Approach to the OB/GYN Patient

Question 1

First thing recorded in OB/GYN history

Answer 1

CC including gravida para

Question 2

First line of H&P CC

Answer 2

“The patient is a n y/o with gravida x and para y and last menstrual period on date, here for…”

Question 3

OB/GYN components of Hx

Answer 3

• Previous pregnancies
• Menstrual history
  
  • calculation of due date
• Contraceptive history
  
  • hormones in early pregnancy can cause defects, retained IUDs
• Medical history
  
  • DM, HTN, renal dz, other conditions know to affect pregnancy outcome
  • psych: associated menstrual abnormalities
  • inheritance patterns
• Surgical/trauma history
  
  • anesthetic complications, transfusions, post-op abdominal adhesions
• Social history
  
  • smoking, alcohol, pets (esp. cats- toxoplasmosis)
  • occupation: exposure to solvents, insulators
    *

Question 4

10 Components of Prior Pregnancies

Answer 4

1. date of delivery/termination
2. location of delivery/termination
3. duration of gestation (in weeks)
4. type of delivery/termination
5. duration of labor (in hours)
6. type of anesthesia
7. maternal complications (UTI, bleeding, HTN, postpartum)
8. newborn weight
9. newborn gender
10. fetal or neonatal complications (APGAR, left hospital w/ mother)

Question 5

Nagele Rule

Answer 5

Expected Date of Confinement (EDC)

• first day of LMP + 9mo and 7 days

Question 6

Gravida Para definition

Answer 6

• gravida - # of pregnancies
• para - # of deliveries > 20 weeks
• para subdivisions (TPAL)
  
  • Term: 37-42+ weeks
  • Preterm: 20-37 weeks
  • Abortion: <20 weeks
  • Live children

Question 7

Symptoms of Pregnancy

Answer 7

• missed menses
• urinary frequency
• breast engorgement
• nausea
• tiredness
• easily fatigued

Question 8

Presumptive Signs of Pregnancy

Answer 8

• Chadwick sign- dark discoloration of vulva and vaginal walls
• discoloration and cyanosis of vulva, vagina, and cervix
• pigmentation of skin:
  
  • linea nigra- midline of abdomen
  • bridge of nose
  • chloasma- under the eyes

Question 9

Probable Signs of Pregnancy

Answer 9

• Piskacek sign- one cornu of the uterus enlarges slightly
• Hegar sign- uterus softens, able to compress/palpate connection between cervix and fundus

Question 10

Positive Signs of Pregnancy

Answer 10

• fetal hearbeat
  
  • endovaginal US: 6w
  • Doppler US: 9-12w
  • stethoscope: 16-20w
• movement
  
  • endovaginal US: 7-8w
  • multiparous woman: 15-17w
  • primigravida woman: 18-20w

Question 11

What serum/urine pregnancy tests check

Answer 11

human chorionic gonadotrophin (hCG) or B subunit

Question 12

Gynecologic History:

abnormal bleeding range

abdominal pain causes

amenorrhea causes

other symptom

Answer 12

• abnormal bleeding
  
  • before age 9 or after age 52
  • menses >7 days or bleeding inbetween
• chronic lower abdominal pain:
  
  • endometriosis
  • chronic pelvic inflammatory disease
  • large pelvic tumors or ovarian CA
• amenorrhea
  
  • pregnancy/menopause MCC
  • primary amenorrhea- no menstruation by age 16
• other sx of concern:
  
  • dysmenorrhea, premenstrual tension, fluid retention, leukorrhea, constipation (dyschezia), dyspareunia, abdominal distention
  • low back/sacral pain- uterine prolapse, enterocele, rectocele

Question 13

Menstrual History

Answer 13

• age at menarche (avg is 12-13)
• interval between periods (normal 21-35 w/ 28 avg)
• duration (avg is 5 days)
• character: scant, normal, heavy, usually w/out clots)
• intermenstrual bleeding (metrorrhagia)
• LMP date of onset
• dysmenorrhea (cramps): age of onset, severity, character, disability

