Pregnancy History and Exam. Adapted from Mosby’s Guide to Physical Examination, 6 th 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
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Pregnancy History and Exam Adapted from Mosby’s 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” • Patient’s 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 (cont’d) • 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 (cont’d) • 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 well-being of the mother and/or fetus. • Diabetes • Pre-term labor • Preeclampsia • Eclampsia • Pregnancy-induced hypertension (PIH)
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 woman’s prepregnancy weight and BMI See Fig 5-23
Always consider… • Woman’s dietary habits • Source of calories • Health status
Please Note • Inadequate weight gain • <20 lbs • often seen in adolescents • May be associated with low-birth-weight 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 A and C • Pica
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
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
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