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Pregnancy risk assessment

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Pre-existing Medical Conditions

  • Diabetes mellitus: Increased risk of congenital anomalies, macrosomia, pre-eclampsia, and stillbirth; requires strict glycemic control.
  • Hypertension: Risk of superimposed pre-eclampsia, intrauterine growth restriction (IUGR), and preterm birth.
  • Cardiac disease: Risks depend on the type and severity; includes heart failure, arrhythmias, and maternal mortality.
  • Renal disease: Associated with pre-eclampsia, IUGR, preterm birth, and worsening maternal renal function.
  • Thyroid disorders: Hyperthyroidism or hypothyroidism can lead to miscarriage, preterm birth, and fetal growth abnormalities.
  • Autoimmune disorders (e.g., SLE, antiphospholipid syndrome): Increased risk of miscarriage, IUGR, pre-eclampsia, and thromboembolic events.
  • Epilepsy: Risk of teratogenicity from antiepileptic drugs, seizures during pregnancy, and preterm birth.
  • Obesity: Increased risk of gestational diabetes, hypertension, pre-eclampsia, and cesarean delivery.
  • Asthma: Poorly controlled asthma can lead to preterm birth, low birth weight, and maternal complications.
  • Mental health disorders: Risk of postpartum depression, poor adherence to prenatal care, and the effects of psychotropic medications.
  • Infections (e.g., HIV, hepatitis B/C): Vertical transmission risks, impact on maternal health, and potential neonatal outcomes.
  • Substance use (e.g., alcohol, tobacco, drugs): Associated with fetal alcohol syndrome, IUGR, preterm birth, and neonatal withdrawal.

Obstetric History

  • Previous cesarean section: Increased risk of uterine rupture, placenta previa, and placenta accreta.
  • History of pre-eclampsia: Increased risk of recurrence, particularly if early onset in previous pregnancy.
  • Previous preterm birth: Increased risk of recurrence; may require closer monitoring and prophylactic interventions.
  • Recurrent miscarriage: May indicate underlying issues such as antiphospholipid syndrome or uterine anomalies.
  • History of gestational diabetes: Increased risk of recurrence and progression to type 2 diabetes postpartum.
  • Placental abruption in prior pregnancy: Increased risk of recurrence, particularly with pre-existing hypertension.
  • Previous stillbirth: Requires thorough investigation of cause and close monitoring in subsequent pregnancies.
  • Multiple gestations: Increased risk of preterm birth, IUGR, pre-eclampsia, and perinatal morbidity.
  • Congenital anomalies in prior pregnancy: Consideration of genetic counseling and detailed anomaly scan in subsequent pregnancy.
  • Intrauterine growth restriction (IUGR) history: Increased risk of recurrence and need for enhanced fetal surveillance.

Lifestyle and Social Factors

  • Age: Advanced maternal age (≥35 years) increases the risk of chromosomal abnormalities, pre-eclampsia, and preterm birth.
  • BMI: Both underweight (BMI <18.5) and obesity (BMI ≥30) are associated with adverse pregnancy outcomes.
  • Smoking: Increased risk of miscarriage, placental abruption, preterm birth, and low birth weight.
  • Alcohol consumption: Risk of fetal alcohol spectrum disorders, miscarriage, and low birth weight.
  • Substance abuse: Associated with adverse fetal outcomes, including neonatal abstinence syndrome and developmental delays.
  • Socioeconomic status: Lower socioeconomic status is associated with higher risks of inadequate prenatal care, poor nutrition, and adverse pregnancy outcomes.
  • Domestic violence: Increased risk of miscarriage, preterm birth, low birth weight, and maternal mental health issues.
  • Occupational hazards: Exposure to teratogens, prolonged standing, and physically demanding work can increase pregnancy risks.
  • Access to healthcare: Delayed or inadequate access to prenatal care increases the risk of undiagnosed complications and poor outcomes.
  • Environmental exposures: Exposure to toxins, radiation, or infectious agents can adversely affect pregnancy.
  • Travel history: Important for assessing risk of infections (e.g., Zika virus, malaria) that can impact pregnancy.
  • Family support: Adequate support is essential for mental well-being and adherence to prenatal care.
  • Cultural factors: Cultural practices or beliefs that may influence prenatal care and childbirth.
  • Diet and exercise: Adequate nutrition and appropriate exercise are important for a healthy pregnancy.
  • Stress levels: High stress can contribute to adverse outcomes such as preterm birth and low birth weight.

Key Points in History 🥼

Medical and Obstetric History

  • Previous pregnancies: Outcomes, complications, and interventions in prior pregnancies provide insight into potential risks in the current pregnancy.
  • Chronic medical conditions: Conditions such as diabetes, hypertension, renal disease, and autoimmune disorders require careful management to minimize risks.
  • Medication history: Review current and past medications, focusing on teratogenicity and the need for adjustments during pregnancy.
  • Surgical history: Prior surgeries, particularly abdominal or pelvic, may impact pregnancy outcomes or the mode of delivery.
  • Infection history: Prior or current infections (e.g., HIV, hepatitis, TORCH infections) can have implications for maternal and fetal health.
  • Genetic history: Family history of genetic conditions, congenital anomalies, or recurrent miscarriages may necessitate genetic counseling.
  • Psychiatric history: Mental health conditions, including depression, anxiety, and psychosis, need to be managed carefully during pregnancy.
  • Allergies: Important to consider, especially for medications that may be required during pregnancy or delivery.
  • Immunization history: Assess for vaccines received and those needed during pregnancy (e.g., influenza, pertussis).
  • Blood group and antibody status: Identifying Rh incompatibility early is essential to prevent hemolytic disease of the newborn.

