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George's and today, I just want to talk to you about how to take an antenatal history focusing on some tips and techniques that are useful for your oscopies as well. So hopefully by the end of today's session, you'll have a better understanding of the different components that make up the ante natal history and also having a systematic approach to taking an antenatal history so that you can score all of the brownie points during your osk ease. Um So in terms of antenatal history, it's very similar to the typical cardiac gastro history that you normally take, but there are just some added stuff that you need to ask your patient's just to ensure that you have a holistic approach to patient care and management. So like with all histories, you start with your introduction, so introducing yourself with your full name, um ensuring that confidentiality is being addressed and sort of setting the agenda between you and your patient and you make it very clear to your examiner about what you what you'll be focusing in that particular conversation. Then you go into the presenting complaint followed by questions regarding the current pregnancy, then a brief gynie history, which includes your menstrual history, um sexual history, contraception and previous pregnancies, and then the past medical, surgical history, medication history, family history, and social history so I'm just gonna go through each individual um parts of the history and if you have any questions just um meet yourself and ask at any time, so in terms of the presenting complaint, that you maybe asked. During your osk ease, there is a wide range of things that could be asked so it could be abdominal pain, vaginal bleeding, vaginal discharge or rupture of membranes, dysuria, unilateral leg swelling, chest pain, shortness of breath, headaches, visual changes, seizures, pruritis, fever or reduced fetal movement. So what I would like to do is ask you the audience with any of these symptoms what sort of differentials are going through your head, so if you could type your thoughts in the chat that would be great. Uh um someone said ms, courage, okay, and which particular symptom I you relating that with someone else said uh percent to abruption because of the abdominal pain and vaginal bleeding very good. Yeah anything else are pretty clumsier, the headache and visual changes very good. Uh this area and uti very good. So thank you for your contribution. So exactly so with each of these symptoms, you have a set of differentials in your head. So with abdominal pain. If you're thinking during the first trimester, you're thinking about possible miscarriage, it could be a possible ectopic pregnancy. If you're looking into 2nd 3rd trimester, your main concerns are is this a placental abruption or is this, if it sort of right epigastric pain could this be preeclampsia or is this a possible still birth. So by having these differentials in your head, it will make a better impression on your examiners about how you be managing the condition and in terms of placental abruption. What I do want to say is that sometimes you may get abdominal pain, but they might not be vaginal bleeding and this could be because it's um a concealed bleed. So with any patient presenting with abdominal pain within the second or third trimester. Presentable abruption should be a red flag differential that you should have and should be the first diagnosis that you're trying to exclude, so in terms of vaginal bleeding like someone said, miscarriage is a very important differential and as you can imagine patient's during the early pregnancy period, there'll be extremely distressed by that, so it's very important that you address the mood and emotions as well in terms of vaginal discharge or rupture of membrane. What you're concerned about is could this be an s. T. I. Plus the pregnancy, could this be an infection of the amniotic fluids or chorioamni itis, or could this actually be the start of labor, um so, dysuria. So if you remember your antenatal examination. One of the first things you ask your patience is have you provided us with a urine sample, and this is because patient's may present with a symptomatic UTI symptoms, so we want to screen for nitrites or the presence of any bacteria. Because what we're concerned about is if there is an untreated UTI, there's a risk that the infection can ascend and cause chorioamni itis, so it's a very important differential to exclude. Um So next one is unilateral leg swelling, so during pregnancy, um the mother becomes hyper coagulant and this is the body's response to prevent a traumatic post um partum hemorrhage, So as a result, pregnant women are more prone to developing clots and one of the main differentials you want to exclude as a DVT because it may possibly cause a PE, which will present with pleuritic chest pain and shortness of breath um and someone rightly said headache, visual changes, seizures, epigastric pain, edema. They all form part of preeclampsia and eclampsia, which is of quite a serious condition to have during pregnancy, so again it's very important to ask those questions so pure itis is something that you get with cholestatic um pregnancy, where patient's may present with deranged liver function test and again fever were trying to exclude sepsis. So with all of the symptoms that we sort of discussed, this tends to relate with the mother showing some sort of problem during pregnancy. The only symptom that the