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A Practical Guide, 3rd Edition

Ultrasound estimates of GA were calculated from equations recently developed using a machine learning algorithm to identify the best set of fetal biometric predictors of GA [ 20 ]. Finally, our measure of LMP was assessed prospectively and likely reduced recall errors; however, this may not represent usual circumstances in other low- and middle-income countries. Our study also has some limitations. Specifically, we are limited by the timing of fetal ultrasound measurements. First trimester ultrasound measurements are optimal when estimating GA because of limited variability in fetal size due to IUGR [ 3 ]; ultrasound estimates in our study are likely influenced by IUGR, which would underestimate GA and may bias results.

In low- and middle-income countries, however, first trimester ultrasound measurements are typically not feasible and previous studies have demonstrated the accuracy of second trimester ultrasound estimates of GA [ 29 ]. Despite being considered gold standard, it is important to recognize that ultrasound estimates of GA are not direct measurements of pregnancy duration and, similar to other GA estimation methods, are subject to some error [ 3 ]; importantly, studies have established the improved accuracy of ultrasound estimates of GA compared with other methods [ 3 , 9 — 11 ].

As ultrasound measurements are frequently not available in low- and middle-income countries, it is important to identify alternative methods that provide accurate estimates of GA. Our findings provide information regarding the utility of LMP-based estimates of GA compared to Farr examination estimates, and the level of accuracy compared to ultrasound estimates. The authors thank O. The authors also thank the Reviewers for their thoughtful feedback to help improve the manuscript. Funding for this research was provided by the Mathile Institute for the Advancement of Human Nutrition and the Micronutrient Initiative.

Deputy was supported in part by U. Data are available on the Additional file 1 submitted together with the manuscript. NPD contributed to developing the research question, conducting the statistical analysis, and drafting and revising the manuscript. HP a day to-day project field director, participated in field supervision, carried out data collection and provided inputs for manuscript. SN participated in field organization and provided inputs for manuscripts.

All authors contributed in the development, review and approval of the final manuscript. Written informed consent was obtained from all study participants. National Center for Biotechnology Information , U. Published online Jan Deputy , 1 Phuong H. Received Oct 25; Accepted Dec This article has been cited by other articles in PMC. Abstract Background Accurate estimation of gestational age is important for both clinical and public health purposes.

Methods Data for this analysis come from a randomized, placebo-controlled micronutrient supplementation trial in Vietnam. Results The median gestational age estimated by ultrasound was Conclusion In this study of women in Vietnam, we found last menstrual period provided a more accurate estimate of gestational age than the Farr examination when compared to ultrasound. Trial registration The trial was registered at ClinicalTrials.

Electronic supplementary material The online version of this article doi: Gestational age, Last menstrual period, Ultrasound, Neonatal examination, Vietnam. Background Accurate estimates of gestational age GA are important for both clinical practice and public health activities. The regression equation relating head circumference and femur length to GA is as follows: Open in a separate window. Table 2 Agreement in gestational age estimated by last menstrual period LMP and Farr examination compared to ultrasound.


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Table 3 Agreement in preterm, term and post-term classification by last menstrual period LMP or Farr examination estimates of gestational age compared to ultrasound estimates. Discussion This was one of the few studies that examined the validity of LMP and neonatal examination estimates of GA compared to ultrasound in a low- and middle-income country.

Availability of data and materials Data are available on the Additional file 1 submitted together with the manuscript. Competing interests The authors declare that they have no competing interests. Consent for publication Not applicable. Additional file Additional file 1: Contributor Information Nicholas P.

Discordance between LMP-based and clinically estimated gestational age: Conceptualization, measurement, and use of gestational age. Clinical and public health practice. Lynch CD, Zhang J.

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The research implications of the selection of a gestational age estimation method. Wegienka G, Baird DD. A comparison of recalled date of last menstrual period with prospectively recorded dates. A comparison of LMP-based and ultrasound-based estimates of gestational age using linked California livebirth and prenatal screening records. Vietnam Data, World Development Indicators. Accessed 8 Jan Ethnic variation in postnatal assessments of gestational age: Clinical assessment of gestational age in the newborn infant. Comparison of two methods.

