Obstetrics History Taking and Explanations

Question 1

What questions should you ask before exploring the presenting complaint in an obstetrics history?

Answer 1

How far along? Is this your first pregnancy? How many pregnancies and deliveries? Mode of delivery and birth weight?

Who is looking after you in this pregnancy?
When did you book in with the midwife? 12-week scan?
Offered Down’s screening? What was the result?
20-week scan? Any structural abnormalities?
Up to date with vaccines?

Question 2

After discussing the presenting complaint, what symptoms should you always screen for in an obs history?

Answer 2

How has this pregnancy been so far?Headaches or vision changes? N+V? Fetal movements? Abdo pain? Losses of blood or fluid down below? Fatigue? Fever? Weight loss?
Maternal MENTAL HEALTH!

Question 3

After exploring the presenting complaint and doing a systems review, what else should you ask in your obs history?

Answer 3

Family Hx ( diabetes, genetic conditions, pre-eclampsia)
Past gynae history + smears
PMHx
Drug Hx and Allergies
Social Hx and ICE

Question 4

Give some key causes of abdominal pain during pregnancy

Answer 4

Early:
Ectopic pregnancy
Miscarriage

Late:
Labour
Placental abruption
Uterine rupture
Symphysis pubis dysfunction
Pre-eclampsia/HELLP syndrome

Any time:
Appendicitis
UTI

Question 5

What should you ask when exploring a presenting complaint of excessive vomiting during pregnancy?

Answer 5

Vomiting – how long, how often, how much volume, any blood (oesophagitis, Mallory Weiss), do you dry heave without bringing anything up?
Can you keep fluids down? Have you had any anti-emetics and can you keep them down?
Have you lost any weight? What was your weight pre pregnancy?
Do you feel lightheaded/ dizzy? (signs of dehydration)

SYSTEMS REVIEW: Fever? Changes in bowel habit? Urinary symptoms?

Question 6

Differntial diagnoses for excessive vomiting during pregnancy?

Answer 6

pregnancy induced N+V, molar pregnancy, hyperemesis gravidarum, gastroenteritis, other infections e.g. pyelonephritis, DKA

Question 7

What would you look for on examination of someone with excessive vomiting during pregnancy?

Answer 7

signs of dehydration: prolonged cap refill, dry mucous membranes, increased skin turgor
signs of weight loss and muscle wasting
Symphysis- fundal height (increased in molar pregnancy)

Question 8

How would you investigate someone with excessive vomiting during pregnancy?

Answer 8

Basic observations e.g., temperature, blood pressure + pulse rate, resp rate and oxygen sats
Weight
Urine dip (MSU) for ketonuria or signs of infection
FBC, U&Es, LFTs, blood glucose
bHCG (raised in molar pregnancy)
USS

Dx criteria = prolonged N+V, 5% pre-pregnancy weight loss, electrolyte imbalance

Question 9

How would you manage someone with excessive vomiting during pregnancy?

Answer 9

Reassurance, often resolves by 16-20 weeks
Bland diet, avoid triggers
Acupressure, ginger
First line anti-emetics: Cyclizine/promethazine

If requires admission: Normal saline (1L over 2 hours) with potassium added and regular monitoring

Question 10

How should you explore a presenting complaint of hypertension during pregnancy?

Answer 10

When was your high blood pressure first picked up? Have you ever had a high blood pressure in the past?

Other sxs:
Headache? Visual disturbance: such as blurring or flashing lights? Swelling of the arms, legs and face? Nausea and vomiting? Abdominal pain (epigastric/ RUQ)? Reduced urine output?

Question 11

What should you ask in the PMH of someone presenting with hypertension in pregnancy?

Answer 11

problems with blood pressure in previous pregnancy? CKD? Diabetes? Autoimmune conditions? Asthma?

Question 12

What should you look for on examination of someone with hypertension in pregnancy?

Answer 12

On edge / agitated
Visible oedema
Reflexes (hyperreflexia) and neurological signs

Question 13

How should you investigate someone with hypertension in pregnancy?

Answer 13

Blood pressure
Urine dip (proteinuria), MSU for protein:creatinine ratio
FBC (haemolysis, low platelets), U&Es (raised urea + creatinine) , LFTs (elevated liver enzymes)

Question 14

How should you manage someone with hypertension in pregnancy?

Answer 14

Oral labetalol first line
Oral nifedipine if asthmatic
Aspirin 75-150 mg from 12 weeks until delivery for prophylaxis of pre –eclampsia
VTE prophylaxis with LMWH

Regularfetal monitoringis also required for all patients with pre-eclampsia including:
Cardiotocography: assessment of the fetal heartbeat
Ultrasound: assessment of fetal growth and amniotic fluid levels

If severe pre-eclampsia / eclampsia : Magnesium Sulphate IV (4g) until 24 hours after last seizure or delivery

Question 15

What should you ask someone in a history of gestional diabetes?

