Physical Examination and Diagnostic Considerations for Pregnant Women

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, 2
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 2

Blood pressure measurement to screen for hypertensive disorders 3
Heart rate assessment, noting that tachycardia may be normal in pregnancy 2
Respiratory rate evaluation, as tachypnea may warrant further investigation 1
Assessment for lower extremity edema, which may be normal in pregnancy but could also indicate DVT 5
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

Assess current physical activity levels and recommend at least 150 minutes of moderate-intensity physical activity weekly, accumulated over a minimum of 3 days 3, 4
Recommend a combination of aerobic exercise and resistance training for optimal benefits 3
Physical activity during pregnancy is associated with decreased risk of pre-eclampsia, gestational diabetes, and excessive weight gain 4
Evaluate for VTE risk factors, particularly important as pregnancy increases VTE risk 1, 2
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

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%) 8, 7
If PE is suspected, radiation exposure concerns should not prevent necessary diagnostic testing 9, 2
Radiation exposure from most diagnostic tests falls well below the 50 mSv threshold considered dangerous to the fetus 1
Consider compression ultrasonography of lower extremities as first-line imaging if DVT is suspected 2, 7

Do not dismiss symptoms like dyspnea and tachycardia as normal pregnancy changes without proper evaluation, as these could indicate PE 1, 2
Avoid unnecessary radiation exposure, but do not withhold essential diagnostic tests when clinically indicated 9, 2
Do not rely solely on D-dimer to exclude PE in pregnant women 8, 7
Avoid the supine position during examination in late pregnancy, as it may lower PaO2 by up to 2 kPa 1