Obstetric Anamnesis And Examination PDF

OBSTETRIC ANAMNESIS AND EXAMINATION Asena Ayar Madenli, M.D., Asst. Prof Istinye University Faculty of Medicine Department of Obstetrics and Gynecology Ob-stet-rics (n.) ETYMOLOGY "science of midwifery, the department of medicine which deals with the treatment and care of...

OBSTETRIC ANAMNESIS AND EXAMINATION Asena Ayar Madenli, M.D., Asst. Prof Istinye University Faculty of Medicine Department of Obstetrics and Gynecology Ob-stet-rics (n.) ETYMOLOGY "science of midwifery, the department of medicine which deals with the treatment and care of women during pregnancy and childbirth," 1819 Midwife : with woman  Antenatal care during pregnancy is an important process to minimize maternal and infant deaths, maintain maternal and fetal health, to identify risky pregnancies, to prevent pregnancy complications such as preeclampsia, gestational diabetes, hypertension, severe anemia, and to achieve early intervention by detecting the presence of smoking, alcohol use and domestic violence during pregnancy. In this process, evidence-based knowledge, skills and practices of health professionals to improve the quality of care will help increase awareness in care, create standardization and reduce medical errors and unnecessary practices Ideally, women who are planning to become pregnant should see a physician before conception; then they can learn about pregnancy risks and ways to reduce risks The purpose of prenatal care: 1-Confirmation of pregnancy 2-Determining the health status of the pregnant woman and the fetus 3-Determining the gestational age of the fetus and monitoring its development 4-Detecting risky pregnancies and taking precautions 5-Creating an obstetric care plan 6-Pregnant education and counseling  High Risk Pregnancy is a pregnancy complicated by a disease or disorder that may endanger the life, or affect the health of the mother, the fetus or newborn Among the targets of prenatal care, maybe the most life saving benefit is the identification of a high risk patient High Risk Pregnancy : Anemia:Haemolytic, megaloblastic anemia Poor obstetric history (previous recurrent miscarriages or preterm deliveries) thalassemia Heart disease Bleeding disorders, History of thrombosis or thrombophilias, antiphosphollipd synd Hypertension or preeclampsia (essential, renal or pregnancy induced) History of neurological disease (epilepsy, brain Diabetes (IDDM/NIDDM) haemorrhage, or tumor) Multiple gestations Malignancy (cervical, ovarian or breast) Placenta previae, Placental abruption Transplant patient’s pregnancy Threatened preterm labour Fibroid uterus Cervical insufficiency Fetal Congenital malformations that can survive Abnormal placentation; accreata, increata, (chromosomal, genetic, structural) percreata During the initial visit: HISTORY TAKING Personal Medical obstetrics current pregnancy PHYSICAL EXAMINATION LAB IMMUNIZATION AND DRUG SUPPORT INFORMATION AND CONSULTANCY Pregnancy-related complaints General Full medical history should include: Previous and current disorders Drug use (therapeutic, social, and illicit) Risk factors for complications of pregnancy Obstetric history, with the outcome of all previous pregnancies(G P A), including maternal and fetal complications (eg, gestational diabetes, preeclampsia, congenital malformations, stillbirth) Past Medical History  Family History Tay-Sachs Cystic fibrosis Sickle cell disease Thromboembolism Birth defects (particularly cardiac anomalies) Medical history of first-degree relatives (particularly diabetes).  