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HoPi in Obstetrics — Common Complaints, Descriptions & State-Format Questions

The History of Present Illness (HoPi) in obstetrics follows the same structured approach as general medicine but is layered with pregnancy-specific context. Below is a clinical guide for the most common obstetric complaints — each section includes how the complaint typically presents in a patient's words, followed by state-format questions (the systematic questions a clinician asks) with explanations of clinical relevance.

1. NAUSEA AND VOMITING (Morning Sickness / Hyperemesis Gravidarum)

How the Patient Describes It

"I've been feeling sick to my stomach since 6 weeks. I vomit almost every morning but also sometimes in the evening. I can barely keep food down. I've lost about 3 kg in 2 weeks."

State-Format HoPi Questions

#	Question	Explanation
1	Onset — "When did the nausea start? How many weeks pregnant were you?"	NVP (nausea/vomiting of pregnancy) typically begins at 4–8 weeks gestation. Late onset raises concern for other GI pathology.
2	Timing — "Does it happen only in the morning or throughout the day?"	Only 2% have true morning-only symptoms; 80% are symptomatic throughout the day — so "morning sickness" is misleading. Persistent all-day vomiting suggests hyperemesis gravidarum (HG). (Creasy & Resnik's MFM)
3	Frequency/Severity — "How many times per day do you vomit? Can you keep fluids down?"	Inability to keep fluids down for >24 hours, or >3 vomiting episodes/day, suggests HG requiring admission.
4	Associated weight loss — "Have you lost any weight? How much?"	Weight loss >5% of pre-pregnancy body weight is a hallmark of hyperemesis gravidarum.
5	Aggravating/relieving factors — "Does food, smell, or movement make it worse? Does anything help?"	Triggers include strong smells, fatty foods, and motion. Relief with small bland meals distinguishes mild NVP from HG.
6	Urine output — "Have you noticed your urine becoming very dark or are you passing less urine?"	Oliguria and dark urine signal dehydration — a key deciding factor for IV fluid treatment.
7	Associated symptoms — "Any abdominal pain, fever, diarrhea, or blood in vomit?"	Fever, diarrhea, or hematemesis point away from NVP toward gastroenteritis, peptic ulcer, or pancreatitis.
8	Gestational age — "How far along are you?"	NVP typically resolves by 12–16 weeks. Persistence beyond 20 weeks requires re-evaluation.

2. VAGINAL BLEEDING IN PREGNANCY

How the Patient Describes It (1st Trimester)

"I noticed bright red bleeding and cramping at 8 weeks. It soaked about one pad. I'm worried I'm losing the baby."

How the Patient Describes It (3rd Trimester)

"I woke up at 32 weeks with a gush of bright red, painless bleeding. There were no contractions."

State-Format HoPi Questions

#	Question	Explanation
1	Gestational age — "How many weeks pregnant are you?"	First-trimester bleeding → threatened abortion, miscarriage, ectopic. Second trimester → cervical causes, miscarriage. Third trimester → placenta previa or abruption.
2	Amount — "How much blood? How many pads soaked? Is there clotting?"	Quantifying blood loss guides hemodynamic assessment. Passage of clots or tissue may indicate incomplete miscarriage.
3	Character — "Is the blood bright red or dark brown?"	Bright red = active bleeding (placenta previa, abruption, ectopic rupture). Dark brown = older blood (often less urgent).
4	Pain — "Is there any associated pain, cramping, or contractions?"	Painless bright red bleeding → placenta previa. Painful bleeding with board-like abdomen → abruptio placentae. Severe unilateral pain + bleeding → ectopic pregnancy.
5	Onset — "Did the bleeding start suddenly or gradually?"	Sudden painless gush after 28 weeks is characteristic of placenta previa. (Barash Clinical Anesthesia)
6	Fetal movement — "Have you felt the baby moving today?"	Reduced fetal movement with bleeding raises concern for placental abruption causing fetal compromise.
7	Recent intercourse or trauma — "Did you have intercourse or any physical trauma recently?"	Post-coital bleeding may indicate cervical ectropion (benign) vs. cervical pathology.
8	Previous placenta previa/abruption — "Has this happened in a previous pregnancy?"	Past placenta previa is a major risk factor for recurrence.

3. HEADACHE IN PREGNANCY

How the Patient Describes It

"I'm 34 weeks and I've had a severe throbbing headache for 2 days that won't go away with paracetamol. My face and hands look puffy."

State-Format HoPi Questions

#	Question	Explanation
1	Character — "Describe the headache: throbbing, pressure, band-like?"	Throbbing frontal/occipital headache in the 3rd trimester is a classic CNS manifestation of preeclampsia. (Rosen's Emergency Medicine)
2	Onset and duration — "When did it start? Is it getting worse?"	Progressively worsening headache after 20 weeks is alarming for evolving severe preeclampsia or eclampsia.
3	Associated visual symptoms — "Any blurred vision, flashing lights, or blind spots?"	Visual disturbances (scotomata, blurred vision) = vasospasm affecting the occipital cortex — a severe feature of preeclampsia.
4	Blood pressure history — "Do you know your blood pressure readings? Has it been high?"	Hypertension ≥140/90 mmHg after 20 weeks + headache = preeclampsia until proven otherwise. (Miller's Anesthesia)
5	Edema — "Have you noticed swelling of your hands, face, or feet, especially in the morning?"	Facial and hand edema (not just ankle edema) in the 3rd trimester is significant for preeclampsia.
6	Epigastric/RUQ pain — "Any pain in the upper right side or below your ribs?"	RUQ pain = hepatic capsule distension → HELLP syndrome. A life-threatening complication of preeclampsia.
7	Proteinuria symptoms — "Any frothy urine?"	Frothy urine suggests significant proteinuria, supporting the diagnosis of preeclampsia.
8	Seizure activity — "Have you had any fits, jerking movements, or lost consciousness?"	New-onset seizure after 20 weeks = eclampsia — a medical emergency requiring immediate magnesium sulfate.

