MATERNAL BACKGROUND
Medical History (Chronic Illness)
? DM, HTN, SCD/Thal, Asthma, Epilepsy, SLE, Coeliac Disease,
Collagen Vascular Disease, Cardiac Disease, Renal Disease,
Cancer – eg. GIT, Cervical Carcinoma, Leukaemia/Lymphoma
etc., Psychiatric illness (eg. depression), Active Liver Disease,
IBD (Crohn’s Disease) NB: Pregnancy may complicate above
conditions & vice-versa
Surgical History
? GIT Resection, Myomectomy, C-Section etc. inc. indication &
complications? (surgical & anaesthetic)
Obstetric History G? P?+? (NB: High parity esp. w/ little spacing of
births or haemorrhage complicating those pregnancy & H/O Multiple
pregnancy ↑ risk)
Viable - ? Date, GA at delivery, MOD, Labour
(spontaneous/induced/assisted eg. forceps/vacuum) + any
complications (eg. prolonged, shoulder dystocia, 3rd & 4th d°
tears, PPH), Features of baby: weight, APGAR, neonatal
complications, Complications (eg. pre-eclampsia, GDM, fetal
abn,) & Mx, Paternity, Stillbirths, Puerperal complications (eg.
infection, PPH, DVT, PE, Psychological d/o)
Non-Viable – GA, reason, D&C?
Gynae History
- ? Menarche, Regularity (N=3-4 days x28-35 days), molimina
symptoms: Bloating, mood changes, breast tenderness
Menorrhagia (#of pads/dy), Dysmenorrhea,
Amenorrhea/Oligomenorrhea, Intermenstrual/Post-coital
bleed, Family Planning Methods: OCP/IUCD/Depo use etc.,
Fertility Enhancing Drugs (eg. Clomiphene Citrate)
-? Coitarche, # of sexual partners, barrier use, dyspareunia
(supf/l or deep)
- ? H/O STI (inc. partners), PID, Vaginal Discharge
- ? H/O Fibroids, Ectopic pregnancy
- ? Last pap smear & results
Drug History
- ? compliance with supplements (Fe, Folate: given to
meet demands of erythroid hyperplasia) NB: ? GI S/E &
use of tea, milk, antacid w/ Fe tablets as these ↓ abs
- ? anti-convulsant → folate def.
? steroids, anti-hypertensive, hypoglycaemics, anti-
coagulants (warfarin, heparin), allergies
Family History
- as in MH above + Twin pregnancy + Congenital abn.
C. Green (MBBS Class of 2010)
CURRENT PREGNANCY
How/When discovered pregnancy? – exaggerated symptoms
Planned/Unplanned? Wanted/Unwanted?
Gravidity? Parity?+?
LMP? (Naegele’s rule=LMP+9mths+7days, reliable w/ Normal
Menstrual Hx) EDD? GA?
New Partner?
- Blood Type
GA [ideal=8-14 wks] & Place of Booking?
- ABO Blood Group & Rhesus type/CBC (Hb, Plt, WBC, PCV,
MCV, MCHC) + blood film, Fe indices, folate & B12 levels, Retic
count/Serology (HIV, VDRL)/Sickle test or Hb electrophoresis
- Weight (NB: Pre-pregnancy weight)/BP/ Urinalysis/Bimanual
Exam in keeping w/ GA
Regular Antenatal Visit/Monitoring:
1st trimester (LMP – 12 weeks)
- Weight/BP/ Urinalysis/SFH
- ? Quickening (primigravida=18-22 wks; multigravida=16-18wks); Early
booking U/S to: confirm dates, placental placement, fetal abn, amniotic
fluid vol., uterine abn. & id single/multiple gestation & det.
Chorionicity; Congenital Anomaly Scan → Nuchal Translucency on U/S,
Pregnancy Asstd. Plasma protein-A (PAPP-A), hyperglycosylated hCG
(a.k.a invasive trophoblastic antigen); Chorionic villous sampling – for
antenatal Dx of SCD; MSU for Microscopy + C/S – done fortnightly;
Stool for Occult blodd & OCP; High vaginal swab to detect maternal
infections eg. Bacterial vaginosis, Grp. B strep, Chlamydia, gonorrhea
etc.,
2nd trimester (13 – 28 weeks)
- Weight/BP/ Urinalysis/SFH: ensures early Dx of pre-
eclampsia
- ? Quad Screen @ 16-18 wks (β-hCG, AFP, unconjugated estriol, inhibin
A); Amniocentesis; Detailed Anomaly scan for structural defects @ 18-
22wks: looking out for placenta abruption etc.; Osullivan’s test/OGTT
@ 24-28 wks; IDCT @24-36wks
- Complications: APH, GDM, PIH, Pre-eclampsia, Eclampsia,
Infections
3rd trimester (29 – delivery)
- Weight/BP/ Urinalysis/SFH
- If IUGR suspected, Growth Scan: U/S biparietal diameter, abd.
circumference & femur length; fetal kick charts and biophysical method
(NST, Doppler & BPP)
F/U – every 2 weeks until 28 weeks – weekly thereafter til
delivery
HPC: *Clinical Feat. - lethargy, SOB, palpitations, chest pain,
headaches, dizziness & fainting, pica, dysphagia 2° pharyngeal
Social History webs (Paterson-Kelly or Plummer-Vinson syndrome), pallor,
- ? Smoking, Alcohol, Illicit drug use (eg. cocaine etc.), icterus, ↑PR, Soft ESM, painless glossitis, angular stomatitis,
Living conditions – Exposure to Lead (car batteries or old brittle, koilonychia; Neuropathy (Vit. B12) – tingling in feet,
paint), Consort, Financial & Social Support, Diet - Vegan difficulty walking, falling over in dark; Chronic blood loss –
& Exercise Menorrhagia, PR bleed 2° angiodysplasia, diverticular disease,
Review of Systems haemorrhoids, parasitic (hookworms) infestation etc.;
GI – Ulcers, Cancer, angiodysplasia, diverticular disease, Symptoms of painful crises in SCD - infection, hypoxia, acidosis,
haemorrhoids, parasitic (hookworms) infestation stress, dehydration, cold.
Mx thus far:
Differentials
Haematinics (Materna) given by 16/40, Blood Transfusion in severe
anaemia Hb ≤ 4 g/dl & SCD crises, partial xch transfusion w/ HbA blood
- Nutritional - Chronic Disease eg. RF, GIT
to keep HbS<30%, Pneumococcal or Penicillin Prophylaxis Vaccine for
Ca, Leukaemia/Lymphoma
SCD; Fe (most common), Folic
acid, Vit. B12 deficiency - Aplastic
HISTORY TEMPLATE: ANAEMIA IN PREGNANCY - Physiological - Haemolytic