baby can actually show is reduced fetal movement, so if a mother reports reduce fetal movement, it's something too be dealt with seriously because this is the early way in which the baby can show that it's struggling inside, So once you've addressed the presenting complaint, you want to take a detailed history about the current pregnancy and start with the basic questions how many weeks is it was it a planned pregnancy, and the reason why this question is extremely important is because some pregnancies might be unplanned, The patient might be unhappy, so don't I know it's quite compelling to sort of say congratulations, but that's something that I would personally avoid because you don't know how that patient is feeling about the pregnancy. Sometimes the patient may have gone through a very very long process, such as using assisted reproductions techniques, so it's very important to ensure that you asked this question very sensitively to ensure that you respect the patient's emotions and feelings, then you have to ask is it a singleton or is it a multiple gestation and then using the antenatal timeline, you want to be asking questions regarding the booking appointment. It's specifically what the what the patient's blood group is and recess status and the reason why it's important is because if the patient presents with antepartum hemorrhage or if the patient is presenting with some sort of bleeding, you would need to give the anti immunoglobulin D, which is uh antibody that you sort of give in order to prevent the mother forming antibodies against recess positive babies. Next you want to discuss about vaccination, so during pregnancy, patient's are offered the influenza vaccine and whooping cough and this is to prevent any foetal um compromise and distress during pregnancy and also after pregnancy. Then you ask about if they've attended the nuchal scan at 12 to 13 weeks, so this is basically a trans abdominal ultrasound that is done during the 12 and 13 week period in which um you scan one of the ligaments at the back of your head and this is a very good indicator to show any chromosome abnormalities, especially tries only 21 so an increased trans trans nuchal um length is indicative of tries only 21 possible congenital heart disease. Next, um at 20 weeks, they do an anomaly scan, which is a very detailed um transseptal abdominal ultrasound where the obstetrician looks at the different parts of the fetal of physiology and, and, and anatomy, looks at the placental position as well as blood flow in the brain of the fetus, which are very strong indicators of preeclampsia and the reason why the location of the placenta is very important is because if it's a low lying placenta, they would have to be rescanned at around 26 to 28 weeks because there's a risk of the patient having placental previa. So this is a condition in which the placenta is located very close to the cervical loss, and it's graded depending on how close it is to the cervical loss, So if the presenter is obscuring the civil obscuring the cervical loss, then spontaneous vaginal delivery cannot be done and this becomes important when you go on to discuss about where the patient would like to have, I would like to deliver the baby and again you want to discuss about the murder of delivery and location, so I sort of discussed this slide in the previous slide, So basically once you've addressed concerns regarding the current pregnancy, you want to be screening for all of these conditions and the reason why you want to do that is, you're trying to exclude any potential conditions that that the mother may have not disclosed to you and also just shows that to the examiner that you're excluding these potential diagnoses, okay, so I've talked a lot, does anyone have any burning questions right now, nothing the chat so far okay, okay, that's good, so I'm just going to move on to the next slides. So after taking a thorough history about the current pregnancy, you do want to take a brief gynie history. So first of all you want to ask about the menstrual history, particularly you want to ask about the last menstrual period and this is to estimate the rough um expected date of delivery and they use something known as the new rules rule in order to calculate this. So from the last menstrual period, you I had one year and you subtract it by a week and add three days, so there's like a fancy thing that you can do in order to calculate the expected date of delivery. You want to ask questions regarding their period and if they're above 25 years, you want to ask about results of the cervical smear tests and if they have had any positive results have, they had any interventions such as a let's procedure, so does anyone know why it's important to ask if a patient has had a let's procedure is there anything on the chat, I'll see you at the moment, thank you okay. Uh It can cause issues with delivery, seven point insufficient ceo och stenosis, sorry what was the last part, difficult, insufficiency or stenosis good, good, so basically let's procedure stands for large loop excision of the transition zone and this is something that has done to patient to have cervical intraepithelial neoplasia and what this procedure does it removes the potential cancerous part of the cervix and by doing this, you shorten the length of the cervix making the patient more prone to have a preterm labor. So if patient's have undergone this procedure, it's very important to educate them that there might be a risk of them