JIPMER

OBSTETRICS
Clinical Case
Presentation
Proforma

Prepared by
students of
Clinical Batch “C”
MBBS 2k13
JIPMER

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General Information
work in any format for educational purposes
General Guidelines 1
provided that you do not alter the wording in any Ultrasonography 1
way do not charge for those copies beyond cost of History
reproduction. Patient Details 3
Any exceptions from the above requires prior Chief Complaints 5
written permission from Tetelestai SG. History of Presenting Illness 5
History of Present Pregnancy 5
First Trimester 5
Note from the authors: Second Trimester 7
Third Trimester 7
It was our desire to compile the practical Menstrual History 8
information relevant to taking a case in obstetrics Marital History 8
into a simple and handy format for quick reference. Previous Obstetric History 8
Past History 9
We are happy to share this work with you. :D
Personal History 9
If you find this useful please help us improve it by Diet History 9
notifying us of any update or error so that it can be Family History 9
quickly corrected. Summary 9
Examination
Please take the effort to notify any mistakes or General Examination 10
Obstetric Abdominal Examination 11
UPDATES via email to:
Diagnosis 14
Investigations 15
[email protected] Annexures:
Annexure 1: Socio-economic Classification 16
We shall correct them and re-upload as soon as Annexure 2: Hypertension in Pregnancy 17
possible. Annexure 3: Screening for and Diagnosis of
20
Diabetes Mellitus in Pregnancy
Annexure 4: Approximate Calorific Value of
22
Thank-you! God Bless You :) some cooked preparations
With Love Annexure 5: Estimated Fetal radiation
exposure for various radiologic imaging 24
studies
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 GENERAL INFORMATION

1. General Guidelines:
a) History must be presented in a sensible and chronological manner akin to telling a story - In the proforma given below
the questions are ordered in such a way as far as possible but since variations are bound to occur use your own
discretion and reorder as seems best
b) All relevant details should be presented and one must know the significance in order to defend if questioned on why
was it asked or why is it important?
c) Irrelevant details and vague history that does not help the diagnosis in any manner is best avoided - patients may
report insignificant details as highly significant. We must use our discretion to filter out the relevant history.
d) Never absolutely commit to a non-clinical diagnosis at the end of your case presentation. In order to not bias yourself
it is best to not look at the case sheet when in a practical examination.
e) Avoid abbreviations when presenting
f) Each faculty has his/her own preferences on the manner of presenting certain details. It is essential to note them
during class and make adequate modifications to your presentation style.

2. Ultrasonography: (This section is sourced from Textbook of Obstetrics, Sheila Balakrishnan, 2nd Edition)
a) Methods are of two types
i. Trans-Vaginal (TVS)
1. Done in the first trimester
2. Timeline for Detection
a) Gestational Sac @ 4.5 weeks
b) Yolk Sac @ 5 weeks
c) Fetal Node @ 5.5 weeks
d) Fetal Heart @ 6 weeks
3. Earliest confirmation of pregnancy - Can detect by 4 - 5 weeks. TAS can only detect about one week later
4. Characteristics of a Normal Intrauterine Gestational Sac
a) Eccentric Location
b) Regular Outline
c) Double Decidual Sac Sign
i. This sign is useful in differentiation of IUG from Ectopic
ii. It is seen as two concentric echogenic rings separated by a hypoechoic space - The rings
represent decidua parietalis and decidua capsularis
iii. Although an ectopic may have a pseudosac the double decidual sign will be absent
d) Presence of Yolk Sac
e) Good Choriodecidual Reaction
5. Abnormal Pregnancies
a) Hydatiform Mole - Snow-Storm Appearance
ii. Trans-Abdominal (TAS) - Done in Second and Third Trimesters
b) Schedule
i. First Trimester Scan - 9 to 14 weeks
1. Dating Scan - Best done between 9 to 11 weeks
a) Crown-Rump Length (CRL) is the most accurate indicator of gestational age between 9 to 11 weeks -
error is about +/- (3 - 5) days
b) At this time, CRL+6.5 = Gestational age in weeks
c) Anencephaly is the earliest detectable gross congenital malformation (GCM) @ 10 weeks
2. 11 - 14 weeks Scan
a) At this time the fetus can be screened for Down’s Syndrome by assessment of Nuchal Translucency
ii. Second Trimester Scan/Targeted Anomaly Scan - 18 to 20 weeks
1. Ideal time to screen for GCM (Gross Congenital Malformations)
2. Gestational Age estimation has an accuracy of only +/-(1 week)
iii. Third Trimester Scan
1. Ideal for assessment of Fetal growth and well being
2. Not good for assessment of gestational age as accuracy is only +/-(3 weeks)
3. Routine USG after 24 weeks should not be offered unless indicated or requested by patient. (NICE 2008,
ACOG 2009)
4. Indications of third trimester scan: APH, Multiple pregnancy, Malpresentation, Low fundal height,
suspected IUGR, Suspected Poly/Oligohydramnios, Complicated Pregnancies like GHTN and GDM

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 c) USG Scan Parameters - What is looked for? - Most significant points to be mentioned with reasons as pertaining to
case
i. Survey
1. Fetal Number
2. Viability
3. Lie
4. Placental Location
5. Subjective Liquor Assessment
ii. Fetal Biometry
1. Biparietal Diameter (BPD)
2. Femur Length (FL)
3. Abdominal Circumference (AC)
4. Head Circumference (HC)
5. Inter-cerebellar Diameter
iii. Fetal Environment
1. Placenta
a) Location
b) Abnormalities - Succentuate lobe/Morbidly Adherent/Circumvalate/Calcifications
c) If Low Lying then relation with internal OS - Distance from internal OS - This is used to diagnose
Placenta Previa
2. Umbilical Cord
a) Insertion into placenta - battledore placenta/velamentous insertion
b) Insertion into Fetus
3. Amniotic Fluid
a) Amniotic Fluid Index (AFI) - Normal Range: 5-24 cms - Less than 5 is considered significant
oligohydramnios
b) Single Deepest Pocket (SDP) - Normal Range: 2-8 cms

iv. Targeted Anomaly Scan - Gross Congenital Malformations (GCM)

v. Doppler Velocimetry
1. Artery Doppler
a) Umbilical Artery
b) Middle Cerebral Artery
c) Uterine Artery
2. Venous Doppler
a) Ductus venosus
b) Umbilical Vein

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 Obstetrics Case Presentation Proforma
HISTORY
1. Patient Details

a) Personal Details
i. Name
1. To give the right treatment to the right patient - ie for Identification
2. To build a good doctor patient relationship
ii. Age
1. Age related complications of pregnancy - the following come under the high risk category
a) Advanced Maternal Age (earlier known as “Elderly Primigravida”) - pregnancy occurring for the first
time in a woman above 35 years of age - more prone to chromosomal abnormalities especially
autosomal trisomies and higher risk of miscarriage (Sheila B., 2nd Edition)
b) Teenage Pregnancy - Pregnancy occurring in a girl below the age of 19 years
iii. Education
1. The management plan can be explained and understood effectively so they can make an informed decision
2. Educated women are more compliant and more adherent to medical advice
3. Morbidity and Mortality are lower among educated pregnant women (K. Park, 23rd Edition)
4. Approach to communication
5. Not easily influenced by taboos and bad traditional advice - easier to give health education
iv. Occupation and Occupational Environment
1. To render appropriate advice with regard to work and workplace
2. To determine if any modifications pertaining to occupation is required
3. Occupational Hazards - Strenuous Physical Activity, Chemical Exposure, Radiation Exposure
4. If occupational environment is favorable for gestation
v. Husbands Name
1. First name may be common, Husbands name adds a differential
vi. Age
vii. Education
1. Important Psycho-social factor
2. Component of Kuppuswamy’s Classification
viii. Occupation
1. Component of Kuppuswamy’s Classification
ix. Socio-Economic Status (Family Income? No of Members?)
1. Higher risk of maternal, infant and under-five mortality in lower Socio-economic classes
2. Urban Residence - Use Modified Kuppuswamy’s Classification
3. Rural Residence - Use Modified Prasad’s
x. Address
xi. Nearest Health Facility
1. Will it be difficult for the patient to come for regular antenatal visits? - Should be properly educated about
the importance and motivated by the doctor
2. Whether emergency situations can be quickly addressed?
3. High Risk Pregnancy - Is admission required due to being far away from a health facility?

