Head and Neck

Stand facing the seated woman and observe the head and neck, including the following features:

■ Face. The mask of pregnancy, chloasma, is normal. It consists of irregular brownish patches around the eyes or across the bridge of the nose.

■ Hair, including texture, moisture, and distribution. Dryness, oiliness, and sometimes minor generalized hair loss may be noted.

■ Eyes. Note the conjunctival color.

■ Nose, including the mucous membranes and the septum. Nasal congestion is common during pregnancy.

■ Mouth, especially the gums and teeth.

■ Thyroid gland. Inspect and palpate the gland. Symmetric enlargement is expected.

Facial edema after 24 weeks of gestation suggests PIH.

Localized patches of hair loss should not be attributed to pregnancy.

Anemia of pregnancy may cause pallor.

Nosebleeds are more common during pregnancy. Signs of cocaine use may be present.

Gingival enlargement with bleeding (p. 203) is common during pregnancy.

Marked or asymmetric enlargement is not due to pregnancy.

H Thorax and Lungs_

Inspect the thorax for the pattern of breathing. Although women late in pregnancy sometimes report difficulty in breathing, there are usually no abnormal physical signs.

If signs of respiratory distress are noted, examine the lungs thoroughly. Expect respiratory alkalosis in later trimesters.

Palpate the apical impulse. In advanced pregnancy, it may be slightly higher than normal because of dextrorotation of the heart due to the higher diaphragm.

Auscultate the heart. Soft, blowing murmurs are common during preg- These murmurs may also accom-nancy, reflecting increased blood flow in normal vessels. pany anemia.

M Breasts_

Inspect the breasts and nipples for symmetry and color. The venous pattern may be marked, the nipples and areolae are dark, and Montgomery's glands are prominent.

An inverted nipple needs attention if breast-feeding is planned.

Palpate for masses. During pregnancy, breasts are tender and nodular.

A pathologic mass may be difficult to isolate.

Compress each nipple between your index finger and thumb. This maneuver may express colostrum from the nipples.

A bloody or purulent discharge should not be attributed to pregnancy.

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