4. ABDOMINAL PAIN IN PREGNANCY

How the Patient Describes It

"I'm 28 weeks and I have a sharp pain on my right side that comes and goes. It's been getting stronger and I feel sick with it."

State-Format HoPi Questions

#	Question	Explanation
1	Location — "Where exactly is the pain? Can you point to it?"	RLQ pain → appendicitis (appendix is displaced superiorly in pregnancy). RUQ → HELLP, cholecystitis. Central cramping → preterm labor or contractions. Unilateral → round ligament pain or ectopic (early pregnancy).
2	Character — "Is it sharp, dull, cramping, or tearing?"	Cramping/rhythmic = contractions (uterine). Constant severe = abruption or acute abdomen.
3	Onset — "Did it come on suddenly or gradually?"	Sudden onset severe pain → ruptured ectopic, uterine rupture, abruption. Gradual = appendicitis, UTI, round ligament.
4	Radiation — "Does the pain move anywhere — your back, shoulder, groin?"	Shoulder tip pain → diaphragmatic irritation (ruptured ectopic). Back radiation → renal colic or labor.
5	Associated features — "Fever, vomiting, urinary symptoms, bleeding, discharge?"	Fever + RLQ pain → appendicitis. Dysuria + frequency → UTI/pyelonephritis. Bleeding + pain → abruption or miscarriage.
6	Fetal movement — "When did you last feel the baby move?"	Reduced fetal movement with abdominal pain is an emergency — suggests fetal compromise.
7	Contractions — "Does the pain come in waves with a regular pattern?"	Regular painful contractions before 37 weeks = preterm labor; requires urgent assessment and possible tocolysis.
8	Aggravating/relieving factors — "Does movement, eating, or urination make it worse or better?"	Pain worse after fatty meal → cholecystitis. Pain with movement only → round ligament pain (benign).

5. REDUCED FETAL MOVEMENTS

How the Patient Describes It

"I'm 36 weeks and I haven't felt the baby move since this morning. Yesterday she was very active. I'm really scared."

State-Format HoPi Questions

#	Question	Explanation
1	Duration — "When did you last feel definite movements?"	No perceived movement for >12 hours (especially in 3rd trimester) warrants immediate CTG monitoring.
2	Baseline pattern — "What is her normal pattern — is she usually active morning or evening?"	Fetal movement patterns are individual; a deviation from the baby's own pattern is more significant than absolute count.
3	Kick count — "Have you been doing kick counts? How many kicks in the last 2 hours?"	<10 movements in 2 hours when the mother is focusing on movement = reduced fetal movement requiring assessment.
4	Associated bleeding or pain — "Any vaginal bleeding or painful contractions?"	Bleeding + reduced movement → placental abruption with fetal compromise.
5	Precipitating factors — "Have you had anything to drink or eat recently? Did you take any sedating medications?"	Maternal hypoglycemia and sedatives (including opioids) can temporarily reduce fetal movements — not immediately dangerous.
6	Gestational age — "How far along are you?"	Reduced movements <28 weeks are harder to assess; after 28 weeks formal kick counts are used.
7	Previous pregnancy complications — "Did you have any problems in previous pregnancies (e.g., stillbirth, IUGR)?"	Previous intrauterine death or IUGR significantly heightens risk and lowers threshold for immediate intervention.

6. LEAKING/RUPTURE OF MEMBRANES (PROM/PPROM)

How the Patient Describes It

"I'm 30 weeks and I felt a sudden gush of watery fluid down my legs about an hour ago. I've been leaking since and it doesn't smell like urine."

State-Format HoPi Questions

#	Question	Explanation
1	Onset and character — "Was it a sudden gush or a slow trickle? Is it continuous?"	Sudden gush = complete ROM. Slow continuous trickle = high rupture. Intermittent = possible urinary incontinence (must differentiate).
2	Color and odor — "What color is the fluid? Does it have an odor? Is there any green or brown color?"	Clear/pale yellow = amniotic fluid. Green/brown = meconium-stained liquor (fetal distress). Foul odor → chorioamnionitis.
3	Amount — "How much fluid — did it soak your clothing/pad?"	Large volume strongly suggests ROM. Small amounts may be discharge or urine.
4	Gestational age — "How many weeks pregnant are you?"	PPROM (<37 weeks) carries significant risks: infection, cord prolapse, preterm delivery — management differs from term PROM.
5	Uterine contractions — "Have you had any contractions or tightenings since the fluid leaking?"	Contractions after ROM = labor, which at preterm gestations may need tocolysis while corticosteroids are administered.
6	Signs of infection — "Do you have a fever, chills, or foul-smelling discharge?"	Fever + ruptured membranes = chorioamnionitis → immediate delivery indicated regardless of gestational age.
7	Fetal movement — "Is the baby still moving normally?"	ROM increases cord prolapse risk → reduced movements may signal cord compression.