b) Booking and Immunization

i. Booked/Not-Booked?
1. Place where she is registered
2. No of antenatal visits
ii. Immunization Status
1. Tetanus Immunized?
Mention simply as “Booked and Immunized at (place)” or “Not Booked due to (reason)”

c) Obstetric Index
i. Gravida - Para - Live - Abortion - Ectopic - MTP - (Mention Positives)

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 d) Period of Gestation -
Expected Delivery Date - Calculation is by Nagele’s Formula which is accurate only when:
 The patient be sure of her LMP date
 The cycles are regular - especially the previous three cycles (Sheila B., 2nd Edition, Pg 43). 6 months is ideal
 No hormonal contraceptive (except Hormone releasing IUDs) be used up to at least 6 months prior ie pregnancy
should not be from a hormonal contraceptive failure and regular cycles must be established for 6 months
before conception

If these prerequisites are not met, it may be presented it in the following manner - “Her LMP is (date), however her
dates are not reliable as (reason). Assuming reliability puts her at (weeks) and (days) of gestation. [E.D.D is not
mentioned]. The patient will be usually told of her corrected dates when dating USG was done. Then you can mention
it as “LMP/EDD corrected by ultrasound is (date) and POG by ultrasound is (POG)”

i. Patient gave H/O of being pregnant since (number of months) or Patient came with H/O of (number of months)
of missed periods (the term “amenorrhea” is not accepted by some people as it is not a word that the patient
would normally use)
ii. LMP - The date of the first day of flow of the last menstrual period
iii. Whether dates are reliable?
1. Sure of Dates?
2. Regular Cycles?
3. Length of Cycle
4. Any Hormonal Contraceptive Use?
iv. Expected Delivery Date - LMP + 7 Days + 9 Months - This corresponds to about 40 weeks (280 days) of gestation.
1. Only 4% of women deliver at EDD
2. Nagele’s formula assumes an average 28 day cycle - but when this is not the case we need to use Parikh’s
Corrected formula - LMP + 7 Days + 9 Months + (Cycle length - 28)
3. This correction is based on the principle that the 14 day duration of the luteal phase is constant in all
women and only the follicular phase varies according to cycle length.
v. POG = Number of weeks and days passed since LMP. Must be manually calculated.

The whole thing becomes a lot faster with an Obstetric Wheel - Apps are available - it is however essential to practice
calculating manually so as to be familiar with the process.

e) Blood Group
i. If Rh negetive - Husbands Blood Group?
ii. Rh Incompatible?
iii. Anti-D Immunized?

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2. Chief Complaints - what complaints did the patient come with and why was she admitted?
a) Complaints with duration of each
b) Reason for admission

3. History of Presenting Illness: Specific to each case. Some questions from trimester history may have to be presented
earlier here as negative history.

4. History of Present Pregnancy: to be taken divided into trimesters and presented in a chronological order of events

a) First Trimester (0 - 12 weeks)

i. Mode of Conception - Spontaneous/Assisted? - If assisted then

1. Type/Method?
a) Ovulation Induction
b) Intrauterine Insemination
c) In-vitro Fertilization
Assisted Reproductive technologies are associated with higher chance of multiple pregnancy and greater risk of
feto-meternal mortality and morbidity and as such ART pregnancies are considered High-Risk Pregnancies

ii. Detection and Confirmation of Pregnancy

1. How was pregnancy detected/diagnosed? - Suspected due to missing of periods? After how much time
since LMP? UTP done? When and Where? (self tested? Or at health facility?)
2. When and How was it confirmed? - Pregnancy cannot be confirmed by Urine Pregnancy Test -
Confirmation of pregnancy is by
a) Clinical Examination (Prof. Gowri)
i. Jacquemier’s Sign/Chadwick’s Sign - Osiander’s Sign - Goodell’s Sign - Hegar’s Sign - Palmer’s Sign
b) Ultrasonography (usually this is the first trimester dating scan) - mention scan findings - Eg: “Showed a
single live Intra-uterine pregnancy and findings were told to be normal”

iii. Number of Antenatal Visits

iv. H/O Nausea and Vomiting -

 Nausea and Vomiting of Pregnancy (NVP) aka “Morning Sickness” is a common phenomenon in early
pregnancy - prevalence is 70% - begins at 4-6 weeks (end of first month), peaks at 8-12 weeks and usually
resolves by 16-20 weeks in most women. (Shiela B., 2nd Edition)
 Hyperemesis Gravidarum is the extreme end of the spectrum where there is severe nausea and intractable
vomiting sufficient to interfere with nutrition and daily activities and/or requires hospitalization. It is a
diagnosis of exclusion. Incidence is 0.5% of all pregnant women. It is more frequent in Primigravide. It is
theorized to be mediated by pregnancy related hormones - strongest culprit is Beta-hCG
 This history is asked because it can point to a nutritional deficiency in early pregnancy which may be the
cause of anemia, edema, decreased weight gain, micro-nutrient deficiency, et cetera late in the pregnancy.
 Gestational Trophoblastic Disease and Multiple Gestation is a common cause of Excessive vomiting due to
greater placentation resulting in increased release of pregnancy related hormones
 Associated with several other life threatening complications which can affect the outcome of the pregnancy
(Ref. Text for complications)

1. Duration? When did it start and subside?

2. Pattern - Frequency of episodes (no/day)
3. Severity - Did it interfere with daily activities or require hospital admission - If yes and there is nothing to
suggest other causes then it is Hyperemesis Gravidarum
4. Was a consultation sought? What advice was given?
5. Management of Nausea and Vomiting of Pregnancy (Williams Obstetrics, 24th Edition)
a) Mild cases - Dietary modification - frequent small meals stopping short of satiety + Vitamin B6 10-30
mg OD +/- Doxylamine 10 mg OD/BD
b) Moderate - Higher H1 antihistamic antiemetic like Promethazine or Chlorpromazine, Ondansetron
c) Severe - Admission + IV hydration with Vitamin B2 + parentral antiemetics like
Metoclopramide/Promethazine/Ondansetron
d) Intractable - enteral/parenteral nutrition
6. Was any medication taken? - is a marker of severity depending on the drug
7. Any complications? - Ref textbook

