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Common obstetric histories

Remember history taking in obstetrics requires you to ask extra questions on the current pregnancy and obstetric history.

Abdominal pain

Exploring symptom

  • Pain
    • Site
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity

Relevant system reviews

  • General
    • Fever, sweats
  • Obstetric
    • Fetal movements
    • Contractions/tightening
    • PV loss
    • Pre-eclampsia symptoms 
  • Gynaecological
    • PV discharge
    • PV bleeding
  • Urological
    • Storage: frequency, volume, urgency, nocturia, incontinence 
    • Infection: dysuria, haematuria, odour
  • Gastrointestinal
    • Weight: loss, appetite change
    • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, bowel habit change, tenesmus, blood/mucus in stool

Differential diagnoses and clues

Obstetric:

Ectopic-Unilateral pain + bleeding
-Usually between 4-12 weeks gestation
Miscarriage-<24 weeks gestation
-Associated PV bleeding
-May pass clots or products of conception
Braxton Hicks contractions-Late pregnancy
-Infrequent, irregular contractions
Labour->24 weeks gestation (premature if <37 weeks)
-Painful regular rhythmic contractions

Gynaecological:

Fibroids (red degeneration or torsion)-Severe abdominal pain 
-May have fever/vomiting 
Pelvic inflammatory disease-PV discharge
-Bilateral pelvic pain
-Dyspareunia
-Fever
-May have post-coital bleeding
-Condomless intercourse with new/multiple partners 
Ovarian torsion/haemorrhage/rupture-Severe unilateral pain
-May have fever/vomiting

General surgical:

 Any cause of acute abdominal pain in non-pregnant patients (see common abdominal histories

Others:

Other differentialsPlacental abruption, Pre-eclampsia, Uterine rupture, Chorioamnionitis, Acute fatty liver of pregnancy, Round ligament pain, Symphysis pubis dysfunction

PV bleeding

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Bleeding
    • Pattern (regular/irregular)
    • Amount of loss
    • Pain with blood loss
    • Anaemia symptoms (tiredness, breathlessness on exertion)

Relevant system reviews

  • General
    • Fever, sweats
  • Obstetric
    • Fetal movements
    • Contractions/tightening
  • Gynaecological
    • PV discharge
    • Pain

Differential diagnoses and clues

Early pregnancy:

Implantation-Light short-lived bleeding/spotting 
-Dark with pink/brown tint
-6-12 days after conception (near when next menstrual period is expected)
Ectopic-Unilateral pelvic pain 
-Usually between 4-12 weeks gestation
Miscarriage-<24 weeks gestation
-Pelvic pain
-May pass clots or products of conception

Late pregnancy:

Labour->24 weeks gestation (premature if <37 weeks)
-Painful regular rhythmic contractions
Placental abruption-Antepartum haemorrhage
-Continuous abdominal pain
-Uterine contractions
Placenta praevia-Painless bleeding >28 weeks
-Sudden profuse intermittent PV bleeding
Vasa praevia -Painless bleeding after membrane rupture
-Fetal bradycardia/death

Any time:

Cervical pathology (polyps / cancer / trauma / ectropion)-Commonly post-coital (contact) bleeding
-May have PV discharge
Other differentialsCervicitis, Vaginitis, Pelvic inflammatory disease

Try a few questions

What do gravida and para refer to in the obstetric history?

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What are the risk factors for ectopic pregnancy?

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How would you differentiate Braxton-Hicks contractions and labour?

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Now try some OSCE stations…

  1. Pre-eclampsia
  2. Abdominal pain in pregnancy
  3. Antepartum haemorrhage
  4. And there’s more
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