What systemic examination should be performed in an antenatal care (ANC) patient?

Systemic Examination in Antenatal Care Patients

Every antenatal care patient should undergo a comprehensive systemic examination that includes blood pressure measurement, weight assessment, abdominal examination, and clinical assessment for edema and clonus, with specific attention to detecting signs of pre-eclampsia, cardiovascular compromise, and fetal well-being.

Essential Clinical Examinations

Cardiovascular Assessment

• Blood pressure monitoring at every ANC visit is universally recommended and shows high compliance (>50%) across settings 1, 2, 3
• Measure BP to screen for hypertension (≥140/90 mm Hg) and pre-eclampsia (≥160/110 mm Hg requires urgent treatment) 2
• Clinical assessment for clonus in women with suspected or confirmed pre-eclampsia 2
• For transgender men on testosterone therapy, assess for increased cardiovascular and atherosclerotic risk similar to natal male populations 4

Maternal Physical Examination

• Weight measurement at each visit (compliance >50% in most settings) 3, 5
• Edema assessment - particularly important for detecting pre-eclampsia, though compliance is often <50% 3, 5
• Abdominal examination including:
  • Uterine height measurement (good predictor of severe growth retardation and perinatal death in rural settings) 6
  • Fetal heart sound assessment (reported in only 26.1% of studies, indicating a gap in practice) 3
  • Fetal position and movement 7

Symptom Assessment

At every assessment after 20 weeks, specifically inquire about 1:

• Headache or visual disturbances (signs of pre-eclampsia)
• Epigastric pain or vomiting (pre-eclampsia warning signs)
• Reduced fetal movements
• Vaginal bleeding

Laboratory Screening Components

The following tests should be performed based on risk assessment 8, 2, 9:

Universal screening:

• Hemoglobin levels for anemia detection
• Syphilis testing (55.1% compliance in studies) 3
• HIV testing (47.8% compliance) 3
• ABO and RhD blood typing
• Proteinuria assessment (dipstick or 24-hour collection if pre-eclampsia suspected) 1, 2

Risk-based screening:

• Gestational diabetes mellitus screening (40.6% compliance) 3
• Urine testing for albumin/sugar (often limited by supply availability) 10, 5

Risk Stratification Framework

Early Pregnancy Risk Assessment (Before 20 Weeks)

Identify women requiring specialist referral if they have 1, 2:

Single high-risk factors:

• Previous pre-eclampsia
• Pre-existing hypertension (booking diastolic BP ≥90 mm Hg)
• Pre-existing renal disease or proteinuria
• Pre-existing diabetes
• Multiple pregnancy
• Antiphospholipid antibodies

Or any two of these factors:

• First pregnancy
• Age ≥40 years
• BMI ≥35
• Family history of pre-eclampsia
• ≥10 years since last pregnancy
• Booking diastolic BP ≥80 mm Hg

Monitoring Frequency After 20 Weeks

Level 1 (Low risk): Follow local protocols for healthy multiparous women 1

Level 2 (Moderate risk):

• 24-32 weeks: Maximum 3-week intervals between assessments
• 32 weeks to delivery: Maximum 2-week intervals 1

Fetal Assessment Components

Ultrasound Evaluation

• Initial detailed ultrasound including fetal echocardiogram when indicated 8, 7
• For pre-eclampsia: Assess fetal biometry, amniotic fluid, and umbilical artery Doppler at diagnosis, then every 2 weeks if normal 2
• More frequent monitoring if fetal growth restriction present 2

Fetal Well-Being Tests (for high-risk pregnancies)

Initiate at 32-34 weeks, individualized based on risk 7:

• Biophysical profile (fetal breathing, movement, tone, amniotic fluid)
• Non-stress testing
• Umbilical artery Doppler velocimetry (particularly for IUGR) 7

Critical Pitfalls to Avoid

1. Don't rely solely on number of visits - content and quality of examinations matter more than visit frequency 11, 3

2. Explain findings to patients - Blood pressure measurements and abdominal examinations are often performed without explanation, reducing patient engagement 10

3. Don't delay initial contact - Many women present after 20 weeks; community-based messaging is needed to encourage earlier care 2, 5

4. Ensure supplies are available - Urine testing and hemoglobin assessment often fail due to lack of supplies, not lack of protocol 10, 5

5. Document danger signs counseling - Only 54% of women can identify obstetric danger signs, indicating inadequate counseling 10

Special Populations

Transgender Men and Non-Binary Patients

• Refer for anesthetic assessment when booking for ANC 4
• Assess cardiovascular risk related to testosterone therapy 4
• Screen for higher rates of autism, anxiety, depression, and other psychiatric conditions 4
• Use patient's chosen name, pronouns, and preferred anatomical terminology 4

High-Risk Conditions Requiring Enhanced Surveillance

Beyond routine examination, assess for 7:

• Advanced maternal age
• Obesity
• Cyanotic heart disease
• Thrombophilia
• Thyroid disorders
• Chronic renal disease
• Connective tissue disease
• Cholestasis
• Hemoglobinopathies
• History of unexplained stillbirth