Obstetric Hx Taking Flashcards
What’s the difference between gynaecological and obstetric Hx taking?
It’s worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your Hx should be ____?
An obstetric Hx involves asking questions relevant to a patient’s current and previous pregnancies! Gynaecological Hx taking focuses more on non-pregnancy related things
Gynaecology focussed
(e.g. abdo pain at 8 weeks gestation could be an ectopic pregnancy)
Anything before 18 weeks gestation –> take a gynaecological Hx instead!
Before getting into the presenting complaint, it’s useful to confirm some key pregnancy details early.
What are the key pregnancy details you would like to find out?
Gestational age - it’s important to ask this first, as anything less than 18 gestation week require a focused gynaecological Hx rather than an obstetric Hx
Gravidity (G) - the number of times a woman has been pregnant, regardless of the outcomes (e.g. G2)
Parity (P) - the total number of times a woman **has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth)
(That means that if a woman is bearing a child that is 26 gestation week, that doesn’t count as a parity, as she hasn’t given birth to it)
Examples of gravidity and parity calculation:
A patient is currently 26 weeks pregnant and already has 2 children of her own. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks. What were her gravidity (G) and parity (P)?
G5 - because she has had 5 pregnancies in total
P3 - the patient’s parity would be 3 because she has had 3 pregnancies which resulted in the birth of a child with a gestational age of greater than 24 weeks (one of which was a stillbirth).
If a mother has given birth to a pair of twins with a gestation age of 24 weeks or more, how do you calculate their parity?
According to the British Journal of Gynaecology, a mother who has carried twins to a viable gestational age (>/= 24 weeks) should be defined as P1
However, in clinical practice, only 20% of UK obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2
What are the key obstetric symptoms you need to cover in your Hx taking? Please give a few differential diagnoses for each symptom
Key Obstetric symptoms:
-
Abdominal pain
- Causes include:
- UTI
- Constipation
- Pelvic girdle pain (also called symphysis pubis dysfunction)
- Placental abruption - when the placenta separates early from the uterus before childbirth
- Causes include:
-
N&V - usually mild in most cases
- Hyperemesis gravidarum is a severe form of vomiting in pregnancy associated with electrolyte imbalance, weight loss and ketonuria. Exact cause unknown
-
Reduced foetal movements
- Can be associated with foetal distress
- Absent foetal movements may indicate early foetal death
-
Vaginal bleeding
- Causes include:
- Cervical bleeding (e.g. cervical ectropion, cervical cancer)
- Placental previa –> severe bleeding
- Placental abruption (usually associated with abdo pain)
- Causes include:
-
Vaginal discharge or loss of fluid
- Abnormal vaginal discharge –> STIs (gonorrhoea)
- Loss of fluid from vagina (‘Water breaking’) due to ruptured amniotic membranes
- Signs include a rapid gush that feels like you have peed in your pants, a constant leak, a slow drip, a leak that starts and stops, it doesn’t smell like pee (it may have a sweet smell)
- Causes include:
- Physiological - this indicates that the baby is ready to be delivered
- Causes of premature rupture of membranes (PROM) - Infection (esp UTIs), polyhydramnios, multiple pregnancy, or abdominal trauma
-
Headache, visual disturbance, epigastric pain and oedema –> pre-eclampsia
- High BP + proteinuria
-
Pruritis
- Associated with obstetric cholestasis –> Intense itch in the palms of the hand and soles of the feet (NO skin rash)
- Uncommon symptoms include nausea, weak/ diminished appetite and jaundice
- Cause is unknown but it’s thought that high oestrogen levels in pregnancy may affect the way the liver works and causes a build-up of bile acids in the body
- Associated with obstetric cholestasis –> Intense itch in the palms of the hand and soles of the feet (NO skin rash)
- Unilateral leg swelling –> DVT (as pregnant women become procoagulative as they approach labour to prevent excessive bleeding during labour)
- Chest pain and SOB due to PE
-
Systemic symptoms
- Fatigue (e.g. anaemia)
-
Fever
-
Chorioamnionitis
- Medical emergency - usually caused by an ascending bacterial infection of the amniotic fluid/ membranes/ placenta
- Major risk factor is preterm premature rupture of membranes which expose the normally sterile environment of the uterus to potential pathogens (however, it can still occur when the membranes are still intact)
- Mx - Prompt delivery of the foetus (via C-section if necessary) + IV Abx
- UTI
-
Chorioamnionitis
- Weight loss (e.g. hyperemesis gravidarum - regurgitation of food causes malnutrition)
What are the differential diagnoses of abdominal pain during pregnancy?