7. DYSURIA / URINARY SYMPTOMS IN PREGNANCY

How the Patient Describes It

"I'm 20 weeks and I've been going to the toilet every 20 minutes. It burns when I urinate and my back is aching. I feel hot."

State-Format HoPi Questions

#	Question	Explanation
1	Symptoms — "Do you have burning, frequency, urgency, or pain passing urine?"	Dysuria + frequency + urgency = UTI. UTI in pregnancy can rapidly ascend to pyelonephritis.
2	Loin/back pain and fever — "Do you have pain in your back/flank and a temperature?"	Loin pain + fever + dysuria → pyelonephritis, the most common non-obstetric cause of hospitalization in pregnancy.
3	Hematuria — "Have you noticed blood in your urine?"	Hematuria with UTI symptoms may suggest cystitis or urolithiasis (renal stones are more common in pregnancy).
4	Previous UTIs in this pregnancy — "Have you had urine infections before in this pregnancy?"	Recurrent UTIs → may indicate resistant organism or undiagnosed structural problem; urinalysis and culture are required.
5	Recent procedures — "Have you had any internal examinations or catheterization recently?"	Recent cervical examinations or catheterization increase UTI risk in pregnancy.
6	Urine output — "Are you drinking enough? Have you noticed reduced urine output?"	Dehydration exacerbates UTI risk and is common in hyperemetic patients.

8. SWELLING (EDEMA) IN PREGNANCY

How the Patient Describes It

"My ankles have been swollen for weeks, but now my face and hands are puffy too when I wake up, and I have a headache."

State-Format HoPi Questions

#	Question	Explanation
1	Distribution — "Is swelling only in your ankles and legs, or also in your face, hands, and feet?"	Ankle edema alone is physiologic in pregnancy (venous stasis). Facial and hand edema = pathological → preeclampsia. (Bradley & Daroff's Neurology)
2	Timing — "Is it worse in the morning (on waking) or in the evening?"	Physiologic edema is worse in the evening (dependent). Preeclamptic edema is notably worse in the morning (renal etiology).
3	Rate of progression — "Has it appeared suddenly or built up slowly?"	Sudden facial swelling → concerning for rapidly evolving preeclampsia.
4	Associated headache, visual disturbance, epigastric pain — "Are you having headaches or seeing flashes?"	Any combination of edema + headache + visual changes + hypertension = severe preeclampsia features — immediate assessment needed.
5	Blood pressure readings — "Has your blood pressure been checked recently? Was it normal?"	BP ≥140/90 mmHg after 20 weeks + pathological edema = preeclampsia screen.
6	Breathlessness — "Are you finding it hard to breathe when lying flat?"	Pulmonary edema (orthopnea) in pregnancy → cardiac failure, severe preeclampsia, or peripartum cardiomyopathy.

Summary Table: SOCRATES Applied to Obstetric Complaints

Feature	Obstetric Consideration
Site	Uterine vs. adnexal vs. urinary vs. epigastric — location guides differential
Onset	Sudden = emergency (ectopic rupture, abruption, ROM). Gradual = physiologic or UTI
Character	Cramping = uterine. Sharp = surgical. Throbbing = vascular (preeclampsia headache)
Radiation	Shoulder tip = diaphragmatic irritation (ruptured ectopic). Back = renal or labor
Associated symptoms	Always ask: bleeding, fetal movement, discharge, fever, urinary symptoms
Timing	Gestational age frames every single symptom — same complaint has different significance at 8 vs 36 weeks
Exacerbating/relieving	Movement-dependent pain = musculoskeletal/round ligament. Positional = reflux
Severity	Quantify: blood loss in pads, vomiting episodes per day, pain scale

Sources: Creasy & Resnik's Maternal-Fetal Medicine; Rosen's Emergency Medicine; Miller's Anesthesia; Barash Clinical Anesthesia 9e; Berek & Novak's Gynecology; Sleisenger & Fordtran's GI & Liver Disease

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I now have solid textbook grounding. Here are fully written, clinically smart HoPi scenario examples for the commonest obstetric complaints — each written as a complete, flowing narrative the way a clinician would document it, from presenting complaint through to summary.

HoPi Scenario Examples in Obstetrics

Each scenario is written in full clinical narrative style — the kind used in ward notes, clerking sheets, and OSCE/OSPE documentation. Read-aloud friendly and examination-ready.

SCENARIO 1 — Nausea & Vomiting (Hyperemesis Gravidarum)

Patient: Mrs. Amina H., 26 years old, G1P0, 9 weeks gestation.

Presenting Complaint

Persistent vomiting and inability to tolerate oral intake for 5 days.

History of Presenting Illness

Mrs. Amina H. is a 26-year-old primigravida at 9 weeks gestation who presented with a 5-day history of severe, persistent nausea and vomiting. She reports that the symptoms began insidiously at 6 weeks of gestation, initially as mild morning queasiness, but over the past 5 days have worsened significantly, occurring continuously throughout the day with no period of relief. She is vomiting approximately 8–10 times per day, initially bringing up undigested food and now producing only bile and saliva, as she is unable to retain any oral intake.

She denies any fever, diarrhea, or abdominal pain. There is no history of blood in the vomit. She has not had any urinary symptoms, and she denies any vaginal bleeding or discharge. Fetal movements are not yet perceived at this gestational age.

She reports a subjective weight loss and her husband estimates she has lost approximately 4–5 kg over the past two weeks. She is unable to drink even sips of water without vomiting. Her urine has become very dark in color and she has noticed a significant reduction in urinary frequency over the past 2 days, passing urine only once in the last 24 hours.

