What is the recommended approach for history taking and physical examination in antenatal care?

History Taking and Physical Examination in Antenatal Care

Begin antenatal care as early as possible in the first trimester, ideally before 12 weeks gestation, with a focused history and physical examination that includes maternal health history, obstetric history, baseline blood pressure, and airway, heart, lung, and back examination. 1, 2

Initial History Taking

Maternal Health History

• Current medications: Review all medications for teratogenicity, particularly discontinuing ACE inhibitors, ARBs, and statins before conception 2
• Chronic medical conditions: Document pregestational diabetes, chronic hypertension, thyroid disease, renal insufficiency, metabolic acidosis, malabsorption, cerebral palsy, neuromuscular disorders, and genetic diseases affecting skeletal development 1
• Substance use: Ask about tobacco, alcohol, and drug use using CAGE or T-ACE questionnaires to screen for alcohol and substance abuse 1
• Psychosocial concerns: Screen for depression, anxiety, domestic violence, and major psychosocial stressors 1
• Reproductive life plan: Inquire about intentions for current and future pregnancies 1

Obstetric History

• Previous pregnancies: Document outcomes including preeclampsia, preterm birth, gestational diabetes, cesarean delivery, and placental complications 1, 2
• Previous infant outcomes: Record history of congenital malformations, stillbirth, or neonatal complications 2
• Current pregnancy symptoms: Assess for vaginal bleeding (painful or painless), abdominal pain, and other danger signs 1

Pregnancy-Specific History

• Last menstrual period: Establish gestational age 1
• Prenatal vitamin use: Document folic acid and iodine supplementation 2
• Pregnancy complications: Screen for nausea, vomiting, hyperemesis gravidarum 1

Family History

• Genetic conditions: Ask about multiple fractures, early-onset hearing loss, abnormally developed dentition, blue sclera, short stature (suggesting osteogenesis imperfecta), and other hereditary conditions 1
• Thrombophilia: Document family history of venous thromboembolism 3

Social History

• Household composition: Identify who lives in the home and provides care 1
• Intimate partner violence: Screen for domestic violence 1
• Substance abuse: Document alcohol and drug use in household 1
• Mental illness: Assess for depression and anxiety 1
• Previous child protective services involvement: Document any history 1

Nutritional Assessment

• Dietary intake: Assess the ABCDs of nutrition: anthropometric factors (BMI), biochemical factors (anemia), clinical factors, and dietary risks 1
• Vitamin supplementation: Document folic acid (400-800 mcg daily, or 5 mg for high-risk women), potassium iodide (150 mcg daily), and vitamin D status 1, 2, 4

Toxin and Teratogen Exposure

• Occupational exposures: Review Material Safety Data Sheets for heavy metals, solvents, pesticides, endocrine disruptors, and allergens 1
• Environmental exposures: Assess home and neighborhood toxin exposure 1

Physical Examination

General Examination

• Vital signs: Measure baseline blood pressure at the initial visit 1
• Weight and BMI: Document prepregnancy weight and calculate BMI; women with BMI ≥30 kg/m² require counseling about pregnancy risks including gestational diabetes, hypertension, miscarriage, and stillbirth 1, 3
• Growth chart review: Assess for abnormal weight suggesting neglect or endocrine/metabolic disorders 1

Focused Physical Examination

• Periodontal examination: Assess for periodontal disease 1
• Thyroid examination: Palpate for thyroid enlargement 1
• Cardiac examination: Auscultate heart sounds and assess for murmurs 1
• Pulmonary examination: Auscultate lung fields 1
• Breast examination: Perform clinical breast examination 1
• Pelvic examination: One vaginal examination during pregnancy is recommended but no repeat procedure unless medically indicated 5
• Back examination: When neuraxial anesthetic is planned, examine the patient's back 1

Specific Physical Findings to Document

• Blue sclera: Suggests osteogenesis imperfecta 1
• Sparse, kinky hair: Associated with Menkes disease 1
• Dentinogenesis imperfecta: May be identified in older children with osteogenesis imperfecta 1
• Signs of dehydration: Assess for orthostatic hypotension, decreased skin turgor, dry mucus membranes in women with hyperemesis gravidarum 1
• Malnutrition: Document weight loss and muscle wasting 1
• Neurologic examination: Assess for neuropathy or vitamin deficiency 1