potentially going into labor quite early and because of that reason, we may need to give the mother some steroids in order to prevent any respiratory distress of the foetus, so that's why it's an important consideration when you do take your histories. So next year, you go on to inquire about st i symptoms are they experiencing any discharge. If so what is the color is it foul smelling, have, they had any previous sdi checks, and if they did have an s. T. I. Was, it treated now. The reason why this becomes quite important is because if someone has had an s. T. I. Has not been treated, There is a risk that the patient may have developed hell vic inflammatory disease and as a result they may have had issues with fertility, so therefore them becoming pregnant, it could have been quite a very difficult journey, so it's very important to establish how easy that journey was. If so next do you want to go on to ask about contraception, what sort of contraception have they used previously and also asked them about if they have any considerations of using contraception after this current pregnancy because you might know that the combined or repel is contraindicated up till six weeks postpartum because of their pro, thrombotic state and the increased risk of developing clots. So when you do take a history, you can say that it might be a consideration later down the line, and if you would like to receive more information regarding contraception after pregnancy, I'll be happy to provide you with a leaf it or something along those lines, so next you go on to ask about previous pregnancy and this is the main bulk of your important gynie history, so you want to establish Gravedigger and parity, so the gravity is the number of times the patient has become pregnant irrespective of the outcome or the location of the pregnancy, So if the patient has had an ectopic terminations of pregnancy any stillbirth. This all comes under gravity parity, establishes the number of pregnancies that has progressed after 24 weeks, then there is a plus and the second number indicates the number of pregnancies that has lasted less than 24 weeks and I do understand that this can be a very confusing term and I found it quite confusing as well. I have an example on the next slide, so hopefully you guys can understand that so if they have been pregnant uh it's important to ask if there were any issues during the pregnancy were there any concerns after the pregnancy that they need to stay in hospital that baby needed to go to nicu, for example what was the mode of delivery and where was it so for patient's who've sort of had um uh C sections abroad, they do something known as a classical uh cesarean scar, and this becomes very important because if that's the case, it's contra indicated for the mother to undergo spontaneous vaginal delivery due to risk of uterine rupture, so that's why it's important to establish how were they delivered and we're it was delivered. Next you want to ask about psychiatry, so usually um after pregnancy, um mothers may develop baby blues, which is basically um a small time period in which they sort of have a very low mood, which sort of becomes better in around a week, a week's time, they may experience postpartum depression and in severe cases puerperal psychosis, in which they may require hospitalization, so it's very important that you ask them about their mood in the previous pregnancy. So that if they have had previous experiences, you can put the support in place for them and next you want to ask about the weight of the baby. This becomes important when you want to um do investigations regarding gestational diabetes one of the criterias if if there was a macro eczemic baby in their previous pregnancy, so if a baby weighs above 4.5 kg that's an indication of doing the oral glucose tolerance test and importantly it's important to ask about miscarriages, stillbirths, ectopic pregnancies, and terminations of pregnancies. I do appreciate that it is a very sensitive and difficult question to ask and therefore, when you ask about these, it's very important to sign post to your patient, so it's something along the lines like next. I'm going to ask a sensitive question. This is something that I ask all my patient's and this is so that i can get a better understanding about your previous pregnancies would that be okay and then you go on to ask have you had any miscarriages, stillbirths, ectopic pregnancies, or termination of pregnancies, so by sign posting you sort of allowed the patient to know that there is something that could potentially be quite triggering. So next, I have a question regarding gravida or parity, so I would like you guys to enter the gravity on parity for this particular patient. So this is a 36 year old female who is currently 13 weeks pregnant, so you've obtained a obst, retic history and you found that she had a miscarriage at eight weeks, She had a stillbirth at 30 weeks, she had a surgical terminations of pregnancy at 12 weeks, elective C section for twins at 37 weeks, spontaneous vaginal delivery at 39 weeks and a stillbirth at 28 weeks. So would you mind typing into the chat the gravity and parity for this lead, Do you have any answers in the chant, no not yet okay, It's okay for you, you're not quite sure it's just very important that you've sort of type in any answers so that you can learn from your mistakes. Uh We have so we have gravity to seven and parities for flustering okay. Anything else, yeah I got the same thing