Committee on Obstetric Practice Committee opinion no Estimating the date of confinement: Am J Obstet Gynecol. A comparison between ultrasound and a reliable last menstrual period as predictors of the day of delivery in 15, examinations. Levels and trends in the use of maternal health services in developing countries. Determining gestational age in a low-resource setting: J Health Popul Nutr. Last menstrual period provides the best estimate of gestation length for women in rural Guatemala. Anthropometric standardization reference manual.

Human Kinetics Publishers; Anthropometric Indicators Measurement Guide. The definition of some external characteristics used in the assessment of gestational age in the newborn infant. Dev Med Child Neurol. The value of some external characteristics in the assessment of gestational age at birth. Ultrasound based gestational age estimation in late pregnancy.

Forming inferences about some intraclass correlation coefficients. A concordance correlation coefficient to evaluate reproducibility. Measuring agreement in method comparison studies. Stat Methods Med Res. Patterns of fetal growth based on ultrasound measurement and its relationship to small for gestational age birth in rural Vietnam. Assessment of gestational age in the Cameroonian newborn infant: Dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban Pakistan. It also makes several turns prior to connecting with the central venous system and is thus not in a direct line with the right atrium.

Look at the area in question for several minutes while the patient's head is turned to the left. The carotid artery is adjacent to the IJ, lying just medial to it. If you are unsure whether a pulsation is caused by the carotid or the IJ, place your hand on the patient's radial artery and use this as a reference. The carotid impulse coincides with the palpated radial artery pulsation and is characterized by a single upstroke timed with systole. The venous impulse at least when the patient is in sinus rhythm and there is no tricuspid regurgitation has three components, each associated with the aforementioned a, c and v waves.

When these are transmitted to the skin, they create a series of flickers that are visible diffusely within the overlying skin. In contrast, the carotid causes a single up and down pulsation. Furthermore, the carotid is palpable. The IJ is not and can, in fact, be obliterated by applying pressure in the area where it emerges above the clavicle. Search along the entire projected course of the IJ as the top of the pressure wave which is the point that you are trying to identify may be higher then where you are looking.

In fact, if the patient's CVP is markedly elevated, you may not be able to identify the top of the wave unless they are positioned with their trunk elevated at 45 degrees or more else their will be no identifiable "top" of the column as the entire IJ will be engorged. After you've found the top of the wave, see what effect sitting straight up and lying down flat have on the height of the column. Sitting should cause it to appear at a lower point in the neck, while lying has the opposite effect. Realize that these maneuvers do not change the actual value of the central venous pressure.

They simply alter the position of the top of the pulsations in relation to other structures in the neck and chest. Shine a pen light tangentially across the neck. This sometimes helps to accentuate the pulsations. If you are still uncertain, apply gentle pressure to the right upper quadrant of the abdomen for 5 to 10 seconds.


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This elicits Hepato-Jugular Reflux which, in pathologic states, will cause blood that has pooled in the liver to flow in a retrograde fashion and fill out the IJ, making the transmitted pulsations more apparent. Make sure that you are looking in the right area when you push as the best time to detect any change in the height of this column of blood is immediately after you apply hepatic pressure.

Once you identify JVD, try to estimate how high in cm the top of the column is above the Angle of Louis. The angle is the site of the joint which connects the manubrium with the rest of the sternum. First identify the supra-sternal notch, a concavity at the top of the manubrium. Then walk your fingers downward until you detect a subtle change in the angle of the bone, which is approximately 4 to 5 cm below the notch.

This is roughly at the level of the 2nd intercostal space. The vertical distance from the top of the column to this angle is added to 5cm, the rough vertical distance from the angle to the right atrium with the patient lying at a 45 degree angle. The sum is an estimate of the CVP. However, if you can simply determine with some accuracy whether JVD is present or not, you will be way ahead of he game! Normal is cm. Bony Structures of the Chest. Finding the Angle of Louis: The wooden Q-tips highlight the different slopes of the sternum and manubrium.

The point at which the Q-tips cross is the Angle of Louis. Determining the CVP Video of patient with markedly elevated central venous pressure. Video simulation and discussion of central venous pressure.