She has had no relief with dietary measures (dry crackers, small frequent meals) or with oral antiemetics (metoclopramide) prescribed by her GP two days ago, as she is unable to keep the tablets down. There is no precipitating trauma, no known sick contacts, and no recent travel. She has no previous history of gastrointestinal disease.

Her last menstrual period was 9 weeks ago. The pregnancy was confirmed by urine and serum hCG. She has had one antenatal visit. She is not on any regular medications other than folic acid.

Obstetric & Gynaecological History

Gravida: 1 Para: 0
LMP: 9 weeks ago (confirmed by early dating scan at 7 weeks — singleton, viable)
No previous miscarriages or terminations
No history of ovarian or uterine pathology

Past Medical / Surgical History

Nil significant. No previous abdominal surgeries.

Drug History

Folic acid 5 mg OD. Oral metoclopramide (unable to retain). No known drug allergies.

Family / Social History

Non-smoker, no alcohol. Works as a teacher, currently signed off sick. Lives with husband. Good social support.

Summary

Mrs. Amina H. is a 26-year-old primigravida at 9 weeks gestation presenting with a 5-day history of intractable nausea and vomiting with complete inability to tolerate oral intake, weight loss exceeding 5% of pre-pregnancy body weight, oliguria, and dark concentrated urine — consistent with hyperemesis gravidarum with dehydration and probable electrolyte imbalance. She has failed outpatient management and requires IV rehydration, electrolyte replacement, and parenteral antiemetics. Thyroid function and urine ketones should be checked urgently.

SCENARIO 2 — Painless Vaginal Bleeding (Placenta Previa)

Patient: Mrs. Fatima K., 32 years old, G3P2, 32 weeks gestation.

Presenting Complaint

A sudden gush of painless bright red vaginal bleeding 2 hours ago.

History of Presenting Illness

Mrs. Fatima K. is a 32-year-old woman in her third pregnancy, currently at 32 weeks gestation, who presented to the emergency department at midnight following a sudden onset of painless bright red vaginal bleeding that began approximately 2 hours prior to arrival. She was sleeping and awoke to find the bed sheets soaked with blood. She estimates approximately 2–3 pads fully soaked. There was no warning pain, no uterine contractions, and no preceding trauma or intercourse.

The bleeding has slowed slightly since arrival but has not completely stopped. She denies any abdominal pain, uterine tightening, or back pain at any point. There is no associated fever or foul-smelling discharge. She reports that fetal movements have been present and felt normally up to the time of bleeding, though she has been too distressed to actively assess movements since.

She had an episode of lighter painless bleeding (approximately half a pad) at 28 weeks, which resolved spontaneously. She was reviewed at a routine scan at that time and recalls being told the placenta was "low-lying," but she did not attend a follow-up ultrasound appointment as advised.

Her current pregnancy has been otherwise uncomplicated. She has had no headache, visual disturbance, or swelling. Her BP has been normal at all previous visits. She has no history of clotting disorders or bleeding tendencies.

Obstetric & Gynaecological History

Gravida: 3 Para: 2 (two previous normal vaginal deliveries, no complications)
Previous history of one caesarean section — denied; no uterine surgery
LMP consistent with 32 weeks by dates, confirmed by scan
Low-lying placenta noted on scan at 28 weeks — follow-up scan missed

Past Medical / Surgical History

Nil significant.

Drug History

Iron supplementation. No anticoagulants. NKDA.

Family / Social History

Non-smoker. Married, 2 children at home. No previous blood transfusions.

Summary

Mrs. Fatima K. is a 32-year-old G3P2 at 32 weeks presenting with her second episode of sudden, painless, bright red antepartum hemorrhage — the first at 28 weeks — in the context of a previously documented low-lying placenta on ultrasound. The clinical picture is highly consistent with placenta previa causing antepartum hemorrhage. She is hemodynamically stable at present. An urgent transabdominal ultrasound is required to confirm placental location. No vaginal examination should be performed until placenta previa is excluded. IV access, cross-match, and continuous fetal monitoring are priorities.

SCENARIO 3 — Painful Vaginal Bleeding (Placental Abruption)

Patient: Mrs. Grace O., 35 years old, G4P3, 36 weeks gestation.

Presenting Complaint

Sudden severe abdominal pain and dark vaginal bleeding for 1 hour.

History of Presenting Illness

Mrs. Grace O. is a 35-year-old woman at 36 weeks gestation in her fourth pregnancy who presented with a 1-hour history of sudden onset severe, constant, non-cramping abdominal pain associated with dark vaginal bleeding. The pain began abruptly while she was at rest at home and is described as a tight, board-like hardness across the entire abdomen, rated 9/10 in severity, and has not eased since onset. It does not come and go in waves. The bleeding is dark red and she soaked 2 pads within the first 30 minutes, after which bleeding appeared to slow — she attributes this to the blood being trapped behind the placenta.

She also reports that she has not felt her baby move since the pain started approximately one hour ago. Prior to onset, fetal movements were normal and vigorous throughout the day.

She denies any prodromal symptoms, vaginal discharge, rupture of membranes, or fever. She reports a frontal headache today, though she attributes it to stress. She was seen at her 34-week visit and her blood pressure was noted to be 148/96 mmHg; she was advised to attend for repeat measurement but did not return. She is a known hypertensive, on labetalol during this pregnancy.

She denies any trauma, falls, or domestic violence.

