Fertility

Subfertile: not conceived after a year of regular, unprotected intercourse

How long the patients have tried to conceive
Previous forms of contraception
Pregnancy history: Date they became pregnant, how (natural or ART), how long the gestation
lasted, whether there are abortion, miscarriage, ectopic pregnancy, preterm birth, term birth,
stillbirth, live birth. Mode of delivery, health outcome of baby.
Menstrual history: regular? How often, how many days; last menstrual period, how much pain
Sexual history: pain and/or bleeding during sex, STIs
Systemic enquiry:

 Systemic: fevers, fatigue

 Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
 Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
 Genitourinary: oliguria, polyuria
 Neurological: visual changes, motor or sensory disturbances, headache
 Musculoskeletal: chest wall pain
 Dermatological: rashes, ulcers

Polycystic ovary syndrome

When taking a fertility history, it’s essential that you identify risk factors for common causes of
infertility as you work through the patient’s history (e.g. past medical history, family history, social
history). Polycystic ovary syndrome (PCOS) is a common cause of infertility.3

Important PCOS symptoms include:

 Infrequent menstrual periods, no menstrual periods and/or irregular bleeding

 Inability to become pregnant
 Increased hair growth on the face, chest, stomach, back, thumbs, and/or toes (hirsutism)
 Weight gain (usually around the waist)
 Acne, oily skin and/or dandruff
 Male pattern baldness and/or thinning hair
 Skin tags and/or small excess flaps of skin in the armpits and/or neck 4

Past medical history: Family history of early menopause (less than 45)
Delayed Puberty

  constitutional delay, which often occurs in adolescents with a family history of

delayed growth
 genetic disorders (Turner syndrome in girls, Klinefelter syndrome in boys)
 central nervous system (CNS) disorders (eg, hypothalamic or pituitary tumors that
reduce gonadotropin secretion),
 thyroid disorder
 CNS radiation
 certain chronic disorders (eg, poorly controlled diabetes mellitus , inflammatory bowel
disorders, renal disorders, cystic fibrosis), 
 Kallman syndrome
 undernutrition/ eating disorders
 and excess physical activity, especially in girls

Signs of possible chronic disease include an abrupt change in growth,

undernutrition, discordant development (eg, pubic hair without breast
development), or stalled pubertal development (ie, puberty starts then
fails to progress). 

Neurologic symptoms (eg, headaches, vision problems), polydipsia,

and/or galactorrhea could suggest a CNS disorder.

Hyposmia or anosmia could indicate Kallman syndrome.  (hypogonadotropic

hypogonadism associated with anosmia or hyposmia.)

Gastrointestinal symptoms could suggest an inflammatory bowel disorder . An

abnormal body image (eg, false belief in being overweight) suggests the need
to evaluate for an eating disorder .

Primary amenorrhea could suggest Turner syndrome.

In primary amenorrhea, the presence of normal secondary sexual characteristics
usually reflects normal hormonal function; amenorrhea is usually ovulatory and
typically due to a congenital anatomic genital tract obstruction. Primary
amenorrhea accompanied by abnormal secondary sexual characteristics is usually
anovulatory (eg, due to a genetic disorder).
In secondary amenorrhea, clinical findings sometimes suggest a mechanism (see
table Findings Suggesting Possible Causes of Amenorrhea ):
 Galactorrhea suggests hyperprolactinemia (eg, pituitary dysfunction, use of
certain drugs); if visual field defects and headaches are also present,
pituitary tumors should be considered.

2
  Symptoms and signs of estrogen deficiency (eg, hot flushes, night sweats,
vaginal dryness or atrophy) suggest primary ovarian insufficiency (premature
ovarian failure) or functional hypothalamic anovulation (eg, due to excessive
exercise, a low body weight, or low body fat)
 Virilization and clitoral enlargement suggest androgen excess (eg, polycystic
ovary syndrome, androgen-secreting tumor, Cushing syndrome, use of
certain drugs). If patients have a high BMI, acanthosis nigricans, or both,
polycystic ovary syndrome is likely.

 History of Present Illness: The provider should first inquire about any signs
of puberty the child or the caregivers have noticed, such as breast
development, testicular enlargement, body odor, axillary hair, pubertal hair,
or acne. The occurrence of adrenarche versus puberty should be
distinguished. A thorough review of systems from head to toe will help to
rule in or rule out the causes of pubertal delay. Fatigue or weight loss could
be concerning for a chronic condition such as sickle cell anemia, depression,
or malnutrition. A young child complaining of headaches and blurry
vision should undergo evaluation for a brain mass. 
 Medical History: Birth history, immunization status, and the involvement
of other specialties in the child's care are all pertinent to medical
history. Does the patient have any medical conditions like asthma or cystic
fibrosis?
 Medications/Treatments: If the patient had a malignancy in the past, did
they receive any total body radiation for treatment? 
 Family History: Were any biological siblings or parents considered "late
bloomers" in their family?
 Surgical History: Did the patient have any previous surgical correction of
cryptorchidism, which would result in primary gonadal failure? 
 Social history: How is the patient's home environment? Do they live with
both parents? Questions about having concerning behavior or mood
instability should also merit investigation. 
 Development: Has the patient missed any milestones or been diagnosed
with any developmental delay? Disorders such as Klinefelter syndrome is
commonly associated with developmental delay or behavioral issues.
 https://www.ncbi.nlm.nih.gov/books/NBK544322/


3
Polycystic Ovary Syndrome

Risk factors for polycystic ovary syndrome include:1

 Obesity
 Diabetes mellitus
 Family history of PCOS
 Premature adrenarche (early onset of pubic hair)

Clinical features

History

PCOS usually presents in a woman around puberty, up to mid-20s.3

Typical symptoms include:

 Hirsutism: excessive hair growth in women, especially affecting the face, chest and back.
Hirsutism is the most common symptom, present in 60% of women with PCOS. 3
 Infertility
 Acne
 Menstrual cycle disturbance: manifesting as either oligomenorrhoea (reduction in menstrual
bleeding, defined as <9 periods per year) or amenorrhoea (no menstrual bleeding)
 Obesity and weight gain
 Alopecia
 Depression and other psychological disorders

Clinical examination 

Hirsutism is the most characteristic examination finding. 3

Other clinical findings include the consequences of hyperandrogenism:

 Acne
 Hair loss and male pattern baldness

Women with PCOS also have an increased risk of metabolic syndrome resulting in:

4
  Hypertension
 Obesity
 Acanthosis nigricans: as a result of insulin resistance (Figure 1)

Differential diagnoses
There are several differentials to consider in a patient with suspected PCOS

PCOS can present similarly to other endocrine disorders, including: 2

 Thyroid dysfunction: particularly hypothyroidism can lead to hair loss and menstrual cycle
irregularities. However, hirsutism is rare.
 Congenital adrenal hyperplasia (21-hydroxylase deficiency): this causes cortisol deficiency
and may also lead to androgen excess, leading to a clinical picture indistinguishable from
that of PCOS.
 Cushing’s syndrome: excess cortisol production, leading to many features similar to PCOS
(e.g. weight gain, acne, hypertension, insulin resistance).
 Hyperprolactinaemia: can lead to changes in the menstrual cycle. Galactorrhoea is usually
present.

5
Ectopic Pregnancy
The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and
vaginal bleeding
Patients may present with other symptoms common to early pregnancy,
including nausea, breast fullness, fatigue, low abdominal pain, heavy
cramping, shoulder pain, and recent dyspareunia. Painful fetal movements (in
the case of advanced abdominal pregnancy), dizziness or weakness, fever,
flulike symptoms, vomiting, syncope, or cardiac arrest have also been
reported. Shoulder pain may be reflective of peritoneal irritation.
Some physical findings that have been found to be predictive (although not diagnostic)
for ectopic pregnancy include the following:
 Presence of peritoneal signs
 Cervical motion tenderness
 Unilateral or bilateral abdominal or pelvic tenderness - Usually much worse
on the affected side
Abdominal rigidity, involuntary guarding, and severe tenderness, as well as evidence of
hypovolemic shock, such as orthostatic blood pressure changes and tachycardia,
should alert the clinician to a surgical emergency; this may occur in up to 20% of cases.
However, midline abdominal tenderness or a uterine size of greater than 8 weeks on
pelvic examination decreases the risk of ectopic pregnancy.  [54] 
On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or
cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may
be palpated but is usually difficult to differentiate from the ipsilateral ovary.
The presence of uterine contents in the vagina, which can be caused by shedding of
endometrial lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an
incomplete or complete abortion and therefore a delayed or missed diagnosis of ectopic
pregnancy.

History

Typical symptoms of ectopic pregnancy include:

 Abdominal pain
 Pelvic pain
 Amenorrhoea or a missed period
 Vaginal bleeding (with or without clots)
 Dizziness, fainting or syncope
 Shoulder tip pain

Other important areas to cover in the history include:

 Menstrual history (e.g. date of last menstrual period)

6
  Sexual history (e.g. when did the patient last have unprotected sexual intercourse)
 Medication history (e.g. contraceptives, anticoagulants)

7
8
9
10
11
12
Appendicitis: history of appendectomy to exclude, symptoms begin as
periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of
the abdomen,
Ovarian torsion: severe, sudden pain in the lower abdomen; cramping; nausea; vomiting; risk
factors include PCOS, long ovarian ligament, tubal ligation, pregnancy, hormonal treatment

Pelvic inflammatory disease: lower abdominal or pelvic pain, vaginal discharge,

dyspareunia, and/or abnormal vaginal bleeding. Risk factors include intercourse
with multiple partners, age, previous history of PID, intrauterine device
implantation, and tubal ligation. As PID is primarily a clinical diagnosis, a thorough
history, and physical exam is crucial. 
Subchorionic hemorrhage:
Trauma:
Urinary calculi:

 Lower abdominal pain

 Pain during urination

 Frequent urination

 Difficulty urinating or interrupted urine flow

 Blood in the urine

 Cloudy or unusually dark-colored urine

13
Gynaecology

Summary of key gynaecological symptoms

Key gynaecology symptoms to ask about include:

 Abdominal and pelvic pain: causes include ectopic pregnancy, ruptured ovarian cyst,
endometriosis, pelvic inflammatory disease and ovarian torsion.
 Post-coital vaginal bleeding: vaginal bleeding occurring after sexual intercourse. Causes
include cervical ectropion, cervical cancer, gonorrhoea, chlamydia and vaginitis.
 Intermenstrual vaginal bleeding: vaginal bleeding occurring between menstrual periods.
Causes include contraception (e.g. Mirena coil), ovulation, miscarriage, gonorrhoea,
chlamydia, uterine fibroids, perimenopause and malignancy (e.g. uterine cancer, cervical
cancer, vaginal cancer).
 Post-menopausal bleeding: bleeding that occurs after the menopause. Causes include
vaginal atrophy, hormone replacement therapy and malignancy (e.g. uterine cancer,
cervical cancer and vaginal cancer).
 Abnormal vaginal discharge: causes include bacterial vaginosis, chlamydia and
gonorrhoea.
 Dyspareunia: causes include endometriosis, vaginal atrophy, gonorrhoea and chlamydia.
 Vulval skin changes and itching: causes include vaginal atrophy, vaginal thrush,
gonorrhoea and lichen sclerosus.
 Systemic symptoms: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease) and
weight loss (e.g. malignancy).

Other symptoms
Urinary symptoms such as frequency, urgency and dysuria can be relevant to gynaecological
problems (e.g. dyspareunia, vaginal prolapse, pelvic pain).

Bowel symptoms such as a change in bowel habit or pain during defecation can be associated with
endometriosis.

