First Aid for the Obstetrics & Gynecology Clerkship

FOR FIRST AID THE® Obstetrics & Gynecology Clerkship Third Edition

MATTHEW S. KAUFMAN, MD PRITI P. SCHACHEL, MD, FACOG Assistant Professor, Albert Einstein College of Co-Director of Academic Curriculum Medicine The Methodist Hospital-Houston Department of Hematology Obstetrics and Gynecology Residency Program North Shore–Long Island Jewish Medical Center Assistant Professor, Weill Cornell Medical College New Hyde Park, New York Houston, Texas JEANÉ SIMMONS HOLMES, MD, LATHA G. STEAD, MD, MS, FACOG FACEP Co-Director of Academic Curriculum Chief, Division of Clinical Research Obstetrics and Gynecology Residency Program Professor of Emergency Medicine The Methodist Hospital-Houston University of Florida College of Medicine at Gainesville Assistant OB/GYN Clerkship Director at Adjunct Professor of Emergency Medicine St. Joseph Medical Center Mayo Clinic, College of Medicine Department of Obstetrics and Gynecology Rochester, Minnesota Assistant Professor, Weill Cornell Medical College Editor-in-Chief, International Journal of Emergency Houston, Texas Medicine

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MARQUITA D. ANDERSON MAE KATHLEEN HAYES Class of 2010 Class of 2010 University of Texas Medical School at Houston University of Texas Medical School at Houston Houston, Texas Houston, Texas 16/Infertility 5/Intrapartum 23/Pelvic Masses JAMIE G. HERNANDEZ MARTINA T. AYAD Class of 2010 Class of 2010 University of Texas Medical School at Houston University of Texas Medical School at Houston Houston, Texas Houston, Texas 13/Contraception and Sterilization 14/Menstruation 15/Premenstrual Syndrome/Premenstrual Dysphoric CATHLEEN G. HOFFMAN Disorder Class of 2010 17/Amenorrhea University of Texas Medical School at Houston 18/Hyperandrogenism Houston, Texas 19/Hyperprolactemia and Galactorrhea Section I: How to Succeed in the Obstetrics and 20/Abnormal Uterine Bleeding Gynecology Clerkship

LAUREN K. BANKS Class of 2010 CHRISTOPHER A. HOLLWEG, MPH University of Texas Medical School at Houston Class of 2011 Houston, Texas St. George’s University School of Medicine 8/Obstetrical Complications of Pregnancy Granada Minicases and Vignettes

ARIELLE L. CAPERS Class of 2010 ROXANNA A. IRANI, PHD University of Texas Medical Branch at Galveston Class of 2011 Galveston, Texas University of Texas Medical School at Houston 6/Postpartum Houston, Texas 4/Antepartum 11/Abortions and Fetal Death LAUREN P. GIBSON Class of 2010 University of Texas Medical School at Houston CHARLIE C. KILPATRICK, MD Houston, Texas Assistant Professor 7/Medical Conditions in Pregnancy Department of Obstetrics, Gynecology and Reproduc- 9/Infections in Pregnancy tive Sciences Lyndon Baines Johnson Hospital University of Texas Health Science Center at Houston TRACILYN HALL, MD Houston, Texas Resident 10/Twin Gestation The Methodist Hospital-Houston 32/Breast Disease Obstetrics and Gynecology Residency Program Houston, Texas 31/Sexually Transmitted Infections/Vaginitis

iii VANESSA M. LOPEZ GAVIN P. PUTHOFF Class of 2010 Class of 2010 University of Texas Medical School at Houston University of Texas Medical School at Houston Houston, Texas Houston, Texas 21/Pelvic Pain 26/Endometrial Hyperplasia and Endometrial Cancer 22/Endometriosis/Adenomyosis 27/Ovarian Cancer and Fallopian Tube Cancer

MARGARET MARKHAM JENNY VAN WINKLE, MD Class of 2010 Resident University of Texas Medical School at Houston The Methodist Hospital-Houston Houston, Texas Obstetrics and Gynecology Residency Program 24/Cervical Dysplasia Houston, Texas 25/Cervical Cancer 28/Vulvar Dysplasia, Vulvar Cancer, and Vaginal Cancer 29/Vulvar Disorders LYNDA E. MBAH Class of 2010 University of Texas Medical School at Houston GERILYNN S. VINE Houston, Texas Class of 2010 11/Abortions and Fetal Death University of Texas Medical School at Houston 12/Ectopic Pregnancy Houston, Texas 3/Physiology of Pregnancy KATHERINE M. NELSON Class of 2010 CRISTINA M. WALLACE University of Texas Medical School at Houston Class of 2010 Houston, Texas University of Texas Medical School at Houston 36/Menopause Houston, Texas 37/Pelvic Relaxation 1/Normal Anatomy 38/Urinary Incontinence 2/Diagnosis of Pregnancy

BRIDGETTE J. PARISH, MD Resident The Methodist Hospital-Houston Obstetrics and Gynecology Residency Program Houston, Texas 30/Gestational Trophoblastic Disease

MICHAEL L. PIRICS, MD Resident The Methodist Hospital-Houston Obstetrics and Gynecology Residency Program Houston, Texas 33/Women’s Health Maintenance 34/Female Sexuality 35/Ethics

iv STUDENT REVIEWERS

SILKE HEINISCH FRANK SANTORO Class of 2010 Class of 2009 Temple University School of Medicine University of Connecticut School of Medicine Philadelphia, Pennsylvania Farmington, Connecticut

v This page intentionally left blank CONTENTS

Introduction xi

Acknowledgments xiii

How to Contribute xv

SECTION I: HOW TO SUCCEED IN THE OBSTETRICS & GYNECOLOGY CLERKSHIP 1 Cathleen G. Hoffman

SECTION II: HIGH-YIELD FACTS IN OBSTETRICS 13

1. Reproductive Anatomy 15 Cristina M. Wallace

2. Diagnosis of Pregnancy 23 Cristina M. Wallace

3. Physiology of Pregnancy 29 Gerilynn S. Vine

4. Antepartum 41 Roxanna A. Irani, PhD

5. Intrapartum 65 Mae Kathleen Hayes

6. Postpartum 95 Arielle L. Capers

7. Medical Conditions in Pregnancy 111 Lauren P. Gibson

8. Obstetric Complications 129 Lauren K. Banks

9. Infections in Pregnancy 155 Lauren P. Gibson

10. Twin Gestation 167 Charles C. Kilpatrick, MD

11. Abortions and Fetal Death 171 Lynda E. Mbah Roxanna A. Irani, PhD

vii 12. Ectopic Pregnancy 183 Lynda E. Mbah

SECTION III: HIGH-YIELD FACTS IN GYNECOLOGY 189

13. Contraception and Sterilization 191 Jamie G. Hernandez

14. Menstruation 207 Martina T. Ayad

15. Premenstrual Syndrome/Premenstrual Dysphoric Disorder 211 Martina T. Ayad

16. Infertility 215 Marquita D. Anderson

17. Amenorrhea 221 Martina T. Ayad

18. Hyperandrogenism 231 Martina T. Ayad

19. Hyperprolactemia and Galactorrhea 237 Martina T. Ayad

20. Abnormal Uterine Bleeding 241 Martina T. Ayad

21. Pelvic Pain 249 Vanessa M. Lopez

22. Endometriosis/Adenomyosis 253 Vanessa M. Lopez

23. Differential Diagnoses of Pelvic Masses 259 Marquita D. Anderson

24. Cervical Dysplasia 269 Margaret Markham

25. Cervical Cancer 277 Margaret Markham

26. Endometrial Hyperplasia and Endometrial Cancer 285 Gavin P. Puthoff

27. Ovarian Cancer and Fallopian Tube Cancer 293 Gavin P. Puthoff

28. Vulvar Dysplasia, Vulvar Cancer, and Vaginal Cancer 303 Jenny Van Winkle, MD

29. Vulvar Disorders 309 Jenny Van Winkle, MD

30. Gestational Trophoblastic Disease 315 Bridgette J. Parish, MD

31. Sexually Transmitted Infections/Vaginitis 323 Tracilyn Hall, MD

viii 32. Breast Disease 335 Charles C. Kilpatrick, MD

33. Women’s Health Maintenance 341 Michael L. Pirics, MD

34. Female Sexuality 351 Michael L. Pirics, MD

35. Ethics 357 Michael L. Pirics, MD

36. Menopause 361 Katherine M. Nelson

37. Pelvic Relaxation 367 Katherine M. Nelson

38. Urinary Incontinence 371 Katherine M. Nelson

SECTION IV: CLASSIFIED 375

Opportunities 376

Web sites of Interest 377

Index 379

ix This page intentionally left blank INTRODUCTION

This clinical study aid was designed in the tradition of the First Aid series of books, formatted in the same way as the other titles in this series. Topics are listed by bold headings to the left, while the “meat” of the topic comprises the middle column. The outside margins contain mnemonics, diagrams, summary or warning statements, “pearls,” and other memory aids. These are further classiﬁ ed as “exam tip” noted by the symbol, “ward tip” noted by the symbol, and “typical scenario” noted by the symbol.

The content of this book is based on the American Professors of Gynecology and Obstetrics (APGO) and the American College of Obstetricians and Gy- necologists (ACOG) recommendations for the OB/GYN curriculum for third- year medical students. Each of the chapters contain the major topics central to the practice of obstetrics and gynecology and closely parallel APGO’s medical student learning objectives. This book also targets the obstetrics and gynecology content on the USMLE Step 2 examination.

The OB/GYN clerkship can be an exciting hands-on experience. You will get to deliver babies, assist in surgeries, and see patients in the clinic setting. You will ﬁ nd that rather than simply preparing you for the success on the clerkship exam, this book will also help guide you in the clinical diagnosis and treatment of the many interesting problems you will see during your obstetrics and gynecology rotation.

xi This page intentionally left blank ACKNOWLEDGMENTS

We would like to thank the following faculty for their help in the preparation of the third edition of this book:

Eugene C. Toy, MD Academic Chief and Program Director Obstetrics-Gynecology Residency The Methodist Hospital Houston, Texas

Patti Jayne Ross, MD Clerkship Director Department of Obstetrics and Gynecology The University of Texas–Houston Medical School Houston, Texas

xiii This page intentionally left blank HOW TO CONTRIBUTE

To continue to produce a high-yield review source for the obstetrics and gynecology clerkship, you are invited to submit any suggestions or correction. Please send us your suggestions for:

New facts, mnemonics, diagrams, and illustrations Low-yield facts to remove

For each entry incorporated into the next edition, you will receive personal acknowledgment. Diagrams, tables, partial entries, updates, corrections, and study hints are also appreciated, and signiﬁ cant contributions will be compensated at the discretion of the authors. Also let us know about material in this edition that you feel is low yield and should be deleted. You are also wel- come to send general comments and feedback, although due to the volume of e-mails, we may not be able to respond to each of these.

The preferred way to submit entries, suggestions, or corrections is via electronic mail. Please include name, address, school afﬁ liation, phone number, and e-mail address (if different from the address of origin). If there are multiple entries, please consolidate into a single e-mail or ﬁ le attachment. Please send submissions to:

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All entries become property of the authors and are subject to editing and reviewing. Please verify all data and spellings carefully. In the event that similar or duplicate entries are received, only the ﬁ rst entry received will be used. Include a reference to a standard textbook to facilitate veriﬁ cation of the fact. Please follow the style, punctuation, and format of this edition if possible.

xv This page intentionally left blank SECTION I How to Succeed in the Obstetrics & Gynecology Clerkship

᭤ How to Behave on the Wards

᭤ How to Organize Your Learning

᭤ How to Prepare for the Clinical Clerkship and USMLE Step 2 Exam

᭤ Terminology

᭤ Sample Obstetric Admission History and Physical

᭤ Sample Delivery Note

᭤ Sample Postpartum Note

᭤ Sample Post-NSVD Discharge Orders

᭤ Sample Post–Cesarean Section Note

᭤ Sample Discharge Orders Post–Cesarean Section

1 THE OB/GYN CLERKSHIP ured out. trytoshow upatleast15minutesrotation, early untilyougettheroutinefi topunctuality,stacles butmakesurethisisinfrequent. Whenyoufi a rst start curred overnight. Likeallworkingprofessionals,youwillfaceoccasionalob- that youarefollowing toseethepatientandlearnabouteventsthatoc- pected to“pre-round,” youshouldgiveyourselfatleast10minutes perpatient of theresidentsandattendings. like you,theycanmakeyour lifealoteasierandmakeyoulookgoodinfront swer onroundsevercould. Also,benice tothe nurses—really nice! Ifthey sional, itwilldamageyour gradeandevaluationquicker thanany dumban- tions. However, ifaresidentorattending spots youbeing impolite orunprofes- attendings andresidents,whichwillberefl ected onpositivelyinfi clerkships. Thus,havingagoodrapportwithyourpatients isusuallynotedby Your relationshipwithpatients isalsousedtoassessyourperformanceinall and withrespect,whichisgoodtobeaware atthestudentlevel. ofstarting A crucial aspectofbeing agooddoctoristoalwaystreatpatientsprofessionally tortured. someone istryingtoteachyousomething,berespectful andlookgrateful,not just notinthemood.Try to lookinterestedtoattendings andresidents. When with anopenmind, but there willbetimeswhenyouareboredor rotation Be aware ofyourdemeanorandreactions.Itisalwaysgoodtoapproacheach you pleaseexplain?…” do not“challenge.” Instead,say, “I’msorry, Idon’tquitecould understand, ordisagreename. Ifyoudonotunderstand withatreatmentplanordiagnosis, experience ifyouarenice tobearound.Befriendlyandtrylearneveryone’s isoftendiffiThe rotation cult, stressful,andtiring. You willhaveasmoother Act inaPleasantManner should beaddressedtotheteamonfirst dayoftherotation. soitisaquestion(professional vs.scrubs)canvarybasedonrotation, that over yourclothesunlessdiscouraged (asinpediatrics). Recommendedattire must dressinaprofessional,conservativemanner. Wear a Even iftheresidentwearsscrubsandattending wearsstilettoheels,you Dress inaProfessionalManner Most OB/GYNteamsbeginrounding between5and7 Be onTime 2 HOW TO BEHAVE ON THE WARDS THE ON TOHOW BEHAVE scrubs available on your hospital-issued scrubcard. scrubs availableonyourhospital-issued on laboranddelivery, soasageneralguideline, alwayskeepasparepairof or intheoperatingroombirthingward.You neverknow whattoexpect Both menandwomen maywearscrubsoccasionally, duringovernight call toed shoes. neckline. Nojeans,nosneakers,heelsgreaterthan1½inches,open- Women shouldwearlongpantsorknee-lengthskirt,andatopwithmodest sleeved shirts.Facial hairshouldbewellgroomed. a long-sleevedcollaredshirt,andtie.Nojeans,nosneakers,short- Men shouldwearlongpants,withcuffscoveringtheankle,dressshoes, AM short whitecoat . Ifyouareex- nal evalua- nal g- THE OB/GYN CLERKSHIP 3 rst Be Aware of the Hierarchy of the Be Aware name, remember to maintain and when working professionalism on rounds resident as “doctor.” with patients by still referring to the involves taking helpful Being responsibility for patients that you’ve been as- haven’t. If you’ve been assigned to a pa- signed to, and even for some that you test results, de- history, about her, her everything there is to know tient, know and prognosis. Keep your interns or tails problems, about her medical of, and not be aware that they might residents informed of new developments ask them for any updates as well. to make a resident look good, takeIf you have the opportunity it. If some new tell the resident about it before the at- complication comes up with a patient, chance to grill the resident on it. Don’t hesitate to gets a to give credit tending These things make a resident for some great teaching in front of an attending. life easier; he or she will be grateful, and the rewards will come the resident’s your way. After rounds, assess what needs to be done on your patients and take owner- out the necessary information or making the ap- nding care by fi ship of their to on rounds. Volunteer discussed up what was propriate phone calls to follow up do things that will help out. So what if you have to run to the lab to follow on a stat Observe and an- everybody out, and it is appreciated. H&H? It helps for some tape If a resident is always hunting around ticipate. to do a dressing change whenever you round on a particular patient, get some tape ahead of time. Be Helpful to Your Residents Be Helpful to Your Address patients as Sir or Ma’am, or Mr., Mrs., or Miss. Don’t address patients Mrs., or Miss. Don’t address patients Mr., Address patients as Sir or Ma’am, or that these names and the like. Although you may feel “sweetie,” as “honey,” name, that you are patients may think you have forgotten their are friendly, un- as “doctor,” physicians or both. Address all familiar, inappropriately being fi may tell you to call them by their less told otherwise. While your resident Address Patients and Staff in a Respectful Way and Address Patients The way in which this will affect you will vary from hospital affect you will in which this will The way hospital to and address your degree. In general, present to some but it is always team to team, when the attend- or residents to interns ward functioning regarding questions an effort make to attendings; questions medical present. Address your ing isn’t please don’t ask to asking. But on your subject prior informed to be somewhat to every- annoying It’s know. off what you show just to transparently a question that you have and asking real questions interested off by seeming one. Show when they come up. of of the time and number but be conscious ask questions, Don’t be afraid to work and go their nish so that everyone can fi asked during rounds questions not the only one who time. Remember, you are usually home at a reasonable able to ask questions student, you are often and as a medical doesn’t know, to the opportunity gives the attending which should know, that the residents for the residents. t of reviewing with the secondary benefi teach the students, THE OB/GYN CLERKSHIP sounds normal”whenyoudid notlisten). that. Neversayordocumentinformationthatisfalse (eg,don’tsay“bowel don’tknow,If youdon’tunderstand, ordidn’t doit,makesureyoualwayssay Be Honest yourresidentshavedonemore. many hoursyouhavebeenatthehospital, look bad.Don’tcomplain—nomatterhow hardyouhaveworkedorhow Never stealthespotlight,aprocedure,ormakefellow medical student have learned.Supportyoursupervisinginternorresidentwheneverpossible. Help othermedical teachtheminformationyou studentswiththeir tasks; Be aTeam Player thebetter. The moreunpleasantthetask, prepare atopic.Volunteer additional totake patients.Volunteer late. tostay heads-up onwhatisgoing tobediscussed aswellhavingtheopportunity to give yourfellow studentsa heads-upbeforehand—theywillappreciate the Whenyoupresentalearninglength andtiming issuetotheteam, of thetalk. onatopicofyourchoice. Askyourresidentaboutthe unteer togiveatalk Be self-propelled.Volunteer tohelpwithaprocedureordiffi Vol-cult task. Volunteer More Respect Patients’ Rights 4 Here isatemplateforthe “bullet” presentation: Present Patient InformationinanOrganized Manner ing aminiature historyandphysical,labs,testresultsathand. Use aclipboard,notebook,orindexcardstokeeppatient information,includ- Keep Patient InformationHandy such asabdominalsurgery, OB/GYNhistory] pertinent This isa[age]-year-old 3. All patientsshouldbeinformedoftherighttoseekadvancedirectives All patientshavetherighttorefusetreatment.Thismeanstheycanre- 2. 1. All patientshavetherighttotheir personalmedical information the subjectofadvancedirectivesyourattending. withtheassistance your patientischronically illorhasalife-threatening illness,address on admission. inabooklet.If Thisisoftendonebytheadmissions staff, suicidal orhomicidal. which caseahealthcareproxyshouldbesought—orpatientwhois not havethecapacity situations—in tomakedecisions or understand ment. Theonlyexceptionstothisruleareapatientwhoisdeemed a specifi c type(Pap smear).Patients canevenrefuselifesavingtreat- fuse treatmentbyaspecifi c individual (you,themedical student)orof patient inhallways,elevators,orcafeterias. family memberswithoutthatpatient’s consent,anddonotdiscuss any kept private.Thismeansdonotdiscuss thepatient’s informationwith [major history of[majorhistory [ethnicity] femalewithahistory who THE OB/GYN CLERKSHIP 5 [major symptoms, such as pelvic pain, pelvic such as symptoms, [major Plan is [state plan]. with ndings]. Yesterday the patient [state important changes, Yesterday [results]. and the physical exam is signifi cant for exam is signifi words], and the physical patient’s [state the Publishers, $8). 3rd edition. scription is $99/year for students). (ISBN Medical Reference and the like, such as Maxwell Quick 0964519119, $7). Pharmacopoeia (Tarascon A small book to look up drugs, such as Pocket , Aid for the® Obstetrics & Gynecology Clerkship This review book, First A full-text online journal database, (sub- such as www.mdconsult.com pathways, A small pocket reference book to look up lab values, clinical [date] on presented done] [Tests diagnosis]. [working to have was found and fever], showed This morningnew medications]. new tests, new plan, the patient feels fi [state major c patient in mind. For example, if a postmenopausal patient comes to the For c patient in mind. HOW TO ORGANIZE YOUR LEARNING YOUR ORGANIZE TO HOW Your reading on the symptom-based topics above should be done with a spe- on the symptom-based topics above should be done with a reading Your cifi As You See Patients, Note Their Major Symptoms Their Note See Patients, As You and Diagnosis for Review We recommend: We Select Your Study Material Select Your The main advantage the OB/GYN clerkship is that you get to see pa- to doing and the source of most satisfaction tients. The patient is the key to learning enormously helpful tip is to try to skim this and frustration on the wards. One book before starting your rotation. Starting OB/GYN can make you feel like rst 2 years doesn’t help land, and all that studying the fi in a foreign you’re have to start will help enor- from scratch in some ways, and it You much. book before you start.mously if you can skim through this Get some of the and it won’t seem so down, straight, get some of the major points terminology strange. Document Information in an Organized Manner Document Information is neat, legible, orga- history and physical student initial A complete medical usually two to three pages long (see page 7). and nized, The newly admitted patient generally deserves a longer presentation patient The newly admitted following and physical format (see below). the complete history history can and probably extensive histories. The whole Some patients have note, but in ward presentation in the admission should be present it is often by your appreciated cases, it will be very much to absorb. In these too much a good summary that maintainsteam if you can generate an accurate picture worth it. usually takesof the patient. This but it’s some thought, THE OB/GYN CLERKSHIP Other helpfulstudyingstrategiesinclude: lamp). light, getahalogendesklamporlightthatsimulates sunlight(notatanning light. Thiswillhelppreventyoufromfallingasleep. Ifyoudon’thaveabright Find theroominyourhouseorlibrarythat hasthebest,brightest Study inaBrightRoom your studytime. to getdistracted byotherpeopleinthe room,limit thistolessthanhalfof you havenotstudied enoughandmayhelp youfocusonthegoal.Iftend Group studyingcanbeveryhelpful.Otherpeoplemaypoint outareasthat Study With Friends great dealaboutmedicine. To studyfortheclerkshipexam,werecommend: If youhavereadaboutyourcoreillnessesandsymptoms,willknow a changes intreatment. years old,andthensearchonlineorinthelibraryforrecentdevelopments a topic,readaboutitinmajortextbookandreviewarticlenotmorethan2 ture. Theidealtopicisslightlyuncommonbutnotrare.To on prepareatalk ever, realizethatthismaybeconsidereddullbythepeoplewhohearlec- not, youshouldvolunteer!Feel freetochooseatopicthatisonyourlist;how- You If onceortwiceduringyourrotation. maybeaskedtogiveasmalltalk Prepare aTalk onaTopic read aboutovariancancerinthereviewbookthatnight. offi 6 of energyfor1–2hours,but thenyou’lldrop. and fi ber. Ahigh-sugar,high-carbohydratemealwillgiveyouaninitial burst Make sureyourmealsarebalanced,withleanprotein, fruitsandvegetables, Eat Light,BalancedMeals HOW TO PREPARE FOR THE CLINICAL CLERKSHIP AND USMLE STEP 2EXAM STEP USMLE AND CLERKSHIP CLINICAL THE FOR TOHOW PREPARE ce withincreasingabdominal girthandisthoughttohaveovariancancer, and gotobedontime.Donothaveanycaffeine after2 1 daybeforeexam:Exercise, eatwell,review yournotesandthemnemonics, 2 daysbeforeexam:Exercise, eatwell,skim thebook,andgotobedearly. and mnemonics. 5 daysbeforeexam:Readthisentirereviewbook,concentratingonlists core contentlistandthecorresponding review booksections. onyour 10 daysbeforeexam:Readthenotesyoutookduringrotation notes. 2–3 weeks beforeexam:Readthisentirereviewbook,taking P . M . THE OB/GYN CLERKSHIP 7 = 1.) P = 1.) G 20 weeks gestation, stillborn (0) T T F T For all questions longer than two sentences, longer all questions rst. For A. endometriosis C. ovarian cancer D. ovarian torsion B. ectopic pregnancy likely to be associated with pelvic pain? is least likely to be associated Which of the following = total number of pregnancies, including normal and abnor- including G (gravidity) 3 = total of pregnancies, number and hydatidi- abortions, ectopic pregnancies, mal intrauterine pregnancies, pregnant with twins, form moles. (Remember, if patient was Read the answers fi Read the answers for the key you sift through the question rst can help the answers fi reading information. “BEST,” “NOT,” “LEAST,” “MOST,” “EXCEPT,” Look for the words “AL- “INCORRECT,” “CORRECT,” “FALSE,” “TRUE,” “WORST,” or underline circle nd one of these words, If you fi and “NEVER.” WAYS,” it for later comparison with the answer. as being either true or false. Example: Evaluate each answer = number of pregnancies that were lost before the 20th that were lost before the 20th pregnancies of Ab (abortus) 0 = number gestational < 500 g. week or in which the fetus weighs of successful pregnancy outcomes. (Re- 3 = number LC (living children) LC = 2.) pregnant with twins, member, if patient was deliveries (3) of Term T = number of Preterm deliveries (0) P = number of Abortions A = number (3) of Living children L = number = number of deliveries > 500 g or > of P (parity) 3 = number pregnant with twins, (dead) or alive. (Remember, if patient was TERMINOLOGY All questions are intended to have one best answer. When answering ques- When answering have one best answer. are intended to All questions these guidelines: tions, follow Tips for Answering Questions Tips The point of practice exams is not so much the content that is contained content that is the in so much exams is not of practice The point to pick the 3 hours and trying of sitting still for training but the the questions questions also use practice can You every question. for each and best answer your future are in order to guide your studying where the gaps in to assess studying. Take Practice Exams Practice Take is the best an- to the answers, “C” noting LEAST, By comparing the question, swer. use the “TPAL” system if it is used at your medical school: system if it is used at your medical Or use the “TPAL” THE OB/GYN CLERKSHIP hospital withmom. baby wenthomefromthe pregnancies istoaskifthe complications inprevious information about A goodwaytoelicit 8 Past GynecologicalHistory Past ObstetricHistory PE SAMPLE OBSTETRIC ADMISSION HISTORY AND PHYSICAL History ofpresentillness(HPI):25yoHispanic female,G3P2002,38 Chief complaint(CC):Uterinecontractions(UCs)q7min since0100 by LMPor____wkUS Estimated dateofconfi Last menstrualperiod(LMP):FirstdayofLMP Past MedicalHx: H/oasthma(asymptomatic× Medications: PNV, Fe Allergies: NKDA Blood group:O–,antiDprophylaxisgivenat30weeksGA Contraception: None Last mammogram: Last papsmear:3/4/09—normal,noh/oabnormalPap smear bleed coital No signifi cant historyofPID,intermenstrualbleeding, dyspareunia, post- regular) 13 yo/28days/regular(ageatfi rst menstrualcycle/how often/regularorir- problemsinchildhood No developmental rhage resolved Postpartum hemorrhage,atonic uterus,syntometrinegivenandhemor- 2) ’04NSVD@term,boy, wt3900g,St. Joseph’s Hospital problemsinchildhood No developmental No complicationsduringpregnancy, delivery, andpuerperium 1) exam (VE)4/90/–2. negative chestx-rayin5/06.Ptadmitted inearlyactivelaborwithavaginal includes h/o+groupBStreptococcus(GBS)anda+PPDwithsubsequent BPrange100–126/64–83.Problem list uterine size=todates,prenatal care(PNC)atMontefinatal (12visits,fiore Hospital rst visitat7wks GA), bleeding, headaches,visualchanges,orrightupperquadrant pain.Pre- movementispresent,denies leakageoffl reports thatfetal GA, whopresentedtoL&DwithCCofuterinecontractionsq7min. She weeks GA,datedbyLMP(10/13/09)andconsistentwithUSat10 age(EGA):38 Estimated gestational Time Date MS3 H&P Neck: Thyroid midline, nomasses,lymphadenopathy(LAD) HEENT: Noscleralicterus,paleconjunctiva Vital signs:T, BP, P, R General appearance:Alertandoriented(A&O),noacutedistress (NAD) sea, vomiting, fever,chills ROS: Bilaterallow backpain.Denies chestpain,shortnessofbreath,nau- Family Hx:Mother—DMII,father—HTN Social Hx:Denies h/oalcohol,smoking,drugabuse.Feels safeathome Surgical Hx:Negative Macrobid 100mg×7d,negPPDwithsubsequent negCXR(5/06) ’02 NSVD@term,girl,wt3700g,St.Joseph’s Hospital nement:Duedate(specifyhowitwas determined) 5 / 7 weeks 7yrs),UTI× 1@30wkss/p ud vaginal uid, 5 / 7 THE OB/GYN CLERKSHIP 9 . Infant was bulb M . P weeks GA presented with regular painful contrac- weeks GA presented with regular painful 7 / 5 GBS) tions. 1. Early active labor. 2. Group B strep + 3. 5/06 – CXR H/o + PPD with subsequent 4. H/o UTI @ 30 wks GA, s/p Rx—resolved 5. H/o asthma—stable × 7 yrs, no meds 1. to L&D Admit 2. NPO except ice chips 3. clot tube HBsAg and hold H&H, RPR, HIV, 4. D5 LR @ 125 cc/hr IV q 4 hr (for units 2.5 million IV load, then units 5 million 5. Penicillin 6. External fetal (EFMs) monitors 7. Epidural when patient desires CTA bilaterally CTA Lungs: tenderness CVA No Back: Heart: II/VI SEM symmetric Breasts: No masses, nontender Gravid, Abdomen: 36 cm Fundal height: Leopold’s 3500 g by (EFW): fetalEstimated weight Presentation: Vertex 2+ DTRs edema, nonpitting, extremity Mild lower Extremities: Adequate Pelvis: mem- Pooling?); exam (SSE)? (Nitrazine?, Ferning?, Sterile speculum branes intact 4 cm/90%/–2 (dilatation/effacement/station) Exam (SVE): Sterile Vaginal rmed, anterior placenta, AFI = 13.2 presentation confi US (L&D): Vertex 150, accelerations present, no decelera- Baseline FHR = monitor: Fetal UCs q 5 min = Toco tions, moderate variability. 25 yo G3P2002 @ 38 SAMPLE DELIVERY NOTE Plan Assessment Always date, time, and sign your notes. Always P3003 s/p spontaneous25 yo G3 now vaginal delivery (SVD) of viable male infant over a second-degree perineal laceration @ 12:35 suctioned on the perineum. Nuchal cord × 1 was reduced. The infant was de- cord was doubly clamped and cut; traction. The livered with gentle downward Cord blood and arterial pH was nurse. the infant was handed to the awaiting obtained. The placenta was delivered spontaneously, intact, 3-vessel with lacer- cord. No vaginal or cervical lacerations were noted. The second-degree ation was repaired with 3-0 vicryl in layers using local anesthesia. Rectal exam Apgars 8 & 9, wt 3654 g. Mom and EBL = 450 cc. was with in normal limits. baby stable. THE OB/GYN CLERKSHIP P: A: O: S: O: S: 10 SAMPLE POST–CESAREAN SECTION NOTE SECTION POST–CESAREAN SAMPLE ORDERS POST-NSVD DISCHARGE SAMPLE POSTPARTUM NOTE SAMPLE 4. D/c meds: Postpartum checkin4–6 weeks 3. 2. Pelvic rest D/c pthome 1. VDRL: NR,HIVneg,HBsAG neg Postpartum Hgb:9.7 Extremities: Noedema,nontender Perineum: noedema Intact, Lochia: Moderateamount,rubra Fundus: Firm,mildly tendertopalpation,1fingerbreadth below umbilicus Breasts: Nonengorged,colostrumexpressedbilaterally Lungs: CTA bilaterally Heart: RRR,nomurmurs/rubs/gallops Lochia: Scant,rubra Incision: normalabdominal bowel sounds(NABS) Fundus: Firm,tendertopalpation,1fi ngerbreadth aboveumbilicus; Breasts: Nonengorged,nocolostrumexpressed Lungs: CTA bilaterally Heart: RRRwithoutmurmurs I&O (urinaryintakeandoutput):Last8hr=750/695 RR: 18 RR: 18 Continue postpartumcare S/p SVD,PPday#1—progressingwell,afebrile,stable T preeclampsia symptoms.Foley inplace. Pt c/oabdominal pain, passingfl atus, minimal ambulation.Denies T symptoms Pt ambulating,voiding, toleratingaregulardiet. Denies preeclampsia c. Ibuprofen 600 mg, 1 tab POq4hours,PRNpain,#60 Ibuprofen 600mg,1tab c. POBIDPRNnobowel movement,#60(Aside Colace 100mg,1tab b. a. FeSO max max effect of Iron supplementation isconstipation) effect ofIronsupplementation postpartum) when togiveIronsupplementation : 99.1T : 99.1T Without erythema/edema;C/D/I(clean/dry/intact) 4 325 mg, 1 tab POTID,#90(For 325mg,1tab Hgb< 10;opinions varyon × 6weeks current current : 98.6BP:128/70(117–130/58–76)HR:86(76–100) : 98.6BP:128/70(117–130/58–76)HR:86(76–100) THE OB/GYN CLERKSHIP Reporting about fl atus and fl Reporting about bowel movements is important after a C-section. These are less relevant after an NSVD. 11 × 4 weeks atus, stable atus, a. #3, 2 tabs PO q 4 hr PRN pain, #30 Tylenol b. Ibuprofen 600 mg, 1 tab PO q 4 hr, PRN pain, #60 c. 1 tabColace 100 mg, PO bid, #60 S/p primary low-transverse c/s for arrest of descent, POD # 1– afebrile, of descent, c/s for arrest low-transverse S/p primary + fl 1 + pitting edema bilateral LEs, nontender LEs, bilateral pitting edema 1 + Extremities: Hgb: 11 Postpartum neg neg, HBsAG VDRL: NR, HIV 2. hr if UO < 120 cc/4 I&O—Call HO Strict 3. diet Clear liquid 4. clears Heplock IV once patient tolerates qid 5. Ambulate 6. Incentive spirometry 10 × hr 7. #3, 2 tabs PO q 4 hr PRN pain Tylenol 1. patient home D/c rest 2. Pelvic 3. check in 1 week Incision meds: 4. Discharge SAMPLE DISCHARGE ORDERS POST–CESAREAN SECTION POST–CESAREAN ORDERS DISCHARGE SAMPLE A: Foley P: 1. D/c THE OB/GYN CLERKSHIP 12 NOTES SECTION II High-Yield Facts in Obstetrics