Obstetric & Gynaecological History

Gravida: 4 Para: 3 (all vaginal deliveries)
History of gestational hypertension in previous pregnancy
LMP: confirmed at 36 weeks by dating scan
Current pregnancy: diagnosed with chronic hypertension, on labetalol

Past Medical History

Chronic hypertension. No diabetes. No renal disease.

Drug History

Labetalol 200 mg BD. Aspirin 75 mg (commenced at booking). NKDA.

Social History

Smokes 10 cigarettes per day — did not stop in pregnancy. Married, 3 children.

Summary

Mrs. Grace O. is a 35-year-old G4P3 at 36 weeks with chronic hypertension and active smoking who presents with sudden onset of constant, severe abdominal pain with a woody hard uterus, dark vaginal bleeding, and absent fetal movements — a clinical triad strongly consistent with major placental abruption. The cessation of fetal movements raises immediate concern for fetal compromise or intrauterine fetal death. This is a maternal and fetal emergency requiring urgent IV access, cross-match, immediate CTG (or bedside ultrasound for fetal heart), and preparation for emergency delivery.

SCENARIO 4 — Preeclampsia with Severe Features

Patient: Mrs. Nneka A., 29 years old, G1P0, 34 weeks gestation.

Presenting Complaint

Severe frontal headache, blurred vision, and facial swelling for 24 hours.

History of Presenting Illness

Mrs. Nneka A. is a 29-year-old primigravida at 34 weeks gestation presenting with a 24-hour history of a severe, constant, throbbing frontal headache rated 8/10, unresponsive to two doses of paracetamol 1 g. She describes associated blurring of vision and episodes of seeing flashing lights ("like camera flashes") in both eyes, which have occurred four times today. She noticed progressive puffiness of her face, particularly around the eyes, when she woke this morning — she reports that her wedding ring has been difficult to remove for the past 3 days.

She denies any vomiting or fever. She reports upper abdominal discomfort/epigastric heaviness over the past 12 hours which she initially attributed to indigestion, but it is not relieved by antacids.

Her blood pressure was recorded at the community midwife clinic at 32 weeks as 126/80 mmHg — within normal limits. She was normotensive throughout the first and second trimesters. However, at a routine visit 1 week ago, her BP was 156/100 mmHg and she was asked to attend the day assessment unit — she did not attend due to work commitments.

She denies any chest pain, shortness of breath, or productive cough. She has not had any seizures or loss of consciousness. Fetal movements are reported as normal. She has no previous history of hypertension, renal disease, or autoimmune conditions.

Obstetric & Gynaecological History

Gravida: 1 Para: 0
LMP confirmed at 34 weeks by dating scan
Uneventful pregnancy until 32 weeks — no proteinuria on booking dipstick
No previous hypertension, no family history of preeclampsia
Primiparous — a recognized risk factor for preeclampsia

Past Medical / Surgical History

Nil significant.

Drug History

Folic acid. Aspirin 75 mg (commenced at 12 weeks due to primigravid status). NKDA.

Social History

Non-smoker. Works full time as an accountant. Married. Adequate social support.

Summary

Mrs. Nneka A. is a 29-year-old primigravida at 34 weeks presenting with a 24-hour history of severe unremitting headache, visual disturbances, facial and hand edema, and epigastric pain — in the context of a documented blood pressure of 156/100 mmHg one week ago. This clinical constellation is consistent with preeclampsia with severe features (BP likely in severe range, CNS symptoms, epigastric pain suggesting hepatic involvement). Urgent assessment includes BP measurement, urine protein:creatinine ratio, FBC, LFTs, uric acid, and LDH to exclude HELLP syndrome. IV labetalol or hydralazine for acute BP control, magnesium sulfate for seizure prophylaxis, and consideration of delivery at 34 weeks are priorities.

SCENARIO 5 — Preterm Labor

Patient: Mrs. Zara M., 24 years old, G2P1, 29 weeks gestation.

Presenting Complaint

Regular painful abdominal tightenings every 6–8 minutes for the past 3 hours.

History of Presenting Illness

Mrs. Zara M. is a 24-year-old woman at 29 weeks gestation in her second pregnancy who presents with a 3-hour history of regular, painful abdominal cramps coming every 6–8 minutes, each lasting approximately 40–50 seconds. She describes the cramps as tightening across the lower abdomen and lower back, gradually increasing in intensity over the past hour. She initially dismissed them as Braxton Hicks but became concerned when they did not resolve with rest, hydration, or change of position and began coming closer together.

She has not noticed any vaginal bleeding, unusual discharge, or fluid loss. She denies any fever, dysuria, or urinary frequency. Fetal movements are active and she has felt the baby moving between contractions.

Her previous pregnancy ended at 34 weeks with preterm labor and vaginal delivery of a 2.1 kg baby — the baby was admitted to the neonatal unit for 3 weeks. She reports that she was told after that pregnancy she had a short cervix. She was placed on vaginal progesterone in this pregnancy from 16 weeks, but she stopped taking it 3 weeks ago without medical advice because she felt it was causing discharge.

She has had no recent illnesses, no sexual intercourse in the past week, and no abdominal trauma. She reports a mild urinary urgency over the past 2 days but no frank dysuria.

Obstetric & Gynaecological History

Gravida: 2 Para: 1 (preterm vaginal delivery at 34 weeks — prior preterm birth = major risk factor)
Short cervix diagnosed in previous pregnancy
Progesterone supplementation commenced at 16 weeks, self-discontinued at 26 weeks
LMP: confirmed at 29 weeks by scan

Past Medical / Surgical History

Nil significant.

