What information should be included in antenatal case history taking?

Antenatal Case History Taking: Essential Components

A comprehensive antenatal history must systematically capture pre-pregnancy health, obstetric history, current pregnancy details, family history, psychosocial factors, and environmental exposures to identify risk factors that predict maternal and fetal complications.

Pre-Pregnancy and Medical History

Chronic Medical Conditions

• Document 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
• Record all medications and supplements currently used, including over-the-counter medications, as certain drugs are teratogenic and require immediate discontinuation 1
• Assess for substance use including tobacco (quantify cigarettes per day), alcohol, cocaine, methamphetamines, and other recreational drugs, as cocaine carries a 3.92-fold increased risk of placental abruption 2

Reproductive and Gynecologic History

• Detailed menstrual history including age at menarche, cycle regularity, and last menstrual period to accurately establish gestational age 1
• Fertility history including use of assisted reproductive technologies, as fertility therapy may increase certain pregnancy risks 1
• Contraceptive history particularly oral contraceptive use, which has implications for thrombotic risk assessment 1
• Age at menopause for older mothers, as early menopause is associated with cardiovascular risk factors 1

Complete Obstetric History

Previous Pregnancies

• Document each pregnancy outcome using standardized scoring: term births (≥37 weeks), preterm births (<37 weeks), spontaneous abortions, therapeutic abortions, and living children 3
• Gestational age at delivery for each previous birth, as history of preterm birth increases risk 1.71-fold for recurrent preterm delivery and 1.65-fold for stroke 1
• Mode of delivery for each pregnancy, specifically number of prior cesarean sections, as risk of placenta accreta spectrum disorder increases 7-fold after one cesarean to 56-fold after three cesareans 1

Pregnancy Complications

• Pre-eclampsia or gestational hypertension in previous pregnancies, as recurrent pre-eclampsia increases stroke risk 1.69-fold 1
• Gestational diabetes history, which increases stroke risk 1.25-fold and indicates need for early glucose screening 1
• Placental complications including placenta previa, abruption, or retained placenta, as previa is present in 49% of placenta accreta cases 1
• Hemorrhage requiring transfusion or surgical intervention 1
• Preterm labor or premature rupture of membranes 1
• Intrauterine growth restriction or stillbirth 1

Neonatal Outcomes

• Birth weights of previous children, particularly low birth weight (<2500g) or macrosomia (>4000g) 1
• Neonatal complications including respiratory distress, hypoglycemia, jaundice requiring phototherapy, or NICU admission 1
• Congenital anomalies in previous children 1

Current Pregnancy Details

Pregnancy Recognition and Dating

• Method of pregnancy recognition (missed period, symptoms, positive test), as recognition by missed period is associated with later ANC initiation 4
• Last menstrual period and regularity of cycles 5
• First positive pregnancy test date 6
• Any early pregnancy bleeding or cramping 5

Current Symptoms

• Nausea, vomiting, and ability to maintain nutrition 6
• Vaginal bleeding or discharge 5
• Abdominal pain or cramping 6
• Urinary symptoms including frequency, dysuria, or urgency, as urinary tract infections increase pyelonephritis risk 5

Family History: Critical for Risk Stratification

Cardiovascular and Thrombotic Disease

• Sudden unexplained death in first- or second-degree relatives before age 35, particularly as infants 1
• Long QT syndrome or arrhythmias in family members 1
• Venous thromboembolism in relatives, particularly at young age 1
• Stroke or myocardial infarction in relatives under age 50 1

Pregnancy-Related Complications

• Pre-eclampsia or eclampsia in mother or sisters 1
• Gestational diabetes in first-degree relatives 1
• Recurrent pregnancy loss in family members 3

Genetic and Metabolic Disorders

• Inborn errors of metabolism or genetic diseases 1
• Congenital anomalies in family members 1
• Consanguinity if applicable 1

Psychosocial Assessment

Social Support and Living Situation

• Family structure and individuals living in home 1
• Housing stability including general conditions, water damage, or mold problems 1
• Recent changes, stressors, or family strife 1
• Support systems and access to needed resources 1

Mental Health Screening

• History of depression or anxiety, as adverse childhood experiences and early-onset depression are associated with hypertension 1
• Current feelings of depression, anxiety, or helplessness 1
• History of domestic violence or previous child protective services involvement 1

Substance Exposure

• Tobacco exposure including active smoking (quantify) and passive smoke exposure 1
• Alcohol consumption frequency and quantity, as alcohol increases abruption risk 2.2-fold 2
• Illicit drug use including cocaine, methamphetamines, opioids, and marijuana 1, 2
• Exposure to toxic substances in home or workplace 1

Nutritional and Lifestyle Assessment

Dietary Patterns

• Sodium intake including processed foods and added salt, as high sodium intake is linked to hypertension 1
• Consumption of fruits, vegetables, and whole grains 1
• Intake of high-fat foods and sugary beverages 1
• Caffeine consumption 1
• Vitamin and supplement use including folic acid, iron, and prenatal vitamins 6

Physical Activity

• Current exercise patterns including type, frequency, and intensity 1
• Occupational physical demands 1
• Sedentary time including screen time 1

Perinatal History for Current Pregnancy Planning

Birth History Details

• Gestational age at birth if patient was born preterm, as prematurity <32 weeks affects risk assessment 1
• Birth weight particularly if low birth weight, which influences later cardiovascular risk 1
• Maternal complications during patient's own birth 1
• Neonatal complications including NICU stay or umbilical catheter placement 1

Immunization and Infectious Disease History

Vaccination Status

• Influenza vaccine current season 6
• Tdap vaccine timing of last dose 6
• Pneumococcal vaccine if indicated by medical conditions 1
• COVID-19 vaccination status 6

Infectious Disease Screening

• History of sexually transmitted infections including syphilis, gonorrhea, chlamydia, HIV, and hepatitis B/C 5
• Recent exposure to infectious illnesses particularly upper respiratory infections, paroxysmal cough, or pertussis 1
• Travel history to areas with endemic infections 6

Documentation and Communication

Record Accessibility

• Establish system for record availability at all visits, as women-held records improve sense of control without compromising record availability 7
• Ensure communication between providers including obstetricians, anesthesiologists, and other specialists 1

Risk Stratification

• Identify high-risk features at first visit, as high-risk pregnancy at first ANC increases complications during pregnancy (OR 1.23) and labor/delivery (OR 1.24) 8
• Plan for multidisciplinary care when risk factors identified, including early involvement of maternal-fetal medicine, cardiology, or other specialists as needed 1

Critical Pitfalls to Avoid

• Do not rely solely on maternal self-reporting for substance use, as this significantly underestimates exposure; consider objective screening when indicated 1
• Do not overlook inadequate prenatal care as a risk factor itself, which clusters with other high-risk behaviors 2
• Do not assume all topics will be covered in time-constrained visits; studies show many ACOG-recommended components are frequently omitted 6
• Do not delay risk assessment beyond first trimester, as 59.4% of women in some populations present late, missing critical early interventions 4