᭤ Reproductive Anatomy

᭤ Diagnosis of Pregnancy

᭤ Physiology of Pregnancy

᭤ Antepartum

᭤ Intrapartum

᭤ Postpartum

᭤ Medical Conditions in Pregnancy

᭤ Obstetric Complications

᭤ Infections in Pregnancy

᭤ Twin Gestation

᭤ Abortions and Fetal Death

᭤ Ectopic Pregnancy

13 This page intentionally left blank CHAPTER I Reproductive Anatomy

Vulva 16 BLOOD SUPPLY 16

LYMPH 16

NERVE SUPPLY 17 Vagina 17 BLOOD SUPPLY 17

NERVE SUPPLY 17 Cervix 18 COMPONENTS 18

CERVICAL EPITHELIUM 18

BLOOD SUPPLY 18

NERVE SUPPLY 18 Uterus 19 COMPONENTS 19

HISTOLOGY 19

BLOOD SUPPLY 19

NERVE SUPPLY 19 Fallopian (Uterine) Tubes 19 ANATOMIC SECTIONS, FROM LATERAL TO MEDIAL 19

BLOOD SUPPLY 20

NERVE SUPPLY 20 Ovaries 20 BLOOD SUPPLY 20

NERVE SUPPLY 20

HISTOLOGY 20 Ligaments of the Pelvic Viscera 20 Muscles 21 BLOOD SUPPLY 22

NERVE SUPPLY 22 Pelvis 22 PELVIC SHAPES 22

15 Reproductive Anatomy HIGH-YIELD FACTS Abscesses: Painful. Cysts: Asymptomatic. Most often: Causes acystorabscess. Bartholin glandblockage lin glandducts,andbilateralSkene’s (paraurethral) glands. theurethalopening, vaginalopening,vestibule itselfcontains bilateralBartho- vagina, vestibularbulb,andthegreaterglands(seeFigure1-1).The It includes:Thelabiamajora,minora, monspubis,clitoris,vestibuleofthe The vulvaconsistsofallstructuresvisibleexternallyfromthepubistoperineum. plexus, whichgivesrisetotheinternaliliacplexus. the pudendalnerve.Themajorsympatheticinnervationisviaaortic nodes. ThemajorparasympatheticinnervationisviaS2,S3,S4,whichforms branches. Thelymphaticsdraintotheinguinal,pelvic,orpara-aorticlymph to thepelvisisfrominternaliliacartery(hypogastricartery)andits chapter willdiscuss themajorstructuresofpelvis.Thebloodsupply cologic surgery, heorshemust bewellversedinanatomyoftheregion.This rics andgynecology. Eachtimeaphysician deliversababyorperformsgyne- An adequate knowledge ofthenormalfemaleanatomyisessentialinobstet- 16 Medial group ofsuperficial inguinal nodes. Lymph divisions ofthehypogastricartery(internaliliac). From branchesoftheexternalandinternalpudendalarteries,whicharesub- Blood Supply VULVA Bartholin’s abscessorcysts,consider adenocarcinomaandtakeabiopsy.Bartholin’s Can considerbroad-spectrumantibiotics.Ifanolderpatientwithrecurrent drainage followedbymarsupialization,packing,orplacementofWord catheter. diagnosis? What isthebesttreatment? pated atthe8o’clockposition;nodrainageisnoted.What isthemostlikely labia majoraisnotedtobeswollen.A4 She hasnomedicalconditionsandtakesmedications.Onexam,theright Bartholin glands: Locatedat4o’clockand8ofthevaginalori- Clitoris: Skene’s glands: Ductsoftheseglandsopenoneither sideoftheure- Bartholin’s glandabscess. The besttreatmentisincision and Answer: Bartholin’s glands inmales. to providevaginallubricationandarehomologous thebulbourethral fi ter is1.5cm. pora, andtwocrura.Rarelyexceeds2cminlength,normaldiame- thral orifi ce andaretypicallynonpalpable.Theyfunctioninsecretingmucous and she is unable to sit. She reports nofever,and sheisunabletosit.Shereports chills,nausea,orvomiting. ↑ the vulvaandacuteonsetofpainfor2days.The painhasgradually A 30-year-old femalepresents totheemergencyroomwithalumpin ce. Homologue ofthemalepenis. Composedofaglans,cor- × 4-cmfl uctuant tendermassispal- HIGH-YIELD FACTS Reproductive Anatomy A pudendal block can provide pain relief at the time of a vaginal delivery. 17 Urethra Labia minora wall Anterior vaginal Fourchette body Perineal Frenulum Clitoris Prepuce External female genitalia. External gina. (internal iliac artery) are secondary blood supplies. the genitofemoral nerves. the genitofemoral thigh. Hypogastric plexus: Sympathetic innervation. Hypogastric innervation. nerve: Parasympathetic Pelvic branch of the uterine artery is the primary supply to the va- Vaginal Middle rectal and inferior vaginal branches of the hypogastric artery Anastomoses with cervical arteries. Hypogastric artery (anastomotic network): nerves and the genital branch of Anterior parts of vulva: Ilioinguinal nerves and posterior cutaneous nerves of the parts: Perineal Posterior Labia majora Hymenal tag wall vaginal Posterior navicularis Fossa Anus Mons pubis VAGINA Nerve Supply Blood Supply The vagina is a tubular, muscular structure that extends from the vulva to the The vagina is a tubular, muscular ce is located anterior to the perineum and the vaginal orifi cervix. Exteriorly, posterior the urethra. Pudendal branches: Nerve Supply Williams FG, Leveno KJ, Bloom SL, et al. Williams from Cunningham (Reproduced, with permission, 2010: Fig. 2-2.) McGraw-Hill, Obstetrics, 23rd ed. New York: FIGURE 1-1. Reproductive Anatomy HIGH-YIELD FACTS and vulva. vagina, view ofthecervix, Colposcopy: Magnifi ed cervix. Both Cervical Epithelium The cervixcanbefurthersubdivided into: Components portion oftheuterusthatisatapexvagina. The cervixisactuallyapartoftheuterus.Itspecialized narrow inferior 18 Hypogastric plexus. Nerve Supply ternal iliacartery. Cervical andvaginalbranchoftheuterineartery, Blood Supply CERVIX is wherethemajorityofcervicalcancersarise. tion ofthecervixmustbecompletelyexcisedtoensurepropertreatment? Sheundergoes aloopelectroexcisionprocedure.What por- epithelial neoplasiaII. Internal os: Uppermostopening ofthecervixintouterinecavity. Endocervical canal: Passageway betweentheexternalosanduter- Ectocervix:Portion ofthecervixexteriortoexternalos. External os: Lowermost opening ofthecervixintovagina. Portio vaginalis: Portion ofthecervixprojectingintovagina. Answer: The transformationzoneshouldbecompletelyexcisedbecausethat columnar andstratifi ine cavity. ital tractneoplasias arise. ital logic andcolposcopiclandmark,asthisiswhereover 90%oflower gen- thelium changestosquamouscyto- epithelium. Itisthemostimportant The meet. The The columnarepitheliumlinestheendocervicalcanal. vix. The stratifi ed nonkeratinized squamous epitheliumcoverstheectocer- intraepithelial lesion (LSIL). The colposcopicbiopsyshows cervicalintra- intraepithelial lesion(LSIL). squamous most recentPap smearwasabnormal,showingalow-grade A 36-year-old G3P3womanpresentstotheoffice forafollow-upvisit.Her is the area of metaplasia wherecolumnarepi- zoneistheareaofmetaplasia transformation qaoounrjunctioniswherethetwotypesofepithelium squamocolumnar e okrtnzdsquamousepitheliacoverthe nonkeratinized ed whicharisesfromthein- HIGH-YIELD FACTS Reproductive Anatomy Most common location for ectopic pregnancy = Ampulla of fallopian tube. The tubes are occluded at the isthmus for permanent sterilization via laparoscopy. Total hysterectomy = hysterectomy = Total cervixUterus and are removed. Supracervical = hysterectomy cervixUterus removed, retained (ovarian status unknown). the The ureter travels under Think “water uterine artery. under the bridge.” 19 Arise from the aorta, and anastamose with uterine vas- cavity. the egg that is released from the ovary into the tube. epithelium. three layers: culature. 1. Outer longitudinal 1. Outer oblique 2. Middle longitudinal 3. Inner Narrowest part. Narrowest Isthmus: part: Pierces uterine wall and connects to the endometrial Intramural Infundibulum: The most distal part the uterine tube. Helps to sweep Ampulla: Widest section. plexus Superior hypogastric plexus Inferior hypogastric nerves Common iliac Arise from hypogastric artery (internal iliac artery). arteries: Arise from hypogastric artery (internal Uterine arteries: Ovarian The mucosal layer of the uterus, made up of columnar Endometrium: The mucosal Part of uterus that connects to the fallopian tubes bilaterally. of uterus that connects to Part Cornu: uterus that protrudes into the vagina. Cervix: Inferior part of the into It is subdivided layer of uterus. Myometrium: The smooth muscle Uppermost region of uterus. Fundus: Uppermost region Corpus: Body of the uterus. FALLOPIAN (UTERINE)FALLOPIAN TUBES UTERUS Anatomic Sections, from Lateral to Medial Anatomic Sections, from Lateral The fallopian tubes extend from the superior lateral aspects of the uterus The fallopian tubes extend from the superior lateral aspects of the through the superior fold of the broad ligament laterally to the ovaries. Nerve Supply Blood Supply Histology Components The uterus is a muscular organ that lies posterior to the bladder and anterior bladder and anterior posterior to the organ that lies is a muscular The uterus the uterus woman. In pregnancy, of a nonpregnant in the pelvis to the rectum becomes an abdominal and progressively of the fetus with the growth enlarges a pelvic organ. as well as Reproductive Anatomy HIGH-YIELD FACTS Left ovarianvein→left Aorta Ovaries Blood Supplyof cancer intheabdomen. dissemination ofovarian ovaries leadstofast No peritoneumaround Right ovarianvein→ arteries renal vein inferior venacava → Bilateralovarian buginea iscoveredbygerminal epithelium. The ovariesarecoveredbytunica albuginea,afibrous capsule.Thetunica al- Histology Derived fromtheaorticplexus. Nerve Supply the inferiorvenacavaonrightsideandrenalvein ontheleft. atthelevelofL1.VeinsBoth ovarianarteriesarisefromtheaorta draininto Blood Supply hormone production. not coveredbyperitoneum.Eachovaryfunctionsinovadevelopmentand tothebroadligamentbymesovarium andare tubes. Theyareattached The ovarieslieontheposterioraspectofbroadligamentandfallopian Pelvic plexus(autonomic) andovarianplexus. Nerve Supply From uterineandovarianarteries. Blood Supply 20 carry thebloodsupplyfor essential organs. Some ligamentsofthepelvisactonlyassupportstructures, butothersalso LIGAMENTS OF THE PELVIC VISCERA PELVIC THE OF LIGAMENTS OVARIES treated withacetaminophenandrest. The keyisworseningpainwithmovementandimprovementrest.Itcanbe exam.Urinalysis(UA) isnegative.Whatvaginal isthispatient’sdiagnosis? isreassuringandnocontractionsarerecorded.Hercervixclosedon (NST) travel. Herlastcoituswas3weeksago.Fetal movementispresent.Non-stresstest Broad ligament: Peritoneal foldextendsfromthelateralpelvic wallto Answer: Roundligamentpain.painisadiagnosisof exclusion. and ureter(seeFigure1-2). ament, uterineandovarian bloodvessels,lymph,ureterovaginalnerves, thefallopian (uterine)tube,roundlig- the uterusandadnexa.Contains denies lossoffl bleeding, fever,uid, vaginal trauma,sickcontacts,and abdominal pain.Pain worsensuponwalkingand↓withrest.Patient A 22-year-old G2P1001 at32 weeks’gestationcomplainsofsharplower HIGH-YIELD FACTS Reproductive Anatomy The perineal body is cut when episiotomy performed. Most hysterectomies start by ligation and transection of the round ligament. Most common site for ureteral injury during hysterectomy = level of cardinal ligament (ureter passes under the uterine artery). Pelvic organ prolapse is caused by a defect in the plevic diaphragm. 21 cial transverse perineal, and cial Supportingstructures of the pelvic viscera. external anal sphincter muscles converge at the central tendon. external anal sphincter muscles posed of the deep transverse perineal muscles, the constrictor of the posed of the deep transverse perineal muscles, coverings. It helps main- urethra, and the internal and external fascial tain urinary continence. between the raphe of the levator ani, of the support. The median much and vagina. Bulbocavernosus, superfi anus nal organs. It is composed of the levator ani complex (iliococcygeus, nal organs. It is composed of the levator ani puborectalis, and the coccygeus muscles. muscles) pubococcygeus terolaterally to the supravaginal portion of the cervix and inserts into the terolaterally to the supravaginal portion the sacrum. Provides some support to the uterus. over fascia (near the level of the internal cervical os) and lateral vagina to the pel- (near the level of the internal cervical vic side wall; most important support structure of the uterus. It contains the uterine artery and vein. ovary): Contains and connects the ovary to the ovarian artery and vein the pelvic wall. and laterally through the inguinal canal and corpus of the uterus down in the labia majora. terminates is external to the pelvic diaphragm and is com- diaphragm is external to the pelvic diaphragm Urogenital body is the central tendon of the perineum, which provides Perineal Pelvic diaphragm forms a broad sling in the pelvis to support the inter- Pelvic Uterosacral ligaments: Each ligament extends from an attachment pos- Uterosacral Cardinal ligament (Mackenrodt ligament): Extends from the cervix Infundibulopelvic (IP) ligament (aka suspensory ligament of the Infundibulopelvic (IP) ligament extends from the ligament: The remains of the gubernaculum; Round MUSCLES Digging Up the Bones: Obstetrics S. Digging Up the Bones: from Lindarkis NM, Lott (Reproduced, with permission, 1998: 2.) McGraw-Hill, New York: and Gynecology. FIGURE 1-2. Various muscles of the pelvis make up the perineum. Most of the support is muscles Various provided by the pelvic and urogenital diaphragms. Reproductive Anatomy HIGH-YIELD FACTS 0 station. head attheishialspine= Leading edgeofthefetus the stationoffetus. landmarks indetermining as The ischialspinesserve through it. ability ofababytopass pelvis inrelationtothe shape andcapacityofthe assessesthe Pelvimetry FIGURE 1-3. FIGURE oval pelvicinlet.(SeeIntrapartumchapter,Table 5-6). vis. Gynecoid istheideal shapeforvaginaldelivery, havingaroundtoslightly poid. Theseshapesaredifferentiated based onthemeasurementsofpel- There arefourmajorshapes:gynecoid,android,platypelloid,andanthro- Pelvic Shapes ilium, ischiumandpubis(seeFigure1-3). innominate bones.Theinnominate bones areformedfromthefusionof The adultpelvisiscomposedoffourbones:sacrum,thecoccyx,andtwo Pudendal nerve,whichoriginatesfromS2,S3,S4levelsofthespinalcord. Nerve Supply labial artery. artery,Internal pudendalarteryanditsbranches,inferiorrectal posterior Blood Supply 22 PELVIS Linea terminalis Ischial spines: Extendfromthemiddle oftheposteriormargineach Coccyx:Composedoffourvertebraefusedtogethertoformasmalltri- Sacrum:Consistsoffi ve vertebraefusedtogethertoformasingle ischium. angular bonethatarticulateswiththebaseofsacrum. for clinical pelvimetry. landmark and itcanbepalpatedduringavaginalexam.Itisimportant the sacroiliac joints. Thesacralpromontoryisthefi wedge-shaped bone.Itarticulateslaterallywithtwoiliacbonestoform Ischial spine Sacrum Bony pelvis. Ischium Pubis Coccyx rstsacralvertebrae, Sacrospinous ligament Sacral promontory Ilium CHAPTER 2 Diagnosis of Pregnancy

Naegele’s Rule 24 Signs and Symptoms 24 Human Chorionic Gonadotropin 26 OVERVIEW 26

PREGNANCY TEST USING HCG 26 Fetal Heart Rate 27 Ultrasound 27 INDICATIONS 27

LIMITATIONS 27

23 As a physician, it is essential to make the accurate diagnosis of pregnancy and establish the estimated date of delivery. The patient’s future prenatal care is dependent on it. This chapter will discuss how to diagnose pregnancy, including symptoms of pregnancy, use of human chorionic gonadotropin (hCG), fetal heart rate (FHR), and ultrasound in its diagnosis.

Naegele’s rule assumes two NAEGELE’S RULE things: 1. A normal gestation is 280 days. A 25-year-old G0P0 presents with complaints of absent menses for 2 2. All patients have a months. Prior to this, she reports regular menses every 28 days, lasting for 28-day menstrual 4 days each month since menarche. She is sexually active but reports cycle. using condoms regularly. What is the best test to evaluate her condition? Answer: Urine pregnancy test (UPT). Pregnancy must be considered in any woman of reproductive age with complaints of amenorrhea or irregular menses and abdominal pain even if she is using contraception. Including or excluding pregnancy will signifi cantly narrow the list of differential diagnoses. When determining the estimated date of delivery Naegele’s rule is used to calculate the estimated date of confi nement (EDC; ie, (EDD), use the fi rst day of due date) +/– 2 weeks.

HIGH-YIELD FACTS HIGH-YIELD bleeding of the last First day of patient’s last normal menstrual period (LMP), minus 3 months, menstrual period (LMP). plus 7 days, plus 1 year. Example: If LMP = July 20, 2006, then EDC = April 27, 2007.

SIGNS AND SYMPTOMS Use Naegele’s rule to A woman’s body goes through drastic physiological changes from the day she calculate the estimated due conceives to weeks after the delivery of her baby. It is important to differenti- date from the LMP. ate the physiological changes of pregnancy from other pathological condi- EDD = (LMP +1 year + 7 tions. This section will discuss signs and symptoms that are indicative of preg- days) – 3 months nancy. Cessation of menses: Pregnancy is highly likely if 10 or more days have passed from the time of expected menses in a woman who previously

Diagnosis of Pregnancy had regular cycles. Breast changes: ↑ breast tenderness. ↑ in breast size. Nipples become larger, more pigmented, and more erectile. Areolae become broader and more pigmented. Colostrum may be expressed from the nipples. Striations on the skin. Skin changes: Nonpregnant cervix feels Striae gravidarum (aka stretch marks): Reddish, slightly depressed streaks on the abdomen, breast, and thighs. like the cartilage of the Linea nigra: Midline of the abdominal wall becomes darkly pigmented. nose. A pregnant cervix Chloasma or melasma gravidarum (aka mask of pregnancy): Irregular feels like the lips of the brown patches of varying size on the face and neck. mouth. Hegar’s sign = Angiomas: Red elevation at a central point with branching vascula- softening of the cervix. ture present on the face, neck, chest, and arms due to estrogens. Palmar erythema.

24 Uterine changes: On bimanual exam, the uterus feels soft and elastic. The uterus ↑ in size throughout the pregnancy (its size correlates to gestational age). By week 12, it is about the size of a grapefruit and the fundus of the uterus becomes palpable above the pubic symphy- → sis (see Table 2-1). Estrogen increased Cervical changes: Cervix becomes softer. sodium chloride in mucus Changes in cervical mucus: Cervical mucus can be dried on a slide → crystallization → and evaluated via microscope. ferning pattern. Fernlike pattern: Not pregnant—estrogen effect. Progesterone → decreased Beaded or cellular pattern: Pregnant—progesterone effect. sodium chloride in mucus Vaginal mucosa discoloration: With pregnancy and ↑ blood ﬂ ow, the → no crystallization → vagina appears dark bluish or purplish-red. beading. Perception of fetal movement: A primigravida may report fetal movement at approximately 20 weeks gestation, and a multiparous at 18 weeks gestation. Nausea and/or vomiting (aka morning sickness): Nausea and/or vomiting occurs in approximately 70–85% of pregnancies, most notably at HIGH-YIELD FACTS 2–12 weeks gestation. It frequently occurs in the morning, but it can oc- Chadwick’s sign: Bluish cur through out the day. Hyperemesis gravidarum is persistent vomit- discoloration of the vaginal ing that typically occurs early in pregnancy. When severe, it can result in weight loss, dehydration, acidosis (from starvation), alkalosis (from and cervical mucosa due to loss of HCl in vomitus), and hypokalemia. vascular congestion in Hair growth changes: Prolonged anagen (the growing hair phase). pregnancy. Fetal heart rate (FHR) detection (discussed later in this chapter). Urologic changes: ↑ pressure from the enlarging uterus result in ↑ urinary frequency, nocturia, and bladder irritability.

Quickening: First fetal

movements felt by the Diagnosis of Pregnancy mother.

TABLE 2-1. Fundal Height During Pregnancy

WEEKS PREGNANT FUNDAL HEIGHT

12 Barely palpable above pubic symphysis

15 Midpoint between pubic symphysis and umbilicus

20 At the umbilicus

28 6 cm above the umbilicus

32 6 cm below the xyphoid process

36 2 cm below xyphoid process

40 4 cm below xiphoid processa aDue to engagement and descent of the fetal head, the fundal height at 40 weeks is typically less than the fundal height at 36 weeks.

25 HUMAN CHORIONIC GONADOTROPIN (hCG)

hCG is a glycoprotein hormone composed of α A 25-year-old female presents with vaginal spotting and right lower quad- and β subunits. rant pain. She denies passage of tissue. Her abdomen is tender to mild palpation in the right lower quadrant. There is minimal dark blood in the vaginal vault, and her cervix is closed and thick. Quantitative serum hCG is 4000 mIU/mL. A transvaginal ultrasound (TVUS) shows no evidence of pregnancy inside The hCG α subunit is the uterus. What is the most likely diagnosis? identical to that in LH, FSH, Answer: Ectopic pregnancy. A gestational sac should be seen inside the uterus and TSH. on a transvaginal ultrasound with an hCG level of 1500 mIU/mL. If the pregnancy is not in the uterus, then an investigation must be carried out for an ectopic pregnancy.

Detection of hCG in the mother’s serum and urine is used to diagnose preg- hCG → supports corpus nancy. This section discusses the various aspects of the hormone, as well as luteum → produces how it is used in the diagnosis of abnormal pregnancies. progesterone → supports early pregnancy Overview hCG can be detected in maternal serum and urine. HIGH-YIELD FACTS HIGH-YIELD It is a glycoprotein made by trophoblasts. Plasma hCG levels should Composed of two subunits—α and β: double every 2 days prior α subunit is similar in luteinizing hormone (LH), follicle-stimulating to 10 weeks. hormone (FSH), thyroid-stimulating hormone (TSH). β subunits are unique: Urine and serum tests are based on antibody specifi city to β subunit of hCG. Function: Helps sustain the corpus luteum during the fi rst 7 weeks. Af- If β-hCG does not rise as ter the fi rst 7 weeks, the placenta makes its own hormones to sustain the expected, consider accidents pregnancy. of pregnancy: spontaneous Can be detected in the maternal serum or urine 6–12 days after fertil- abortion, missed abortion, ization (3–3.5 weeks after the LMP). ↑ ectopic pregnancy. by 66–100% every 48 hours prior to 10 weeks. In general, hCG should double every two days. Peaks at 10 weeks gestation. Nadirs at 14–16 weeks. Keep in mind that pregnancy tests not only detect hCG produced by Diagnosis of Pregnancy the syncytiotrophoblast cells in the placenta, but also in: Do not assay for hCG Hydatidiform mole. Choriocarcinoma. before a woman has missed Germ cell tumors. a menstrual period because hCG produced by breast cancers and large cell carcinoma of the of low test sensitivity before lung. this time. A gestational sac can be visualized with transvaginal ultrasound (TVUS) when hCG levels are >1500. If hCG is >1500 and no evidence of intrauterine pregnancy, think “ectopic pregnancy.”

Pregnancy Test Using hCG Serial hCGs are used to hCG can be detected in plasma and urine. Each test has speciﬁ c uses, which follow and make prognosis are discussed below. of ﬁ rst-trimester bleeding.

26 URINE HCG Preferred method to diagnose normal pregnancy. Total urine hCG closely parallels plasma concentration. First morning specimens are more accurate. hCG concentration is higher in the morning. Normal fetal heart rate Assays detect 25 mU/mL of hCG, and diagnose pregnancy with 95% ranges from 110 to 160 sensitivity by 1 week after the fi rst missed menstrual period. bpm. False negatives may occur if: The test is performed too early (ie, before the fi rst missed period). The urine is very dilute. False positives may occur with: Proteinuria (confi rm with plasma hCG). Urinary tract infection (UTI). If fetal heart tones are not PLASMA HCG auscultated by 10 weeks gestation, an US evaluation Used when quantitative information is needed: should be performed to HIGH-YIELD FACTS To aid in the diagnosis of ectopic pregnancy. document a viable Monitoring trophoblastic tumors. intrauterine pregnancy. Screening for fetal abnormalities. Serial levels to monitor accidents of pregnancy. Do not provide cost-effective additional information in diagnosing routine pregnancy since they are positive < 1 week before urine hCG. Up to 12 weeks, the crown- rump length is predictive of FETAL HEART RATE (FHR) gestational age within 4 days. Hearing the fetal heartbeat confi rms the presence of a viable pregnancy. Elec- tronic Doppler device can detect fetal heart tones as early as 10 weeks gestation. Diagnosis of Pregnancy

ULTRASOUND (US) Early pregnancy US is more US is a noninvasive tool that serves multiple purposes in the setting of a preg- precise in establishing the nancy: EDD: US done in T1 can vary by ± 4 days. Indications US done in T2 can vary by Conﬁ rm an intrauterine pregnancy (especially important if an ectopic ± 14 days. is suspected). US done in T3 can vary by Document the viability of embryo. Fetal cardiac motion can be seen ± 21 days. when the embryo measures ≥ 5 mm. Diagnose multiple gestations. Estimate gestational age. To screen for fetal structural anomalies.

Limitations US dating is used when menstrual data is unreliable Ultrasound dating becomes progressively less accurate after 20 weeks’ or conﬂ icts with clinical gestation. It can be used later, keeping in mind its limitations. US measures the size of the fetus, not the gestational age. ﬁ ndings. Biologic variation in size ↑ as gestation advances.

