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Pregnancy History and Exam

Adapted from Mosbys Guide to


Physical Examination, 6th Ed.

History

Since pregnancy is a normal


occurrence, the usual format of the
clinical history should be modified

Not your typical 8 parameters

Should Include:

Current Pregnancy (PG)


Past Pregnancies
Medical Hx
Contraceptive Hx
Family Hx
Psychological Hx
Plans for Childbirth
Risk Factors

Chief Complaint

Patients age
Marital status
Gravidity and parity
Last menstrual period (LMP)
Previous usual menstrual period (PUMP)
Expected date of delivery (EDD)
Occupation
Father of the baby and his occupation

Present Problem

Description of current PG
Previous medical/health care
Attention should be given to specific
problems
Nausea
Vomiting
Fatigue
Edema

Obstetric History

Information on each previous


pregnancy
Date

of delivery
Length of PG
Weight and sex of infant
Length of labor

Obstetric History (contd)


Type

of delivery

Spontaneous vaginal
Induced vaginal
Cesarean
Spontaneous or elective abortion

Complications

Pregnancy
Labor
Postpartum
or with the Infant

Medical History

Typical medical history with the


addition of risk factors for
AIDS
Hepatitis
Tuberculosis
Exposure

to environmental and
occupational hazards

Medical History
NOTE:

A mother who herself had


intrauterine growth restriction
(IUGR) carries this risk factor for her
children.

Family History
In addition to the usual family Hx

Genetic conditions
Twins
Congenital anomolies

Personal & Social History

Additional information includes


Feelings

towards the PG
Whether the PG was planned
Preference for sex of child
Social supports available
Experiences with mothering
History of abuse in relationships

Review of Systems
Effects of PG are seen in all systems.

Special attention is given to:


Reproductive

system
Cardiovascular system

Review of Systems (contd)

Endocrine system
Diabetes

Urinary tract
Infection
Kidney

function

Respiratory function
May

be compromised

later PG
tocolytic therapy for preterm labor

Risk Assessment
Identify from the Hx and physical exam
those conditions that threaten the wellbeing of the mother and/or fetus.

Diabetes
Pre-term labor
Preeclampsia
Eclampsia
Pregnancy-induced hypertension (PIH)

Weight Gain

Weight Gain

Progressive weight gain is expected


during pregnancy, but the amount
varies among women.

Weight Gain

The growing fetus accounts for only 5-10


lbs of the total weight gained

The remainder results from an increase in


maternal tissues

Placenta
Amniotic fluid
Uterus
Blood and fluid volume
Breasts
Fat reserves

See Figure 5.6

Weight Gain

Weight gain should follow a curve


through the trimesters of pregnancy
Slow

during the first trimester


Rapid during the second
Less rapid during the third

Weight Gain

Maternal tissue growth accounts for


most of the weight gain in the 1st
and 2nd trimesters
Fetal growth accounts for weight
gained in the 3rd trimester

Weight Gain

Weight gain in PG should be


calculated from the womans
prepregnancy weight and BMI
See Fig 5-23

Expected Weight Gain


Ideal Prepregnancy BMI (19.8-26.0)
Trimester

Weight Gain

1st

variable

2nd

0.3-1.5 lb / week

3rd

0.4-1.4 lb / week

TOTAL

25-35 lbs

Always consider

Womans dietary habits


Source of calories
Health status

Please Note

Inadequate weight gain


<20

lbs
often seen in adolescents

May be associated with low-birthweight infants and other perinatal


complications

Nutritional Considerations

Prepregnancy
Folate:

neural tube defects

During pregnancy
Protein
Calories
Iron
Folate
Calcium

Nutritional Considerations

Lactation
Calories
Protein
Calcium
Vitamins

Pica

A and C

Skin, Hair, and Nails

Overview

Striae gravidarum
Telangiectasias
Hemangiomas
Cutaneous tags
Increased pigmentation
Linea

nigra
Chloasma

Striae Gravidarum

Stretch marks
May appear over the abdomen,
thighs, and breasts
2nd trimester

Telangiectasias

Vascular Spiders
May be found on the face, neck,
chest, and arms
Appear during the 2nd-5th month
Usually resolve after delivery

Hemangiomas

Those present before pregnancy


may increase in size, or new ones
may develop

Cutaneous tags

Molluscum Fibrosum Gravidarum


Pedunculated or sessile
Result from epithelial hyperplasia
Most often found on the neck and
upper chest

Increased Pigmentation

Common; found to some extent in


all pregnant women
Areolae

and nipples
Vulvar and perianal regions
Axillae
Linea alba

Linea Nigra

Pigmentation of
the linea alba

Extends from the symphysis pubis


to the top of the fundus in the
midline.