Fever may be associated with pelvic inflammatory disease.

Fatigue is a non-specific symptom, but its presence may indicate anaemia or malignancy.

Unintentional weight loss is a concerning feature that may indicate underlying malignancy.

Abdominal distension is often a benign symptom, however, it can be associated with serious
underlying pathology such as ovarian cancer with ascites.

Some examples of symptoms you could screen for in each system include:

14
  Systemic: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease, urinary tract
infection), weight loss (e.g. endometrial cancer)
 Respiratory: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)
 Gastrointestinal: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea), painful
defecation (e.g. endometriosis), abdominal bloating (e.g. ovarian cancer)
 Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection),
abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
 Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)
 Dermatological: white patches on the vulva/vagina associated with pruritis (e.g. lichen
sclerosus)

Gynaecological history

Presenting complaint
Allow the patient to tell you their problem. They may need sensitive prompting over more
delicate issues.

Direct questioning will then depend on the complaint but the following list includes issues which
may need to be covered.

Menstrual history
 Last menstrual period (LMP) - date of first day of bleeding.
 Cyclelength and frequency - eg, 5/28, five days of bleeding every 28
days.
 Heaviness of bleeding. (Number of tampons per
day/clots/flooding/need for double protection.)
 Presence or absence of intermenstrual bleeding (IMB).
 Presence or absence of postcoital bleeding (PCB).
 Age of menarche/menopause.
 Presence or absence of postmenopausal bleeding (PMB).
Vaginal discharge
 Presence or absence of vaginal discharge.
 Colour.

15
  Amount.

 Smell.

 Itchiness.

 Duration.

 Timing within menstrual cycle.

 Rash.

 Any symptoms in a partner.

Pain or discomfort
 Duration, type, alleviating or aggravating factors, radiation.
 Any relation to menstrual cycle (mid-cycle or period-related).
 Anypossibility of pregnancy. (Consider ectopic pregnancy.)
 Bowel problems.

 Any feeling of 'something coming down below' - may be a prolapse.

 Dyspareunia - superficial or deep.

Urinary symptoms
 Leakage.

 Cloudiness.

 Haematuria.
 Hesitancy.

 Dysuria.

 Frequency.

 Strangury (slow, painful urination, caused by muscular spasms of the

urethra and bladder).
 Stress or urge incontinence.
Obstetric history
 Number of children, details of pregnancy, labour and delivery, birth
weights, complications.

16
  Miscarriages/terminations.
 Any postnatal problems - eg, depression.
 Conception difficulties/subfertility. 
Contraception
 Historyof contraception used.
 Any recent unprotected intercourse.

 Reliability of method and user.

 Potential contra-indications to different methods - eg, combined pill.
 Permanent or temporary method required.
Sexual history
 Whether sexually active.
 Sexual orientation.
 Relationship difficulties. Ask open-ended questions - eg, "How are
things between you?"
Past gynaecological history
 Infection:

 Any past history of pelvic inflammatory disease (PID).

 Whether it was adequately treated, including contact
tracing.
 Any known contact with sexually transmitted infections.
Assessment of the risk of HIV and hepatitis B.

 Gynaecological operations.

 Smear history - date and result of last cervical smear, previous

abnormalities.
General health
 Smoking/alcohol/drugs (especially intravenous usage).
 Presence of other relevant symptoms such as:
 Breast symptoms (such as tenderness, discharge, lumps).

17
  Acne.
 Hirsutism.
Weight changes.

 Other health symptoms or concerns - eg, arthritis or physical mobility
problems.

Gynaecological examination

In keeping with General Medical Council (GMC) guidance for intimate examinations, you
should[1]:
 Explain why the examination is necessary and what it will involve. Do
this before you start, rather than as you do it.
 Obtain permission for the examination and record this.
 Offer a chaperone and record this discussion and the outcome.
 Respect their dignity. For example, allow privacy to undress. Provide a
cover (eg, a few squares of couch roll) for them to use if they wish.

General examination
 General appearance:
 Pallor or signs of anaemia.
 Jaundice.
 Smoke-stained fingers.
 Obesity.
 Extreme thinness.
 Swollen abdomen.
 Ankle swelling.
Pyrexia.

 Blood pressure.

18
  Palpation of the abdomen - feeling for:
 Peritonitis.

 Abnormal lumps including enlarged uterus, liver, spleen,

nodes in the groin.
 Ascites.
 Umbilical abnormalities.
 Bladder. Percuss the bladder if palpably enlarged or if
indicated from history.

Vaginal examination
 Usually done with the patient lying on their back.
 Use a good examination light positioned over your shoulder.
 Lookat the vulva for any abnormalities of skin texture, lumps, rashes,
vesicles, excoriation, lichenification and whitening.
 Look for atrophic changes (if menopausal).
 Choosean appropriately sized speculum - usually Cusco's bivalve
speculum - for the patient.
 Warm the speculum before use. (Usually with warm water, as
lubrication jelly may interfere with swab or smear results.)
 Partthe labia with your hand from above and introduce the speculum
at a slight tilt to the vertical and twist it gently to the horizontal.
 Pointthe speculum downwards, at about 45°; open, making sure that
the handle is not impinging on the clitoris.
 Look at the vaginal mucosa and locate the cervix.
 Noteany discharge. Take a vaginal swab if there is discharge present.
Consider a cervical swab for chlamydia.
 Check for any retained tampon.

19
  If no cervix visualised:
 Try partially withdrawing and try again.

 Perform a bimanual examination to establish the position

of the cervix.
 Ask the patient to hold on to her knees or put hands under
the sacrum to tilt the pelvis. A pillow could also be used.
 The left lateral position may be more successful.
 If you are still unsuccessful, try on a different occasion.