Skin Examination

• Bruising: Complete skin examination to look for bruises and other skin findings; bruising in unusual locations (ears, neck, trunk) should raise suspicion for intimate partner violence 1
• Point tenderness: Document any swelling, limitation of motion, or point tenderness suggesting fractures 1

Laboratory Testing at Initial Visit

Routine Testing

• Complete blood count: Screen for anemia 1
• Urinalysis: Screen for proteinuria and urinary tract infection 1
• Blood type and screen: Identify women requiring Rh immunoglobulin prophylaxis 1, 4
• Urine culture: Dipstick for leucocyte esterase and nitrite with subsequent treatment of positive cases reduces risk of pyelonephritis 6

Infectious Disease Screening

• HIV testing: Use opt-out screening for all pregnant women at the first prenatal visit, as this approach achieves higher testing rates 4
• Syphilis serologic testing: Conduct RPR or similar test at first visit; repeat in third trimester and at delivery for high-risk populations 1, 4
• Hepatitis B surface antigen: Test at initial visit; repeat late in pregnancy for high-risk women (injection drug users, those with concurrent STDs) 1, 4
• Gonorrhea and chlamydia screening: Perform at first visit for women at risk or in high-prevalence areas 1, 4
• Rubella serology: Test for rubella seronegativity and vaccinate if indicated 1

Additional Testing When Indicated

• Thyroid-stimulating hormone: Consider measuring levels, particularly for women with thyroid disease history 1
• Diabetes screening: Early pregnancy screening for pre-existing type 2 diabetes using fasting plasma glucose or 50-g glucose challenge test at 12 weeks for high-risk women 1, 2
• Cervical cytology: Perform when indicated 1
• Genetic screening: Offer cystic fibrosis and other carrier screening based on family history, ethnic background, and age 1

First-Trimester Screening

• Combined screening: Perform nuchal translucency measurement plus biochemical markers between 11 weeks 4 days and 13 weeks 6 days, achieving detection rates of 85-92% for Down syndrome 4
• Cell-free DNA screening: Offer as a more sensitive option where cost permits 4

Risk Stratification for Preeclampsia

Identify women requiring low-dose aspirin (81-150 mg daily) starting before 16 weeks gestation based on major risk factors: 2, 4

• Previous preeclampsia
• Chronic hypertension
• Pregestational diabetes
• BMI ≥35 kg/m²
• Chronic kidney disease
• Antiphospholipid syndrome

Special Populations

Women with Pregestational Diabetes

• Establish multidisciplinary care: Include endocrinologist, maternal-fetal medicine specialist, registered dietitian, and diabetes educator 3
• Target A1C <6.5%: Achieve before conception to reduce congenital malformations from 1.4-10.9% range to 1.0-1.7% 2

Women with Obesity (BMI ≥30 kg/m²)

• Folic acid supplementation: Continue 5 mg daily until end of first trimester 1
• Vitamin D supplementation: Provide for women confirmed to be vitamin D deficient 1
• Aspirin prophylaxis: Women with BMI ≥35 kg/m² may take 75-180 mg aspirin daily from 12 weeks until birth to reduce preeclampsia risk, provided gastrointestinal hemorrhage risk is low 1
• Anesthesiology referral: Refer women with BMI >40 kg/m² for antenatal consultation 1

Women with History of Bariatric Surgery

• Communication: Ensure good communication between obstetrician and bariatric surgery team 1
• Nutritional supplements: Provide supplements over and above usual pregnancy requirements 1
• Alternative diabetes testing: Consider 1 week of home glucose monitoring (fasting and 2-hour postprandial) between 24-28 weeks for those with malabsorptive surgery 1

Mental Health Screening

Inquire about mental health at every consultation and connect women to relevant resources such as counseling or support groups. 2, 3, 4

Common Pitfalls to Avoid

• Overfilled bladder during ultrasound: Can obscure visualization of lower uterine segment and cervix due to shadowing from maternal symphysis pubis 1
• Delayed care initiation: Early antenatal care visits (before 12 weeks) are associated with optimal maternal and fetal outcomes 4, 7
• Missing high-risk factors: Failure to identify women requiring aspirin prophylaxis before 16 weeks gestation 2, 4
• Inadequate substance abuse screening: Use validated questionnaires (CAGE or T-ACE) rather than general questioning 1
• Incomplete medication review: All medications must be reviewed for teratogenicity, particularly FDA pregnancy category X and D medications 1, 2