Antenatal Case History Taking: Essential Components

Pre-Pregnancy and Medical History

The American College of Obstetricians and Gynecologists recommends documenting all pre-existing conditions, including diabetes, hypertension, cardiovascular disease, thyroid disorders, and autoimmune conditions, as these significantly impact pregnancy outcomes and require specialized management 1
The American Academy of Pediatrics suggests recording all medications and supplements currently used, including over-the-counter medications, as certain drugs are teratogenic and require immediate discontinuation 2
Assess for substance use, including tobacco, alcohol, cocaine, methamphetamines, and other recreational drugs, as cocaine carries a increased risk of placental abruption 3

A detailed menstrual history, including age at menarche, cycle regularity, and last menstrual period, is necessary to accurately establish gestational age, as recommended by the British Medical Journal 4
Fertility history, including use of assisted reproductive technologies, may increase certain pregnancy risks, according to the British Medical Journal 4

Document each pregnancy outcome using standardized scoring, including term births, preterm births, spontaneous abortions, therapeutic abortions, and living children, as suggested by the American College of Radiology 5
Gestational age at delivery for each previous birth is crucial, as history of preterm birth increases risk of recurrent preterm delivery and stroke, according to the British Medical Journal 4
Mode of delivery for each pregnancy, specifically number of prior cesarean sections, is important, as risk of placenta accreta spectrum disorder increases after one cesarean, as reported by the Journal of the American College of Radiology 6

Pre-eclampsia or gestational hypertension in previous pregnancies increases stroke risk, according to the British Medical Journal 4
Gestational diabetes history increases stroke risk and indicates need for early glucose screening, as recommended by the British Medical Journal 4
Placental complications, including placenta previa, abruption, or retained placenta, are associated with increased risk of placenta accreta, according to the Journal of the American College of Radiology 6

Sudden unexplained death in first- or second-degree relatives before age 35 is a significant risk factor, as reported by the American Academy of Pediatrics 10
Venous thromboembolism in relatives, particularly at young age, is a risk factor, according to the American Journal of Hematology 8

Family structure and individuals living in home are important factors, as reported by the American Academy of Pediatrics 10
History of depression or anxiety is associated with adverse childhood experiences and early-onset depression, which are linked to hypertension, according to the American Academy of Pediatrics 9

Tobacco exposure, including active smoking and passive smoke exposure, is a significant risk factor, as reported by the American Academy of Pediatrics 10 and the American Heart Association 11
Alcohol consumption frequency and quantity increase abruption risk, according to the American College of Obstetricians and Gynecologists 3

Sodium intake, including processed foods and added salt, is linked to hypertension, as reported by the American Academy of Pediatrics 9
Consumption of fruits, vegetables, and whole grains is important for a healthy diet, according to the American Heart Association 11

Gestational age at birth, if patient was born preterm, affects risk assessment, as reported by the American Academy of Pediatrics 10
Birth weight, particularly if low birth weight, influences later cardiovascular risk, according to the American Academy of Pediatrics 9

Pneumococcal vaccine is recommended if indicated by medical conditions, as suggested by the American College of Obstetricians and Gynecologists 1

Ensure communication between providers, including obstetricians, anesthesiologists, and other specialists, as recommended by the American Society of Anesthesiologists 12
Plan for multidisciplinary care when risk factors are identified, including early involvement of maternal-fetal medicine, cardiology, or other specialists as needed, according to the Journal of Anaesthesia 7