History taking (Gynaecological, sexual, obstetrics) Flashcards
In the UK, pregnant women attend a booking appointment with a midwife at between
8 and 12 weeks’ gestation
- much of the histroy is covered here
Overview of obstetric history
- Presenting complaint
- History of presenting complaint
- Previous obstetric history
- Previous gynaecological history
- Current pregnancy
- Past medical history
- Drug history
- Family history
- Social history
Previous obstetric history can be split into:
- term pregnancies
- other pregnancies
A good starting point is to ask about number of children the patient has given birth to. Next, sensitively ask about miscarriages, stillbirths, ectopics and terminations.
term pregnancies
- Gestation – previous preterm labour is a risk factor for subsequent preterm labour.
-
Mode of delivery – spontaneous vaginal, assisted vaginal or Caesarean.
Gender - Birth weight – a previous small for gestational age (SGA) baby increases the risk of a subsequent one.
- Complications – e.g. pre-eclampsia, gestational hypertension, gestational diabetes, obstetric anal sphincter injury (3rd, 4th degree tears), post-partum haemorrhage.
- Assisted reproductive therapies (ART) – e.g. ovulation induction with clomiphene, IVF. can increase risk of pre-eclampsia
- Care providers – was the patient’s care completely with a midwife or was there previous obstetric input, if so, why
other pregnancies: pregnancies not carried beyond 24 weeks
1) Gestation – miscarriages can be classified into early pregnancy (12 weeks or less) or second trimester (13-24 weeks).
2) Miscarriages – outcome (spontaneous, medical management, surgical management – evacuation of retained products of conception).
3) Terminations – method of management: medical or surgical.
4) **Identified causes of miscarriage **/ stillbirth – e.g. abnormal parental karyotype, fetal anomaly.
other pregnancies: ectopic pregnancies
1) Site of the ectopic
2) Management: expectant (monitoring of serum hCG levels), medical (methotrexate injection), surgical (laparoscopy or laparotomy; salpingectomy (removal of tube) or -otomy (cutting of tube and suctioning of trophoblastic tissue))
define gravidity
total number of pregnancies, regardless of outcome.
Parity
is the total number of pregnancies carried over the threshold of viability (24+0 in the UK).
what does G3 P2 mean
Patient is currently pregnant; had two previous deliveries
Patient is currently pregnant; had two previous deliveries
G1 P1
Patient is not pregnant, had one previous delivery
G3 P1+1
Patient is currently pregnant, had one previous delivery and one previous miscarriage
(the +1 refers to a pregnancy not carried to 24+0).
Current pregnancy history
1) Establish gestational age
2) Establish folate use prior to conception and currently
3) Agreed estimated date of delivery
4) Singleton or multiple gestation
Investgiations that have already been done
5) Bloods
6) Urine MSU
7) Uptake and result of Down syndrome screening
8) Scan results (20 weeks)
- Fetal anomalies
- Placenta position
- Amniotic fluid index (oligohydoaminos, normal, polyhydraminos)
- Estimated fetal weight
when is the estimated date of delivery
this date is when the woman will be 40+0.
how is gestation described
weeks + days
e.g. 8+4; 30+7; 40+12 – post-dates
how are pregnancies dated
1) Crudely by LMP (Naegeles rule)
2) More accuratley using crown-rump length (CRL)
Naegele’s rule
uses last menstrual period to estimate gestation
Method
- to the first day of the LMP add 1 year
- subtract 3 months
- add 7 days
Crown-rump length is measured using
ultrasound scan between 10+0 and 13+6.