Ethnic Background Population screening for certain inheritable genetic diseases is not cost effective because of the relative rareness of those genes in the general population. Many genetic diseases affect certain ethnicities in disproportionate amounts, allowing cost-effective screening of those particular groups. Screening for Carriers of Genetic Disease should be offered to susceptible subgroups in general population SMA and CF genetic screening would be wise to offer if not done as premarital screening Maternal Age !! Adolescents are at increased risk for ; preeclampsia-eclampsia intrauterine growth restriction maternal malnutrition. Women of increasing age at increased risk for; preeclampsia diabetes, and obesity cesarean section stillbirth placenta accreta fetal aneuploidy Fetal Aneuplody Screening Maternal age of 35 years no longer be used as a cutoff to determine who is offered screening and who is offered invasive testing. Patient counseling regarding options, followed by maternal serum screening, should occur. The first- and second-trimester screen should not both be ordered independently during a pregnancy; this approach leads to unacceptably high false-positive rates for aneuploidy. Aneuploidy Screening Using Cell-Free DNA: Cell-free DNA is a relatively new modality that works by sequencing millions of fragments of DNA in maternal bloodstream, identifying their chromosome origin, and then quantifying their relative proportion It is also a screening test, not accepted as a definitive test  Gravidity and parity Gravidity is the number of confirmed pregnancies; a pregnant woman is a gravida. Parity is the number of deliveries after 20 weeks. Multifetal pregnancy is counted as one in terms of gravidity and parity. Abortus is the number of pregnancy losses (abortions) before 20 weeks regardless of cause (eg, spontaneous, therapeutic, or elective abortion; ectopic pregnancy). Sum of parity and abortus equals gravidity.  Calculating the estimated delivery date according to Last Menstrual Date Pregnancy lasts 10 lunar months of 28 days The average duration of pregnancy is 267 days from fertilization,280 days from the date of last menstrual period. NAEGELE'S RULE: 7 days are added to the first day of the last menstrual period and 3 months are removed EDD: Day + 7; Month – 3; Year + 1 Example: SAT: 10.06.2004 10 +7 6 -3 2004 +1 BDT:17.3.2005 Fundus Height According to Week of Pregnancy Compatibility of gestational week and uterus size (2nd and 3rd trimesters) (McDonald Formula: Symphisis Pubis-fundus is measured in cm. Cm x 8 / 7 = gives the gestational week) Pregnancy week fundal height (weeks) 40 close to the 36 week level (under the xiphoid process) 38 At the level of the xiphoid process 30 four fingers above umbilicus 24 umbilicus 20 two fingers below umbilicus 16 between the upper margin of the pubic bone and the umbilicus 12 with deep palpation above the upper margin of the pubic bone 20  The initial routine prenatal visit should occur between 6 and 8 weeks gestation. 0-14 weeks 1. trimester Follow-up visits should occur at: 14-28 weeks 2. trimester 28-42 weeks 3. trimester About 4-week intervals until 28 weeks 2-week intervals from 28 to 36 weeks Weekly thereafter until delivery Prenatal visits may be scheduled more frequently if risk of a poor pregnancy outcome is high or less frequently if risk is very low. Initial visit A definitive diagnosis of pregnancy must be made. First transvaginal USG,if not seen then β-hCG. the gestational sac is larger than 20 mm it is suggestive of anembryonic pregnancy. Presence of Yolk sac distinguishes the sac from pseudosac. (otherwise Ectopic pregnancy?) If there is more than 5 days difference between CRL measurement and LMP, CRL should be taken as basis.  Laboratory testing Prenatal evaluation involves urine tests and blood tests. Initial laboratory evaluation is thorough; some components are repeated during follow-up visits Components of Routine Prenatal Evaluation If a woman has Rh-negative blood, she may be at risk of developing Rh(D) antibodies, and if the father has Rh-positive blood, the fetus may be at risk of developing erythroblastosis fetalis. Rh(D) antibody levels should be measured in pregnant women at the initial prenatal visit if at risk and again at about 26 to 28 weeks. At that time, women who have Rh- negative blood are given a prophylactic dose of Rh(D) immune globulin. Additional measures may be necessary to prevent development of maternal Rh antibodies. Urine is also tested for protein. Proteinuria before 20 weeks gestation suggests kidney disease. Proteinuria after 20 weeks gestation may indicate preeclampsia. Generally, women are routinely screened for gestational diabetes between 24 and 28 weeks using a 50-g, 1-hour glucose tolerance test. However, if women have significant risk factors for gestational diabetes, they are screened during the 1st trimester.  