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Obstetric Histories

Obstetric Histories. Amy Chan (5 th Year Medical Student). Presenting Complaint. Elicit why the patient has come in Start with open questions and allow them time to talk The patient may have attended clinic as part of standard antenatal care or because of symptoms

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Obstetric Histories

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  1. Obstetric Histories Amy Chan (5th Year Medical Student)

  2. Presenting Complaint • Elicit why the patient has come in • Start with open questions and allow them time to talk • The patient may have attended clinic as part of standard antenatal care or because of symptoms • Common presenting complaints in pregnancy: • Bleeding • Abdominal pain • Hypertension • Physiological changes of pregnancy

  3. History of presenting complaint • Explore each symptom • SOCRATES • Predisposing events? • Have there been previous episodes? • Systemic features

  4. Current Pregnancy • First pregnancy? • Planned pregnancy? • Date of LMP • Menstrual history: regularity and length of cycles • How was the pregnancy confirmed? • Calculate gestation and expected due date (obstetric wheel) • Folic acid • Preconception and in 1st trimester • Scans so far • Dating (8 – 14 weeks) • Anomaly (18 – 21 weeks) • Fetus growth/structural abnormalities • Placental location • Growth scan • Investigations so far • Blood type and rhesus status • Down’s syndrome screening • Nuchal translucency • Blood test • CVS/amniocentesis • Progress and any problems through current pregnancy?

  5. ICE • Any concerns about the pregnancy? • What are the expectations for pregnancy? • Planned mode of delivery • Vaginal • Caesarean section • Location of delivery • Hospital (consultant led) • Birth centre (midwife led) • Home

  6. Signs and symptoms of pregnancy • Nausea and vomiting • Severity • Managing to keep food and fluids down? • Tiredness • Indigestion, constipation • Breast tenderness • Back pain • Oedema • Urinary frequency • Carpal tunnel syndrome • Fetal movements • When did they start? • Has the baby established a pattern? • Have movements stopped or reduced in frequency?

  7. Past Obstetric History Details of each pregnancy • Term, pre-term, post-term • Gender • Singleton / twin / multiple • Onset of labour: spontaneous / induced • Use of oxytocin • Hours in labour • Mode of delivery: vaginal, instrumental, C-section • Place of delivery • Birth weight • Breastfeeding • Current health of children • Gravidity • = The total number of pregnancies achieved, regardless of outcome • Parity • = The number of pregnancies that completed 24 weeks gestation (i.e. potentially viable) Enquire sensitively about miscarriages, stillbirths and terminations.

  8. Complications of previous pregnancies • Antenatal • Intrauterine growth restriction (IUGR) • Hyperemesis gravidarum • Pre-eclampsia • Foetal abnormalities • Labour • Breach presentation • Failure to progress • Fetal distress • Consultant intervention with instruments / C-section • Perineal tears • Shoulder dystocia • Post-natal • Post-partum haemorrhage • Neonatal problems • Retained products of conception • Urinary incontinence • Mental health

  9. Gynaecological History • Cervical smears • Up to date? Results? • Previous gynae problems and treatment • STI, PID, ectopic pregnancy • Contraception • Subfertility • Previous Caesarean sections • Increased risk of uterine rupture, adhesions, placenta accreta

  10. Past Medical History • Immunisations • Diabetes • Hypertension • Epilepsy • Asthma • Thyroid disease • Clotting abnormalities • Previous abdominal surgery • Blood-borne viruses: HIV, Hep B, Hep C • Congenital heart disease • Systemic autoimmune disease e.g. SLE, RA Family history • Inherited genetic conditions • Recurrent miscarriages in mother/sisters • Pre-eclampsia

  11. Drug History • Regular medications • OTC drugs • Teratogenic medications • ACE Inhibitors • Sodium valproate • Methotrexate • Trimethoprim • Medications in pregnancy • Folic acid • Iron • Anti-emetics • Antacids • Metformin • Allergies

  12. Social History • Smoking • Alcohol • Recreational drug use • Living situation • Marital status • Partner • Who lives with the patient? • Is home close to the hospital? • Occupation • Maternity leave • Social and financial support • Screen for domestic violence • “Pregnancy can be a particularly difficult time. Many women suffer from abuse, whether physical or emotional. It is hard to talk about but has anything like this happened to you?” • Offer appropriate support

  13. Systems Review Briefly screen other body systems for symptoms. • CVS • Respiratory • GI • Genitourinary • CNS • Musculoskeletal • Dermatological

  14. PV Bleeding • Implantation spotting • Miscarriage • <24 weeks gestation • Threatened/inevitable/incomplete/complete • Ectopic pregnancy • Molar pregnancy • Heavy and prolonged bleeding • Exaggerated symptoms of pregnancy • Uterus large for dates • Vaginal infections • “Show” • Sign of labour • When cervical mucus plug comes away • Placental abruption • Placenta previa (low lying placenta) • Vasa previa (fetal blood vessels run though the membranes covering the cervix)

  15. Abdominal Pain Obstetric Causes • Labour pain • Painful, regular rhythmic contractions • Premature / term • Braxton-Hicks contractions • Infrequent, irregular contractions • Pre-eclampsia • Epigastric/RUQ pain • Placental abruption • Sudden severe pain • Woody hard, tender uterus • Fetal distress • +/- PV bleeding • Uterine rupture • Constant pain, shock, PV bleeding • Fetal distress • History of uterine scar • Presents during labour • Acute polyhydramnios • Acute fatty liver of pregnancy • 2nd half of pregnancy • Abdo pain, nausea/vomiting, jaundice, malaise, headache

