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Pregnancy - diagnosis

Maternitatea Cantacuzino- 2018

Dr Ilinca Gussi
How does a pregnancy occur?

CLINICA: APLICATIONS :
- contraception

- assisted reproductions

- diagnosis tests
How to diagnose a pregnancy

CLINICAL APLICATION :
- contraception
Pregnancy tests- hormone assay:
- Assisted reproduction
- betaHCG urinary
- betaHCG serum (in IU) - Diagnostic test
Early pregnancy dgn
 Early ultrasound (trans-vaginal):

 Location of gestational sac


 Identify the embryo and the yolk sac
 Objectively show cardiac activity
 Number of embryos- and chorionicity in multiple pregnancies
 CRL- crown rump length- establish appropiate date
 Assess uterus and adnaexe
Early pregnancy dgn
 Early ultrasound (trans-vaginal):

 Location of gestational sac


 Identify the embryo and the yolk sac
 Objectively show cardiac activity
 Number of embryos- and chorionicity in multiple pregnancies
 CRL- crown rump length- establish gestational age
 Assess uterus and adnaexe
Diagnosis after 24 wks
 Formulation

 Trim I- up to 14 SA

 Trim II – up to viability (24-26 wks)

 Viability threshold 24 wks (cf Decret Apr 2012)

 Trim III- after 24 SA wks

 Term from 37 + 0 up to 42 + 0
Antenatal Care
Spitalul Clinic Dr I Cantacuzino- 2018

Dr Ilinca Gussi
What is to be done?

 FIRST PRENATAL VISIT

 FOLLOW UP

 WHEN to plan FETAL DETAILED US (i.e.


morphological scan)

Dr Ilinca Gussi
What to LOOK FOR ?

 FIRST PRENATAL VISIT

 FOLLOW UP

 WHEN to plan FETAL DETAILED US (i.e.


morphological scan)

Dr Ilinca Gussi
Follow up for RISKS

 Prevent premature birth

 Prevent major maternal complications, e.g. preeclampsia

 Detect fetal disease and abnormalities before birth

Dr Ilinca Gussi
Pyramid of care
 Turning the pyramid of care (K. Nicolaides, FMF)

For almost a century


Pyramid of care
 Turning the pyramid of care (K. Nicolaides, FMF)

Current progress
First prenatal visit
Look for How to look for PLAN/ advice
Pregnancy confirmation betaHCG + eco - plan visits
- mandatory: 10, 12, 22,
32, early term, 40/41
Is it an ectopic? Eco or - instruct on alarming
repeated betaHCG symptoms

Singleton or multiple? - diet advice, lifestyle


advice
Any obstetrical risk Prematurity, smoking,
factors? parity, preeclampsia

Any other risk factors? First trimester tests


First prenatal visit
 W (eight) and arterial pressure

 1st trimester work-up: general (blood type and Rh, FBC,


glycemia, hepatic function tests, APTT, INR) + urinary
tests

 Repeat at 28 wks and early term

 Infectious dis test: DEPENDS on THE COUNTRY


Romania= hepatitis, VDRL/TPHA, Toxo IgG/IgM,
Rubeola IgG, IgM (NO Chlamydia, Mycoplasma,
Ureaplasma, Lysteria, Brucella)

 Vaginal swab: bacterial vaginosis, cultures for Group B


Streptococcus (GBS) at 34 wks
Dr Ilinca Gussi
Follow up- when and how
 Be systematic ! Check-list manifesto

 Every time: confirm pregnancy evolutivity, maternal


arterial pressure, signs and symptoms
 10 wks: discuss results, confirm evolution, plan screening
 12 wks: first trimester detailed scan
 16 wks: regular visit
 20-22 wks: second trimester detailed scan
 24 - 28 wks: regular visit and repeated testing
 32 wks: third trimeser detailed scan
 36/37 wks: confirm fetal position, fetal growth, vaginal cultures, blood tests
 41 wks: plan induction

Dr Ilinca Gussi
What are we looking for?

No need for repeated vaginal


examination.
Dr Ilinca Gussi
Follow up- when and how
 Be systematic ! Check-list manifesto

 Every time: confirm pregnancy evolutivity, maternal


arterial pressure, signs and symptoms
 10 wks: discuss results, confirm evolution, plan screening
 12 wks: first trimester detailed scan
 16 wks: regular visit
 20-22 wks: second trimester detailed scan
 24 - 28 wks: regular visit and repeated testing
 32 wks: third trimeser detailed scan
 36/37 wks: confirm fetal position, fetal growth, vaginal cultures, blood tests
 41 wks: plan induction

Dr Ilinca Gussi
What are we looking for?

Ultrasound fetal markers are dependent on the gestational age.

Dr Ilinca Gussi
Genetic testing- possibilities
 CVS- chorionic villus sampling at 11-14 wks

 Amniocentesis = AF sampling at 16- 24 wks or after 32 wks

 Free cell DNA testing in maternal blood- when and why?

 Whole exome sequencing – WES

 (rarely) Fetal blood sampling


Follow up- what next ?
 Be systematic ! Check-list manifesto

 Every time: confirm pregnancy evolutivity, maternal


arterial pressure, signs and symptoms
 10 wks: discuss results, confirm evolution, plan screening
 12 wks: first trimester detailed scan
 16 wks: regular visit + cervical lenght
 20-22 wks: second trimester detailed scan
 24 - 28 wks: regular visit and repeated testing
 32 wks: third trimeser detailed scan Normal cervix
 36/37 wks: confirm fetal position, fetal growth, vaginal cultures, blood tests
 41 wks: plan induction

Dr Ilinca Gussi
Follow up- what next ?
 Be systematic ! Check-list manifesto

 Every time: confirm pregnancy evolutivity, maternal


arterial pressure, signs and symptoms
 10 wks: discuss results, confirm evolution, plan screening
 12 wks: first trimester detailed scan Blood pressure
 16 wks: regular visit + cervical lenght +
 20-22 wks: second trimester detailed scan Infectious dis
 24 - 28 wks: regular visit and repeated testing screening
 32 wks: third trimeser detailed scan
 36/37 wks: confirm fetal position, fetal growth, vaginal cultures, blood tests
 41 wks: plan induction

Dr Ilinca Gussi
Follow up- to delivery
 Be systematic ! Check-list manifesto

 Every time: confirm pregnancy evolutivity, maternal


arterial pressure, signs and symptoms
 10 wks: discuss results, confirm evolution, plan screening
 12 wks: first trimester detailed scan
 16 wks: regular visit + cervical lenght
 20-22 wks: second trimester detailed scan
 24 - 28 wks: regular visit and repeated testing
 32 wks: third trimeser detailed scan
 36/37 wks: confirm fetal position, fetal growth,
vaginal cultures, blood tests
 41 wks: plan induction

Dr Ilinca Gussi
Fetal medicine
- how the fetus became a patient-
Maternitatea Cantacuzino- 2018

Dr Ilinca Gussi
Diagnosing the fetus

 Screening of fetal conditions

 Diagnostic of structural malformations

 Diagnostic of medical conditions (infections,


haematologic diseases, muscular distrophy)

 Twins and specific complications

 Genetic conditions

Dr Ilinca Gussi
Treating the fetus

 Correction of structural malformations (from cardiac


malformations to fetal tumours)

 Treating fetal infections and fetal anemia (work-up and


follow-up)

 Twins and specific complications – recognizing new


entities

 Genetic conditions – is there some influence on the


prognosis?
Dr Ilinca Gussi