again, okay, again, okay, okay, does anyone want to explain why they sorry, sorry, uh sorry, got g, psa, g seven and then priority as four plus two priority of full Plastic, okay, okay, so you guys have got the right answer, which is good. So in terms of gravity, so with this patient, um she's been pregnant six different times and she's currently pregnant so that makes it seven, so remember, irrespective of whether it was an ectopic whether it was the termination of pregnancy. Everything counts towards the gravida. In terms of the parity, the first number indicates the number of pregnancies that has progressed after 24 weeks and the reason why we say as 24 weeks is because that's the number of weeks which we establish as the fetus being a viable life or pregnancy and then the number afterwards basically shows the number of pregnancies that was less than 24 weeks. So in terms of the outcome, there is a stillbirth at 30 weeks, then there is an elective C section at 37 weeks with twins. Then there's a spontaneous vaginal delivery at 39 followed by a still burp at 28 weeks. So that's why it's four plus two, which is because there's a surgical terminations at 12 week and a miscarriage at eight weeks. So just uh um point to make is that twins people get quite confused with it, so for any twins, the gravity is one, and the parity is one as well, so just keep that in mind okay, so it's good that most of you have got the correct answer, So once we've discussed the gynie history, we move onto past medical history or surgical history, and there are certain medical conditions that make it a high risk pregnancy and when we talk about high risk pregnancy. What this means is that it's usually led by an OB strategy. Obstetrician, most low risk to medium risk are usually managed by midwives so that's what we mean by low risk and high risk pregnancy and certain conditions that make it a high risk pregnancy are diabetes because of the risk of developing gestational diabetes, hypertension because of the risk of preeclampsia and eclampsia sle, because of the risk of recurrent miscarriages, and the risk of complete heart block in the feet is due to the antibodies present in sle, CKD because the risk of preeclampsia, bleeding problems, hypothyroidism, and blood borne infections such as hepatitis next year go on to ask about the medication history, so always ask about allergies, it's a very common thing that we miss, so just ask that and this becomes very important especially if the mother or the baby's of um that mother has been tested for group B strap because during the intrapartum period, you give I am benzel, penicillin, so if they have penicillin allergy, then you would have to find an alternative antibiotics according to that your local micro mhm, micro guidelines, then you want to ask about folic acid, have they been taking folic acid up till 12 weeks, so for most patient's is 400 micrograms daily for patient's who have diabetes, epilepsy, or who have a b. M. I. Above, 30 you take 5 mg 5 mg of folic acid have they been on any supplements such as vitamin D, iron supplements, and have they been on any medications that are contra indicated such as if they've had BP were they on ramipril, if they had high cholesterol were, they on any statins, epileptic medications, so in particularly sodium valproate, so this sodium valproate, as you may know is a very potent um medication that causes lack of development with the limbs, but sometimes these patient's have been on sodium valproate for many years and have had the epilepsy under control, so usually the risk benefit is managed by an obstetrician, neurologist, and they combine the risk and a benefit to see if they should continue with the surgeon val parade, or whether they should consider an alternative medication. If the patient has had a past medical history of acne were they on any retinoids and if they have a uti, we're remember that trimethoprim is contraindicated because it's a folate antagonist. Therefore, there's a high risk of um spinal bifida and neural tube defects. Next you go onto family history, so is there a history of diabetes, high BP, thyroid problems, bleeding problems, or any inherited conditions like cystic fibrosis, and it's always good to ask if any of their close family members have had any problems during pregnancy. Next, you want to go on to ask about social history, so do they drink alcohol. If so how much because whatever quantity of alcohol they drink, especially during the first trimester, there is a risk of fetal alcohol syndrome and the reason why the first trimester is very important is because that's where your organogenesis takes place and alcohol severely disrupts this fetal organ development, so it's important to educate them on that during the booking appointment. Next you want to ask about smoking because it's associated with stillbirth, preeclampsia, and a lot of maternal conditions during pregnancy. You want to establish family friend support network, and in order to sort of get more brownie points, it's important to ask about domestic abuse because during pregnancy, the rates of domestic abuse increases by 33% so it's a very important question to ask and shows that you are prioritizing patient safety and having a holistic approach to care, so it's something that I would ask would be this is something This is a question that we ask. All our patient's some patient's have reported that whilst they are pregnant, they feel unsafe at home, have you ever had that feeling so