OSCE: Obstetric History Flashcards
What are the key aspects of taking an obstetric history?
Introduction.
Key pregnancy details.
Presenting complaint:
- SOCRATES for pain
- Obstetric symptoms
ICE
Systemic enquiry.
Current pregnancy.
Previous obstetric history.
Gynaecological history.
PMH.
DH & allergies.
FH.
SH.
Closing.
What should you ask about for ‘key pregnancy details’?
1) Gestational age
2) Gravidity
3) Parity
What is gravidity?
The number of times a woman has been pregnant, regardless of outcome
What is parity?
The total number of times a woman has given birth to a child with a gestational age of ≥24 weeks, regardless of whether the child was born alive or not (stillbirth).
What are some key obstetric symptoms to ask about?
1) N&V
2) Reduced foetal movements (from 20 weeks)
3) Vaginal bleeding
4) Abdo pain
5) Vaginal discharge or loss of fluid (colour, smell, pain & itch)
6) Headache, visual disturbance, epigastric pain, swelling
7) Pruritus
8) Unilateral leg swelling
9) Chest pain & SOB
10) Systemic symptoms: fatigue, fever, weight loss
What is hyperemesis gravidarum?
A severe form of vomiting in pregnancy associated with electrolyte disturbance, weight loss and ketonuria.
N&V in pregnancy is common. It is typically mild and only requires reassurance and basic hydration advice.
When does it typically begin/peak/end?
Begins between 4th & 7th week gestation.
Peaks between 9th and 16th week.
Resolves around 20th week.
When do women typically start to feel fetal movements?
Between 16-24 weeks gestation (primigravida women will often not feel fetal movements until 20 weeks gestation).
What should you ask about fetal movement (once the patient is of the appropriate gestation to be able to feel them)?
“Have you noticed any change in the amount of your baby’s movement?”.
A mother will know what is the ‘usual’ amount of fetal movements she experiences.
If a reduction in fetal movements is reported, it should be taken very seriously.
What are reduced fetal movements associated with?
Adverse pregnancy outcomes: stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations.
What to ask about regarding vaginal bleeding in obstetric history?
Causes:
- Pain
- Associated trauma (including DV)
- Fever/malaise
- Recent US scan (e.g. position of placenta)
- Cervical screening history
- Sexual health history
- PMH
Effect:
- Fatigue (if anaemia suspected)
- Symptoms of hypovolaemic shock (e.g. pre-syncope/syncope)
What to ask about regarding vaginal discharge?
Important to distinguish between normal and abnormal vaginal discharge for them.
- Pain & itching
- Colour, constistency & smell
- Volume
What are untreated UTIs in pregnany associated with?
Increased risk of fetal death, developmental delay and cerebral palsy .
Common symptoms of UTI to ask about?
o Dysuria
o Frequency
o Urgency
o Fever
What are some key symptoms of pre-eclampsia to ask about?
- Headache (typically severe and frontal)
- Swelling of hands, feet and face
- Pain in upper part of abdomen (epigastric tenderness)
- Visual disturbance (blurring of vision or flashing lights)
- Reduced fetal movement
What is pre-eclampsia?
Characterised by maternal HTN, proteinuria, oedema, fetal intrauterine growth restriction and premature birth.
Other key symptoms to ask about in obstetric history?
1) Fever: important when considering infections e.g. UTIs, cervical infections, chorioamnionitis
2) Fatigue: e.g. anaemia
3) Weight loss: hyperemesis gravidarum or other serious conditions (e.g. malignancy, anorexia)
4) Pruritus: obstetric cholestasis (typically affects palms and soles of feet)
What are 2 key obstetric conditions that can cause fever?
Chorioamnionitis & UTIs
What conditions should you consider in obstetric histories?
- Miscarriage
- Pre-eclampsia
- Anaemia
- PE/DVT
- STIs
- Hyperemesis gravidarum
- UTI
- Chorioamnionitis
- Placental abruption
What aspects should you ask about their ‘current pregnancy’?