27 NOTES HIGH-YIELD FACTS HIGH-YIELD Diagnosis of Pregnancy

28 CHAPTER 3 Physiology of Pregnancy

Conception 31 OVULATION 31

FERTILIZATION 31

PREIMPLANTATION 31

IMPLANTATION 31

PLACENTATION 31

POSTIMPLANTATION 33

THE PLACENTA 33 Reproductive Tract 33 UTERUS 33

CERVIX 34

VAGINA 34

SKIN 34

BREASTS 34 Metabolic Changes 34 WATER METABOLISM 35

CARBOHYDRATE METABOLISM 35 Hematologic Changes 36 BLOOD VOLUME 36

IRON 36

IMMUNOLOGY 36

COAGULATION 37 Cardiovascular System 37 Respiratory System 37 Urinary System 38 KIDNEYS 38

URETERS 38

BLADDER 38 Gastrointestinal Tract 38 LIVER 39

GALLBLADDER 39 Endocrine System 39

29 PITUITARY GLAND 39

THYROID GLAND 39

PARATHYROID GLAND 39

30 HIGH-YIELD FACTS Physiology of Pregnancy Human chorionic gonadotropin (hCG) is detectable in maternal serum after implantation has taken place, approximately 8–11 days after conception. The decidua produces steroids and proteins that are related to the maintenance and protection of the pregnancy from immunologic rejection. Fertilization occurs in the ampulla of the fallopian tube. 31 rst other trophoblasts form the chorionic membranes. other trophoblasts form the chorionic blasts. and the endometrium. cavity after conception (see Table 3-1). 3-1). cavity after conception (see Table types of cells in the embryo. form all different called a morula. female nuclear material combine to form a single cell called a zygote. female nuclear polar body. an additional with the help of adhesion molecules on the secretory endometrial surface. polar body. nearest the myometrium form the placental the The trophoblasts disk; into tropho- During week 2, cells in the outer cell mass differentiate boundary between the embryo A trophoblastic shell forms the initial After attachment, the endometrium proliferates around the blastocyst. . blastomere to form a multicellular The morula divides the fallopian tube into the uterine cavity. The blastomere passes from oats in endometrial The embryo develops into a blastocyst as it freely fl Each cell of the preimplantation is totipotent; each cell can embryo zygote starts At the 16 cells stage, The cleavage (divide). it is to undergo and of the ovum. The male the zona pellucida The sperm penetrates II and to discharge meiosis signals the ovum to complete Fertilization tube. the ovary and be carried into the fallopian leave must The ovum zona pellucida. ovum is surrounded by its The unfertilized its fi and carries division rst meiotic has completed its fi This oocyte the blastocyst adheres to the endometriumOn day 5–6 after ovulation, CONCEPTION Placentation Implantation Preimplantation Fertilization ampulla of the typically occurs within 24 hr after ovulation in the Fertilization fallopian tube: Ovulation is necessary for normal fertilization to occur: Ovulation is necessary Ovulation Pregnancy induces changes in the female body from the onset of conception. conception. onset of from the body the female in changes induces Pregnancy but a fetus, of and growth the development only for not body prepares The is at risk for devel- the mother result of these alterations, As a also for delivery. pregnancy. can be serious in which oping complications, Physiology of Pregnancy HIGH-YIELD FACTS TABLE 3-1. Viable Fetal Period Previable Fetal Period Period Embryonic W 30 28 24 22 20 18 16 14 12 11 10 9 8 7 6 5 4 3 2 1 EEK Embryology accelerated formation. andsulci,whichbegantoforminweek26, arenowprominentandbegin Cerebral gyri eyelidsunfuse;muscletone↑ . Third trimesterbegins; 27. fetusgenerallycapableofbreathingairbyweek Fetal lungsdevelopalveoliandsecretesurfactant, Fetus canhear, willrefl exively moveinresponsetoloudnoise. descentinmales. Head andbody(lanugo)visible;testesbegin Egg cells,ovaries,anduterusdevelopinfemales. begin. Head andnecktakeanerect,straight-linealignment. trimester ends. colonicrotation;fetusactive;fi Sex distinguishableexternally;fetalbreathingmovementsbegin; formed insockets. excretingurineintoamnioticflFetal kidneysbegin tofunction;babyteeth uid; fetalliverbegins Intestines inabdomen;thyroid,pancreas,andgallbladderdevelopment. Eyes closingorclosed. approximately30 mm. Human appearance;tailhasdisappeared;CRL outsideabdominalcavity). growth Umbilical herniation(intestinesbegin rays;upperlip,nose,andexternalearformed. Hand platesdevelopdigital Hand andfootplatesdevelop. approximately4.0mm. (CRL) crown-rumplength Primitive heartbeat; First missedmenstrualperiod;formationofprimitivestreakandneuralgroove. Formation ofyolksacandembryonicdisk. ofimplantation. andstart Fertilization ↑ fetalactivity;ultrasoundcandeterminesex;myelinationofnervesandossifi cation ofbones 32 P REEMBRYONIC P ERIOD rst- HIGH-YIELD FACTS Physiology of Pregnancy weeks 14–27 weeks weeks–term Braxton Hicks contractions do not cause cervical change. Most common cause for abnormal maternal serum screen for aneuploidy is incorrect gestational age. The human placenta is hemochorionic—there is NO direct mixing of fetal and maternal blood. First trimester (T1): 1–13 First trimester (T1): 1–13 Second trimester (T2): Third trimester (T3): 28 37–42 weeks Term: 33 uid. ERIOD P REEMBRYONIC P Fetal immune system functioning and capable of responding to mild infections. and capable of system functioning immune Fetal thickens. Vernix sucking; meconium present in fetal intestines. capable of Fetus Due date. (continued) in frequency during the last month of pregnancy. ↑ in frequency as a result of vasodilation from the effects of estradiol and from the effects of estradiol ↑ as a result of vasodilation ow Embryology spontaneous with an intensity ranging from 5–25 mmHg. and irregular They may may They These contractions, also known as Braxton Hicks contractions, are These contractions, also known from uterine and ovarian arteries. cells contract after delivery thereby constricting the blood ves- muscle sels. in uterine size is due to mechanical distention. pregnancy progresses, ↑ in uterine size is due to mechanical tract. progesterone. panding to hold the fetus, placenta, to hold fl and amniotic panding ometrial smooth muscle. decidua. week postconception. Perfusion of the placenta depends on uterine blood fl ow, which comes ow, of the placenta depends on uterine blood fl Perfusion fl Blood These uterine muscle. Blood vessels lie between the various layers of with estrogen. As this process is primarily stimulated in pregnancy, Early cells will spontaneously these muscle con- Throughout the pregnancy, of ex- structure that is capable thin-walled, muscular The uterus is a of uterus is due to hypertrophy and hyperplasia of the my- Enlargement pregnancy is termed of the uterus during endometrium or lining The lacunae in the second RBCs may be seen in the trophoblastic Maternal EEK 32 34 36 40 REPRODUCTIVE TRACT W Uterus The Placenta The T2 and T3. It is the primary producer of The placenta to adapt over continues hormones after 7 weeks gestation. steroid The human placenta is hemochori- and fetus is via maternal blood transfer of materials between mother onic; in contact of maternal coming mixing with placental direct villi. There is no and fetal blood. Postimplantation TABLE 3-1. TABLE Physiology of Pregnancy HIGH-YIELD FACTS pregnancy. more than20lbduringthe a BMI>26shouldgainno 28–40 lbwhilethosewith <19, weightgainshouldbe If pre-pregnancyBMIis and T3. most ofweightgaininT2 little weightgaininT1,with pregnancy. Thereshould be 25–35 lbduring weight, patientshouldgain If normalpre-pregnancy pregnancy. andvascularityasaresultof The skinundergoeschangesinpigmentation Skin delivery. The vaginaalsoundergoeschangesduringpregnancyinpreparationforlabor/ Vagina Cervix 34 Breasts METABOLIC CHANGES METABOLIC Certain dermatologicconditions Certain areunique topregnancy. SeeTable 3-2. The tissuebecomesmorevascularleading to Highlevelsofestrogencause vascularspidersandpalmarerythema. The Thevaginalsecretionsbecomethickerwithawhitecolorduetoinfl Thevaginalwallspreparefordistention byincreasingthethicknessof Otherchangesinclude↑vascularityoftheentirecervixandhypertro- The cervixiscomposedofsmoothmuscle andconnectivetissue.↓ Ideal weight gain: Afterafewmonthsofpregnancy, thebreastmayexpressathick,yellow Breasts may T2 andT3:0.8 lb/wk T1: 1.5–3lbgained most pathogensandfavorsgrowth ofyeasts. ture asaresultof↑ ence ofprogesterone.Additionally, thesecretionsaremoreacidic inna- wick’s sign. trogen, andprogesterone. smooth muscle cells. the mucosa, loosening oftheconnectivetissue,andhypertrophy phy andhyperplasiaoftheglands. soften andbecomecyanotic. amount ofcollagenandaccumulation ofwatercausethecervixto fluid calledcolostrum. ↑ inglandactivityleadstotheformationofamucous plug. Facial in chloasma/melasma:Lighttodarkbrown hyperpigmentation Darkening ofthenipple andareola. Lineanigra: Blackline/discoloration oftheabdomenthatrunsfrom Cervicaleffacementcausesexpulsionofthemucous plugasthecer- The mucous plugiscomposedofimmunoglobulins andcytokines, exposed areas(faceorneck). umbilicus topubis. vical canalshortensinlabor. which actasabarriertobacteria. in pigmentation isduetomelanocyte-stimulating↑ inpigmentation hormone,es- ↑ insizeandbecomepainful. Lactobacillus acidophilus.Thisinhibitsgrowth of a purplishtinge—Chad- u- HIGH-YIELD FACTS Physiology of Pregnancy in NTERVENTION I acids, liver function tests, Antipruritics, ursodeoxycholic acid, fetal testing antipruritic drugs (hydroxyzine, diphenhydramine, calamine lotion / Hyperlipemic Glycosuric Anabolic Normal pregnancy state is: The placental hormone human placental lactogen is thought to cause gestational diabetes because it causes insulin resistance as it ↑ pregnancy. The optimal time to screen for glucose intolerance is at 26–28 weeks gestation. ETAL No steroids, Topical F NCIDENCE ORTALITY ORBIDITY Stillbirth Check serum bile M ↑ I M 35 NCIDENCE Common (1–2%) I Common (1:160– 1:300) its energy needs. its energy needs. ISTRIBUTION Generalized, palms, soles D Abdomen, thighs, buttocks, occasionally arms and legs by 300 kcal/day. by 300 kcal/day. ESIONS L common urticarial papules and plaques RURITUS P in fi rst half of pregnancy. ↑ in fi NSET T3 Severe Excoriations T2–T3 Severe Erythematous O Dermatologic Pruritic to Pregnancy Unique Disorders postprandial hyperglycemia, and hyperinsulinemia. hyperglycemia, postprandial sition. cose and lipids for energy. venous pressure in the lower extremities due to compression of the due to compression extremities ↑ venous pressure in the lower by the gravid uterus. vena cava and pelvic veins osmotic pressure. ↓ in interstitial colloid fasting hypoglycemia, have mild As a result, pregnant women will Insulin sensitivity Insulin for glycogen synthesis and fat depo- fasting glucose levels allow Lower Insulin resistance develops and plasma insulin levels rise. utilization of glu- Higher levels of both insulin and glucose stimulate ISEASE the ankles and legs is seen in pregnant women, especially at the end of women, especially the ankles and legs is seen in pregnant is due to several factors, including: This the day. hydration of connective tissue leading to laxity and swelling of con- ↑ hydration of connective tissue leading in T3. that mainly occur nective tissue and joints By the last trimester, requirements ↑ By the last trimester, requirements D After 20 weeks: 20 weeks: First edema of Often, pitting is a normal part of pregnancy. retention Water body ↑ the mother’s As both baby and placenta grow, Intrahepatic cholestasis of pregnancy (bile not properly excreted from the liver) Pruritic urticarial papules and plaques of pregnancy (PUPPP) (polymorphic eruption of pregnancy) Carbohydrate Metabolism Carbohydrate Water Metabolism Water TABLE 3-2. TABLE Physiology of Pregnancy HIGH-YIELD FACTS fetus. risk ofinheritanceforthe the fathertodetermine sickle celltrait/disease,test thalassemia trait/diseaseor If amotherhasBeta- compared tosingleton. higher ordergestationsas more ifhavingtwinsor Maternal bloodvolume↑ intravascular volume. due togreaterexpansionof pregnancy developsinT2 Physiologic anemiaof Immunology Iron Blood Volume 36 HEMATOLOGIC CHANGES The ↑inbloodvolumebufferstheanticipatedlossattimeofdelivery. loss duetothenormal↑ the explanationforpatient’sresponsetolargebloodloss? Duringpregnancy, thereissuppressionofhumoraland cell-mediated Theamountofironfromthediet isinsuffi cient tomeettheneedsof Mostoftheironisusedfor hematopoiesis, especially inthelasthalf of Iron requirements Bothhemoglobinandthehematocrit↓slightly. Expandedvolumeiscomposedofplasmaanderythrocytesbutpropor- Maternal bloodvolume↑duringpregnancytolevelsthatare50% Markersofinfl suchasleukocytealkalinephosphatase, ammatory states Theleukocytecountvariesduring normalpregnancy. Usually, itranges Answer: The patientremainedhemodynamically stabledespitealargeblood ulocyte count. muooia ucin.During T3: immunological functions. the pregnancy,iron. sopatientsmustsupplemental take pregnancy. tionately moreplasma.↑erythrocyteproductionisrefl above thatofpre-pregnancy. ↑bloodvolumeisneededto: C-reactive protein, anderythrocytesedimentationrate(ESR)alsorise. however, itaverages14,000–16,000/μL. from 5000to12,000/μL.Duringlabor,countscanrise25,000/ μL; Levelsbelow 11.0g/dL,especially lateinpregnancy, shouldbecon- Hemoglobinaverages12.5g/dL. Protectthemotherfrombloodlossattimeofdelivery. Protectthemotherandfetusagainstimpairedvenousreturn. Meetthedemandsofenlargeduterus. sidered abnormal. ↓ inCD4Tlymphocytes,monocytes. ↑ granulocytes, ↑CD8Tlymphocytes. A 29-year-old G3P2103 at38 deliversa7lb6ozbabygirl normal limitswhileherhemoglobin↓ estimated bloodlossforthedeliverywas950 mL.Vitals remainwithin in bloodvolumethattakesplacethesecondtrimester. ↑ inpregnancytoabout1000mg/day. from 12 g/dLto10 g/dL.What is ected by ected 3 / 7 weeks.The ↑ retic- HIGH-YIELD FACTS Physiology of Pregnancy blown off). 2 Normal acid-base status in pregnancy = compensated respiratory alkalosis (more CO ↑ CO = ↓ SVR + ↑ HR. Patients with hypertensive heart disease may develop progressive or sudden deterioration in pregnancy. 37 risk in clotting factors, ↑ in midpregnancy and rises during the last trimester. trimester. and rises during the last in midpregnancy ↓ SYSTEM being blown off. pH = 7.45 off. blown being SYSTEM 2 brinogen. A 36-year-old G3P2002 at 32 weeks gestation presents with a sudden gestation presents weeks at 32 G3P2002 A 36-year-old onset of shortnessthat has been and palpitations of breath, dyspnea, sick contacts, cough, worsening. She denies 1 hour and is now ongoing for systemic vascular resistance.↓ systemic ↑ heart rate. concentrations of all clotting factors, except factors XI and XIII. ↑ concentrations of all clotting factors, ↑ fi ↑ resistance C. to activated protein S. ↓ protein more CO subcostal angle widens, and thoracic circumference ↑ about 6 cm. subcostal circumference and thoracic angle widens, rotates slightly. valves. aortic and pulmonic across ow pregnant women due to ↑ fl diologist. Diastolic pressure ↓ more than systolic. emboli, DVT). tidal volume, minute ventilatory volume, and minute oxygen uptake. ventilatory volume, and minute ↑ tidal volume, minute volume due to the elevated and residual ↓ functional residual capacity diaphragm. Pulmonary embolus (PE).Answer: Pulmonary embolus causes an Estrogen status alkalosis due to Normal acid-base is respiratory in pregnancy rises about 4 cm, the uterus, diaphragm of the expanding As a result Respiratory rate unchanged. Blood pressure Blood to the left and upward and rises, the heart is displaced diaphragm As the occur in 96% of along left sternal border Systolic ejection murmurs by a car- are never normal and should be evaluated Diastolic murmurs Changes in cardiac function begin in the fi rst 8 weeks of pregnancy. function begin in the fi Changes in cardiac due to: fth week of pregnancy output is ↑ as early as the fi Cardiac is ↓ slightly. The average platelet count state Pregnancy is a hypercoagulable stroke, pulmonary (risk factor for resulting in a hypercoagulable state in pregnancy. Pregnant patients are at ↑ Pregnant state in pregnancy. resulting in a hypercoagulable for pulmonary embolus and deep venous thrombosis (DVT)for pulmonary embolus during the pregnancy delivery. and immediately after fever, or leg swelling. She has no medical conditions and has a negative family and has a negative no medical conditions swelling. She has or leg fever, She and BP respirations 25, 120/80. is afebrile, pulse is 120, On exam, she history. side. Her are absent breath sounds on the right There appears to be in distress. heart Fetal rate is reassuring. Pulse oxim- edema bilaterally. pitting legs show 1+ is the most likely diagnosis? What air. on room etry is 75% RESPIRATORY RESPIRATORY CARDIOVASCULAR CARDIOVASCULAR Coagulation Physiology of Pregnancy HIGH-YIELD FACTS appendix up. gravid uteruspushesthe abdomen becausethe occur muchhigherinthe Pain fromappendicitismay pregnancy. normal fi ndingin Right hydronephrosisisa other medications. dose ofantibioticsand leads toreducedeffective rate ofrenalclearance In pregnancy, thehigher Bladder Ureters Kidneys 38 URINARY SYSTEM URINARY GASTROINTESTINAL TRACT GASTROINTESTINAL nancy, sopreventioniskey. tory failure;itisthemostcommonnonobstetriccauseforhospitalizationinpreg- inpregnantwomencanleadtosepsisandrespira- left untreated.Pyelonephritis topyelonephritisif developing asymptomaticbacteruria,andUTIscanprogress Due tothechangescausedbyprogesterone,pregnantwomenareat (UTI). The antibioticscanbe modifi ed oncetheurinecultureresultsareavailable. blood. What isthenextstep? Decreased ureteral peristalsis andincreasedureteralcompressioncause Decreased ureteralperistalsis Dilated ureterscause↑ DilationR>Lduetothedextroversionofuterus. Dilate duetocompressionfromuterusatthepelvicbrimandeffect Renaltubuleslosesomeoftheir resorptivecapacity: Amino acids, uric Hemorrhoids, Effects ofprogesterone: Thestomach,appendix, andintestinesaredisplaced upwardbytheen- Stress incontinencedevelopsasaresultofrelaxation ofbladdersup- Answer: The patientshouldbeempirically treatedforaurinarytractinfection phritis. whichcanleadtoasymptomaticbacteruriaandpyelone- urinary stasis of progesterone. higher levelsinthepregnantfemale. acid, andglucoseare notcompletelyabsorbed.Sodiumin isretained elevated pressure inveins below the leveloftheuterus. larging uterus. ports. uterus. ↑ urinaryfrequency isduetobladdercompressionbyanenlarged ↓ tone,↑capacity progressivelyduringpregnancy. ↓ serumcreatinine, blood ureanitrogen. ↑ glomerularfiltration rate,creatinine clearance,renalplasmafl kidneys. bowel peristalsis →constipation. ↓ bowel peristalsis ↓ lower esophagealsphinctertone→heartburn. urine showed the presence of large nitrites, large leukocytes, andsmall urine showedthepresenceoflargenitrites,leukocytes, nocomplaints.However,tine prenatalvisit.Patient reports analysisofher A 31-year-old G1P0at24 weekspresentstoherobstetricianforrou- common inpregnancy, arecausedbyconstipationand glomerular sizeand↑ fl uid fl uid ow ow → enlarged ↑ risk for ow. HIGH-YIELD FACTS Physiology of Pregnancy , normal 3 , and normal 4 Pitocin is synthetic oxytocin. It is used to start or enhance labor. TSH is unchanged during pregnancy. Pregnant women have elevated TBG and therefore will have elevated total thyroxine and T Cholestasis with increased lipids and cholesterol leads to higher incidence of and gallstones, cholecystitis, biliary obstruction. thyroid-stimulating hormone. free T 39 hor- in fi rst trimester but then rises rst trimester in fi in size; therefore, all goiters need to be investigated. in size; therefore, all goiters ↓, but total of of a greater volume ↑ because albumin ↑ throughout pregnancy due to estradiol. high estrogen levels. However, free thyroxine remains normal and the high estrogen levels. However, mother remains euthyroid. kinin-mediated smooth muscle stimulation. smooth muscle kinin-mediated cholestasis. nancy. Serum aspartate transaminase, alanine transaminase, γ-glutamyl transaminase, Serum aspartate alanine transaminase, nancy. are slightly lower. and bilirubin levels transferase, distribution. ↑ throughout the pregnancy. progressively the remainder of the pregnancy. Estrogens block the ac- progressively the remainder of the pregnancy. resulting in ↑ hormone on bone resorption, tion of parathyroid supply. calcium the fetus to have adequate mone levels, which allow for bone deposition. allowing levels The fetus has ↑ calcitonin hormone ↓ In the mother, parathyroid globulin ↑ in response to thyroxine levels and thyroxine-binding Total disease. marker for thyroid hormone is a sensitive Thyroxine-stimulating and infant crying. stimulation Released by nipple Causes uterine contractions. production. milk Main function is to ensure Levels letdown. Responsible for lactation, milk especially inhibiting cholecysto- gallbladder contraction by Progesterone impairs intraductal Estrogen inhibits also contributing to of bile acids, transport Alkaline phosphatase preg- during doubles almost in serum activity Alkaline albumin Serum The gland does not ↑ XYTOCIN ENDOCRINESYSTEM ROLACTIN Parathyroid Gland Parathyroid Thyroid Gland Thyroid P Pituitary Gland The pituitary during pregnancy gland ↑ in size and weight Contractility of the gallbladder is reduced, leading to an increased residual to an increased gallbladder is reduced, leading Contractility of the volume and cholestasis. Gallbladder Liver O Physiology of Pregnancy HIGH-YIELD FACTS 40 NOTES CHAPTER 4 Antepartum

Prenatal Care 43 DEFINITIONS 43

TERMINOLOGY OF REPRODUCTIVE HISTORY 43

FREQUENCY OF OBSTETRIC VISITS 43

FIRST VISIT 44

SUBSEQUENT VISITS 45

FUNDAL HEIGHT 47 Fetal Surveillance 47 FETAL MOVEMENT COUNTS 47

NON-STRESS TEST 47

CONTRACTION STRESS TEST 48

ULTRASOUND 48

BIOPHYSICAL PROFILE 49

MODIFIED BIOPHYSICAL PROFILE 49

DOPPLER VELOCIMETRY 50 Screening For Congenital Abnormalities 50 FIRST-TRIMESTER SCREEN 51

QUAD SCREEN 51

MATERNAL SERUM α-FETOPROTEIN 52

UNCONJUGATED ESTRIOL 53

HUMAN CHORIONIC GONADOTROPIN 53

INHIBIN A 53

SPECIALIZED (LEVEL II) ULTRASOUND 53

AMNIOCENTESIS 55

CHORIONIC VILLUS SAMPLING 56

CORDOCENTESIS 57

GENETIC TESTING 58 Nutritional Needs of the Pregnant Woman 58 WEIGHT GAIN 58

DIET 59

FOLIC ACID 59

MINERALS 59

VEGETARIANS 59

PICA 60

41 Common Questions 60 CAFFEINE IN PREGNANCY 60

EXERCISE 60

NAUSEA AND VOMITING 60

HEARTBURN 61

CONSTIPATION 61

VARICOSITIES 61

HEMORRHOIDS 61

LEG CRAMPS 62

BACKACHE 62

ROUND LIGAMENT PAIN 62

SEXUAL INTERCOURSE 62

EMPLOYMENT 62

TRAVEL 62

IMMUNIZATIONS 63 Notify the Physician 63

42 This chapter focuses on the care provided for the pregnant patient prior to delivery. The prenatal or antepartum course often inﬂ uences the outcome of the pregnancy. During this time, patients are encouraged to maintain healthy practices and abstain from practices that are harmful for the pregnancy. Regu- lar visits at speciﬁ c intervals are used to screen patients and fetus for abnormal medical conditions that may develop.

PRENATAL CARE

The goal of prenatal care is as follows: 1. Determine the health status of mother and fetus. 2. Determine gestational age. 3. Initiate plan for obstetrical care (routine vs. high risk). 4. Lower maternal/perinatal morbidity/mortality. 5. Enhance pregnancy, childbirth experience for patient/family. HIGH-YIELD FACTS

Deﬁ nitions Gestational age (GA): The time of pregnancy counting from the ﬁ rst day of the last menstrual period (LMP). Developmental age: The time of pregnancy counting from fertilization. First trimester: 0–13 weeks. Second trimester: 14–27 weeks. Gravidity: The number of Third trimester: 28 weeks–birth. times a woman has been Embryo: Fertilization–8 weeks. Fetus: 9 weeks–birth pregnant. Previable: < 24 weeks. Parity: The number of Preterm: 20–36 weeks. times a woman has had a Term: 37–42 weeks. pregnancy that led to a

birth after 20 weeks Antepartum gestation or an infant Terminology of Reproductive History > 500 g. The mother’s pregnancy history is described in terms of gravidity (G) and parity (P). Gravidity is the total number of pregnancies, regardless of the outcome. Parity is the number of pregnancies that have reached a gestational age of ≥ 20 weeks. It can be further subdivided into term births, preterm births, abortions, and living children. Parity: TPAL A woman that is gravida 3, para 1201 (G3P1201) has been pregnant Term three times, has had one term birth, two preterm births, no abortions, Preterm and has one live child. Abortuses Living Children Frequency of Obstetric Visits < 28 weeks: Every month. 28–36 weeks: Every 2–3 weeks. 36–41 weeks: Once per week. 41–42 weeks: Every 2-3 days for fetal testing. 42 weeks or more: Plan for delivery. See Table 4-1.

43 TABLE 4-1. Prenatal Visits

FIRST VISIT 11–13 WEEKS 16–20 WEEKS 26–28 WEEKS

1. History and physical (H&P) 1. H&P 1. H&P 1. H&P 2. Labs: 2. Fetal exam: 2. Fetal exam: 2. Fetal exam: Hct/Hgb Fetal heart tones Fetal heart Fetal heart Rh factor 3. Urine dip: Protein, glucose, Fundal height Fundal height Blood type leukocytes 3. Urine dip: Protein, glucose, 3. Labs: Antibody screen 4. First-trimester screen leukocytes Complete blood Pap smear 4. Fetal ultrasound: Anatomy, count Gonorrhea and dating Ab screen Chlamydia cultures 5. Quad screen Gonorrhea and Urine analysis (protein, 6. Genetic amniocentesis (if Chlamydia cultures glucose, ketones) indicated) (optional) Urine culture Diabetes screen Infection screen: Urine dip: Protein, Rubella, syphilis, glucose, leukocytes hepatitis B, human Syphilis screen immunodeﬁ ciency (optional) virus (HIV), 4. Give anti D tuberculosis (TB) immunoglobulin if

HIGH-YIELD FACTS HIGH-YIELD Cystic ﬁ brosis screen indicated (28 weeks) Urine drug screen Hemoglobin electrophoresis

Week 32 Week 36 Week 38 Week 39 Week 40

1. H&P 1. H&P 1. H&P 1. H&P 1. H&P 2. Fetal exam: 2. Fetal exam: 2. Fetal exam: 2. Fetal exam: 2. Fetal exam: Fetal heart Fetal heart Fetal heart Fetal heart Fetal heart Fundal height Fundal height Fundal height Fundal height Fundal height 3. Urine dip: protein, Fetal presentation Fetal Fetal Fetal presentation

Antepartum glucose, leukocytes 3. Urine dip: Protein, presentation presentation 3. Urine dip: Protein, glucose, leukocytes 3. Urine dip: 3. Urine dip: glucose, leukocytes 4. Group B strep culture Protein, glucose, Protein, glucose, 5. HIV—required in some leukocytes leukocytes states 4. Cervical exam (frequency is controversial)

First Visit

HISTORY Biographical: Age, race, occupation, marital status. Obstetrical: Gravidity, parity, prior labor/deliveries (vaginal, cesareans), complications, infant status, birth weight.

44 Menstrual: Last menstrual period (LMP), menstrual irregularities. Contraceptive use: What type and when was it last used? Medical: Asthma, diabetes, hypertension, thyroid disease, cardiac dis- Remember that alcohol use ease, seizures, rubella, previous surgeries, sexually transmitted infections, allergies, medications, smoking, alcohol, recreational drugs. has the highest correlation Family history: Multiple gestations, diabetes, hypertension, bleeding with congenital disorders, hereditary disorders, mental retardation, anesthetic problems. abnormalities.

PHYSICAL EXAM Vitals: Blood pressure (BP), weight, height, temperature, heart rate. Head, neck, heart, lungs, back. Pelvic: External genitalia: Bartholin’s gland, condyloma, herpes, other le- Patient’s history and sions. physical determines Vagina: Discharge, inﬂ ammation. whether the patient Cervix: Polyps, growths. receives routine or high risk

Uterus: Masses, irregularities, size compared to gestational age. care. HIGH-YIELD FACTS Adnexa: Masses. Clinical pelvimetry: Following are dimensions of a gynecoid pelvis shape: Pelvic inlet: Diagonal conjugate > 12.5 cm. Distance between the inferior border of symphysis pubis to sacral promontory. Midpelvis: Ischial spines blunt, >10 cm. Pelvic outlet: Intertuberous diameter > 8 cm, pubic arch > 90 degrees.

Subsequent Visits

A 31-year-old G2P1001 at 17 weeks gestation undergoes routine prenatal tests. Her results show that her blood type is A negative, and her antibody screen is positive. She does not report undergoing a blood transfusion in the past or any complications with her last pregnancy. What is the next step in the Antepartum management of this patient? Answer: The next step is to identify the antibody. There are many types of antibodies, and in a patient that is Rh negative, it should not be assumed that she has Rh antibodies.

HISTORY Ask each patient the following at each subsequent visit: Presence of fetal movement. Vaginal bleeding. Leakage of ﬂ uid. Contractions/abdominal pain. Preeclampsia symptoms: Headache. Visual disturbances. Right upper quadrant pain.

45 PHYSICAL EXAM After thorough initial exam, each subsequent exam must record four ﬁ ndings: BP Urine dip for protein, glucose, leukocytes Fundal height Fetal heart rate

ROUTINE INITIAL TESTS Complete blood count (CBC) Blood type Rh status Antibody screen Urinalysis (UA) Urine culture Urine drug screen (UDS) Rapid plasma reagin (RPR) Human immunodeﬁ ciency virus (HIV) Hepatitis B surface antigen (HBsAg) Rubella Tuberculin skin test Wet mount Gonorrhea Chlamydia HIGH-YIELD FACTS HIGH-YIELD Pap smear Cystic ﬁ brosis screen Hemoglobin electrophoresis

ROUTINE TIMED TESTS Certain prenatal tests should occur at speciﬁ c times during pregnancy (see Table 4-1): 11–13 weeks: First trimester screen; only for Down syndrome. Nuchal translucency (NT) measured via ultrasound. Maternal serum pregnancy-associated plasma protein A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG). In Down syndrome, the NT is ↑, PAPP-A ↓, free β-hCG ↑. Antepartum 16–18 weeks: Quad screen (range 15–21 weeks). Unconjugated estriol α-fetoprotein β-hCG Inhibin A 18–20 weeks: Ultrasound for anatomy/dating. 26–28 weeks: One hour 50-g glucose tolerance test (GTT) to screen for gestational diabetes. 28 weeks: Recheck antibody screen, administer Rhogam if indicated. 35–37 weeks: Group B streptococcus (GBS) culture. Third-trimester HIV testing is mandated by law in some states.

46 Fundal Height As the fetus grows, the leading edge of the uterus, or the fundus grows superiorly in the abdomen, toward the maternal head. Fundal height (in centimeters) roughly corresponds to gestational age (in weeks). Uterus at level of pubic symphysis: 12 weeks Uterus between pubic symphysis and umbilicus: 16 weeks Uterus at the level of umbilicus: 20 weeks Uterine height correlates to weeks gestation: 20–36 weeks Most common cause of size not equal to date—incorrect Fundal height (cm) should correlate to gestational age (weeks) ± 3. If not, gestational age. Order an consider inaccurate dating (most common), multiple gestations, or molar US to establish the correct pregnancy. Past approximately 36 weeks gestation, the fundal height may not dates. correspond to the gestational age due to the fetal descent into the pelvis.