Bimanual examination
 Use your left hand to palpate abdomen and your right for internal (if
examining from the right).
 Feel for any abnormalities of the vagina.
 Feel the cervix for areas of roughness, hardness, lumps. Note any
cervical excitation.
 Assess the uterine position, size, mobility, lumpiness, tenderness.
 Feel the adnexae bimanually for any swelling or tenderness.
NB: an ectopic pregnancy can be ruptured by bimanual examination, so be gentle.
Uterine size
 Within the pelvis (size of an orange) = 8 weeks.
 Suprapubic = 12 weeks.
 Mid-suprapubic umbilicus = 16 weeks.
 To umbilicus = 20 weeks.
 To
xiphisternum = 36 weeks.
NB: the height drops as the fetal head engages into the pelvis at term.

20
Urinary incontinence
Confirmation of leakage can be done by asking the patient to cough whilst holding a tissue over
the urethral opening, either lying or standing with the feet slightly apart.

Prolapse
 Ask them to bear down to look for descent of the vaginal walls or
uterus. It may be necessary to ask them to stand up to visualise any
prolapse.
 Assessability to use pelvic floor musculature by asking them to
squeeze on your examining finger in the vagina.
 Vaginal examination with a Sims' speculum in the left lateral position is
helpful in looking for a cystocele or rectocele. Look for uterine or
vaginal prolapse whilst withdrawing the Sims' speculum.

Taking a smear
 Smears are indicated for screening purposes. Most laboratories will
not process them if taken earlier than at the recommended interval.
Therefore, they are not part of most gynaecological examinations.
 Ideally, smears should be done mid-cycle.
 Liquid-based cytology (LBC) is now the method of choice . [2]

 A brush is used rather than a spatula, which is rotated against the

squamocolumnar junction (usually in the cervical canal). Two
systems for LBC are in use. Both systems use brushes which look
similar. In one, the head of the brush that contains the cells is
broken off into a pot that contains special preservative liquid. The
brush head is sent to the laboratory in the pot (this is the SurePath®
brand method). In the other system, the brush is rinsed in the
preservative to wash the cells into the pot. The brush is then
discarded (this is the ThinPrep® brand).

21
  LBC is now used nationally. It has significantly reduced numbers of
inadequate smears, as the liquid is spun and treated to remove
other cells such as pus or blood. Numbers of inadequate smears
dropped from over 9% to 2.6% when LBC was introduced . [2]

 Older methods include the Papanicolaou (Pap) smear test which uses
a brush or the Ayre spatula to sample the ectocervix, by rotating it
twice through 360°. In both these methods, the material obtained is
smeared on to a microscope slide, which is then sprayed with or
immersed in a fixative solution prior to transporting to the
laboratory. 

22
Obstetrics

Summary of key obstetric symptoms

Key obstetric symptoms to ask about include:

 Nausea and vomiting: common in pregnancy and mild in most cases. Hyperemesis
gravidarum represents a severe form of vomiting in pregnancy associated with electrolyte
disturbance, weight loss and ketonuria.
 Reduced fetal movements: can be associated with fetal distress and absent fetal movements
may indicate early fetal demise.
 Vaginal bleeding: causes include cervical bleeding (e.g. ectropium, cervical
cancer), placenta praevia and placental abruption (typically associated with abdominal
pain).
 Abdominal pain: causes may include urinary tract infection, constipation, pelvic girdle pain
and placental abruption.
 Vaginal discharge or loss of fluid: abnormal vaginal discharge may be caused by sexually
transmitted infections such as gonorrhoea and the loss of fluid from the vagina indicates
rupture of the amniotic membranes.
 Headache, visual disturbance, epigastric pain and oedema: these are typical clinical
features of pre-eclampsia. Mild oedema is common and normal in the later stages of
pregnancy.
 Pruritis: associated with obstetric cholestasis (typically affecting the palms and soles of the
feet).
 Unilateral leg swelling: consider and rule out deep vein thrombosis.
 Chest pain and shortness of breath: pregnant women are at increased risk of developing
pulmonary emboli.
 Systemic symptoms: fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss (e.g.
hyperemesis gravidarum).

Nausea and vomiting

Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only
reassurance and basic hydration advice.

Nausea and vomiting typically begin between the fourth and seventh week of gestation,

then peak between the ninth and sixteenth week and resolve by around the 20th week of
pregnancy.

23
Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis
gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte
disturbance, weight loss and ketonuria. ¹

Reduced fetal movements

Women typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida
women will often not feel fetal movements until after 20 weeks gestation). A mother will know what
is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal
movements is reported, it should be taken very seriously.

Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal
growth restriction, placental insufficiency, and congenital malformations. ²

You should always ask about fetal movements once the patient is of the appropriate gestation to

be able to feel them:

 “Have you noticed any change in the amount of your baby’s movement?”

Vaginal bleeding
Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and
gynaecological diseases.

It is important to ask about pain, associated trauma (including domestic violence), fever/malaise,

recent ultrasound scan results (e.g. position of the
placenta), cervical screening history, sexualhistory and past medical history to help narrow the
differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic

shock(e.g. pre-syncope/syncope).

Vaginal discharge
All healthy women will have some degree of regular vaginal discharge, so it is important to
distinguish between normal and abnormal vaginal discharge when taking an obstetric history.

You should ask the patient if they have noticed any changes to the following characteristics of
their vaginal discharge:

 Volume
 Colour (e.g. green, yellow or blood-stained would suggest infection)
 Consistency (e.g. thickened or watery)
 Smell (e.g. fish-like smell in bacterial vaginosis)

24
Urinary symptoms
Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated
urinary tract infections in pregnancy have been associated with increased risk of fetal death,
developmental delay and cerebral palsy.

Common symptoms of urinary tract infections include:

 Dysuria: pain whilst passing urine.

 Frequency: increased frequency of passing urine.
 Urgency: a sudden need to pass urine, with no earlier warning.
 Fever

Headache, visual changes, epigastric pain, oedema

Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal
hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The
condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about
symptoms of pre-eclampsia as part of every patient review during pregnancy.