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Take some time to look across the left chest and try to identify the transmitted impulse caused by ventricular contraction, which may be apparent when contractions are particularly vigorous. There are several sources of tension relating to the physical exam in general, which are really brought to the fore during the chest examine. Keys to performing a sensitive yet thorough exam: Ask pt to remove bra prior you can't hear the heart well thru fabric Expose left side of chest to extent needed Enlist patient's assistance, asking them to raise their breast to a position that enhances your ability to listen to and palpate the heart Don't rush, act in a callous fashion, or cause pain PLEASE The palm of your right hand is placed across the patient's left chest so that it covers the area over the heart.

The heel should rest along the sternal border with the extended fingers lying below the left nipple. Focus on several things: If so, where is it located? After identifying the rough position with the palm of your hand, try to pin down the precise location with the tip of your index finger. The normal sized and functioning ventricle will generate a penny sized impulse that is best felt in the mid-clavicular line, roughly at the 5th intercostal space.

If the ventricle becomes dilated, most commonly as the result of past infarcts and always associated with ventricular dysfunction, the PMI is displaced laterally. In cases of significant enlargement, the PMI will be located near the axilla. Occasionally, the PMI will not localize to any one area, which does not necessarily indicate ventricular enlargement or dysfunction. Obesity and COPD may also limit your ability to identify its precise location.

Palpating while the patient is in the left lateral decubitus position can make the PMI more obvious. What is the duration of the impulse? In the setting of hypertension or any other state of chronic pressure overload, the ventricle hypertrophies and the PMI becomes sustained i. This is actually pretty subjective and can be tough to detect.

Note that hypertrophy and dilatation are not synonymous. They can exist separately or in conjunction with one another. How vigorous is the transmitted impulse? Processes associated with ventricular hypercontractility e. Do you feel a thrill, a vibratory sensation produced by turbulent blood flow that is usually secondary to valvular abnormalities? The feeling is similar to that produced when you squeeze on a garden hose, partially obstructing the flow of water.

The location of the thrill will depend on the involved valve e. If a loud murmur is detected during auscultation, you may then go back and reassess for the presence of a thrill. In general, thrills are an uncommon finding. Make sure that you tell that patient what you are about to do and why before actually performing this maneuver.

Remember that with age tissue turgor often declines, causing the breasts to hang below the level of the heart. This is of greatest value during the assessment of aortic valvular and out flow tract disease see below and should thus be performed after auscultation so that you know whether or not these problems exist prior to palpation. However, for the sake of completeness it will be described here. The carotids can be located by sliding the second and third finger of either hand along the side of the trachea at the level of the thyroid cartilage i.

The carotid pulsation is palpable just lateral to the groove formed by the trachea and the surrounding soft tissue. The quantity of subcutaneous fat will dictate how firmly you need to push. The pulsations should be easily palpable.

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Diminution may be caused by atherosclerosis, aortic stenosis, or severely impaired ventricular performance. Do not push on both sides simultaneously as this may compromise cerebral blood flow. The following anatomic pictures will aid you in understanding the principles of cardiac auscultation. There are multiple brands on the market, each of which incorporates its own version of a bell low pitched sounds and diaphragm higher pitched sounds.

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Some have the diaphragm and bell on opposite sides of the head piece. Others have the bell and diaprhragm built into a single side, with the bell engaged by applying light pressure and the diaphragm engaged by pushing more firmly. Adult, pediatric, and newborn sizes also exist. And some combine adult and pediatric scopes into a single unit. Take the time to read the instructions for your particular model so that you are familiar with how to use it correctly. Several sample stethescopes are pictured below. It's worth mentioning that almost any commercially available scope will do the job.

The most important "part" is what sits betwen the ear pieces! Adult Stethoscope Adult Stethoscope: Then move it to the other side of the sternum and listen in the 2nd left intercostal space, the location of the pulmonic valve. Move down along the sternum and listen over the left 4th intercostal space, the region of the tricuspid valve. And finally, position the diaphragm over the 4th intercostal space, left midclavicular line to examine the mitral area. These locations are rough approximations and are generally determined by visual estimation.

In each area, listen specifically for S1 and then S2. Note that the time between S1 and S2 is shorter then that between S2 and S1. Compare the relative intensities of S1 and S2 in these different areas. Auscultation of the Heart In younger patients, you should also be able to detect physiologic splitting of S2. That is, S2 is made up of 2 components, aortic A2 and pulmonic P2 valve closure.