FETAL SURVEILLANCE HIGH-YIELD FACTS

When the mother is diagnosed with a medical condition that can affect the fetus, or when the fetus is diagnosed with a condition that may result in a poor outcome, several tests can be used to monitor the health of the fetus. They include fetal movement counts, non-stress test (NST), contraction stress test (CST), biophysical profi le (BPP), the modifi ed BPP (mBPP), and Doppler ultrasonography. In general, they are performed in T3, but may be done earlier. These tests assess for chronic uteroplacental insuffi ciency and cannot predict acute events. The choice and frequency of testing depends on indication, gestational age, medical condition, and experience of the practitioner.

Fetal Movement Counts Fetal movement counts, or kick counts, may be performed at home by the pa-

tient in order to monitor the baby’s health. The patient should select a time at Antepartum which the fetus usually is active, usually after a meal. The level of activity dif- fers for each baby, and most have sleep cycles of 20–40 min. There are several ways to assess fetal movements: Ask the patient to record daily how long it takes the fetus to make 10 movements. For most, this is usually achieved in about 2 hr; however, this is variable. Alternatively, ask the patient to record the number of fetal movements in 1 hr three times per week. A baseline is established in this way. For both of these strategies, a physician should be contacted if there is a change from the normal pattern or number of movements recorded.

Non-stress Test (NST) The NST evaluates four components of the fetal heart rate (FHR) tracing: Baseline: Normally 110–160 beats/min. Variability: Beat-to-beat irregularity and waviness of the FHR. Pres- ence of variability reﬂ ects an intact and mature brain stem and heart. Periodic changes: Transient accelerations or decelerations: Early deceleration: Vagally mediated, caused by head compression usually at cervical dilation of 4–7 cm. Variable deceleration: Caused by cord compression.

47 Late deceleration: Reﬂ ects hypoxemia. Acceleration: At least two accelerations of at least 15 beats/min above baseline for 15 sec in a 20-min period. Presence of accelerations = fetal well-being. Reactive NST = two or more accelerations over 20 min. Uterine contractions are also recorded to help interpret the NST. Preterm fetuses are frequently nonreactive: 24–28 weeks: Up to 50% nonreactive. 28–32 weeks: 15% nonreactive. An NST usually takes 20–40 min to complete. If the NST is nonreactive, the baby may be asleep. If this is suspected, ask the patient to eat or drink to make the baby active if not reactive within 1–2 hours, then additional testing may need to be performed.

Contraction Stress Test (CST) The contraction stress test (CST) measures how the fetal heart rate (FHR) re- acts to uterine contractions. The CST can be performed if the NST is nonreactive. The FHR and the contractions are recorded simultaneously. During a contraction, the blood fl ow to the placenta briefl y ↓. A well-oxygenated fetus can compensate, and there are no decels in the FHR. If the fetus is already compromised with low levels of oxygen, the contraction may cause a late deceleration in FHR, which refl ects hypoxemia in the fetus. Patient is placed in lateral recumbent position and contractions are HIGH-YIELD FACTS HIGH-YIELD stimulated. Administration of oxytocin (pitocin). Nipple stimulation (2 min self-stimulation through clothes every 5 min). Adequate contractions: Occur three times in 10 min. Lasting at least 40 sec. Moderate to palpation. Interpreted as the presence or absence of late decelerations: Negative: No late or signifi cant variable decelerations. Positive: Late decelerations following 50% or more of contractions. Equivocal: Intermittent late decels or signifi cant variable decelerations. Antepartum Unsatisfactory: Fewer than three contractions in 10 min. Contraindications: A reactive NST has two or Preterm labor patients at high risk of delivery. more accelerations over 20 Premature rupture of membranes (PROM). min = fetal well-being. History of extensive uterine surgery or previous cesarean section. Known placenta previa.

Ultrasound (US) Standard US performed for: Fetal number Presentation Fetal viability Gestational age assessment Amniotic ﬂ uid volume Fetal biometry Fetal anatomic survey Placental location

48 Limited—goal-directed US: Presentation Placental location intrapartum Adjuct to invasive procedures Specialized (Level II)—performed when high suspicion of anomaly: Fetal Doppler When can a baby’s Biophysical profi le heartbeat be detected with Doppler? 8–12 weeks of gestation Biophysical Profi le (BPP) Fetal heart starts beating A biophysical profi le (BPP) is the combination of the non-stress test and at 22–24 days an ultrasound exam, for a total of fi ve components: 1. NST: Appropriate variation of fetal heart rate. 2. Breathing: ≥ 1 episode of rhythmic breathing movements of 30 sec or more within 30 min. 3. Movement: ≥ 3 discrete body or limb movements within 30 min. 4. Muscle tone: ≥ 1 episode of extension with return to fl exion or HIGH-YIELD FACTS opening/closing of a hand. 5. Determination of amniotic fl uid volume: Single vertical pocket of amniotic fl uid measuring ≥ 2 cm is considered adequate* (or an amniotic fl uid index > 5 cm). Each of the category is given a score of 0 or 2 points: 0: Abnormal, absent, or insuffi cient. 2: Normal and present as previously defi ned. Total possible score is 10 points. Normal score: 8–10. Equivocal: 6. Abnormal: ≤ 4.

* In the presence of oligohydramnios (largest pocket of amniotic ﬂ uid ≤ 2 cm), further investigation is required.

Modifi ed Biophysical Profi le (mBPP) Antepartum A modifi ed biophysical profi le (mBPP) includes two components: An NST and an amniotic fl uid index (AFI). Normal amniotic fl uid volume varies and ↑ with gestational age. The peak volume is 800–1000 mL at 36–37 weeks gestation. In the late T2 or T3, amniotic fl uid volume represents fetal urine output. If there is uteroplacental dysfunction and ↓ oxygenation to the fetus, the fetus mBPP = NST + AFI preferentially shunts blood to the brain and heart, leaving the fetal kidneys underperfused. This results in ↓ fetal urine output and, as a result, ↓ amniotic fl uid. Therefore, the AFI is used as a measure of chronic uteroplacental function. The AFI is the sum of amniotic fl uid measured in four quadrants of the uterus via the US. AFI > 5 cm: Adequate. Most common cause of ≤ AFI 5 cm: Abnormal (oligohydramnios). Oligohydramnios = rupture ≥ AFI 25 cm: Abnormal (polyhydramnios). of membranes. Oligohydramnios: Most common cause: Ruptured membranes. Associated with intrauterine growth restriction 60% of the time. Evaluate for genitourinary malformations.

49 Polyhydramnios: Many causes, including: Fetal malformation (anencephaly, esophageal atresia). Genetic disorders. Maternal diabetes. Multiple gestation. Fetal anemia. Viruses. Associated with uterine overdistention, resulting in: Preterm labor PROM Fetal malposition Uterine atony

Doppler Velocimetry Doppler sonography is a noninvasive technique used to assess fetal hemodynamic vascular resistance by imaging speciﬁ c fetal vessels: Umbilical artery (UA) and umbilical vein. Aorta. Heart. Middle cerebral artery (MCA). Commonly measured ﬂ ow indices are: Peak systolic frequency shift (S).

HIGH-YIELD FACTS HIGH-YIELD Peak diastolic frequency shift (D). Mean peak frequency shift over the cardiac cycle (A). Systolic to diastolic ratio (S/D). Resistance index (S-D/S). Pulsatility index (S-D/A). Flow velocity waveforms differ in normal-sized fetuses as compared to those suffering from growth restriction: Fetuses with normal growth: High-velocity diastolic fl ow. Fetuses with restricted growth: ↓ velocity diastolic fl ow, ↑ fl ow resistance (↑ S/D) in umbilical artery and ↓ resistance (↓ S/D) in MCA. Very severe intrauterine growth restriction: Flow may be absent or even reversed. “Brain sparing” may occur Abnormal fl ow is usually the result of placental insuffi ciency and dys- Antepartum in hypoxic fetuses = ↑ S/D function, resulting in fetal hypoxia and acidosis. This may induce the in umbilical artery + ↓ phenomenon of brain sparing: ↑ S/D in umbilical artery (↑ resistance). S/D in middle cerebral ↓ S/D in MCA (↓ resistance). artery. Adaptive response to fetal hypoxemia.

SCREENING FOR CONGENITAL ABNORMALITIES

Screening for fetal abnormalities can include testing during the ﬁ rst and second trimesters, and the tests can be noninvasive or invasive. Commonly used techniques are maternal serum screen, ultrasound, amniocentesis, chorionic villus sampling (CVS), and cordocentesis.

50 First-Trimester Screen (FTS) The FTS is an optional noninvasive evaluation performed between weeks 11 and 13. It is a screening test and may require further diagnostic tests if the results are abnormal. The FTS combines a maternal blood screening test with a fetal US evaluation to identify risk for Down syndrome (trisomy 21). It can also detect trisomy 13, Turner syndrome, Edwards syndrome (trisomy 18), but not neural tube defects (NTDs). The results of maternal hormone levels and fetal US, along with the mother’s age, are combined to determine risk factors. The following is assessed in the FTS: Maternal serum: Free or total β-hCG, PAPP-A. US at 11–13 weeks gestation: Nuchal translucency (NT)—measurement of ﬂ uid under the baby’s skin at the level of the neck (see Fig- Down (Trisomy 21) ure 4-1). β-hCG ↑ β ↑ ↓ In the case of Down syndrome, -hCG will be and PAPP-A will be . PAPP-A ↓ HIGH-YIELD FACTS The FTS is considered the most accurate noninvasive screening Nuchal translucency ↑ method available, with a sensitivity of 85% for Down syndrome.

Quad Screen

A 19-year-old Caucasian female, G1P0, at 16 weeks gestation based on an unsure LMP has an ↑ risk for Down syndrome on her second-trimester quad screen. Her blood pressure is within normal limits, urine protein is negative, and fetal heart tones are 148 bpm. You palpate the fundal height 2 cm above the umbilicus. What is the most likely cause of the abnormal quad screen? What diagnostic tests can confi rm the screening test? Answer: The most common cause for the abnormal quad screen is incorrect A targeted US evaluates the dates. This patient’s fundal height indicates that her pregnancy is further than fetus for congenital what her LMP indicates. The next step is to perform an ultrasound to confi rm the structural abnormalities Antepartum gestational age of the fetus and recalculate the quad screen. If the quad screen is that may correlate with abnormal serum screening abnormal with correct dating, the patient should undergo genetic counseling and fi ndings. be offered a genetic amniocentesis.

The quad screen is a screening test of maternal serum that evaluates the risk a patient has for delivering a baby with Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), or NTDs. The result does not indicate that the fetus does or does not have the indicated condition, only the risk. If the quad screen Most neural tube defects ↑ shows an risk for any of the screened conditions, further diagnostic tests may are thought to be polygenic be performed to conﬁ rm the ﬁ ndings. See Table 4-2 for a summary of quad or multifactorial. screen results. Ideally performed at 16–18 weeks gestation (range is 15–21 weeks). Sensitivity: 81%. Evaluates four maternal serum analytes: Maternal serum α feto protein Unconjugated estriol Human chorionic gonadotropin Inhibin A

51 FIGURE 4-1. Nuchal translucency measurement.

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. New York: McGraw-Hill, 2010: 351.)

Abnormal quad screen → conﬁ rm dates (US) → genetic counseling + targeted US → diagnostic procedure (amniocentesis to obtain fetal HIGH-YIELD FACTS HIGH-YIELD cells) → karyotype analysis. If there is high α-fetoprotein Most common cause of abnormal quad screen: Incorrect dates. at 16 weeks, a neural tube defect is a likely diagnosis, Maternal Serum α-Fetoprotein (MSAFP) especially if the woman is older than 35. Low MSAFP is ﬁ rst produced in the yolk sac and then by the fetal gastroin- α-fetoprotein is associated testinal tract and liver. with certain chromosomal Normally, it passes by diffusion through the chorion and amnion. It be- defects (eg, trisomy 21 or gins to rise at 13 weeks and peaks at 32 weeks. trisomy 18). In general, MSAFP levels > 2.0–2.5 multiples of the mean (MOM) warrant further investigation, as they are suspicious of NTDs. MSAFP screening is most accurate between 16 and 18 weeks. High levels are associated with: Antepartum Underestimation of gestational age. NTDs. Abdominal wall defects (gastroschisis and omphalocele).

TABLE 4-2. Quad Screen Summary

DOWN (TRISOMY 21) EDWARDS (TRISOMY 18) NTD

uE3 ↓↓Normal

AFP ↓↓↑

β-hCG ↑↓Normal

Inhibin A ↑↓Normal

AFP, α-fetoprotein; β-hCG, β-human chorionic gonadotropin; NTD, neural tube defect; uE3, unconjugated estriol.

52 Fetal death. Placental abnormalities (eg, abruption). Multiple gestations. Others: Low maternal weight, fetal skin defects, cystic hygroma, sac- rococcygeal teratoma, oligohydramnios. Low levels are associated with: Overestimation of gestational age. Chromosomal trisomies: Down syndrome (trisomy 21), Edwards’ syndrome (trisomy 18). Fetal death. Molar pregnancy. High maternal weight.

Unconjugated Estriol (uE3) What can ultrasound Low levels are associated with: determine? Diagnosis of early Trisomy 21 (Down syndrome). pregnancy HIGH-YIELD FACTS Trisomy 18 (Edwards syndrome). Determine if fetus is still Possibly low in trisomy 13 (Patau syndrome). viable in the setting of vaginal bleeding in Human Chorionic Gonadotropin (hCG) early pregnancy High levels are associated with: Trisomy 21. Determination of Low levels are associated with: Trisomy 18, anencephaly. gestational age and assessment of fetal size Diagnosis of fetal Inhibin A malformation (cleft lip, This hormone is secreted the placenta and granulosa cells in the female. polydactyly, club foot, High levels are associated with: Trisomy 21. fetal sex, NTDs, Low levels are associated with: Trisomy 18. abdominal wall defects, abdominal renal

Specialized (Level II) Ultrasound anomalies) Antepartum Placental localization Performed by maternal-fetal specialists. Hydramnios and Evaluates the fetal anatomy for markers of aneuploidy. oligohydramnios See Figures 4-2 through 4-10 for normal and abnormal US ﬁ ndings.

× × ×

FIGURE 4-3. Measurement of biparietal diameter and FIGURE 4-2. Normal four-chamber heart. head circumference

53 FIGURE 4-4. Double-bubble sign of duodenal atresia (marker for Down syndrome). FIGURE 4-5. Anencephaly.

(Reproduced, with permission, from Cunningham FG, (Reproduced, with permission, from Cunningham FG, Leveno Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. New York: New York: McGraw-Hill, 2010: 359.) McGraw-Hill, 2010: 354.) HIGH-YIELD FACTS HIGH-YIELD

A. B.

FIGURE 4-6. A. Cleft lip B. Normal lip. Antepartum

FIGURE 4-7. Measurement of crown-rump length. FIGURE 4-8. Umbilical cord insertion.

54 FIGURE 4-9. Omphalocele. FIGURE 4-10. Gastroschisis.

Amniocentesis HIGH-YIELD FACTS Amniocentesis is the most frequently employed technique used to obtain fetal cells. A needle is placed through the maternal abdominal wall and uterus with ultrasound guidance (see Figure 4-11). Amniotic ﬂ uid is obtained for various purposes. Usually done at 15–20 weeks. Karyotype: Fetal cells obtained via amniocentesis are cultured and an evaluation of the chromosomes is performed in the following circumstances: Fetal anomaly suspected on US. Abnormal serum quad screen. Family history of congenital abnormalities.

Ultrasound transducer Antepartum

Placenta

FIGURE 4-11. Amniocentesis.

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. New York: McGraw-Hill, 2010: 299.)

55 Indicated for patients ≥ 35 years of age because they have a higher risk of aneuploidy. Fetal lung maturity: Usually done near term in order to deliver the baby. Others: Rule out infection, check bilirubin. Risks: Pain/cramping. Vaginal spotting (resolves spontaneously). Amniotic ﬂ uid leakage in 1–2% of cases. Symptomatic amnionitis in < 1 in 1000 patients. Rate of fetal loss is ≤ 0.5% (1 in 200) and is less in experienced hands.

Chorionic Villus Sampling (CVS) CVS is a diagnostic technique in which a small sample of chorionic villi is taken transcervically or transabdominally and analyzed (see Figure 4-12). Typically done between 9 and 12 weeks gestation. Information on fetal karyotype. Biochemical assays or DNA tests can be done earlier than amniocentesis. Complications—0.5–1%: Preterm delivery. PROM. Fetal injury, especially limb abnormalities if performed before 9 HIGH-YIELD FACTS HIGH-YIELD weeks gestation.

DIFFERENCES BETWEEN CVS AND AMNIOCENTESIS CVS: Transvaginal or transabdominal aspiration of precursor cells in the intrauterine cavity. Evaluates chromosomal abnormalities but does not evaluate NTDs. Done at 9–12 weeks. Antepartum

FIGURE 4-12. Transcervical chorionic villus sampling (CVS).

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. New York: McGraw-Hill, 2010: 300.) 56 Higher risks (fetal loss has 1% risk, limb defects if done < 9 weeks), diagnosis accuracy is comparable to amniocentesis. Amniocentesis: Transabdominal aspiration of amniotic ﬂ uid using ultrasound-guided needle. Evaluates chromosomal abnormalities. Done at 15–20 weeks. Indicated if > 35-year-old mother at time of delivery. Risks of fetal loss (0.5%).

Cordocentesis Cordocentesis is also known as percutaneous umbilical blood sampling (PUBS), fetal blood sampling, and umbilical vein sampling. It is a procedure in which a spinal needle is advanced transabdominally under US guidance into a cord vessel to sample fetal blood (see Figure 4-13). Typically performed after 17 weeks. HIGH-YIELD FACTS Allows for rapid diagnosis because of the high number of nucleated cells (WBCs) collected which require no culturing.

Ultrasound transducer

Uterine wall Placenta

Umbilical cord Antepartum

FIGURE 4-13. Cordocentesis.

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed. New York: McGraw-Hill, 2010: 301.)

57 INDICATIONS Fetal karyotyping because of fetal anomalies. To determine the fetal hematocrit in isoimmunization or severe fetal anemia. To assay fetal platelet counts, acid-base status, antibody levels, blood chemistries, etc.

Genetic Testing Advanced maternal age (AMA) is the most common Genetic testing is not required for every pregnancy. There are specifi c circum- indication for prenatal stances where it is appropriate to perform. Certain common genetic muta- genetic testing. tions that are easily screened for can be readily identifi ed using routine scientifi c techniques.

INDICATIONS Advanced maternal age. Chromosomal abnormalities Previous child with abnormal karyotype. occur in 0.6% of all live Known parental chromosome abnormality (balanced translocation or births, account for 5% of point mutation). stillbirths and 50–60% of Fetal structural abnormality on sonogram. spontaneous abortions. Unexplained intrauterine growth retardation (IUGR). Abnormal quad screen.

HIGH-YIELD FACTS HIGH-YIELD TECHNIQUES Fluorescent in situ hybridization (FISH): A specifi c DNA probe with a fl uorescent label that binds homologous DNA; allows identifi cation of specifi c sites along a chromosome. Looks for specifi c abnormalities. Very sensitive. Karyotyping: Allows visualization of chromosome size, banding pattern, and centromere position. Looks for all chromosomal abnormalities, but not as sensitive.

Body Mass Index (BMI) BMI ≥ 30: Obese NUTRITIONAL NEEDS OF THE PREGNANT WOMAN 25.0–29.9: Overweight 18.5–24.9: Normal

Antepartum Proper nutritional habits are important for every woman; this is especially true < 18.5: Underweight for those who are pregnant. ↑ energy needs and speciﬁ c vitamins are required by the mother to supply the appropriate nutrients essential to the normal development of the fetus. Without proper dietary control, certain common deﬁ - ciencies and complications in both mother and baby may occur.

Weight Gain Weight gain in pregnancy: BMI > 25: 15–25 lbs Weight gain for normal BMI: 25–35 lb. BMI normal: 25–35 lbs Weight gain of < 15 lb (unless obese) can cause fetal IUGR. ↑ BMI < 18: 30–40 lbs Weight gain of > 40 lb morbidity. Target weight gain of 1–5 lb in T1; 3–4 lb/month in remaining pregnancy. Risk factors for IUGR: Poor nutrition How do you monitor IUGR? Tobacco smoking Serial ultrasound Drug addiction Alcoholism

58 Severe anemia Thrombophilia Prolonged pregnancy Preeclampsia Chromosomal abnormalities Placental infarction/hematoma Infections Multiple gestations

Diet The average woman must consume an additional 300 kcal/day beyond baseline needs and an additional 500 kcal/day when breast-feeding. High protein (70–75 g/day), low simple carbohydrates and fats, high ﬁ ber.

Folic Acid HIGH-YIELD FACTS

A 32-year-old Hispanic female, G3P2002, at 16 weeks gestation What should be taken to presents for initial obstetric visit. She reports that the last child born 3 prevent NTDs? Folic acid years ago has spina biﬁ da. What is the amount of folic acid she 400 μg/day or 0.4 mg/ should take? day. Answer: Women with a previous child with an NTD should take 4 mg/day of folic acid well before conception.

↑ dietary folate is required to prevent NTDs. 400 μg/day is required. Ideal if started 3 months before pregnancy. If previous child with NTD, need folic acid 4 mg/day, starting 4 weeks The neural tube is nearly prior to conception and through T1. formed by the time of the ﬁ rst missed period. Starting folic acid supplementation Minerals when pregnancy is Antepartum 30 mg elemental iron per day is recommended in T2 and T3. Total diagnosed is too late. of 1 g iron is needed for pregnancy (500 mg for ↑ RBC mass, 300 mg for fetus, 200 mg for GI losses). The recommended dietary allowance (RDA) for calcium is ↑ in pregnancy to 1200 mg/day and may be met adequately with diet alone. The RDA for zinc is ↑ from 15 to 20 mg/day.

Vegetarians Pregnant women develop Lacto-ovovegetarians in general have no nutritional defi ciencies, ex- iron defi ciency anemia due ↑ cept possibly iron and zinc. to the hematopoietic Vegans must consume suffi cient quantities of vegetable proteins to pro- demands of both mother vide all essential amino acids normally found in animal protein. Sup- and baby. plementation of zinc, vitamin B12, and iron is necessary.

59 Pica Occasionally seen in pregnancy, pica is the compulsive ingestion of nonfood substances with little or no nutritional value, such as ice, clay (geophagia), or starch (amylophagia). Pica may occur during pregnancy, but all normal dietary and nutritional COMMON QUESTIONS needs must be met and the substances consumed Pregnancy is a complicated time for most women. Their bodies undergo a should be nontoxic (ice). transformation which entails many physiologic adaptations. These changes Advise patients against the may be alarming to some women, and as a physician, one must be able to dis- consumption of nonedible cern between normal pregnant physiology and pathophysiologic changes, and possibly toxic items, which may require further investigation or immediate attention in a hospital such as dirt. setting.

Caffeine in Pregnancy Contained in coffee, tea, chocolate, cola beverages. Ingestion of caffeine (> 300 mg/d) may ↑ risk of early spontaneous abortion among nonsmoking women carrying fetuses of normal karyotype. This risk ↑ according to amount of caffeine ingested. Adverse maternal effects include: Insomnia HIGH-YIELD FACTS HIGH-YIELD Acid indigestion Reﬂ ux Urinary frequency

Exercise No data exist to indicate that a pregnant woman must ↓ the intensity of her exercise or lower her target heart rate. Women who exercised regularly before pregnancy should continue. Exer- cise may relieve stress, ↓ anxiety, ↑ self-esteem, and shorten labor. The form of exercise should be one with low risk of trauma, particularly abdominal (water exercises are ideal). Exercise that requires prolonged time in the supine position should be Antepartum avoided in T2 and T3. Exercise should be stopped if patient experiences oxygen deprivation Hyperemesis gravidarum: (manifested by extreme fatigue, dizziness, or shortness of breath). Contraindications to exercise include: Excessive vomiting during Evidence of IUGR. pregnancy + dehydration + Persistent vaginal bleeding. electrolyte imbalances. A Incompetent cervix. hypochloremic alkalosis Risk factors for preterm labor. may occur. What is the Rupture of membranes. treatment? IVF 5% Pregnancy-induced hypertension/preeclampsia/eclampsia. dextrose, antiemetics. Nausea and Vomiting (N&V) Recurrent N&V in T1 occurs in 50% of pregnancies. If severe, can result in dehydration, electrolyte imbalance, and malnutri- tion. Management of mild cases includes: Avoidance of fatty or spicy foods.

60 Eating small, frequent meals. Inhaling peppermint oil vapors. Drinking ginger teas. Management of severe cases includes: IV fl uids (usually with dextrose-containing fl uid). Discontinuation of vitamin/mineral supplements until symptoms sub- Why is dextrose included in side. the IV fl uid for hyperemesis Antihistamines. gravidarum? The dextrose Promethazine. helps to ↓ the ketosis, Metoclopramide. which can cause a vicious Intravenous droperidol. cycle of nausea. Dextrose can help break the cycle. Heartburn “Morning sickness” can occur day or night. Occurs in 30% of pregnancies. Etiology: Normal relaxation of lower esophageal sphincter Mechanical forces HIGH-YIELD FACTS Treatment: Elimination of spicy/acidic foods. Small, frequent meals. Pregnancy is a Decreasing amount of liquid consumed with each meal. Limiting food and liquid intake a few hours prior to bedtime. hypercoagulable state, and ↑ Sleeping with head elevated on pillows. there is an in clotting factor levels. Utilizing liquid forms of antacids and H2-receptor inhibitors.

Constipation Common in pregnancy. Management: Increasing intake of high-ﬁ ber foods. Hypercoagulable state and Increasing liquids. mechanical compression of

Use of psyllium-containing products (eg, Metamucil). Antepartum venous blood fl ow from the Avoid enemas, strong cathartics, and laxatives. lower extremities cause increased risk of Varicosities thrombosis. Common in pregnancy, particularly in lower extremities and vulva. Can cause chronic pain and superfi cial thrombophlebitis. Management: Avoidance of garments that constrict at the knee and upper leg. Use of support stockings. ↑ periods of rest with elevation of the lower extremities. Most hemorrhoids improve after delivery. Hemorrhoids Varicosities of the rectal veins are common in pregnancy. Management: Cool sitz baths. Stool softeners. ↑ fl uid and fi ber intake to prevent constipation. Hemorrhoidal ointment to ↓ swelling, itching, and discomfort. Hemorrhoidectomy can be Topical anesthetic spray or steroid cream for the severe pain of thrombosed hemorrhoids. performed safely during pregnancy if necessary.

61 Leg Cramps Occur in 50% of pregnant women, typically at night and in T3. Most commonly occur in the calves. Massage and stretching of the affected muscle groups is recommended.

Backache Typically progressive in pregnancy (30–50%). Management: Minimizing time standing. Wearing a support belt over the lower abdomen. Acetaminophen for pain as needed. Exercises to ↑ back strength. Supportive shoes and avoidance of high heels. Gentle back massage.

Round Ligament Pain Sharp, bilateral or unilateral groin pain. Frequently occurs in T2. May ↑ with sudden movement/change in position. May be alleviated by patient getting on hands and knees with head on ﬂ oor and buttocks in air. HIGH-YIELD FACTS HIGH-YIELD Sexual Intercourse There are no restrictions during the normal pregnancy. Nipple stimulation, vaginal penetration, and orgasm may cause release of oxytocin and prostaglandins, resulting in uterine contractions. Contraindications: Ruptured membranes Placenta previa Preterm labor

Employment

↑ Antepartum Work activities that risk of falls/trauma should be avoided. Exposure to toxins/chemicals should be avoided.

Travel The best time to travel is in T2. Past possible complications of miscarriage in T1 and not yet encountered risk of preterm labor of T3. If prolonged sitting is involved, the patient should attempt to stretch her lower extremities and walk for 10 min every 2 hr. This is to avoid DVTs. The patient should bring a copy of her medical record. Wear seat belt when riding in car. Airplane travel in pressurized cabin presents no additional risk to the pregnant woman (if uncomplicated pregnancy). Air travel is not recommended after 35 weeks. In underdeveloped areas or when traveling abroad, the usual precau- tions regarding ingestion of unpuriﬁ ed water and raw foods should be taken. Appropriate vaccines should be given.

62 Immunizations (Table 4-2) General principles: Delay vaccines until after the ﬁ rst trimester to avoid potential teratoge- nicity. Risk from vaccines is generally small. Always consider whether risk of Ideally, women should the disease is worse than the risk of the vaccine. avoid getting pregnant for Live vaccines are not given in pregnancy. 4 weeks after receiving live Viral vaccines may be safely given to the children of pregnant women. vaccines, such as measles, Immune globulins are safe in pregnancy and are recommended for mumps, rubella (MMR) or women exposed to measles, hepatitis A and B, tetanus, varicella (chick- varicella. enpox), and rabies.