Answer 15

Mode of delivery and birth weight of previous babies? (macrocosmic baby >4.5kg increases risk of GD)

If presents with symptoms : polyuria? How many times going to the toilet each day? Polydipsia? Weight loss? Fatigue? Any other symptoms?

Can you describe your diet to me? Exercise?
Fam hx of gestational diabetes or first degree relative with diabetes?

Question 16

What management options are there for patients with gestational diabetes?

Answer 16

Trial diet and exercise, then metformin (500mg tablet, side effects tummy upset), then insulin (SC injection into your tummy, rotate the site due to risk of lipohypertrophy)

If fasting glucose over 7 go straight to insulin

Question 17

How would you explain OGTT to a patient?

Answer 17

We will measure your blood glucose using a small pricking device to take blood from the tip of your finger, then we will give you a sugary drink and repeat the test after two hours
You can’t eat or do any excessive exercise in those two hours
We can then discuss the results

Question 18

How would you explain gestational diabetes to a patient?

Answer 18

In pregnancy everyone’s bodies become a bit resistant to a hormone called insulin which helps us to take sugar out of our blood, and some peoples bodies can compensate quite well for that, whereas others struggle a bit more.

You have a bit more sugar in your blood than normal which can affect you and your baby and can cause your baby to be a bit bigger than normal, which just means we need to keep a closer eye on you to keep both you and baby safe.

We will do additional growth scans to monitor for complications and 28, 32 and 36 weeks .

Question 19

How should you explore the presenting complaint of someone presenting with itching in pregnancy?

Answer 19

When did it come on? Is it constant or does it come and go? Are you itchy in any particular part of your body e.g. palms and soles? Changes in colour of skin or eyes? Rashes? Have you changed your detergents or been exposed to any new products recently? Have you tried anything to relieve the itching? Feeling more tired? Changes to urine/stool?

Question 20

What are your differentials for someone presenting with itching in pregnancy?

Answer 20

Obstetric Cholestasis
HELLP syndrome
Acute fatty liver of pregnancy
Chronic liver diseases

Other causes of pruritus: Pemphigoid gestationis, Polymorphic eruption of pregnancy, Pruritis gravidarum, Allergic reactions

Question 21

How should you examine and investigate someone with itching in pregnancy?

Answer 21

Examination:
Look for visible jaundice, rashes, excoriations

Investigations: (for obstetric cholestasis):
LFTs and serum bile salts, ALT is typically elevated e.g., 500 u/l
blood glucose may show hypoglycaemia

Question 22

How would you explain the diagnosis of obstetric cholestasis to a patient?

Answer 22

you have a build-up of something called bile in your blood due to changes in hormones in pregnancy, this happens to 1% of pregnant women

there is an increased risk of stillbirth, preterm birth and bleeding but that’s why we are going to keep a very close eye on you.

Question 23

How would you manage a patient with obstetric cholestasis?

Answer 23

Ursodeoxycholic acid , emollients, antihistamines to help sleeping, Vitamin K supplementation

Induce labour at 37 weeks

Question 24

What should you ask in the history of presenting complaint of RFM in pregnancy?

Answer 24

When did you first notice a change in the baby’s movements?
Are baby’s movements reduced in nature, frequency, or both?
Have there been any significant bumps or knocks to your tummy recently?
Have you had any fluid leaking / bleeding down below?
Have you experienced any painful tightenings or abdominal pain?
Have you noticed any other unusual symptoms today, including headache or abdominal pain?

Question 25

What other questions are relevant to ask in a history of RFM?

Answer 25

Did you need any help conceivingthis pregnancy, such as with IVF?

How has this pregnancy been progressing?

Have you had any trouble with your blood pressure (such aspre-eclampsia) or blood sugar (such as gestational diabetes)?

Were any issues identified on your first-trimester screening, or on any tests in this pregnancy?
When was your last ultrasound?

Do you smoke or use any other substances?

Question 26

How would you examine a patient with RFM?

Answer 26

Maternal observations,particularly blood pressure
Measurement of symphyseal-fundal height
Abdominal palpation, particularly feeling for uterine tone and any pain on palpation of the fundus
Targeted maternal physical examination

Question 27

How would you investigate a patient with RFM?

Answer 27

doppler ultrasound straight away
if no heartbeat then do an USS
if there is a heartbeat then do CTG

Question 28

How would you answer a patient who asks about risk to her baby from RFM?

Answer 28

70% of women who experience RFM have a baby who is completely healthy

but sometimes can be a sign of something serious underlying

Question 29

What can affect fetal movements?

