Obstetric Topic 02. Obstetric and gynecologic evaluation

I. History Taking

General History

• Chief complaint: pain, bleeding, dyspareunia, vaginal discharge, pruritus, urinary symptoms, incontinence, fever, pregnancy symptoms.
• Past history: chronic diseases, previous operations, medications, allergies, transfusions.
• Family history: genetic disease, thrombosis, diabetes, hypertension, breast/ovarian/endometrial/colon cancer.
• Social history: tobacco, alcohol, drugs, nutrition, exercise, work exposure, domestic safety, psychosocial support.

Menstrual History

• Menarche/menopause: age and timing.
• LMP: first day of last menstrual period; normal or abnormal.
• Cycle: length, regularity, bleeding duration, amount, days without bleeding.
• Abnormal bleeding: intermenstrual, postcoital or heavy bleeding.
• Painful periods / dysmenorrhea and premenstrual symptoms.

Obstetric History: GTPAL

• G: gravidity = total number of pregnancies, including current pregnancy.
• T: term deliveries ≥37 weeks.
• P: preterm deliveries 24-36 weeks.
• A: abortions/miscarriages/terminations/ectopic pregnancies before viability.
• L: living children.
• Each pregnancy: date/place, gestational age, birth weight, sex, delivery mode, labor duration, anesthesia, complications.
• Ask specifically: preeclampsia, GDM, preterm birth, FGR, macrosomia, stillbirth, congenital anomaly, PPH, puerperal infection.

Sexual and Fertility History

• Sexual activity, partner history, dyspareunia, sexual dysfunction.
• STD/STI history, PID, cervical screening history.
• Contraception: method, satisfaction, failure, contraindications.
• Infertility: duration of trying, previous evaluation/treatment, partner factor.

II. Obstetric Evaluation

Prenatal Care Schedule

• Preconception visit: optimize chronic disease, medication safety, vaccination, folic acid and risk reduction.
• Initial prenatal visit: GW6-8, ideally in the 1st trimester.
• Follow-up:

• Until GW28 → every 4 weeks.
• GW28-35 → every 2 weeks.
• GW36 onward → weekly until delivery.

• High-risk pregnancy: individualized and usually more frequent follow-up.

Naegele's Rule and Gestational Age

• Naegele's rule: EDD = first day of LMP - 3 months + 7 days + 1 year.
• Equivalent: 280 days / 40 weeks from the first day of LMP.
• Gestational age is written as completed weeks + days, e.g. 33+3.
• US dating: most accurate in the 1st trimester; corrects uncertain or unreliable LMP.

Diagnosis of Pregnancy

1. History: Amenorrhea, pregnancy symptoms, unprotected intercourse, contraception failure.
2. Physical signs: uterine enlargement and pregnancy signs.
3. hCG measurement:

• Serum β-hCG becomes positive earlier than urine hCG.
• Abnormal rise → wrong dating, ectopic pregnancy or failing pregnancy.
• High value → wrong dating, multiple gestation, molar pregnancy or screening context.

4. Ultrasound: Confirms intrauterine pregnancy, viability, number of embryos and dating.

First Obstetric Visit

1. Full history + risk assessment: maternal disease, previous obstetric complications, genetic, infection and psychosocial risk.
2. Physical examination:

• Height, weight, BMI, blood pressure, pulse, temperature if indicated.
• Signs of anemia, thyroid disease, edema, cardiopulmonary disease.
• Breast, abdominal and pelvic examination when indicated.

3. Initial tests:

• CBC, ABO/Rh blood type, antibody screen.
• Urinalysis and urine culture.
• Blood glucose/HbA1c if risk; routine GDM screening later.
• Infection/immunity: HIV, syphilis, hepatitis B/C, rubella; chlamydia/gonorrhea by risk.
• Cervical cytology/HPV test if due.

4. Ultrasound: Confirm pregnancy location, viability, gestational age and plurality.
5. Education: warning symptoms, safe medications, vitamins/folic acid, nutrition, exercise, alcohol/tobacco/drugs, dental care, vaccination and screening options.