1) Current gestation age of the pregnancy
2) Scan results
3) Screening
4) Other details:
- singleton or multiple gestation
- pregnancy symptoms
- folic acid
- planned mode of delivery
- medical illness before/during pregnancy
5) Immunisation history
6) Mental Health history
How would a gestation age of 26 weeks and 5 days be written?
26+5
What to ask about regarding scan results in obstetric history?
1) Are they up to date with their scans?
2) Results of scans (or check medical records if patient is unsure)?
Key findings to note about results of US scans?
1) Growth of fetus: clarify if within normal limits for gestation
2) Placental position: if embedded in lower third of uterine cavity, there is an increased risk of placenta praevia
3) Fetal abnormalities
When are women offered US scans during pregnancy?
Between 18+0 weeks and 20+6 weeks
What screening is offered to pregnant women?
1) Down’s syndrome
2) Rhesus status and presence of any antibodies
3) Hep B, HIV and syphilis
What to ask about regarding screening n pregnancy?
1) Have they opted for screening?
2) If so, what were the results?
What other details to ask about when exploring ‘current pregnancy’?
1) Pregnancy symptoms
2) Check if this is a singleton or multiple gestation
3) Clarify if the patient took folic acid prior to conception and during the first trimester
4) Explore the planned mode of delivery (e.g. vaginal or Caesarean section)
5) Ask about any medical illness during pregnancy (clarify what type of illness and if the patient is still receiving any treatment)
What key medical issues during pregnancy should you ask about?
1) HTN
2) Diabetes
3) Anaemia
4) UTI
5) Pre-eclampsia
Check patient’s immunisation history to see if they are up to date with their vaccinations.
What should you ask about?
1) Flu vaccination
2) Whooping cough vaccination
3) Hep B vaccination (if at risk)
What should you ask about regarding mental health history?
Essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder, schizophrenia):
- ask about mood etc
Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if relevant.
What to ask about regarding previous obstetric history?
1) Gravidity & parity
2) Term pregnancy (>24 weeks):
- gestation at delivery
- birth weight
- mode of delivery
- complications
- assisted reproduction e.g. IVF
3) Stillbirth
4) Miscarriage
5) Termination of pregnancy
6) Ectopic pregnancy
Why is it important to ask about gestation at delivery during previous pregnancies?
Previous pre-term labour increases the risk of pre-term labour in later pregnancies
Why is it important to ask about birth weight during previous pregnancies?
High birth weight in previous pregnancies raises possibility of previous gestational diabetes.
Low birth weight (SGA) in a previous pregnancy increases risk of a further SGA baby.
What does high birth weight in previous pregnancies raise the possibility of?
Previous gestational diabetes
What are some complications during the antenatal period to ask about regarding previous pregnancies?
- pre-eclampsia
- gestational diabetes
- gestational HTN
- placenta praevia
- shoulder dystocia
What are some complications during the postnatal period to ask about regarding previous pregnancies?
- post-partum haemorrhage
- perineal/rectal tears during pregnancy
- retained products of conception
Define a stillbirth
A stillbirth is when a baby is born dead after 24 weeks completed of pregnancy.
What is it important to ask about regarding previous stillbirths?
Asking about stillbirths needs to be done in a sensitive manner.
Sensitively clarify the gestation of stillbirth.
Define miscarriage
The loss of pregnancy before 24 weeks gestation.
What to ask about regarding previous miscarriages?
1) Gestation: clarify the trimester at which miscarriage occurred (most common in 1st trimester)
2) Clarify if medical or surgical management was required
3) Clarify if any cause was identified (e.g. genetic syndromes)
What to ask about regarding previous terminations of pregnancies?
1) Gestation at which termination was performed
2) Method of management (e.g. medical or surgical)
What to ask about regarding previous ectopic pregnancies?
