Case taking in obstetric and gynaecological cases

Dr Rakhal Panakkool
Dr Meenu Mariamathew

INTRODUCTION
Obstetrics and Gynecology is a branch of Medicine that specializes in the care of women during pregnancy and childbirth and in the diagnosis and treatment of diseases of the female reproductive organs. The richness of female symptoms in the Homoeopathic Materia medica aligns naturally with the tendency of women to use Homoeopathy for their various ailments. Homoeopaths take into account both physical and mental symptoms in case taking thus providing holistic care to women. By using medicines which have been clinically tested on healthy human beings, Homoeopathy enhances the patient’s overall well–being and for specific problems that may arise during pregnancy in a safe and effective way.

Case taking is a unique art of getting into conversation, observation and collecting all the facts about the patient and the bystanders so that the physician can define the patient as a person and the disease. Case taking in Obstetric and Gynecological cases differ from the general case taking as the former includes much more information which helps the physician to understand women mentally, physically, psychologically and socially. This article aims at highlighting the points to be remembered by a Homoeopathic Physician during Obstetric and Gynecological case taking.

CASE TAKING IN OBSTETRIC AND GYNECOLOGICAL CASES

AIM AND OBJECTIVES

• To prevent or identify and treat conditions that may threaten the health of the Women / Mother / Fetus / Newborn
• To help women to approach pregnancy and birth as positive experiences
• To provide highest ideal of cure, which is rapid, gentle and permanent restoration of health or annhilation of the disease in its whole extend in the shortest , most reliable , and most harmless way , on easily comprehensible principles ( aphorism 2)

PRE – REQUISITES : Aphorism 3,98

• Knowledge of the disease
• Knowledge of the medicines
• Application of drug knowledge to disease knowledge
• Mode of preparation, administration and repetition of the dose 

KNOWLEDGE OF THE DISEASE:With so many patients coming for gynecological and obstetrical help, it behooves the practitioner to be well trained in women’s health issue. Hence, the Homoeopathic physician should possess the knowledge about the following:

In Obstetric cases: Knowledge of problems that can arise in each trimesters, Parturition and Puerperium.

First Trimester

• Hyperemesis Gravidarum – dehydration, dizziness, weakness
• Picca
• Bleeding per vagina (miscarriage or ectopic pregnancy)
• Vaginal discharge
• Cramps (miscarriage)
• Abdominal pain (can be a sign of ectopic pregnancy)
• Flare-ups of chronic diseases – Thyroid complaints, Diabetes Mellitus, Hypertension, Asthma)

Second Trimester

• Bleeding – Early labor (Placenta previa, abruptio placenta, miscarriages due to chromosomal abnormalities, congenital defects, cervical incompetency)
• Pre term labor
• Pre-eclampsia
• Gestational diabetes
• Cervical insufficiencies (incompetent cervix — cervix is weak and begins dilating and opening soon)- backache, vaginal bleeding, pelvic pressure, abdominal cramps or vaginal discharge between 14-20 weeks of pregnancy

Third trimester

• Gestational diabetes
• Breathing problems
• Placenta previa (placenta partially or totally covers the cervix)
• Abruptio placenta (premature separation of the placenta)
• Intra uterine growth retardation
• Pre term labor
• Varicose veins
• Fatigue

Parturition
Labor that does not progress: weak contractions, cervix does not dilate enough, infant’s descent in the birth canal is not progressing

Perineal tears

Problems with the umbilical cord: may get caught on an arm or leg or cord around the neck as the infant travels through the birth canal

• Premature rupture of the membranes
• Perinatal asphyxia
• Shoulder dystocia
• Excessive bleeding

Puerperium

• Puerperal pyrexia (puerperal sepsis, breast infection, respiratory tract infections, UTIs, thrombophlebitis, Wound infection)
• Problems with breast feeding

Engorgement of the nipples
Cracked nipples
Acute mastitis
Breast abscess
Suppression of lactation
Galactocele (retention cyst)
Carcinoma breast

• Coagulation disorders – thrombo-embolism
• Psychiatric disorders
  Psychological stress
  Concern about the child
  Experience of labor
  Change in sexual interest, loss of attractiveness
  Puerperal psychosis (deep depression, delusions and homicidal feelings)

In Gynaecological cases( Female) : He should possess knowledge about :

• Menstrual disorders: (Heavy menstrual bleeding, menstrual pain or irregularity, Pre-menstrual syndrome)
• General Gynecological issues

1.  Ovarian cysts
2.  Pelvic inflammatory diseases
3.  Endometriosis
4.  Uterine fibroids
5.  PCOD
6.  Acne and abnormal hair distribution
7.  Genital tract infections
8.   Vulva and vagina skin disorders

• Menopause
• Pelvic floor disorders (Pelvic organ prolapse, Urinary incontinence, Recurrent urinary tract infections)
• Infertility
• Carcinomas
• Diseases of the breast

In the diseases of the Male Reproductive system: He should have knowledge on the following conditions:

• Erectile dysfunction
• Carcinoma – (Prostate, Penile, Scrotal)
• Prostitis
• Prostatomegaly

APHORISM 4 – PRESERVER OF HEALTH
Master Hahnemann in aphorism 4 of Organon of Medicine writes that the physicians are not only the healers of the sick but also an advisor of health to the community. He should identify and remove the factors that can cause disease in people. The primary causative factors that decrease the vital force and predispose a woman to sick are:

(i)Stress creates hormonal imbalances, which over extended periods of time can affect woman’s general health

Example: Amenorrhea during stress, Hair loss during stress

Physician should put effort to identify the stress factor and remove it through moral remedies (footnote aphorism 17) and healthy life style changes

(ii) Diet and Regimen: sedentary lifestyle and unhealthy eating habits often destroys the health of the women. Homoeopathic physician must encourage the patients to adopt a heathy lifestyle including regular exercising and eating healthy.