NOTIFY THE PHYSICIAN

While many physiologic changes in pregnancy are uncomfortable, most are HIGH-YIELD FACTS nonemergent. There are, however, some situations when a pregnant woman should contact her obstetrician immediately: Vaginal bleeding. Leakage of ﬂ uid from the vagina. Rhythmic abdominal cramping or back pain, > 6/hr that does not improve with hydration and lying supine. Progressive and prolonged abdominal pain. Fever and chills. Dysuria or abnormally cloudy urine (indicative of a urinary tract infection). Prolonged vomiting with inability to hold down liquids or solids for > 24 hr. Progressive, severe headache; visual changes; or generalized edema (preeclamptic symptoms). Seizure (eclampsia). Pronounced ↓ in frequency or intensity of fetal movements. Antepartum

TABLE 4-2. Vaccine Safety in Pregnancy

NOT WELL STUDIED IN PREGNANT ADMINISTER ONLY WOMEN, SO DEFER UNTIL FURTHER IF RISK OUTWEIGHS SAFE RECOMMENDATIONS ISSUED BENEFIT UNSAFE (LIVE)

Inactivated polio Human papillomavirus (HPV) Yellow fever Oral polio (IPV) Meningococcus (MPV4) Anthrax Oral typhoid Inactivated typhoid Pneumococcus (PPV) Pertussis Intranasal inﬂ uenza Inactivated inﬂ uenza Hepatitis A Measles, mumps, Diphtheria rubella (MMR) Tetanus Varicella Rabies Bacillus Calmette- Meningococcus Guérin (BCG) (MPSV4) Shingles Hepatitis B

63 NOTES HIGH-YIELD FACTS HIGH-YIELD Antepartum

64 CHAPTER 5 Intrapartum

Three Stages of Labor 67 FIRST STAGE 67

SECOND STAGE 68

THIRD STAGE 68 True Labor Versus False Labor 68 Assessment of Patient in Labor 69 HISTORY 69

VAGINAL EXAM 69

RUPTURE OF MEMBRANES 69

CERVICAL EXAM 71

BISHOP SCORE 72 Assessment of the Fetus 73 LEOPOLD MANEUVERS 73

NORMAL PRESENTATION 74

MALPRESENTATIONS 75 Cardinal Movements of Labor 77 ENGAGEMENT 77

DESCENT 77

FLEXION 77

INTERNAL ROTATION 77

EXTENSION 77

EXTERNAL ROTATION (RESTITUTION) 79

EXPULSION 79 Normal Spontaneous Vertex Vaginal Delivery 79 DELIVERY OF THE HEAD 79

CHECKING FOR NUCHAL CORD 79

DELIVERY OF SHOULDERS 79

DELIVERY OF THE INFANT 79

DELIVERY OF THE PLACENTA 80

INSPECTION 80

PERINEAL LACERATIONS 80

EPISIOTOMY 81

POSTDELIVERY HEMOSTASIS 81

65 Management of Patients in Labor 81 VAGINAL EXAMS 81

MATERNAL VITAL SIGNS 82

OTHER CONSIDERATIONS 82 Monitoring During Labor 82 UTERINE CONTRACTIONS 82

FETAL HEART RATE 82 Fetal Heart Rate Patterns 82 DEFINITIONS 83

DECELERATIONS 83

FETAL TACHYCARDIA 85

BEAT-TO-BEAT VARIABILITY 86

SHORT-TERM VARIABILITY 86

LONG-TERM VARIABILITY 86 Abnormal Labor Patterns 86 DYSTOCIA 86 Pelvic Shapes 87 Induction of Labor 88 INDICATIONS 88

CONTRAINDICATIONS 89

CONFIRMATION OF FETAL MATURITY 89

INDUCTION METHODS 89 Cesarean Delivery 90 TYPES 90

INDICATIONS 90 Trial of Labor After Cesarean 91 CANDIDATES FOR TOLAC 91

CONTRAINDICATIONS TO TOLAC 91 Operative Vaginal Delivery 91 FORCEPS DELIVERY 91

VACUUM DELIVERY 92 Pain Control During Labor and Delivery 92 LOWER GENITAL TRACT INNERVATION 92

NONPHARMACOLOGICAL METHODS OF PAIN CONTROL 92

INTRAVENOUS ANALGESIA AND SEDATION 92

LOCAL ANESTHESIA 93

REGIONAL ANESTHESIA 93

GENERAL ANESTHESIA 94

66 HIGH-YIELD FACTS Intrapartum Power (strength and frequency of contractions) Passenger (size of the baby) Pelvis (size and shape pelvis) of mother’s Labor is deﬁ ned as Labor is deﬁ contractions resulting in cervical change. Remember the three “Ps” that affect the duration of the active phase of labor: Duration of labor is Duration of in the typically shorter in multiparous woman than nulliparous women. of There are three stages phases of and two labor, stage 1. -

t ar p ing t resen p of t en c es D +4 +3 +2 +1 0 16 y

age t s nd co Se

14 Deliv

ase ph n o i t era l e c e D

e lop s m u im x ma of ase Ph

e phase

ase ph

Activ n o i t era

l- e cc A 8642 Hours of labor First stage Latent phase Progression of labor. rst stage of uterine contractions of sufﬁ of labor begins with onset rst stage phases: of labor consists of two A 25-year-old Hispanic female, G1P0, at 38 weeks gestation presents to gestation presents weeks at 38 female, G1P0, Hispanic A 25-year-old increasing in strength that have been of contractions triage complaining She denies vaginal period. leakage bleeding, over a 12-hr and frequency approximately 4 cm cervical dilation. 8 6 4 2 0 cient frequency, intensity, and duration to result in effacement and dila- intensity, frequency, cient the cervix is fully/completely dilated tion of the cervix, and ends when to 10 cm.

1.ends at Latent phase: Begins with the onset of labor and

She is in the active phase of the ﬁ rst stage of labor. Since she is a of labor. rst stage phase of the ﬁ Answer: She is in the active

The fi The The fi The ) m (c n o i t a t a l di l a c i v er C of fl uid and preeclampsia symptoms. She reports preeclampsia symptoms. uid and movement. Fetal good fetal of fl Her cervical heart contracting every 2 min on the monitor. rate is reassuring. She is of stage 0 station, cephalic by sutures. What effaced, 50% exam is 6 cm dilated, labor progresseslabor is she in? If her cervical dila- as expected, what should her tion be at the next vaginal in 2 hours? exam in 2 hours, So, primigravida, dilate at a minimum of 1.2 cm/hr. her cervix should (or 8–9 cm) dilated. she should be 8.4 cm THREE STAGES OF LABOR OF THREE STAGES (Reproduced, with permission, from DeCherney AH, Pernoll ML. Current Obstetrics & Gyne- from DeCherney AH, Pernoll (Reproduced, with permission, 211.) Appleton & Lange, 1994: Norwalk, CT: cologic Diagnosis & Treatment. FIGURE 5-1. First Stage Labor is defi ned as contractions that result in cervical change. The progres- ned as contractions Labor is defi 5-1. sion of labor is illustrated in Figure Intrapartum HIGH-YIELD FACTS . Fundus ofuterusrises 3. 2. Umbilical cord Gushofblood 1. placental separation? What arethethreesignsof placenta mayberequired. manual removalofthe without placentalextrusion, If 30minhavepassed a multipara). nullipara and<2cm/hrin descends <1cm/hrina descent (thefetalhead protraction orarrestof stage maybeeither Abnormalities ofthesecond should bedone. cephalopelvic disproportion malposition, or contractions, fetal for adequacyofuterine these fi gures,evaluation active phaseisslowerthan If progressduringthe and fi rms lengthening that shorten Relieved bymedications Occuratregularintervals No cervicalchange Discomfort inlower abdomen Intensity remainsthesame TrueOccur atirregularintervals Labor False Labor(Braxton HicksContractions) membranes. placental and ately afterthedeliveryoffetusandendswithfetal separation.Itbeginsimmedi- isplacental The maineventofthethirdstage Third Stage A cervix isfullydilated andendswiththe delivery ofthefetus. expulsion.Itbeginswhenthe offetal oflaboristhestage The secondstage Second Stage 68 TRUE LABOR VERSUS FALSE VERSUS LABOR TRUE LABOR VERAGE The three signs of placental separationare: Thethreesignsofplacental Duration: Multiparous:<1hr(2withepidural) Nulliparous:<2hr(3withepidural) Fundusoftheuterusrisesupandbecomesfi 3. Umbilicalcordlengthening. 2. Gushofbloodfromvagina. 1. 2. Active phase: Rapiddilation. Beginsat4cmdilation andendsat10 P cm. Average durationofcervicaldilation from4to10cm(minimal nor- Fetal descentbeginsat7–8cmofdilation innulliparas andbe- Activephaseisfurtherclassifi ed according totherateofcervicaldi- Multiparous:Prolongedif>14hr. Nulliparous:Prolongedif>20hr. TENOF ATTERN mal rate): comes mostrapidafter8cm. eration phase. lation: Multiparous:<1.5cm/hr Nulliparous:<1.2cm/hr Usually <10minutes; consideredprolongedif>30minutes. Acceleration phase,phaseofmaximum slope,anddecel- F ETAL D ESCENT Not relievedbymedications Cervix dilates lower abdomen Discomfort inbackand ↑ inintensity rm. HIGH-YIELD FACTS Intrapartum Trichomonas vaginalis Trichomonas infections with Vaginal Blood Semen ~500 cc Vaginal: Cesarean: ~1000 cc What can cause a false- positive nitrazine test? Diagnosis of ROM history alone The patient’s is correct in 90% of patients. Urinary leakage or excess vaginal discharge can be mistaken for ROM. Blood supply to the uterus Blood supply and ovarian from uterine arteries. Normal blood loss for deliveries: 69 uid. rst if: rst A 25-year-old G1P0 at 39 weeks presents to labor and delivery triage weeks presents to labor and G1P0 at 39 A 25-year-old uid from the vagina leak- followed by constant complaining of a gush of fl tests can help deter- What uid is clear and without odor. fl The age for 2 hr. should be noted (positive pooling). uid is seen to come through the cervical os Note if fl manuever. (positive Valsalva). per quadrant pain). per quadrant undergo a cesarean delivery). (mostly in case the patient needs to of blood mixed with cervical mucus that is present with cervical dila- that mucus with cervical of blood mixed from vaginal bleed- It should be distinguished tion and effacement. ing. gush of fl uid with continuous leakage. Color may be clear or yellow/ continuous uid with gush of fl green (meconium). Rupture of membranes is suspected. The patient is in preterm labor. for placenta suspicious previa is present. Bleeding right up- of preeclampsia (headache, visual disturbances, Symptoms History of allergies. much how and ago patient consumed food or liquids long How Use of medications. is small amount show Bloody bleeding. Presence/absence of vaginal Notation of fetal activity. contractions. of frequency of onset and Time Status history for ruptured membranes: of fetal membranes. Typical patient: (H&P), and those with prenatal care require an update and focused an update and those with prenatal(H&P), and care require Prenatalphysical. be obtained record should when possible. 1. uid collection in the posterior fornix The presence of fl Pooling: Valsalva and perform a Ask the patient to bear down 2. Valsalva: Answer: Perform fern- a sterile speculum exam, testing for pooling, valsalva, speculum exam: a sterile Perform Otherwise, a sterile digital VE may be performed. a sterile speculum exam fi Perform should always be obtained information The following from a laboring physical history and a complete without prenatal require care Patients uid? ing, and nitrazine. If these are positive, the membranes are likely ruptured and the ing, and nitrazine. If these are positive, the membranes are likely ruptured and uid noted on the exam is likely amniotic fl fl mine whether the patient has ruptured the membranes and the fl uid is amniotic mine whether the patient has ruptured the membranes and the fl fl ASSESSMENT OF PATIENT IN LABOR IN PATIENT OF ASSESSMENT Rupture of Membranes Vaginal Exam (VE) Vaginal History Intrapartum HIGH-YIELD FACTS time ofbirth. discharged atornearthe in thefetalintestinesandis fecal materialthatcollects Meconium: the termfetus. normally coverstheskinof and sebaceousmatterthat desquamated epithelialcells substance consistingof Vernix: Thefatty course ofactivelabor. often occursduringthe membranes (SROM)most Spontaneous ruptureof A darkgreen 70 5-2. FIGURE Fluidshouldalsobeexamined formeconium. Thepresenceofpooling,valsalva,ferning, andnitrazine indicates that .Nitrazine:Placethevaginalfluid onnitrazine papertoassessthe 4. .Ferning: Placeathinlayerofthefluid onaslide.Viewthedried 3. amniotic fl the membranesarelikelyrupturedandfl uid notedontheexamis Meconium ismorecommonintermandposttermpregnan- staining Thepresenceofmeconium intheamniotic fl uid mayindicate fetal cies thaninpretermpregnancies. stress. tion postpartum. vent MASviaamnioinfusion nasopharynxsuc- intrapartumandfetal which bypassesthelungsinordertoprovideoxygenbaby. Pre- fants withMASmayrequire extracorporeal membranousoxygenation oxygenation duetothelunginjuryandpulmonaryhypertension.In- velop pulmonaryhypertension.Intubationdoesnotprovideadequate At birth,theinfantwillpresentwithrespiratorydistress andcande- lungs,causinglungdamage. the meconium isinhaled intothefetal leads tomeconium in theamniotic fl gasping, uid. Withfurtherfetal Meconium aspiration syndrome(MAS): secretions thathaveacidic pH.Confirms ROMin90–98%ofcases. nitrazine). Amniotic fluid hasbasicpH ascomparedtovaginal pH. Ifnitrazine paperturnsblue,thisindicates basicpH(positive Figure 5-2). fluid (positiveferning). Confi rms ROMin85–98%ofcases(see sodiumpattern madebythecrystallized chlorideinamniotic amniotic fluid underamicroscope fora characteristicferning Ferning pattern. uid. Fetal stress,likehypoxia, HIGH-YIELD FACTS Intrapartum Know this cervical exam stuff cold for the wards! 71 is at the level

When the cervix shortens by 50% (to around 2 cm), it is When the cervix shortens by 50% Ranges from zero to 10 cm dilated (closed to completely di- to 10 cm dilated Ranges from zero divided into thirds. Above the ischial spines are stations into thirds. –3, –2, and divided the furthest above the ischial spines and –1 being –1, with –3 being stations describe fetalclosest. Positive the ischial descent below spines. +3 station and +1 is just past is at the level of the introitus, the ischial spines. Above centimeters, up to 5 cm above and 5 cm below. by are divided ve stations –5 being or centimeters: –5, –4, –3, –2, and –1, with are fi 1 cm above. Positive the 5 cm above the ischial spines and –1 being stations describe fetal the ischial spines. +5 station descent below is past the ischial spines. and +1 is 1 cm at the level of the introitus, of the ischial spines, the station is 0. the biparietal diameter (BPD), not the tip top of the head, which may the biparietal (BPD), not the tip top of the head, which may diameter simply be caput and not the head at all. So when the BPD length from the internal to external os. length from the internal to external said to be 50% effaced. When the cervix becomes as thin as the adja- said to be 50% effaced. When the uterine segment, it is 100% effaced. cent lower serted in the cervical opening and are separated as far as the cervix will and are separated as far as the opening serted in the cervical esti- ngers is two fi between the The distance (cervical dilation) allow. mated. lated). The presenting part of a term-sized infant can usually pass part of a term-sized infant lated). The presenting is fully dilated. through a cervix that 1. zero station, The ischial spine is are above and below and the areas 2. the ischial spines except that the areas above and below similar Very If the fetus is vertex, the station by the location of should be determined (two systems): Terminology Terminology: the nger and estimate fi with of effacement: Palpate Determination Ranges: ngers are infi the middle of dilation: The index and/or Determination ILATION TATION FFACEMENT Cervical Exam Cervical of the presenting part in relation to ischial Describes the degree of descent of the presenting part in relation spines, which are designated at 0 station. With labor, the cervix thins out and soft- With labor, the cervix Describes the length of the cervix. normal length is 3–4 cm. ens, and the length is reduced. The D os. at the external of the cervix the size of the opening Describes There are fi ve parameters of the cervix that are examined: dilation, efface- dilation, are examined: that of the cervix ve parameters fi There are and position. ment, station, consistency, S E Intrapartum HIGH-YIELD FACTS Labor-inducing agents: of contractions. strength andfrequency IV pitocinisusedto↑ (softening) ofcervix. inserted forripening prostaglandins are Vaginal rior. During labor,thecervicalpositionusuallyprogressesfromposteriortoante- TABLE 5-1. able orunfavorable—forsuccessfulvaginaldelivery. ofthecervix—favor- This isascoringsystemthathelpstodetermine thestatus Bishop Score classified asoneofthefollowing: presenting part.Itis Describes thelocationofcervixwithrespecttofetal P labor. vix progressivelyfromfi rm tomedium tosoft,inpreparationfordilation and Breakdown ofcollagenbondsinthecervixchangesconsistencycer- C 72 a Station refl ects –3to+3 scale. OSITION ONSISTENCY Consistency Position in spontaneouslabor. induction oflabor. deliveryissimilartothosewhopresent Herchanceofvaginal delivery? successful vaginal anterior position,andsoft.What isherBishopscore?What isthelikelihoodofa Dilation (cm) Station Effacement (%) Ascoreof≥6indicates thattheprobabilityofvaginal deliverywithin- Ifinductionoflaboris indicated,ofthecervixmust thestatus beevalu- Answer: HerBishopscoreis9showingthatshehasafavorablecervixfor duction of labor is similar to that of spontaneous labor.duction oflaborissimilar tothatofspontaneous lized. SeeTable 5-1andsectiononLaborInduction. ated tohelpdetermine themethodoflaborinductionthatwillbeuti- Anterior: Easytopalpate,low inpelvis. Midposition. and usuallyhighinthepelvis. Posterior: Diffi cult topalpatebecauseitisbehindthepresentingpart, a presentation. Hercervicalexamis3cmdilation,70% effaced,–2station, induction. Herdatesareverifi ed, andtheinfantisnotedtobecephalic A 26-year-old G2P1001 at41 weekspresentstothehospitalforan F BishopScoringSystem ACTOR –3 Firm otro ipsto neir— Anterior Midposition Posterior lsd1–2 Closed 3 0–060–70 40–50 0 –30 0 P OINTS –2 eimSoft Medium 1 P OINT 1t +1to+3 –1 to0 3–4 2 P OINTS — ≥ 80 ≥ 5 3 P OINTS HIGH-YIELD FACTS Intrapartum 73 Leopold maneuvers. answers the question: “On which side is the ce- “On which answers the question: maneuver Fourth phalic prominence?” answers the question: “What fetal “What part occupies the maneuver answers the question: First fundus?” side is the fetal “On what answers the question: Second maneuver back?” “What fetal part lies over the maneuver answers the question: Third pelvic inlet?” Position Attitude Lie Presentation way the baby is presenting in the uterus. (Figure 5-3). Consist of four 5-3). Consist in the uterus. (Figure baby is presenting way the parts: from the Leopold maneuvers: aspects of the fetus are described Four which pregnancy to determine are begun in late maneuvers Leopold ASSESSMENT OF THE FETUS THE OF ASSESSMENT Leopold Maneuvers Leopold FIGURE 5-3. Handbook of Obstetrics ML. Benson & Pernoll’s from Pernoll (Reproduced, with permission, 2001: 159.) McGraw-Hill, and Gynecology, 10th ed. New York: Intrapartum HIGH-YIELD FACTS head invariouspositions. birth canalwiththefetal represents themother’s mom’s legs.Figure the bedlookingbetween body. You areattheendof occiput inrelationtoher in stirrups)andthebaby’s position (onherback,legs in thedorsallithotomy Imagine themotherlying Positions Interpreting Fetal triangle shape Posterior fontanel:Smaller diamond shape Anterior fontanel:Larger 5-4 A P spine, neck,andface. (“attitude/habitus”), whichtypicallydescribestheposition ofthearms,legs, In thelatermonthsofpregnancy, thefetusassumesacharacteristicposture (P). the birthcanalanditsdirection anteriorly (A),transversely(T),orposteriorly Refers totherelationofpresentingpartright(R)orleft(L)side normally determined bypalpatingthroughthecervixonvaginalexamination. Describes theportionoffetusthatisforemostwithinbirthcanal.It P breech (buttocksfirst). Theliemaybetransverseoroblique. longitudinal (99%oftermornear-termbirths)liecanbevertex(headfi Lie describestherelationoflongaxisfetustothatmother. A L 74 V Normal Presentation the fetal skullthathastopassthroughthe pelvis. the fetal isthepresentingpart.This createstheshortestdiameterposterior fontanel of tions). Theheadisfl withthechest.The exed sothatthechinisincontact Vertex ismostcommon (96%oftermornear-termpresenta- presentation IE OSITION RESENTATION ERTEX TTD AND TTITUDE fetal skulliscomposedoffi Thetopofthefetal twopari- ve bones:twofrontal, The For theocciputisusedasreferencepoint acephalicpresentation, Ifthelieistransverse,shoulder,back,orabdomenmaybepre- Ifthelieislongitudinal,either thehead(cephalic), thepresentation etal meet the occipital bone. meettheoccipital etal lieswherethetwopari- meet,andtheposteriorfontanel and twoparietal lieswherethetwofrontal Theanteriorfontanel andoneoccipital. etal, crum to determine theposition: senting part. presenting part. isthe inwhichtheposteriorfontanel tion isthevertexpresentation buttocks (breech),brow, orface.Themostcommontypeofpresenta- P Rightocciput transverse(ROT) Rightocciput posterior(ROP) Rightocciput anterior(ROA) Leftocciput transverse(LOT) Leftocciput posterior(LOP) Leftocciput anterior(LOA) Occiput posterior(OP) Occiput anterior(OA) RESENTATION chin The isusedasthereferencepoint forfacepresentation. is usedasthereferencepoint forbreechpresentation. /P P OSTURE RESENTING (O CCIPUT P ART P RESENTATION ) rst) or sa- HIGH-YIELD FACTS Intrapartum anterior position. Vaginal deliveryVaginal is possible only if the fetus is mentum anterior; mentum posterior cannot deliver vaginally— must be delivered by cesarean section. Ninety percent of babies presenting in the occiput posterior position spontaneously rotate to occiput 75 rst. This ROT ROP ROA rst. OP OA LOA LOP Vertex positions. Vertex RESENTATION LOT P RESENTATION RESENTATION P P INCIPUT ROW ACE FIGURE 5-4. Malpresentations B vaginal delivery is possible through the pelvis; usually, forces a large diameter only if the presentation is converted to a face or vertex presentation. The fetal present fi a position such that the eyebrows head assumes The fetal a position between vertex presentation head assumes and face presentation fontanel so that the anterior presents fi S In face presentation of presentations (0.3% at or near term), the fetal neck is is in contactsharply extended so the occiput with the fetal back. The face is the presenting part. Diagnosis is made by palpation of the fetal face on vaginal exam. F Intrapartum HIGH-YIELD FACTS ham FG,LevenoKJ,BloomSL, etal.Williams 23rded.NewYork: Obstetrics, McGraw-Hill, 2010:528–529.) A. Frank breech.B. 5-5. FIGURE A signifi cant. uncommon andnot weeks, malpresentationnot breech. Note:If<34 version ifpersistent attempt externalcephalic at 36weeksandthen Recheck fetalpresentation What’s yournextstep? a breechpresentation. at 31weeksgestationwith A pregnantwomanpresents Types ofbreechpresentations. Complete breech.C.Incompletebreech(singlefootling). (Reproduced,withpermission, from Cunning- T D R proaches. converttovertex astermap- in earlypregnancywilloftenspontaneously 3.5% atorneartermbutmuch greaterinearlypregnancy(14%).Thosefound partisthe thepresentingfetal In breechpresentations, B 76 PSOF YPES REECH ISK IAGNOSIS F Incomplete(footling)breech(10%):Oneorbothofthehipsarenot Frank breech(65%):Thethighsarefl Vaginal exam Ultrasound Leopold maneuvers Multiparity. Hydramnios, oligohydramnios. Placenta previa. Multiple gestation. Uterine anomalies. anomaliessuchashydrocephalusoranencephaly. Congenital Low birthweight (20–30%ofbreeches). ACTORS flexed sothatafootliesbelow thebuttocks. and thekneesareflexed (folded)aswell. Complete breech(25%):Thethighsarefl front oftheheadorface). are extended(straight)overtheanteriorsurfacesofbody(feetin P B RESENTATIONS B REECH ( SEE F IGURE 5-5) C exed (bentforward)andknees exed(bent)ontheabdomen buttocks. Incidence: HIGH-YIELD FACTS Intrapartum Engagement is determined by palpation of the presenting part of the occiput. The fundal height ↓ at term due to engagement of the fetus. Complete and incomplete Complete and incomplete breeches are not delivered vaginally due to risk of umbilical cord prolapse. 77 exed to exed ETUS F EMENTS OF LABOR OF EMENTS REECH B margin of the symphysis pubis, where the birth canal curves upward. nally. nally. abdomen. the maternal pressure through position by applying cephalic labor and the before onset of is diagnosed only if breech Can be done gestational rate is 50%, and the risks age is 35–37 weeks. The success are placental abruption, fetal heart rate abnormalities, and reversion. the extended position, curving under and past the pubic symphysis. The delivery of the fetal head occurs when it changes from the fl Occurs after the fetus has descended to the level of the maternal vulva. into contact action brings the base of the occiput This with the inferior via cesarean. is the delivery frequently, Most vagi- may deliver ideal conditions positions with other breech Frank the infant to a that maneuvers version: Procedure cephalic External ANAGEMENT OF CARDINAL MOV Extension the fetal toward back: Extension moves the occiput Internal Rotation Internal the sym- gradually toward occiput of the head that moves the Refers to turning of the sacrum. the hollow physis pubis or less commonly toward Flexion to the fetalOccurs when the chin is brought close This passive motion thorax. facilitates of the fetal the presentation diameter head of the smallest possible to the birth canal. Descent Occurs when the fetal into the pelvis. It occurs in a discon- head passes down The greatest rate of descent is in the deceleration phase of fashion. tinuous rst stage of labor and during the second stage of labor. the fi Engagement of the (the largest transverse diameter The descent of the biparietal diameter fetal Can occur in late head, 9.5 cm) through the plane of the pelvic inlet. part is at 0 station, if the presenting Clinically head the pregnancy or in labor. is thought to be engagd in the pelvis. The cardinal movements of labor are movements of the fetal movements of labor head that allows The cardinal engagement, as follows: the birth canal. The movements are it to pass through rotation,exion, internal and external rotation extension, (restitu- descent, fl (see Figure 5-6). the shoulders follows tion). Delivery of M Intrapartum HIGH-YIELD FACTS 78 Obstetrics, 22nded.NewYork:McGraw-Hill,2005:418.) (Reproduced, withpermission,fromCunninghamFG,Leveno KJ, BloomSL,etal.Williams FIGURE 5-6. Cardinal movementsoflabor. HIGH-YIELD FACTS Intrapartum Respirations Grimace Tone Color Pulse Squeeze the bulb between rst, then place in ngers fi fi fetal mouth/nares. Know your Apgar scores: Assigns score of 0–2 for the following: The anterior shoulder is the The anterior to the superior one closest the vagina, portions of shoulder while the posterior the perineum is closest to and anus. Fundal pressure should a never be used to relieve shoulder dystocia. 79 nger should NAL DELIVERY EOUS VERTEX VAGI VERTEX EOUS gentle upward traction is applied to deliver the posterior shoulder. ngers of one hand on the occiput as it is seen passing under the as it is seen passing hand on the occiput ngers of one ward traction is applied until the anterior shoulder descends from under the pubic arch. The sides of the head are grasped with both hands and gentle down- Next, care not to grasp the throat. tation spontaneously. and are delivered if loose enough, the cord should be slipped over the infant’s head. slipped over the infant’s if loose enough, the cord should be between two clamps. squeeze the bulb fi rst, place it inside the baby, then release. rst, place it inside the baby, fi the bulb squeeze a fi delivery of the head, following check for this condition, be passed along the fetal neck to ascertain the presence of the cord. episiotomy. Performing an episiotomy may create more room for the fe- Performing episiotomy. tus to deliver. to the left or the right. symphysis pubis to control the delivery of the head and avoid lacera- of the head and avoid symphysis pubis to control the delivery tions. The rest of the infant is delivered with maternal pushing. taking head with one hand by grasping the neck, Support the infant’s delivered with the other hand. buttocks as they are Support the infant’s external ro- the shoulders appear at the vulva just after Most frequently, be extracted: the shoulders must Occasionally, If nuchal cord is present, a fi slipped under the cord and, nger should be a fi cord is present, If nuchal neck, it should be cut tightly around the infant’s If the cord is wrapped Bulb suction the infant’s mouth fi rst, then the nares. Remember to rst, mouth fi Bulb suction the infant’s fetal Occurs when loops of umbilical cord wrap around the neck. To to assess for the need of an Evaluate the posterior vagina and perineum either head will deliver and restitute effort, the infant’s With maternal Place fi Place NORMAL SPONTAN Delivery of the Infant Delivery of Shoulders Checking for Nuchal Cord Delivery of the Head After external rotation,the brings the anterior shoulder to further descent under the pubic sym- symphysis. The shoulder is delivered level of the pubic delivered. rest of the body is quickly physis, and then the Expulsion Occurs after delivery of the head, when the fetus resumes its normal “face-for- fetus resumes its head, when the delivery of the Occurs after shoul- the same plane. One spine lying in and with the occiput ward” position and the other is posterior. symphysis, behind the pubic der is anterior External Rotation (Restitution) Rotation External Intrapartum HIGH-YIELD FACTS rectovaginal fi stula. fecal incontinenceand essential topreventfuture degree lacerationis Proper repairoffourth- vein inthecord. arteries andoneumbilical There aretwoumbilical inversion mayoccur. uterine occurred; otherwise, placental separationhas never beforcedbefore should Placental delivery delivery. within 5minofinfant separation typicallyoccur Signs ofplacental spontaneous lacerationstothevagina,labia,perineum,andrectum. spontaneous The perineumandanus becomestretched andthin,whichresultsin↑riskof Perineal Lacerations to berepaired.Lookat: Inspect patientforanylacerationsorextensionsofepisiotomythatmayneed Inspection Delivery ofthePlacenta 80 Second degree: First degree: Involvethefourchette,perinealskin,andvaginalmucosa, Perineum Labia Vaginal walls Circumferential cervix Perform fundalmassagetohelptheuteruscontractdown and↓ ispasttheintroitus, graspwithhandsandgentlyremove Onceplacenta Applypressurewithonehandinthesuprapubicregionandapplygen- separation: Monitor forsignsofplacental arterialpHifindicated,bloodtyping. Obtain andvenousbloodforfetal Handthebabytonurse orpediatrician. Transfer theinfant’s buttocksinthecrookofelbow ofthehandthat Fourth mucosadegree: Extendthroughtherectal toexposelumen Third degree: Seconddegreeplusinvolvementoftheanalsphincter. body butnottheanalsphincter. but nottheunderlyingfascia andmuscle (skidmark). cord. cotyledonsandthree-vessel forintact membranes. Inspecttheplacenta out. tle tractionontheumbilicalcordtoguideplacenta clamp andcutthecord. is holding thehead.Thisfreesotherhandtosuctionbabyand of therectum. bleeding. Theumbilicalcordlengthens,indicating descentoftheplacenta. Theuterusrises intheabdomenafterbulkofseparatedpla- Uterusbecomesglobularandfi Thereisoftenasuddengushofblood. centa passesintothevagina. centa First degreeplusthefascia andmuscle oftheperineal rmer. the HIGH-YIELD FACTS Intrapartum Most common cause for postpartum hemorrhage = with Treat Uterine atony. uterotonics like pitocin, methergine, hemabate, misoprostol. Postpartum hemorrhage causes— The 4 T’s Tissue: Retained placenta Trauma: Instrumentation, lacerations, episiotomy Tone: Uterine atony Thrombin: Coagulation defects, DIC 81 cult EDIOLATERAL M More diffi More common More Occasional IDLINE M Easy Rare Less Rare Common Uncommon Episiotomy Mediolateral Versus Midline GEMENT OF PATIENTS IN LABOR IN PATIENTS OF GEMENT myometrial contractions and reduces maternal blood loss. vaginal delivery and > 1000 mL for C-section. striction. HARACTERISTICS uterine contraction. Fundal massage stimulates in the third stage It causes of labor. is administered (Pitocin) Oxytocin for ned as > 500 mL of blood loss Often defi hemorrhage: Postpartum to vasocon- is myometrial contraction leading The primary mechanism C position of the vagina. Causes more bleeding and pain. bleeding position of the vagina. Causes more fourchette. Most common. ↑ the risk of a fourth-degree laceration. Surgical repair Faulty healing Faulty Postoperative painPostoperative Anatomical results MinimalBlood loss Excellent Common Occasionally faulty Dyspareunia Extensions MANA Vaginal Exams Vaginal for required number should be kept to the minimum examinations Vaginal latent the evaluation of a normal labor pattern, for example, every 4 hr in be phase and every 2 hr in active phase. Sterile gloves and lubricant should used. Postdelivery Hemostasis Postdelivery and the placentaAfter the uterus has been emptied hemostasis delivered, be achieved: must The incision of the perineum and/or labia to aid delivery by creating more of the perineum and/or labia to aid delivery by creating more The incision cation of episiotomy is the same as perineal lacerations. Ta- room. The classifi types of episiotomies: ble 5-2 compares the two different 1. the posterior from is made in the midline Midline: The incision 2. starting is oblique from 5 o’clock or 7 o’clock Mediolateral: The incision Episiotomy TABLE 5-2. TABLE (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom from Cunningham FG, Leveno KJ, Bloom (Reproduced, with permission, McGraw-Hill, 2005: ed. New York: SL, et al. Williams Obstetrics, 22nd 436.) Intrapartum HIGH-YIELD FACTS postpartum hemorrhage. in theWestern worldis of maternalmortality The mostcommoncause uterine activity. > 200Montevideounitsof fi rststage for>2hrwith changeinactive cervical Arrest oflabor:Lack order toavoidaspiration. liquids isdiscouragedin consumption offoodsor stage oflabor. Thus, complications inthethird management of orfor delivery be neededforcesarean Inhalation anesthesiamay .Continuous electronic monitoring oftheFHRanduterinecontractions 2. stethoscope orDopplerultrasonic withafetal Intermittent auscultation 1. The RateFetal Heart Uterine activityismonitored byexternalorinternaluterinemonitors. Uterine Contractions heartratearemonitored closely.During labor,uterinecontractionsandfetal Usually, islimited tosmallsipsofwater,icechips,orhardcandies. oralintake Other Considerations min. Maternal bloodpressureandpulseshouldbeevaluatedrecordedevery10 Maternal Vital Signs 82 MONITORING LABOR DURING FETAL HEART RATE PATTERNS device. the bottom. heartrateonthetopportionandcontractions ing recordsthefetal monitor trac- fetal Thestandard is mostcommonlyusedinUnited States. fetal heartrate(FHR)canbeassessedintwoways: fetal Periodic changesaboveandbelow termedaccelerations( Baseline ratereferstothemostcommonheart ratelasting≥10min- heartrateis110–160bpm. The normalbaselineforthefetal decelerations (↓inHR). utes. fetal monitoring isrequired.fetal electrocardiogram.the fetal Thisismoreinvasiveand isusedifcloser of scalp,whichdetectsthepeakR-wavevoltage tofetal trode attached Internal electronic FHRmonitoring: Donewithabipolarspiralelec- ing aDopplerdeviceplacedonthematernalabdomen. External (indirect)electronic FHRmonitoring: Intrauterine pressurecatheters: External monitors: StrengthofcontractionmeasuredinMontevideounits. Recordfrequency, duration,andstrengthofthecontraction. informationisneeded. Morecommonlyusedunlessmoredetailed Accuratelydisplay thefrequency ofthecontraction. Ifyouhavetime,don’tmultiply––add everycontraction. Calculated by contraction frequency over10min. ↑ inuterinepressureabovebaselinemultiplied by FHRisdetectedus- ↑ inHR)and HIGH-YIELD FACTS Intrapartum /20 min. always note the accelerations decelerations Reactive: 15 beats/min above the baseline lasting 15 sec; 2 × A fetus < 28 weeks gestation age is neurologically immature and thus is not expected to have a “reactive” FHR. The left lateral recumbent position is best for maximizing cardiac output (In ow. and uterine blood fl the supine position, the vena cava and aortoiliac vessels may be compressed by the gravid uterus.) When reading the fetal When reading tracing, following: 1. Baseline 2. Variability of 3. Presence of 4. Presence 5. Contractions - 83 oxygen content in blood. ↓ oxygen content in concentration of hydrogen ions in the blood. ↑ concentration of hydrogen level of oxygen in tissue. ↓ level of oxygen in concentration of hydrogen ions in tissue. ↑ concentration of hydrogen Uteroplacental insuffi ciency is the most likely cause for this patient’s Uteroplacental insuffi (blood without enough oxygen) during contractions. A 32-year-old G2P1001 at 40 weeks gestation presents to labor and at 40 weeks gestation G2P1001 A 32-year-old effaced, to be 5 cm dilated, 50% delivery with contractions. She is noted contractions every 2 monitor shows –1 station, cephalic by sutures. The fetal tracing has two accelerations of at least 15 beats/min fetalreassuring 15 beats/min of at least two accelerations has tracing ECELERATIONS recovery occurring after uterine contraction onset, peak, and recovery, recovery occurring after uterine contraction onset, peak, and recovery, respectively. ing contractions usually between 4 and 7 cm dilation. ing contractions usually between 4 and 7 cm dilation. during labor is to avoid metabolic which can and asphyxia, avoid during labor is to acidosis neurological injury. cause permanent above the baseline, lasting for at least 15 sec, in 20 min. It indicates a It indicates 20 min. 15 sec, in at least for lasting the baseline, above an intact fetus with well oxygenated and cardiovascular neurological system. contraction. ciency ECELERATIONS Answer: D and nadir, the baseline with onset, They are a gradual decrease below epidural (hypotension) or uterine hyperstimulation. Can follow The effect is regulated gradual by vagal nerve activation. No intervention is necessary. Late decelerations are abnormal and are due to uteroplacental insuffi Early decelerations are normal and are due to head compression dur- Hypoxemia: Hypoxia: Acidemia: Acidosis: Asphyxia: Hypoxia with metabolic Goal of fetal acidosis. monitoring A of the gradual deceleration corresponds to the peak of the The nadir D nitions min, and the FHR pattern shows a baseline of 150 beats/min, minimal variability, beats/min, minimal variability, min, and the FHR pattern shows a baseline of 150 and gradual decelerations that nadir after the peak of the contractions. No ndings on the FHR? of the fi is the most likely cause accelerations are noted. What is the next step in management? What on her left side to maximize patient should be turned late decelerations. The scalp electrode Fetal to the mother. oxygenation to the fetus. Administer oxygen monitors) will help with the FHRand an intrauterine pressure catheter (internal ciency should be of uteroplacental insuffi monitoring. A search for the cause carried out. ARLY ATE E Decelerations during labor have different interpretations on when depending Decelerations during labor have different 5-3 and Figure 5-7.) (See Table they occur in relation to contractions. Decelerations Defi L Intrapartum HIGH-YIELD FACTS Ctx, contraction;decel,deceleration;gradual, baselinetonadir>30 sec;abrupt,baselinetonadir<30 sec. TABLE 5-3. Pitocin off Give thepatientOxygen side Turn thepatienttoherleft Sterile vaginalexam decelerations: STOP whenyousee et hlo hlo Variable Abrupt Uteroplacentalinsuffi O Variable (oftenVorWshaped) Headcompression Shallow Nonerequired Gradual Initial treatment andendafterthe Start Ushaped Nadirofdecel=peakctx Why Shallow Gradual When Ushaped Depth Onset Shape Signifi cneBng bomlVariable Abnormal Benign cance Types ofDecelerations E ARLY D monitoring. M 84 Obstetrics, (Reproduced, withpermission, fromCunningham FG,LevenoKJ,BloomSL,etal.Williams 5-7.FIGURE ECELERATION ANAGEMENT If repetitive(>50%ofthecontractionshavelatedecelerations)andno orposition. station Sterilevaginalexamtoassessforchangeinfetal Monitor maternalbloodpressure.Treat hypotensionwithmedications. Consider tocolysis. ProvideanIVfl Stopoxytocin (Pitocin) infusion. Giveoxygenbyfacemask. Changematernalpositiontotheleftlateralrecumbentposition. other reassuringfinding present,consider immediate delivery. 22nd ed.NewYork: McGraw-Hill, 2005:452–454.) A

