mammary glands and the release of colostrum from them when pressed, loosening and cyanosis of the vestibule of the vagina and cervix (Scrobansky’s sign); enlargement and changes in the uterus.

As pregnancy progresses, the size of the uterus changes. Changes in the shape of the uterus are determined by two-handed (bimanual) examination. The uterus in non-pregnant women is pear-shaped, somewhat compacted in the anteroposterior dimension. With the onset of pregnancy, the shape of the uterus changes. Conventionally, you can use the following rule: at 8 weeks the body of the uterus increases 2 times compared to its original size, at 10 weeks - 3 times, at 12 weeks - 4 times.

Enlargement of the uterus is noticeable in the 5th–6th week of pregnancy; The uterus initially increases in the anteroposterior direction (becomes spherical), and later its transverse size also increases. The longer the pregnancy, the clearer the increase in uterine volume. 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 fundus of the uterus is at the level of the symphysis or slightly above it.

Doubtful signs:

Perversion of appetite.

Changes in olfactory sensations.

Lability of the nervous system.

Skin pigmentation (face, parapapillary area, linea alba).

Possible signs:

Stopping menstruation.

The appearance of colostrum.

Changes in the size, shape and consistency of the uterus.

Cyanosis of the mucous membrane of the cervix and vagina.

1. Visualization of the ovum in the uterus using ultrasound.

2. Visualization of the contraction of the heart of the embryo (fetus) with ultrasound.

Special examination methods performed during pregnancy in the first trimester include speculum examination and vaginal examination. When conducting a vaginal examination, you can note:

uterine enlargement - significant after 5-6 weeks;

Horwitz-Hegar sign: softening of the uterus in the isthmus area - fingers converge;

Snegirev's sign: change in consistency during palpation - the softened uterus becomes somewhat denser;

Piskachek's sign: asymmetry of the uterus, protrusion of one of the corners;

Gubarev-Gauss sign: cervical displacement;

Genter's sign is an anterior bend of the uterus and a comb-like thickening along the anterior wall of the uterus.

Hormonal examination methods: Determination of blood hormones is a direct method. Aschheim-Tsondek reaction - determination of gonadotropic hormones in urine. There are simple express methods - a woman herself can determine the presence of pregnancy by coloring the stripes on a test piece of paper placed temporarily in a portion of urine.

Late diagnosispregnancy

Reliable signs of pregnancy:

Feeling parts of the fetus.

Listening to fetal heart sounds.

Sensation of fetal movement by the examined person.

An X-ray image of the fetal skeleton is now only for the mother’s vital indications (for example, a fracture of the pelvic bones, a malignant tumor of the pelvic bones, etc.).

ECG or FCG of the fetus.

Fetal ultrasound is the most reliable method.

To determine the position of the fetus in the uterus, a special palpation examination technique is used - Leopold's techniques.

Ultrasound diagnostics. The current stage of development of perinatology is characterized by the widespread introduction of various instrumental research methods to assess the condition and characteristics of fetal development. In this case, the primary role is given to ultrasound diagnostics. The non-invasiveness and safety of the ultrasound method, its high information content and relative simplicity have contributed to its widespread introduction into obstetric practice.

Echography makes it possible to obtain fairly complete information about the functional state of the fetus, allows you to objectively assess its development throughout pregnancy, as well as diagnose pathological changes in the fetoplacental complex at the earliest stages of development.

In the first trimester of pregnancy you can establish:

fact of pregnancy;

markers of chromosomal pathology;

pregnancy complications;

multiple pregnancy;

isthmic-cervical insufficiency (ICI);

gestational age;

fetal malformations.

In the II-III trimesters of pregnancy, echography is carried out to determine the gestational age, monitor the condition and development of the fetus, assess its maturity, determine its weight and height, determine the amount of amniotic fluid, the sex of the fetus, its malformations, etc. Prenatal determination of the fetal body weight has important practical significance in developing rational delivery tactics.

V.N. Demidov and B.E. Rosenfeld (1996) published data on determining fetal body weight using computer fetometry. In this case, the authors obtained an error equal to 175.5 (133.0 g, which amounted to 4.9% of its mass).

Intrauterine growth restriction is one of the main clinical manifestations of placental insufficiency. Of the variety of modern methods for studying the fetoplacental system in diagnosing intrauterine growth retardation, echography is the most widely used, along with cardiotocography and Doppler. The main indicators for ultrasound fetometry of intrauterine growth retardation are the biparietal size of the head, the average diameter of the abdomen and the length of the femur. However, current experience suggests that the reliability of these parameters varies. Most authors recognize that for ultrasound diagnosis of intrauterine growth retardation, the average diameter of the abdomen is of greatest importance, and the biparietal size of the head is the smallest.

There are symmetrical and asymmetrical forms of intrauterine growth retardation. The echographic criteria for a symmetrical form are considered to be a proportional lag in all the main ultrasound parameters, the numerical value of which is below the individual fluctuations (below the 10th percentile) inherent in a given period of pregnancy.

The symmetrical form of intrauterine growth retardation can be diagnosed during the first ultrasound examination only if the gestational age is precisely established. When the gestational age is not precisely determined, it is necessary to conduct dynamic ultrasound examinations. V.N. Strizhakov et al. (1988), as a result of dynamic control after 1-2 weeks, it was established that with intrauterine growth retardation of the 1st degree, the rate of increase in ultrasonic parameters is reduced by 25%, with the 2nd degree - by 25-75%, and with the 3rd degree - more than 75% or completely absent.