HAHNEMANN’S VIEW ABOUT OBSTETRIC & GYNAECOLOGICAL CASES
FOOTNOTE OF APHORISM 94
In chronic diseases of females, it is specially necessary to pay attention to pregnancy, sterility, sexual desire, accouchements, miscarriages, suckling, and the state of the menstrual discharge. With respect to the last-named more particularly, we should not neglect to ascertain if it recurs at too short intervals, or is delayed beyond the proper time, how many days it lasts, whether its flow is continuous or interrupted, what is its general quality, how dark is its color, whether there is leucorrhoea before its appearance or after its termination, but especially by what bodily or mental ailments, what sensations and pains, it is preceded, accompanied or followed; if there is leucorrhoea, what is its nature, what sensations attend its flow, in what quantity it is, and what are the conditions and occasions under which it occurs?

APHORISM 86 (Complete the symptoms, inquires for further particulars)
“When the narrators have finished what they would say of their own accord, the physician then reverts to each particular symptom and elicits more precise information respecting it in the following manner; he reads over the symptoms as they were related to him one by one, and about each of them he inquires for further particulars, e.g., at what period did this symptom occur? Was it previous to taking the medicine he had hitherto been using? While taking the medicine? Or only some days after leaving off the medicine? What kind of pain, what sensation exactly, was it that occurred on this spot? Where was the precise spot? Did the pain occur in fits and by itself, at various times? Or was it continued, without intermission? How long did it last? At what time of the day or night, and in what position of the body was it worst, or ceased entirely? What was the exact nature of this or that event or circumstance mentioned – described in plain words?”

Homoeopathic physician should complete each symptom obtained by him while case taking and should inquire for further particulars. The particulars which should be obtained are :

Pregnancy:

• No: of conceptions
• All trimesters normal or not
• Pica or aversion
• h/o of jaundice, bleeding, UTI, DM, HTN?
• H/o Caesarean section?
• H/o puerperal infection?

Sterility: Sexual functioning

Sexual desire: Age, excess, diminished, any concomitant symptoms

Accouchements:

• Lochia, duration
• Fever
• Abdominal pain
• Bleeding

Miscarriages:

• Cause?
• Character of the blood?
• Quantity of the blood?
• H/o recurrent abortion?
• Abdominal pain?
• Passage of fetal tissue?
• Fever?
• Outcomes of previous pregnancies?

Suckling:

• Oral abnormalities
• Cleft lip or cleft palate
• Short frenulum (tongue –tie or short-tie)
• Retracted jaw or tongue
• Biting, clamping or clenching

Menses:

• Menarche?
• Last menstrual period?
• Duration of the cycle?
• Cycles are regular or irregular?
• Quantity of the menstrual blood?
• How dark the blood is?
• Flow – continuous or interrupted?
• Too short intervals or delayed beyond the proper time?
• Concomitants – Before, During and After Menses

• FN Aphorism 89: In women, note the character of menstruation and other discharges

Leucorrhea:

• Onset – before or after menses?
• Color? Odor?
• Sensations attend its flow
• Quantity?
• Backpain or abdominal pain or weakness?

APHORISM 91 – PAST HISTORY
“The symptoms and feelings of the patient during a previous course of medicine do not furnish the pure picture of the disease; but on the other hand, those symptoms and ailments which he suffered from before the use of the medicines, or after they had been discontinued for several days, give the true fundamental idea of the original form of the disease, and these especially the physician must take note of”

Past Obstetric history– Outcomes of the previous pregnancies and complications, h/o abortion or ectopic pregnancy

Past Gynecological history– PCOS, DM, Thyroid dysfunction

Past Medical History– Toxoplasmosis, rubella, CMV

Past Surgical history– Cervical / Uterine surgery, Tubal surgery, Contraception

He should also obtain Social history (smoking, Alcohol, Drug abuse), Family history (Abortion , Diabetes, Hypertension, Thyroid complaints) , Occupational History ( Exposure to heat , toxins etc) and Sexual functioning as it is mentioned in the Aphorism 5.

APHORISM 90 – PHYSICAL EXAMINATION
“When the physician has finished writing down these particulars, he then makes a note of what he himself observes in the patient, and ascertains how much of that was peculiar to the patient in his healthy state.”

The following examinations must be done:

In Obstetric cases:

• Inspection: Shape, Size, Scars, Linea nigra, Striae, Movements, color.
• Palpation: Fundal height, Lie, Presentation, Position, Engagement
• Four Leopold’s Manure: Fundal grip, Lateral grip, Pawlik’s grip and Deep pelvic grip.
• Auscultation: Fetal heart sounds

In Gynecological cases:

• General examination
• Chest Examination: heart, lungs, breast
• Abdominal Examination:

• Inspection: Shape, size, movements, scars, pigmentation
• Palpation: Tenderness, Mass in the abdomen
• Auscultation: Bowel sounds
• Pelvic examination: Digital and Speculum examination

Dr Rakhal Panakkool
Assistant Professor,Department of Case Taking and Repertorisation
Father Muller Homoeopathic medical college, Mangaluru
E mail: rakhalp@gmail.com

Dr Meenu Maria Mathew
MD Part 2
Department of Case Taking and Repertorisation
Father Muller Homoeopathic Medical College, Mangaluru
E mail: meenumaria.mathew27@gmail.com