History and examination ©MaanasJain

Friday, 27 January 2023 4:35 PM

Demographic
• Name
• Age
• Residence
• Occupation
• Education

• Husband name, occupation

• Married for __ years

• She is primi/multi(GPTPAL)
Tests in 1st antinatal visit
C/C 1. Blood
• History of amenorrhoea for ….. Months a. CBC
Prevent NTD Prevent NTD recurrence b. Blood group
• And has presented for routine anti-natal checkup
• Any other complaints, Fetal movements, bleeding, leaking pv, pain abdomen 400 mcg/day 4mg/day c. Rh
d. HIV, HBsAg
1 month before conception 3 months e. VDRL
HOPI
Till 3 months after 3 months f. HBA1c(AIIMS) or
HOPP DIPSI(others)
1. Booked
a. First anti-natal visit 2. Urine<E>
2. Planned ○ Microscopy
3. Spontaneous ○ Culture if
4. Conception how many years after marriage or LCB microscopy +ve
5. Preconception folic acid
6. Preconception weight
IFA tablet: 100mg Fe sulphate(60mg elemental) +
7. Blood group
500mcg folic acid(RDA)(Tab contains 5mg)
1st trimester 1. Oral iron preparations
Asymptomatic bacteruria
a. Ferrous sulphate(less absorption)
1. Diagnosed by UPT • Can cause: PPROM, chorioamnionitis, pyelonephritis
b. Ferrous fumerate(more tolerable)
2. Confirmed by USG • Tx
2. Parenteral
3. Folic acid tablets ○ Nitrofurantoin
a. Iron dextran(not used)
4. Negative history ○ Fosfomycin(once)
b. Iron sucrose(mc used)
○ Excessive nausea and vomiting
c. Ferric carboxymaltose(best but expensive)
○ Fever with rash
○ Drug intake Diabetes
○ X-ray exposure • Screened at 24-28 wk(bc max insulin resistance)
○ Pain abdomen • Risk factors
○ Bleeding ○ Previous h/o GDM
○ Family h/o diabetes
○ H/o baby >4kg
2nd Trimester ○ H/o stillbirth
1. Quickening ○ PCOS
○ — 16 wk in multi, 18 wk in primi ○ Deranged lipid profile
2. Fe/Ca tablets(500mg Ca) 1. IADPSG: international association of diabetes in
3. Anomaly scan(18-20wk) pregnancy study group
4. Tetanus vaccination ○ 8 hours fasting: don’t eat anything after last
○ 16th week or 1st anti-natal visit meal at night
○ 1 month later ○ 75 gm glucose in water: 200-300 ml
a. FBS: <92
5. Diabetes — X-ray Upto 5 rads is safe b. 1 hr sample: <180
6. Negative history • Microcephaly is mc congenital anomaly c. 2 hr sample: <153
• Booked: 1 visit in 1st tri, 1 in 2nd and 2 in 3rd
○ Anemia: palpiations, fatigue ○ Diagnosis if even 1 value abnormal
• Registered: 1 visit
○ Bleeding: cervical polyp, malignancy • Supervised: was showing outside first but has ○ Drink within 15 min
○ Pre-eclampsia: headache, vision bluring, urine output, edema come to AIIMS 1st time in 3rd tri ○ Vomiting
§ If within 30 min(of finishing drinking),
3rd trimester —N/V: Starts at 5-6wk, stop at 16wk(like HCG levels) repeat test Next day
Normal ANC visits acc to
1. Foetal movements • Hyperemesis: ketonuria, can’t take solids or 1. Old WHO: 1 in 1st, 1 in 2nd, 2 in 3rd § In after 30 min can continue test
a. During rest: 3-5/hr or 8-10/2hr liquids 2. Acc to Govt India 2. DIPSI: screened at 1st antinatal visit and 24-28wk
b. During full day: 10 a. 1st(<12wk): registration/dating scan • Px come randomly and give 75 gram glucose and
2. Lightening: after 8th month b. 2nd(14-26wk): anomaly scan then 2 hr PP
3. Negative history c. 3rd(28-32 wk): a. >_200 hence pre-gestational diabetes
• Pain abdomen d. 4th(36wk - term) b. >_140 but <200 hence gestational diabetes
○ Anemia: palpiations, fatigue 3. New WHO: total 8 3. ACOG
○ Bleeding: Placenta previa, vasa previa, abruptio • 1 in 1st tri • Goal after MNT, after 2 wk —>> is fasting(<95), 1 hr
○ Pre-eclampsia: headache, vision bluring, urine output • 2 in 2nd PP(<140) and <120mg 2 hr post-prandial
○ Leaking • 5 in 3rd • Mx
4. Ideal: 1. Gestational: MNT 2wk, insulin or metformin
Obstetrics history a. Every month till 28 wk 2. Chronic diabetes: insulin
• G_P_TPAL b. Twice monthly till 36 wk
• LCB or how many years after marriage c. Weekly after 36 wk Hypertension
• Previous births • PIH: >20wk gestation, >140/90, 2 occasions 4 hours
○ Years back 1st trimester apart or 160/110 15 min apart
○ Place and type of delivery 1. Dating scan(6-8wk) • ACOG classification of hypertension in pregnancy
○ Method of delivery: indication of CS § Viability 1. Pre-eclampsia-eclampsia syndrome
○ Complications at birth § If ectopic or molar, multifetal 2. Gestational HTN
2. Combined screening: biochemical + 3. Chronic HTN of pregnancy
Menstrual history radiological 4. Chronic HTN of pregnancy superimposed with
• LMP § 11-13wk +6 days pre-eclampsia
• POG § Dual markers + nuchal • Diagnosis of pre-eclampsia
• EDD translucency(>-3mm) + nasal ○ PIH + (proteinuria(300mg/day) or urine
• Menstrual cycle history bone(should be present in normal protein/creatine ratio of 0.3) or end organ
○ Age of menarche § HCG damage
○ Cycle duration § PAPP-A: pregnancy associated • Pre-eclampsia
○ Bleeding duration plasma protein A a. Mild: no severe fetures, no end organ damage
○ Amount of bleeding: pads used/day 2nd trimester b. Severe: BP >160/110, headache not relieved by
○ Clots passed • biochemical analgesics, epigastric pain, end organ damage
○ Pain a. Triple marker: HCG, estriol, AFP • Risk factors of pre-eclampsia
b. Quadruple triple + inhibin A ○ High risk: start aspirin before 16wk to 36
Past history • radiological § Previous history in self or family
1. Surgical: operation a. TIFA: targeted imaging for fetal anomaly § Female with chronic HTN