Ultrasound examination of the placenta

Currently, ultrasound diagnostics is the most common method of monitoring the condition of the placenta. One of the indicators of the condition of the placenta is its thickness. Measuring the thickness of the placenta is of great practical importance in the diagnosis of various pregnancy complications. Depending on the pathology of pregnancy, there may be either a decrease or an increase in the thickness of the placenta.

N. Holland et al. (1980) used the ultrasound method to determine the area of ​​the placenta. During complicated pregnancy, a decrease in the area of ​​the placenta is often observed.

Particular attention is paid to the echostructure of the placenta and the degree of its maturity. Ultrasound assessment of placental maturity proposed by P. Grannum et al. in 1979, who identified 4 stages of placental maturity and correlated them with the degree of maturity of the fetal lungs, has been the most recognized and widespread for many years.

The premature appearance of more “mature” stages of the placenta is generally called “premature aging” of the placenta. The echographic criteria for premature maturation of the placenta include the detection of stage II maturity before 32 weeks, and stage III before 36 weeks of pregnancy. According to G. Luckert et al. (1985), the frequency of stage III up to 34 weeks occurs 13.5 times more often in pregnant women who gave birth to children weighing less than 2500 g.

Detection of premature “aging” of the placenta should be interpreted as a risk factor for placental insufficiency, which is an indication for dynamic monitoring using echography, cardiotocography and Doppler.

Ultrasonic diagnosis of placenta previa and low placentation, echographic examination of amniotic fluid (for the diagnosis of oligohydramnios and polyhydramnios) are very important.

Doppler

The physical principle used in modern medicine to measure blood flow was discovered in 1842 by Johann Christian Doppler and was subsequently named after him.

The study of blood flow in the uterine arteries, umbilical cord arteries and fetal aorta has practical value. Analysis of blood flow velocity curves (BVR) in the fetal aorta and middle cerebral artery allows us to judge the severity of fetal hemodynamic disorders and its compensatory capabilities.

Dopplerometry of uteroplacental and fetal placental blood flow is a highly informative method for diagnosing chronic placental insufficiency. It has been proven that the intensity of uteroplacental blood flow depends on structural changes in the spiral arteries. With elostosis and degeneration of the muscle layer, the lumen of the placental bed increases, which leads to an increase in peripheral resistance. Changes in blood flow in the spiral arteries of the uterus are the morphological substrate of placental insufficiency.

To assess blood flow velocity curves, the most commonly used parameters are: Resistance Index (RI), Pulsatility Index (PI) and Systolic Diastolic Ratio (SDR).

Doppler results:

I degree:

A – violation of uteroplacental blood flow with preserved fetal-placental blood flow;

B – violation of fetal-placental blood flow with preserved uteroplacental blood flow;

II degree: simultaneous disturbance of uteroplacental and fetal placental blood flow, not reaching critical changes;

III degree: critical disturbances of fetal-placental blood flow (zero or negative diastolic blood flow) with preserved or impaired uteroplacental blood flow.

Cardiotocography

In modern obstetric practice, the cardiotocography method has found widespread application. This method is of great value for antenatal diagnosis of the fetal condition, assessing the effectiveness of therapy in the presence of fetal hypoxia and complicated pregnancy.

The specificity of the method, according to various authors, is estimated to range from 86 to 91%.

The Perinatal Committee of the International Federation of Obstetricians and Gynecologists (FIGO) in 1987, in order to avoid an unjustified increase in the frequency of cesarean section in the interests of the fetus according to cardiotocography, recommended determining the pH of the fetal blood in case of suspicious or pathological cardiotocography. In our country, this method has not found widespread use in clinical practice; however, most authors recognize the high diagnostic value of determining blood pH during childbirth with pathological indicators of cardiotocography.

Main parameters of CTG: oscillations, basal rhythm, basal rhythm variability, acceleration, deceleration, NST - non-stress test, STV.

Normal CTG parameters look like this:

1. variability 10-25;

   acceleration - 2 or more in 10 minutes;

   there are no decelerations;

   NST - positive.

Depending on the type of CTG, the functional diagnostics doctor is required to issue a conclusion and recommendations:

Normal type of CTG (monitoring the pregnant woman as usual).

Doubtful Type of CTG (dynamic observation of the pregnant woman no later than after 3 days).

3. Pathological type of CTG (the issue of emergency delivery is being resolved).

The most widely used cardiotographs (fetal monitors) are the Sonicaid Team modification (DUO, Care, IP) FM 800 (Oxford Instruments Medical, UK). Antenatal automated CTG analysis makes it possible to assess with a high degree of reliability the severity of chronic hypoxia of the fetus(es), starting from 24 weeks of pregnancy. Intrapartum automated CTG analysis allows you to determine the degree of distress in the first stage of labor. In case of twins, automated analysis of antenatal/intrapartum CTG monitoring is performed simultaneously. The use of fetal monitors with automated analysis in a antenatal clinic can reduce the average time of a CTG examination to 14-16 minutes. without reducing the reliability of assessing the functional state of the fetus.