History and Physical Examination of a Pregnant Patient
The history and physical examination of a pregnant patient must systematically assess maternal medical conditions, obstetric risks, and pregnancy-specific complications to optimize both maternal and fetal outcomes.
Essential History Components
Medical and Diabetes History (if applicable)
For patients with pre-existing diabetes, obtain 1, 2, 3:
- Duration and type of diabetes (type 1 vs type 2)
- Acute complications: history of infections, ketoacidosis, hypoglycemia episodes
- Chronic complications: retinopathy, nephropathy, hypertension, atherosclerotic vascular disease, autonomic and peripheral neuropathy
- Current diabetes management: insulin regimen, oral glucose-lowering agents (must be discontinued), self-monitoring patterns, nutrition therapy, physical activity
- Concomitant conditions: particularly thyroid disease in type 1 diabetes
Comprehensive Obstetric and Gynecologic History
- Previous pregnancy outcomes: infant deaths, fetal losses, birth defects, low birth weight, preterm births, macrosomia
- Previous complications: cesarean sections, congenital malformations, hypertensive disorders, postpartum hemorrhage, Rh incompatibility, thrombotic events (DVT/PE)
- Menstrual history and contraceptive use
- Current gestational age and method of conception
Medication and Supplement Review
- Current medications: identify FDA pregnancy category X and D medications requiring discontinuation
- Over-the-counter medications, herbs, and supplements
- Folic acid supplementation: confirm 400 mg daily intake
- Teratogenic exposures: warfarin, phenytoin, certain antihypertensives
Cardiovascular and Hypertension Risk Assessment
- Chronic hypertension history
- Previous preeclampsia or gestational hypertension
- Cardiac disease: obtain modified WHO classification if heart disease present
- Risk factors for preeclampsia: obesity (BMI >30), diabetes, antiphospholipid syndrome, assisted reproduction
Psychosocial and Behavioral Assessment
- Depression and anxiety
- Domestic violence
- Substance use: tobacco, alcohol, illicit drugs (use CAGE or T-ACE questionnaires)
- Support systems: family and work environment
- Barriers to care
Infectious Disease and Immunization History
- Immunization status: rubella, varicella, hepatitis B, influenza, Tdap, HPV
- Previous infections: sexually transmitted infections, TORCH infections, periodontal disease
Genetic and Family History
- Ethnic background and age-related risks
- Family history of genetic disorders
- Carrier screening needs: cystic fibrosis, sickle cell anemia, Tay-Sachs, thalassemia based on ethnicity
Critical Physical Examination Elements
Blood Pressure Assessment
- Baseline blood pressure measurement at initial visit
- Orthostatic blood pressure testing if diabetes or autonomic neuropathy suspected
- Serial BP monitoring: treat if consistently ≥140/90 mmHg in office (≥135/85 mmHg at home)
- Urgent treatment required if BP ≥160/110 mmHg
Cardiovascular Examination
Evaluate 1:
- Cardiac auscultation for murmurs or abnormal sounds
- Peripheral vascular examination for evidence of vascular disease
- ECG screening in women ≥35 years with cardiac symptoms, risk factors, or diabetes 2, 3
Ophthalmologic Assessment
Dilated retinal examination by ophthalmologist or eye specialist knowledgeable about diabetic eye disease is mandatory for diabetic patients 1, 2, 3
Neurological Examination
- Deep tendon reflexes and clonus (critical for preeclampsia monitoring)
- Signs of autonomic neuropathy: gastroparesis symptoms, orthostatic hypotension
- Peripheral neuropathy: sensation and motor function
Back and Spine Examination
Examine the patient's back when neuraxial anesthetic is planned or placed 7
Airway Assessment
Conduct airway, heart, and lung examination consistent with ASA preanesthesia evaluation standards 7
Anthropometric Measurements
Document 4:
- Body Mass Index: ideal prepregnancy BMI is 19.8-26.0 kg/m²
- Weight gain goals based on prepregnancy BMI
Laboratory Evaluation
Initial Screening Tests
- Hemoglobin/hematocrit for anemia
- Platelet count (baseline for preeclampsia monitoring)
- Serum creatinine and urine protein-to-creatinine ratio
- Liver transaminases (ALT/AST)
- Thyroid-stimulating hormone (TSH)
- Lipid panel
- Hemoglobin A1C if diabetic (target <1% above normal range)
Infectious Disease Screening
- Neisseria gonorrhoeae/Chlamydia trachomatis
- Hepatitis B and C serology
- HIV
- Syphilis
- Rubella immunity
- Pap smear if due
Proteinuria Assessment
Screen with 5:
- Automated dipstick urinalysis
- Urine protein-to-creatinine ratio if dipstick positive (≥30 mg/mmol or 0.3 mg/mg is abnormal)
Common Pitfalls to Avoid
Failing to obtain comprehensive diabetes complication screening in diabetic patients before pregnancy—retinopathy can worsen rapidly during pregnancy 1
Missing cardiovascular disease screening in high-risk patients—women with significant cardiac disease may not tolerate pregnancy's increased cardiac demands 1, 6
Inadequate medication review—many commonly used medications are teratogenic and must be discontinued before conception 2, 3, 4
Overlooking psychosocial risk factors—depression, domestic violence, and substance abuse significantly impact pregnancy outcomes 4, 6
Not establishing baseline blood pressure early—essential for diagnosing gestational hypertension and preeclampsia later 5, 7
Failing to assess for preeclampsia risk factors—women with strong clinical risk factors should receive low-dose aspirin (75-162 mg/d) before 20 weeks gestation 5
Ongoing Monitoring Requirements
For patients with preexisting conditions or pregnancy complications, establish protocols for 5:
- BP monitoring frequency based on hypertension severity
- Twice-weekly blood tests for preeclampsia: hemoglobin, platelets, liver enzymes, creatinine, uric acid
- Clinical assessment for clonus in preeclampsia
- Fetal monitoring: biometry, amniotic fluid, umbilical artery Doppler at diagnosis and every 2 weeks if normal