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 v. H/O Vaginal Bleeding
1. ?Threatened abortion is the significance of this question when the patient is beyond the first trimester
2. Physiological Implantation Bleeding should be kept in mind - it is usually in and around the time of the next
menstrual period ie around one cycle duration from LMP (This is called Hartman’s Sign)

vi. H/O Fever with/without Rashes

1. Vertically Transmitted Infections in Pregnancy - CHEAPTORCHES - (Ford-Jones and Kellner, 1995)
a) C – Chickenpox and shingles
b) H – Hepatitis - C, E
c) E – Enteroviruses
d) A – HIV/AIDS
e) P – Parvovirus B19 (produces Hydrops fetalis secondary to aplastic anemia ie non-immune hydrops)
f) T – Toxoplasmosis
g) O – Other (Group B Streptococcus, Listeria, Candida, Lyme disease)
h) R – Rubella - One of the most potent teratogenic agents - Congenital Rubella Syndrome
i) C – Cytomegalovirus
j) H – Herpes simplex
k) E – Everything else sexually transmitted (gonorrhea, Chlamydia infection, Ureaplasma
urealyticum, human papillomavirus)
l) S – Syphilis
m) Also ZIKA Virus
2. Influenza B - It cannot be transmitted to the fetus but it puts the mother at risk of pyrexia which can lead to
maternal tachycardia which can cause fetal distress. There is also risk of preterm labor. Current guidelines
state that all pregnant women should be vaccinated for influenza during an epidemic. Being a component
vaccine it is not contraindicated.
(The ones in bold are most important and should be mentioned first. Avoid saying “TORCH infections”)

vii. H/O Exposure to Radiation

1. Research has shown that cumulative exposure to high energy radiation beyond 5 Rads during pregnancy is
teratogenic
2. 5 Rads is considered the “cumulative fetal exposure limit”
3. Background Radiation in the environment is about 0.3 Rads/year for an adult - for the baby it is even less -
0.09 Rads through the entire period of gestation
4. The most sensitive time period for central nervous system teratogenesis is between 10 and 17 weeks of
gestation. Non-urgent radiologic testing should be avoided during this time. (Refer Appendix 4)

viii. H/O of Difficulty Micturition

1. H/O Increased Frequency - Physiological - Up-to 12 weeks the uterus is still a pelvic organ which can
compress on the bladder and cause increased frequency
2. H/O Burning Micturition - Indicates an infection - Suspect UTI, DM

ix. Drugs taken: First Trimester Drugs

1. Folic acid supplementation
2. Aspirin Prophylaxis
3. Oral Iron supplementation is avoided in first trimester as it causes gastritis which aggravates morning
sickness and hyperemesis gravidarum if present. In general, tolerance to iron in the first trimester is low. So
it should not be said that “Iron was not taken in the first trimester” - If anemia is moderate to severe there
may be H/O of blood transfusions.
4. Any teratogenic drugs taken? - Commonly prescribed teratogenic drugs:
a) ACE Inhibitors and ARBs - Hypertension
b) Valproate, Carbamazepine, Phenytoin, Lamotrigine, Topiramate - Anti-Epileptics
c) Chloramphenicol, Tetracycline, Fluconazole - Antibiotics
d) Efavirenz, Ribavarin - Anti-Retroviral agents
e) Warfarin
f) Danazol
g) Alcohol, Tobacco, Cocaine

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 b) Second Trimester (12 - 28 weeks)

i. No. of Antenatal Visits

ii. Tetanus Immunization

iii. When did she perceive quickening? (Usually by 5 to 6 months in Primigravidae, earlier in multigravidae)

iv. USG Scan Findings - Anomaly Scan? Other Scans?

v. H/O of Diabetes Mellitus - pregnancy is a diabetogenic state

1. Glucose Tests done?
2. OGTT done? When?
3. If Positive? How was she managed?
a) What dietary advice given?
b) Was she started in drugs? Oral/Insulin?
c) Was she compliant? How was she monitored? Self monitored or Was monitored on subsequent visits
d) Was she controlled well? - Uncontrolled GDM has higher risk of sudden IUD
4. Note that Polydipsia, Polyuria and Polyphagia are physiological in pregnancy

vi. H/O of High BP Recordings or symptoms of severe Pre-eclampsia

1. Headache
2. Blurring of Vision/Visual Disturbances
3. Nausea and Vomiting
4. Epigastric Pain
5. Oliguria

vii. H/O Vaginal Bleeding

1. ?Placenta Previa
2. ?Abruptio Placentae

viii. H/O Vaginal Leaking

1. ?PPROM

ix. Drug Intake - Iron/Folic Acid/Calcium/Others (as treatment for specific medical conditions)

c) Third Trimester (28 - 42 weeks)

i. No. Of Antenatal Visits

ii. USG Scan Findings

iii. Continues to perceive fetal movements?

iv. H/O of Diabetes Mellitus

1. Ref. Above for sub-questions

v. H/O of High BP Recordings or symptoms of severe Pre-eclampsia

1. Ref. Above for sub-questions

vi. H/O Vaginal Bleeding

1. ?Placenta Previa
2. ?Abruptio Placentae

vii. H/O Vaginal Leaking

1. ?PPROM/?PROM/?ROM

viii. Drug Intake

ix. Treatment after Admission (Treatment history need not be presented separately but must be mentioned in a
chronological order within the history of present pregnancy

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5. Menstrual History
i. Age at Menarche?
ii. Cycle Characteristics - Regularity, Cycle duration, No of Days of flow, No of pads used per day, Painful
menstruation?, Passage of clots? Bleeding in between periods?
iii. H/O of Contraceptive use

6. Marital History
i. No. of years married
ii. Consanguineous - Degree of Consanguinity/Non-Consanguineous

7. Previous Obstetric History

Each pregnancy to be described individually in a chronological order of events
a) How long back (in months or years)
i. Asked so as to know the Inter-pregnancy interval
b) Conception - Spontaneous/Assisted - How many years after marriage/previous pregnancy
i. This is asked to check for any history pointing to infertility
ii. And to determine inter-pregnancy interval which has a bearing on the present pregnancy
c) Booked and Immunized?
d) Antenatal Period - any problems? - If not describe it as “uneventful”
e) How did she go into labor? Spontaneous/Induced? Period of Gestation? When did membranes rupture?
f) Where was she admitted for delivery? Home/Specific Institution
i. Home deliveries have disadvantages - aseptic precautions may not be taken - often conducted by untrained Dais
- Complications cannot be managed properly- hence there is high risk of maternal and neonatal morbidity and
mortality
ii. Place is important in PCS as the surgeon’s skill level and the institutional infrastructure will have a bearing on the
success of TOLAC
g) How long was she in labor? When was the baby born?
h) Mode of Delivery - NVD/Operative +/- Episiotomy
i. Operation - Vacuum/Instrumental/LSCS
ii. Indication for Operation
1. To ascertain if it is a recurrent/non-recurrent indication - this will impact present obstetric management
and play a role in assessment for TOLAC in PLSCS cases
iii. Type of Anesthesia - GA/Spinal - patient will be conscious in spinal
1. Can indicate if there was an obstetric emergency that required quick delivery - GA will be used in such cases
i) Baby
i. Sex
ii. Birth weight
1. Previous Preterm/IUGR/Macrosomia?
iii. Baby cried at birth? If not what was done?
iv. NICU Admission?
v. Any congenital malformations?
vi. Any Birth Injuries? (Esp important in malpresentations and operative deliveries)
vii. When was Breastfeeding started? - to be started as soon as possible - ideally within 2 hours of birth
viii. Whether Exclusively Breast Fed? If not, why? Age when complimentary feeding started and age when weaned?
ix. Immunization?
j) Puperium
i. If NVD +/- MLE
1. Any complaints in the Puperal Period?
2. H/O of PPH
3. H/O of Blood Transfusion
4. Foul Smelling Lochia
5. Episiotomy/Perineal Tear complications?
a) Symptoms of Hematoma
i. H/O of Severe Pain
ii. Inability to Pass Urine
b) How was it managed? - Perineal Hematoma is managed surgically. Sutures are removed under general
anesthesia and the hematoma is cleared. A drain is placed and the tissue is re-sutured.
c) Was there a perineal tear? - How was it managed?
d) Long Term Complications?