The key symptoms to ask about include:

 Headache (typically severe and frontal)

 Swelling of the hands, feet and face (oedema)
 Pain in the upper part of the abdomen (epigastric tenderness)
 Visual disturbance (blurring of vision or flashing lights)
 Reduced fetal movements

Other symptoms
Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections,
cervical infections, chorioamnionitis).

Fatigue is a non-specific symptom, but its presence may indicate anaemia or other systemic
pathology.

Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g.
malignancy, anorexia nervosa).

Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the
palms and soles of the feet).

25
Ideas, concerns and expectations

A key component of history taking involves exploring a

patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a
patient currently perceives their situation, what they are worried about and what they expect from the
consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation
in response to patient cues. This will help ensure your consultation is more natural, patient-
centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but
we have provided several examples for each of the three areas below.

Ideas
Explore the patient’s ideas about the current issue:

 “What do you think the problem is?”

 “What are your thoughts about what is happening?”
 “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what
you think might be going on.”

Concerns
Explore the patient’s current concerns:

 “Is there anything, in particular, that’s worrying you?”

 “What’s your number one concern regarding this problem at the moment?”
 “What’s the worst thing you were thinking it might be?”

Expectations
Ask what the patient hopes to gain from the consultation:

 “What were you hoping I’d be able to do for you today?”

 “What would ideally need to happen for you to feel today’s consultation was a success?”
 “What do you think might be the best plan of action?”

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Summarising

Summarise what the patient has told you about their presenting complaint. This allows you
to check your understanding of the patient’s history and provides an opportunity for the patient
to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so
far and what you plan to discuss next. Signposting can be a useful tool when transitioningbetween
different parts of the patient’s history and it provides the patient with time to prepare for what is
coming next.

Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your
concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then
talk about your current pregnancy.”

Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which
may or may not be relevant to the primary presenting complaint. A systemic enquiry may also
identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of
experience.

Some examples of symptoms you could screen for in each system include:

 Systemic: fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, urinary tract infection), weight
loss (e.g. hyperemesis gravidarum)
 Respiratory: dyspnoea (e.g. pulmonary embolism, anaemia), chest pain (e.g. pulmonary
embolism)

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  Gastrointestinal: abdominal pain (e.g. placental abruption), vomiting (e.g. hyperemesis
gravidarum)
 Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection),
abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
 Neurological: visual changes, motor or sensory disturbances, headache (e.g. pre-eclampsia)
 Musculoskeletal: pelvic pain (e.g. symphysis pubis dysfunction)
 Dermatological: rashes, skin lesions, linea nigra

Current pregnancy

Gestation

Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as
“26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using

an ultrasound scan to measure the crown-rump length.

Scan results

Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6

weeks. You should ask about the results of the scan (or check the medical records if the patient is
unsure). The key findings to note include:

 Growth of the fetus: clarify if it was within normal limits for the current gestation.
 Placental position: if embedded in the lower third of the uterine cavity there is an increased
risk of placenta praevia.
 Fetal anomalies: note any abnormalities identified.

Screening

There are several types of screening that women are offered during pregnancy:

 Down’s syndrome screening

 Rhesus status and the presence of any antibodies
 Hepatitis B, HIV and syphilis.

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You should clarify if the patient has opted for screening and if so, what the results were.

Other details of the pregnancy

 Check if this is a singleton or multiple gestation.

 Clarify if the patient took folic acid prior to conception and during the first trimester.
 Explore the planned mode of delivery  (e.g. vaginal or Caesarean section).
 Ask about any medical illness during pregnancy (clarify what type of illness and if the
patient is still receiving any treatment).

Immunisation history

Check the patient is currently up to date with their vaccinations including:

 Flu vaccination
 Whooping cough vaccination
 Hepatitis B vaccination (if at risk)

Mental health history

Pregnancy can have a significant impact on maternal mental health, therefore it is essential that
patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar
disorder, schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide if

relevant.

Previous obstetric history

It is important to ask about a woman’s previous obstetric history, as this may help inform the
assessment of risk in the current pregnancy and have implications for the mode of delivery.

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Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0
weeks).

Term pregnancies (>24 weeks)

Gestation at delivery:

 Previous pre-term labour increases the risk of pre-term labour in later pregnancies.

Birth weight:

 A high birth weight in previous pregnancies raises the possibility of previous gestational
diabetes.
 A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a
further small for gestational age baby.

Mode of delivery:

 Spontaneous vaginal delivery

 Assisted vaginal delivery (e.g. forceps)
 Caesarean section (will have implications for the choice of future mode of delivery)

Complications:

 Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension, placenta

praevia and shoulder dystocia.
 Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and retained
products of conception.

Assisted reproduction:

 Clarify if IVF or other assisted reproductive techniques were used for any previous
pregnancies.

Stillbirth
As stated below, asking about stillbirths need to be done in a sensitive manner.

A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy.

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Sensitivity clarify the gestation of the stillbirth if this is not already documented.

Other pregnancies (<24 weeks)

Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive
manner in a private setting. It can be very difficult for women to discuss these topics. These
questions should only be asked when relevant and by a person who is competent to do so.

Miscarriage
A miscarriage is the loss of a pregnancy before 24 weeks gestation.

Gestation:

 Clarify the trimester at which the miscarriage occurred (miscarriage is most common in the
first trimester).

Other details:

 Clarify if medical or surgical management was required for the miscarriage and if any cause
was identified for the miscarriage (e.g. genetic syndromes).

Termination of pregnancy
Termination of pregnancy is the medical process of ending a pregnancy so it doesn’t result in the
birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical
procedure.

Clarify the gestation at which the termination of pregnancy was performed and the method of
management (e.g. medical or surgical).

Ectopic pregnancy
An ectopic pregnancy is when a fertilised egg implants itself outside of the uterus, usually in one
of the fallopian tubes.

Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant, medical,

surgical).