1) Site
2) How it was managed (e.g. expectant, medical, surgical)
What to ask about regarding gynaecological history?
1) Cervical screening
2) Previous gynaecological conditions & treatments
If relevant: contraception, periods
What to ask about cervical screening?
1) Are they up to date?
2) Date of last scan
3) Results of last scan
4) Have they ever had any abnormal smears?
5) Have they ever received any treatment if test was abnormal? (check that follow up is in place)
What are some gynaecological conditions to ask about/consider?
1) STIs
2) Endometriosis
3) Bartholin’s cyst
4) Cervical ectropion
5) Malignancy (e.g. cervical, endometrial, ovarian)
What to ask about regarding PMH?
1) PMH & management
2) Surgeries & procedures
What surgeries should you ask about in PMH?
1) Abdominal or pelvic surgery (may influence decisions regarding delivery due to the presence of scar tissue and adhesions)
2) Previous C-sections
3) Loop excision of the transitional zone (LETZ)
What do previous c-sections increase the risk of in future pregnancies?
uterine rupture
What does LETZ increase the risk of?
Cervical incompetence
What are some medical conditions to be aware of during pregnancy?
1) Diabetes type 1 & 2
2) Hypothyroidism
3) Epilepsy
4) Previous VTE
5) Blood-borne viruses e.g. HIV, hepatitis B, hepatitis C
6) Genetic disease e.g. cystic fibrosis, sickle cell, thalassaemia
Why is it important to know about diabetes during pregnancy?
Plood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia)
What is a potential complication of hypothyroidism during pregnancy?
Can result in congenital hypothyroidism with significant neurodevelopmental impact
What is a potential complication of epilepsy during pregnancy?
Seizures during pregnancy pose a risk to both the mother and fetus (e.g miscarriage) and many antiepileptics are teratogenic.
Why is it important to ask about previous VTE in an obstetric history?
Pregnancy is pro-thrombotic state, may require prophylactic treatment (e.g. LMWH)
Why is it important to ask about HIV, hepatitis B, and hepatitis C during obstetric history?
Risk of vertical transmission
What to ask about during DH & allergies?
1) Prescribed medications
2) OTC medications
3) Contraception
4) Allergies
What to ask bout regarding contraception during obstetric history?
1) Ask what contraception was using prior to becoming pregnant
2) Check if they have stopped their contraception or have had contraceptive device removed (e.g. coil, implant)
What are some teratogenic drugs?
1) Sodium valproate
2) Methotrexate
3) ACEi
4) Retinoids
5) Trimethoprim (1st trimester)
What are some medications frequently used during pregnancy?
1) Folic acid (400ug)
2) Oral iron: used frequently in pregnancy to treat anaemia
3) Antiemetics
4) Antacids: manage GORD during pregnancy
5) Aspirin
What dose of folic acid is recommended?
400ug daily for 1st trimester of pregnancy to reduce risk of neural tube defects in developing fetus
What to ask about regarding FH in obstetric history?
1) Inherited genetic conditions: cystic fibrosis, sickle cell disease
2) T2DM: if 1st degree relatives are affected, there is an increased risk of gestational diabetes
3) Pre-eclampsia: most relevant if maternal mother or sister is affected as this is associated with an increased risk of developing pre-eclampsia
What to ask about for SH in obstetric history?
1) General Social Context:
- type of accommodation & adaptions
- who they live with & personal support network
- independent tasks & assistance
2) Smoking
3) Alcohol
4) Recreational drugs
5) Diet & weight
6) Occupation & plans for maternity leave
7) Domestic abuse
What can smoking during pregnancy increase the risk of?
An SGA baby
What can drinking alcohol during pregnancy increase the risk of?
Fetal alcohol syndrome
What can cocaine use during pregnancy increase the risk of?
Placental abruption
What can obesity during pregnancy increase the risk of?
VTE, pre-eclampsia & gestational diabetes
1st line investigations in suspected pre-eclampsia?