Question 14

Mittelschmertz

Answer 14

midcycle pain (may be accompanied by increased vaginal secretions)

indicative of ovulatory cycles

Question 15

Parts of Gynecologic History

Answer 15

• Present illness
• Menstrual history
• Contraceptive history
  
  • type, duration, complications (amenorrhea, thrombosis, heavy bleeding (menorrhagia), infection w/ IUD, failure with barrier device)
• Obstetric history
  
  • each pregnancy, delivery, assoc. complications sequentially
  • problems w/ infetility
• Sexual history
  
  • assoc. bleeding, dyspareunia
  • STIs
• Past history
  
  • family, surgical, meds
• ROS, habits (alcohol, tobacco, drugs), weight and height changes

Question 16

Gynecologic Physical Exam Components

Answer 16

• Vital signs w/ BMI
• General appearance
• Head and neck
• Breasts
• Heart and lungs
  
  • pleural effusion may indicate ovarian cancer mets
• Abdomen
  
  • contour (flat, scaphoid, protuberent), hair, tenderness, masses, distention (percussion)
• Back
  
  • curvature of spine, CVA tenderness
  • psoas m. spasm- gynecological infections, malignant infiltration, appendicitis
• Extremeties

Question 17

Pelvic Exam

Bartholin vs. Skene glands

Nulliparous vs. Multiparous cervix

Pre- vs. Postmenopausal cervix

Answer 17

• Bartholin glands- either side of posterior vagina
• Skene glands- either side of posterior urethra
• Nulliparous cervix- circular os
• Multiparous cervix
  
  • transverse os
  • Nabothian follicles- plugged distended cervical glands
• Premenopause cervix- squamocolumnar junction visible around os
• Postmenopause cervix- SCJ retracted within cervical canal

Question 18

Adnexa

Answer 18

fallopian tubes + ovaries

Question 19

Purpose of Bimanual Exam

Answer 19

• palpation of cervix, uterus, adenexa, pouch of douglas (rectouterine pouch)
• check for masses in cul-de-sac, rectovaginal septum
• check for rectocele vs. enterocele
• **essential for checking parametrium in pts. w/ cervical cancer
• guaiac test
• anal lesions, hemorrhoids, sphincter tone

Question 20

Gynocological Special Needs/Circumstances

Answer 20

• pediatric/adolescents
  
  • congenital anomalies, injuries, pubertal problems, inflammation, psychosexual
• genital ambiguity
  
  • monitor fluid and electrolyte balance
  • serum 17-hydroxyprogesterone and cortisol
    
    • must rule out 21-hydroxylase deficiency
• trauma
  
  • saddle injuries MC
  • sexual assult must always be considered if penetrating injury
• prepubertal vaginal bleeding
  
  • usually benign (estrogen withdrawl from mom, bleeding dz, Vit K withheld)
  • precocious puberty
    
    • transitional - d/t functional ovarian cyst
    • exogenous hormonal exposure (ingested birth control)
    • ovarian tumor
  • vulvovaginitis
  • vaginal tumors (ex. sarcoma botryoides)

Question 21

Geriatric Patient Considerations

Answer 21

• underreporting
• more commonly seen:
  
  • atrophic vaginitis
  • uterine/vaginal prolapse
  • genital tract malignancies
  • pessary insertion/removal

Question 22

LGBT Considerations

Answer 22

• higher rates of psychiatric disorders, substance abuse, suicide

Question 23

Annual Exam Plan

Answer 23

• lifestyle counseling
  
  • exercise, addition of weights, Ca+ w/ Vit D supplements
• colorectal screening (sigmoidoscopy vs. colonoscopy)
• mammogram
• cholestrol and thyroid screening
• counsel on Kegel exercises w/ empty bladder
• UA and 3 fecal occult cards