OBSTETRIC HISTORY & WRITE-UP By Associate Professor Dr Hanifullah Khan
Importance of History Taking• Obtaining an accurate history• The critical first step in determining the aetiology of a patients problem.• A large percentage of the time, a diagnosis can be made based on the history alone.
The obstetric history• 2 purposes – Provide a synopsis of background risk – An account of the progress of the pregnancy• A carefully taken history – provides a clinical guide for the P/E to follow• History should be taken & presented in a logical sequence
Complete History Taking• Chief complaint• History of present illness• History of current pregnancy• Past medical /surgical history• Family history• Drug /blood transfusion history• Social history• Gyn/ob history.
Order of histories• Mandatorily, the initial sequence must include – CC, HOPI, HOCP & HOPP – in that order, – although HOPI and HOCP may be combined if required.• Other histories such as – medical, surgical, family, social, drug and menstrual or gynae history then follow – but these may be rearranged – in order of relevance to the HOPI or HOCP.
What is the “Chief Complaint”• This is the main reason the pt presented• Usually a single symptom, – occasionally more than one complaint eg: chest pain, palpitation, shortness of breath• The patient describes the problem in their own words It should be recorded as such• Short/specific in one clear sentence• Must have duration of problem – “per Vaginal bleeding for 3 days prior to admission”.
Details & progression, regression of the CC:HISTORY OF PRESENT ILLNESS
History of Present Illness - overview• Elaborate on the chief complaint in detail• Ask relevant associated symptoms• Have differential diagnosis in mind
Components of HOCI1. Demographic info2. Primary history – Proper HOCI Analysis of the - Onset, course, severity, duration complaint3. Associated symptoms +4. Symptoms of any complications symptoms
Important points• Always relay story in days before admission e.g. • “the patient was apparently well until 1 day prior to admission…”• If patient has > 1 symptom, • take each symptom individually and • follow it through fully • mentioning significant negatives as well• Avoid medical terminology
Demographic information• Appropriate to begin with a summary of the details• Name, age , gravidity, parity, LMP, EDD (Naegele’s rule) Gravidity no. of pregnancies including current pregnancy (regardless of the outcome) Parity no. of births beyond 24 wk gestation
Primary history• Describes the onset, – -Anatomic location course, severity and duration of the chief – -Quality complaint – -Quantity or severity – elaborates on the main – -Timing complaint – -Setting in which the – deals with the chronology symptoms occur & the characteristics of the – -Aggravating or relieving chief complaint. factors• Chronology & – -Associated symptoms characteristics of the current symptom:
Primary Hx cont..• If > 1 chief complaint, repeat this series of questions for each complaint• Not all questions may be relevant for a symptom – For example, a location cannot be determined for “difficulty in breathing”.
Associated symptoms• A general review of systems• Requires more experience on the part of the interviewer than before• Information gathered here serves to – support the diagnosis – as well as to gauge the severity of the disorder• Examples – abdominal pain - presence or absence of nausea and vomiting – vaginal bleeding - per vaginal discharge, pruritis or smell.
Symptoms of complications• Again - help to confirm the diagnosis and assess the severity of the problem – thus establishing an idea of the management that is to follow• Examples – For complaint of symptoms of dysuria & increased frequency of micturition - loin to groin pain, backache & fever – might suggest ascending infection complicating the UTI
Components of HOCP• Chronological & concise account – 1st, 2nd & 3rd trimesters• How was pregnancy confirmed?• First trimester symptoms• Results of routine tests• Ultrasound scans• Subsequent antenatal check-ups• MOGTT, H/T
Confirm dates• LNMP – Sure of date – Regular menstrual cycle• UPT – Brand?(Clearview®most sensitive UPT), detect β-hCG• Early pregnancy symptoms?when? (vomiting started at 6-7 week)• Quickening – Primigravida: 22-23 weeeks – Multigravida: 16-18 weeks
Investigations• Routine tests – just mention if normal• Of particular importance – Hb & early BP reading – ABO and Rhesus blood grouping• Early u/s scanning – Document the number of fetuses, the viability & gestational age• Subsequent ANC – just mention if normal – 2nd trimester u/s scanning - to assess for fetal anomalies – This should be specifically mentioned even if not done.
