Taking the proper patient medical history during an Obstetric ultrasound exam is vital to our study.
I find that most omissions of medical history is accidental. For example: a patient may not be thinking of a miscarriage they had a few years ago unless directly asked.
However some patients omit purposely. They may have a partner or family member at their visit that they wish to hide this part of their history from.
I find that asking specific questions, in a very non-judgmental way, has always been received well. They are more open and honest with me.
Let's quickly touch base on what Gs & Ps represent:
- Gravida is defined as the to the TOTAL number of times a woman has been pregnant.
- Para is defined as the act of giving birth. The term "para" comes from the Latin "pario," to bring forth or bear.
There are some resources that say the pregnancy has to be past 20 weeks and others say 24 weeks. This can be better defined by infant weight. The infant must weigh at least 500 grams if they are born alive or not. For Multiples- the Para is the act of labor so it only counts as 1 labor.
'TPAL' is one of the methods to provide a quick overview of a person's obstetric history
"T" refers to term births (after 37 weeks)
"P" refers to premature births (before 37 weeks)
"A" refers to Abortions (which simply means 'loss of pregnancy')
"L" refers to living children
So for example:
A woman had 1 singleton pregnancy and delivered at 40 weeks, then had twins that delivered at 32 weeks and is now newly pregnant.
So she would be G3P1103
G= 3 pregnancies
T= 1 labor at term
P= 1 labor preterm
A= 0 Abortions
L= 3 Living Children
Let me give you a basic run down on what type of questions you should ask a patient:
The bold and bulleted (•) lines are types of questions you ask the patient
The Arrowed (---->) questions are things you should be asking the patient depending on the answer to the original question.
The asterisks (**) are what you should be looking for on an Ultrasound
How many times have you been pregnant? Including miscarriages and terminations?
---->If miscarriage or termination: Any history of D & C?
** Yes? Look for uterine synechia or amniotic bands
** Cervical length: Multiple D & Cs = higher risk for an incompetent cervix
How many deliveries?
----> At Term? Past 37 weeks
----> Pre-term? Before 37 weeks
----> Does the patient know the reason for preterm delivery?
---->spontaneous rupture of membranes (SROM)
---->premature rupture of membranes (PROM)
---->Incompetent cervix (IC)
** Evaluate the cervix by transvaginal US (TVUS)
----> Cesarean sections?
----> Is the placenta near the scar?
** Evaluate for any type of placenta accreta
----> Any multiple births?
Family history/Personal history of abnormalities?
----> Is there a family history of heart defects?
----> A congenital heart defect?
** Evaluate the fetal heart well - possible screening FE
----> Is there a family history of chromosomal abnormalities?
Any genetic testing in this pregnancy?
----> NIPT (any time after 10 weeks)
----> 1st trimester combined screen with nuchal translucency US
----> Quad screen (done at ~ 16 weeks)
----> Integrated screen
Any past surgeries?
----> Uterine anomaly -- ie: septum removal?
Any known history of issues with Uterus or Ovaries prior to pregnancy?
----> History of uterine fibroids?
**If yes- evaluate/describe location/size
----> History of ovarian cysts?
----> Does the patient still have both ovaries?
**Ovaries are included on 76811 and 76805 exams
----> Polycystic ovarian syndrome? (PCOS)
----> If yes, how was EDC calculated? Known LMP?
Any complications in previous pregnancies?
----> Maternal complications
----> Gestational Diabetes (GDM)
----> Controlled how?
----> Oral Medication (ie: Metformin)
----> Type 1 Diabetes (T1DM)
----> Well controlled prior to pregnancy?
----> Type 2 Diabetes (T2DM)
----> Well controlled prior to pregnancy?
----> Chronic (cHTN)
----> Gestational (gHTN)
----> Medication use?
----> Fetal complications
----> Intrauterine growth restriction/Fetal Growth Restricted
What medications is she currently taking
----> Types of medication could indicate acute or chronic problems
Some times you can back into the patient's history by asking medication questions.
For example: If a patient tells me she is taking Labetalol she is indicating some type of hypertension. I would then ask if it is chronic or gestational. See how that works? ;)
It looks like a lot of questions but learning how to ask these questions prior to the beginning of the OB ultrasound exam can be helpful for you, as the sonographer.