Features ofearly (A),variable(B),andlate (C)decelerationson fetal heart uid bolus. monitoring position, Pitocinoff, close of ctx Nadir ofdecelafterpeak uterine ctx L ATE 2 , lateraldecubitus D ECELERATION B C ciency Cord compression Cord ciency Amnioinfusion Variable V ARIABLE D ECELERATION HIGH-YIELD FACTS Intrapartum If an FHR of 160 beats/min lasts for ≥ 10 min, then tachycardia is present. 85 . 2 60 sec and depth = 70–80 beats/min depth = 70–80 > 60 sec and 70–80 beats/min and depth > 70–80 sec Lasts < 30 beats/min < 70–80 sec and depth Lasts 30–60 OR Lasts 70 beats/min < 70 Lasts > 60 sec and depth uids. cation of Variable Decelerations Variable cation of ECELERATIONS Classifi D ECELERATIONS D Intrauterine infection Intrauterine fever Maternal Drugs Fetal hypoxia Fetal or fetal descent. uterine pressure catheter to alleviate cord compression. Most com- uterine pressure catheter to alleviate monly used for severe variable decelerations. vere (Table 5-4). vere (Table cord. or a nuchal nios for > 10 min. Baseline HR > 160 beats/min Causes: Change maternal position. IV fl Administer vasopressors. If mother is hypotensive, administer maternal O Administer to exclude cord prolapse, sudden cervical dilation, Sterile vaginal exam Uterine hyperactivity. Uterine to transient fetal hypoxia. Maternal hypotension leading Umbilical cord compression. and prostaglandins. Stop oxytocin or nonreassuring. if worsening Plan delivery of fetus soon examinations. Cervical They can occur at any time. through the intra- Infuse normal saline into the uterus Amnioinfusion: position. to side/Trendelenburg Change maternal position or se- moderate, are abnormal and can be mild, decelerations Variable oligohydram- are due to cord compressionand can be seen with They that looks like a “v”. Abrupt deceleration Mild Moderate Severe ANAGEMENT ANAGEMENT ARIABLE ROLONGED Fetal Tachycardia Fetal M Isolated decelerations that last 2–10 min. Causes include: min. Isolated decelerations that last 2–10 M V TABLE 5-4. TABLE P Intrapartum HIGH-YIELD FACTS delivered immediately. and thefetusmustbe No BTBV=fetalacidosis, outcome. important predictoroffetal thought tobethemost Short-term variabilityis BTBV. the bestwaytodetermine Internal FHRmonitoringis acidosis. and ruleoutmetabolic elicit areactiveacceleration between decelerationsto Scalp stimulationisdone with mild fetal hypoxemia.Beat-to-beat variability↑withmild fetal Beat-to-beat variability↓with: I D Long-Term Variability (LTV) Short-Term Variability (STV) Beat-to-Beat Variability (BTBV) 86 Dystocia CESSIN NCREASES MAL LABOR PATTERNS ABNORMAL LABOR CESSIN ECREASES pelvis is adequate for a normal vaginal delivery.pelvis isadequateforanormal vaginal delivery,if thefetalsizeandpositionare amenableforavaginal andwhetherthe The nextstepinmanagementistodetermineifthereare adequatecontractions, dilate 1.5cm/hrataminimum andshouldhavebeen8cmoveraspanof2hr. pattern? What isthenextstepinmanagement? Refl Normal:3–6cycles/min. Resultsinwavinessofbaseline. Describestheoscillatory changesthatoccurin1min. May be The Acquired neurologicabnormality. orcongenital Drugs(narcotics,magnesiumsulfate[MgSO Maternal acidemia. Fetal asphyxia. Fetal acidemia. age,thefetusisneurologicallyimmature; At <28weeksgestational Variation ofsuccessivebeatsintheFHRBTBViscontrolledprimarily characteristicofthebaselineFHR. Thesinglemostimportant Answer: Shehasaprotractedactivephase. Sincesheisamultipara,should genation. tracing. thus, CNS. indicates fetal intact the sympatheticandparasympatheticsystemscreatesBTBV, which pushand pull of of theparasympatheticnervoussystem.Theconstant sympathetic nervoussystem.The↓ by theautonomic nervoussystem.↑ ects instantaneous beat-to-beat (RwavetoRwave)changesinFHR. ects instantaneous station. Herexamnowis6cm/80%effaced/–2What isherlabor active labor. Two hoursagohercervicalexamwas5cm/80% effaced/–2 A 32-year-old G3P2002 at38 weeksisadmittedtolaboranddeliveryfor roughness (STVpresent)orsmoothnessabsent)oftheFHR ↓ variabilityisexpected. BTBV BTBV ↓/absent duetoalterationsintheCNSorinadequateoxy- fetal in theFHRisduetoactivation in FHRisduetoactivationofthe 4 ], barbiturates,etc.). HIGH-YIELD FACTS Intrapartum Power (contractions) Power (fetus) Passenger Pelvis Dystocia is the most common indication for primary cesarean delivery. With the diagnosis of abnormal labor pattern, assess the three Ps: 87 ULTIPARAS M 14 hr > 14 < 1.5 cm/hr < 2 cm/hr > 2 hrs > 1 hr > 1 hr ULLIPARAS N pitocin to obtainpitocin stronger contrac- 20 hr > 20 < 1.2 cm/hr < 1 cm/hr > 2 hrs > 1 hr > 1 hr A slow rate of cervical dilation or descent. of cervical dilation rate A slow (prolonged latent (prolonged ATTERN P ABOR L Patterns Labor Abnormal tions. abnormal? Contraction strength: Start or ↑ big to pass through pelvis? Position size and position: Baby too Fetal pelvis? adequate Does pelvimetry indicate Pelvis: following: following: tion (CPD), excessive sedation, conduction analgesia, and fetaltion (CPD), excessive sedation, conduction malposition (ie, persistent OP). inappropriately coordinated to efface and dilate cervix. to efface and dilate inappropriately coordinated deceleration phase or second stage of deceleration phase or labor) Protraction disorders: Protraction of labor, assess the disorder of protraction or arrest With the diagnosis 5-5). phase (see Table Prolonged latent Active phase abnormalities: May be due to cephalopelvic dispropor- Complete cessation of dilation or descent (see Table 5-5). or descent (see Table Complete cessation of dilation disorders: Arrest Uterine dysfunction can lead to uterine forces insuffi ciently strong or ciently dysfunction can lead to uterine forces insuffi Uterine second stage voluntary effort during Inadequate muscle of labor. Prolongation disorder Prolongation phase) Protraction disorder Protraction 1. phase dilatation Protracted active descent 2. Protracted Arrest disorders 1. Dilatation 2. Descent 3. of descent (no descent in Failure AUSES PELVIC SHAPES PELVIC 2. Abnormalities of presentation, position, or fetal development. 3. Abnormalities of the maternal bony pelvis. 4. Abnormalities of the birth canal. See Table 5-6. See Table C 1. Abnormalities of the expulsive forces: literally means diffi cult labor and is characterized by abnormally cult labor and is characterized by Dystocia literally means diffi progress of labor. or no slow TABLE 5-5. TABLE Intrapartum HIGH-YIELD FACTS TABLE 5-6. to maternalillness. fetus maybedelivereddue In somecases,animmature infiac odponssfr iie otro pc Go rgoi o Poor prognosisfor Goodprognosisfor Limitedposteriorspace Goodprognosis for Significance armIcie ete Fradadsrih Straight Forward andstraight Inclinedneither Sacrum rqec n5%o l eae n hr fwie n orho ht Rarest, ofwhite Onefourth Onethirdofwhite In50% ofallfemales Frequency ne hp on er hpdVrial retd Horizontallyoriented Vertically oriented shaped Heart Round Inlet shape sha pnsNtpoiet rmnn daee Poiet(imtr Notprominent Prominent(diameter Prominent(diameter Notprominent Ischial spines ieal tagtCnegn ovretDivergent,then Convergent Convergent Straight Sidewalls Pelvis Shapes G YNECOID aia eieyforfetalhead delivery vaginal neirynr ihltl uvtr eprta te rotatedbackward; deeperthanother withlittlecurvature anteriorly nor (diameter ylr o ir e ts o p ≥ 10 cm) pregnancy. outweigh therisksofcontinuing status livery toeither the thematernalorfetal Medically indicated induction oflaborisperformedwhenthebenefi ts ofde- Indications 88 INDUCTION OF LABOR Fetal: Maternal: Infection. testing. Abnormal fetal (IUGR). Intrauterine growth retardation Maternalconditions: Diabetes,renaldisease, chronic pulmonarydis- Severe preeclampsia/eclampsia. Chorioamnionitis. Prolonged pregnancy. Fetal demise. ease, chronic hypertension,antiphospholipidsyndrome. rgoi o aia commonlyseen delivery prognosis forvaginal oe;oesxho women; one half of women; onesixthof owiewmnnonwhitewomen nonwhite women A < NDROID 10 cm) or vaginal delivery; → poor with OPposition A < NTHROPOID 0c)(diameter 10 cm) lavo = sepyteerht evs Well curvedand pelvis short short convergent P vaginal delivery LATYPELLOID lavo = < shallow pelvis 3% ofwomen > 10 cm) HIGH-YIELD FACTS Intrapartum 89 RITERIA Previous myomectomy. Previous distress. Acute fetal lie. Transverse prolapse. Cord Placenta or vasa previa. surgery/malpresentation. Prior uterine cesarean delivery. Classical Active genital herpes infection. Isoimmunization. Oligohydramnios. Postterm. ROM. Premature C toxication (ie, hyponatremia), which can lead to convulsions, coma, which can toxication (ie, hyponatremia), and functionally to vasopres- is related structurally and death. Oxytocin hormone. sin or antidiuretic abnormality in the FHR. high doses can cause water in- in effects of oxytocin antidiuretic Potent strong contractions that cause an Frequent, Risk of hyperstimulation: uterine contraction. A synthetic polypeptide hormone that stimulates Half-life about 5 min. Acts promptly when given intravenously. Fetal: Maternal: fetoscope. 20 weeks by nonelectronic 30 weeks by Doppler. determined by clinical history (LMP) and physical exam (ultrasound ges- history (LMP) and physical by clinical determined tational age is consistent with LMP). supports a gestational age of 39 weeks or more (gestational age is deter- by the ultrasound). mined XYTOCIN ATING OMPLICATIONS Ultrasound at 12–20 weeks confi rms a gestational age of 39 weeks or more 4. at 12–20 weeks confi Ultrasound 2. serum pregnancy test. 36 weeks since a positive urine or 3. at 6–11 weeks dates the pregnancy and length Ultrasound of crown-rump C O Induction Methods 1. Documented fetal heart tones for: D Elective induction and/or cesarean should have fetalElective induction and/or cesarean documented by maturity that there is no Elective indicates accurate dating criteria or amniocentesis. for delivery of fetus; it is more for convenience. reason medical Confi Maturity rmation of Fetal Confi Contraindications Intrapartum HIGH-YIELD FACTS transverse uterineincision. incision butalow- may haveamidlineskin For example,awoman that thepatientreceived. the typeofuterineincision abdomen doesnottellyou see onthematernal The skinincisionthatyou = previousCD (CD) for cesareandelivery The mostcommonreason delivery. progress andcesarean (CPD) leadstofailure Cephalopelvic disproportion head (ie,asynclitism). malposition ofthefetal and isoftendueto diagnosed withcertainty This conditioncanrarelybe precludes vaginaldelivery. the fetalheadthat of thematernalpelvisand disparity betweenthesize been usedtodescribea disproportion (CPD)has The termcephalopelvic stone, 2007,Fig19-3.Copyright ©Elsevier.) son J.Obstetrics:NormalandProblem Pregnancies, 5thed.Philadelphia:Churchill Living- A. 5-8. FIGURE M 2. Classical: Indications Low-transverse cesareansection(LTCS): 1. Types (SeeFigure5-8) the uterinewall(hysterotomy). The birthofafetusthroughincisions intheabdominal wall(laparotomy)and P 90 ROSTAGLANDINS CESAREAN DELIVERY (CD) DELIVERY CESAREAN ECHANICAL Low Transverse. B. Horizontal incision madeinlower Horizontal uterinesegment. Performed when: Vertical incision madeinthecontractileportionofuterinecorpus. Mostcommontypeperformed. Breech presentation. Dystocia orfailuretoprogressinlabor. Priorcesarean(electiverepeat,previousclassical). Laminaria: Organic/synthetic materialthatslowly hygroscopicallyex- Foley balloon:Passed throughtheinternalcervicalosintoextra-am- PGE Misoprostol,asyntheticPGE pands whenplacedinthecervix. dilation. niotic space,inflated andrestedwithtractionontheinternalostocause Placenta Placenta previa. Fetus istransverseliewithbackdown. Lower uterinesegmentisnotdeveloped(ie,prematurity). Usedforcervicalripening inwomenatornearterm. dinoprostone. Bothcontain Usedforcervicalripening andinduction. Canbeadministered intravaginallyororally. 2 gelandvaginalinsert: Types ofuterine incisions. AB Classical. (Reproduced,withpermission, fromGabbeS,NiebylJ,Simp- 1 analog: HIGH-YIELD FACTS Intrapartum Remember, if a young Remember, woman has an 18- or a 20-week-size uterus but negative pregnancy test, is the most likely diagnosis broid uterus. a fi 91 with risk of uterine rupture with a failed trial of labor fol- with a failed trial cant lowed by cesarean delivery. lowed rysm, etc. esthesia, suffi staff,cient or facility. esthesia, suffi surgery. monitoring labor and performing an emergency CD. an emergency labor and performing monitoring Presenting part is not engaged. known. is not precisely of head Position Membranes are not ruptured. Cervix is not fully dilated. Presence of cephalopelvic disproportion. Fetal distress. Fetal pulmonary edema, aneu- heart disease, Maternal factors: Exhaustion, head for a breech delivery. After coming Lack of progress in the second stage of labor. of unavailable surgeon, an- Inability to perform emergency CD because Prior classical or T-shaped incision or other transmyometrial uterine incision Prior classical or T-shaped pelvis. Contracted complication that precludes vaginal delivery. Medical/obstetric pelvis. adequate Clinically rupture. No other uterine scars or previous capable of available throughout active labor immediately Physician of anesthesia and personnel for emergency CD. Availability infant complications are ↑ Maternal and LTCS. One 10% risk. uterine incision: Classical risk. 1% incision: Low-transverse Transverse lie. Transverse for fetal Concern fetalnonreassuring (ie, well-being tones). heart malformations/scars. Uterine ONTRAINDICATIONS OPERATIVE VAGINAL DELIVERY TRIAL OF LABOR AFTER CESAREAN (TOLAC) NDICATIONS C I Forceps are an important tool to allow for a vaginal delivery. The cervix must The cervix must are an important for a vaginal delivery. tool to allow Forceps be fully dilated. Forceps Delivery Forceps Contraindications to TOLAC Candidates for TOLAC Candidates TOLAC is associated with a small but signifi with TOLAC is associated poor outcome for mother and infant: poor outcome for Intrapartum HIGH-YIELD FACTS the vulvaandclitoris. medial andinferiorpartsof perineum, anus,andthe tothe innervation sensory provide the pudendalnerve The peripheralbranchesof Resolves in1–2days. does crosssuturelines. engagement ofthehead; head fromprolonged Temporary swellingoffetal Caput succedaneum: Vs. weeks. spontaneously overseveral vessels; resolves head. Duetoruptureof the suturesonfetal therefore, itdoesnotcross periosteum oftheskull; Collection ofbloodunder Cephalohematoma: tal tract: tal oflabor,muchDuring thesecondstage ofpainarisesfromlower geni- Lower GenitalTract Innervation homeostasis. of fetal Three essentialsofobstetricpainreliefaresimplicity, safety, andpreservation D A Vacuum Delivery 92 with nosignificant risktothemotherorinfant: Pain reliefwith anopiateoropioid plusanantiemeticistypicallysuffi Intravenous Analgesiaand Sedation requirestaff smalleramountsofpainmedication: Women whoarefreefromfearandhaveconfi dence intheir obstetrical Methods ofPain Control Nonpharmacological PAIN CONTROL DURING LABOR AND DELIVERY AND LABOR PAIN DURING CONTROL DVANTAGES ISADVANTAGES Painful stimuli fromthelower tractareprimarilytransmitted genital by Deliveryshouldnotbeonethatwillrequireorexcessivetraction. rotation The sensorynervefi bers ofthepudendalnervearederivedfrom Small Possible longerdeliverythanwithforceps. Propertractionisnecessarytoavoid losingvacuum. Traction isappliedonlyduringcontractions. concern. Lessparental Lessmaternalsoft-tissueinjury. Noincreaseindiameter ofpresentinghead. Lessanesthesiaisnecessary(localanestheticmaysuffi head. Lessforceappliedtofetal inapplication. Simplertoapplywithfewermistakes Priorscalpsamplingisacontraindication. Avertexfetusisrequired. Asafe,effectivealternativetoforcepsdelivery. Sameindications andcontraindications asforceps. Considerate obstetricians and labor assistants whoinstillconfi Considerateobstetricians andlaborassistants Appropriatepsychological support (eg,byafriendorfamily member). Appropriateantepartumtraining inbreathing. Anunderstandingofpregnancy andthebirthprocess. sacrospinous ligament (just as the ligament attaches totheischialspine). sacrospinous ligament(justastheattaches the ventral branchesofthesecond,third,andfourthsacralnerves. which passes beneath the posterior surface of the nerve,whichpassesbeneaththeposteriorsurfaceof pudendal ↑ inincidence ofcephalohematomas. ce). dence. cient, HIGH-YIELD FACTS Intrapartum Uterine contractions and Uterine contractions cervical dilation cause discomfort. Always pull back on the syringe prior to injection of anesthetic to look for blood into the syringe; if ow fl present, you are in a vessel and must reposition your needle. 93 LOCK Inadvertent intravascular injection will cause systemic will cause systemic Inadvertent intravascular injection Fetal bradycardia (usually transient). bradycardia Fetal ) B prolong labor. ltration of the pudendal nerve with a local anesthetic agent of the pudendal nerve with a ltration LOCK B in uterine activity. ↑ in uterine not LOCK B UBARACHNOID emic stroke. emic Coagulation/hemostasis disorders. Coagulation/hemostasis disorders. Neurologic Infection at the puncture site. emergency. Surgical Spinal (postpuncture) headache—worse with sitting or standing. Seizures. dysfunction. Bladder Severe preeclampsia: Hypotension from anesthesia can cause isch- Maternal hypotension (common). spinal blockade. Total sion. cervix. labor. are not blocked. ous delivery. hematoma, infection. toxicity, out pain. (eg, lidocaine) by obstetrician. (eg, lidocaine) by (S Contraindications: pain from uterine contractions. Provides excellent relief of Preceded by infusion of 1 L of crystalloid prevent hypoten- solution to Complications: Complication: space. into the subarachnoid Introduction of local anesthetic delivery and vaginal delivery. Used for uncomplicated cesarean Agent is injected at the 3 o’clock and 9 o’clock positions around the rst stage of Provides good relief of pain of uterine contractions during fi nerves analgesia for delivery because the pudendal additional Requires analgesia for spontane- Effective, safe, and reliable method of providing analgesia. Can be used along with epidural Complications: Local infi Local vulva bilaterally with- vagina and posterior pinching of the lower Allows more tolerable. but is contractions during uterine still felt is Discomfort Slight Does PINAL ARACERVICAL UDENDAL P Nerve blocks that provide pain relief for women in labor and delivery without provide pain relief for women in labor Nerve blocks that loss of consciousness. Regional Anesthesia Local Anesthesia a laceration. a delivery to repair episiotomy or after before an Administered S P Intrapartum HIGH-YIELD FACTS avoid aspiration: Prophylactic measuresto analgesia. catheter toeffectperineal given throughtheepidural a rapidlyactingagentis anticipated in10to15min, is When vaginaldelivery Cricoidpressure before Administer antacids. Fastingfor6hrs. induction ofanesthesia. C fetus, therebyavoiding newbornrespiratorydepression. delivery havebeencompleted,soastominimize transferof the agentto General anesthesiashouldnotbeinduceduntilallstepspreparatorytoactual General Anesthesia E 94 PIDURAL ONCERNS Maternal:Inductionofgeneralanesthesiacancauseaspirationgas- Fetal: Contraindications EffectsonLabor: Complications: Relievespainofuterinecontractions,abdominal delivery(blockbegins Injectionoflocalanestheticintotheepiduralorperiduralspace: edema, and/ordeath. tric contents,resultinginairwayobstruction,pneumonitis, pulmonary CNS. anddepressthefetal placenta dermatome). vaginal delivery(blockbeginsfromthetenththoracic tothefi at theeighth thoracic levelandextends tofi rst sacraldermatome)or Sameasspinalcontraindications above. Longerdurationoflabor. Seizures. Hypotension. Ineffective analgesia. Inadvertentspinalblockade(punctureof dura withsubarachnoid in- A jection). ↑ incidence of: sacral canal. Caudal epidural analgesia:Injectionthroughthesacralhiatusand space. Lumbar epidural analgesia:Injectionintoalumbarintervertebral Maternal pyrexia Cesarean deliveries Low-forceps procedures Chorioamnionitis NALGESIA All anestheticagentsthatdepressthematernalCNScross fth sacral fth CHAPTER 6 Postpartum

The Puerperium of the Normal Labor and Delivery 96 UTERUS 96

CERVIX 97

VAGINA 97

PERITONEUM AND ABDOMINAL WALL 97

URINARY TRACT 97

HEMATOLOGY/CIRCULATION 97

BODY WEIGHT 98 Routine Postpartum Care 98 IMMEDIATELY AFTER LABOR 98

FIRST SEVERAL HOURS 98

THE FIRST FEW DAYS 99 Postpartum Infection 100 TYPES OF POSTPARTUM INFECTIONS 101 Discharge from Hospital 102 VAGINAL DELIVERY 102

CESAREAN DELIVERY 102

DISCHARGE INSTRUCTIONS 102 Coitus in Postpartum 102 CONTRACEPTION 103 Infant Care 104 Breasts 104 DEVELOPMENT OF MILK-SECRETING MACHINERY 104

MILK DEVELOPMENT 104

MATURE MILK AND LACTATION 104

LACTATION SUPPRESSION 105

BREAST FEVER 105

BREAST-FEEDING 106 Postpartum Psychiatric Disorders 107 MATERNITY/POSTPARTUM BLUES 107

POSTPARTUM DEPRESSION 108

POSTPARTUM PSYCHOSIS 108 Postpartum Thyroid Dysfunction 109

95 THE PUERPERIUM OF THE NORMAL LABOR AND DELIVERY

Late postpartum The puerperium is the period of conﬁ nement between birth and 6 weeks af- hemorrhage due to atony ter delivery. During this time, the reproductive tract returns anatomically to a occurs when uterine normal nonpregnant state. involution is defective. Presents with vaginal Uterus bleeding and boggy uterus. Treat with oxytocin. INVOLUTION OF THE UTERINE CORPUS Immediately after delivery, the fundus of the contracted uterus is slightly below the umbilicus. After the ﬁ rst 2 days postpartum, the uterus begins to shrink in size. Within 2 weeks, the uterus has descended into the cavity of the true pelvis. The contraction of the uterus immediately after delivery is critical for the achievement of hemostasis. “Afterpains” due to uterine contraction are Uterine size: ↓ In pregnancy: > 36 common and may require analgesia. They typically in intensity by the third postpartum day. weeks fundal height Postdelivery: Just below ENDOMETRIAL CHANGES umbilicus (20 weeks) Returns to normal in 6 weeks A 27-year-old woman undergoes a normal spontaneous vaginal delivery and spontaneous placental delivery without any lacerations. An hour later she has persistent vaginal bleeding. What is the likely diagnosis? What is HIGH-YIELD FACTS HIGH-YIELD the next step? Answer: Most likely cause is retained placental tissue. An ultrasound may help with the diagnosis. Palpate the endometrium to remove any retained placenta. The patient may need to undergo a curettage of the uterus to remove any retained products.

Within 2–3 days postpartum, the remaining decidua becomes differentiated Lochia (lóke-ah) is decidual into two layers: tissue that contains erythrocytes, epithelial 1. Superﬁ cial layer becomes necrotic, sloughs off as vaginal discharge = lochia. Basal layer (adjacent to the myometrium) becomes new endometrium. cells, and bacteria. See 2.

Postpartum Table 6-1. PLACENTAL SITE INVOLUTION Within hours after delivery, the placental site consists of many thrombosed vessels. Immediately postpartum, the placental site is the size of the palm of the hand and rapidly ↓ in size.