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 ii. If Previous LSCS
1. Was labor attempted? - Induction given/Asked to bear down/etc?
2. How many hours in labor prior to LSCS? - Gives an idea if Lower segment was sufficiently formed
3. Was she admitted to ICU?
4. Was Blood/Blood Products Transfused?
5. When was the urinary catheter removed?
a) It is normally removed in 1-2 days. Up-to 5 days is usually not significant
b) Prolonged catheterization (More than 5 days) is indicated when there is intra op injury to the bladder
6. H/O Fever
7. Wound Complications
a) Did the wound get infected?
b) Was there purulent discharge from the wound? (serous discharge is normal)
c) Is there H/O of severe abdominal pain at the time? (There can be mild to moderate pain which is
expected and is not significant, mention only if there is a strong history)
d) Did it require removal of sutures and re-suturing?
8. When was IV antibiotics switched to Oral tablets?
9. When was she discharged? Duration of stay in hospital
10. When were the sutures removed? - Usually removed 7 to 10 days post-op
iii. Previous Still Birth - Was there a known reason?
1. H/O of DM, GHTN?
k) Previous Miscarriage
i. Gestational Age
ii. Any Precipitating Factor
iii. Whether D&C was done? Where?
iv. Any subsequent complications? Uterine rupture, Hemorrhage, Surgery, Fever
l) Present health of the Baby (where ever applicable)
m) Contraceptive Use

8. Past History:
a) Previous Surgery f) Epilepsy
b) Previous blood transfusion g) Cardiac Disorder
c) Jaundice h) Hypertension
d) Tuberculosis i) Diabetes
e) STD j) Thyroid Disorder

9. Personal History:
a) Sleep pattern
b) Appetite
c) Bowel and Bladder habits
d) Addictions/Substance abuse
i. Tobacco
ii. Psychoactive agents
e) Alcohol abuse

10. Diet History - Diet taken prior to admission ie home diet and not the hospital diet
a) Type of Diet
b) Number of meals/day - important in DM
c) Calorie and protein intake
d) Requirements
e) % Deficit/Excess

11. Family History of: These have a strong genetic/familial risk factor
a) Diabetes mellitus
b) Hypertension
c) Multiple pregnancy
d) Congenital anomalies
e) Tuberculosis
f) Bleeding disorders
g) Sexually Transmitted Diseases - Esp. The husband

12. Summary: (often omitted in OBS cases) - Name - Age - Chief Complaint - Significant History - Reason for Admission

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 EXAMINATION:

Pre-requisites:
Prior to examination, informed consent must be obtained verbally.
The patient must be asked to void/should have voided within the last 30 mins - This is because a full bladder will interfere with
the pelvic grips and can also cause pain to the patient when the grips are done. Palpation becomes difficult and can lead to
erroneous interpretations. Fundal height can be increased due to the bladder displacing the lower uterus upwards. The privacy
of the patient must be ensured by using screens. MALE EXAMINERS MUST HAVE FEMALE ATTENDERS WITH THEM. Ensure
lighting is adequate. The woman is asked to expose the abdomen herself after which her legs must be covered with a sheet
which is to be tucked underneath her clothing at the waist. Patient should be examined only after these prerequisites. The
examiner, if right handed, must stand to the right of the patient and if left handed, to the left.
(These 7 steps must be explained and done when asked to demonstrate the examination process in the practical exam as well)

13. General Examination:

a) Patient Comfortable at Rest? - The terms “conscious” and “oriented” are redundant after a detailed history in OG
b) Build - this is a skeletal parameter - Ref medicine criteria
c) Nourishment - (Best avoided as a statement, directly mention BMI instead) - usually based on mid-arm circumference
- Ref medicine criteria
d) Pre-pregnancy Weight
i. For BMI Calculation in order to assess nourishment
e) Height
i. Short stature - height less than 140 cm (4’7”) - may have an inadequate pelvis which will be an indication for LSCS
ii. For BMI Calculation
f) Pre-pregnancy BMI = Pre-pregnancy Weight in kg/(height in meters)2
i. BMI should be pre-pregnancy and must be interpreted according to WHO Asian Guidelines
ii. Has to be used to determine if weight gain during pregnancy is adequate. Higher BMIs need only lower values of
weight gain in pregnancy
iii. Obesity in Pregnancy
iv. To ascertain daily nutrient requirements which is based on BMI (esp. In GDM/Overt DM)
v. Mention as “Her pre-pregnancy BMI was (value) kg/m2 which falls under (class) according to WHO Asian BMI
Guidelines”
g) Present Weight - Weight gain during pregnancy - Normal: 1kg in 1st Trimester, 5kg each in 2nd and 3rd . avg 9-11 kg at
term for the average woman is ideal. Obese women should have lower weight gain, 5-7 kg at term.
i. Increased weight gain of more than 0.5 kg/week or 2 kg/month in the second half of pregnancy may be an early
sign of pre-eclampsia
ii. Static weight or loss of weight may be due to IUGR or IUD
h) Pallor - Anemia
i) Icterus - Liver Disease/Other causes of Jaundice
j) Cyanosis - Cyanotic Heart Disease/Respiratory Distress
k) Clubbing - Heart Disease/Chronic Lung Pathology
l) Generalized Lymphadenopathy - TB/Malignancy
m) Edema
i. Generalized or Localized? Commonly Pedal edema
ii. Pitting/Non-Pitting
iii. In case of pedal edema - up-to what level is it found (ankle, knee, etc)
n) Spine
i. To check for spine abnormalities (like spondylosis) which have a bearing on the mechanism of labor as they
effect pelvic parameters. The pelvis may not be adequate in such patients.
o) Gait
i. To check for gross spine and pelvic abnormalities. Pelvis may not be adequate.
p) Oral Cavity
i. Periodontal disease has been linked to pre-term labour. (Williams Obstetrics, 24th Ed, Pg. 184)
q) Signs of Malnutrition (If BMI is low/In a case of Anemia, IUGR)
i. Stomatitis
ii. Glossitis
iii. Angular Chelitis
iv. Koilonychia

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14. Vitals:

a) Pulse - Must be elaborate in cases of Cardiac disease and Hypertensive Disorders

i. Rate - Rhythm - Volume - Character - Site of measurement (Left/Right Lateral Forearm) and Position when
measured (Recumbent/Semi-recumbent)
ii. Peripheral Pulses
b) Blood-Pressure - must be elaborate in cases of Cardiac disease and Hypertensive Disorders
i. Value in mm Hg - Site of measurement - Position when measured
ii. In pregnant women BP is best measured in the sitting position
iii. It can also be measured in a 30o semi-recumbent position with a 15o lateral tilt
iv. Korotkoff Phase 5: Point of disappearance of the sounds is taken because it is more easily identified and found to
correspond more closely to Intra-arterial diastolic pressure (NICE Guidelines 2008)
v. Automated BP Recording (these devices measure BP using Oscillometry) is known to underestimate BP in
pre-eclamptic women and hence in these women BP must be checked manually to confirm.
vi. Not to be forgotten in any case. A reading should be taken for all women during exam
c) Temperature: Mention as “Afebrile” if normal. If pyrexic then specify temperature
d) Respiratory Rate: In no. of breaths/min

15. Thyroid - Enlarged/Not enlarged

16. Breast Examination

a) Nipple Inversion? - Treatment is frequent mechanical eversion with lubricated fingers which can be taught to the
mother and done by herself - This must only be started after term because the patient might go into labour as
stimulation of the nipple releases oxytocin. If done before term there is risk of preterm labour.