Demographics: Name? Age? [inadeq adolescent diet] - Haemoglobinopathies AIHA, SLE

Race? Occupation? [indirectly affects diet] Religion? SCD, Thalassaemia
Syndromes
[Rastafarian & vegan diet] Address? Marital Status?

PC: (i) Hb of ≤ 10 g/dl @ booking (ii) Symptoms of anaemia (see HPC)

C. Green (MBBS Class of 2010)

TREATMENT (Joint Care by Obstetrician & Haematologist)

NB: depends on cause, severity of anaemia (whether symptomatic or not) and period of gestation

Aim:

 To prevent complications:

o PPH

o Cardiac Failure (In severe cases, Hb ≤ 4 g/dl)

o Puerperal Infection & DVT

o In Vit. B12 & Folic acid

 Neuropathy (Vit. B12 only)

 Sterility
 Neural tube defects
 Reversible melanin skin pigmentation (rare)
 ↓ osteoblastic activity
o Oligohydramnios & IUGR in Thalassaemia

o In SCD

 Asymptomatic bacteriuria, haematuria, pyelonephritis, & other infections eg.m

pneumococcal pneumonia, salmonella osteomyelitis & pueperal sepsis, chronic
renal disease
 Spontaneous M/C, stillbirth, thrombo-embolism, pre-eclampsia, abruptio
placentae, PTL, IUGR
 High Perinatal & Maternal Mortality rate although latter less common nowadays
b/c of improved obstetric care
Investigations:
 Blood Film
o Microcytic, hypochromic with occasional target cells and pencil shaped poikilocyte in Fe
def.
o Macrocytic, Megaloblactic in vit. B12 & folic acid def.
o Hypersegmentation of polymorph neutrophils in folate def.
o Nucleated red cells in SCD
 BM aspirate stain (in complicated cases)
o With prussian blue demonstrates iron stores
o Megaloblastic changes in vit B12 & folate def.
 Hb electrophoresis: ↑ Hb A2 ± ↑ Hb F in βThal; Hb SS, SC, Sthal, AS in SCD