Subsequent Prenatal Visits

• Ask: bleeding, leakage of fluid, contractions/pain, fever, headache, visual symptoms, edema, dysuria, reduced fetal movements later.
• Measure: BP and weight at each visit.
• Urine check: Protein and infection/glucose according to local practice/risk.
• Fetal assessment: fundal height from about 20 weeks, fetal heart tones, fetal movements later.
• Leopold maneuvers: later pregnancy palpation → fetal lie, presentation, position and engagement.

III. Gynecologic Physical Examination

General Examination

• Vital signs: BP, pulse/HR, temperature, respiratory status if relevant.
• Height, weight, BMI; signs of anemia, thyroid disease, edema, hirsutism/virilism, cachexia.
• Breast examination: mass, skin change, nipple discharge, axillary nodes.
• Abdominal examination: scars, distension, tenderness, guarding, masses, organomegaly, hernias.

Pelvic Examination: Preparation

• Explain procedure, obtain consent, offer chaperone according to local policy.
• Bladder should be empty before bimanual examination.
• Position: Lithotomy / dorsal lithotomy.
• Pregnancy caveat: avoid unnecessary digital cervical examination with bleeding, placenta previa suspicion or ruptured membranes unless indicated.

Inspection of External Genitalia

• Inspect: vulva, perineum, clitoris, labia, urethral meatus, vestibule and hymen.
• Assess: symmetry, hair distribution, atrophy, erythema, swelling, ulceration, rash, bruising, discharge, warts, tumors.
• Bartholin glands: lower/posterior vestibule at about 5 and 7 o'clock; mass → cyst/abscess.
• Palpate inguinal nodes if malignancy or infection is suspected.

Speculum Examination

• Vagina: discharge, color/estrogenization, atrophy, erythema, lesions, prolapse, trauma.
• Cervix: size, shape, color, os, ectropion, polyp, ulcer, wart, mass, bleeding, discharge.
• Nulliparous cervix: round external os. Multiparous cervix: transverse/slit-like os.
• Infection suspicion: pH, wet mount, culture or NAAT according to risk.
• Pap smear / liquid-based cytology / HPV test: take before bimanual exam and before lubricant contamination when due.

Colposcopy

• Colposcopy: magnified view of cervix, vagina and vulva to distinguish normal vs abnormal tissue.
• Key area: squamocolumnar junction / transformation zone.
• Extended colposcopy:

• Acetic acid → white area = higher nuclear density → suspicious epithelium.
• Lugol iodine → normal glycogenated squamous epithelium stains dark brown; abnormal epithelium remains iodine-negative.
• Biopsy: directed biopsy from abnormal area; endocervical sampling only if indicated and not pregnant.

Bimanual Pelvic Examination

1. Insert index and middle fingers of dominant hand into vagina.
2. Palpate cervix: consistency, mobility and tenderness.
3. Assess uterus with abdominal hand:

• Size, shape, position, mobility and tenderness.
• Mass/nodularity → fibroid, adenomyosis, pregnancy or malignancy.

4. Assess adnexa:

• Normal ovary: almond-size; not always palpable.
• Tenderness → inflammation, ectopic pregnancy, torsion.
• Mass → cyst, tumor, tubo-ovarian abscess, ectopic pregnancy.

Rectal / Rectovaginal Examination

• Indications: suspected endometriosis, pelvic malignancy, posterior lesion, rectal symptoms or cul-de-sac mass.

IV. Investigations

Common Gynecologic / Obstetric Tests

• Pregnancy test: urine or serum β-hCG.
• Blood tests: CBC, blood group/Rh, antibody screen, glucose/HbA1c; thyroid tests when indicated.
• Hormonal assay when indicated: FSH, LH, estradiol, progesterone, prolactin, testosterone/DHEAS.
• Urinalysis and urine culture.
• Infection/immunity: syphilis, hepatitis B/C, HIV, rubella; chlamydia/gonorrhea or cultures/NAAT by risk.
• Ultrasound: transvaginal for early pregnancy/pelvic organs; transabdominal for later pregnancy or large masses.
• MRI: complex pelvic mass, placenta accreta spectrum, fetal anomaly or staging problem.
• Mammography / breast US: according to age, symptom and breast risk.
• Dental examination/care during pregnancy when relevant.