TABLE 6-1. Lochia

TYPE DESCRIPTION WHEN OBSERVED

Lochia rubra Red due to blood in the lochia Days 1–3

Lochia serosa More pale in color Days 4–10

Lochia alba White to yellow-white due to leukocytes and reduced ﬂ uid Day 11 → content

96 CHANGES IN UTERINE VESSELS Large blood vessels are obliterated by hyaline changes and replaced by new, smaller vessels.

The thinned-out lower Cervix uterine segment (that The external os of the cervix contracts slowly and has narrowed by the contained most of the fetal end of the ﬁ rst week. The multiparous cervix takes on a characteristic head) contracts and retracts ﬁ sh mouth appearance. over a few weeks and As a result of childbirth, the cervical epithelium undergoes much re- forms the uterine isthmus. modeling. Approximately 50% of women with high-grade cervical dys- The uterine isthmus is plasia will show regression after a vaginal delivery due to the remodel- located between the uterine ing of the cervix. corpus above and the internal cervical os below. Vagina HIGH-YIELD FACTS Gradually diminishes in size, but rarely returns to nulliparous dimensions: Rugae reappear by the third week. The rugae become obliterated after repeated childbirth and menopause.

At the completion of Peritoneum and Abdominal Wall involution, the cervix does The broad ligaments and round ligaments slowly relax to the nonpreg- not resume its pregravid nant state. appearance: The abdominal wall is soft and ﬂ abby due to the prolonged distention Before childbirth, the os and rupture of the skin’s elastic ﬁ bers; it resumes pre-pregnancy appear- is a small, regular, oval ance in several weeks. However, the silver striae persist. opening. After childbirth, the os is a horizontal slit.

Urinary Tract Postpartum The puerperal bladder has an ↑ capacity and is relatively insensitive to intravesical ﬂ uid pressure. Hence, overdistention, incomplete bladder emptying, and excessive residual urine are common and can result in a urinary tract infection (UTI). Between days 2 and 5 postpartum, “puerperal diuresis” typically occurs Instrument-assisted to reverse the ↑ in extracellular water associated with normal preg- delivery, regional and nancy. Dilated ureters and renal pelves return to their pre-pregnant state 2–8 general anesthesia are risk weeks postpartum. factors for postpartum urinary retention.

Hematology/Circulation Leukocytosis occurs during and after labor (up to 30,000/μL). During the fi rst few postpartum days, the hemoglobin and hematocrit fl uctuate moderately from levels just prior to labor. Plasma fi brinogen and the erythrocyte sedimentation rate may remain All postpartum women who ≥ elevated for 1 week postpartum. cannot void should be ≥ The cardiac output is higher than during pregnancy for 48 hours promptly catheterized. postpartum due to ↓ blood fl ow to the uterus (much smaller) and ↑ systemic intravascular volume. By 1 week postpartum, the blood volume has returned to the patient’s nonpregnant range. 97 Body Weight Most women approach their pre-pregnancy weight 6 months after delivery, The likelihood of cardiac but still retain approximately 1.4 kg of excess weight. overload is most likely in Five to six kilograms are lost due to uterine evacuation and normal the immediate postpartum blood loss. period, due to the Two to three kilograms are lost due to diuresis. autotransfusion of blood.

ROUTINE POSTPARTUM CARE

Immediately After Labor

Hemostasis is obtained FIRST HOUR primarily by mechanical Take blood pressure (BP) and heart rate (HR) at least every 15 min. clamping of vessels by Monitor the amount of vaginal bleeding. contracted myometrium. Palpate the fundus to ensure adequate contraction. If the uterus is re- laxed, it should be massaged through the abdominal wall until it remains contracted. Massaging the uterus leads to ↑ release of oxytocin, which helps promote uterine contraction.

Inadequate postpartum First Several Hours

HIGH-YIELD FACTS HIGH-YIELD uterine contraction EARLY AMBULATION (= atony) is a major cause of early postpartum Women are out of bed (OOB) within a few hours after delivery. Advantages bleeding. include: Reduced frequency of puerperal venous thrombosis and pulmonary embolism. ↓ bladder complications. Less frequent constipation.

CARE OF THE VULVA Blood can accumulate within the uterus without The patient should be taught to cleanse and wipe the vulva from front to back visible vaginal bleeding: (toward the anus). Postpartum Watch for: Palpable uterine IF EPISIOTOMY/LACERATION REPAIR enlargement during the initial few hours An ice pack should be applied for the ﬁ rst several hours to reduce postpartum. edema and pain. At 24 hr postpartum, moist heat (eg, via warm sitz baths) can ↓ local discomfort. The episiotomy incision is typically well healed and asymptomatic by week 3 of the puerperium.

BLADDER FUNCTION Sitz baths: Soaking the Ensure that the postpartum woman has voided within 4-6 hr of delivery. If perineum in plain warm not: water or water with Epsom This indicates further voiding trouble to follow. salts. An indwelling catheter may be necessary. Bladder sensation and capability to empty may be diminished due to anesthesia. Consider a hematoma of the genital tract as a possible etiology.

98 The First Few Days

BOWEL FUNCTION Lack of a bowel movement may be due to a cleansing enema administered prior to delivery. Encourage early ambulation and feeding to ↓ the possibility of constipation. Ask the patient about ﬂ atus.

IF FOURTH-DEGREE LACERATION Fecal incontinence may result, even with correct surgical repair, due to injury to the innervation of the pelvic ﬂ oor musculature. Keep the patient on a stool softener and a low residue diet to avoid straining and ↓ risk of ﬁ stula formation. Avoid enemas or suppositories which can disrupt the repair.

DISCOMFORT/PAIN MANAGEMENT During the ﬁ rst few days of the puerperium, pain may result from:

Afterpains: Contractions of the uterus as it involutes. Treat with non- HIGH-YIELD FACTS steroidal anti-inﬂ ammatory drugs (NSAIDs). Episiotomy/laceration pain: May require a narcotic medication, but NSAIDs or plain acetaminophen can help. Breast engorgement: Well-ﬁ tted with brassiere. NSAIDs. Postspinal puncture headache: Positional headache that is worse when upright, improved when lying down. Caffeine may help. Occasionally, patient may need a blood patch (performed by an anesthesiologist). Constipation: Treat with stool softeners over 2–3 weeks. May discon- tinue iron supplementation because it may cause constipation. Urinary retention: May need intermittent bladder catheterizations. Evaluate the patient for causes and treat accordingly

ABDOMINAL WALL RELAXATION Exercise may be initiated any time after vaginal delivery and after abdominal

discomfort has diminished after cesarean delivery. Postpartum

DIET There are no dietary restrictions/requirements for women who have delivered vaginally. Two hours postpartum, the mother should be permitted to eat and drink. Those with an uncomplicated CD can be given clear liquids and regular diet as tolerated. Continue iron supplementation for a minimum of 3 months postpartum.

IMMUNIZATIONS Kleihauer-Betke test detects The non-isoimmunized D-negative mother whose baby is D-positive is fetal-maternal hemorrhage given 300 μg of anti-D immune globulin within 72 hours of delivery. in Rh-negative mothers; Mothers not previously immunized against/immune to rubella should 300 μg of anti-D immune be vaccinated prior to discharge. Rubella vaccine is not given during globulin neutralizes 30 mL the pregnancy because it is a live attenuated virus. of fetal whole blood or 15 Unless contraindicated, mothers may receive a diphtheria–tetanus tox- mL of Rh-positive RBCs. oid booster prior to discharge.

99 POSTPARTUM INFECTION

A 30-year-old G1P1001 is postpartum day 1 from a vaginal delivery over an intact perineum. On rounds, she reports pain in the lower abdomen. She denies cough, back pain, leg pain, dysuria, or breast pain. She has a The uterine cavity is sterile before rupture of the temperature of 100.1ºF (37.8ºC) 4 hr ago, and now has a temperature of 101.0ºF amniotic sac. (38.3ºC). Her lungs are clear to auscultation, breasts are soft, costovertebral angle tenderness (CVAT) is not present and has no tenderness in her legs. She has fundal tenderness and foul-smelling lochia. She has no suprapubic tenderness. She was admitted with ruptured membranes at 2 cm dilation and delivered after 20 hr in labor. Fetal heart tones were concerning for late decelerations, so she had Endometritis is relatively uncommon following internal monitors. She pushed for 3 hr before the infant was delivered. What is the vaginal delivery, but 5–10 most likely diagnosis? What risk factors did this patient have? times more frequent after Answer: Endometritis. Fever, fundal tenderness, and foul-smelling lochia in C-section. the absence of other ﬁ ndings is consistent with endometritis. This patient’s risk factors include prolonged rupture of membranes and internal monitors, and she likely had multiple vaginal exams during her long labor course.

Pelvic infections are ascending infections. The bacteria responsible for pelvic HIGH-YIELD FACTS HIGH-YIELD Following delivery, the infections are those that normally reside in the bowel and colonize the bladder and lower urinary perineum, vagina, and cervix. tract remain somewhat hypotonic, resulting in CAUSES residual urine and reﬂ ux, Gram-positive cocci: Group A, B, and D streptococci. which predisposes to Gram-positive bacilli: Clostridium species, Listeria monocytogenes. urinary tract infection. Aerobic gram-negative bacilli: Escherichia coli, Klebsiella, Proteus species. Anaerobic gram-negative bacilli: Bacteroides bivius, B fragilis, B disiens. Other: Mycoplasma hominis, Chlamydia trachomatis.

Postpartum RISK FACTORS Prolonged rupture of membranes > 18 hr. Prolonged second stage. Cesarean delivery/uterine manipulation. GBS colonization leads to Colonization of the lower genital tract with certain microorganisms (ie, group B streptococci [GBS], C trachomatis, M hominis, and Gardnerella 80% greater likelihood of vaginalis). postpartum endometritis. Premature labor. Frequent vaginal exams. Foreign body. Diabetes.

DIAGNOSIS Fever > 100.4°F (38°C). Soft, tender uterus. Lochia has a foul odor.

100 Leukocytosis (WBC > 10,000/μL) (remember physiologic leukocytosis; look for trends). Identify source of infection (urinalysis, culture of lochia).

MANAGEMENT Postdelivery causes of Broad-spectrum antibiotics. fever: The 5 W’s + B Types of Postpartum Infections Wind: Atelectasis, 1–2 ENDOMETRITIS (METRITIS, ENDOMYOMETRITIS) days postop Water: Urinary tract A postpartum uterine infection involving the decidua, myometrium, infections, 2–3 days and parametrial tissue. postpartum More common after cesarean delivery than vaginal delivery. Hypoxic Wound: Surgical site tissue and foreign body (suture) with cesarean delivery are ideal for infections. infection—cellulitis, purulence, ﬂ uctuance, Typically develops postpartum day 2–3. HIGH-YIELD FACTS Treat with IV antibiotics until patient is afebrile for 24–48 hr. tenderness; 5–7 days GBS colonization ↑ risk of endometritis. postpartum Cesarean: Abdominal URINARY TRACT INFECTION incision Caused by catheterization, birth trauma, conduction anesthesia, and Vaginal: Episiotomy frequent pelvic examinations. Walking: Deep vein Presents with dysuria, frequency, urgency, and low-grade fever. thrombosis (DVT) and Rule out pyelonephritis (costovertebral angle tenderness, pyuria, hema- subsequent pulmonary turia). embolus, 4–10 days Obtain a urinalysis and urinary culture (E coli is isolated in 75% of postpartum postpartum women). Wonder drugs: Drug Treat with appropriate antibiotics. fever, 7–10 days postpartum CESAREAN DELIVERY: SURGICAL SITE INFECTION (SSI) Breast: Engorgement,

mastitis, abscess, Postpartum A 30-year-old G2P2002 is 2 weeks postoperative from a repeat cesarean 3 days–4 weeks delivery and presents to the ofﬁ ce for an incision check. She reports indu- postpartum ration around the incision site and ↑ tenderness. Her pain medications do not help. She reports a small amount of white malodorous drainage from the incision. She is tolerating her diet well and voiding spontaneously. On physical exam, she is afebrile. Her surgical site is indurated 2 cm around the incision and erythematous 3 cm around the incision. Purulent drainage is noted from a 1-cm Wound infection occurs in opening at the right margin. What is the next step in management? 4–12% of patients Answer: Next step is to differentiate whether this is a superﬁ cial or deep surgi- following C-section. cal site infection. The wound should be opened further and should be probed to evaluate whether the fascia is intact. Cultures should be obtained and the patient should receive antibiotics.

Antibiotic prophylaxis with Classiﬁ cation: Superﬁ cial SSI: Involves skin and subcutaneous tissue. IV cefazolin is commonly Deep SSI: Involves fascia and muscle. employed during cesarean deliveries.

101 DIAGNOSIS Fever, wound erythema and persistent tenderness, purulent drainage. Management: Obtain Gram stain and cultures from wound material. Wound should be drained, irrigated, and debrided. The more extensive the Antibiotics should be given along with: laceration/incision, the Superﬁ cial SSI: Wet-to-dry packing placed. Consider closure of incision when wound healthy. greater the chance of Deep SSI: May need debridement in the operating room under anes- infection and wound thesia. Consider necrotizing fasciitis. breakdown. EPISIOTOMY INFECTION Look for pain at the episiotomy site, disruption of the wound, and a necrotic membrane over the wound. Rule out the presence of a rectovaginal ﬁ stula with a careful rectovaginal exam. Open, clean, and debride the wound to promote granulation tissue formation. Sitz baths are recommended. Reassess for possible closure after granulation tissue has appeared.

DISCHARGE FROM HOSPITAL HIGH-YIELD FACTS HIGH-YIELD Vaginal Delivery One to two days postdelivery, if no complications. Return to the ofﬁ ce at 4–6 weeks for postpartum exam.

Cesarean Delivery Two to three days postdelivery, if no complications. Return to the ofﬁ ce in 2 weeks to check the incision and 4–6 weeks for postpartum exam.

Discharge Instructions

Postpartum The patient should call the doctor or go to hospital if she develops: Fever > 100.4°F (37ºC). Excessive vaginal bleeding—soaking a pad an hour. Suspicious for retained placenta. Lower extremity pain and/or swelling: Suspicious for DVT. Shortness of breath: Suspicious for pulmonary embolus (PE). Chest pain—can occur with PE.

COITUS IN POSTPARTUM

After 6 weeks, coitus may be resumed based on patient’s desire and comfort. A vaginal lubricant prior to coitus may improve comfort. Dangers of premature intercourse: Pain due to continued uterine involution and healing of lacerations/ episiotomy scars. ↑ likelihood of hemorrhage and infection.

102 Contraception

A 25-year-old G1P1001 is postpartum day 2 from a vaginal delivery. She is overall healthy and is breast-feeding. She wants contraception that is easy to use. She reports that she had used a combination oral contraceptive pill prior to conceiving this baby and had no bad side effects. She is afraid of needles. What is the best contraceptive option for this patient? Answer: Progestin-only pill. Progestin does not have an effect on breast milk, and it is easy to use.

Do not wait until fi rst menses to begin contraception; ovulation may come before fi rst menses. Contraception is essential after the fi rst menses unless a subsequent pregnancy is desired.

See contraception chapter. HIGH-YIELD FACTS

LACTATIONAL AMENORRHEA METHOD OF CONTRACEPTION Lactational amenorrhea involves exclusive breast-feeding to prevent ovulation. It can be used as a contraceptive method. It is 98% effective for up to 6 months if: The mother is not menstruating. The mother is nursing > 2–3 times per night, and more than every 4 hr during the day without other supplementation. The baby is < 6 months old.

ORAL CONTRACEPTIVE PILLS IN POSTPARTUM Combined oral contraceptive pills reduce the amount of breast milk, and very small quantities of the hormones are excreted in the milk. Progestin-only oral contraceptive pills are 95% effective with typical use without substantially reducing the amount of breast milk. Need to Postpartum take it the same time every day.

DEPO-MEDROXYPROGESTERONE A progesterone-containing injection, given every 3 months, does not have any effect on breast milk production; 99% effective.

INTRAUTERINE DEVICE Nursing mothers rarely Not used while the uterus in undergoing involution due to risk of expulsion ovulate within the ﬁ rst 10 and uterine perforation. weeks after delivery. Non- nursing mothers typically IMPLANON ovulate 6–8 weeks after delivery. A progestin-releasing implant that is placed in the arm; lasts for 3 yr.

103 INFANT CARE

Prior to discharge: Follow-up care arrangements should be made. All laboratory results should be normal, including: Coombs’ test. Bilirubin. Hemoglobin and hematocrit. Blood glucose. Maternal serologic tests for syphilis and HbsAg should be nonreactive. Initial HBV vaccine should be administered. All screening tests required by law should be done (eg, testing for phe- nylketonuria [PKU] and hypothyroidism). Patient education regarding infant immunizations and well-baby care.

BREASTS

Development of Milk-Secreting Machinery Progesterone, estrogen, placental lactogen, prolactin, cortisol, and insulin act together to stimulate the growth and development of the milk-secreting ma- HIGH-YIELD FACTS HIGH-YIELD chinery of the mammary gland: Midpregnancy: Lobules of alveoli form lobes separated by stromal tissue, with secretion in some alveolar cells. T3: Alveolar lobules are almost fully developed, with cells full of pro- teinaceous secretory material. Postpartum: Rapid ↑ in cell size and in the number of secretory organ- elles. Alveoli distend with milk. Colostrum is a yellow– colored liquid secreted by Milk Development the breasts that contains At delivery, the abrupt, large ↓ in progesterone and estrogen levels al- minerals, protein, fat, low for milk production. All vitamins, except vitamin K, are found in Postpartum antibodies, complement, human milk, necessitating neonatal administration of vitamin K to pre- macrophages, lymphocytes, vent hemorrhagic disease of the newborn. lysozymes, lactoferrin, and Colostrum can be expressed from the nipple by the second postpartum lactoperoxidase. day and is secreted by the breasts for 5 days postpartum. It has more minerals and protein than breast milk. It has less sugar and fat when compared to breast milk. Antibodies in colostrum protect the infant against enteric organisms.

Mature Milk and Lactation Milk letdown may be provoked by the cry of the Colostrum is composed of protein, fat, carbohydrates (lactose), secretory IgA, and minerals. infant and suckling and Milk comes in within the ﬁ rst week postpartum and is composed of pro- inhibited by stress or fright. tein, fat, carbohydrates (lactose), and water. Protein: Colostrum > milk. Fat: Milk > colostrum. Carbs: Milk > colostrum.

104 Colostrum is gradually converted to mature milk by 4 weeks postpartum. Subsequent lactation is primarily controlled by the repetitive stimulus of nursing and the presence of prolactin. Breast engorgement with milk is common on days 2–4 postpartum: Often painful. Often accompanied by transient temperature elevation. Oxytocin stimulates milk Often present in non-breast-feeding women. letdown/ejection. Suckling stimulates the neurohypophysis to secrete oxytocin in a pulsa- Prolactin stimulates milk tile fashion, causing contraction of myoepithelial cells and small milk production. ducts, which leads to milk expression. Progesterone has an inhibitory effect on production of milk. Lactation Suppression

A 26-year-old female, 1 month postpartum, presents to the ofﬁ ce with complaints of fever of 100.9ºF (37.3ºC) and breast tenderness for 1 day. She has been breast-feeding without problems and reports no other HIGH-YIELD FACTS symptoms. On physical exam, her temperature is 100.8ºF (38.2ºC). Her left breast has a 4-cm area of induration and erythema at the 3 o’clock position that is tender to palpation. Milk expressed from that breast is white. What is the most likely What is Sheehan diagnosis? What is the treatment? syndrome? Postpartum Answer: Mastitis. Focal area of breast infection and fever approximately 1 pituitary dysfunction, month postpartum is consistent with mastitis. Milk should be cultured, and the possibly due to intrapartum patient should be started on dicloxacillin empirically until culture and sensitivities ischemia. These patients are available. cannot breast-feed due to the absence of prolactin.

Women who do not want to breast-feed should wear a well-ﬁ tting brassiere, breast binder, or “sports bra.” Pharmacologic therapy with bromocriptine is not recommended due to its associations with strokes, myocardial infarction, seizures, and psychiatric disturbances. Postpartum

Bromocriptine no longer Breast Fever FDA approved for Breast engorgement is a result of milk collecting in the breast. suppression of lactation. Occurs within 2–4 days of delivery. Seldom persists for > 24 hrs. Presents with bilateral painful, ﬁ rm, globally swollen breasts. Rule out other causes of postpartum fever. Treat with supportive bra, 24 hr demand feedings, ice packs. Mastitis is an infection of the breast. It affects 1–2% of postpartum women. Approximately 10% of women with mastitis develop breast abscess. Caused by: Staphylococcus aureus from the infant’s nasopharynx (40%). More likely to cause an abscess. Staphylococcus coagulase negative, Streptococcus viridans (60%). Presents approximately 4 weeks postpartum with fever, chills. Focal area of erythema and induration. No ﬂ uctuance. Culture milk to identify the organism. Treat with dicloxacillin for 7–10 days. Continue breast-feeding. Re- solves within 48 hr.

105 Breast abscess may follow mastitis: Suspected when fever does not defervesce within 48–72 hr with antibiotics. Palpable mass may be present. Ultrasound can visualize the ﬂ uid collection. Treat with broad-spectrum antibiotics and incision and drainage or ultrasound-guided needle aspiration.

Breast-Feeding Human milk is the ideal food for neonates for the ﬁ rst 6 months of life. Breast-fed infants are less prone to enteric infections than are bottle-fed babies.

RECOMMENDED DIETARY ALLOWANCES

CMV, HBV, and HIV are Lactating women need an extra 500 nutritious calories per day. Food choices excreted in breast milk. should be guided by the Food Guide Pyramid, as recommended by the U.S. Department of Health and Human Services/U.S. Department of Agriculture.

BENEFITS Uterine involution: Nursing accelerates uterine involution (increases oxytocin). Immunity: Colostrum and breast milk contain secretory IgA antibodies against HIGH-YIELD FACTS HIGH-YIELD Escherichia coli and other potential infections. Milk contains memory T cells, which allows the fetus to beneﬁ t from maternal immunologic experience. Colostrum contains interleukin-6, which stimulates an ↑ in breast milk mononuclear cells. Nutrients: All proteins are absorbed by babies, and all essential and nonessential amino acids available. Gastrointestinal (GI) maturation: Milk contains epidermal growth factor, which may promote growth and maturation of the intestinal mu- A common misperception: cosa. Mothers who have a common cold should not CONTRAINDICATIONS TO BREAST-FEEDING breast-feed (false).

Postpartum Mothers with the following infections: HIV infection. Breast lesions from active herpes simplex virus. Tuberculosis (active, untreated). Breast-feeding not contraindicated: Cytomegalovirus (CMV): Both the virus and antibodies are present in breast milk. Hepatitis B virus (HBV): If the infant receives hepatitis B immune globulin. Hepatitis C: 4% risk of transmission same for breast- and bottle-fed infants. Medications: Mothers ingesting the following contraindicated medications (not an exhaustive list): Bromocriptine. Cyclophosphamide. Cyclosporine. Doxorubicin. Ergotamine.

106 Lithium. Methotrexate. Estrogen-containing oral contraceptives (OCPs). Drug abuse: Mothers who abuse the following drugs should not breast- What type of oral feed: contraceptives are okay Amphetamines with breast-feeding? Cocaine Progesterone-only OCPs Heroin Marijuana Nicotine Phencyclidine Ethanol Most drugs given to the Radiotherapy: Mothers undergoing radiotherapy with the following mother are secreted in should not breast-feed: breast milk. However, the Gallium amount of drug ingested by Indium the infant is typically small. Iodine Radioactive sodium HIGH-YIELD FACTS Technetium

POSTPARTUM PSYCHIATRIC DISORDERS

Maternity/Postpartum Blues

A 25-year-old G1P1001 presents 1 week postpartum to the ofﬁ ce with complaints of tearfulness, inability to sleep, fatigue, and decreased appetite. She has enough support at home and is still very involved in taking care of her infant. What is the most likely diagnosis? What therapy should be offered? Answer: Postpartum blues. She should be given supportive therapy with mon- Postpartum itoring for more severe signs of depression.

A self-limited, mild mood disturbance due to biochemical factors and psychological stress: Affects 50% of women. Begins within 3–6 days after parturition. May persist for up to 10 days. May be related to progesterone withdrawal. Thirty percent of adolescent

SYMPTOMS women develop postpartum depression. Similar to depression, but milder (see below).

TREATMENT Supportive—acknowledgment of the mother’s feelings and reassurance. Monitor for the development of more severe symptoms (ie, postpartum depression or psychosis).

107 Postpartum Depression Similar to minor and major depression that can occur at any time: Classifi ed as “postpartum depression” if it begins within 3–6 months after childbirth. Criteria for Major Eight to fi fteen percent of postpartum women develop postpartum de- Depression/Postpartum pression within 2–3 months. Depression Up to 70% recurrence. Two-week period of depressed mood or SYMPTOMS anhedonia nearly every Symptoms are the same as major depression. day plus one of the following: NATURAL COURSE 1. Signifi cant weight loss or Gradual improvement over the 6-month postpartum period. weight gain without The mother may remain symptomatic for months to years. effort (or ↑ or ↓ in appetite). TREATMENT 2. Insomnia or Pharmacologic intervention is typically required: hypersomnia. Antidepressants 3. Psychomotor agitation/ Anxiolytic agents retardation. Electroconvulsive therapy 4. Fatigue or loss of Mother should be comanaged with a psychiatrist (ie, for psychotherapy energy. to focus on any maternal fears or concerns). HIGH-YIELD FACTS HIGH-YIELD 5. Feelings of worthlessness/excessive Postpartum Psychosis or inappropriate guilt. 6. ↓ ability to concentrate/ Mothers cannot discern real vs. unreal (can have periods of lucidity). think. Hearing voices, seeing things. 7. Recurrent thoughts of Occurs in 1–4 in 1000 births. suicide/death. Peak onset: 10–14 days postpartum, but may occur months later.

RISK FACTORS History of psychiatric illness. Family history of psychiatric disorders. Younger age.

Postpartum Primiparity.

COURSE Variable and depends on the type of underlying illness; often 6 months.

TREATMENT Psychiatric care. Pharmacologic therapy. Hospitalization (in most cases).

108 POSTPARTUM THYROID DYSFUNCTION

Postpartum thyroiditis is a transient lymphocytic thyroiditis in 5–10% of women during the ﬁ rst year after childbirth. The two clinical phases of postpartum thyroiditis are thyrotoxicosis and hypothyroidism (see Table 6-2).

TABLE 6-2. Thyrotoxicosis vs. Hypothyroidism

THYROTOXICOSIS HYPOTHYROIDISM

Onset 1–4 months postpartum 4–8 months postpartum

Mechanism Destruction-induced hormone release Thyroid insufﬁ ciency

Symptoms Small, painless goiter Goiter, fatigue, inability to concentrate

Palpitations, fatigue HIGH-YIELD FACTS

Treatment β-blocker Thyroxine for 6–12 months

Sequela Two-thirds euthyroid One-third permanent hypothyroidism One-third hypothyroid Postpartum

109 NOTES HIGH-YIELD FACTS HIGH-YIELD Postpartum

110 CHAPTER 7 Medical Conditions in Pregnancy

Pregestational Diabetes 113 Thyroid Disease 115 HYPERTHYROIDISM 115

HYPOTHYROIDISM 116 Chronic Hypertension 117 Cardiovascular Disease 118 MITRAL STENOSIS 118

MITRAL VALVE PROLAPSE 118

AORTIC STENOSIS 118

EISENMENGER SYNDROME AND CONDITIONS WITH PULMONARY HYPERTENSION 119 Pulmonary Disease 119 ASTHMA 119

PNEUMONIA 119 Renal and Urinary Tract Disorders 120 ASYMPTOMATIC BACTERIURIA 120

PYELONEPHRITIS 120 Gastrointestinal Disorders 121 DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMEN 121

APPENDICITIS 121

CHOLELITHIASIS AND CHOLECYSTITIS 122 Seizure Disorder 122 Thromboembolic Disorders 122 DEEP VEIN THROMBOSIS 122

PULMONARY EMBOLISM 124

THROMBOPHILIAS 124 Sickle Cell Disease 124 Anemia 125 Antiphospholipid Syndrome 125 Systemic Lupus Erythematosus 126 Pruritic Urticarial Papules and Plaques of Pregnancy 126

