3- Obstetric Anamnesis and Examination quiz

Obstetric Anamnesis and Examination

• Obstetric anamnesis and examination are important for minimizing maternal and infant deaths.
• Maintaining maternal and fetal health.
• Identifying risky pregnancies.
• Preventing pregnancy complications.
• Achieving early intervention.
• Detecting smoking, alcohol use, and domestic violence.

Etymology of Obstetrics

• Science of midwifery.
• Department of medicine.
• Deals with treatment and care of women during pregnancy and childbirth.
• Date of terminology: 1819
• Midwife: with woman

Antenatal Care

• Important process to minimize maternal and infant deaths.
• Maintaining maternal and fetal health.
• Identifying risky pregnancies.
• Preventing pregnancy complications.
• Early intervention for risk factors.
• Detecting smoking, alcohol use, and domestic violence during pregnancy.
• Evidence-based knowledge, skills, and practices of health professionals to improve the quality of care increase awareness in care.
• Standardization and reduce medical errors and unnecessary practices.

Prenatal Care Purpose

• Confirming pregnancy.
• Determining health status of pregnant woman and fetus.
• Determining gestational age and monitoring development.
• Detecting risky pregnancies and taking precautions.
• Creating an obstetric care plan.
• Pregnant education and counseling.

High Risk Pregnancy

• Pregnancy complicated by a disease/disorder that endangers life or affects health.
• Mother, fetus, and/or newborn can be affected.
• Identification of high-risk patients is crucial for life-saving benefits.

High Risk Pregnancy Factors

• Poor obstetric history (recurrent miscarriages/preterm deliveries).
• Heart disease.
• Hypertension or preeclampsia (essential, renal or pregnancy-induced).
• Diabetes (IDDM/NIDDM).
• Multiple gestations.
• Placenta previa/abruption.
• Threatened preterm labor.
• Cervical insufficiency.
• Abnormal placentation(accreta, increta, percreta).
• Anemia: Hemolytic, megaloblastic, thalassemia.
• Bleeding disorders
• Thrombosis/thrombophilia
• Antiphospholipid syndrome (APS).
• Neurological disease (epilepsy, brain hemorrhage, or tumor).
• Malignancy (cervical, ovarian, or breast).
• Transplant patient's pregnancy.
• Fibroid uterus.
• Fetal congenital malformations.

Causes of Death in Pregnant Women

• 28% - Pre-existing medical conditions exacerbated by pregnancy (diabetes, malaria, HIV, obesity).
• 27% - Severe bleeding.
• 14% - Pregnancy-induced high blood pressure (preeclampsia).
• 11% - Infections.
• 3% - Blood clots.
• 8% - Abortion complications.
• 9% - Obstructed labor and other direct causes.

Initial Visit: History Taking

• Personal history.
• Medical history.
• Obstetrical history.
• Current pregnancy.

Initial Visit: Physical Examination

• Physical examination of the pregnant woman.
• Check specific areas (including but not limited to: thyroid, heart, lungs, breasts, abdomen, extremities, and optic fundus, and ankles for edema).

Initial Visit: Lab

• Immunization and drug support.
• Information and consultancy.
• Pregnancy-related complaints.
• General evaluation

Initial Visit: Full Medical History

• Previous and current disorders.
• Drug use (therapeutic, social, and illicit).
• Risk factors of pregnancy complications.
• Obstetrical history.
• Maternal/fetal complications (gestational diabetes, preeclampsia, congenital malformations, stillbirth).

Past Medical History

• Chronic hypertension.
• Diabetes mellitus.
• Thromboembolic disease.
• Thyroid disorders.
• Cardiac disease.
• Renal disease.
• Pulmonary disease (asthma, sarcoidosis).
• Connective tissue disorders.
• Maternal cancer.
• Epilepsy.
• Blood disorders (anemia, coagulopathy, hemoglobinopathy).
• Psychiatric disorders

Family History

• Tay-Sachs disease.
• Cystic fibrosis.
• Sickle cell disease.
• Thromboembolism.
• Birth defects (particularly cardiac anomalies).
• Medical history of first-degree relatives.
• Diabetes

Ethnic Background

• Population screening for genetic diseases.
• Effective cost-wise screening targeting particular ethnic groups susceptible to genetic diseases.
• Screening for carriers of genetic diseases in susceptible subgroups.

Diseases and Risk Groups

• Table listing diseases (Alpha thalassemia, Beta thalassemia, Bloom’s syndrome, etc.) and populations at increased risk (Chinese, Southeast Asians, etc.) for each disease.
• Testing method for each disease listed.
• Method of testing includes CBC, Hemoglobin electrophoresis, Mutation analysis, Enzyme and mutation analysis .

Maternal Age

• Adolescents are at increased risk for preeclampsia-eclampsia, intrauterine growth restriction, and maternal malnutrition.
• Women of increasing age are at increased risk for preeclampsia, diabetes, obesity, cesarean section, stillbirth, placenta accreta, and fetal aneuploidy.

Fetal Aneuploidy Screening

• Maternal age of 35 is no longer a cutoff for screening.
• Patient counseling and options evaluation.
• Maternal serum screening should occur.
• First- and second-trimester screens should not be ordered independently.
• Cell-free DNA in maternal blood for screening aneuploidy through sequencing and quantifying DNA chromosome fragments proportions.

