CHAPTER 6 Operative Obstetrics

ObstetricsandGynecology BOARDREVIEW Third Edition

Stephen G. Somkuti, MD, PhD Associate Professor Department of Obstetrics and Gynecology and Reproductive Sciences Temple University School of Medicine School Philadelphia, Pennsylvania Director, The Toll Center for Reproductive Sciences Division of Reproductive Endocrinology Department of Obstetrics and Gynecology Abington Memorial Hospital Abington Reproductive Medicine Abington, Pennsylvania

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CONTENTS

Contributors ...... vii

Introduction ...... xi

1. Anatomy of the Pelvis and Reproductive Tract ...... 1

2. Embryology of the Genital Tract ...... 13

3. Physiology of Normal Pregnancy ...... 21

4. Antepartum Fetal Monitoring and Fetal Surveillance ...... 39

5. Labor and Delivery ...... 51

6. Operative Obstetrics ...... 57

7. Multiple Gestations ...... 73

8. Breech ...... 79

9. Postdates Pregnancy and Fetal Demise ...... 87

10. Labor Abnormalities ...... 91

11. The Puerperium ...... 95

12. Obstetric Complications ...... 103

13. Hypertension and Pregnancy ...... 109

iii iv Contents ...

14. Medical and Surgical Complications in Pregnancy ...... 121

15. Gastrointestinal Disorders in Pregnancy ...... 143

16. First Trimester Ultrasound ...... 153

17. Obstertical Ultrasound and Fetal Abnormalities ...... 163

18. Amniotic Fluid ...... 169

19. The Placenta and Umbilical Cord ...... 177

20. Rh Isoimmunization ...... 189

21. Genetics for the Obstetrician ...... 199

22. Lactation ...... 207

23. Primary and Preventative Care ...... 215

24. Functional and Dysfunctional Uterine Bleeding ...... 221

25. Adenomyosis and Endometriosis ...... 231

26. Benign Disorders of the Upper Genital Tract ...... 239

27. Dysmenorrhea and Premenstrual Syndrome ...... 249

28. Ectopic Pregnancy ...... 253

29. Genital Tract Infections and Pelvic Inﬂammatory Disease ...... 263

30. Benign Vulvar and Vaginal Lesions ...... 269 ... Contents v

31. Hysterectomy ...... 275

32. Menopause ...... 285

33. Osteoporosis ...... 291

34. Preoperative Evaluation and Preparation for Gynecologic Surgery ...... 309

35. Postoperative Care of the Gynecologic Patient ...... 319

36. Urinary Tract Injuries ...... 329

37. Genital Prolapse ...... 335

38. Urinary Incontinence and Urodynamics ...... 345

39. Pediatric and Adolescent Gynecology ...... 349

40. Breast Disorders ...... 361

41. Ethics and Psychiatric Pearls ...... 379

42. Cervical Lesions and Cancer ...... 393

43. Endometrial Hyperplasia and Carcinoma ...... 401

44. Uterine Sarcomas ...... 411

45. Epithelial and Nonepithelial Ovarian Tumors ...... 415

46. Fallopian Tube Neoplasms ...... 421

47. Vulvar and Vaginal Carcinoma ...... 427 vi Contents ...

48. Radiation Therapy, Chemotherapy, Immunotherapy, and Tumor Markers ...... 437

49. Gestational Trophoblastic Disease ...... 455

50. Gynecologic Pathology ...... 463

51. Hypothalamic-Pituitary-Ovarian-Uterine Axis ...... 481

52. Amenorrhea ...... 503

53. Infertility ...... 513

54. Assisted Reproductive Technology ...... 527

55. GnRH and GnRH Analogs ...... 533

56. Laparoscopy and Infertility Surgery ...... 541

57. Hyperandrogenism ...... 551

58. Disorders of Prolactin Secretion ...... 565