  16. Gynaecological Causes • Ectopic pregnancy • Unilateral abdominal pain, PV bleeding • Usually presents between 5 – 9 weeks gestation • Cervical excitation (but do not palpate for adnexal masses in case of rupturing ectopic) • Miscarriage • <24 weeks gestation • Associated PV bleeding – may pass clots or products of conception • Pelvic inflammatory disease • PV discharge • Bilateral pelvic pain • Fever • Ovarian or fallopian tube torsion • Ovarian cysts – torsion, haemorrhage or rupture • Fibroids – red degeneration or torsion General surgical causes of acute abdomen

  17. Review • SOCRATES • General • Sweating • Fever • Obstetric • Fetal movements – reduced / change in pattern? • Contractions • PV bleeding / discharge / loss • Pre-eclampsia symptoms • Urological • Frequency, volume, urgency • Dysuria • Haematuria • Gastrointestinal • Weight loss, change in appetite • Nausea, vomiting, dysphagia, indigestion, heartburn • Change in bowel habit • Blood/mucus in stools

  18. Ectopic Pregnancy • A&E: haemodynamically unstable, concern about degree of pain or bleeding • EPAU for further assessment with positive pregnancy test and examination findings • Expectant management if pregnancy <6 weeks and not in pain • Repeat urine pregnancy test after 7 – 10 days. • Return if positive or symptoms continue/worsen. • Negative pregnancy test = miscarried • Transvaginal ultrasound • Identify location of pregnancy, fetal pole, fetal heartbeat • Pregnancy of unknown location • Monitor clinical symptoms • Take 2 serum hCG measurements 48 hours apart • >63% increase after 48 hours: likely developing intrauterine pregnancy, cannot exclude ectopic • >50% increase after 48 hours: pregnancy unlikely to continue • Methotrexate • Unruptured ectopic, adnexal mass <35 mm, no visible heartbeat • Serum hCG <1500 IU/litre • No significant pain • Woman able to return for follow-up • Serum hCG days 4 and 7 in 1st week • 1 serum hCG every week until negative result • Surgery (salpingectomy vssapingotomy) • Woman unable to return for follow-up with methotrexate • Ectopic with signficant pain • Adnexal mass >35 mm • Fetal heartbeat visible • Serum hCG >5000 IU/litre • Offer anti-D rhesus prophylaxis

  19. Miscarriage Threatened • Painless PV bleeding • Before 24 weeks, typically 6 – 9 weeks gestation • Cervical os closed • Confirmed intrauterine pregnancy with fetal heartbeat Missed / delayed • Light PV bleeding/discharge. Symptoms of pregnancy disappear. Usually no pain. • Cervical os closed • Gestational sac >25 mm with no fetal part (“blighted ovum”) Inevitable • Heavy bleeding, clots, pain • Cervical os open Incomplete • Pain and PV bleeding • Not all productions of conception expelled • Cervical os open Complete • All products of conception expelled • Bleeding has stopped Recurrent • 3 or more consecutive spontaneous miscarriages

  20. Expectant management • Confirmed miscarriage • Expectant management for 7 -14 days • Give oral and written information on what to expect • Pain management • When to seek help • Wait for products of conception to be expelled Medical management • Vaginal misoprostol: missed or incomplete miscarriage • Pain relief and anti-emetics if needed Surgical management • Ensure anti-D immunoglobulin given to Rh negative women • Manual vacuum aspiration (LA in outpatient or clinic) • Surgical removal of products of conception (GA)

  21. Hypertension in Pregnancy Normal physiological effects of pregnancy: blood pressure usually falls between the first and second trimesters.

  22. Management • Aspirin 75mg OD from 12 weeks until birth if at risk of pre-eclampsia • Stop any ACE-I, ARBs or chlorothiazide in pregnancy (risk of congenital abnormality) • First line: labetalol. Alternatives: methyldopa, nifedipine • Admit to hospital if there are signs/symptoms of pre-eclampsia • Magnesium sulphate • Critical care setting • Give if has / had eclamptic fit • Severe pre-eclampsia, birth planned within 24 hours

  23. Pre-Eclampsia • Severe headache • Increasing frequency • Not relieved by regular analgesics • Visual disturbance e.g. blurring, flashing lights, double vision • Persistent epigastric or RUQ pain • Vomiting • Breathlessness • Sudden swelling of the face, hands and feet HELLP syndrome: Haemoloysis, elevated liver enzymes, low platelets Eclampsia: seizures in woman with pre-eclampsia

  24. Consultant plan. • Offer elective birth • Before 34 weeks if: severe HTN refractory to treatment; maternal or fetal indications develop • After 34 weeks if: mild/moderate HTN, depending on maternal/fetal conditions, risk factors, NICU availability • Recommend elective birth • After 34 weeks if: BP in severe HTN is controlled and corticosteroid course has been completed • After 37 weeks: within 24-48 hours of pre-eclampsia with mild/moderate HTN

  25. Tips • Practice scenarios where you take a history AND give an explanation/management plan to the patient. Manage your timing. • Know the common conditions managed in obstetrics – risk factors, clinical features, classifications, investigations, treatment (conservative, medical, surgical) • There’s not that many ways for the med school to catch you out in O&G • Remember to read up on post-partum mental health • Make sure you can discuss plans for delivery (e.g. home/birth centre/labour ward, vaginal/Caesarean/VBAC, pool birth, pain relief in labour) • Rule out differentials, even if you think the diagnosis is obvious from the presentation. • Safe doctor = PASS. Safety net the patient, speak to senior for advice, admit to hospital for serious problems. • Don’t forget: • Do a pregnancy test! (Acute abdomen, female, sexually active  ?ECTOPIC) • Check Rhesus status

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