Gravidity and Parity

• Gravidity is the number of confirmed pregnancies.
• Parity is the number of deliveries after 20 weeks.
• Muti-fetal pregnancy counts as one delivery.
• Abortus is the number of pregnancy losses before 20 weeks.
• Sum of parity and abortus equals gravidity.

Calculating Estimated Delivery Date

• Pregnancy lasts 10 lunar months or 280 days (average) .
• Nagele's rule to calculate estimated delivery date (EDD) is used, adding 7 days to the first day of the last menstrual cycle, and subtracting three months from that date.
• The rule gives year + 1.

Fundal Height

• Measuring symphysis pubis to fundus gives gestational week (cm x 8 / 7 = gestational week)
• The fundus height is used to understand which fetal part is at the fundus during the second and third trimester
• Fetal position and size are studied during second and third trimesters using the height of the fundus.

Initial Routine Prenatal Visit

• Occurs between 6 and 8 weeks gestation.
• Follow-up visits: ~4 weeks until 28 weeks, ~2 weeks from 28 to 36 weeks, and weekly thereafter until delivery.
• Visits may be more or less frequent depending on risk factors.

Initial Visit: Definitive Diagnosis

• Definitive diagnosis of pregnancy needed.
• First transvaginal ultrasound (USG) for visualization.
• β-hCG measurement if no visualization of gestational sac.
• Gestational sac size bigger than 20 mm suggests anembryonic pregnancy.
• Yolk sac presence differentiates the gestational sac from pseudosaic .
• Ectopic pregnancy excluded

Laboratory Testing

• Prenatal evaluation involves testing urine and blood.
• Repeats during follow-ups.
• Rh-negative women and Rh-positive fathers at risk of Rh-disease.
• Prophylactic doses of Rh(D) immune globulin may be necessary.
• Urine tests for proteinuria (before/after 20 weeks).
• Gestational diabetes screening (between 24 and 28 weeks with 50-g, 1-hour glucose tolerance test).
• Thyroid disorders screening (TSH) in all trimesters.

Risk Factors for Gestational Diabetes

• Diagnosis factors include:
  • Gestational diabetes or macrosomic neonate (weight > 4500 g at birth) in a previous pregnancy.
  • Unexplained fetal losses
  • Strong family history of diabetes in first-degree relatives
  • History of persistent glucosuria
  • Body mass index (BMI) > 30 kg/m²
  • Polycystic ovary syndrome with insulin resistance

Screening for Thyroid Disorders

• Thyroid-stimulating hormone (TSH) measurement in all trimesters.
• Risk factors for thyroid disorders:
  • Symptoms
  • Moderate to severe iodine insufficiency in an area
  • Family or personal history of thyroid disorders
  • Type 1 diabetes
  • Infertility, preterm delivery, or miscarriage history
  • Head/neck radiation therapy
  • Morbid obesity (BMI > 40 kg/m²)
  • Age > 30 years

Initial Visit: Physical Examination

• Height and weight measurement.
• Blood pressure (BP) measurement.
• Examination of thyroid, heart, lungs, breasts, abdomen, extremities and optic fundus, checking for edema.
• Pelvic exam for determining pelvic capacity, uterus size, and fetal position..
• Fetal heart sounds evaluation.

Laboratory Tests

• Complete blood count (CBC).
• Thyroid function tests (TFT).
• Blood typing and Rh(D) antibody level.
• Hepatitis B serologic test.
• HIV test.
• Toxoplasmosis, cytomegalovirus (CMV), and varicella immunity tests.
• Serologic test for syphilis.
• Cervical cultures (gonorrhea and chlamydia).
• Papanicolaou (Pap) test.
• Urine culture.
• Urine protein and glucose determination.
• Tuberculosis (TB) screening (if at risk).
• Genetic screening (including first-trimester screening for aneuploidy).

Vaccination During Pregnancy

• Risks to the fetus are theoretical from maternal vaccination; minimal evidence exists of risks.

• Inactivated viral and bacterial vaccines/toxoids are safe.

• Live-attenuated vaccines generally contraindicated.

• CDC recommendations include the inactivated influenza vaccine (injection, not nasal) and the Tdap vaccines is recommended between 27 and 36 weeks.

• Certain travel vaccines (yellow fever, typhoid fever) should be avoided unless benefits outweigh the risks.

Different Guidelines Across the World

• Varies between different countries and healthcare organizations (e.g., US, UK, Australia, Canada, Japan, WHO, and Turkey).

Prenatal Visit Follow-Up

• Follow-ups are based on different guidelines among organizations.
• The most common practice includes:
  • 12-14 weeks (Nullipar 10, multipar 7 times)
  • Routine checkups for weight, BMI, fundal height, blood pressure, edema, proteinuria, educations, and consultations,

4th Visit

• Review of the previous visit (including the initial exam, lab tests) evaluation
• Medication and immunization support (iron and vitamin D supplementation, tetanus immunization).
• Information and consultations on pregnancy, childbirth, breastfeeding, postpartum family planning.
• Ultrasound(USG) and non-stress test(NST).

Evaluation of Fetal Presentation and Position

• Leopold maneuvers are used to evaluate fetal presentation and position.
  • Fundal height and position of the back.
  • Presenting part and fetal engagement are used as guidelines for evaluation.

This quiz explores essential concepts related to genetic screening for conditions like SMA and CF, as well as the implications of maternal age on pregnancy outcomes. It covers important terminology, methodologies, and the calculation of pregnancy duration. Test your knowledge on these critical aspects of maternal and fetal health.