Mnemonic: LARA CROFT (see image)
- Labour
- Abruptio placenta
- Rupture (ectopic/ uterine) = ruptured ectopic pregnancy, rupture of the uterus
- Abortion (spontaneous) i.e. miscarriage
- Cholestasis
- Rectus sheath haemtoma
- Ovarian tumour
- Fibroids
- Torsion of the uterus
What are the functions of the amniotic fluid?
To learn the implications of early amniotic sac ruptures, we first need to know the function of the amniotic fluid:
- Allow room for foetal growth, movement and development
- Maintains temperature (prevent hypothermia)
- Acts as a shock absorber to protect the foetus from external trauma
- Prevents adhesion formation between the foetal parts and the amniotic sac
- Contains antibacterial properties
- Provides nutrition due to small amounts of protein and salt content
- Foetal pulmonary development at 20 weeks
- Allows MSK development in babies
- Aids dilatation of the cervix during labour
What are the implications of pre-term pre-labour rupture of amniotic membranes (i.e. early ‘water breaking’)?
(Normally, your waters break around the time labour is due, but in around 2% of pregnancies they break early for various reasons, and we call those pre-term pre-labour rupture of membranes)
Implications:
- If the waters around your baby have gone early there is a risk of infection spreading into your womb and to your baby. It is not possible to repair the hole in the membranes and replace the fluid, but you will be given antibiotics to help reduce the risk of infection to your baby
- There is also a chance you may go into labour early and your baby will be premature. Unfortunately, premature babies can often have problems with their breathing, feeding and also infections.
a) . When does N&V typically begin in pregnancy? At which period of gestation is N&V most frequently experienced by pregnant women? and when does it usually resolve?
b) . What is persistent and severe N&V in pregnancy called?
a) . N&V typically begin at 4-7th week of gestation, then peak at 9-16th week and resolve by 20th week of pregnancy
b) . Hyperemesis gravidarum = persistent and severe vomiting associated with dehydration, electrolyte imbalance (loss of Cl-, Na+, K+, HCO3-), weight loss and ketonuria
a) . When do pregnant women typically first notice or feel foetal movements?
b) . Is it abnormal if primigravida women (women who are pregnant for the first time) do not feel any foetal movements before week 20?
c) . What may reduced foetal movements indicate? (what adverse outcomes?)
d) . How would you ask the patient about foetal movements?
a) . Women typically start to feel foetal movements at 16-24 weeks gestation
b) . No, primigravida women will often not feel foetal movements until after 20 weeks! (so it’s nothing abnormal before week 20)
c) . Adverse outcomes:
- Stillbirth
- Foetal growth restriction
- Placental insufficiency - failure of the placenta to deliver sufficient nutrients to the foetus during pregnancy, and is often caused by insufficient blood flow to the placenta (see image for the causes)
- Congenital malformations
d). “Have you noticed any change in the amount of your baby’s movement?
(This MUST BE ASKED if the patient is of the appropriate gestation to be able to feel them)
What information do you want to obtain if a pregnant woman presents with vaginal bleeding?
- Pain (SQIPTARS) - vaginal bleeding associated with abdo pain indicates placental abruption
- Associated trauma (including domestic violence)
- Fever/ malaise (infection) –> UTI, STI
- Recent USS results (e.g. position of the placenta - placental previa can make you bleeding throughout pregnancy)
- Cervical screening history (e.g. cervical cancer can cause PV bleeding)
- When was the last time they had their cervix examined? or when was her last checkup?
- Sexual Hx
- PMHx
- Ask about fatigue if anaemia is suspected and symptoms of hypovolemic shock (e.g. pre-syncope/ syncope)
Vaginal discharge:
All healthy women will have some degree of regular vaginal discharge, so it’s important to distinguish between normal and abnormal vaginal discharge when taking an obstetric Hx
What questions do you want to ask the patient about their vaginal discharge?
