Gynecological & Obstetrical History

Terminology u Menarche = age at which menses began u LMP (last menstrual period) = first day of last normal period u Dysmenorrhea = cramping with periods u Menopause = cessation of menses u Climacteric = time of transition when ovarian function begins to wane

Terminology, continued u Postmenopausal bleeding = bleeding 6 months after cessation of menses u Gravidity = number of pregnancies u Parity = outcomes of each pregnancy u Gravida = a woman who is or has been pregnant u Primigravida = a woman who is in or who has experienced her first pregnancy

Terminology, continued u Multigravida = a woman who has been pregnant more than once u Nulligravida = A woman who has never been and is not now pregnant u Primipara = A woman who has delivered one pregnancy (regardless of the number of fetuses) that progressed beyond the gestational age of an abortion

Terminology, continued u Multipara = a woman who has delivered two or more pregnancies that progressed beyond the gestational age of an abortion u Nullipara = a woman who has never had a pregnancy progress beyond the gestational age of an abortion u Parturient = a woman currently in labor u Puerpera = a woman who just gave birth

Obstetric History Gravida (G) T Para (P) F P A L T = # of pregnancies F = # of term pregnancies (>37 weeks) P = # of preterm pregnancies (viable through 36 weeks) A = # of abortions (spontaneous or induced) and ectopic pregnancies L = number of living children

OB/GYN History u Age u Chief complaint primary problem duration severity precipitating factors occurrence in relation to other functions

OB/GYN History, continued previous similar sx and its diagnosis and management change in normal life-style resulting from the complaint outcome of previous therapies impact of the CC on the patient’s quality of life, self-image, relationship with family, and daily activities role of other stresses on CC

OB/GYN History, continued u Menstrual Hx Menarche LMP; PMP Duration; Interval; Flow; Regularity; Frequency Abnormal menses Pain PMS symptoms

Menstrual Cycle Average cycle is 28 days Over the age range of 20 to 40 years, women have the tightest regularity to their cycles, with more variability in the immediate postmenarche and premenopause years Polymenorrhea cycle lengths less than 24 days Oligomenorrhea cycle length more than 35 days

Menstrual cycles u Most ovulatory cycles (as determined by a luteinizing hormone [LH] surge and normal luteal-phase progesterone) vary from 24 to 35 days. u The average duration of menstruation is between 3 and 7 days, and shorter (hypomenorrhea) or longer (hypermenorrhea) than this is considered abnormal

Menstrual Flow u Normal duration of menstrual flow ranges from 3 to 7 days u The amount of total blood loss is generally 80 mL or less u Blood loss greater than 80ml correlates with anemia

OB/GYN History, continued u Contraceptive hx present contraception past contraception conception plans complications with contraceptives reasons for discontinuing use desired contraception

OB/GYN History, continued u Obstetric History Gravidity and Parity History of previous pregnancies –duration of pregnancy –antepartum complications –duration of labor –type of delivery –anesthesia used –intrapartum complications

OB/GYN History, continued –Postpartum complications –Hospital –Physician Perinatal status of fetuses –birth weights –early growth and development of children feeding habits growth –overall well-being –current status

OB/GYN History, continued u Gynecologic History Gyn diseases and treatment, including surgery and medical treatment STDs –vaginitis, vulvitis –local lesions –PID Infertility DES exposure

OB/GYN History, continued Personal hygiene u Menopause Climacteric sxs, if any Age at onset Perimenopausal and postmenopausal hx Postmenopausal bleeding

OB/GYN History, continued u Breast disease masses discharge pain biopsy information any family hx of breast cancer

OB/GYN History, continued u Sexual history coital activity libido dyspareunia orgasm satisfaction

Sexual assault and abuse, adult and child u Does your partner treat you well? u Does your partner threaten you…verbally or physically? u Look for signs of trauma while doing physical exam

OB/GYN History, continued u Past Medical History Allergies Medications currently used Medical problems Hospitalizations Surgical history –outcome –complications

OB/GYN History, continued u Family History u Review of Systems pulmonary sxs cardiac sxs GI sxs urinary sxs vascular sxs

OB/GYN History, continued u Social history exercise dietary habits drug use alcohol use tobacco use marital status; number of years married occupational hx

OB/GYN Physical Examination u Height, weight, and blood pressure u Thyroid u Heart u Lungs u Breast examination teach self-breast exam u Examination of the abdomen, back, and lymphatics

OB/GYN P.E., continued u Pelvic examination Vulva/Clitoris BUS (Bartholin’s, urethral, Skene’s glands) Vagina Cervix Uterus Adnexa Rectovaginal examination (guaiac, if needed)

Menstrual Cycle u Ovarian Phase Follicular Phase Ovulation Luteal Phase u Endometrial Phase Menstrual Phase Proliferative Phase Secretory Phase

Diagnostic Tests in OB/GYN u KOH/wet prep u Pap smears u colposcopy u biopsies vulva vagina cervix endometrium

Diagnostic Tests in OB/GYN, continued u cultures GC Herpes, other virus chlamydia aerobic, anaerobic u culdocentesis u hysteroscopy

Diagnostic Tests in OB/GYN, continued u fern test for ovulation u post-coital test u pregnancy tests u pelvic and OB ultrasound u non-stress test u fetal movement counts u amniocentesis