Answer 29

Maternal obesity
distraction
medications - alcohol and benzos

Question 30

How would you investigate a patient with suspected VTE in pregnancy?

Answer 30

Bloods- FBC, U&Es, LFTs, coagulation screen, D dimer not recommended as raised in pregnancy anyway

Signs of DVT:
duplex USS, if DVT is confirmed then no other investigations required for PE, just start LMWH

Sxs of PE :
ECG (sinus tachycardia, S1Q3T3) , ABG
CTPA (risk of maternal BC) or VQ (risk of childhood cancer)

Question 31

How should you manage VTE in pregnancy?

Answer 31

LMWH for anyone with sxs, dose based on booking weight
Maintain throughout pregnancy and 6-12 weeks PP, omits 24 hours prior to induction/ C section

Question 32

Outline the timing of the screening tests in pregnancy

Answer 32

between 11-13 weeks : Combined nuchal test for Down’s syndrome, Edward’s syndrome and Patau’s syndrome (blood tests and USS) . If unable to have combined test (late booking or baby in difficult position) = quadruple test

If higher chance of Down’s on combined, can do NIPT - not a diagnostic test but very accurate

Diagnostic tests:
Between 11-13 weeks: chorionic villous sampling, greater accuracy than combined test so can be used for high chance mothers

after 15 weeks : quadruple test, only to identify Down’s

After 15 weeks : amniocentesis – tests fetal cells for karyotyping

Question 33

How would you explain chorionic villous sampling to a patient?

Answer 33

Procedure to take a small sample from your placenta which supplies your baby with blood and nutrients
We will give you a local anaesthetic and guide a needle either through your tummy or up your vagina using an ultrasound scanner and take a biopsy
If you have a certain blood type we may need to give you an injection after the procedure (rhesus)

Question 34

How would you explain the risks v benefits of chorionic villous sampling to a patient?

Answer 34

Allows us to test for genetic conditions such as Down’s syndrome, results will come back in 48 hours so allows for quick decision making

Accuracy = 97.5-99.6% (high)

Complications: less than 1% risk of miscarriage, bleeding, pain and infection , chance that we may have to do another test if results unclear

Question 35

How would you explain amniocentesis to a patient?

Answer 35

prcoedure used to take a small amount of amniotic fluid (your waters)

Give you a local anesthetic and use an USS to guide a small needle through your tummy to take some fluid

If you have a certain blood type we may need to give you an injection after the procedure (rhesus)

Question 36

How would you explain the advantages and disadvantages of amniocentesis to a patient?

Answer 36

Can be used for genetic testing, over 97% accuracy

Complications : less than 1% risk of miscarriage, infection, risk of club foot, false reassurance because we can never rule anything out 100%

Question 37

What questions do you need to ask patients before considering them for ECV?

Answer 37

Singleton or twin pregnancy?
Have your waters broken?
Any bleeding in the past week?
Abnormal tracing of baby’s heart?
Any abnormalities of the womb?
Have you had a C-section in the past?

Question 38

How could you explain ECV to a patient?

Answer 38

We can try and put pressure on the outside of your tummy to turn your baby into a head down position so that you can have a vaginal delivery

Question 39

What are the benefits of ECV?

Answer 39

50% success rate, 60% in multiparous women

chance of baby turning on it own is low (8%) in primiparous women, avoids need for C section if successful

Question 40

What are the risks of ECV?

Answer 40

• Fetal distress
• Breaking waters early
• Bleeding
• Rupture of your placenta – having a baby in an abnormal position can do that anyway
• 1/200 risk of emergency C section within 24 hours

Question 41

What should you check before offering someone a VBAC?

Answer 41

which way is your previous C section scar?
have you been told that your placenta is lying in a different position to normal?
do you have any ongoing infections?

Question 42

What are the pros and cons of VBAC?

Answer 42

Chance of successful VBAC 72-76%, increasing to 87-90% for previous NVD/VBAC

More positive birth experience, shorter recovery period , reduced complications from surgery/anaesthetics, increased chance of uncomplicated vaginal delivery in future, better chance of successful breast feeding

0.5% risk of uterine rupture, Risk of repeat emergency c/s

Question 43

What are the pros and cons of repeat C section as opposed to VBAC?

Answer 43

Planned date of delivery
Almost zero risk of scar rupture
Less damage to pelvic floor, no risk of perineal tearing
Increased risk of bladder and other organ damage
Scar tissue can cause long term pain/ adhesions and sub-fertility
Increased risk of repeat c/s for subsequent delivery
Increased risk of infection
Increased risk of placenta accreta
Increased risk of thrombosis
Associated with an increased risk of transient tachypnoea of the newborn