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Gynaecological history
Cervical screening:

 Confirm the date and result of the last cervical screening test.
 Ask if the patient received any treatment if the cervical screening test was abnormal and
check that follow up is in place.

Previous gynaecological conditions and treatments:

 Sexually transmitted infections

 Endometriosis
 Bartholin’s cyst
 Cervical ectropion
 Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history
A patient’s past medical history is particularly relevant during pregnancy, as some medical
conditions may worsen during pregnancy and/or have implications for the developing fetus.

Ask if the patient has any medical conditions: 

 “Do you have any medical conditions?”

 “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to
assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also
important to ask about any complications associated with the condition
including hospital admissions.

Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:

 Abdominal or pelvic surgery: may influence decisions regarding delivery due to the presence
of scar tissue and adhesions.
 Previous Caesarean section: increased risk of uterine rupture in subsequent pregnancies.
 Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence.

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Allergies
It’s essential to clarify any allergies the patient may have and to document these clearly in the notes,
including the type of allergic reaction the patient experienced.

Medical conditions which are particularly important to be aware of during pregnancy

Diabetes (type 1 or 2): blood glucose control can deteriorate significantly during pregnancy
resulting in poor maternal health and fetal complications (e.g. macrosomia).

Hypothyroidism: untreated or undertreated hypothyroidism can result in congenital hypothyroidism

with significant neurodevelopmental impact.

Epilepsy: seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage) and
many anti-epileptic drugs are teratogenic.

Previous venous thromboembolism (VTE): pregnancy is a pro-thrombotic state, therefore, women

who have previously developed a venous thromboembolism are at significantly increased risk of
developing further VTEs without prophylactic treatment (e.g. low molecular weight heparin).

Blood-borne viruses: HIV, hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical
transmission).

Genetic disease: it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-cell
disease, thalassaemia) carried by both the mother and father as this may influence the management of
the patient and their pregnancy (e.g. arranging input from the paediatric team immediately after
delivery).

Drug history
It is essential to gain an accurate overview of the medications the patient is currently and has
previously taken during the pregnancy. The first trimester is when the fetus is most at risk of
teratogenicity from drugs, as this is when organogenesis occurs.

Prescribed medications

Clarify the prescribed medications the patient has been taking since falling pregnant, noting which
they are still taking and which they have now stopped (including drug name, dose and route).

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  “Are you currently taking any prescribed medications or over-the-counter
treatments?”
 “Have you stopped taking any prescribed medication since you became pregnant?”

Ask if the patient was using contraception prior to becoming pregnant and if so, clarify
what method of contraception was being used. Check the patient has stopped their contraception or
had their contraceptive device removed (e.g. coil, implant).

If the patient is taking prescribed or over the counter

medications, document the medicationname, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

 “Have you noticed any side effects from the medication you currently take?”

Teratogenic drugs

Some examples of drugs that are known to be teratogenic include:

 ACE inhibitors
 Sodium valproate
 Methotrexate
 Retinoids
 Trimethoprim

Medications frequently used during pregnancy

Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations
and treat the symptoms of pregnancy.

Some examples of medications commonly used in pregnancy include:

 Folic acid (400μg): recommended daily for the first trimester of pregnancy to reduce the risk
of neural tube defects in the developing fetus.
 Oral iron: frequently used in pregnancy to treat anaemia.
 Antiemetics: frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis
gravidarum).
 Antacids: frequently used to manage gastro-oesophageal reflux symptoms during pregnancy.
 Aspirin

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Family history
Taking a brief family history can help to further assess the risk of adverse outcomes to the mother
and fetus during pregnancy. This can also help inform discussions with parents about the risk of their
child having a specific genetic disease (e.g. cystic fibrosis).

Some important medical conditions to ask about include:

 Inherited genetic conditions: such as cystic fibrosis and sickle cell disease.
 Type 2 diabetes: if first-degree relatives are affected there is an increased risk of gestational
diabetes.
 Pre-eclampsia: most relevant if maternal mother or sister is affected as this is associated
with an increased risk of developing pre-eclampsia.

Social history
Understanding the social context of a patient is absolutely key to building a complete picture of their
health. Social factors have a significant influence on a patient’s pregnancy.

General social context

Explore the patient’s general social context including:

 the type of accommodation they currently reside in (e.g. house, bungalow) and if there are
any adaptations to assist them (e.g. stairlift)
 who else the patient lives with and their personal support network
 what tasks they are able to carry out independently and what they require assistance with
(e.g. self-hygiene, housework, food shopping)

Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.

Offer smoking cessation services (see our smoking cessation guide for more details).

Smoking increases the risk of a small for gestational age baby.

35
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol
history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Excess alcohol use during pregnancy can result in conditions such as fetal alcohol syndrome.

Recreational drug use

It is important to ask about recreational drug use, as these can have significant consequences on the
mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).

If recreational drug use is identified, patients can be offered input from drug cessation services.

Diet and weight

Ask if the patient what their diet looks like on an average day.

Ask about the patient’s current weight (obesity significantly increases the risk of venous

thromboembolism, pre-eclampsia and gestational diabetes during pregnancy).

Occupation
Ask about the patient’s current occupation and if there are plans in place for maternity leave.

Domestic abuse
It is important to privately ask all pregnant women if they are a victim of domestic abuse to provide
an opportunity for them to seek help.

PREECLAMPSIA

Pre-eclampsia is a multisystem syndrome, developing after 20 weeks of pregnancy. It is

characterised by de novo hypertension which co-exists with one or more of the following clinical
features:

 Proteinuria
 Maternal dysfunction
 Uteroplacental dysfunction

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Hypertension may also develop after delivery but typically resolves by 6 weeks postpartum.