1) BP: HTN
2) Urine dipstick: proteinuria
3) Full examination including fetal heartbeat auscultation and reflexes
Further investigations in pre-eclampsia?
1) Bloods: FBC, U&Es, LFTs, clotting
2) Placental growth factor (PIGF) blood test
3) Fetal US: assessment of fetal growth and amniotic fluid levels.
4) Fetal CTG: assessment of the fetal heartbeat.
What is the diagnostic criteria for pre-eclampsia (4 components)?
1) HTN
2) Proteinuria
3) Maternal organ dysfunction
4) Uteroplacental dysfunction: e.g. intrauterine growth restriction and stillbirth.
What defines HTN in pre-eclampsia?
≥140mmHg systolic or ≥90mmHg diastolic.
What defines proteinuria in pre-eclampsia?
Either:
a) ≥300 mg protein in a 24-hour urine collection
b) a urine protein/creatinine ratio ≥30 mg/mmol; or
c) two readings of at least ++ protein on urinary dipstick analysis
What may FBC show in pre-eclampsia?
low platelet count may suggest HELLP syndrome
What may U&Es show in pre-eclampsia?
Renal insufficiency: raised urea, raised creatinine and low eGFR
What may LFTs show in pre-eclampsia?
raised ALT or AST indicate liver dysfunction.
What may clotting profile show in pre-eclampsia?
Clotting may be deranged in the context of disseminated intravascular coagulation (DIC).
What is role of investigating placental growth factor (PIGF) in pre-eclampsia?
PIGF supports trophoblastic growth so has a role in placental angiogenesis.
Measuring PIGF levels can be used to aid diagnosis in pre-eclampsia, particularly in patients with chronic or gestational hypertension.
Elevated levels of PIGF suggest that pre-eclampsia is unlikely to be present. However, low PIGF levels only indicate, but do not confirm a diagnosis of pre-eclampsia.
Give 3 differentials for pre-eclampsia
1) Chronic HTN
2) Gestational HTN
3) Pre-eclampsia superimposed on chronic HTN
Define chronic HTN in pregnancy
Hypertension that occurs before 20 weeks gestation or persists after 12 weeks postpartum.
Define gestational HTN
Hypertension that occurs after 20 weeks gestation that develops without any co-existing complications.
Define pre-eclampsia superimposed on chronic hypertension?
Hypertension that already exists but worsens after 20 weeks gestation alongside the development of co-existing complications.
Management of estbalished pre-eclampsia?
1) Regular monitoring of BP, proteinuria, bloods, CTG, US & umbilical artery Doppler velocimetry
2) Antihypertensives
3) Consider antiemetics & analgesia
4) VTE prophylaxis
5) Senior review to consider admission or outpatient management
6) Explain the diagnosis to the patient (ideally including risks)
7) If severe enough –> consider early delivery
Role of umbilical artery Doppler velocimetry in pre-eclampsia?
assessment of placental and fetal circulation.
Anticoagulant of choice in pregnancy?
LWMH (doesn’t cross placenta)
1st line antihypertensives in pre-eclampsia?
1st –> labetalol (beta blocker)
2nd –> nifedipine
3rd –> methyldopa
Which 3 classes of antihypertensives are contraindicated in pregnancy (and could be a red card)?
ACEi, ARBs & thiazide diuretics
What is 1st line antihypertensive in pre-eclampsia in Afro-Caribbean patients?
Nifedipine
Why is VTE prophylaxis indicated in pre-eclampsia?
Due to an increased risk of VTE development in pre-eclampsia patients, particularly during hospital admission.
LMWH and/or anti-embolism stockings.
Define severe pre-eclampsia
A BP of ≥160mmHg systolic or ≥110mmHg diastolic
Requires hospital admission.
What should be given to women with RISK FACTORS for pre-eclampsia?
Aspirin from 12 weeks
Give 5 complications of pre-eclampsia
1) Multi-organ dysfunction: with progressive worsening to multi-organ failure.