What are the examples of abnormal vaginal discharge? What are their differential diagnoses?
“Have you noticed any changes to the ___ of the vaginal discharge?”
- Volume
- Colour
- Consistency
- Smell
Normal vaginal discharge can be clear/ white, slippery and wet, thick and sticky, and does NOT have a strong or unpleasant smell. It’s totally normal to get heavier discharge during pregnancy, if you are sexually active or if you are using birth control
Fishy smell –> BV
Thick and white, like cottage cheese –> Thrush
Green, yellow, frothy –> Trichomoniasis
With pelvic pain or bleeding –> Chlamydia or gonorrhoea
With blisters or sores –> Genital herpes
It’s very important to ask about urinary symptoms in a pregnant woman in a obstetric Hx, as UTIs are very common in pregnancy due to hormonal changes and they need to be treated promptly.
a) . Why are pregnant women more prone to developing UTIs?
b) . What are the potential complications of untreated UTI?
c) . What information do you want to obtain from the patient about their urinary symptoms?
a) . The uterus sits right above the bladder and expands during pregnancy. As it expands, the gravid uterus can compress on the ureters causing urinary stasis and backflow of urine. In addition, hormonal effects of progesterone may also cause relaxation of smooth muscles leading to ureteral dilatation and urinary stasis –> UTI
b) . If left untreated –> foetal death, premature rupture of membranes (PROM) which can cause chorioamnionitis, developmental delay, cerebral palsy
c) . Ask about LUTS
- Storage
- Frequency
- Urgency
- Nocturia
- Urge incontinence
- Voiding
- Hesitancy
- Poor flow (<10mL/s) or weak stream
- Terminal dribble
- Feeling of incomplete emptying
- Dysuria (can be UTIs or STIs)
- Fever
There is one common condition in pregnancy that can be life-threatening for both the mother and the foetus, and in your Hx taking you MUST ask questions to screen for the symptoms of this condition.
What is this SUPER IMPORTANT condition that you MUST RULE OUT?
Pre-eclampsia
(If you don’t ask this in your OSCE, you will surely fail your station! YESSS it’s THAT IMPORTANT!)
What is pre-eclampsia?
(Please read separate flashcards on ‘Pre-eclampsia’ for further details)
Pre-eclampsia is a relatively common condition in pregnancy seen after 20 weeks gestation, which is characterised by maternal HTN, proteinuria (> 0.3 g/24 hrs), oedema, foetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the foetus. Therefore, early recogition of symptoms is absolutely vital (DON’T FORGET TO ASK IN OSCE!)
Systemic review:
What symptoms could you screen for in each system?
Systemic review:
- Systemic: fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, UTI), weight loss (e.g. hyperemesis gravidarum, malignancy)
- Respiratory: dyspnoea (e.g. PE, anaemia), chest pain (e.g. PE)
- GI: abdo pain (e.g. placental abruption), vomiting (e.g. hyperemesis gravidarum)
- GU: LUTS such as urinary frequency, dysuria, urgency (e.g. UTI), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
- Neurological: visual changes, motor or sensory disturbances, headache (e.g. pre-eclampsia)
- MSK: pelvic pain (e.g. symphysis pubis dysfunction)
- Dermatological: rashes, skin lesions, linea nigra (see image)
-
Linea nigra (pregnancy line) - a linear hyperpigmentation that runs vertically along the midline of the abdomen from the pubis to the umbilicus (can also run from the pubis to the top of the abdomen)
- Due to increased melanocyte-stimulating hormone (MSH) made by the placenta, which also causes melasma and darkened nipples
-
Linea nigra (pregnancy line) - a linear hyperpigmentation that runs vertically along the midline of the abdomen from the pubis to the umbilicus (can also run from the pubis to the top of the abdomen)
Once you have taken the Hx of presenting complaint, you need to ask about a patient’s current pregnancy. What information would you want to obtain about her current pregnancy?