by phrasing it in that sort of manner you sort of normalize that situation, making it easier for the patient to open up if they have had any experiencing that they've been experiencing domestic abuse and finally you want to be asking about exercise and occupation, so when you summarize your findings to your examiner or your senior, you want to establish the age, gravity, parity, what the presenting problem was any significant gynie or previous pregnancy history, current pregnancy concerns, medication history, any significant family or social history, what your impression is and how you want to go about investigating it and possible management plan. State this is basically a summary of how to approach your antenatal history and how to present your findings in a very concise manner for your your skis, does anyone have any question at this point in time, okay, we've got nothing in the chart okay, that's fine. So in terms of your potential Loski stations, you maybe um given a symptom for example abdominal pain, vaginal bleeding enough to take a focused history on that or you might be given a scenario in which you're given readings of the BP during that the patient is hypertensive, the urine analysis showing protein present and you're asked to explain to the patient. What do these results mean what is the condition how are you going to be managed or you could be given the results of the oral glucose tolerance test at 28 weeks in keeping with gestational diabetes. So in terms of tackling these stations, you go about asking your and you go about doing your antenatal history, then you go on to sort of discuss what the test was about what the results were and how they will be managed. So when it comes to a station like this, there is a lot of steps that sort of make up the station, so during your introduction, it's very important to set your agenda very clearly, so First of all, I'm just going to ask some questions about your general health and questions regarding your pregnancy, Then, I'll go in to talk about the results of the test that you've done talk about what this what the results I mean and how you'll be managed and then finally I'll be able to address any concerns or questions you may have is there anything else you would like me to discuss so by sort of structuring your um intro like that it's very clear for both the patient and the examiner in an or ski setting about what you'll be covering in that particular station. So in terms of the station you want to go on to ask about why they have had this test done in the first place, is it because they've had that condition in the previous pregnancy, was it because they have significant risk factors that increases their chance. Then you want to disclose the result explain to them how they will be managed and usually this post is a lot of question for the patient, such as um will this mean I have to be in a hospital when I deliver my baby, um what would what are the risk to me or my baby um Will this impact my work um is there a risk that I may develop this condition in later pregnancies and with some of the questions, you may know the answer and with some of the questions, you might not know the answer and if that's the case just say that I'm not quite sure about this what I would do is, I will talk to my seniors and I'll come back to you. I can also provide you with the leaf that with these information for example, and usually when it comes to these sort of um complex medical conditions, reassure them that there will be a team from different expertise, who'll be there to provide the care for both her and the baby, so providing that reassurance is a huge deal for mothers, and if it's a diagnosis of preeclampsia always safety net them about symptoms to look out for for example if they notice any visual changes, any headaches, any abnormal jerking of their arms or legs too, come to hospital because this could be quite a serious condition in which we need to manage promptly and with all conditions provide them with the leaflets, it always helps and one of the mistakes that I made during my or skis was because I was concerned about time. I didn't um chunk and check the information and that was one of the feedbacks that I received, so. It's important that after a chunk of information, you give you ask them do you mind just repeating back to me what you've understood so far just to make sure I haven't missed out anything. It just shows that um you're just checking if the patient has understood you so far and in terms of potential stations for Oskin is regarding ob statics and antenatal, you may be asked to take a focused antenatal history on presente abruption, placental previa, eclampsia, and with these um stations remember that you'll be managing these patient's b. B. C. D. E. E. Um because of these are medical emergency, potential medical emergencies or you might be asked to discuss diagnosis of gestational diabetes, preeclampsia or possible down syndrome as well, So I've come to the end of my presentation and these are the resources that I've used in order to give this presentation. I can only stress the importance of placement because this is the only place where you'll be able to practice your antenatal history. So when you go to the litter. Nitty assessment units, which is usually led by midwives, This is like the best place to practice your antenatal history and examination, so make the most of your placement, so thank you so much for listening to me, and I'm happy to take any questions.