OBS HX TAKING (WHY I CLERK?) [note to myself]

Obstetric hx taking learning point:

Pt identification data: to assess risk, eg age>25 must do MOGTT, eg. If you get pregnant at age 25, your risk of having a baby with Down syndrome, for example, is about 1 in 1,250, according to the National Institutes of Health. At age 40, the risk is 1 in 100. If you'll be 35 or older on your due date, you'll be offered genetic counseling.

Occupation, socioeconomic class, does the mother able to take care of the baby after C-sec at home? Does the mother BF when she needs to go to work? the home using well water? can she take water after surgery while recovering?

gravida: G, P and +
multipara will has dx of false labour if dilatation is only 1cm
if +3 indicates recurrent miscarriage, need to find out cause

LMP: naegeles rule, SOD, regular menses, no BF, no hormonal therapy
EDD, REDD, POA
(must knw how to count)
used to detect postdate and also date for IOL for cases like GDM, PIH,...
date also help to identify IUGR, SGA...
read about U/S and discrepancy

C/O what bring pt to hospital? electively admitted? referred case?
(pt came in due to contraction pain? distinguish from braxton hicks, VE see any favourable cervix using Bishop score, ask for any show/leaking of liquor)


HOPI:
must knw disease:

1. GDM/pre-existing DM, clerk MOGTT, presence of risk factors, glycosuria, sx of DM (3Ps, numbness, blurring of vision), HbA1C, family hx of GDM, any congenital anomalies in fetus, any macrosomic baby, polyhydramnios, currently admitted blood sugar profile, insulin how many unit taken, any diet control? mx: IOL? cx that may arise, macrosomic, shoulder dystocia, perineal tearing? neonatal hypoglycemia?

2. Pre-eclampsia, Bp, proteinuria, mx

3. Placenta previa, PV bleed? pain? woody hard uterus?(abruptio) grade of placenta previa, causes such as multiparity,..., mx Mcafree Regime!

4. Postdate

5. Oligohydramnios, how to see AFI

6. Abnormal lie, whether to manually betulkan lie or let it be

anemia, iron metabolism
CVD, how to terminate pregnancy

IOL indications, C-sec indication, trial of scar


HOPP
missed period? UPT? (read UPT test principle, hCG, amino acids...)
failed contraception or planned pregnancy? assess pt's desire of having baby

if not because of missed period? sx of pregnancy? vomitting, abd distension, quickening?

confirm pregnancy where?

BOOKING! READ ABOUT EACH COMPONENT OF BOOKING AND KNOW WHY WE SHOULD KNOW.

(every month till 28, every  2w  until 36, every 1w until delivery)

SUBSEQUENT FOLLOW UP? ULTRASOUND OK?

quickening? primid 18-20w, multi 16-18w

sx of pregnancy, breast engorgement, frequency, constipation, ankle edema, backache? (look for any symptomatic tx?)

Immunization
ATT (principle)
hep B (3x) last time...
Rubella secondary sch

Past OBS

consanguinous marriage?

Mode of delivery, Complication? preterm, full term? C-sec? episiotomy? poor spacing? healing scar? exclusive breastfeeding?
Recurrent miscarriage?  D&C? (uterine scar...risk of placenta previa...)

any contraception?

Menstrual hx

menorrhagia? oligomenorrhea? amenorrhea?
PCOS? subfertility?

Gynae

PCOS? Uterine fibroid? any malignancy? ectopic pregnancy? recurrent miscarriage?

Pap smear done? when? where? result?  (check how many times pap smear must be done every duration?)

PAST MEDICAL, SURGICAL, DM? HPT? HEART DISEASE? ASTHMA? TB?
uterine surgery, risk of placenta previa...

Family hx?
GDM, DM, HPT, HEART DISEASE, twins pregnancy, recurrent miscarriage, stillbirth, congenital abnormalities, gynae malignancy...

Personal and Social hx
socioeconomic status
does husband take care of family
children under care of
smoking, alcohol (husband? pt?)

Drug hx
iron, folic acid, vit b, vit c
*vit b complex contained folic acid
*obimin contain all

insulin for GDM (read back why Oral hyperglycemic Agent cannot be given)
magnesium sulphate for PIH (not sure, read back)

Prostin induction of labour, syntometrine, pitocin...(how to use)

Miseprostol, mifepristone for expulsion of POC

check for drugs use for termination of pregnancy

progesterone for maintaining pregnancy in threatened miscarriage

infection in pregnancy how to treat? common: UTI

any traditional med? any OTC drugs? any allergy?

Dietary
DM diet

Summary
AGE, GRAVIDA, PARA, POA, C/O

Female Reproductive Cycle

MENSTRUAL cycle: Day 0 of 1st cycle = Day 28 of 2nd cycle

FOLLICULAR phase in OVARIAN cycle:
1.ANT PITUITARY GLAND secretes FSH and LH, follicular cells slowing forming.

2. GRANULOSA cells secrete ESTROGEN; THECA cells secrete androstenedione and converted to estrogen by granulosa.

3. High estrogen level act as NEGATIVE feedback and suppress secretion of FSH and LH, thus we see a "dip" near 2/3 of the phase

4.Granulosa cell also secretes INHIBIN, which inhibit FSH secretion

5.However, later on Super High estrogen secreted by granulosa cells in turn act as POSITIVE feedback and thus the hormone "FSH and LH" increase again.  FSH is up a little as it is still inhibited by inhibin. LH is back high up until a level which its called LH SURGE, and this is when the ovum released during OVULATION (DAY 14).

PROLIFERATIVE phase of UTERINE cycle, ESTROGEN is the one that induce production of NEW ENDOMETRIAL layer.

after ovulation, LUTEAL phase of ovarian cycle:
high FSH and LH induce follicle into CORPUS LUTEUM (yellow body)


CORPUS LUTEUM still produces PROGESTERONE and estrogen but estrogen is not the primary product thus there is a "dip".

THERE IS A CHANCE FOR THE EGG TO GET FERTILISED, THUS MUST PREPARE ENDOMETRIUM FOR IMPLANTATION.

PRO-GEST-ERONE
(FOR GESTATION= FOR PREGNANCY)

SECRETORY phase of UTERINE cycle:
PROGESTERONE:
Increase blood flow to endometrial by stimulationg development of SPIRAL ARTERIES, allow embryo to have good access to nutrient


Induce SECRETION from uterine GLANDS, for nourishment

REDUCE CONTRACTILITY of uterine MUSCLES

LITTLE ESTROGEN + LOTS PROGESTERONE prepare endometrium for pregnancy.

Also, they suppress FSH and LH, so they are LOW in LUTEAL PHASE

corpus luteum also produce INHIBIN that suppress FSH and LH

corpus luteum needs FSH and LH to SURVIVE, thus it becomes ATROPHY

when it ATROPHY, ESTROGEN & PROGESTERONE DROPS!

MENSTRUATION occurs, endometrial lining starts to SHED. (AVERAGE: 40ml)

AND FSH LH BACK UP AGAIN, as low estrogen and progesterone. START OF NEW CYCLE!

IF PREGNANCY OCCURS,
when Blastocyst implanted, embryo start to produce HCG, which structurally similar to LH, and enough to keep corpus luteum ALIVE.

ALIVE CP continue to produce ESTROGEN and PROGESTERONE to maintain pregnancy.
(first 2-3mths only)

PLACENTA then take over production of progesterone.

PREGNANCY TEST:
CHECK HCG