Pre-eclampsia is common, occurring in 2-8% of pregnancies.1

Around 0.5% of pregnant women can develop severe pre-eclampsia which can be life-threateningfor
both the mother and baby.2

Severe pre-eclampsia can progress to eclampsia (1 in 4000 pregnancies), a complication resulting

in maternal seizures.2

You might also be interested in our medical flashcard collection which contains over 1000

flashcards that cover key medical topics.

Aetiology
The underlying pathophysiology of pre-eclampsia is poorly understood. It is thought to be due
to abnormal placentation or maternal microvascular disease. Poor perfusion of the placenta
results in oxidative stress and the release of pro-inflammatory cytokines, which then cause maternal
peripheral endothelial dysfunction. This sequence of events ultimately results in the typical clinical
features of pre-eclampsia:

 Oedema and proteinuria: due to increased capillary permeability and movement of fluid

into interstitial spaces.
 Hypertension and end-organ damage (e.g. kidneys, liver): systemic vasoconstriction occurs
secondary to the release of vasoconstrictive factors.

Risk factors
The risk factors for pre-eclampsia are shown in table 1. 4

Table 1. Pre-eclampsia risk factors.

High risk Moderate risk

Chronic hypertension Aged 40 years or over

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 Hypertensive disease in a previous pregnancy
First pregnancy
Type I or type II diabetes mellitus
Pregnancy interval >10 years
Chronic kidney disease
Multiple pregnancy
Autoimmune disease:
Pre-pregnancy obesity (BMI >35kg/m2)
 Anti-phospholipid syndrome
Family history of pre-eclampsia (first-degree relative)
 Systemic lupus erythematous

The risk of adverse maternal and fetal outcomes is increased if pre-eclampsia develops early, before
33 weeks gestation, or at any gestation in those with additional risk factors.

Clinical features

History

Patients with pre-eclampsia often have no symptoms.

However, symptoms of pre-eclampsia may include:

 Headache
 Visual disturbance: such as blurring or flashing lights
 Swelling of the arms, legs and face
 Nausea and vomiting
 Abdominal pain
 Reduced urine output

Clinical examination

Clinical signs of pre-eclampsia may include:

 Hypertension
 Oedema: typically in the peripheries and face
 Epigastric/right upper quadrant tenderness
 Hyper-reflexia and clonus (indicates an increased risk of eclamptic seizure)
 Papilloedema

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Differential diagnoses
It is important to differentiate between other hypertensive disorders of pregnancy such as:

 Chronic hypertension: hypertension that occurs before 20 weeks gestation or persists after
12 weeks postpartum.
 Gestational hypertension: hypertension that occurs after 20 weeks gestation that develops
without any co-existing complications.
 Pre-eclampsia superimposed on chronic hypertension: hypertension that already exists but
worsens after 20 weeks gestation alongside the development of co-existing complications.

Investigations
Antenatal screening is used to detect pre-eclampsia at an early stage to allow appropriate
management to prevent adverse outcomes. Antenatal appointments include assessment of blood
pressure, a urine dipstick test to identify proteinuria (as well as signs of infection) and fetal heart
auscultation.

Laboratory investigations

Specific blood tests performed if there is a suspicion of pre-eclampsia include:

 FBC: low platelet count may suggest HELLP syndrome (see complications).
 U&Es: raised urea, raised creatinine and low eGFR indicate renal impairment.
 LFTs: raised ALT or AST indicate liver dysfunction.
 Clotting profile: clotting may be deranged in the context of disseminated intravascular
coagulation (DIC).

Placental growth factor (PIGF) supports trophoblastic growth and therefore has a role in placental
angiogenesis. A blood test measuring PIGF levels can be used to aid diagnosis in pre-eclampsia,
particularly in patients with chronic or gestational hypertension. Elevated levels of PIGF suggest that
pre-eclampsia is unlikely to be present. However, low PIGF levels only indicate, but do not confirm a
diagnosis of pre-eclampsia.

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Diagnostic criteria

The diagnostic criteria for pre-eclampsia are as follows:

 Hypertension: blood pressure of ≥140mmHg systolic or ≥90mmHg diastolic.

 Proteinuria: ≥300 mg protein in a 24-hour urine collection, a urine protein/creatinine ratio
≥30 mg/mmol or two readings of at least ++ protein on urinary dipstick analysis. 4
 Maternal organ dysfunction: liver involvement, renal insufficiency, haematological
complications (e.g. thrombocytopenia, DIC) and neurological involvement (e.g. visual
disturbance).
 Uteroplacental dysfunction: intrauterine growth restriction and stillbirth.

Preeclampsia is a complication of pregnancy. With preeclampsia, you might have high

blood pressure, high levels of protein in urine that indicate kidney damage (proteinuria),
or other signs of organ damage. Preeclampsia usually begins after 20 weeks of
pregnancy in women whose blood pressure had previously been in the standard range.

Left untreated, preeclampsia can lead to serious — even fatal — complications for both
the mother and baby.

Early delivery of the baby is often recommended. The timing of delivery depends on
how severe the preeclampsia is and how many weeks pregnant you are. Before
delivery, preeclampsia treatment includes careful monitoring and medications to lower
blood pressure and manage complications.

Preeclampsia may develop after delivery of a baby, a condition known as postpartum

preeclampsia.

Products & Services

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40
Symptoms

The defining feature of preeclampsia is high blood pressure, proteinuria, or other signs
of damage to the kidneys or other organs. You may have no noticeable symptoms. The
first signs of preeclampsia are often detected during routine prenatal visits with a health
care provider.

Along with high blood pressure, preeclampsia signs and symptoms may include:

 Excess protein in urine (proteinuria) or other signs of kidney

problems
 Decreased levels of platelets in blood (thrombocytopenia)
 Increased liver enzymes that indicate liver problems
 Severe headaches
 Changes in vision, including temporary loss of vision, blurred
vision or light sensitivity
 Shortness of breath, caused by fluid in the lungs
 Pain in the upper belly, usually under the ribs on the right
side
 Nausea or vomiting
Weight gain and swelling (edema) are typical during healthy pregnancies. However,
sudden weight gain or a sudden appearance of edema — particularly in your face and
hands — may be a sign of preeclampsia.