DM• Nowadays, routine • Document if DM screening for DM screening was done, when – At first booking & the results – At 24-28 weeks of • Must still list the risk gestation if suspicion of factors of DM DM arises or persists • If results abnormal, ?• Previously, this was done subsequent action based on the presence of – regular serial sugar risk factors monitoring – Pts were being missed out – diet modification• 75g OGTT, HbA1c – oral or insulin therapy
Fetal growth• Fetal growth is an important indicator of diabetic control and any development of macrosomia & polyhydramnios must be mentioned
Prepregnancy disorders• Medical disorders in pregnancy - presence of the disorder prepregnancy – Must actively determine this – Important implications on the classification of the condition, the risks involved & the management of the pregnancy.• DM & HT - the most common medical disorders encountered – Epilepsy, thalassemia, anaemia and heart disease.
Past Obs History• This section details the events & outcomes in the patient’s past pregnancies – May have important implications on current pregnancy – May also give clues on the current problem the patient is facing• Enough to summarize significant points rather than listing them out – Any significant antenatal, intrapartum or postpartum events – Any abortions & ectopic pregnancies &their outcomes have to be mentioned – Previous maternal complications
• Mode of delivery• B Wt• Life & health of the baby• Contraception – – Type, when begun, why stopped, any side effects• Did the current complaint occur in past pregnancy?
The order of appearance• Usually presented as separate individual sections• There should be flexibility in the order of listing them – depending on their importance with regards to the current complaint• Examples – Pt referred for management of DM - family, dietary & social history more important than menstrual history. – Problem of wrong dates - a detailed menstrual history becomes very important
Important points• LMP details ( does it conform to the usual in terms of timing, volume, and appearance)• Regular or irregular cycles• Length of the cycle• OCP• Surgical procedures• Hx of infertility• Sexually transmitted diseases• Uterine anomalies
Importance• Important to know because – Current complaint may be part of past illness – Past illness may affect pregnancy , e.g. hypothyroidism – Pregnancy might impact past illness, e.g. heart disease• Any known pre-existing illness – time of diagnosis/current medication/clinic check up• Surgery – indications, type – Any blood transfusions
Other past illnesses• Include past trauma & accidents – time/place/ and what type of accident• Minor procedures such as endoscopies, biopsies, dental procedures – e.g. tooth extraction & cavity filling may be a source of infective endocarditis in patients with valvular heart disease• Childhood diseases• Vaccinations if relevant – In the case of suspected fetal anomaly, past history of Rubella vaccination is important
Relevance• Drug taken may be relevant to the pregnancy• Although most drugs are safe during pregnancy, some are not – Teratogenic – e.g. - sodium valproate (epilepsy) is prone to congenital anomaly , relevant in a patient referred for a uterus that is smaller than dates
Medications• With regards to medicines – Purpose – Dose – Route – Frequency – Side effects• Immunizations
Protein binding• Medications also affected by ↑amounts of proteins produced by the pregnant women – →increased drug protein binding – → decreased bioavailability and efficacy of the drug ● for example in the case of replacement thyroid hormone for hypothyroidism• Some drugs have side effects that may be exacerbated during pregnancy – Patients on aspirin for heart disease, hypertension or recurrent abortion may have gum and other bleeding.
Important points• Always use generic name – May put trade name in brackets – with dosage, timing & how long.• Do not forget – OCT/Vitamins/Traditional /Herbal medicine & alternative medicine as cupping or acupuncture.• Blood transfusion
Designer drugs• Smoking history - amount, duration & type. – A strong risk factor for IHD – Not so prevalent in Malaysian society• Consumption of alcohol – Is the pt really alcoholic or just a social drinker.
Major illnesses in the immediate family (parents,grandparents, siblings)Determine the presence of any heritable or communicabledisorders that may impact the pregnancyFAMILY HISTORY
Most common• DM & hypertension most important – These & other disorders may occur during pregnancy and be the cause of the current complaint• Also good to know as a means of determining & documenting the risks• Communicable diseases – e.g. dengue & avian flu common – should be asked for especially if the chief complaint is fever
Family History• Any familial disease/running in families – e.g. breast cancer, IHD, DM, schizophrenia,• Infections running in families – such as TB, Leprosy – Cholera, typhoid in case of epidemics.• Endemic conditions – such as AGE, Dengue
The aim is to detect a preventable cause of illnessSOCIAL HISTORY
Occupational & Home• Occupation, social & education background, – family social support& financial situation. – Social class.• Home conditions as: – Water supply. – Sanitation status in his home & surrounding. – Animals / birds in his/her house.