2. Medical § Multifetal preg
a. HTN, diabetes, thyroid, TB All these were screening, if any positive go for § Diabetic
b. Blood transfusion confirmatory § CKD
c. Admission in hospital • Invasive § APLA
○ 1st tri: chorionic villi sampling ○ Primi
Personal § Quick result ○ New paternity
1. Bowel and bladder movements § High risk of fetal loss ○ Molar, multifetal
2. Vegetarian non-vegetarian § 2 cell lines because maternal and ○ Obese
3. Sleep fetal ○ Age<18 or >40
4. Addiction ○ 2nd tri: amniocentesis • Mx
5. Allergy history § Safer ○ Absent end diastolic flow: 32-34
§ Takes time for result ○ Reverse end diastolic flow: 30-32 wk
Dietary history § Single cell line • Pritchard’s regimin
… Protein Calories • Non-invasive: NIPT ○ Loading dose given and after every 4 hr
maintainance dose till 24 hr after delivery or last
Req 36.3 + Sedentary: 2000Kcal Moderate: 2500kcal 3rd trimester seizure
• T1: 0 Growth scan(32-34wk) Loading dose give IM IV
T2: 7.6 • Abdominal circumference both
T3: 17.6 Biophysical score ○
1 ampule(2ml) 10gm 50% sol in 4g 20%
1. T: tone: full flexion and extension in 30
has 1gm MgSO4 each buttock sol
min
Family 2. B: breathing: 1 in 30 sec
• Type of family(nuclear or joint), No. of family members 3. Meningitis: motor: 3 movements in 1 hr • Maintenance dose: 5gm IM 50% sol alternate
• Of mother, father and maternal side 4. Very: single largest Vertical pocket: buttock every 4 hr
• H/o of abortion, twins, eclampsia 2-8cm
5. Notorious: NST — reactive Rh -ve preg
Socioeconomic • ICT at 28 wk
• Modified kupuswami scale • If -ve give prophylaxis of 300 microgm anti-D
• If +ve check titers
Summary: § If <1/16 then check every 4 wk
Name a AGE year old female of G_P_TPAL of POG and EDD with LIE and PRESENTATION who had § If >1/16 then do MCA dopler
come for routine anti-natal checkup and has COMPLAINTS □ <1.5 MOM then monitor every week
Positive findings history and examination □ >1.5 MOM then significant anemia
® If >34 wk then delivery
Diagnosis ® If <34 wk then cordocentesis
A age female, obstetric formula, primigravida with pog with twin pregnancy with first fetus in and check Hb
cephalic ◊ If <8gm/dL then
intrauterine transfer
Singlton Thyroid
A age, primi/multi(GPTAL), pog, singlton lie presentation, c/c/complications or no complaints • Normal TSH < 2.5-3 IU/L
• Subclinical: 3-10 TSH but T3 and T4 normal
• Tx: 25microgm levothyroxine sodium
EXAMINATION • Clinical: 2.5-10 and T3 and T4 low; or TSH >10
• Consent
• Tx: 50 microgram levothyroxine
• Patient conscious, oriented to time, place, person and is compliant and confertable at rest
• Target: 3 IU/L TSH after 6mk
• Vitals: BP, pulse, RR
• Height, weight(preconceptional), BMI
• PICCLE
• Systemic d/d for bleeding in 1st trimester
○ CNS • Placental sign: cyclic bleeding may occur up to 12 weeks of
§ Higher mental function normal pregnancy until the decidual space is obliterated
§ No focal neurologic deficits • Implantation bleeding(spotting)
§ Sensory or motor System intact • Ectopic pregnancy
○ CVS • Abortion
§ S1S2 heard
… Threate Inevitab Incompl Comple
§ No murmur
○ Respiratory ned le ete te
○ OS Closed Open Open Closed
§ RR
§ Bilateral equal air entry POC No No Partial All
§ Normal vesicular sounds
• Per abdominal D/d for pain abdomen in 1st trimester
1. Inspection • Abortion
• Uniformly distended, longitudinal/transverse/oblique ovoid • Ectopic pregnancy
• Umbilicus: flat or everted • Fibroids
• Linia nigra • Sx causes like in 3rd trimester
• Stria gravidarum
• Stria albicans D/d of pregnancy
• Hernial sites free • abdominopelvic swellings: uterine fibroid, cystic ovarian
• Distended veins tumor, encysted tubercular peritonitis, hematometra or
2. Palpation even distended urinary bladder.
i. Fundal height
• Correct dextrorotation D/d of pain abdomen in 3rd trimester
• Ulnar border of left hand i. Obstetric
ii. SymOhysiofundal height 1) Preterm labour
• Cm corrospond to weeks 2) False labour pain
• Diff of 3 cm compared to POG is abn 3) Abruptio
iii. Abdominal girth: 4) Pre-eclampsia, HELLP
• inches to weeks 5) Chorioamnionitis
• At level of umbilicus 6) Fibroids
iv. Fundal grip 7) AFLP
v. Lateral grip ii. Surgical
vi. First pelvic or paulik grip 1) Ovarian cyst
vii. 2nd pelvic/deep pelvic grip 2) Appendicitis
viii. FHS 3) Cholycystitis
• FHS is below the umbilicus in cephalic presentation and around the 4) Pancreatitis
umbilicus in breech. iii. Medical
• In occipitoanterior position, the FHS is located in the middle of the 1) Constipation
spinoumbilical line 2) Pyelonephritis
3) UTI
Twin examination
• Fundal height more D/d of bleeding in 3rd trimester
• Symphysiofundal heart more Placenta previa Vasa previa
• Multiple fetal parts: search for head • Fetal distress
• Multiple heart sounds: mark distance between 2 location, at least 10 cm and 10 beat diff
• Lie of 1st fetus is most important because it decides course Contraction not started Contraction started
• Abruptio
C Section of twins • Show: mucous plug + blood
• Placentomagally: give incision in lower shment of uterus but above boginess which is placenta • Uterine rupture
• Find margin of placenta and then touch fetal part • Preterm labour
• If placenta is ant and cannot feel margin then cut placenta and deliver fetus quickly • Vaginal tear
• Need to deliver 2nd fetus quickly because uterus starts gripping if both are CS • Cervical polyp