59. Miscarriage, Recurrent Miscarriage, and Pregnancy Termination ...... 573

60. Family Planning and Sterilization ...... 581

61. Reproductive Toxicology ...... 593

62. Epidemiology and Clinical Biostatistics ...... 605 CONTRIBUTORS

Oren Azulay, MD Hipolito Custodio III, MD, MS Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Kaiser Permanente Albert Einstein Medical Center Fontana, California Philadelphia, Pennsylvania Genital Prolapse Gastrointestinal Disorders in Pregnancy Pediatric and Adolescent Gynecology Julie A. Braga, MD Ethics and Psychiatric Pearls Department of Obstetrics and Gynecology Dartmouth Hitchcock Medical Center Lebanon, New Hampshire Primary and Preventative Care Darnelle L. Dorsainville, MS, CGC Board Certiﬁed Genetic Counselor Miki Chiguchi, MD Division of Genetics Division of Obstetrics and Gynecology Department of Pediatrics Department of Obstetrics and Gynecology Albert Einstein Medical Center Abington Memorial Hospital Philadelphia, Pennsylvania Abington, Pennsylvania Genetics for the Obstetrician Anatomy of the Pelvis and Reproductive Tract Dysmenorrhea and Premenstrual Syndrome

Jerry Cohen, MPH Mitchell I. Edelson, MD Research Consultant Gynecologic Oncology Institute Residency Training Program Abington Memorial Hospital Department of Obstetrics and Gynecology Abington, Pennsylvania Abington Memorial Hospital Uterine Sacromas Abington, Pennsylvania Epithelial and Nonepithelial Ovarian Cancer Epidemiology and Clinical Biostatistics Fallopian Tube Neoplasms Rachel Cohen, DO Vulvar and Vaginal Carcinoma Department of Obstetrics and Gynecology Radiation Therapy, Chemotherapy, Immunotherapy, Mercy Suburban Hospital and Tumor Markers Norristown, Pennsylvania Gestational Trophoblastic Disease Embryology of the Genital Tract Gynecologic Pathology Physiology of Normal Pregnancy Breech Primary and Preventative Care Stephanie J. Estes, MD Family Planning and Sterilization Assistant Professor Frank Craparo, MD Division of Reproductive Endocrinology and Division Director Infertility Maternal Fetal Medicine Department of Obstetrics and Gynecology Abington Memorial Hospital Penn State Milton S. Hershey Medical Center Abington, Pennsylvania Hershey, Pennsylvania Labor and Delivery Amenorrhea Rh Isoimmunization Disorders of Prolactin Secretion

vii

Gretchen E. Glaser, MD Namita Kattal, MD Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Abington Memorial Hospital Albert Einstein Medical Center Abington, Pennsylvania Philadelphia, Pennsylvania Rh Isoimmunization Miscarriage, Recurrent Miscarriage, and Pregnancy Lactation Termination Benign Disorders of the Upper Genital Tract Family Planning and Sterilization

Abby M. Gonik, MD Radmilla Kazanegra, MD Department of Obstetrics and Gynecology Gynecologic Endoscopy Fellow Abington Memorial Hospital Center for Minimally Invasive Surgery Abington, Pennsylvania Stanford University Cervical Lesions and Cancer Palo Alto, California Endometrial Hyperplasia and Carcinoma Ectopic Pregnancy Hyperandrogenism Karen Hancock, MD Department of Obstetrics and Gynecology Rosanne B. Keep, MS, CGC Mercy Suburban Hospital Abington Reproductive Medicine, P.C. Norristown, Pennsylvania Abington IVF & Genetics, LP Menopause Abington, Pennsylvania Osteoporosis Genetics for the Obstetrician