Drug History

Progesterone pessaries (self-stopped). Folic acid. NKDA.

Social History

Non-smoker. Single parent. Mild financial stress. One child at home (4 years).

Summary

Mrs. Zara M. is a 24-year-old G2P1 at 29 weeks with a prior preterm birth at 34 weeks, a documented short cervix, and self-discontinuation of progesterone at 26 weeks — now presenting with a 3-hour history of regular, painful uterine contractions every 6–8 minutes. This presentation is highly consistent with preterm labor at 29 weeks. Urgent cervical assessment, CTG, and fetal fibronectin (or speculum exam) are required. If labor is confirmed: IV access, IM betamethasone for fetal lung maturation (two doses 24 hours apart), MgSO₄ for fetal neuroprotection, tocolysis to allow steroid administration window, and neonatal team notification are immediate priorities.

SCENARIO 6 — Ectopic Pregnancy

Patient: Miss Sadia B., 22 years old, G1P0, approximately 7 weeks gestation.

Presenting Complaint

Right-sided lower abdominal pain and light vaginal bleeding for 2 days.

History of Presenting Illness

Miss Sadia B. is a 22-year-old woman with a positive pregnancy test 2 weeks ago who presents with a 2-day history of right-sided lower abdominal pain and intermittent light vaginal bleeding (spotting, dark brown, less than one pantyliner per day). She describes the pain as initially a dull, persistent ache in the right iliac fossa that has today become sharper and more intense. It does not radiate. She rates it 6/10 at rest and 8/10 with movement.

One hour prior to arrival, she experienced a sudden worsening of the pain which spread across the lower abdomen and into her right shoulder tip, associated with a brief episode of feeling faint and profuse sweating. She vomited once. She denies passing any tissue.

Her last menstrual period was 7 weeks ago. She has not had a formal dating scan or antenatal visit as the pregnancy was unplanned.

She has a history of chlamydia infection two years ago treated with azithromycin. She had a right-sided pelvic pain episode one year ago that was investigated with ultrasound — no abnormality was found at the time. She is not using any contraception. She denies any urinary symptoms or bowel changes.

On further questioning, she notes that her pregnancy test line was lighter than expected and has been monitoring it with home tests, which have not been getting darker over the past week.

Obstetric & Gynaecological History

Gravida: 1 Para: 0
LMP: approximately 7 weeks ago — no scan confirmed
Past history of chlamydial infection (risk factor for tubal damage and ectopic)
Previous right-sided pelvic pain — possible previous tubal pathology
No IUD, no previous ectopic

Past Medical / Surgical History

Nil significant. No previous abdominal or pelvic surgery.

Drug History

No regular medications. NKDA.

Social History

Non-smoker. University student. Not in a stable relationship.

Summary

Miss Sadia B. is a 22-year-old G1P0 at approximately 7 weeks gestation with a history of previous chlamydial PID — a recognized risk factor for tubal damage — presenting with the classic triad of ectopic pregnancy: amenorrhea, unilateral lower abdominal pain, and abnormal vaginal bleeding. The recent sudden deterioration with ipsilateral shoulder tip pain, syncope, and diaphoresis is strongly suggestive of tubal rupture with hemoperitoneum — a surgical emergency. She requires immediate IV access (two large-bore cannulae), urgent serum βhCG, transvaginal ultrasound, cross-match, and immediate surgical review. Resuscitation must proceed simultaneously.

SCENARIO 7 — Rupture of Membranes (PPROM)

Patient: Mrs. Halima Y., 28 years old, G2P1, 31 weeks gestation.

Presenting Complaint

A sudden gush of clear fluid from the vagina 4 hours ago.

History of Presenting Illness

Mrs. Halima Y. is a 28-year-old woman at 31 weeks gestation in her second pregnancy who presents with a 4-hour history of a sudden gush of clear, watery fluid from the vagina while she was standing in the kitchen. She describes the volume as soaking through her trousers to the floor. Since the initial gush, there has been a continued slow, persistent trickle of fluid on standing and with coughing, which she is collecting on a maternity pad. She confirms the fluid does not smell like urine.

The fluid appears clear and odorless. She denies any green or brown discoloration. There has been no associated abdominal pain, uterine tightening, or contractions before or after the episode. There is no vaginal bleeding. She reports that fetal movements have been active throughout the day and continue to be felt.

She has no fever, chills, rigors, or foul-smelling vaginal discharge. She denies any recent intercourse, vaginal examination, or trauma in the past week.

Her previous pregnancy resulted in a full-term vaginal delivery without complications. She had a cervical length scan at 20 weeks in this pregnancy which was reported as normal. There is no history of recurrent UTI, cervical procedures, or polyhydramnios in this pregnancy.

Obstetric & Gynaecological History

Gravida: 2 Para: 1 (normal term vaginal delivery)
LMP confirmed at 31 weeks by dating scan
Cervical length: normal at 20 weeks
No history of PPROM in previous pregnancy

Past Medical / Surgical History

Nil significant.

Drug History

Iron supplementation. Folic acid. NKDA.

Social History

Non-smoker. Housewife. Married with good family support.