2) CVS complications: e.g. MI
3) Placental abruption
4) Eclampsia
5) HELLP syndrome
Define eclampsia
A severe complication of pre-eclampsia involving the development of seizures secondary to HTN.
Defined as seizures occurring in pregnancy or within 10 days of delivery PLUS the development of at least two of the following features within 24 hours of the seizure:
1) HTN
2) Proteinuria
3) Thrombocytopenia
4) Raised AST
Management of eclampsia?
It is considered an obstetric emergency requiring hospital admission.
1) Early delivery if possible (consider corticosteroids if <34 weeks gestation)
2) IV magnesium sulphate
Role of IV magnesium sulphate in eclampsia?
To treat the mother’s seizures and prevent reoccurrence.
What % of women with pre-eclampsia develop HELLP syndrome?
10-20%
What is HELLP?
Develops as a result of endothelial damage and consequent thrombi formation, associated with pre-eclampsia.
H - Haemolysis
E L - Elevated Liver enzymes
L P - Low Platelets
Cause of haemolysis in HELLP? What does it result in?
RBCs become damaged by the abnormal endothelium, resulting in microangiopathic haemolytic anaemia.
Cause of elevated liver enzymes in HELLP?
Raised ALT and/or AST can occur due to hepatic sinusoid obstruction by fibrin.
Cause of low platelets in HELLP?
Platelet levels drop below 150 x109/L due to platelet consumption as a result of thrombi formation.
What can a blood film from a patient with HELLP syndrome typically show?
Schistocytes (fragmented RBCs).
What are the 4 key causes of antepartum haemorrhage (APH)?
1) Placenta praevia
2) Placental abruption
3) Vasa praevia
4) Uterine rupture
Others: polyps, carcinoma, cervical ectropion, infection (local causes)
What are 2 safe antihypertensives in pregnancy?
Labetalol & nifedipine
Specific questions to ask about APH?
1) When it started? (& what they were doing at the time)
2) Quantity of blood (e.g. how many pads?)
3) Colour & clots
4) Has it stopped?
What symptoms to ask about in APH?
- Pain
- PV discharge
- Contractions
- Bleeding from anywhere else
- Reduced fetal movements
- Anaemia: SOB, dizziness, syncope, pallor
Typical symptoms of placenta praevia?
1) painless PV bleeding
2) may have light contractions
Investigations in suspected placenta praevia?
1) A-E with abdominal exam (to assess foetal lie/presentation).
2) Full set of obs including BP.
3) Auscultation of foetal heartbeat.
4) Bloods: FBC, XM, clotting, U&Es and LFTs (can exclude hypertensive conditions such as HELLP or pre-eclampsia)
5) Foetal monitoring (CTG)
6) Abdo USS: to assess placental position.
1st line antihypertensives in pregnant women with asthma?
Nifedipine
What should be AVOIDED in suspected placenta praevia?
Speculum & bimanual examination –> can cause sudden, massive bleeding.
Placenta praevia must be first ruled out by ultrasonography.
Management of placenta praevia?
1) Admit for review & monitoring
2) Further management will depend on senior review but may involve:
- Emergency delivery (if mother or baby is in haemodynamic distress)
- Re-scan with elective caesarean section if the placenta remains low
- Consultant led monitoring, likely as an inpatient due to bleed
3) Materal steroids given if early delivery indicated
4) Advise to avoid physical tasks due to risk of bleeding e.g. housework and sexual intercourse
Cause of gestational diabetes?
1) Increased insulin resistance in second trimester and progresses as pregnancy advances due to hormones (oestrogen, progesterone, cortisol, prolactin and human placental lactogen).
2) Placental degradation of insulin.
What can meconium stained liquour indicate?
Hypoxia (note - can be more normal in post-term babies)
What conditions does a woody, tense uterus indicate on examination?
Placental abruption
