Initial Assessment and Management of a Pregnant Patient in the Clinic
The initial assessment of a pregnant patient presenting to the clinic should include a comprehensive evaluation of maternal and fetal well-being, with immediate pregnancy confirmation, vital signs assessment, and screening for high-risk conditions that could affect pregnancy outcomes.
Initial Evaluation
Confirmation of Pregnancy and Dating
- Perform urine or serum pregnancy test
- Document last menstrual period (LMP) to estimate gestational age
- Schedule ultrasound for pregnancy dating and viability assessment 1
- Transvaginal ultrasound if <10 weeks
- Transabdominal ultrasound if >10 weeks
Vital Signs Assessment
- Blood pressure (urgent treatment needed if ≥160/110 mmHg) 2
- Heart rate
- Respiratory rate
- Temperature
- Weight and BMI calculation (ideal BMI is 19.8-26.0 kg/m²) 2
Immediate Red Flag Assessment
- Evaluate for vaginal bleeding or fluid leakage
- Assess for severe abdominal/pelvic pain
- Check for severe headache, visual changes, or epigastric pain (preeclampsia signs)
- Screen for shortness of breath or chest pain (cardiovascular concerns)
- Evaluate for decreased fetal movement if >20 weeks gestation
Comprehensive History
Medical History
- Pre-existing medical conditions:
- Hypertension, diabetes, thyroid disease, asthma
- Autoimmune disorders, cardiac disease
- Seizure disorders, psychiatric conditions 2
- Current medication use (avoid FDA category X medications) 2
- Prior surgeries, especially uterine or cervical procedures
- Family history of genetic disorders or pregnancy complications
Obstetric History
- Previous pregnancies and outcomes
- Prior pregnancy complications:
- Preeclampsia, gestational diabetes, preterm birth
- Cesarean deliveries, postpartum hemorrhage
- Fetal growth restriction, stillbirth 2
Social History
- Tobacco, alcohol, and substance use (use CAGE or T-ACE questionnaires) 2, 3
- Occupational exposures to potential teratogens
- Domestic violence screening
- Psychosocial stressors and support systems
Physical Examination
General Examination
- Thyroid assessment
- Cardiac examination (murmurs, rhythm)
- Pulmonary examination
- Abdominal examination
Obstetric Examination
- Fundal height measurement if >20 weeks
- Fetal heart tones assessment (doppler after 10-12 weeks)
- Assessment for uterine tenderness or contractions
- Pelvic examination if indicated (avoid if placenta previa suspected) 1
Laboratory Testing
Initial Laboratory Tests
- Complete blood count
- Blood type and Rh status
- Urinalysis and urine culture
- Rubella immunity status
- Hepatitis B surface antigen
- HIV testing
- Syphilis screening
- Cervical cytology if due
- Consider thyroid-stimulating hormone 2
Additional Tests Based on Risk Factors
- Hemoglobin A1c or glucose tolerance test
- Genetic carrier screening based on ethnicity
- Chlamydia and gonorrhea testing
- Urine drug screen if indicated
Management Plan
Routine Prenatal Care
- Prescribe prenatal vitamins with folic acid 0.4-0.8 mg daily 2, 4
- Establish frequency of prenatal visits
- Provide education on expected pregnancy changes
- Discuss warning signs requiring immediate attention
Nutrition and Lifestyle Counseling
- Recommend balanced diet with adequate protein, calcium, and iron
- Encourage appropriate weight gain based on pre-pregnancy BMI
- Advise regular moderate exercise if no contraindications
- Counsel on avoiding alcohol, tobacco, and illicit drugs 2
Management of Common Pregnancy Symptoms
- Nausea/vomiting: Lifestyle modifications first, then vitamin B6 and doxylamine 5
- Heartburn: Dietary changes, then antacids without salicylates 5
- Low back pain: Physical therapy and acetaminophen 5
- Constipation: Increased fluids, fiber, and exercise
Management of Pre-existing Conditions
- Asthma: Continue appropriate medications, monthly monitoring 2
- Hypertension: Target diastolic BP of 85 mmHg (systolic <160 mmHg) 2
- Diabetes: Tight glycemic control
- Seizure disorders: Medication adjustment if needed
Special Situations
Acute Concerns
- Vaginal bleeding: Immediate ultrasound evaluation 1
- Severe hypertension (≥160/110 mmHg): Urgent treatment with oral nifedipine or IV labetalol/hydralazine 2
- Preeclampsia signs: Hospital assessment, consider magnesium sulfate 2
- Suspected ectopic pregnancy: Emergency ultrasound and OB consultation 1
High-Risk Pregnancy Identification
- Advanced maternal age (≥35 years)
- Multiple gestation
- History of preterm birth or pregnancy complications
- Pre-existing medical conditions
- Abnormal placentation (previa, accreta)
- Fetal anomalies or growth concerns
Follow-up Planning
- Schedule next prenatal visit (typically every 4 weeks until 28 weeks)
- Arrange for appropriate screening tests based on gestational age
- Refer to maternal-fetal medicine specialist if high-risk factors identified
- Provide emergency contact information and warning signs
Pitfalls to Avoid
- Failing to confirm intrauterine pregnancy location in patients with pain or bleeding 1
- Performing digital examination before ruling out placenta previa 1
- Underestimating the significance of hypertension in pregnancy 2
- Neglecting to administer Rh immunoglobulin to Rh-negative women with bleeding 1
- Prescribing teratogenic medications (FDA category X) 2
By following this structured approach to the initial assessment and management of pregnant patients in the clinic, healthcare providers can ensure comprehensive care that prioritizes maternal and fetal well-being while identifying and addressing potential complications early.