Summary

Mrs. Halima Y. is a 28-year-old G2P1 at 31 weeks presenting with a sudden, large-volume gush of clear, odorless watery fluid with continued leaking on positional change — clinically consistent with preterm premature rupture of membranes (PPROM) at 31 weeks. She is currently asymptomatic for infection. Management priorities include speculum examination (to visualize pooling and collect high vaginal swab), nitrazine/fern testing, ultrasound for AFI, IV access, broad-spectrum antibiotics (erythromycin per ORACLE trial protocol), corticosteroids (betamethasone IM) for fetal lung maturation, and MgSO₄ for neuroprotection. Chorioamnionitis must be actively screened for and delivery expedited if signs of infection develop.

Quick Reference: HoPi Summary Template for Any Obstetric Complaint

[Name] is a [age]-year-old [G_P_] at [GA] weeks gestation 
presenting with a [duration] history of [chief complaint].

ONSET:         [Sudden/Gradual] — [what they were doing when it started]
CHARACTER:     [Quality, severity, constant or intermittent]
SITE/RADIATION: [Location, any spread]
ASSOCIATED:    [Bleeding, pain, fever, FM, discharge, urinary Sx]
TIMING:        [Duration, progression, episodic or continuous]
EXACERBATING: [Movement, eating, position, stress]
RELIEVING:     [Rest, analgesia, position — effective or not]
FETAL MOVEMENT: [Normal / Reduced / Absent — since when]
OBSTETRIC Hx:  [G_P_ — relevant previous pregnancies]
RED FLAGS:     [Hemodynamic instability, absent FM, severe BP, signs of infection]

SUMMARY STATEMENT: [Patient] presents with [complaint] at [GA] weeks 
consistent with [working diagnosis]. Immediate priorities: [top 3 actions].

Sources: Rosen's Emergency Medicine; Creasy & Resnik's Maternal-Fetal Medicine; Tintinalli's Emergency Medicine; Textbook of Family Medicine (9e); Berek & Novak's Gynecology; Barash Clinical Anesthesia 9e; Miller's Anesthesia 10e; Goldman-Cecil Medicine

A patient who is asthmatics who is gravida 6 and para 2 currently pregnant came who is at 34GA came complaining of palpitations, fatigue, and dizziness

Finding Sources

Excellent — solid textbook grounding secured. Here is the full, smartly written clinical HoPi for this patient:

Complete HoPi — Obstetric Patient with Palpitations, Fatigue & Dizziness

Patient: Mrs. Khadijah N., 38 years old | G6 P2 | 34 weeks gestation Background: Known asthmatic

Presenting Complaint

Palpitations, generalized fatigue, and episodic dizziness for 3 weeks, worsening over the past 4 days.

History of Presenting Illness

Mrs. Khadijah N. is a 38-year-old woman in her sixth pregnancy (G6P2) at 34 weeks gestation, with a background of bronchial asthma, who presents with a 3-week history of palpitations, generalized fatigue, and episodic dizziness that have progressively worsened over the past 4 days.

Palpitations

She describes the palpitations as an awareness of her heart "racing and fluttering" in her chest. The episodes come on suddenly, without a clear precipitant, and last between 30 seconds and 5 minutes before resolving spontaneously. She has had approximately 4–5 distinct episodes over the past week. There is no relation to exertion — some episodes occur at rest, including one that woke her from sleep last night. She denies any associated chest pain, chest tightness, or shortness of breath at the time of palpitations. She has not experienced syncope during an episode, though she reports feeling lightheaded immediately after each one. She has no prior history of known cardiac disease or diagnosed arrhythmia before this pregnancy.

She uses a salbutamol (albuterol) metered-dose inhaler for her asthma and has been using it more frequently over the past 2 weeks — approximately 4–5 puffs per day — due to worsening wheeze in the cooler weather. She is aware that the inhaler can cause her heart to "feel fast" but reports the current palpitations feel different in character and are occurring even when she has not recently used her inhaler.

Fatigue

She reports profound, worsening generalized fatigue over the past month that she initially attributed to the late stage of pregnancy and caring for her other children. However, she now feels exhausted even after a full night's sleep, struggles to climb one flight of stairs without needing to rest, and has had to stop housework midway due to breathlessness and exhaustion. She is pale, according to her husband, who noted the change about 2–3 weeks ago. She reports reduced appetite with no nausea or vomiting. She admits she has not been taking her prescribed iron supplementation consistently — she stopped approximately 6 weeks ago due to constipation.

Dizziness

She describes the dizziness as a sensation of lightheadedness and "greyness" of vision when she stands up quickly from a sitting or lying position, consistent with postural symptoms. It lasts for a few seconds and resolves on sitting back down. She has not had any falls. She denies true vertigo (spinning sensation), tinnitus, or hearing changes. She denies any headache, visual blurring, or flashing lights. She has had no seizure activity and no loss of consciousness.

Review of Systems Relevant to Differentials

She denies any chest pain, orthopnea, or paroxysmal nocturnal dyspnoea (to help screen for peripartum cardiomyopathy). She denies ankle swelling beyond what she considers normal for late pregnancy. There is no fever, chills, dysuria, or foul-smelling discharge. She denies heat intolerance, excessive sweating, or weight loss beyond the context of reduced appetite (screens for hyperthyroidism as a cause of palpitations in pregnancy). There is no history of thyroid disease.

Fetal movements are described as present but she feels they may be slightly less than her previous pregnancies — she is uncertain whether this is significant.

She denies vaginal bleeding, fluid leaking, or painful contractions.

Current Asthma Status

Her asthma is normally mild and intermittent, managed with PRN salbutamol inhaler only, with no regular preventer (inhaled corticosteroid). She reports that her wheeze has been worse over the past 2 weeks. She has not attended any asthma review during this pregnancy. She has had no previous hospital admissions for asthma and no intubations.