Social and Lifestyle Factors

  • Smoking, alcohol, and drug use: These factors are major contributors to adverse pregnancy outcomes and should be addressed early.
  • Diet and nutrition: Adequate intake of folic acid, iron, calcium, and other nutrients is critical for a healthy pregnancy.
  • Physical activity: Appropriate exercise is beneficial, but strenuous activity or lack of activity can pose risks.
  • Living conditions: Assess for safety, stability, and support in the home environment.
  • Work environment: Exposure to physical, chemical, or biological hazards at work may impact pregnancy.
  • Support system: Emotional and practical support from partners, family, and friends is crucial for maternal well-being.
  • Mental health: Anxiety, depression, or high stress levels can negatively affect pregnancy and should be managed appropriately.
  • Financial stability: Financial concerns can impact access to prenatal care, nutrition, and overall pregnancy outcomes.
  • Cultural or religious beliefs: These may influence decisions about prenatal care, delivery, and neonatal care.
  • Domestic violence: Screening is essential as it poses significant risks to both mother and fetus.
  • Travel plans: Important for assessing risks related to Zika, malaria, or other travel-related health concerns.
  • Access to healthcare: Ensure the patient can attend regular prenatal appointments and has access to emergency care if needed.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count (FBC): To check for anemia, thrombocytopenia, and infections.
  • Blood group and antibody screen: To identify Rh incompatibility or other alloantibodies.
  • Blood glucose: Screening for gestational diabetes, especially in women with risk factors.
  • Thyroid function tests: To assess for hyperthyroidism or hypothyroidism.
  • Renal function tests (U&E): To monitor kidney function, especially in women with pre-existing renal conditions.
  • Liver function tests (LFTs): Important in women with pre-existing liver disease or those developing symptoms like jaundice.
  • Urinalysis: To check for proteinuria (pre-eclampsia) and urinary tract infections.
  • HbA1c: To assess for pre-existing diabetes and monitor glycemic control.
  • Serum ferritin: To assess iron stores and guide supplementation in women with anemia.
  • Serology for infections: TORCH screen (Toxoplasmosis, Other [syphilis], Rubella, Cytomegalovirus, Herpes simplex) if indicated.
  • Viral load (e.g., HIV, Hepatitis B/C): To monitor and manage viral infections during pregnancy.
  • Antiphospholipid antibodies: If there is a history of recurrent miscarriage or thrombosis.
  • Coagulation profile: Important in women with bleeding disorders or on anticoagulant therapy.
  • Genetic testing: Consider in women with a family history of genetic disorders or those with abnormal findings on prenatal screening.
  • Vitamin D levels: Important for bone health and immune function, particularly in women with limited sun exposure or dietary intake.
  • Syphilis screen (VDRL/RPR): Routine in early pregnancy to prevent congenital syphilis.
  • Glucose tolerance test (GTT): To screen for gestational diabetes in high-risk women.
  • Urine culture: To detect and treat asymptomatic bacteriuria, which can lead to pyelonephritis and preterm labor.
  • Nuchal translucency scan and serum screening: To assess the risk of chromosomal abnormalities such as Down syndrome.
  • Anti-D antibodies: Important for Rh-negative women to prevent hemolytic disease of the newborn.
  • Rubella immunity: To determine if vaccination is needed postpartum.
  • Chlamydia and gonorrhea screen: Important in preventing neonatal complications.
  • Group B Streptococcus (GBS) screening: Usually done at 35-37 weeks to prevent neonatal GBS disease.
  • Bone profile: In women with a history of osteoporosis or chronic steroid use.

Imaging and Other Tests

  • Ultrasound scans: Routine at 11-14 weeks for dating and nuchal translucency, and at 18-20 weeks for anomaly detection.
  • Fetal echocardiography: Indicated in women with a history of congenital heart disease or diabetes.
  • Doppler studies: To assess uteroplacental blood flow, particularly in women at risk of IUGR or pre-eclampsia.
  • Amniocentesis or chorionic villus sampling (CVS): Consider if there is a high risk of chromosomal abnormalities.
  • Cardiotocography (CTG): Used in the third trimester to monitor fetal well-being, especially in high-risk pregnancies.
  • Magnetic resonance imaging (MRI): Safe for fetal imaging when detailed anatomical assessment is required.
  • Non-stress test (NST): To assess fetal heart rate patterns and identify potential fetal distress.
  • Oral glucose tolerance test (OGTT): Conducted at 24-28 weeks for women at risk of gestational diabetes.
  • Cervical length measurement: By transvaginal ultrasound, particularly in women with a history of preterm birth or cervical incompetence.
  • Pelvic MRI: Consider in cases of suspected pelvic masses or complex gynecological conditions.
  • Thyroid ultrasound: If there are thyroid nodules or an enlarged thyroid gland detected on examination.
  • DEXA scan: For bone mineral density in women with significant risk factors for osteoporosis.
  • Fetal MRI: Used for detailed imaging when ultrasound findings are inconclusive or complex anomalies are suspected.
  • Genetic counseling: Essential for women with a family history of genetic disorders or abnormal prenatal screening results.
  • Echocardiography: For women with known cardiac conditions to monitor maternal heart function during pregnancy.

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