Obstetric History

History of Presenting Complaint

• how long
• onset – gradual or sudden
• associated symptoms
  • pain?
    • site
    • onset
    • character
    • radiation
    • associated symptoms
    • timecourse
    • exacerbating and relieving factors
    • severity 1-10/10
  • any blood or protein in the urine?
  • any bleeding?
  • any high blood pressure?
• have you noticed anything making it worse?
• better?
• was there anything you think triggered it?
• have you had anything like it before?
  • any investigations?
  • diagnosis?
  • treatment?

• Have you been pregnant before?
  • how many times
    • what year
    • how long was the gestation
    • what was the outcome
      • if live-birth, how are they now
        • were/are they breast/bottle/mixed fed?
• How has this pregnancy been so far?
  • any problems?
    • have you noticed any bleeding in early pregnancy?
  • how far along are you?
    • when’s the estimated date of delivery?
      • was that confirmed on ultrasound?
      • when was your last menstrual period?
      • have you had scans?
        • any prenatal diagnostic tests?
      • have you felt the baby kicking?

• Any previous gynaecological problems?
  • (have you had to see a gynaecologist before?)
• When was your last period?
  • were your periods regular?
  • how heavy was the bleeding?
• When was your last smear?
  • what was the result?
• Were you using contraception prior to this pregnancy?
  • what were you using?
  • was it for contraception, or for problems with bleeding?

• Do you have any long-term health conditions?
• Do you see your GP for anything?
• Have you been admitted to hospital for any reason?
• Have you ever had any kind of surgery?

• Do you take any regular medications?
• Do you take any HRT (hormonal replacement therapy?)
• Any over-the-counter supplements? (St. John’s Wort?)

• Does anything run in the family that you know of?
  • heart disease
  • diabetes
  • thromboembolism
  • hypertension
• Were there any complications with your mother during her pregnancy?
• Any sisters who’ve been pregnant?
  • did they have any issues?

• How is everything at home?
• Who is at home with you?
  • do you feel like you have enough help at home?
  • do you receive any social support/do your other children have a social worker?
• Any financial trouble?
• Alcohol
• Smoking
• Drugs
• Allergies

• Are there any concerns that you have?
• Do you have any questions for me?

Summary

• So just to confirm… (1-2 sentence summary of what you’ve found out)

• Thank you very much for talking to me
• Wash hands
• Present

Hypertension:

• Chronic hypertension
  • present before 20 weeks
  • 3-5% of pregnancies
• Pre-eclampsia
  • hypertension
  • proteinuria
  • oedema
• HELLP syndrome
  • Haemolysis
  • Elevated liver enzymes
  • low platelets
• Eclampsia
  • pre-eclampsia + convulsions

• positive pregnancy but lower B-hCG than expected
• abdominopelvic pain
• bleeding

Epilepsy:

• 0.5% of pregnancies
• Highest risk in puerperium
• folate metabolism main concern

• Pelvic inflammatory disease
  • abdominopelvic pain
  • fever
  • discharge

• Higher risk of UTI
• Hypertension
• CKD
  • 1/30 pregnancies complicated by ckd
    • largely due to increased maternal age 
    • increased diabetes 
• RISKS:
  • miscarriage
  • IUGR
  • preterm delivery
  • Foetal death

• defined as less than 10.5 g/dl
• haemodilution occurs in pregnancy as plasma volume increases by 50%
• 2-3x increased iron requirement
  • 90% of pregnancy anaemia thought to be due to iron
• 10-20x increased folate requirement
  • 5% of pregnancy anaemia thought to be due to folate
• Sickle cell disease increased risk, as is thalassaemia

• SLE – 1/1000
  • Lupus nephritis carries poor prognosis
    • high risk of miscarriage
    • IUGR
    • preterm delivery
    • IUD
    • transient neonatal lupus
    • maternal hypertension
  • symptoms may improve during pregnancy due to immunosuppression but often flare during pueperium

• 1-4% of women of childbearing age
  • 1/3 have no change
  • 1/3 improve
  • 1/3 deteriorate
• asthma doesn’t affect course of pregnancy unless poorly controlled:
  • small for gestational age
  • IUGR
  • preterm delivery
• treatment is the same as in non-pregnant women

Hyperemesis gravidarum

• 0.1-1% have persistent nausea and vomiting
• weight loss
• tachycardia
• dehydration
• fluid and electrolyte imbalance
• postural hypotension
  • think about vitamin B1 deficiency (Wernicke’s encephalopathy)
  • hyponatraemia
  • malnutrition
  • thrombosis
  • psychological issues

• 50% risk of Ulcerative colitis exacerbation in 1st and 2nd trimester
• 75% of Crohn’s remains quiescent
  • improves in 1/3 of those with inactive disease at conception
  • may have puerperial flare
• active disease at conception associated with
  • miscarriage
  • prematurity

• 1/5 pregnant women obese
• risk of
  • pre-eclampsia
  • thromboembolism
  • diabetes
  • shoulder distocia (fat deposits on baby’s shoulders)
  • wound infection
  • resp infection
  • caesarean section
  • miscarriage
  • macrosomia
  • stillbirth
  • congenital abnormalities

Direct

• sepsis
• pre-eclampsia
• thromoembolism
• amniotic embolism
• early pregnancy death
• haemorrhage
• anaesthesia

Indirect

• Cardiac disease
• Neurological disease
• Psychiatric causes
  • suicide
  • substance abuse
  • violence
• Malignancy