On inspiration, venous return to the heart is augmented and pulmonic valve closure is delayed, allowing you to hear first A2 and then P2. On expiration, the two sounds occur closer together and are detected as a single S2. Ask the patient to take a deep breath and hold it, giving you a bit more time to identify this phenomenon. The two components of S1 mitral and tricuspid valve closure occur so close together that splitting is not appreciated. You may find it helpful to tap out S1 and S2 with your fingers as you listen, accentuating the location of systole and diastole and lending a visual component to this exercise.

While most clinicians begin asucultation in the aortic area and then move across the precordium, it may actually make more sense to begin laterally i. Try both ways and see which feels more comfortable. While present in normal subjects up to the ages of , they represent pathology in older patients. An S3 is most commonly associated with left ventricular failure and is caused by blood from the left atrium slamming into an already overfilled ventricle during early diastolic filling.

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The S4 is a sound created by blood trying to enter a stiff, non-compliant left ventricle during atrial contraction. It's most frequently associated with left ventricular hypertrophy that is the result of long standing hypertension. Either sound can be detected by gently laying the bell of the stethoscope over the apex of the left ventricle roughly at the 4th intercostal space, mid-clavicular line and listening for low pitched "extra sounds" that either follow S2 i.

These sounds are quite soft, so it may take a while before you're able to detect them. Positioning the patient on their left side while you listen may improve the yield of this exam. The presence of both an S3 and S4 simultaneously is referred to as a summation gallop. Listening for Extra Heart Sounds Murmurs: These are sounds that occur during systole or diastole as a result of turbulent blood flow. Leaking backwards across a valve that is supposed to be closed. These are referred to as regurgitant or insufficiency murmurs e. These valves suffer from varying degrees of stenosis e.

It's worth mentioning that sometimes "flow murmurs" can occur, resulting from high output across structurally normal valves. In addition, some valves with insignificant degrees of pathology e. Distinguishing which murmurs are clinically relevant takes thought and practice. Ive added a description of some helpful features below. Traditionally, students are taught that auscultation is performed over the 4 areas of the precordium that roughly correspond to the "location" of the 4 valves of the heart i.

This leads to some misperceptions. Valves are not strictly located in these areas nor are the sounds created by valvular pathology restricted to those spaces. So, while it might be OK to listen in only 4 places when conducting the normal exam, it is actually quite helpful to listen in many more when any abnormal sounds are detected.

If you hear a murmur, ask yourself: Does it occur during systole or diastole? What is the quality of the sound i. It sometimes helps to draw a pictoral representation of the sound. What is the quantity of the sound? The rating system for murmurs is as follows: Louder generally but not always indicates greater pathology. What is the relationship of the murmur to S1 and S2 i. What happens when you march your stethescope from the 2nd RICS the aortic area out towards the axilla the mitral area?

Where is it loudest and in what directions does it radiate? By moving in small increments i. Auscultation over the carotid arteries see under aortic stenosis for additional information: In the absence of murmurs suggestive of aortic valvular disease, you can listen for carotid bruits sounds created by turbulent flow within the blood vessel at this point in the exam.

Place the diaphragm gently over each carotid and listen for a soft, high pitched "shshing" sound. It's helpful if the patient can hold their breath as you listen so that you are not distracted by transmitted tracheal sounds. The meaning of a bruit remains somewhat controversial. I was taught that bruits represented turbulent flow associated with intrinsic atherosclerotic disease However, a number of studies provide evidence that atherosclerotic disease is frequently absent when a bruit is present as well as the reverse situation.

This is actually of clinical importance because recent data suggest that it may be beneficial to surgically repair carotid disease in patients who have significant stenosis yet have not experienced any symptoms e. Transient ischemic attacks or strokes.

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Surgery in these settings has already proven to be beneficial. Thus, it is becoming increasingly important to determine the best way of identifying asymptomatic carotid artery disease Press the "Back" button to return to this page. Blaufuss Multimedia Heart Sounds Tutorial. This University of Washington site also provides a variety of simulated heart sounds.