These risk factors include Gestational diabetes or a macrosomic neonate (weight > 4500 g at birth) in a previous pregnancy Unexplained fetal losses A strong family history of diabetes in 1st-degree relatives A history of persistent glucosuria Body mass index (BMI) > 30 kg/m2 Polycystic ovary syndrome with insulin resistance If the 1st-trimester test is normal, screening tests as 1 step or 2 steps per choice should be repeated at 24 to 28 weeks. Also screening for thyroid disorders by measuring thyroid-stimulating hormone [TSH]) in all trimesters is suggested Women who are at risk of thyroid gland disorders: Have symptoms Come from an area where moderate to severe iodine insufficiency occurs Have a family or personal history of thyroid disorders Have type 1 diabetes Have a history of infertility, preterm delivery, or miscarriage Have had head or neck radiation therapy Are morbidly obese (BMI > 40 kg/m2) Are > 30 years  İnitial visit follow ups Height measurement Weight and BP measurement X Examination of thyroid, heart, lungs, breasts, abdomen, extremities, and optic fundus Examination of ankles for edema X Physical examination Complete pelvic examination Examination to determine pelvic capacity Examination of uterus to determine size X and fetal positiona Evaluation for fetal heart sounds [a] X  CBC [c] , TFT (thyroid function tests) Blood typing and Rh(D) antibody levels [d] Hepatitis B serologic test Blood tests (b) Human immunodeficiency virus (HIV) Toxo,CMV,Rubella and varicella immunity [e] Serologic test for syphilis Cervical cultures for gonorrhea and chlamydial infection [f] Cervical tests Cervical Papanicolaou (Pap) test Urine culture Urine tests Urine protein and glucose X determination Screening for TB (if at risk) Genetic screening, including 1st- Other tests trimester screening for aneuploidy Pelvic ultrasonography [g] [a] Component may not be detectable depending on the stage of pregnancy at presentation. [b] Diabetes screening is done only once—routinely at 24–28 weeks but earlier in women at risk. [c] Hematocrit is repeated in the 3rd trimester. [d] Rh(D) antibody levels are remeasured at 26–28 weeks in Rh-negative women. [e] Rubella and varicella titers are measured unless women have been vaccinated or have had a documented previous infection, thus confirming immunity. [f] For women at high risk, cervical cultures for gonorrhea and chlamydial infection are repeated at 36 weeks. [g] Ideally, pelvic ultrasonography is done in the 2nd trimester, between 18 and 22 weeks; it is not obtained routinely by all practitioners around the world, in our country it is a routine BP = blood pressure; CBC = complete blood count; TB = tuberculosis; X = repeated at follow-up visits. TC SAĞLIK BAKANLIĞI 2014  Kılavuza göre: Açlık Kan Glukozu, TİT, hemogram, Ferritin, HBsAg, TSH Kan Grubu (Rh uygunsuzluğu riski varsa indirekt Coombs), İdeal İlk Vizit Testleri: -CBC, Ferritin -BİYOKİMYA(Glukoz,BUN,Kreatin,AST,ALT,LDH) -ELIZA (HBsAg, Anti-HBs, Anti-HCV, Anti-HİV) -TSH -TİT, İdrar Kültürü -Kan Grubu (KG uygunsuzluğu ihtimali varsa indirekt Coombs), İKİLİ TARAMA NEDİR DUYARLILIK %79-87 DÖRTLÜ TARAMA DUYARLILIK %67-81  DETAILED SURVEY OF THE FETAL ANATOMY 18-24 HAFTALAR ARASI YAPILABİLİR ORGAN TARAMASI İLERİ DÜZEY USG AYRINTILI USG -DAHA DETAYLI ÖLÇÜMLER ALINIR ANOMALİ TARAMASI -ANOMALİ VARSA TESBİT EDİLİR -ASLA %100 HERŞEYİ GÖREMEYİZ BAĞIŞIKLAMA  OGTT 75 GR ÖNERİLİR 24-28 HAFTALAR ARASI YAPILABİLİR ANNE VE BEBEĞE KESİNLİKLE ZARARI YOKTUR 1- Story: Question what has happened since the previous viewing 2- Physical Examination: What was done in the 1st follow-up should be reviewed again. Edema, breast examination and Vaginal examination should be performed for pelvic evaluation. 