Pregnancy History and Exam

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Pregnancy History and Exam

• Adapted from Mosbys Guide to Physical
  Examination, 6th Ed.

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History

• Since pregnancy is a normal occurrence, the
  usual format of the clinical history should be
  modified
• Not your typical 8 parameters

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Should Include

• Current Pregnancy (PG)
• Past Pregnancies
• Medical Hx
• Contraceptive Hx
• Family Hx
• Psychological Hx
• Plans for Childbirth
• Risk Factors

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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

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Present Problem

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

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Obstetric History

• Information on each previous pregnancy
• Date of delivery
• Length of PG
• Weight and sex of infant
• Length of labor

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Obstetric History (contd)

• Type of delivery
• Spontaneous vaginal
• Induced vaginal
• Cesarean
• Spontaneous or elective abortion
• Complications
• Pregnancy
• Labor
• Postpartum
• or with the Infant

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Medical History

• Typical medical history with the addition of risk
  factors for
• AIDS
• Hepatitis
• Tuberculosis
• Exposure to environmental and occupational hazards

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Medical History

• NOTE
• A mother who herself had intrauterine growth
  restriction (IUGR) carries this risk factor for
  her children.

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Family History

• In addition to the usual family Hx
• Genetic conditions
• Twins
• Congenital anomolies

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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

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Review of Systems

• Effects of PG are seen in all systems.
• Special attention is given to
• Reproductive system
• Cardiovascular system

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Review of Systems (contd)

• Endocrine system
• Diabetes
• Urinary tract
• Infection
• Kidney function
• Respiratory function
• May be compromised
• later PG
• tocolytic therapy for preterm labor

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Risk Assessment

• Identify from the Hx and physical exam those
  conditions that threaten the well-being of the
  mother and/or fetus.
• Diabetes
• Pre-term labor
• Preeclampsia
• Eclampsia
• Pregnancy-induced hypertension (PIH)

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Weight Gain
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Weight Gain

• Progressive weight gain is expected during
  pregnancy, but the amount varies among women.

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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
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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

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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

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Weight Gain

• Weight gain in PG should be calculated from the
  womans prepregnancy weight and BMI
• See Fig 5-23

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Expected Weight GainIdeal Prepregnancy BMI
(19.8-26.0)
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Always consider

• Womans dietary habits
• Source of calories
• Health status

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Please Note

• Inadequate weight gain
• lt20 lbs
• often seen in adolescents
• May be associated with low-birth-weight infants
  and other perinatal complications

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Nutritional Considerations

• Prepregnancy
• Folate neural tube defects
• During pregnancy
• Protein
• Calories
• Iron
• Folate
• Calcium

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Nutritional Considerations

• Lactation
• Calories
• Protein
• Calcium
• Vitamins A and C
• Pica

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Skin, Hair, and Nails
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Overview

• Striae gravidarum
• Telangiectasias
• Hemangiomas
• Cutaneous tags
• Increased pigmentation
• Linea nigra
• Chloasma

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Striae Gravidarum

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

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Telangiectasias

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

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Hemangiomas

• Those present before pregnancy may increase in
  size, or new ones may develop

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Cutaneous tags

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

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Increased Pigmentation

• Common found to some extent in all pregnant
  women
• Areolae and nipples
• Vulvar and perianal regions
• Axillae
• Linea alba

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Linea Nigra

• Pigmentation of the linea alba

Extends from the symphysis pubis to the top of
the fundus in the midline.
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Moles Freckles

• Preexisting pigmented moles (nevi) and freckles
  may darken
• Nevi may increase in size
• New nevi may form

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Chloasma

• Mask of Pregnancy
• 70 of pregnant women
• Hyperpigmentation
• forehead, cheeks, bridge
• of nose, and chin
• Blotchy, usually symmetric pattern

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Mask of Pregnancy

• Begins after 16 weeks of gestation
• May darken with sun exposure
• May be permanent usually fades after delivery

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Other Common Changes

• Skin, Hair, and Nails

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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

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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

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Hair Growth

• Altered by hormones
• Increased shedding of hair 3-4 months after
  delivery
• main continue for 6-24 weeks

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Acne Vulgaris

• May be aggravated during the 1st trimester
• Often improves in the 3rd trimester

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Head Neck
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Thyroid

• Must ensure production of sufficient thyroid
  hormones
• compensates for increased iodine clearance during
  pregnancy
• Some degree of goiter may develop if iodine
  deficient

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Thyroid

• Because of increased vascularity, a thyroid bruit
  may be heard

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Eyes
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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

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Krukenberg Spindles

• Increase in corneal epithelial pigmentation

The corneal endothelium (over the iris) contains
vertically orientated deposition of pigment
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Diabetic Retinopathy

• May worsen significantly

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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.

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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

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Retinal Examination

• May be useful in differentiating between chronic
  hypertension and pregnancy-induced hypertension
  (PIH)

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Retinal Examination
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Ear, Nose, and Throat
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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

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• Gums
• increased vascularity and proliferation of
  connective tissues
• Laryngeal Changes
• Hoarseness
• Deepening or cracking of the voice
• Persistent cough

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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

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Chest and Lungs
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Anatomic Changes

• Lower ribs flare and chest expands
• increased transverse diameter (2 cm)
• Increased circumference (5-7 cm)
• Costal angle
• 68 degrees gt 103 degrees
• (before PG) (3rd trimester)

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Anatomic Changes

• Diaphragm rises as much as 4 cm above its usual
  resting position
• Diaphragmatic movement increases

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Progesterone

• Increased level of progesterone acts as a
  respiratory stimulant
• Causes an increased tidal volume without changing
  respiratory frequency

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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.

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Heart and Blood Vessels
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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 pre-pregnancy levels
  within 3-4 weeks of delivery

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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

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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

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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

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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

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Offsetting the Increased Volume

• Vascular resistance decreases with peripheral
  vasodilation
• Palmar erythema
• Spider telangiectases
• Blood pressure decreases during the 2nd trimester
  but returns to pre-pregnancy levels in the 3rd
  trimester

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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

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Heart Rate

• Gradually increases throughout PG until it is
  10-15 bpm higher by the end of the 3rd trimester

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Blood Pressure

• Gradually falls until 16-20 weeks
• Then, gradually rises to pre-pregnancy levels at
  term
• Pregnancy Induced Hypertension
• sustained systolic BP gt140 mm Hg or diastolic
  pressure gt90 mm Hg

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Breasts and Axillae
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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

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Changes in the Breast

• Areolae
• more deeply pigmented
• diameter increases
• Nipples
• more prominent, darker, and more erectile
• Montgomery tubercles develop
• sebaceous glands hypertrophy

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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

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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

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Abdomen
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• 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

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• Assessment of the abdomen includes
• Uterine size estimation for gestational age
• Fetal growth
• Position of the fetus
• Monitoring of fetal well-being

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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

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Measurement of Fundal Height

• Estimate for the length of the pregnancy and
  growth of the fetus

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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.

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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
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Fundal Height Gestational Age
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Measurement of Fundal Height

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

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Fetal Well-Being

• Assessment includes
• Fetal heart rate (FHR)
• Fetal movements

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Fetal Position

• Leopolds maneuvers