Moles & Freckles

Preexisting pigmented moles (nevi)


and freckles may darken
Nevi may increase in size
New nevi may form

Chloasma

Mask of Pregnancy
70% of pregnant women
Hyperpigmentation
forehead,

cheeks, bridge
of nose, and chin

Blotchy, usually symmetric pattern

Mask of Pregnancy

Begins after 16 weeks of gestation


May darken with sun exposure
May be permanent; usually fades
after delivery

Other Common Changes


Skin, Hair, and Nails

Palmar Erythema

Common finding in pregnancy


Usually disappears after delivery
Cause unknown
Diffuse redness
covers the entire
palmar surface or
the thenar and
hypothenar eminences

Itching

Abdomen and breasts


Results

from stretching
Common; not a concern

Generallized itching
Starts

in the 3rd trimester


Initially affecting the palms and soles
before spreading
Sign of a more serious condition

Hair Growth

Altered by hormones

Increased shedding of hair 3-4


months after delivery
main

continue for 6-24 weeks

Acne Vulgaris

May be aggravated during the 1st


trimester

Often improves in the 3rd trimester

Head & Neck

Thyroid

Must ensure production of sufficient


thyroid hormones
compensates

for increased iodine


clearance during pregnancy

Some degree of goiter may develop


if iodine deficient

Thyroid

Because of increased vascularity, a


thyroid bruit may be heard

Eyes

Corneal Changes

Mild corneal edema and corneal


thickening may occur
3rd

trimester

Can result in hypersensitivity and


can change the refractory power of
the eye

Krukenberg Spindles

Increase in corneal epithelial pigmentation

The corneal endothelium


(over the iris) contains
vertically orientated
deposition of pigment

Diabetic Retinopathy

May worsen significantly

Contact Lenses

Tears contain an increased level of


lysosome
greasy

sensation
blurred vision

Because of various changes in the


eye, new lens prescriptions should not
be obtained until several weeks after
delivery.

Other Changes in the Eye

Intraocular pressure falls


latter

half of the pregnancy

Ptosis may develop


unknown

reasons

Subconjunctival hemorrhages
occur

spontaneously in pregnancy or
during labor
resolve spontaneously

Retinal Examination

May be useful in differentiating


between chronic hypertension and
pregnancy-induced hypertension
(PIH)

Retinal Examination
Chronic Hypertension PIH
Vascular tortuosity

Angiosclerosis
Hemorrhage
Exudates

Segmental arteriolar
narrowing with a
wet, glistening
appearance (edema)
Rare
Rare

Ear, Nose, and Throat

Common ENT Symptoms

Nasal stuffiness

congestion, sinusitis

Decreased sense of smell


Epistaxis
Fullness in the ears
Impaired hearing
Result of increased vascularity of the
upper respiratory tract

capillaries become engorged due to elevated


levels of estrogen

Gums
increased

vascularity and proliferation


of connective tissues

Laryngeal Changes
Hoarseness
Deepening

or cracking of the voice


Persistent cough

Common Exam Findings

Edema and erythema in the nose and


pharynx

Tympanic membrane

increased vascularity
retracted or bulging with serous fluid

Gums may appear reddened, swollen, and


spongy

hypertrophy should resolve within 2 months of


delivery

Chest and Lungs

Anatomic Changes

Lower ribs flare and chest expands


increased

transverse diameter (2 cm)


Increased circumference (5-7 cm)

Costal angle
68 degrees ~> 103 degrees
(before PG)

(3rd trimester)

Anatomic Changes

Diaphragm rises as much as 4 cm


above its usual resting position

Diaphragmatic movement increases

Progesterone

Increased level of progesterone acts


as a respiratory stimulant

Causes an increased tidal volume


without changing respiratory
frequency

Dyspnea

Common in PG; result of normal


physiological changes

Adaptation
Increased

vital capacity
Increased tidal volume

Increases ventilation by breathing more


deeply, not more frequently.