Obstetric History

	Pregnancy	Outcome	Details
G1	First pregnancy	Miscarriage	~10 weeks, no surgical management
G2	Second pregnancy	Miscarriage	~8 weeks, spontaneous
G3	Third pregnancy	Live birth (P1)	Vaginal delivery at term, 3.2 kg
G4	Fourth pregnancy	Miscarriage	~12 weeks, ERPC performed
G5	Fifth pregnancy	Live birth (P2)	Vaginal delivery at 38 weeks, 3.5 kg
G6	Current pregnancy	In progress	34 weeks, singleton

Note: G6P2 with 3 miscarriages — classifies as a grand multipara in terms of viable births; recurrent pregnancy loss history noted.

Current pregnancy:

Booked at 10 weeks. Dating scan confirmed singleton, cephalic presentation at 20 weeks.
Anomaly scan: no structural fetal abnormality.
Last growth scan: 30 weeks — appropriate for gestational age.
BP at last visit (30 weeks): 122/78 mmHg — within normal limits.
Urine dipstick at 30 weeks: no protein, no glucose.
Hemoglobin at booking (10 weeks): 10.2 g/dL — already below normal. Ferrous sulfate prescribed but patient non-compliant for past 6 weeks.
No repeat FBC since booking.

Past Medical History

Bronchial asthma — mild intermittent; diagnosed in childhood; no hospital admissions
Recurrent miscarriages — 3 previous pregnancy losses (investigated? — not on record)
No known hypertension, diabetes, thyroid disease, cardiac disease, or renal disease

Past Surgical History

ERPC following 4th pregnancy (G4 miscarriage)
No other surgeries

Drug History

Medication	Dose	Compliance
Salbutamol MDI	PRN (currently 4–5 puffs/day)	Compliant
Ferrous sulfate 200 mg	TDS	Non-compliant × 6 weeks
Folic acid 5 mg	OD	Compliant

No known drug allergies (NKDA) No use of NSAIDs, aspirin, beta-blockers (contraindicated in asthma), or herbal preparations.

Family History

Mother: type 2 diabetes
Father: hypertension
No family history of cardiac disease, arrhythmia, or haematological disorders

Social History

Marital status: Married, husband present and supportive
Occupation: Homemaker; caring for 2 children at home (ages 4 and 7)
Smoking: Non-smoker
Alcohol: None
Illicit substances: None
Diet: Reduced appetite currently; limited iron-rich food intake reported
Accommodation: Lives in a house; no recent travel

Summary

Mrs. Khadijah N. is a 38-year-old G6P2 at 34 weeks gestation with known bronchial asthma and a booking hemoglobin of 10.2 g/dL, who presents with a 3-week progressive history of palpitations, profound fatigue, and postural dizziness — having been non-compliant with iron supplementation for 6 weeks.

The clinical picture points to three intersecting differentials that must be worked up simultaneously:

Differential Diagnosis Framework

Priority	Diagnosis	Supporting Features
1st	Iron deficiency anaemia (worsening)	Booking Hb 10.2 g/dL, 6 weeks off iron, fatigue, pallor, postural dizziness, grand multipara, inadequate diet
2nd	Pregnancy-related cardiac arrhythmia (SVT)	Sudden-onset paroxysmal palpitations, episodic, self-terminating, no structural cardiac Hx — SVT is the most common sustained arrhythmia in pregnancy (Fuster & Hurst's The Heart)
3rd	Salbutamol-induced tachycardia	Increased PRN salbutamol use (4–5 puffs/day) — β₂ agonists cause tachycardia and palpitations; however, patient reports episodes differ from her usual salbutamol effect
4th	Peripartum cardiomyopathy	Fatigue, exertional dyspnea, palpitations — must be excluded in any late-pregnancy patient; no orthopnea or PND currently (Tintinalli's Emergency Medicine)
5th	Hyperthyroidism / Thyroid storm	Palpitations + fatigue; screen with TFTs — hyperthyroidism in pregnancy can be triggered by high hCG or Graves' disease
6th	Asthma exacerbation contributing	Worsening wheeze + increased salbutamol use + fatigue — inadequately controlled asthma increases maternal/fetal hypoxia risk at 34 weeks

Immediate Priorities

FBC urgently — repeat Hb, MCV, MCH, serum ferritin → quantify degree of anaemia
ECG — document rhythm during or between palpitations; identify SVT, AF, or sinus tachycardia
TFTs (TSH, free T4) — screen for hyperthyroidism as cause of palpitations
Echocardiogram — exclude peripartum cardiomyopathy if any features of cardiac failure present
CTG — fetal wellbeing given possible reduced fetal movements at 34 weeks
Oxygen saturation + Peak Flow — assess current asthma control; consider stepping up to regular ICS if not already
Urine dipstick — exclude preeclampsia (maternal age + late pregnancy)
Parenteral/IV iron — restart iron supplementation; consider IV iron sucrose if Hb significantly low and oral poorly tolerated
Asthma review — ensure appropriate step-up of therapy; avoid beta-blockers (contraindicated in asthma) when treating any cardiac arrhythmia

Sources: Fuster & Hurst's The Heart 15e; Tintinalli's Emergency Medicine; Creasy & Resnik's Maternal-Fetal Medicine; Braunwald's Heart Disease; Barash Clinical Anesthesia 9e

What are the questions u will asked in obstetrics that never misses in any hopi analysis

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