History taking and risk factor identification
Initial contact with the patient takes place in an outpatient setting (antenatal clinic) or inpatient hospital. The physician collects general and obstetric-gynecological history to immediately identify high-risk patients. Special attention is paid to age: nulliparous women under 18 and over 30, as well as women over 35 (due to the increased risk of fetal congenital anomalies), require careful monitoring.
Complaints are assessed depending on the gestational age:
- In the first trimester of an uncomplicated pregnancy, missed menstruation, nausea, and changes in well-being are considered normal.
- The appearance of spotting is a warning sign indicating an incipient miscarriage, ectopic pregnancy, or associated gynecological pathology.
Working conditions (vibration, chemicals, static loads), the environmental situation, and bad habits must be recorded. A crucial step is analyzing the outcomes of past pregnancies. If there was a fetal loss in the past, the physician clarifies its timing (antenatal, intranatal, or postnatal) and causes, which may include asphyxia, birth trauma, hemolytic disease, or malformations.
Objective examination of the pregnant woman
External examination provides essential information about potential anatomical obstacles to labor and the woman's overall health.
- Height and pelvic structure: Women 150 cm and under often have a contracted pelvis of varying degrees. Tall stature is frequently associated with a male-type pelvis. Any skeletal deformations require close attention.
- Body mass: Evaluated not in absolute figures, but via the body mass index (BMI). Obesity (BMI over 30 kg/m²) of alimentary or endocrine origin negatively affects gestation.
- Skin and mucous membranes: Physiological changes include pigmentation of the linea alba, face, nipples, and the appearance of stretch marks (striae gravidarum). Pallor, scleral icterus, cyanosis of the lips, or pronounced edema indicate serious extragenital diseases.
- Shape of the abdomen: In the second half of pregnancy, the abdomen normally has an ovoid shape. A spherical contour indicates polyhydramnios, a transverse oval indicates transverse fetal lie, and a pendulous abdomen is characteristic of overstretched abdominal wall muscles in multiparous women.
Specific obstetric examination
Obstetric examination is aimed at assessing uterine dimensions, pelvic parameters, and the position of the fetus in the uterine cavity.
- In the first trimester, the main method is bimanual vaginofacial-abdominal examination, which allows for precise determination of uterine size.
- Ultrasound examination (US): The goals of fetal and placental examination strictly depend on the current trimester of pregnancy.
- Prenatal screening: Includes biochemical and ultrasound tests performed within strictly regulated (mandated) timeframes to detect developmental anomalies.
- Invasive diagnostics: Used according to strict indications. At the preimplantation preparation stage, micromanipulations are possible: polar body biopsy of the oocyte/zygote or embryo biopsy.
Diagnosis of vascular complications
Pregnancy increases the risk of thrombotic events requiring immediate diagnosis and treatment.
Deep vein thrombosis (DVT) manifests as edema, tenderness upon palpation along the veins, and local temperature elevation of the leg. The main confirmation method is Doppler ultrasound. In late terms, the enlarged uterus obstructs visualization, so angiography may be required. Conservative treatment includes elastic compression, direct anticoagulants (discontinued 6 hours before delivery), antiplatelet agents, and NSAIDs. If a floating thrombus is detected, placement of a vena cava filter or plication of the inferior vena cava is indicated. In the case of an emboligenic thrombus without a vena cava filter, delivery is performed via Cesarean section.
Pulmonary embolism (PE) is a life-threatening condition often occurring against the background of DVT or valvular heart defects. Massive PE causes acute cardiopulmonary failure and loss of consciousness. ECG, chest X-ray (to rule out pneumonia), and lung perfusion assessment are used for diagnosis. A specific marker in arterial blood is hypoxemia without hypercapnia. Treatment includes infusion therapy, vasopressors, oxygen therapy, and heparin administration.
Abdominal shape rule: Ovoid — Excellent (physiological norm), Sphere — Wide (polyhydramnios), Transverse oval — Transverse fetal lie.
Class and exam questions
How is uterine size determined in early pregnancy?
In the first trimester, uterine size is assessed using bimanual vaginofacial-abdominal examination, which begins with inspection.
What blood gas parameters are characteristic of PE?
A key sign of pulmonary embolism is hypoxemia, which occurs without concomitant hypercapnia.
How does the height of a pregnant woman affect the course of labor?
Short stature (150 cm and less) is often associated with pelvic contraction, while tall stature may indicate the formation of a male-type pelvis, which must be considered when planning labor.
In which cases of deep vein thrombosis is a Cesarean section indicated?
Cesarean section with simultaneous plication of the inferior vena cava is performed in the presence of an emboligenic (floating) thrombus if a vena cava filter has not been previously placed in the patient.
What else to study on this topic
- Rules and technique for measuring pelvic dimensions (pelvimetry)
- Techniques of external obstetric examination of a pregnant woman
- Methods for obtaining objective information about the intrauterine condition of the fetus
- Indications and technique for invasive research methods in obstetrics
- Goals and specific methods of prenatal screening by trimesters
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