Heart and Blood Vessels

Blood Volume Increases 40%

Mainly due to an increase in plasma


volume
Begins

in the 1st trimester and reaches a


maximum after the 30th week
50% increase in a single pregnancy
70% increase with twins

Blood volume returns to prepregnancy levels within 3-4 weeks of


delivery

Heart Compensates

Increased heart rate and stroke


volume
Left ventricle increases wall
thickness and mass
Aorta, pulmonary artery, and mitral
orifice increase in size by 12 weeks
of pregnancy
maximum

size by 32-38 weeks

Cardiac Output

Increases 40-50%
Reaches its highest level by 24
weeks and is maintained until term
Returns to pre-pregnancy levels
about 2 weeks after delivery

Heart Position

As the uterus enlarges, the


diaphragm moves upward and the
heart is shifted toward a horizontal
position with slight axis rotation

Apical pulse
upward

and 1-1.5 cm more lateral

Heart Sounds

Changes are expected because of the


increased blood volume and extra effort of
the heart
Audible

splitting of S1 and S2
S3 may be heard after 20 weeks
Grade II systolic ejection murmurs
heard over the pulmonic area in 90%
of PG women
intensified during inspiration or
expiration

Offsetting the Increased Volume

Vascular resistance decreases with


peripheral vasodilation
Palmar

erythema
Spider telangiectases

Blood pressure decreases during the


2nd trimester but returns to prepregnancy levels in the 3rd trimester

Blood Stasis (later pregnancy)

Occlusion of pelvic veins and IVC


from pressure created by the
enlarged uterus
Dependent

edema
Varicosities of the legs and vulva
Hemorrhoids

**Lateral recumbent position

Heart Rate

Gradually increases throughout PG


until it is 10-15 bpm higher by the
end of the 3rd trimester

Blood Pressure

Gradually falls until 16-20 weeks


Then, gradually rises to prepregnancy levels at term

Pregnancy Induced Hypertension

sustained

systolic BP >140 mm Hg or
diastolic pressure >90 mm Hg

1st Tri

2nd Tri

3rd Tri

Labor &
Delivery

HR

Increased

Peaks at
Slightly
Increased & Pre- w/in
28th week decreased Bradycardia 2-6 weeks
at delivery

BP

Pre-

Slightly
Predecreased

BV

Increased

Peeks at
20th week

Gradually Rises
decreased sharply

Pre- w/in
2-6 weeks

SV

Increased

Peeks at
28th week

Gradually Decreased
decreased

Pre- w/in
2-6 weeks

CO

Increased

Peeks at
20th week

Slightly
Increased
decreased

Pre- w/in
2-6 weeks

Pre-

Postpartum

Pre- w/in
2-6 weeks

Breasts and Axillae

Changes in the Breast

Lactiferous ducts proliferate


Alveoli increase in size and number

Breasts may enlarge 2-3x pre-pregnancy size


May experience a sensation of fullness with
tingling and tenderness

Increased glandular tissue displaces


connective tissue

Tissue becomes softer and looser

Changes in the Breast

Areolae
more

deeply pigmented
diameter increases

Nipples
more

prominent, darker, and more


erectile

Montgomery tubercles develop


sebaceous

glands hypertrophy

Secretory Activity

Colostrum can begin as early as the


6th week of gestation
Can

notice crust on the nipple

Toward the end of the pregnancy


Epithelial secretory activity increases
Colostrum is produced and
accumulates in the alveoli

Elevated Estrogen Levels

Dilated subcutaneous veins may


create a network of blue tracing
across the breast

2nd trimester
Vascular

spiders may develop

Bluish in color
Do not blanch

Abdomen

Auscultation
Bowel sounds will be diminished as a
result of decreased peristaltic activity
Inspection
Striae and linea nigra may be present
Linea

nigra: midline band


of pigmentation

Assessment of the abdomen


includes:
Uterine

size estimation for gestational

age
Fetal growth
Position of the fetus
Monitoring of fetal well-being

Gestational Age

Naegele Rule: add 7 days to the first day


of the last normal mestrual period and
count back 3 months

Average duration of a pregnancy:


40 weeks (280 days)
*Clinically appropriate unit of
measurement is weeks of gestation
completed

Measurement of Fundal Height

Estimate for the length of the pregnancy


and growth of the fetus

Measurement of Fundal Height

Have the patient empty her bladder


Patient lies supine
Measure from the upper part of the
pubis symphysis to the superior fundus
(over the midline)
Recorded in cm.

Measurement of Fundal Height

Most accurate between 20-30 weeks

Fundal height (cm)=gestational age (weeks)

1cm. increase per week is expected


Larger than expected?
-Consider twins or other conditions that
enlarge the uterus
Smaller than expected?
-Possible intrauterine growth retardation

Fundal Height ~ Gestational Age

Measurement of Fundal Height


Factors that may affect accuracy:
Obesity
Amount of amniotic fluid
Multiple gestation
Fetal size and attitude
Position of the uterus

Fetal Well-Being
Assessment includes
Fetal heart rate (FHR)
Fetal movements

Fetal Position

Leopolds
maneuvers

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