17. Systemic Examination

a) CVS - To be examined in detail in a cardiac case
b) RS - To be examined in detail in HTN and Pulmonary Edema

18. Obstetric Abdominal Examination

When asked to demonstrate Obstetric Exam - always start by mentioning and ensuring the PRE-REQUISITES to examination
given above

a) Inspection
i. Abdominal Distention - Is it Uniformly/Non-uniformly distended
ii. Are flanks full?
iii. Do all quadrants move equally with respiration?
iv. Is the Umbilicus central? Or deviated Upwards/downwards? - The umbilicus is central if its position corresponds
to the mid-point of the longitudinal line joining the symphysis pubis to the xiphisternum. If it is not central then it
cannot be used as a landmark for 24 weeks in fundal height and an imaginary point at the midpoint of the curve
joining the xiphisternum to the pubic symphysis has to be taken as the landmark for 24 weeks and fundal height
ascertained from this point. Note that being “central” is different from being “mid-line” - mid-line is with respect
to the transverse axis.
v. Umbilicus Inverted/Flush to Skin/Everted
vi. Linea Nigra
vii. Striae Gravidarum
viii. Any abdominal edema? (Orange peel appearance)
ix. Previous CS Scar - (mention only if present)
1. Length in cm + Longitudinal/Transverse?
2. Site - approximate distance from pubic symphysis/mid-line
3. Healed by primary/secondary intention?
x. Other Scars - (mention only if present)
xi. Hernial Orifices - free (Expose and ask patient to cough)
1. Inguinal Area
2. Femoral Area

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 b) Palpation -

Except while measuring Symphysio-Fundal Length, the woman must be asked to keep her legs SEMI-FLEXED and
SEMI-ABDUCTED. This allows the abdominal musculature to relax and makes palpation easier. Palpation is always
done when the uterus is RELAXED (if the uterus is acting then palpation is done in-between contractions).

i. Fundal Height
1. There are two schools of thought on ascertaining fundal height. Some people prefer coming from below
upwards so as to not push the uterus down and get a lower reading. Others prefer coming from the
Xiphisternum downwards (most people in JIPMER) saying it is easier to feel the start of the resistance than
the end of it. Both are acceptable in practicals. One must however make sure that it is the resistance of the
uterine fundus that is used to mark and not the resistance offered by the fetal parts by not pushing too
deep and stopping at the first resistance (when coming from above)/as soon as resistance is lost (when
coming from below)
2. Steps:
a) Use the dominant hand to stabilize the uterus and to correct dextro/laevo-rotation if present
b) Ascertain fundal height with ulnar border of the non-dominant hand
c) Obtain consent again to place the mark on the woman’s abdomen
d) Keeping the non-dominant hand in place use the dominant hand to mark the fundal height with a pen.
Mark must be made below the hand and not above.
3. Fundal height is told in weeks
4. Interpretation:
a) At the level of umbilicus - 24 weeks
b) When it lies in between the umbilicus and xiphisternum
divide the line joining umbilicus to xiphisternum into 3 equal parts
i. Upper border of lower part - 28 weeks
ii. Upper border of middle part - 32 weeks
c) At the level of xiphisternum (aka ensiform cartilage) - 36 weeks
d) After 36 weeks fundal height drops down. At 40 weeks it will be corresponding to the 32 week level
5. At term when the flanks are full fundal height should be described as “corresponds to term” (Prof. Papa
Desari)

ii. Symphysio-Fundal Height/Length

1. Steps:
a) Ask patient to extend her legs
b) Place the beginning of the inch tape on the pubic symphysis with the inch side facing you (to avoid
observer bias) and measure up-to the mark made previously along the mid-line.
2. Must be said in centimeters
3. From 20th to 36th week the Symphysio-Fundal length will correspond to gestational age in weeks provided
(Sheila Balakrishnan, 2nd Edition, Pg. 40)
a) It is a singleton pregnancy
b) Lie is longitudinal
c) Abdomen is not obese
d) Bladder is empty
4. A variation of +/- 2 weeks is considered normal.
5. After 36 weeks the flanks become full and fundal height drops.

iii. Abdominal Girth - It is measured in inches at the level of umbilicus - corresponds to gestational age in weeks
from 30 to 37 weeks
Periodic measurement and plotting of SFL and Abdominal Girth on a “Gravidogram” can give an early warning of
impending IUGR/Macrosomia/Polyhydramnios/Oligohydramnios - making for a low cost screening tool in pregnancy

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 Leopold’s Maneuvers - (refer Bedside Clinics in Obstetrics, by Arup Kumar Majhi, for a more detailed description)

iv. Fundal Grip

1. In the first two pelvic grips the rule is that only one hand must be used to palpate at a time and the other be
used to stabilize - the neurological reasoning here is that the brain is not wired to precisely interpret fine
sensory inputs from both hands simultaneously when the inputs are very similar in nature. There will be a
intermixing of sensations to a significant extend. (Dr. Ashraf)
2. Steps:
a) Palpation must be with the plantar aspect of the fingers and not the fingertips or the palm
b) Palpate the upper pole of the uterus and ascertain what part of the fetus occupies the cavity
c) Palpate with one hand at a time using the other hand to stabilize the uterus
d) Check for balotability by grasping the part gently with left hand and stabilizing over the mid-line with
the right hand
e) The fundal grip is roughly confined to the upper 1/4th of the uterus
3. Standard reporting descriptions:
a) Irregular, firm (do not say “soft”), broad, non-balotable part is felt suggestive of breech
b) Hard, globular, balotable part is felt suggestive of fetal head
c) No parts palpable - In Transverse Lie

v. Lateral Grip
1. Steps:
a) Palpation must be with the plantar aspect of the fingers and not the fingertips or the palm
b) Palpate the sides of the abdomen and ascertain how the fetus is lying and to which side
c) Then palpate the anterior region over the mid-line
d) Palpate with one hand at a time using the other hand to stabilize the uterus
e) The lateral grip is confined to the lower 2/3rd of the uterus
2. This grip also gives information about:
a) Amount of liquor
b) Tone of the uterus
c) Size of the fetus
3. Standard reporting descriptions:
a) Uniform, smooth, convex resistance suggestive of fetal back felt on the (side)
b) Irregular knobby projections suggestive of fetal limbs felt on (side)
c) Multiple fetal parts felt suggestive of twin pregnancy

vi. 1st Pelvic Grip (Pawlick’s Grip)

1. Steps:
a) Place the ulnar border of the right hand over the upper border of the pubic symphysis resting them on
the bony prominence
b) With the thumb and fingers, go deep and try to grasp the part of the fetus occupying the lower pole
c) The OTHER HAND must be used to put mild pressure over the fundus to prevent the fetus from being
pushed up and to stabilize the uterus
d) Check for the head/breech - if head check engagement via balotability and no of 5ths palpable

2. Standard reporting descriptions

a) Irregular, firm, broad, non-balotable part is felt suggestive of breech
b) Hard, globular, balotable/non-balotable (if engaged) part is felt suggestive of fetal head
c) No parts palpable/Pelvic grip is empty - In Transverse Lie - Subsequently don’t mention 2nd Pelvic Grip
3. Palpation of Fifths in cephalic presentation is not usually expected to be said. If head is 1/5th palpable or less
it means that the head is engaged.
 5/5 - Floating - 4/5 - Brim - 3/5 and 2/5 - Not engaged - 1/5 - Engaged - 0/5 - Deeply Engaged

vii. 2nd Pelvic Grip

1. Steps:
a) Face the patients legs
b) Starting slightly above the ASIS and keeping hands parallel to the inguinal ligament feel for the two
poles (sinciput and occiput) of the fetal head as you move the hands down
c) Once located check the attitude - if they are not palpable which will be the case when the head is
deeply engaged then report as “No poles palpable per abdomen”
d) After this try to get under the head and approximate the fingers together. If you are able to
approximate then it is ‘converging’ and if the fingers are deflected then it is ‘diverging’.
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 2. Reporting:
a) The findings of the 1st Pelvic Grip are confirmed
b) Fingers are Converging(Not Engaged)/Diverging(Engaged)?
c) Attitude is - (ascertained only in cephalic presentation)
i. “Well Flexed” - when the sinciput is felt higher and above the level of the occiput
ii. “De-Flexed” - when the sinciput and occiput are felt at the same level
iii. “Partially-Extended” - when the sinciput is lower than the level of the occiput
iv. “Extended” - only sinciput felt, occiput not palpable

