Cardiac disease in pregnancy physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]

Normal physical exam signs of pregnancy include an “innocent” systolic flow murmur in 96% of patients due to the hyperdaynamic circulation, a diastolic murmur in 18% of patients, jugular venous distension and a displaced cardiac apex due to volume expansion, an S₃ in 84% of patients, an occasional S₄, varicose veins and pedal edema.

• Arterial pulses are high volume and collapsing in nature. Such collapsing pulse must be differentiated from other hyperdynamic states including aortic insufficiency and hyperthyroidism.

• The carotid upstroke is brisk due to the volume expansion and hyperdynamic state
• Jugular venous distension may be present due to the volume expansion

• Increased intensity of the first heart sound secondary to physiologic hyperdynamic circulation during pregnancy
• An S₄ is occasionally heard
• An S₃ is heard in 84% of cases

• In general there are often innocent murmurs of pregnancy. These are the result of a hyperkinetic circulation. These murmurs are usually midsystolic and soft and heard best at the left lower sternal border and over the pulmonic area.
• A systolic murmur is heard in 96% of patients, and a diastolic murmur is heard in 18% of patients.
• Pulmonic midsystolic murmur
• Continuous murmur (mammary soufflé, cervical hum)

• Adventitious sounds such as basal rales may be appreciated

• Varicosities and ankle edema secondary to inferior vena caval compression

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