Obestetric history: gynaecological history
- PID
- STI
- Ovarian cysts
- Abnormal smear
- Myomectomy
obestetric history: PMH
Ask the usual questions about past medical history, abdominal or pelvic surgery and mental health conditions. Remember that the medical co-morbidities that are most likely to affect women of childbearing age include:
- Asthma
- Cystic fibrosis
- Epilepsy
- Hypertension (older women)
- Congenital heart disease
- Diabetes – check if type 1 or type 2
- Systemic autoimmune disease e.g. systemic lupus erythematosus (SLE), rheumatoid arthritis
- Haemoglobinopathies: sickle-cell disease, thalassaemias
- Blood-borne viruses: HIV, hepatitis B, hepatitis C
obesteric history: Drug history
- allergies
- use of drugs in first 12 weeks (teratogeneicity)
- current drugs inc herbal
- illicit drugs and alcohol
- recommend patient takes 400ug of folic acid for first 12 weeks
obstetric history: family history
- heritable: CF and sickle cell
- pre-eclampsia
- type 2 diabetes in first degree relative considered RF for gestational diabetes
- blood clotting disorders and VTE
obstetric history: social history
- work
- who they live with/ support
- domestic violence
- mental health problems
- smoking
- drugs
- alcohol
partner
- inheritable disease
- congential
- epilepsy
- haemoglobinopathies
Overview of gynaecological history taking
- Intro: introduce, N and DoB, consent
- PC
- History of PC (explore symptoms)
- Systems review
- Past medical history
- Drug history
- Family history
- Social history
gynaecological history: PC
open question ‘what has brought you here today’
gynaecological history: HPC
- SOCRATES
- explore common gynaecological symptoms
gynaecological history: HPC
- SOCRATES
- explore common gynaecological symptoms
gynaecological history: common symptoms of gynaecological disease
- vaginal bleeding
- abdominal or pelvic pain
- vaginal discharge
- menstrual history
- Dyspareunia
- Vulval itching
- inferility
gynaecological history: Vaginal bleeding
3 main forms
- Intermenstrual
- post-coital
- post menopausal
Intermenstrual (between menstrual periods) can be caused by .
- infection
- malignancy
- fibroids
- endometriosis
- pregnancy
- hormonal contraception
Post-coital (after sexual intercourse) causes
- cervical ectropion
- infection
- vaginitis
- malignancy.
Post-menopausal (after the menopause) causes
- malignancy
- vaginal atrophy
- hormone replacement therapy.
gynaecological history taking: abominal/ pelvic pain
Use the acronym SOCRATES to elicit the key features of any abdominal or pelvic pain:
Site
Onset
Character
Radiation
Associations
Time course
Exacerbating and relieving factors
Severity
gynaecological history taking: vaginal discharge
Vaginal discharge is most often a normal and regular occurrence. However, a change in the character of discharge can indicate infection. Inquire about:
*
* Color
* Consistency
* Amount
* Smell
gynaecological history taking: menstrual history
gynaecological history taking: dysparaeunia
pain during sexual intercourse. This can be divided into superficial or deep pain.
gynaecological history taking: infertility
- duration
- investgiations that have been performed
- whether assited cocneption has been attempted
gynaecological history: PMH
- pregnancies
- cervical smear
- surgical history
- previous gynae problems
- previous STI
gynaecological history: Pregnancies
- Number of births/miscarriages/abortions/ectopics.
- Means of delivery, age of child and birth weight.
- Explore any obstetric/delivery complications.
gynaecological history: cervical smear
ascertain the date of the last smear, its result, and any treatment arising
gynaecological history: drug history
- contraception
- HRT
- recent antibiotics- thrush
- any medications inc over the counter
- known allergies
gynaecological history: family history
- Breast/ovarian cancer/endometrial cancer – can be familial (e.g BRCA 1/2 gene).
- Diabetes – associated with some reproductive abnormalities.
- Bleeding disorders – can be associated with menorrhagia.
gynaecological history: family history
- Breast/ovarian cancer/endometrial cancer – can be familial (e.g BRCA 1/2 gene).
- Diabetes – associated with some reproductive abnormalities.
- Bleeding disorders – can be associated with menorrhagia.
gynaecological history: Social history
- weight
- occupation
- home situation
- smoking and alcohol
- diet and exercise
- safe sex
Overview of sexual history
- Presenting complaint
- History of presenting complaint
- Explore other symptoms
- Menstrual history
- Sexual contact history
- Past medical history
- Drug history
- Social history
sexual history: history of presenting complain
use SOCRATES
sexual history: other symptoms (screening for common STIs)
- Vaginal bleeding
- Abdominal or pelvic pain (SOCRATES)
- Vaginal discharge (colour, consistency, amount, smell)
- Dyspareunia
- Vulval intching
- Infertility
- Systemic and extragenital symptoms e.g. anal discharge, fever, urinary symptoms, joint pain and eye symptoms
sexual history: menstrual history
- last menstrual period
- if cycle is regular
- length of period
- any change to bleeding
sexual history: sexual contact history
sexual history: past medical history
- Previous sexually transmitted infections (including in partners)
- Previous STI screens including HIV tests
- Cervical smears – the date of the last smear, its result and any treatments arising
- Previous gynaecological problems
- Surgical history – particularly any pelvic or abdominal surgery
- Pregnancies (a full obstetric history can be found here)
- Other medical conditions
sexual history: drug history
- contraception (type, correct use, previous contraceptive hx)
- HRT
- recent antibiotic use
- allergies
sexual history: social hx
- smoking
- alcohol
- recreational drug use