When to see a doctor

Make sure you attend your prenatal visits so that your health care provider can monitor
your blood pressure. Contact your provider immediately or go to an emergency room if
you have severe headaches, blurred vision or other visual disturbances, severe belly
pain, or severe shortness of breath.

Because headaches, nausea, and aches and pains are common pregnancy complaints,
it's difficult to know when new symptoms are simply part of being pregnant and when

41
they may indicate a serious problem — especially if it's your first pregnancy. If you're
concerned about your symptoms, contact your doctor.

Causes

The exact cause of preeclampsia likely involves several factors. Experts believe it
begins in the placenta — the organ that nourishes the fetus throughout pregnancy.
Early in a pregnancy, new blood vessels develop and evolve to supply oxygen and
nutrients to the placenta.

In women with preeclampsia, these blood vessels don't seem to develop or work
properly. Problems with how well blood circulates in the placenta may lead to the
irregular regulation of blood pressure in the mother.

Other high blood pressure disorders during pregnancy

Preeclampsia is one high blood pressure (hypertension) disorder that can occur during
pregnancy. Other disorders can happen, too:

 Gestational hypertension is high blood pressure that

begins after 20 weeks without problems in the kidneys or
other organs. Some women with gestational hypertension
may develop preeclampsia.
 Chronic hypertension is high blood pressure that was
present before pregnancy or that occurs before 20 weeks of
pregnancy. High blood pressure that continues more than
three months after a pregnancy also is called chronic
hypertension.
 Chronic hypertension with superimposed
preeclampsia occurs in women diagnosed with chronic high
blood pressure before pregnancy, who then develop
worsening high blood pressure and protein in the urine or
other health complications during pregnancy.

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Risk factors

Conditions that are linked to a higher risk of preeclampsia include:

 Preeclampsia in a previous pregnancy

 Being pregnant with more than one baby
 Chronic high blood pressure (hypertension)
 Type 1 or type 2 diabetes before pregnancy
 Kidney disease
 Autoimmune disorders
 Use of in vitro fertilization
Conditions that are associated with a moderate risk of developing preeclampsia include:

 First pregnancy with current partner

 Obesity
 Family history of preeclampsia
 Maternal age of 35 or older
 Complications in a previous pregnancy
 More than 10 years since previous pregnancy
Other risk factors

Several studies have shown a greater risk of preeclampsia among Black women
compared with other women. There's also some evidence of an increased risk among
indigenous women in North America.

A growing body of evidence suggests that these differences in risk may not necessarily
be based on biology. A greater risk may be related to inequities in access to prenatal
care and health care in general, as well as social inequities and chronic stressors that
affect health and well-being.

43
Lower income also is associated with a greater risk of preeclampsia likely because of
access to health care and social factors affecting health.

For the purposes of making decisions about prevention strategies, a Black woman or a
woman with a low income has a moderately increased risk of developing preeclampsia.

Complications

Complications of preeclampsia may include:

 Fetal growth restriction. Preeclampsia affects the arteries

carrying blood to the placenta. If the placenta doesn't get
enough blood, the baby may receive inadequate blood and
oxygen and fewer nutrients. This can lead to slow growth
known as fetal growth restriction.
 Preterm birth. Preeclampsia may lead to an unplanned
preterm birth — delivery before 37 weeks. Also, planned
preterm birth is a primary treatment for preeclampsia. A baby
born prematurely has increased risk of breathing and feeding
difficulties, vision or hearing problems, developmental
delays, and cerebral palsy. Treatments before preterm
delivery may decrease some risks.
 Placental abruption. Preeclampsia increases your risk of
placental abruption. With this condition, the placenta
separates from the inner wall of the uterus before delivery.
Severe abruption can cause heavy bleeding, which can be
life-threatening for both the mother and baby.
 HELLP syndrome. HELLP stands for hemolysis (the destruction of red
blood cells), elevated liver enzymes and low platelet count. This severe form
of preeclampsia affects several organ systems. HELLP syndrome is life-
threatening to the mother and baby, and it may cause lifelong health
problems for the mother.

Signs and symptoms include nausea and vomiting, headache, upper right
belly pain, and a general feeling of illness or being unwell. Sometimes, it

44
 develops suddenly, even before high blood pressure is detected. It also may
develop without any symptoms.

 Eclampsia. Eclampsia is the onset of seizures or coma with signs or

symptoms of preeclampsia. It is very difficult to predict whether a patient
with preeclampsia will develop eclampsia. Eclampsia can happen without
any previously observed signs or symptoms of preeclampsia.

Signs and symptoms that may appear before seizures include severe
headaches, vision problems, mental confusion or altered behaviors. But,
there are often no symptoms or warning signs. Eclampsia may occur before,
during or after delivery.

 Other organ damage. Preeclampsia may result in damage

to the kidneys, liver, lung, heart, or eyes, and may cause a
stroke or other brain injury. The amount of injury to other
organs depends on how severe the preeclampsia is.
 Cardiovascular disease. Having preeclampsia may
increase your risk of future heart and blood vessel
(cardiovascular) disease. The risk is even greater if you've
had preeclampsia more than once or you've had a preterm
delivery.

Prevention
Medication

The best clinical evidence for prevention of preeclampsia is the use of low-dose aspirin.
Your primary care provider may recommend taking an 81-milligram aspirin tablet daily
after 12 weeks of pregnancy if you have one high-risk factor for preeclampsia or more
than one moderate-risk factor.

It's important that you talk with your provider before taking any medications, vitamins or
supplements to make sure it's safe for you.

45
Lifestyle and healthy choices

Before you become pregnant, especially if you've had preeclampsia before, it's a good
idea to be as healthy as you can be. Talk to your provider about managing any
conditions that increase the risk of preeclampsia.

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