What essential history, physical examination, investigations, red‑flag assessment, and initial management should be included when taking an obstetrics‑gynecology case in a reproductive‑age woman?

Essential Components of an Obstetrics-Gynecology Case Assessment

When taking an OB-GYN case, you must systematically obtain a comprehensive reproductive and obstetric history, perform a targeted physical examination focusing on vital signs and pelvic assessment, and screen for red-flag conditions including ectopic pregnancy, ovarian torsion, and pregnancy-related complications. 1, 2, 3

History Taking

Menstrual History

• Document cycle characteristics: cycle length, duration of bleeding, regularity, and age at menarche using a menstrual chart for at least 6 months 2, 3
• Assess menstrual irregularities: oligomenorrhea, amenorrhea, polymenorrhea, or delayed menarche 2
• Evaluate dysmenorrhea: onset, severity, and response to NSAIDs 2, 3

Reproductive and Obstetric History

• Gravidity and parity: number of pregnancies, outcomes (term births, preterm births, miscarriages, ectopic pregnancies, living children), and complications 1, 2
• Previous pregnancy complications: cesarean sections, congenital malformations, fetal loss, hypertensive disorders, postpartum hemorrhage, macrosomia, preterm delivery, thrombotic events 1
• Infertility assessment: duration of attempting pregnancy, coital frequency and timing, previous evaluations or treatments 1

Sexual and Contraceptive History

• Current contraception: method, consistency of use, contraindications to hormonal contraceptives 1, 2
• Sexual practices: coital frequency, dyspareunia 1
• STD history: previous infections, pelvic inflammatory disease, exposure risk 1, 2
• Cervical cancer screening: results and any follow-up treatment 1

Medical and Surgical History

• Comorbidities: diabetes, hypertension, thyroid disorders, PCOS, cardiovascular disease, nephropathy, retinopathy 1
• Current medications: review appropriateness during pregnancy, identify potentially harmful drugs (ACE inhibitors, ARBs, statins) 1
• Previous surgeries: gynecologic procedures, indications, outcomes 1
• Allergies: document all medication allergies 1

Trauma and Psychosocial Assessment

• Trauma history: unwanted sexual activity or assault using trauma-informed approach 2
• Psychological factors: depression, anxiety, stress, eating disorders 2
• Lifestyle factors: exercise patterns, dietary intake, smoking, alcohol, recreational drugs 1, 2

Physical Examination

Vital Signs and General Assessment

• Baseline measurements: blood pressure, heart rate, respiratory rate, height, weight, BMI calculation 1, 2
• Thyroid examination: assess for enlargement, nodules, or tenderness 1, 2
• Clinical breast examination: assess for masses or discharge 1
• Signs of androgen excess: hirsutism, acne 1

Pelvic Examination

Note: A complete pelvic examination is not necessary for asymptomatic patients but is indicated for persistent vaginal discharge, dysuria in sexually active patients, dysmenorrhea unresponsive to NSAIDs, amenorrhea, abnormal vaginal bleeding, or lower abdominal pain 3

• External genitalia: assess for abnormalities, lesions 1, 2
• Speculum examination: evaluate vaginal and cervical abnormalities, secretions, discharge 1, 2
• Bimanual examination: assess uterine size, shape, position, mobility; adnexal masses or tenderness; cul-de-sac masses, tenderness, or nodularity; pelvic or abdominal tenderness 1, 2
• Back examination: when neuraxial anesthesia is planned 1

Initial Laboratory Investigations

Routine Screening

• Pregnancy test: perform if any doubt exists, especially before prescribing NSAIDs or hormonal contraceptives 2
• Complete blood count: if heavy bleeding present to assess for anemia 2
• Coagulation studies: if heavy bleeding present 2

Endocrine Evaluation (when indicated)

• Thyroid function tests: TSH if menstrual irregularities or thyroid symptoms present 1, 2
• Prolactin level: if menstrual irregularities or galactorrhea 2
• FSH/LH levels: if amenorrhea or infertility concerns 2
• Fasting glucose and insulin: if PCOS suspected 2

Infectious Disease Screening

• STD testing: Neisseria gonorrhoeae, Chlamydia trachomatis 1
• Hepatitis B and C: screening as indicated 1
• HIV: screening as indicated 1
• Syphilis: screening 1

Diabetes-Specific Screening (if applicable)

• Comprehensive metabolic panel: serum creatinine, lipid panel 1
• Urine albumin-to-creatinine ratio: assess for nephropathy 1
• ECG: in individuals ≥35 years with cardiac signs/symptoms or risk factors 1
• Comprehensive ophthalmologic exam: especially with preexisting diabetic retinopathy 1

Red-Flag Assessment and Urgent Conditions

Life-Threatening Emergencies Requiring Immediate Consultation

• Ectopic pregnancy: abdominal pain, vaginal bleeding, positive pregnancy test with no intrauterine pregnancy on ultrasound 1, 4
• Ovarian torsion: acute pelvic pain with adnexal mass 4
• Tubo-ovarian abscess: fever, pelvic pain, elevated inflammatory markers 4
• Ruptured hemorrhagic ovarian cyst: acute abdomen with hemodynamic instability 4

High-Risk Obstetric Conditions

• Preeclampsia/HELLP syndrome: hypertension, proteinuria, thrombocytopenia 1
• Diabetic ketoacidosis: in pregnant diabetics 1
• Severe hypoglycemia: in diabetics 1

Conditions Requiring Platelet Assessment

• Pregnancy-related hypertensive disorders: obtain platelet count before neuraxial anesthesia 1
• Suspected coagulopathy: obtain coagulation studies 1

Common Pitfalls to Avoid

• Never assume primary dysmenorrhea without excluding secondary causes: perform pelvic examination if risk factors for endometriosis, PID, or structural abnormalities present 2
• Always perform pregnancy test when in doubt: before prescribing NSAIDs, hormonal contraceptives, or potentially teratogenic medications 2
• Use trauma-informed approach during examination: avoid approaching from behind during thyroid exam, provide patient control, explicitly ask permission before sensitive exams 2
• Do not delay consultation for suspected ectopic pregnancy: even with β-hCG <1,000 mIU/mL, ultrasound findings may be suggestive 1
• Recognize communication importance: establish early contact between obstetric providers, anesthesiologists, and multidisciplinary team members 1

Initial Management Priorities

Preconception Counseling (when applicable)

• Folic acid supplementation: 400 mg routine 1
• Glycemic control: achieve target goals before conception in diabetics 1
• Medication review: discontinue potentially harmful drugs (ACE inhibitors, ARBs, statins) 1
• Immunizations: influenza, Tdap, COVID-19, hepatitis A/B as indicated 1
• Contraceptive plan: prevent pregnancy until medical optimization achieved 1

Referral Indications

• Gynecologic oncology: adnexal masses O-RADS 4-5, elevated CA-125 in postmenopausal women, adenocarcinoma in situ 4
• Reproductive endocrinology: infertility (≥12 months unprotected intercourse, or ≥6 months if age >35 years) 4
• Urgent gynecologic consultation: acute pelvic pain with suspected torsion, ectopic pregnancy, or tubo-ovarian abscess 4