Denise Hartman, MD John S. Kukora, MD Adjunct Assistant Professor Professor of Surgery Division of Gynecology Department of Surgery Department of Obstetrics and Gynecology Drexel University College of Medicine Temple University School of Medicine Philadelphia, Pennsylvania Philadelphia, Pennsylvania Chairman Obstetrician and Gynecologist Department of Surgery and Abington Memorial Hospital Division of Gynecology Abington, Pennsylvania Department of Obstetrics and Gynecology Breast Disorders Abington Memorial Hospital Abington, Pennsylvania Benign Vulvar and Vaginal Lesions Richard Latta, MD Preoperative Evaluation and Preparation for Division Director Gynecologic Surgery Maternal Fetal Medicine Postoperative Care of the Gynecologic Patient Abington Memorial Hospital Abington, Pennsylvania Maria A. Giraldo-Isaza, MD Operative Obstetrics Department of Obstetrics and Gynecology Albert Einstein Medical Center Annette Lee, MD, FACOG Philadelphia, Pennsylvania Reproductive Endocrinologist The Puerperium Abington Reproductive Medicine Genital Tract Infections and Pelvic Abington, Pennsylvania Inﬂammatory Disease Assisted Reproductive Technology ... Contributors ix

Michael S. Lempel, DO Diane M. Opatt, MD Obstetrician/Gynecologist Clinical Assistant Professor of Surgery Department of Obstetrics and Gynecology Department of Surgery Potomac Hospital Drexel University College of Medicine Woodbridge, Virginia Philadelphia, Pennsylvania Antepartum Fetal Monitoring and Fetal Surveillance Assistant Surgeon Adenomyosis and Endometriosis Department of Surgery Abington Memorial Hospital Abington, Pennsylvania Vincent Lucente MD, MBA Breast Disorders Clinical Professor of Obstetrics and Gynecology Division of Gynecology Department of Obstetrics and Gynecology David Peleg, MD Temple University College of Medicine Department of Obstetrics and Gynecology Philadelphia, Pennsylvania Abington Memorial Hospital Chief of Gynecology Abington, Pennsylvania Division of Urogynecology First Trimester Ultrasound Department of Obstetrics and Gynecology St. Luke’s Hosptial Roberto Prieto-Harris, MD Allentown, Pennsylvania Obstetrician/Gynecologist Urinary Tract Injuries Department of Obstetrics and Gynecology Urinary Incontinence and Urodynamics Doctors Hospital at Renaissance McAllen, Texas Multiple Gestation Amy Mackey, MD Department of Obstetrics and Gynecology Abington Memorial Hospital Shai Pri-Paz, MD Abington, Pennsylvania Department of Obstetrics and Gynecology Obstetric Complications Albert Einstein Medical Center Philadelphia, Pennsylvania Hypertension and Pregnancy Julio Mateus, MD Medical and Surgical Complications Maternal Fetal Medicine Fellow in Pregnancy Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology University of Texas Medical Branch at Galveston Kristen Quinn, MD, MS Galveston, Texas Department of Obstetrics and Gynecology Breech Abington Memorial Hospital Abington, Pennsylvania Amniotic Fluid Vasiliki A. Moragianni, MD, MSc Department of Obstetrics and Gynecology Abington Memorial Hospital Jeffrey Sellers, MD Abington, Pennsylvania Department of Obstetrics and Gynecology Infertility Abington Memorial Hospital GnRH and GnRH Analogs Abington, Pennsylvania Laparoscopy and Infertility Surgery Functional and Dysfunctional Uterine Bleeding x Contributors ...

Dana Shanis, MD Hima Bindu Tam Tam, MD Department of Obstetrics and Gynecology Maternal Fetal Medicine Fellow University of Connecticut Health Center North Shore University Hospital Farmington, Connecticut Manhasset, New York Hypothalamic-Pituitary-Ovarian-Uterine Axis Obstetrical Ultrasound and Fetal Abnormalities

Ruby Shrestha, MD Department of Obstetrics and Gynecology Chase M. White, MD Abington Memorial Hospital Department of Obstetrics and Gynecology Abington, Pennsylvania Albert Einstein Medical Center The Placenta and Umbilical Cord Philadelphia, Pennsylvania Hysterectomy Stephen J. Smith, MD Assistant Clinical Professor Division of Maternal-Fetal Medicine Emese Zsiros, MD Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Abington Memorial Hospital Northwestern University’s Feinberg School of Abington, Pennsylvania Medicine Postdates Pregnancy and Fetal Demise Chicago, Illinois Labor Abnormalities Reproductive Toxicology INTRODUCTION