If it is a twin gestation only mention “On palpation multiple fetal parts felt suggestive of twin pregnancy” - If asked to
elaborate - give further details

viii. Contractility - Uterus is non-acting/mildly acting/acting - if acting describe strength, duration of each contraction
and frequency per 10 mins

ix. Liquor
1. Reduced - If the uterine wall seems to tightened snugly over the baby and ease of palpating fetal parts is
lost. Symphysio-Fundal length will be less than gestational age by more than 2 cms
2. Adequate - The normal situation
3. Increased - If the baby seems to be floating in liquor such that a push makes him/her bounce back.
Palpation of fetal parts is difficult. Abdomen is tense. Can be correlated with increased Fundal
Height/Symphysio-Fundal length

x. Scar Tenderness (if PCS)

1. Tenderness is checked for the inner uterine scar and not the skin incision scar
2. With fingertips of both hands get below the superior border of the pubic bone and apply pressure over the
uterine wall and watch the patient’s face for a change in expression or wince. Start on the right side and
move over to the left keeping fingertips close together.

c) Auscultation
i. Steps:
1. Auscultate over the region where the fetal back is close to the head of the fetus. (as determined from the
lateral grip)
2. In LOA/ROA positions (most common) - it will be somewhere along the left/right Spino-Umbilical line
3. Once located, ALWAYS palpate RADIAL PULSE OF THE MOTHER to make sure that what you are hearing is
in-fact the fetal heart and not the uterine artery bruit.
4. Then count over 1 min
ii. FHS Location - it is reported with respect to the spino-umbilical line, mid-line or said to be over the flank.
Eg: “Fetal Heart sound heard over the mid-point of the right spino-umbilical line”
iii. FHS Rate - 110 - 160 bpm is normal - count over 1 min
iv. In Twin pregnancy the two FHSs must be 10 cm apart and have 10 bpm difference and ideally should be
auscultated by two people simultaneously to conclude that they are indeed two different hearts

d) Clinically Estimated Fetal Weight (by Johnson’s Formula) = [(Symphysio-Fundal Height(cm) - N) x 155g]
i. N = 12 if not engaged, 11 if engaged
ii. This formula is not reliable and grossly overestimates fetal weight
iii. Nowadays USG is used for estimating fetal weight using the “Hadlock” formula or “Schluzer’s” formula

DIAGNOSIS

19. Diagnosis - Should be said in a single flowing statement

Age - Obstetric Index - Period of Gestation - with Single/Multiple Live Intrauterine Gestation - Presentation -
Engagement - Clinical Diagnosis - Complications - Whether in labour - Reason for Admission

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20. Investigations Common to all Patients:
a) Hemoglobin
b) Blood Grouping:
i. ABO grouping
ii. Rh Typing
c) STD Testing:
i. VDRL
ii. HIV Screening
iii. HBsAg
iv. HCV
d) Urine:
i. Microscopy
ii. Culture - to rule out asymptomatic bacteruria
iii. Protien level
1. Protien:Creatinine ratio (preferred)
2. 24-hr Urine Protien
e) Tests for DM/Monitoring for Glycemic control (Ref. Appendix 3)
f) Ultrasound

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 Table 1.1: Modified Kuppuswamy’s Socio-Economic Classification (2019)

Annexure 1: Socio-Economic Classifications

(A) Education of Head Score
1 Profession or Honours 7
2 Graduate or post graduate 6
3 Intermediate or post high school diploma 5
4 High school certificate 4
5 Middle school certificate 3
6 Primary school certificate 2
7 Illiterate 1
(B) Occupation of Head Score
1 Profession 10
2 Semi-Profession 6
3 Clerical, Shop-owner, Farmer 5
4 Skilled worker 4
5 Semi-skilled worker 3
6 Unskilled worker 2
7 Unemployed 1
(C) Family income per month Score
1 >46577 12
2 23289 - 46576 10
3 17466 - 23288 6
4 11644 - 17465 4
5 6986 - 11643 3
6 2352 - 6985 2
7 <2351 1
Final SCORING
Total score Socioeconomic Class
1 26 to 29 Upper
2 16 to 25 Upper middle
3 11 to 15 Lower middle
4 6 to 10 Upper lower
5 less than 5 Lower
Table 1.2: Modified B G Prasad’s Socio-Economic Classification (2019)
Class Per Capita Income per month (Rs./month)
I above 6893
II 3447 - 6892
III 2068 - 3446
IV 1034 - 2067
V below 1033
Income scores based on CPI(IW) = 302 [Base - 2001=100] as of November 2018
Source:
1. Sharma R. Revision of Prasad’s social classification and provision of an online tool for real-time updating.
South Asian J Cancer 2013;2(3):157.
2. Sharma R. Revised Kuppuswamy’s Socioeconomic Status Scale: Explained and Updated.
Indian Pediatr. 2017;54:867-70
3. Sharma R. Online interactive calculator for real-time update of the Prasad’s social classification.
Available at: www.prasadscaleupdate.weebly.com (Accessed on 26 JAN 2019)
4. The Kuppuswamy’s socioeconomic status scale revised for 2019 using real-time update tool, was used for
the socioeconomic status classification. https://scaleupdate.weebly.com

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 Table 2.1: MgSO4 Anti-Convulsant Therapy
Zuspan’s
Low dose
Dhaka Regimen Regimen
Regimen: Pritchard’s Regimen (under ICMR
(Followed in JIPMER) (Continuous
trial)
IV)
Total Loading
14 grams 10 grams 4 grams 8 grams
Dose
3 g - given as 15
cc of 20%
4 g - given as 20 cc of 20% 4 g - given as 20 cc of 20%
Intra Venous (IV) solution IV @
solution IV @ 60 ml/hour solution IV @ 60 ml/hour
Dose 4 g - given as 60 ml/hour
(ie over 20 mins) (ie over 20 mins)
Loading 20 cc of 20% (ie over 15
Dose solution IV @ mins)
60 ml/hour 5 g - given as
Intra Muscular 10 g - given as two 5 g 6 g - given as two 3 g (ie over 20 two 2.5 g
(IM) Dose injections - each as 10 cc injections - each as 6 cc mins) injections -
(promptly given after of 50% solution IM of 50% solution IM each as 5 cc of
IV dose) (on each buttock) (on each buttock) 50% solution
IM
2 g/hour -
given as 2% 2.5 g - given as
5 g - given as 10 cc of 50% 2.5 g - given as 5 cc of solution @ 5 cc of 50%
Maintenance Dose solution IM q4h 50% solution IM q4h 100ml/hour solution IM q4h
(on alternate buttocks) (on alternate buttocks) Prepared by (on alternate
adding 20 g to buttocks)
1000 ml
All regimens are continued up-to 24 hours after the last convulsion or 24 hours after
For how long?
delivery which ever is later.
Therapeutic range of Mg is a serum level of 4 - 7 meq/L (4.8 -8.4 mg/dL).
Pretreatment level is 2 meq/L
Patient must be monitored for signs of Mg toxicity:
1. Loss of Patellar reflex - earliest sign, probably because of curariform action of Mg -
occurs at serum level of 10 meq/L (12 mg/dL)
2. Respiratory depression - Respiratory Rate <16/min - depression occurs above 10
meq/L and respiratory paralysis occurs at 12 meq/L
3. Cardiac Arrhythmia - probably secondary to respiratory depression and hypoxia
Urine output should be more than 100 ml in the last 4 hours - this is because Mg is
Monitoring
excreted via kidneys and low urine output means that it is still in the system.
If any one criteria is not met then further MgSO4 is withheld and the antidote is
administered
Antidote to Mg toxicity is Calcium gluconate - 1 g - administered as 10 ml of 10% solution IV
bolus
And is effective in mild to moderate toxicity
Severe toxicity resulting in respiratory arrest will require prompt intubation and mechanical
ventilation
(Source: WIlliam’s Obstetrics, 24 Ed, Pg 758)
If convulsions persist or
she has a repeat episode
within 15 mins of loading Strict
dose (seen in 10 -15% of Monitoring
women) - additional 2 with serum
Remarks grams given as 10 cc of Mg assay
20% solution slow IV q4h-q6h is
bolus (not exceeding 1 essential in
g/min) this regimen
If obese then 4 g can be
given
Mg apart from having an anticonvulsant activity is also seems to be neuroprotective for both mother and fetus - pre-term
and LBW babies seem to have a better outcome.

