What is the recommended approach for a female patient of childbearing age presenting with obstetrics (OB) or gynecology (GYN) concerns?

Recommended Approach for Female Patients of Childbearing Age with OB/GYN Concerns

For women of childbearing age presenting with obstetric or gynecologic concerns, obtain a comprehensive reproductive history including prior pregnancy complications, screen for chronic medical conditions (diabetes, hypertension, thyroid disease), and identify any FDA pregnancy category X medications that require discontinuation. 1

Initial Assessment Framework

Reproductive and Medical History

• Document all previous pregnancies, complications, and outcomes to stratify risk for future pregnancies 1
• Screen for preexisting medical conditions including diabetes (target A1C <6.5% before conception), hypertension (target BP <140/90 mmHg with pregnancy-safe medications), and thyroid disorders 1
• Identify and discontinue teratogenic medications such as isotretinoin and warfarin immediately 1
• Obtain detailed family history to assess cardiovascular and genetic risks, particularly during menarche to premenopause 2

Laboratory and Genetic Screening

• Order comprehensive laboratory panel: complete blood count, blood type, Rh screen to identify maternal and fetal risks 1
• Perform genetic carrier screening based on ethnicity and family history 1
• Consider pregnancy testing as a core service, using qualitative urine testing in most cases 2

Pregnancy-Specific Management

Timing and Planning

• For women with diagnosed placenta accreta spectrum, schedule delivery at 34 0/7 to 35 6/7 weeks gestation at a center experienced with this condition, as approximately half require emergent delivery for hemorrhage beyond 36 weeks 2
• Administer antenatal corticosteroids for anticipated delivery before 37 0/7 weeks 2
• Coordinate multidisciplinary team including anesthesiology, maternal-fetal medicine, neonatology, and expert pelvic surgeons 2

Prenatal Care Essentials

• Administer Tdap vaccine at 27-36 weeks gestation for infant pertussis protection 1
• Provide influenza vaccination during flu season 1
• Counsel on nutrition: five servings of fruits and vegetables daily 1
• Mandate complete abstinence from alcohol, tobacco, and recreational drugs 1
• Target prepregnancy BMI of 19.8-26.0 kg/m² and follow Institute of Medicine weight gain guidelines 2

Gynecologic Concerns Requiring Referral

Urgent Referrals

• Acute pelvic pain with suspected ovarian torsion, ectopic pregnancy, or tubo-ovarian abscess requires immediate gynecologic consultation 3
• Adnexal masses classified as O-RADS 4 or 5 require referral to gynecologic oncology 3
• Atypical glandular cells on cervical cytology mandate colposcopy, endocervical curettage, and HPV testing 3
• Adenocarcinoma in situ requires gynecologic oncologist evaluation 3

Non-Urgent Referrals

• Abnormal uterine bleeding unresponsive to medical therapy or causing severe anemia 3
• Dysmenorrhea refractory to medical management 3
• Primary amenorrhea by age 16 or secondary amenorrhea 3
• Infertility after 12 months of unprotected intercourse (6 months if age >35 years) requires reproductive endocrinology referral 3
• Elevated CA-125 in postmenopausal women with pelvic mass, or CA-125 >200 units/mL in premenopausal women 3

Contraception Counseling

General Population

• Provide contraception as core family planning service 2
• Assess cardiovascular risk factors before initiating oral contraceptives, particularly in women with family history of cardiovascular disease 2

Special Populations

• For women with hereditary angioedema (HAE-C1-INH): avoid estrogens; recommend barrier methods, intrauterine devices, or progestins 2
• For cancer survivors diagnosed before age 25: counsel on increased risk of cesarean delivery (particularly elective/primary cesarean) but reassure about no increased risk of congenital anomalies 2

Cardiovascular Risk Assessment

Pregnancy serves as a physiological stress test revealing underlying disease processes, with 30-40% of pregnant women having at least one cardiovascular risk factor. 2

• Screen for traditional and nontraditional cardiovascular risk factors throughout reproductive years 2
• Encourage 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (20-30 minutes most days during pregnancy when not contraindicated) 2
• Address mental health, as it significantly affects cardiovascular health and optimal risk factor attainment 2

Common Pitfalls to Avoid

• Do not delay prenatal care referral for positive pregnancy tests; expedite appointments and follow through on all referrals 2
• Do not perform amniocentesis for pulmonary maturity testing at 34-36 weeks gestation in placenta accreta cases, as results do not change delivery recommendations 2
• Do not recommend bedrest or pelvic rest routinely for placenta accreta spectrum without evidence of bleeding, as benefits are unproven 2
• Do not overlook mental health screening in women with fetal anomalies, who have significantly higher anxiety rates (mean score 43.6 vs 29.1) and 35.9% elevated risk of major depression postpartum 2