Dr. Esraa abdulkareem al-Qassab F.I.C.O.G.\C.A.B.O.G. Dr. Esraa abdulkareem al-Qassab F.I.C.O.G.\C.A.B.O.G.

Taking history Appearance : should be suitable before you enter the room. Always introduce your self. Privacy : record the event that are not known by other family members e,g TOP. Some women wish another person to be present if the doctor or student is male. Opening questions: asking for patients age, date of birth

Name Age Occupation Address Blood group & Rh For women and for her partner

GPA G: gravida is a total number of pregnancies regardless of outcome P: parity is the number of deliveries after 24 th week of gestation whether stillbirth or live birth A : abortion or miscarriage is the expulsion of the conceptus before 24 th week of gestation

Women now pregnant and never had a pregnancy before is G1 P0---primigravida Twin counts as 2 : pregnant at 12wk with previous delivery of twin ---- G2 P2. Women in her eighth pregnancy, she has had 6 miscarriage and 1 delivery at 32 wk of alive baby G8 P1 A6

LMP: 1 st day of last menstrual period. The median duration of pregnancy is 280 days (40wk) and this give expected date of delivery EDD: is calculated by counting forward 9 months & adding 7 days.

But the cycle should be reliable, this assumes that: The cycle length is 28 days The cycle was not straight after stopping COCP or after previous pregnancy. At least 3 regular cycles before conception.

E,g 4 / 2 / / 7 / / 1 / / 7 /2011 If the cycle is unreliable,depend on late 1 st trimester or early 2 nd trimester US

The gestational age wk term <37 wk preterm wk postdate >42 wk postterm Every 2 months = 9wk Every 3 months = 13wk

1 st TMS –up to 13 wk 2 nd TMS –14- 27completed wk 3 rd TMS – 28wk - delivery CRL Crown – rump length – 13 wk+6 days BPD biparietal diameter, HC head circumference14 wk -20 wk

Date of admission Chief complaint ( in the term of patient) E,g lower abdominal pain watery vaginal discharge vaginal bleeding reduced fetal movement History of present illness

History of present pregnancy eg,in 1 st trimester ---excessive nausea and vomiting, vaginal bleeding, exposure to drug or radiation and when she start ANC In 2 nd trimester any disease, UTI, vaginal bleeding, queckening. In 3 rd trimester leg oedema, symptoms of preeclampsia( headache, blurring of vision, epigastric pain) Review of systems

Past obstetrical history:- - When she get married? when she conceive? Spaces between each pregnancy. - Discuss antenatal, intrapartum, postpartum period in details Antepartum period: e,g threatened miscarriage, GDM, PE, PTL, placenta previa, abruption,IUGR Intrapartum period :place of delivery (home or hospital), route of delivery (VD, NVD, CS), outcome ( alive or dead, term,preterm, postdate, male, female, weight of the baby, admission to NCU, congenital anomaly). Postpartum period: bleeding, infection, thromboembolism.

Past gynecological history: - Menstural history - PCOS: irregular cycle (unreliable date, risk of GDM) - Contraceptive history(COCP, IUCD) - Previous history of PID( risk of EP) - The date of last cervical smear &any previous treatment for cervical abnormalities (cx insufficiency or stenosis) - Previous history of PID(risk of EP) - Recurrent miscarriage(APS, IUGR,PE) - Previous gynecological surgery(myomectomy) - History of subfertility.

Past medical history: -DM( macrosomia, IUGR, congenital anomaly, preeclampsia, stillbirth, neonatal hypoglycemia) - Hypertension(PE) - Renal diseases(PE, PTL, IUGR, worsening renal disease). - Epilepsy( increased frequency of fit, congenital anomaly) - VTE(risk or thromboembolism, PE, IUGR) - SLE( PE, IUGR) - Myasthenia gravis( maternal muscular fatigue in labour)

Past surgical history: e,g pelvic surgery Drug history: Antihypertensive(ACEI, B-blockers)—change to methyl dopa. Antiepileptic (continue the medication even increase the dose) Oral hypoglycemic agents( teratogenicity?, poor control in pregnancy, risk of neonatal hypoglycemia) change to insulin. Drug allergy.

Family history: DM( risk of GDM) HT( PE) Thrombo embolic ( risk of thrombophilia) PE Family history of congenital anomaly Close family history of TB

Examination BMI:- weight (kg)\height(cm)2 BMI below IUGR & increase perinatal mortality rate BMI above GDM &HT Blood pressure measurement:- Measure in seated or semi recumbent position With appropriate size cuff, obese women with a large cuff, small cuff will over-estimate the BP Use Korotkoff V (disappearance of sound)

General examination Cardiovascular examination Breast examination:- women should report a new lump, Ix should not b delayed bc of pregnancy

Abdominal examination: in semi-recumbent position or a pillow below one buttock to move the wt of uterus to Rt or Lt, cover the legs with sheets, ensure that the women is in comfortable position, chaperone should be present. Inspection:- shape & symmetry of the uterus, any scar e,g pfanennstiel scar, linea nigra &stria gravidorum

Palpation - Superficial palpation - Obstetrical palpation: Symphysis -fundal height(SFH) Place the tape measure from upper border of symphysis pubis to the fundus in the midline. 1cm =1wk (in late 3 rd TMS 2 cm less than number of weeks)

Causes of large for date: 1. Wrong date 2. Macrosomia 3. Multiple pregnancy 4. polyhydramnios Causes of small for date: 1. Wrong date 2. IUGR 3. oligohydramnios

Fundal grip Lateral grip 1 st pelvic grip 2 nd pelvic grip

Auscultation