IRON DEFICIENCY

– Hb ↓, ↓ MCV, ↓ MCH, Serum ferritin ↓, Serum Fe ↓ (NB: affected by recent ingestion of Fe

rich food) , TIBC ↑

– Rx underlying cause

– Prophylaxis: 60-120mg po od starting at 16/40 when N/V of early pregnancy has

subsided

– In severe anaemia (Hb ≤ 4 g/dl), admit to hospital & transfuse with packed cells

– Aim: Hb ≥ 10 g/dl @ 40/40

• 1st week of Rx: no rise in Hb, only a reticulocytosis

• 2nd week of Rx: Hb ↑ by ~ 1 g/dl/wk

– Parenteral Fe [Ventofer] for patients who cannot tolerate S/E of oral Fe and those who
are non-compliant

C. Green (MBBS Class of 2010)

 • NB: rate of rise slightly faster than with oral Fe & fills stores directly

• Amount (g)= (13 g/dl – pt’s Hb) x 0.25

FOLATE DEFICIENCY

– Hb ↓, ↑ MCV, RBC Folate Levels ↓ (NB: more superior than plasma folate)

– Prophylaxis: 200-300mcg po od

• to all pregnant women

• Grand Multiparas, pts w/ previous abruptio placentae, multiple pregnancy

– 5mg po od if megaloblastic anaemia is confirmed

B12 DEFICIENCY

– Hb ↓, ↑ MCV, Serum Vit B12 ↓

– Recommended Intake of Vit. B12: 3.0 mcg/dy

– Rx: Cyanocobalamin IM wkly

THALASSAEMIA

– Hb ↓, ↓ MCV, ↓ MCH in βThal

– Pregestational Genetic Screening & Counselling

– Oral Fe & Folic acid supplements

NB: NEVER USE PARENTERAL IRON.

If serrum ferritin is high in early pregnancy then Fe supplements should be withheld

SICKLCE CELL DISEASE

• Antepartum [as above in table]

– Admit to Antenatal Ward for: Crises, Pre-eclampsia, IUGR, PTL, P. Abruptio, Fetal distress,
Pyelonephritis, Thromboembolism

– Painful Crises: Admit; Bed Rest; O2 via nasal cannulae is saturation < 95%; Reassurance;
Investigation for infection: sputum & MSU for C/S & Microscopy; Rehydration: Oral & IV
fluids w/ N/S & LR; Analgesics: Acetaminophen (mild), Pentazocine (severe); Limited xch
transfusion (to ↓ HbS conc to < 30%) in severe or recurrent crises; BSA; NST to
determine fetal well being if >30/40

– Acute Anaemia: Cause: aplastic crisis or acute splenic sequestration seen mainly in 3 rd
trimester; Rx: Blood Transfusion – spontaneous recovery of marrow w/I 5-10 days;

– Acute Chest Syndrome: PC: Sudden onset of pleuritic chest pain, fever, dyspnoea &
tachypnoea consistent with either pneumonua or PE (necrotic BM, fat, spicules of bone
emboli); Rx: Supportive w/ blood transfusion, O 2 & heparin

• Time & Mode of Delivery

C. Green (MBBS Class of 2010)

 – IOL @ 38-40/40 NB: Earlier delivery if any of the above mentioned conditions present

– C-Section required for obstetric indications and sometimes for pelvic deformity

• Intrapartum

– O2, IVF, GXM Blood available on ward, Adequate Analgesia, Active Mx of 1 st stage of
labour inc. use of Oxytocin/Methergine, Continuous CTG monitoring, Episiotomy ±
assisted outlet forceps delivery

• Postpartum

– Haematinics

– Antibiotics for postpartum pyrexia

– Breastfeeding encouraged

– Neonatal Dx: Agar electrophoresis of cord blood

– Advise adequate pregnancy spacing

– Effective Contraception: to ↓ menstrual blood loss

• Sterilization (esp. if no further pregnancies required)

• POP or Depot medroxyprogesterone acetate NB: do not ↑ risk of thrombo

embolism cf. COCP

• IUCD considered C/I b/c of ↑ risk of infection (debatable)

C. Green (MBBS Class of 2010)