Current pregnancy:
-
Gestation
- Clarify the current gestational age of pregnancy with the patient
- For example, 26 weeks and 5 days would be written as “26+5”
- Accurately estimate gestation and estimated date of delivery using an USS to measure the crown-rump length (CRL)
- CRL is the length of the embryo from the top of its head to bottom of torso (see image)
- Clarify the current gestational age of pregnancy with the patient
-
Scan results
- Women are offered an USS to check for foetal anomalies at 18-26 weeks of gestation. Ask about the scan results and note key findings such as:
- Growth of the foetus - clarify if it was within normal limits for the current gestation
- Placental position - if embedded in the lower 1/3rd of the uterine cavity –> Increased risk of placenta previa
- Foetal anomalies - note any abnormalities identified
- Women are offered an USS to check for foetal anomalies at 18-26 weeks of gestation. Ask about the scan results and note key findings such as:
-
Screening (read separate flashcards on ‘screening’)
- Ask the woman what screening has been offered to the woman during pregnancy and if the patient has opted for screening. If so, what the results were
- Screening offered during pregnancy includes:
- Sickle cell and thalassaemia screening (during the first 10 weeks of pregnancy)
- Blood tests for HIV, Hep B and syphilis (at 8-12 weeks of pregnancy)
- Eyes screening for those with diabetes during pregnancy
- 12-week scan (also called the dating scan) - an USS offered at 10-14 weeks to check how many weeks pregnant you are and your estimated date of delivery, whether you are expecting more than 1 baby, that the baby is growing in the right place and the baby’s development. It’s also used to detect health conditions e.g. spina bifida and Down’s syndrome
-
Combined test (USS + blood test) is offered at 10-14 weeks of pregnancy to screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
- Note that if the patient has agreed to have screening for these conditions at the dating scan and the scan is taking place at 10-14 weeks, they don’t need a separate USS for the combined test, they just need an additional blood test. The dating scan and the screening will usually happen at the same time
- The USS measures the fluid at the back of the baby’s neck to determine nuchal transluency
- If women book later in pregnancy or it was not possible to obtain a nuchal translucency measurement during the combined test –> offer quadruple test at 14-20 weeks (although this only screens for Down’s syndrome)
-
20-week scan, an USS performed at 18-21 weeks of pregnancy
- It screens for 11 physical conditions in the baby including anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos (omphalocoele), serious cardiac abnormalities, bilateral renal agenesis, lethal skeletal dysplasia, Edwards’ syndrome (trisomy 18), Patau’s syndrome (trisomy 13)
- NIPE screening (check paediatric flashcards) within 72 hrs of being born + hearing test
- Newborn blood spot test (heel prick test) at 5 days after birth to screen for 9 conditions including sickle cell disease, CF, congenital hypothyroidism, phenylketouria (PKU), homocystinuria (HCU), MCADD, MSUD, IVA, GA1
-
Other details of pregnancy
- Singleton or multiple gestation (e.g. twins or quadriplets)
- Check if the patient took folic acid prior to conception and during the 1st trimester
- Explore the planned mode of delivery (vaginal vs C-section)
- Ask about any medical illness during pregnancy - what type? and if the patient is still receiving any treatment?
-
Immunisation Hx
- Check if the patient is up to date with their vaccinations including flu vaccine, whooping cough vaccine and hepatitis B vaccine
-
Mental health Hx
- Screen for symptoms suggestive of psychiatric illness e.g. depression, bipolar disorder, schizophrenia
- Ask about previous mental health diagnoses and assess self-harm/ risk of suicide (see psychiatric flashcards)
Nuchal translucency
Past Medical Hx:
What are the key questions do you need to ask?
Any medical conditions?
- If so, when was it diagnosed? how well controlled? what treatment(s) the patient is receiving? any complication? hospital admission?
Any surgery or procedure done in the past such as:
- Abdominal or pelvic surgery - may influence decisions regarding delivery due to the presence of scar tissue and adhesions
- Previous C-section - ***increased risk of uterine rupture in subsequent pregnancies
-
Loop excision of the transitional zone (LETZ) for cervical cancer - increased risk of cervical incompetence
- Cervical incompetence (or cervical weakness/ insufficiency) is a medical condition of pregnancy where the cervix begins to dilate (widen) and efface (thin) too early before the pregnancy has reached term - See image
