Pregnancy (main)

(Redirected from Fundal exam in pregnancy)

Background

Timeline of pregnancy, including (from top to bottom): Trimesters, embryo/fetus development, gestational age in weeks and months, viability and maturity stages.
Preembryonic development showing fertilization and implantation.

Clinical Features

Normal pregnancy at 26 weeks.
Estimated gestational age based on physical exam.
Melasma: pigment changes to the face due to pregnancy.
Linea nigra in a woman at 22 weeks pregnant.

Normal Vitals in Pregnancy[1]

Vital Nonpregnant 1st Trimester 2nd Trimester 3rd Trimester
HR 70 78 82 85
SBP 115 112 112 114
DBP 70 60 63 70
Hcrt 40 36 33 34
WBC 7.2k 9.1k 9.7k 9.8k

Estimated Gestational Age by Fundal Height[2]

Weeks Fundal Height / Finding
12 Pubic symphysis
20 Umbilicus
20-32 Height (cm) above symphysis = gestational age (weeks)
36 Xiphoid process
>37 Regression
Post delivery Umbilicus

Physiologic Changes in Pregnancy[3]

  • Heart rate (HR) increases 15-20 bpm (75-95 bpm)
  • Mean arterial pressure (MAP) increases 10 mmHg (80 mmHg)
  • Tidal volume (TV) increases 40% (700 cc)
  • Minute volume (MV) increases 40% (10.5 L/min)
  • Functional residual capacity (FRC) decreases 25% (1300ml)

Differential Diagnosis

Abdominal distention

Vaginal Bleeding in Pregnancy (<20wks)

Vaginal Bleeding in Pregnancy (>20wks)


Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks


>20 Weeks


Any time

3rd Trimester/Postpartum Emergencies

Evaluation

Estrogen, progesterone, beta-hcg levels throughout pregnancy.

Repeat B-hCG Levels

Pregnancy Type B-hCG Change
Normal
  • Minimum expected rise depends on initial hCG value:[4][5]
    • Initial hCG <1,500 mIU/mL: minimum 49% rise in 48hrs
    • Initial hCG 1,500-3,000 mIU/mL: minimum 40% rise in 48hrs
    • Initial hCG >3,000 mIU/mL: minimum 33% rise in 48hrs
  • hCG typically doubles approximately every 48-72 hours in early pregnancy
  • Rate of rise slows after hCG reaches approximately 6,000-10,000 mIU/mL
Ectopic
  • Increases or decreases more slowly than expected ("plateau")
  • Approximately 21% of ectopic pregnancies have a normal hCG rise[6]
Miscarriage
  • Expected to decline >21-35% in 48 hrs[7]
  • A single hCG level cannot reliably distinguish intrauterine from ectopic pregnancy[8]
  • The discriminatory zone (typically 1,500-3,500 mIU/mL depending on institution) is the hCG level above which a gestational sac should be visible on transvaginal ultrasound[9]

Maternal Laboratory Changes in Pregnancy[10]

  • CBC
    • Increased WBC count (5k-15k)
    • Decreased hematocrit (32-34%) due to increased plasma volume
    • Decreased platelets
  • Chemistry
    • Decreased BUN and creatinine (<0.8mg/dL)
    • GFR increases up to 60% (140ml/min)
    • Decreased Bicarb
  • Other
    • Increased D-dimer and Fibrinogen
    • Increased ESR ~78
    • Decreased PaCO2 ~30
  • ECG with Qs in III & aVF, left axis
  • Beta-HCG Levels

Management

Disposition

  • Uncomplicated pregnancy is managed as an outpatient
  • For particular problems in pregnancy, see individual pages

See Also

External Links

References

  1. ↑ Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113:1299-1306.
  2. ↑ Vasquez V, Desai S. Labor and delivery and their complications. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:2296–2312.
  3. ↑ Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113:1299-1306.
  4. ↑ Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004; 104(1):50-55. PMID 15229000.
  5. ↑ Barnhart KT, Guo W, Cary MS, et al. Differences in serum human chorionic gonadotropin rise in early pregnancy by race and value at presentation. Obstet Gynecol. 2016; 128(3):504-511. PMID 27500347.
  6. ↑ Silva C, Sammel MD, Zhou L, et al. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006; 107(3):605-610. PMID 16507930.
  7. ↑ Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013; 369(15):1443-1451. PMID 24106937.
  8. ↑ Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005; 173(8):905-912. PMID 16217116.
  9. ↑ Connolly A, Ryan DH, Stuber AR, Postma HJ. Reevaluation of discriminatory and threshold levels for serum beta-hCG in early pregnancy. Obstet Gynecol. 2013; 121(1):65-70. PMID 23262929.
  10. ↑ Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113:1299-1306.
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