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 Table 2.2: Diagnostic Criteria for Pregnancy-Associated Hypertension

Condition Sign/Parameter Considered Criteria Required

BP > 140/90 mmHg after 20 weeks in a

Gestational Hypertension Arterial Blood Pressure
previously normotensive woman

 ≥ 300mg/24h, or
 Protein-Creatinine ratio ≥ 0.3 or
Proteinuria  Dipstick 1+ persistent
(recommended only if it is the sole
available test)

OR
(latest guidelines do not require there to be proteinuria in-order to make a
diagnosis of preeclampsia in view of the finding that overt proteinuria may not
be a feature in some women with preeclampsia. Rather signs of multiorgan
involvement in the background of hypertension is sufficient for diagnosis)

Preeclampsia:
BP > 140/90 mmHg after 20 weeks in a Thrombocytopenia  Platelets < 100,000/μL
previously normotensive woman
AND
 Serum Creatinine > 1.1 mg/dL or
Renal Insufficiency doubling of baseline
(provided there is no prior renal disease)

 Serum Transaminase (AST/ALT)

Liver Involvement
levels twice normal

Cerebral Symptoms  Headache, Visual disturbances

Pulmonary Edema Present

Eclampsia Preeclampsia with convulsions that cannot be attributed to any other cause

(Source: William’s Obstetrics, 24 Ed, Pg 729 : modified from ACOG 2013b Guidelines)

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 Table 2.3: Indicators of Severity of Gestational Hypertensive Disorders

Abnormality Non-Severe (mild) pre-eclampsia Severe pre-eclampsia

Diastolic BP < 110 mmHg ≥ 110 mmHg

Systolic BP < 160 mmHg ≥ 160 mmHg

Proteinuria None to Positive None to Positive

(older criteria defines it as 3+ ie ≥ 5 g/24h)

Headache Absent Present

Visual Disturbances Absent Present

Epigastric pain Absent Present

Oliguria Absent Present

(Output < 500 mL/24h)

Serum creatinine Normal Elevated

( >1.1 mg/dL or doubling of baseline)

Thrombocytopenia Absent Present

(Platelets < 100,000/μL)

Serum Transaminase elevation Minimal Marked

Fetal Growth Restriction Absent Present

Pulmonary Edema Absent Present

Convulsions Eclampsia is always severe and a medical emergency

(Source: William’s Obstetrics, 24 Ed, Pg 730)

Table 2.4: Diagnostic Criteria for HELLP Syndrome

 Abnormal Peripheral Blood Smear (showing hemolysis)

 Lactate Dehydrogenase levels > 600 u/L
Hemolysis
 Bilirubin > 1.2 mg/dL
 Low Serum Haptoglobin

 SGOT > 70 u/L

Elevated Liver Enzymes
 Lactate Dehydrogenase levels > 600 u/L

Low Platelet Count  Platelet count < 100,000/μL

(Source: Textbook of Obstetrics by Sheila Balakrishnan, 2nd Ed, Pg 260)

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 Annexure 3:
Screening for and Diagnosis of Diabetes Mellitus in Pregnancy

There is no clear global consensus on which strategy of GDM Screening and Diagnosis is the best.
To get understand the history of GDM Screening visit the article from which Table 3.1 is sourced from.

Some of the currently followed strategies:

1. Single Step Strategy - Simultaneous Screening cum Diagnosis with an OGTT- new threshold values were recommended by
IADPSC Consensus Group in 2010, adopted by ADA (2011). The WHO adopted and modified the criteria in 2013. It is
currently followed in India and JIPMER.
a) In this strategy all women are administered an OGTT after fasting overnight
b) The prerequisites for any OGTT are that:
i. The person should be on an overnight fast for at-least 8 hours but not more than 14 hours
ii. The subject should have had an carbohydrate unrestricted diet for at-least three days prior to taking the test
(≥ 150 g/day)
iii. The subject should remain seated and should not smoke during the test
c) The OGTT can be administered as 100g/75g of oral glucose. This is the weight of anhydrous glucose. The hydrated
form would weigh a little more.
d) In single step the IADPSC and WHO recommendations are to use the standard 75g OGTT and not 100g, the former
being easier and more economically feasible.
e) 75 g anhydrous glucose is given in 300 mL of water.

2. Two Step Strategy - continues to be recommended by ACOG (2013)

a) A 50g Glucose Tolerance Test (GCT) is given regardless of time of last meal and venous plasma glucose levels
measured at end of one hour.
b) If plasma glucose level is ≥ 140 mg/dL it is followed by an 100 g OGTT for diagnosis using the Carpenter and Coustan
criteria given in Table 3.1

3. Screening without glucose challenge: Random, Fasting and 2 hour Postprandial plasma glucose levels are measured
without a glucose challenge - This is not recommended due to various sources of error. The same thresholds as that of the
75g OGTT for diagnosis of DM recommended by the WHO (Table 3.2) is used.

4. Note that Glycosuria is physiological in pregnancy and is not a reliable screening criteria

When to Screen?
1. ADA 2011 Guidelines:
a) Overt GDM can be diagnosed by Fasting and Random Blood Glucose in the First Antenatal visit. Ref Table 3.1 for
cutoffs
b) An 75 g OGTT done between 24-28 weeks for all women not known to be diabetic
2. DIPSI (Diabetes in Pregnancy Study Group India) Guidelines [Revised 2010]:
a) Universal Screening - Indians are high risk due to ethnicity
b) A 75 g OGTT given regardless of last meal time and 2 hour plasma glucose values are measured. GDM diagnosis is
made if value is ≥ 140 mg/dL
c) If the 2 hour value is between 120-139 mg/dL then it is regarded as Gestational Glucose Intolerance (GGI) and
requires followup
d) Recommendation to administer OGTT in the first antenatal visit itself so as to not miss the diagnosis of Overt DM.

