CASE : BAD OBSTETRICAL HISTORY

 HISTORY

-       Age of the patient at conception, education status of husband and wife.

-       Husband’s occupation

-       Last Menstrual period

-       Period of gestation

PRESENTING COMPLAINTS

-       Bleeding per vaginum

-       Gestational age at the time of its occurrence

-       Amount of bleed, ( fresh , old, clloted blood)

-       Any passage of clots, products of conception or grape like vesicles pain abdomen

-       Nature of pain and duration

-       History of any intercourse or trauma

-       Syncopial attacks

-       Duration and recurrence of bleeding

-       History of nausea and vomiting or its sudden cessation

-       H/o of fever with rash or genital ulcers

-       H/o urinary frequency, urgency or dysuria

-       H/o UPT done or documentation of USG examination and appearance of cardiac activity

2^ND TRIMESTER PREGNANCY

-       Period of gestation

-       H/o quickening

-       H/o pelvic pressure

-       H/o bleeding P/V or leaking P/v

-       H/o recurrent lower abdominal pain

-       History suggestive & thyroid disorder ( constipation, weight gain, heat and cold intolerance)

-       History S/o diabetes mellitus (polyuria, polyphagia, polydypsia)

-       History S/o APLA (arterial or venous thrombosis, swelling of limbs, transient ischaemic attack)

-       H/o S/o cardiac disease (breathlessness, palpitation, chest pain, swelling of feet)

MENSTRUAL HISTORY

-       Age of menarche

-       Regularity of the cycles

-       History of prolonged cycles, duration of flow, amount of bleeding

-       Passage of clots

-       History s/o dysmenorrhea

OBSTETRIC HISTORY

-       Age at marriage and first conception

-       History regarding early fetal losses

-       Gestational age at fetal loss

-       History of blighted ovum (UPT + USG documentation)

-       Pattern of expulsion

-       Any pain abdomen and bleeding PV

-       Any operative intervention (D & C procedure)

2^ND TRIMESTER FOETAL LOSSES

-       Any history of bleeding or leaking per vaginum and pain abdomen

-       Duration of expulsion of foetus

-       Any bleeding P/v

-       Pattern of fetal ( with increasing or decreasing gestational age of the losses)

-       Any congenital abnormality in the fetus

-       H/o IUGR

-       Early PIH or feature suggestive of arteriovenous thrombosis

PAST HISTORY OF THYROID DISORDER

-       Obesity

-       DM

-       HT(hypertension)

-       Hyperprolactinemia (galactorrhoea)

-       Cardiac, renal or hematological illness

-       H/o any surgery or trauma to the cervix

-       History s/o leiomyoma, adenomyosis PCOD ( treatment taken for infertility)

-       History s/o autoimmune disease (fever, joint and muscular pain)

FAMILY HISTORY

-       DM

-       Hypertension

-       Recurrent pregnancy loss

-       Congenital and chromosomal defects in the babies

PERSONAL HISTORY OF

-       Cigarette smoking

-       Drug abuse

-       Alcohol intake

EXAMINATION SPECIFIC TO RECURRENT PREGNANCY LOSS

-       Height

-       Weight

-       BMI

-       Hirsutism

-       Acanthosis

-       Body habitus

-       Pulse

-       BP

-       Thyroid examination

-       Breast examination (for sign of pregnancy)

PRE ABDOMINAL (2^nd trimester pregnancy)

-       Uterine fundal height

-       Estimated baby weight

-       Presentation

-       Liquor volume

-       Fetal heart sound

PER SPECULUM

-       Cervix (blue or not)

-       Length of the cervix

-       Internal os open or closed

-       Bleeding or product of conception coming through os

PER VAGINUM

-       os closed or open, funneling of the cervix, cervical length

Uterine size corresponding to POG or not

-       Adnexal mass and tenderness

INVESTIGATIONS

-       Blood group+ Rh typing

-       Complete blood cont ( haemoglobin with platelet count)

-       Blood sugar (fasting and postprandial)

-       VDRL

-       TORCH

Lateral vaginal wall smear ( to rule out progesterone deficiency)

USG examination for

-       Foetal biometry

-       GCA

-       Liquor volume

-       Placental localization

-       Congenital malformation of uterus, associated fibroid

-       Cervical length/dilataion of funneling cervix coning of the membrane

-       Parental peripheral karyotyping

-       ACA, LAC, ANA, levels

-       Fetal karyotyping by CVS ( if indicated)

MANAGEMENT

1. Management of etiology found if any
2. Management current pregnancy

Management of current pregnancy

-       Complete bed rest during the critical period

-       Diet

-       Folic acid supplementation

-       Luteal phase support

-       Heg injection ( 1500-5000iu biweekly following LH surge for 8 weeks)

-       Inj. Proulation depot 500mg i/m weekly till 14 weeks.

-       Natural micronized progesterone by oral and vaginal route, 100-200mg BD till 14 weeks

-       Symptomatic treatment of nausea and vomiting

-       Reassurance to the patient

Treatment of etiological factors

-       Syphilis, toxoplasmosis, thyroid disorder, disbetes mellitus

-       Immunotherapy (APLA syndrome ) from 5 weeks of pregnancy

o   Low dose aspirin – 80mg daily

o   Heparin 10000 IU s/c BD

o   Prednisolone 40mg to 80mg OD

o   Other trials regarding immunomodulation are going on

o   Limitation of physical activity during critical peiod