Is an annual physical examination (PE) recommended for a 10-week pregnant woman?

Annual Physical Examination for a 10-Week Pregnant Woman

An annual physical examination is recommended for a 10-week pregnant woman, with modifications to account for pregnancy-specific considerations and avoidance of unnecessary radiation exposure.

Importance of Physical Examination During Pregnancy

• Pregnancy represents a hypercoagulable state with increased risk of venous thromboembolism (VTE), making regular assessment important for maternal health 1
• Pulmonary embolism (PE) is a leading cause of pregnancy-related maternal death in developed countries, with incidence between 1 per 1000 and 1 per 3000 deliveries 1, 2
• Regular assessment can help identify risk factors for pregnancy complications early, allowing for timely intervention 1

Recommended Components of Physical Examination

Vital Signs Assessment

• Blood pressure measurement to screen for hypertensive disorders 1
• Heart rate assessment (noting that tachycardia may be normal in pregnancy) 1
• Respiratory rate evaluation (tachypnea may warrant further investigation) 1

Cardiovascular Examination

• Cardiac auscultation to detect murmurs or abnormal heart sounds 3
• Assessment for lower extremity edema, which may be normal in pregnancy but could also indicate DVT 1

Respiratory Examination

• Lung auscultation to assess for abnormal breath sounds 1
• Note that arterial oxygen levels are typically normal during pregnancy, but blood should be drawn in upright position if testing is needed 1

Thyroid Examination

• Inspection and palpation for thyromegaly, as thyroid disorders can affect pregnancy outcomes 3

Abdominal/Uterine Examination

• Fundal height measurement appropriate for gestational age 3
• Assessment of fetal heart tones 3

Other Components

• Cervical lymphadenopathy assessment 3
• Pelvic examination for STI screening and pelvimetry assessment 3

Special Considerations for Pregnant Women

Physical Activity Assessment and Recommendations

• Assess current physical activity levels and recommend at least 150 minutes of moderate-intensity physical activity weekly, accumulated over a minimum of 3 days 1
• Recommend a combination of aerobic exercise and resistance training for optimal benefits 1
• Advise that yoga and gentle stretching may be beneficial for musculoskeletal discomfort 4
• Emphasize that physical activity during pregnancy is associated with decreased risk of pre-eclampsia, gestational diabetes, and excessive weight gain 1, 5

Venous Thromboembolism Risk Assessment

• Evaluate for VTE risk factors, particularly important as pregnancy increases VTE risk 1
• Note that risk of DVT is approximately four times higher in post-partum period and 20 times higher after cesarean section 1
• Be aware that DVT is more frequent in the left leg during pregnancy due to mechanical compression of iliac veins by the enlarged uterus 1

Diagnostic Testing Considerations

D-dimer Testing

• D-dimer levels increase physiologically throughout pregnancy, limiting its utility 6
• The American Thoracic Society/Society of Thoracic Radiology recommends against using D-dimer alone to exclude PE in pregnancy due to inadequate sensitivity (73%) and poor specificity (15%) 1, 6

Imaging Considerations

• If PE is suspected, radiation exposure concerns should not prevent necessary diagnostic testing 1
• Radiation exposure from most diagnostic tests falls well below the 50 mSv threshold considered dangerous to the fetus 1, 7
• Consider compression ultrasonography of lower extremities as first-line imaging if DVT is suspected 1, 6

When to Consider Additional Evaluation

• Persistent excessive shortness of breath (beyond normal pregnancy-related dyspnea) 4
• Severe chest pain 4
• Regular and painful uterine contractions 4
• Vaginal bleeding 4
• Persistent dizziness 4

Key Pitfalls to Avoid

• Do not dismiss symptoms like dyspnea and tachycardia as normal pregnancy changes without proper evaluation, as these could indicate PE 1
• Avoid unnecessary radiation exposure, but do not withhold essential diagnostic tests when clinically indicated 1
• Do not rely solely on D-dimer to exclude PE in pregnant women 1, 6
• Avoid the supine position during examination in late pregnancy, as it may lower PaO2 by up to 2 kPa 1