JIPMER Protocol (Prof. Paapa Desari)

1. Strategy
a) Single Step Strategy - with a 75 g OGTT - 75 g anhydrous Glucose in 250 - 300 mL water - Interpreted with IADPSG
2010/WHO 2013 Criteria (Ref. Table 3.1). GCT is not used.
2. Schedule
a) First visit selective screening - If there is any risk factor for DM - OGTT administered at first visit itself (regardless of
gestational age at the time of first antenatal visit) - Risk assessment is done as per 5th International
Workshop-Conference on Gestational Diabetes guidelines (Table 3.4)
b) Universal screening at 24-28 weeks (end of 2nd trimester) - OGTT done for ALL Women (including those who were
found to be negative earlier) who are not previously known to be diabetic @ 24-28 weeks
c) Repeat OGTT for ALL women (including those who were found to be negative earlier) in third trimester @ 32-36
weeks - as early as possible

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 Table 3.1: Screening and Diagnostic Criteria for Gestational Diabetes Mellitus

Venous blood glucose values (mg/dl)

Given/Adopted by Diagnostic test Diagnostic criteria
fasting 1-hour 2-hours 3-hours

100g OGTT - plasma 2 or more values

Carpenter and Coustan, 1982 95 180 155 140
glucose above limit

75g OGTT - plasma not

WHO, 1998 126 140 - 1 value above limit
glucose measured

75g OGTT - plasma

ADA, 2011 and IADPSG, 2010 92 180 153 - 1 value above limit
glucose

75g OGTT - plasma

WHO, 2013 92-125 180 153-199 - 1 value above limit
glucose

WHO 2013 - Criteria for 75g OGTT - plasma

≥126 - ≥200 -
Overt DM (same as 2006) glucose

(Source: https://dmsjournal.biomedcentral.com/articles/10.1186/1758-5996-5-22)
(Scan the QR Code)

Table 3.2: Non-Pregnant OGTT Screening Criteria (WHO/IDF 2006)

Random
Diagnostic Test: Fasting Plasma Glucose 2 Hour Values HbA1c
Glucose
Normal Values < 110 mg/dL < 140 mg/dL <200 mg/dL < 6.0%
Impaired Glucose Tolerance <126 mg/dL 140 mg/dL - 200mg/dL - 6.0 - 6.4%
Impaired Fasting Glucose 110 mg/dL - 125 mg/dL <140 mg/dL - -
Diabetes Mellitus ≥ 126 mg/dL ≥ 200 mg/dL ≥ 200 mg/dL ≥ 6.5%

(Source: http://www.who.int/diabetes/publications/diagnosis_diabetes2006/en/)
(Scan the QR Code)

Table 3.3: Self monitored Capillary Blood Glucose Table 3.4: 5th IWCGDM - Risk Assessment Criteria
Goals Risk assessment to be done at first antenatal visit
Fasting ≤ 95 High Risk: OGTT done at first visit itself if one of the following in
present:
Premeal ≤ 100  Severe obesity
 Strong Family H/O Type 2 DM
1-hr Postprandial ≤ 140  Previous H/O GDM, Impaired Glucose tolerance, or glycosuria

2-hr Postprandial ≤ 120 Also in the Indian scenario (not given by IWCGDM):
 Previous Bad Obstetric History suggestive of GDM/Overt DM
0200-0600 ≥ 60

Mean (average) 100 If not diagnosed, OGTT to be repeated @ 24-28 weeks or whenever
any symptoms arise.
HbA1c ≤ 6%

(Source: William’s Obstetrics, 24 Ed, Pg 1135) (Source: Modified from William’s Obstetrics, 24 Ed, Pg 1137)

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 Table 4: Approximate Calorific Value of Some Cooked Preparations
Preparation Quantity for one serving Calories (Kcal) Protiens (grams)
Cereal
Rice 1 katori (100 grams) 110 2
Phulka 1 No. (35 grams) 80 3
Paratha 1 No. (50 grams) 150 4
Puri 1 No. (25 grams) 80 2
Bread 2 slices (50 grams) 170 4
Poha 1 katori (100 grams) 200 2
Upma 1 katori (130 grams) 200 5
Idli 1 No. (60 grams) 75 2
Dosa 1 No. (40 grams) 125 3
Kichidi 1 katori (100 grams) 210 4
Wheat porridge 1 cup 220 -
Semolina porridge 1 cup 220 -
Cereal flakes with milk (corn/wheat/rice) 1 cup 220 -
Pulse
Plain dhal 1 katori (140 grams) 170 10
Sambar 1 katori (100 grams) 81 4
Vegetable
Vegetable with gravy 1 katori (130 grams) 130 3
Vegetable Dry 1 katori (100 grams) 115 2
Non-Vegetarian
Boiled egg 1 No. (50 grams) 90 7
Ommelette 1 No. (65 grams) - made with 1 egg 160 7
Fried egg 1 No. (50 grams) - made with 1 egg 160 7
Mutton curry 1 katori (145 grams) 260 10
Chicken curry 1 katori (125 grams) 240 26
Fish fried 2 big pieces (85 grams) 260 18
Fish cutlet 2 No. (80 grams) 190 14
Prawn curry ¾ cup (145 grams) 220 18
Keema kofta curry ¾ cup (6 small koftas) 240 -
Savoury snacks
Bajji or pakora 8 No. 280 8
Besan ka pura 1 No. 220 -
Chat (Dahi-pakori) 5 pieces 220 -
Cheese balls 2 No. 250 -
Dahi vada 2 No. 180 10
Vada 2 No. 140 6
Masala vada 2 No. 150 4
Masala dosa 1 No 200 4
Pea-kachori 2 No. 380 6
Potato bonda 3 No. 200 6
Sago vada 4 No. 210 2
Samosa 1 No. 200 2
Sandwiches (butter - 2 tbsp) 2 No. 200 3
Vegetable puff 1 No. 200 3
Pizza (Cheese and tomato) 1 slice 200
Chutneys
Coconut/groundnuts/til 1 tbsp 60 1.5
Tomato 1 tbsp 10 0.3
Tamarind 1 tbsp 60 0.3

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 Sweets and Desserts
Besan barfi 1 piece 222 7.2
Chikki 2 pieces 290 8
Fruit cake 1 piece 270 3.3
Rice puttu 1 katori (100 grams) 280 2.8
Sandesh 2 No. (44 grams) 140 5.5
Double ka meetha ½ cup 280 -
Halwa (kesari) 1 katori (130 grams) 430 1.5
Jelly/Jam 1 tbsp (7 grams) 20 0
Custard (caramel) 1 katori (110 grams) 160 5
Srikhand ½ cup (100 ml) 380 -
Milk chocolate 25 g 140 -
Ice-cream ½ cup (100 ml) 200 -
Beverages
Tea (2 tsp sugar + 50 ml toned milk) 1 cup (200 ml) 75 -
Coffee (2 tsp sugar + 100 ml toned milk) 1 cup (200 ml) 110 -
Cow's milk (2 tsp sugar) 1 cup (150 ml) 100 5
Buffalo's milk (2 tsp sugar) 1 cup (150 ml) 175 6
Lassi (2 tsp sugar) 1 cup/glass (200 ml) 110 -
Squash 1 cup/glass (200 ml) 80 -
Syrups (Sharabats) 1 cup/glass (200 ml) 200 -
Cold drinks/Sodas 1 cup/glass (200 ml) 150 -
Fresh lime juice 1 cup/glass (200 ml) 60 -
Fruits
Apple 1 medium 65 -
Banana 1 medium 90 -
Grapes 30 No. 70 -
Guava 1 medium 50 -
Jackfruit 4 pieces 90 -
Mango 1 medium 180 -
Mosambi 1 medium 40 -
Papaya 1 piece 80 -
Pineapple 1 piece 50 -
Sapota 1 medium 80 -
Custard Apple 1 medium 130 -
Watermelon/muskmelon 1 slice 15 -
Salads
Beetroot 1 medium 30 -
Carrot 1 medium 20 -
Cucumber 1 medium 15 -
Onion 1 medium 25 -
Radish 1 medium 10 -
Tomato 1 medium 10 -
 1 Katori = 150 ml - an average fist sized portion
 1 tbsp = 1 tablespoon = 15 ml
 Nutrient value will vary based on amount of sugar/ghee/oil etc added

(Source: Dietary Guidelines for Indians, National Institute of Nutrition, 2011)

(http://ninindia.org/dietaryguidelinesforninwebsite.pdf)
(Scan the QR Code)

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 Appendix 5

ACOG Guidelines
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