Delivery of twins Leaking P/V causes

• After delivery of first twin can wait until fetal part descends because currently high up • Preterm labour
• Afyer it descends then rupture the membranes • PROM
• Continuous fetal monitoring, maintain adequate contractions • Show: mucous plug + blood
• Urine
4 T of PPH: tone, tissue, trauma, thrombus
True pph is after delivery of placenta
3rd stage of bleeding is bleeding before delivery of placenta Hypertension
• Edema? Not relieved on lying down

Causes of abortion
• Chromosomal anomalies(Aneuploidy — trisomy 21)
• Uterine malformations
• Trauma
• Previous h/o abortion
• Infection: ToRCHeS ext toxoplasma
• Uncontrolled Diabetes, HTN, thyroid

Causes of recurrent pregnancy loss(after 20wk is stillbirth)

• >_3 consecutive pregnancy losses at <20wk
• Causes
1. Endocrine: uncontrolled DM, thyroid
2. Uterine: cervical incompetence, asherman syndrome
3. Immunological: APLA
4. Chromosomal

Nutritive value
Item Kcal Protein
Rice(100gm or 1 katori) 110 2
Roti 85 3
Dal(1 katori) 125 7
Sabsi(green leafy)(1 katori) 130 2
• Potato sabsi(1 katori) 130 2
Biscuit(100g) 450 6.4
Milk(250ml)(1 glass) 212.5 9
Chai(100ml) 100 3.6
Fruit 80 1.1
Egg 80 6