3-Lab Tests: urine test cbc (+-ferritin) evaluation of the previous tests 4- Medication support, Immunization and treatments: checking if iron and D-vitamins have been started, tetanus immunization should be done if not administered yet 5- Information and Consultancy: The importance of baby movements birth information 4th Visit Breast milk and breastfeeding information Postpartum family planning counseling 6. USG / NST Evaluation of Fetal Presentation and Position: Leopold Maneuvers: 1- Fundus height is used to understand which fetal part is in the fundus. 2- fetal situs describes which side the back is on 3- Understands the presenting part 4- It is done to evaluate the engagement. Vaccination during Pregnancy Risk to a developing fetus from vaccination of the mother during pregnancy is theoretical. No evidence exists of risk to the fetus from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Live vaccines administered to a pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and live bacterial vaccines generally are contraindicated during pregnancy !!! Vaccination during Pregnancy CDC recommends that pregnant women get two vaccines during every pregnancy: the inactivated flu vaccine (the injection, not the live nasal flu vaccine) and the Tdap vaccine. Flu vaccine CDC recommends getting the flu vaccine during flu season. While flu seasons vary in their timing, CDC recommends getting vaccinated by the end of October, if possible. Getting vaccinated later during flu season, though, can still be beneficial. Flu vaccines have been given to millions of pregnant women over the years, and scientific evidence shows that it is safe. Tdap vaccine Pregnant women are also encouraged to get the Tdap vaccine at any time during pregnancy, but optimally between 27 and 36 weeks of each pregnancy, to protect the mother and the baby from pertussis, also known as whooping cough. This vaccine is recommended during every pregnancy, regardless of how long it has been since the last Tdap vaccine. If the patient never got the Tdap vaccine during the present pregnancy and have never gotten it, CDC recommends that the vaccine should be administered immediately after giving birth. Vaccination during Pregnancy Some vaccines are not recommended during pregnancy, such as: Human papillomavirus (HPV) vaccine, Measles, Mumps, and Rubella (MMR) vaccine, Live influenza vaccine (nasal flu vaccine), Varicella (chicken pox) vaccine Certain travel vaccines: yellow fever, typhoid fever, and Japanese encephalitis Note: these travel vaccines should generally not be given during pregnancy, unless the healthcare provider determines that the benefits outweigh the risks.  Different guidelines across the world: US (ACOG, 2012) UK (RCOG, 2016) Austalia (ANZSOG, 2014) Canada (SCOG, 1998 ) Japan(JSOG & JAOG, 2014) WHO(WHO, 2016) Turkey ( T.C Sağlık Bakanlığı, 2015)  Amerika İngiltere Avustralya Kanada Japonya WHO Türkiye (ACOG) (NICE) (ANZSOG) (SOGC) (JSOG) (Sağlık Bakanlığı) Önerilen 12-14 Nullipar 10 Nullipar 10 8-12 16 4 4 İzlem Sayısı Multipar 7 Multipar 7 Her İzlemde Rutin Olarak Önerilenler; Kilo, BMI + _ + + + _ + Fundus + + + + + + + yüksekliği FKA + + + + + + + Kan Basıncı + + + + + + + Ödem + _ _ + + + + Proteinuri _ + + + + _ + takibi Eğitim ve + + + + + + + Danışmanlık  Amerika İngiltere Avustralya Kanada Japonya WHO Türkiye (ACOG) (NICE) (ANZSOG) (SOGC) (JSOG) (Sağlık Bakanlığı) İlk İzlemde Rutin Olarak Önerilen Lab Testleri; Kan grubu,Rh + + + + + + + Hemogram + + + + + + + HBsAg + + + + + _ + HCV Risk varsa _ Risk varsa Risk varsa + _ _ HIV + + + + + + + Sifilis + + + + + + + Klamidya +