Congratulations on your purchase of Obstetrics and Gynecology Board Review: Pearls of Wisdom will help you learn some medicine. Originally designed as a study aid to improve performance on the Ob/Gyn Inservice and Written Boards exams, this book is full of useful information. A few words are appropriate discussing intent, format, limitations, and use Wisdom, third edition. Since Obstetrics and Gynecology Board Review is primarily intended as a study aid, the text is written in rapid-fire question/answer format. This way, readers receive immediate gratification. Moreover, misleading or confusing “foils” are not provided. This eliminates the risk of erroneously assimilating an incorrect piece of information that makes a big impression. Questions themselves often contain a “pearl” intended to reinforce the answer. Additional “hooks” may be attached to the answer in various forms, including mnemonics, visual imagery, repetition, and humor. Additional information not requested in the question may be included in the answer. Emphasis has been placed on distilling trivia and key facts that are easily overlooked, that are quickly forgotten, and that somehow seem to be needed on board examinations. Many questions have answers without explanations. This enhances ease of reading and rate of learning. Explanations often occur in a later question/answer. Upon reading an answer, the reader may think, “Hmm, why is that?” or, “Are you sure?” If this happens to you, go check! Truly assimilating these disparate facts into a framework of knowledge absolutely requires further reading of the surrounding concepts. Information learned in response to seeking an answer to a particular question is retained much better than information that is passively observed. Take advantage of this! Use this book with your preferred source texts handy and open. Obstetrics and Gynecology Board Review has limitations. We have found many conflicts between sources of information. We have tried to verify in several references the most accurate information. Some texts have internal discrepancies further confounding clarification. Obstetrics and Gynecology Board Review risks accuracy by aggressively pruning complex concepts down to the simplest kernel—the dynamic knowledge base and clinical practice of medicine is not like that! Furthermore, new research and practice occasionally deviates from that which likely represents the right answer for test purposes. This text is designed to maximize your score on a test. Refer to your most current sources of information and mentors for direction for practice. Obstetrics and Gynecology Board Review is designed to be used, not just read. It is an interactive text. Use a 3 × 5 card and cover the answers; attempt all questions. A study method we recommend is oral, group study, preferably over an extended meal or pitchers. The mechanics of this method are simple and no one ever appears stupid. One person holds this book, with answers covered, and reads the question. Each person, including the reader, says “Check!” when he or she has an answer in mind. After everyone has “checked” in, someone states his/her answer. If this answer is correct, on to the next one; if not, another person says their answer or the answer can be read. Usually the person who “checks” in first receives the first shot at stating the answer. If this person is being a smarty-pants answer-hog, then others can take turns. Try it, it’s almost fun!

Obstetrics and Gynecology Board Review is also designed to be re-used several times to allow, dare we use the word, memorization. A hollow bullet is provided for any scheme of keeping track of questions answered correctly or incorrectly. We welcome your comments, suggestions and criticism. Great effort has been made to verify these questions and answers. Some answers may not be the answer you would prefer. Most often this is attributable to variance between original sources. Please make us aware of any errors you ﬁnd. We hope to make continuous improvements and would greatly appreciate any input with regard to format, organization, content, presentation, or about speciﬁc questions. We look forward to hearing from you! Study hard and good luck! S.G.S.

DEDICATION

To my loving family Andrea my wife, Fiva and Michael our children. Anatomy of the Pelvis CHAPTER 1 and Reproductive Tract

Miki Chiguchi, MD

❍ Where are Gartner ducts located? In the lateral walls of the vagina.

❍ Gartner duct cysts are persistent portions of what embryonic structure? Mesonephric duct.

❍ The portion of the gubernaculum between the ovary and uterus becomes what structure? The ligament of the ovary (utero-ovarian ligament).

❍ The portion of the gubernaculum between the uterus and the labium majus becomes what structure? The round ligament.

❍ Failure of the development of adhesions between the uterus and what structure can result in the ovary migrating through the inguina