History And Physical Examination

Obstetric and gynecologic history, including menstrual status and contraceptive use, should be obtained on every woman of reproductive age. Cessation of menses, as well as such symptoms as nausea, vomiting, fatigue, and urinary frequency, may be suggestive of pregnancy. The date of the last normal menstrual period aids in determination of gestational age (although it may be misleading if, for example, contraceptive use was recently discontinued). Quickening, the first maternal perception of fetal movement, could also help establish gestational age. Primigravida women note fetal movement between 18 and 20 weeks' gestation. With subsequent pregnancies, quickening typically occurs about 2 weeks earlier (i.e., between 16 and 18 weeks' gestation). The patient's history of prenatal care and the course of current and past pregnancies, as well as the essential components of any medical history (past medical history, medications, allergies, social history, family history, and review of systems), should be obtained.

Physical examination of pregnant women should include routine assessment of maternal well-being as well as an evaluation of fetal status. When a fetal stethoscope is used, fetal heart tones can be heard by 16 to 19 weeks' gestation. The normal fetal heart rate ranges from 120 to 160 beats per minute. Since the fetus easily changes position, the site on the maternal abdomen where the fetal heart tones are best detected varies. Pulsation of the maternal aorta should be distinguished from the fetal heart tones.

A pelvic examination should be performed whenever pregnancy is part of the differential diagnosis. Appearance of the cervix and the presence of discharge or blood in the vaginal vault should be noted. Wet preparation and culture for Neisseria gonorrhoeae and Chlamydia trachomatis may be indicated. Bimanual examination determines size and tenderness of the uterus and adnexa.

By the end of the first trimester, the size of the uterus can also be assessed by abdominal examination. At 12 weeks' gestation, the fundus should be palpable at the level of the symphysis pubis. At 16 weeks, the fundus should be midway between the symphysis and the umbilicus; at 20 weeks, it should be at the umbilicus. From 20 to 32 weeks, the height (in centimeters) of the fundus above the symphysis approximates the gestational age. For an accurate measurement, the pregnant patient should have an empty bladder when fundal height is determined. Later in pregnancy, the presenting part of the fetus should also be determined by palpating the maternal abdomen.

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