111 Cancer Therapy During Pregnancy 127 SURGERY 127

RADIATION 127

CHEMOTHERAPY 127

112 HIGH-YIELD FACTS Medical Conditions in Pregnancy Most common medical Most common of pregnancy complication + = diabetes (gestational pregestational). with pregestational Women cant diabetes have signifi maternal and fetal complications when compared to those with gestational diabetes. 113 HERAPY HERAPY Insulin Insulin Insulin T T Insulin Diet controlled Insulin Williams Obstetrics, ISEASE EVEL D L OSTPRANDIAL P R ciency. LUCOSE ASCULAR Heart Proliferative retinopathy Insulin Nephropathy Benign retinopathy Insulin None None 2-H G )V LASMA YR P ( URATION ASTING Any Any Any 10–19 < 10 F D NSET Complicating Pregnancy cation of Diabetes O NSET GE OF GestationalA mg/dL > 105 mg/dL > 120 O Gestational mg/dL < 105 mg/dL < 120 Classifi OMPLICATIONS C loss weight Unexplained Polyuria Polydipsia insulin defi Absolute 1 diabetes: Type resistance. or insulin insulin secretion Defective 2 diabetes: Type OMPLICATIONS Macrosomia. Preterm birth. Preterm restriction. Fetal-growth Preterm delivery Preterm section Cesarean Polyhydramnios Infections Impaired wound healing mg/dL; random > 200 mg/dL. > 126 Fasting hypertension Gestational Preeclampsia Classes B through H in the White Classifi cation (see Table 7-1). Table cation (see H in the White Classifi B through Classes symptoms: Classic before pregnancy: that existed Diabetes C LASS 2 1 H Any R Any DF Before 10 Any > 20 C to 19 10 A C B Over 20 A LASS ATERNAL IAGNOSIS C NAL DIABETESNAL PREGESTATIO ETAL (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. 1171.) McGraw-Hill, 2005: ed. New York: 22nd TABLE 7-1. TABLE F M D Medical Conditions in Pregnancy HIGH-YIELD FACTS dramatically insulin requirements following delivery, hormones. Immediately effect ofpregnancy due totheantagonistic during thesecondtrimester Insulin requirements↑ vascular disease. concurrent maternal restriction especiallydueto diabetes causesgrowth high. Pregestational when fastingglucoseis macrosomia, especially Gestational diabetescauses diabetics by: be inducedintype1 Diabetic ketoacidosismay Infections. Hyperemesis Corticosteroids(forlung gravidarum. maturity). tocolysis). β mimetics (for ↓. M 114 ANAGEMENT Second Trimester First Trimester Third Trimester Preconception 18–20 weeks: Get targeted ultrasound(US),thenUSevery 4 weeksfor 18–20weeks:Gettargeted 16–20weeks:Offerquad screen. Checkfastingand2-hrpostprandial glucose. individualized Start insulinregimen. Thyroid-stimulating hormone(TSH). Electrocardiogram (ECG). Ophthalmology exam. protein andcreatinine Baseline24-hrurinefortotal clearance. Folic acid 0.4mg/dayduringpreconceptionandearlypregnancyto↓ HbA Optimize glycemic control: Polycythemia. Neonatal hyperbilirubinemia. Neonatal hypocalcemia. Respiratory distressageat syndrome—likelyduetoearliergestational hypoglycemia—chronic Neonatal maternalhyperglycemia →hyperpla- Perinatal deaths. Stillbirths—unexplained. Congenital anomalies: Start insulindrip inlaborforglycemic control. Start weight is>4500g. Consider cesareandeliveryifestimatedfetal lungmaturitywithout am- Considerdeliveryat38weekswithoutfetal lungmaturityanddeliveryat37weeks Consideramniocentesis forfetal testingat32–34weeksorwhenpoorglycemic control. Antenatal 22weeks:Fetal echocardiogram lookingforcardiac anomalies. mations. growth. risk ofNTDs. delivery. plasmaglucoseafterdelivery.tal insulin → rapiddecline β-isletcells→increasedfetal sia offetal niocentesis ifgoodglycemic control. if poorglycemic control. Goal HbA Postprandial: <140mg/dLand120at12hr,respec- Preprandial: 70–100 mg/dL. Neuraltubedefects(NTDs). Cardiac anomalies. Caudal regression—absenceofthesacrumwithvariabledefects tively. the lower spine. prior toconceptionandinearlypregnancy. ↑ risk of fetal anomaliesindiabeticsrisk offetal isduetopoorglycemic control 1C levels>10%signifi 1C is<6mg/dL. cantly increase the risk of congenital malfor- cantlyincreasetheriskofcongenital in fe- HIGH-YIELD FACTS Medical Conditions in Pregnancy and TSH do not and TSH do 4 , and thyroid-binding 4 , T 3 In normal pregnancy, total In normal pregnancy, T Free T globulin (TBG) are elevated, but free thyroxine levels do not change = euthyroid. change in pregnancy and change in pregnancy sensitive are the most markers to detect thyroid disease. 115 ne . Hyperthyroidism should be 4 . 3 to T 4 ↑ in pregnancy. ): Unchanged in pregnancy. 4 ve percent mortality rate. She has symptoms most consistent with hyperthyroidism.She has symptoms most consistent with Although DISEASE tremor is noted in her hand, and her heart rate is 120 beats/min. What is What beats/min. tremor is noted in her hand, and her heart rate is 120 A 32-year-old G2P1001 at 16 weeks gestation presents with complaints of weeks gestation presents with complaints at 16 G2P1001 A 32-year-old fatigue. On physical exam a fi palpitations, nervousness, insomnia, and management. women who fail medical For Inhibits conversion of T Small amount transfer across the placenta. crosses placenta. Readily with aplasia cutis in fetus. Associated Seldom done in pregnancy. for treatment during pregnancy. Drug of choice dysfunction in pregnancy. of thyroid for diagnosis Essential in pregnancy. Unchanged cross the placenta. Does not stimulating antibodies. stimulating dence of preeclampsia, heart failure, and adverse perinatal outcomes (stillbirth, preterm labor). nancy. Answer: Neonatal thyrotoxicosis: 1% risk due to placental transfer of thyroid- (PTU). propylthiouracil goiter/hypothyroid—from Fetal despite treatment have higher inci- who remain hyperthyroid Women Methimazole: Thyroidectomy: Precipitatingare infection, labor, and C-section. factors contraindicated. iodine Ablation with radioactive (PTU): Propylthiouracil Twenty-fi 1 in 2000 pregnancies. Thyrotoxicosis complicates cause of thyrotoxicosis in preg- is the most common Graves’ disease TSH: thyroxine (T Free globulin Thyroid-binding the most likely diagnosis? What is the best treatment? the most likely diagnosis? What be she should are normal for pregnancy, this patient has many symptoms that and free T screened for thyroid disorder with TSH treated with PTU in pregnancy. OMPLICATIONS THYROID REATMENT C T Hyperthyroidism Thyroid hormone is essential for the normal development of the fetal the normal development is essential for hormone Thyroid brain and hypothyroidism, and mentalof hyperthyroidism, The incidence function. each about 1%. is thyroiditis Medical Conditions in Pregnancy HIGH-YIELD FACTS trophoblastic disease. and gestational hyperemesis gravidarum miscarriage rates. infertility andhigher often associatedwith Overt hypothyroidismis ↑ TSH,normalfreeT4 Subclinical Hypothyroidism: Free T4 Hypothyroidism: T Hyperthyroidism (↑free 4 , ↓ TSH)arenotedin ↑ TSH,↓ C Levothyroxine replacement: T Hypothyroidism 116 REATMENT OMPLICATIONS Still births Low birthweight Cardiac dysfunction Placental abruption Preeclampsia TSHismonitored everytrimesterifnochangeinmedication isneeded TSHismonitored every8weeks aftertheinitiation oftreatmentora TheAmericanCollegeofObstetricians and Gynecologistsrecommends Diagnosismaybediffi Subclinical hypothyroidism ismorecommonthanoverthypothyroid- Hashimoto’s thyroiditis isthe most commoncauseofhypothyroidism Thyroid storm: Preeclampsia. Stillbirth. Preterm delivery. nancy. (weight gain,fatigue, constipation,etc.)arealsosymptomsofpreg- in intensivecareunit (ICU)setting: tients withthyrotoxicosis.Oftenassociated withheartfailure.Treatment due toincreasedthyroxinerequirements inadvancing pregnancy. change indosage. screening forsubclinicalagainst routineprenatal hypothyroidism. ism. during pregnancy. Subclinical hypothyroidism isan↑TSHwithnormalfreeT Overthypothyroidism isdiagnosed by↑TSHand↓freeT DexamethasoneblocksperipheralconversionofT Sodium iodide inhibitsreleaseofT PTUorallyornasogastrictube. gic). β blockertocontroltachycardia. An acute, life-threatening, hypermetabolic state inpa- state An acute,life-threatening, hypermetabolic cult,asmanyofthesymptomshypothyroidism 3 andT 4 (lithiumifiodine aller- 4 toT 3 . 4 . 4 . HIGH-YIELD FACTS Medical Conditions in Pregnancy . If a 2 , she may 2 in T ↓ Blood pressure is dynamic It during pregnancy. normally Development of complications may require the delivery of a very premature infant. Poorer control of hypertension and presence ↑ of end organ damage = adverse outcomes in pregnancy. appear normotensive. patient with chronic hypertension is seen for the rst time in T fi 117 risk with severe hypertension. Smoking com- ↑ risk with severe hypertension. Smoking A 37-year-old G3P2002 at 37 weeks by an unsure last menstrual period by an unsure last menstrual weeks at 37 G3P2002 A 37-year-old (LMP) 1 day that is severe headache for complaining of a comes to triage has been compli- Her prenatal course with acetaminophen. unrelieved should deliver at term. ting of chronic hypertension. Infant should be delivered for maternal ting of chronic interest, even if markedly premature. dysrhythmias indicate long-standing or poorly controlled hypertension long-standing or poorly controlled indicate dysrhythmias in pregnancy. to ↑ risk for congestive heart failure (CHF) leading verse pregnancy outcome. pounds the risk. Answer: Chronic hypertension with preeclampsia. Women with superimposed hypertension Unless other complications develop, patients with chronic delivery is preferred to cesarean. Vaginal of hypertension. restriction: Directly related to the severity growth Fetal delivery. Preterm perfusion. should undergo testing to assess for adequate Fetus growth. ultrasounds to monitor should receive Fetus preeclampsia in the set- Superimposed preeclampsia: Development of Abruptio placenta: or cardiac with left ventricular hypertrophy Women Echocardiography: risk for ad- Abnormal results indicate and proteinuria: Serum creatinine week of gestation. Hypertension prior to 20th patients. Prevalence is markedly ↑ in obese and diabetic cated by chronic hypertension (meth- that has been well controlled with Aldomet no proteinuria during She had are normally 140/90. yldopa). Her blood pressures quadrant pain, con- denies any visual changes, right upper her prenatal visits. She uid. She reports Her good fetal movement. tractions, vaginal of fl bleeding, leakage heart Fetal She has 3+ proteinuria. rate and 175/100. blood pressure is 180/110 likely diagnosis? is the most is reassuring. What chronic hypertension worsening high risk for developing preeclampsia; are at of superimposed proteinuria can indicate the development blood pressure and preeclampsia. ANAGEMENT OMPLICATIONS RECONCEPTION CHRONIC HYPERTENSION M C P function: Evaluate for renal and cardiac Medical Conditions in Pregnancy HIGH-YIELD FACTS S P P Think: PPSS Epidural anesthesia. during laboranddelivery: Pain controlofchoice pregnancy. antihypertensives usedin most common acting agent):Oneofthe α-Methyldopa (centrally pregnancy tenosis— regnant rolapse—okay tobe S ick in Mitral Stenosis (MS) M 118 Stenosis Aortic Mitral Valve Prolapse CARDIOVASCULAR DISEASE EDICATIONS Considerintrapartumendocarditis prophylaxis. Peripartum periodisthemosthazardoustime. Fetus isatriskforgrowth restriction. Twenty-fi Tachycardia associated withlaboranddeliveryexacerbates thepulmo- Vaginal forceps,vacuum)desiredovercesarean delivery(spontaneous, Pain control: heartlesionsareinherited.Thereisa4%riskofcon- Somecongenital Needtomonitor forCHF. Pregnancy-induced hemodynamic changeshaveprofoundeffectson Angiotensin-converting enzyme (ACE)inhibitors/angiotensinreceptor Nifedipine: Calcium channelblocker. Alsousedfortocolysisinpreterm Hydralazine: Vasodilator. Labetalol: Give antibioticprophylaxis. Avoid tachycardia andfl Similar problemswithmitral stenosis. Considerintrapartumendocarditis prophylaxis. Generallysafepregnancy. Haveasystolicclickonphysical exam. Normally asymptomatic. for thefirst timeduringpregnancy. edema. nary HTNbecauseofdecreasedfi lling time.Mayleadtopulmonary delivery. heartdiseasegenital in theinfantofawomanwithparticulardefect. underlying heartdisease. Cardiac output↑by50%inmidpregnancy. and renaldefects). blockers (ARBs):Notgivenduetoteratogenic potential(hypocalvaria labor. ↑ α-Methyldopa: Generallynotusedoutsideobstetrics. in load. Generalanesthesiacancausehypotension. Continuous epidural anesthesiaisrecommended. Essentialduringlaboranddeliverytodecreasethecardiac workload. preload duetonormal↑ pulmonary hypertension(HTN). ↑ pressure intheleftatriumistransmitted intothelungs,resulting ve percentofwomenwithmitral stenosishavecardiac failure α- andβ-adrenergicblocker. uid overload. in bloodvolumeresultsleftatrialover- HIGH-YIELD FACTS Medical Conditions in Pregnancy F-series prostaglandins exacerbate asthma, so avoid in pregnancy. Severe pneumonia is a common cause of acute respiratory distress syndrome (ARDS). 119 ↑ in pregnancy complications. cant demands of the hyperdynamic circulation and the fetus. Ad- circulation hyperdynamic demands of the ve percent of asthmatics worsen in pregnancy. ve percent improve. 2 O trimesters. is recommended for prevention in all uenza vaccine PO is reportedly effective in 99% of uncomplicated pneumonia cases. PO is reportedly effective in 99% of uncomplicated pneumonia dergo chest radiography (CXR) with an abdominal shield. dergo chest radiography (CXR) with an abdominal or have severe tients. Use in patients who are immunocompromised disease. cardiac/renal/pulmonary infl should be given. uenza vaccine infl used outside of pregnancy). (same medications inhaled steroids of asthma. grounds. postpartum. Infl IV then empirical therapy with erythromycin bacterial pneumonia For Any pregnant woman suspected of having pneumonia should un- suspected of having pneumonia Any pregnant woman Abnormalities seen on CXR may take up to 6 weeks to resolve. for healthy pregnant pa- is not recommended Pneumococcal vaccine Premature rupture of membranes. Preterm delivery due to acidemia. killed asthma is exacerbated by respiratory tract infections, so Generally, epinephrine, and asthmatics can be treated with β agonists, Pregnant are complicated by asthma. One to four percent of pregnancies Twenty-fi Twenty-fi Fifty percent have no change. signifi Asthmatics have a small but restriction ↑ with the severity of asthma. growth Fetal analysis provides objective information as to severity Arterial blood gases to the mother. dangerous Extremely on medical of pregnancy justify the termination may condition This mortality Maternal usually occurring with death be as high as 50%, can ANAGEMENT OMPLICATIONS PULMONARY DISEASE PULMONARY PIDEMIOLOGY REATMENT vanced pregnancy may worsen the pathophysiological effects of many acute may worsen the pathophysiological vanced pregnancy lung diseases. and chronic M Pneumonia C T E Asthma The adaptations to the respiratory system during pregnancy must be able to The adaptations during pregnancy must to the respiratory system satisfy the ↑ Eisenmenger Syndrome and Conditions with Pulmonary Hypertension with Pulmonary and Conditions Syndrome Eisenmenger Medical Conditions in Pregnancy HIGH-YIELD FACTS Urosepsis. septic shockinpregnancy: Most commoncauseof sickle-cell trait. African-Americans with asymptomatic bacteriuria: Highest incidenceof R >L Hydronephrosis: Usually developing pyelonephritis. of their↑ should betreatedbecause asymptomatic bacteriuria Pregnant womenwith risk of Pyelonephritis Asymptomatic Bacteriuria ters; R>L): Pregnancy causeshydronephrosis(dilatationofrenalpelvis,calyces,andure- 120 D C RENAL AND URINARY TRACT DIS TRACT URINARY AND RENAL OMPLICATIONS IFFERENTIAL should be admitted to the hospital and given IVhydrationandantibiotics. should beadmittedtothehospitalandgiven What isthenextstepinmanagement? nitrites, andketones.What isthe mostlikelydiagnosis? many bacteria,leukocytes, shows contractionsevery2min.Cervixisclosed/thick/high.Urinedip rateisreassuring.The tenderness. Fetal monitor heart and rightcostovertebral Unilateral, right-sided>50%ofthetime. Acutepyelonephritisisthemostcommonseriousmedical complication Routinescreening atthefi visitrecommended. rst prenatal Ifuntreated,25%willdeveloppyelonephritis. Fivepercentincidence. and↑ May causeurinarystasis Hormonal milieu Pregnantuteruscompressesthelower ureter. Vancomycin isaddedforcommunity-acquired methicillin-resistant Severe disease mayrequire+macrolide(amoxicillin-clavu- β-lactams Chorioamnionitis Preterm labor Preterm labor. Hemolysis. ARDS. Pulmonaryedema:Endotoxin-induced alveolarinjury. Renal dysfunction: Bacteremia in15–20%ofwomenwithacutepyelonephritis. Escherichia coli Answer: of pregnancy. Staphylococcus aureus(MRSA). lanate), orthird-generationcephalosporins(ceftriaxone). tomatic upperurinarytractinfections(UTIs). lower abdominalpain.Shehasafeverof101.2ºF (38.9ºC), clearlungs, fever, nausea,andvomitingfor1day. Shecomplainsofbackpainand A 23-year-old G3P2002 at25 weeksgestationpresentstotriagewith D IAGNOSIS The clinicalpresentationismostconsistentwithpyelonephritis.She cultured 80%ofthetime. ↓ ureteraltone. ↑ creatinine. ORDERS vesicoureteral refl ux leading tosymp- HIGH-YIELD FACTS Medical Conditions in Pregnancy → increased → increased biliary Appendicitis masses Adnexal Cholecystitis Increased estrogen in pregnancy cholesterol saturation in bile stasis and gallstones. Most common indications for surgery in pregnancy: Most common cause of Most common persistent pyelonephritis despite adequate therapy: Nephrolithiasis. - 121 cult rst (10%). rst → neonatal neurologic injury. ORDERS located at McBurney’s point (RLQ). point located at McBurney’s curs in 1 in 2000 births). in third trimester (40%) than fi diffi complaints, making diagnosis also be a part of normal pregnancy cult. for recurrent pyelonephritis. Laparotomy in later pregnancy. Preterm labor. Preterm sepsis Maternal-fetal appendectomy. Immediate Laparoscopy (early pregnancy when uterus is small). not be may Pain and laterally. superiorly the appendix Uterus displaces Physical exam may be obscured from the enlarging uterus. Abortion. in pregnancy (oc- is the most common surgical condition Appendicitis but rupture is more frequent pregnancy, is same throughout Incidence and anorexia, may vomiting, such as nausea, Symptoms of appendicitis, Ectopic pregnancy (early pregnancy) Labor Pyelonephritis Appendicitis Pancreatitis Cholecystitis torsion Ovarian Hospitalization. cephalosporins. antibiotics usually IV urinary output. for adequate IV hydration pregnancy suppression for remainder of Consider long-term antibiotic Appendicitis abruption Placental myoma Infracted ANAGEMENT OMPLICATIONS GASTROINTESTINAL DIS REATMENT T C Appendicitis Differential Diagnosis of Acute Abdomen Differential Diagnosis of Acute During advanced pregnancy, gastrointestinal (GI) symptoms become diffi gastrointestinal pregnancy, During advanced M uterus. are often obscured by the enlarged ndings fi to assess, and physical Medical Conditions in Pregnancy HIGH-YIELD FACTS of lower-extremity DVT. gold standardfordiagnosis Contrast venographyisthe of congenitalanomalies. seizure disorder↑therisk Remember thatmaternal T C Cholelithiasis andCholecystitis 122 S Deep Vein Thrombosis (DVT) REATMENT GSAND IGNS THROMBOEMBOLIC DISORDERS SEIZURE DIS OMPLICATIONS ing. What isthemostlikelydiagnosis? tress. Herleftcalfmeasures4cmmorethantheright.The fetalstatusisreassur- Blood levelsofanticonvulsantmedications shouldbecheckedatthe Once pregnant,thefetusshouldbescreenedforNTDsandcongenital an- Folic bythosewomentaking shouldbe taken acid supplementation Anticonvulsanttherapyshouldbereducedtotheminimum doseofthe Managementoftheepilepticfemaleshouldbeginwithpre-pregnancy Thefetusisatriskformegaloblasticanemia. Pregnant epilepticsaremorepronetoseizures duetotheassociated Women withaseizure disorder havean↑ Women anticonvulsantsduringpregnancyhavedou- withepilepsytaking Highriskofpretermlabor. Medical managementunlesscommonbileductobstructionorpancrea- Sameclinical pictureasnonpregnant. Incidence ofcholecystitisis1in1000pregnancies (morecommonthan Palpate cordsinleg. Calf pain. Calf/leg swelling. Answer: when they do not take anticonvulsantmedications.when theydonottake leptic episodessuccessfully. beginning ofpregnancy todetermine thedruglevelthatcontrolsepi- malformations. ticonvulsants. minimum number ofanticonvulsantmedications. counseling. stress andfatigueofpregnancy. malformationsandpreeclampsia. ble thegeneralpopulationriskoffetal titis develops,inwhichcaseacholecystectomyshouldbeperformed. nonpregnant). S denies anydyspneaorchestpain.Sheisafebrileandinno apparentdis- left legandthighsincethepreviousnight.Shedeniesany trauma.She A 27-year-old G1at26 weekspresentstotheoffi ce withswelling ofthe YMPTOMS Deep veinthrombosis. ORDER risk ofbirthdefectseven HIGH-YIELD FACTS Medical Conditions in Pregnancy Warfarin is a terotogen, so Warfarin Can not used in pregnancy. breast-feed with it postpartum. 123 a ys k phy enous e result w ris Lo sitiv in 1–7 da sonogra Po Repeat v e result e result Negativ No treatment phy or phy Negativ eins a k phy enogra t v high ris te or Modera imaging of v magnetic resonance Contras the risk of pulmonary embolism to less than 5%. ↓ the risk of pulmonary enous sonogra e result V ein thrombosis in pregnancy sitiv 7-1) Po Signs or symptoms of suspected deep-v Diagnosis of Deep Venous Thrombosis Diagnosis of Deep Venous IGURE e result (F reatment sitiv after 12–48 hr, depending on the degree of trauma to the genital on the tract. after 12–48 hr, depending (LMWH) during pregnancy. (LMWH) during cumbersome. T and delivery and restarted should be suspended during labor Heparin pregnant). warfarin postpartum (do not use warfarin when Convert to Anticoagulation heparin with unfractionated or low-molecular-weight Anticoagulation Venography: Gold standard. Gold consuming, time complications, Many Venography: for larger veins. Better plethysmography: Impedance often used currently. most Test ultrasonography: Compression Po IAGNOSIS OMPLICATIONS REATMENT FIGURE 7-1. Health Care: from Lockwood C: Clinical Updates in Women’s (Reproduced, with permission, VI, No. 4. American College of Ob- , Vol. and Thromboembolism Thrombophilia, Thrombosis, and Gynecologists, October 2007.) stetricians Pulmonary embolism develops in about 25% of patients with untreated DVT. develops in about 25% of patients Pulmonary embolism T C D Medical Conditions in Pregnancy HIGH-YIELD FACTS Do notusecoumadin. molecular-weight heparin. (DVT)? Heparinorlow- deep veinthrombosis pregnant womanwitha How doyoutreata contraceptive pills. combination oral asymptomatic womanstarts diagnosed whenan Leiden mutation,often thrombophilia: FactorV Most common heritable coagulopathies. thrombogenic ofthe defi Antithrombin pregnancy. rather thanthecalfin originate intheiliacveins embolusmay Pulmonary ciency:Most Heparin orLMWH. T C Thrombophilias Pulmonary Embolism(PE) 124 P REATMENT SICKLE CELLDISEASE REGNANCY OMPLICATIONS Stillbirth. Recurrent abortion. Placental abruption. Fetal growth restriction. HELLPsyndrome(hemolysis,elevatedliverenzymes,low platelets). Preeclampsia/eclampsia. Hyperhomocysteinemia. mutation. Prothrombin G20210A antibodies: Antiphospholipid Factor VLeidenmutation: ProteinSdefi ProteinCdefi HalfofwomenpresentingwithaDVT willhavea“silent”PE. Complicationsincludematernaldeath. Signs:Tachypnea, tachycardia,apprehension,rales,hypoxemia. Symptoms:Dyspnea,chestpain,cough,syncope,hemoptysis. Pyelonephritis. Pneumonia. Thromboses (cerebralvein thrombosis,DVT, PE). Acute chestsyndrome:Pleuriticpain,fever,cough,lunginfi Crisismorecommoninpregnancy. Onein12African-Americans arecarriers. Redcellswith hemoglobinSundergosicklingwith↓ trates, hypoxia. cell membranedamage. coagulopathies. Antithrombin IIIdefi ↑ riskofthrombusformationandassociated complications. Treatment: Anticoagulationwithheparin/LMWH. Diagnosis: Infarction ofbonemarrow causesseverebonepain. Sickle-cell crisis:Pain duetoischemia andinfarctioninvariousorgans. See sectiononAntiphospholipidSyndrome. lism (VTE)inpregnancy. Four toeightfold ↑riskoffi rst VTEinpregnancy. Heterozygous inheritance. thrombophilia;5–8%ofthegeneralpopulation. Mostcommon heritable C OMPLICATIONS Spiral CT. ciency: ciency: The most thrombogenic of the heritable ciency:Themostthrombogenic oftheheritable 2- to6-fold↑riskoffirst VTEinpregnancy. 6- to12-fold↑ Commonly seeninpatientswithlupus. risk offi rstvenousthromboembo- oxygen leading to l- HIGH-YIELD FACTS Medical Conditions in Pregnancy The two most common causes of anemia during pregnancy and the puerperium are iron ciency and acute blood defi loss. 125 sick- ↓ ciency type. ciency OMPLICATIONS C At least one preterm birth before 34 weeks. At least three consecutive spontaneous abortions before 10 weeks. At least one otherwise unexplained fetal death at or beyond 10 weeks. or hematocrit < 30%. tion from volume expansion. cell turnover. sial. ling. Arterial and venous thrombosis. morbidity: Pregnancy Preterm delivery. Preterm restriction (IUGR). Intrauterine growth birth weight. Low 10 g/dL drop in hemoglobin below for a pregnant woman is a Anemia in pregnancy due to hemodilu- is normal anemia Physiologic anemia Supplementation to accommodate for rapid of folic acid with 4 mg/day and pain control for crises. IV hydration in an attempt to administered nasal cannula Oxygen given via pregnancy are controver- Prophylactic blood transfusions throughout Placental abruption Placental delivery Preterm restriction growth Fetal Stillbirth Sepsis syndrome. Sepsis HTN. Gestational Preeclampsia. Eclampsia. Clinical Criteria Clinical ANAGEMENT IAGNOSIS ELIVERY OMPLICATIONS ANTIPHOSPHOLIPID SYNDROME ANTIPHOSPHOLIPID ANEMIA REATMENT NCIDENCE D Two hundred milligrams of elemental ferrous sulfate, hundred milligrams iron daily from either Two fumarate, or gluconate. T Twenty to sixty percent of pregnant women; 80% is iron defi Twenty C I M D Medical Conditions in Pregnancy HIGH-YIELD FACTS remain thesame. get worse,andone-third third getbetter, one-third patients withlupus:one- Rule ofthumbforpregnant congenital heartblock. associated withfetal and anti-La(SS-B)are Presence ofanti-Ro(SS-A) M Signifi C the patient’s pasthistoryofthrombosisandpregnancymorbidity. Ranges fromnotreatmenttodailylow-dose aspirintoheparin,depending on M 126 I NCIDENCE SYSTEMIC LUPUS ERYTHEMATOSUS LUPUS SYSTEMIC PRURITIC URTICARIAL PAPULES AND PLAQUES OF OF PLAQUES AND PAPULES URTICARIAL PRURITIC OMPLICATIONS ANAGEMENT ANAGEMENT Laboratory Criteria Cyclophosphamide, methotrexate,andmycophenolate mofetilshould Azathioprineisanimmunosuppressant thatcan be usedsafelyinpreg- High-dosemethylprednisolone canbegivenforalupusfl compromise, thepregnancyshould Unless thereisevidence offetal Monitor fordisease fl ares andhypertensiveepisodes. Patients shouldbecounseledtogetpregnant whiletheir disease isinre- Neonatesmayhavesymptomsoflupusforseveralmonthsafterbirth. Thrombophilia. Anemia. Fetal growth restriction. Preterm labor. Preeclampsia. Eachofthesefi ndings must bepresentinplasma, onatleasttwoocca- Anti-β Medium tohightitersofanticardiolipin antibody. Lupus anticoagulant. Puerperium: Seldom occursinsubsequent pregnancies. Onein200singletonpregnancies, ↑to8in200withmultiples. Themostcommonpruritic dermatosisinpregnancy. cant be avoided, or at least not started until after12weeksgestation. be avoided, oratleastnotstarted nancy. progress toterm. mission. sions >12weeksapart. anti-Ro (SS-A)andanti-La(SS-B). Congenital heartblockmaybeseenintheoffspringofwomenwith Acutebloodloss. Fe defi ↑ inmaternalmorbidity/mortalityandothercomplications: 2 glycoprotein. ciency. PREGNANCY (PUPPP) are. HIGH-YIELD FACTS Medical Conditions in Pregnancy 127 rst trimester. rst YMPTOMS S IGNS AND S tardation, and the risk of future malignancies. used after the fi seen if chemotherapeutic agents are cancers can be done relatively safely but if directed toward abdominal abdominal toward but if directed cancers can be done relatively safely tumors, it may cause fetal death. such as carcinogenesis, cell death, and brain damage. such as carcinogenesis, nancy. palms, and soles. volve face, restriction, mental malformations, growth Risks to the fetus include re- and few adverse outcomes are Risk is highest during organogenesis, is during organogenesis. The most susceptible period is important to head and neck The site of the tumor radiation as well; Therapeutic radiation can cause signifi cant complications in the fetus, cant complications can cause signifi Therapeutic radiation mainstays are the Oral antihistamines and topical steroids of treatment. for severe pruritus. corticosteroids systemic May require delivery. shortly before or a few days after disappears Rash usually cutaneous pruritic Intensely in preg- late usually appears that eruption target and eczematous vesicles, Erythema, seen. lesions may be may in- and legs. Rarely and spread to arms on the abdomen Begins LINICAL CANCER THERAPY DURING PREGNANCY THERAPY CANCER REATMENT Chemotherapy Radiation As long as the reproductive organs are not involved, surgery is generally well As long as the reproductive organs fetus during pregnancy and should not be tolerated by both the mother and delayed. Surgery T C NOTES HIGH-YIELD FACTS HIGH-YIELD Medical Conditions in Pregnancy

128 CHAPTER 8 Obstetric Complications

Hypertension in Pregnancy 130 HYPERTENSIVE DISEASES OF PREGNANCY 130

HELLP SYNDROME 133

ECLAMPSIA 133

ANTIHYPERTENSIVE AGENTS USED IN PREGNANCY 134 Gestational Diabetes Mellitus 134 Shoulder Dystocia 136 Hyperemesis Gravidarum 137 Isoimmunization 138 ANTI-D ISOIMMUNIZATION 138

KELL ISOIMMUNIZATION 142 Preterm Labor 142 MANAGEMENT OF PRETERM LABOR 143 Premature Rupture of Membranes 144 Third-Trimester Bleeding 146 PLACENTAL ABRUPTION (ABRUPTIO PLACENTAE) 148

PLACENTA PREVIA 150

FETAL VESSEL RUPTURE 150

UTERINE RUPTURE 151

OTHER OBSTETRIC CAUSES OF THIRD-TRIMESTER BLEEDING 152 Abnormalities of the Third Stage of Labor 152 EARLY POSTPARTUM HEMORRHAGE 152

PLACENTAL ATTACHMENT DISORDERS 153

UTERINE INVERSION 154

129 HYPERTENSION IN PREGNANCY

Hypertensive Diseases of Pregnancy

What is the treatment of A 28-year-old G2P1001 at 37 weeks gestation complains of severe head- choice for seizure aches and black spots in her visual ﬁ eld. Her blood pressures are 165/95 prophylaxis in pregnant and 163/96 and she has 4+ protein on urine dipstick. Her cervical exam is female with pregnancy- induced HTN? Magnesium closed, thick, and high. The fetal heart tones are reassuring and she has no contractions. The ultrasound (US) shows a fetus that is appropriate for 37 weeks, with sulfate (MgSO4) What is its antidote in the normal amniotic ﬂ uid index (AFI), and in cephalic position. What is the next best case of toxicity? Calcium step? gluconate Answer: This patient has signs and symptoms of severe preeclampsia and should be delivered immediately, especially when term. Vaginal delivery is usually attempted. Patients with preeclampsia can have a seizure at any point before, during, or after labor, so seizure prophylaxis with magnesium sulfate is indicated.

Hypertensive disorders of pregnancy include gestational hypertension (HTN), mild and severe preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets), and eclampsia. These may all be a spectrum of the same disease process that manifest at different levels of severity at different gestational ages. HIGH-YIELD FACTS HIGH-YIELD Hypertension-related deaths in pregnancy account for 15% of maternal deaths Chronic HTN: (second after pulmonary embolism). ↑ BP outside of There are four categories of HTN in pregnancy: pregnancy. ↑ BP prior to 20 weeks 1. Preexisting or chronic HTN during pregnancy: Preexisting HTN begins prior to pregnancy or before the 20th week gestation. of gestation. ↑ BP persisting after 12 Defi ned as a sustained systolic BP ≥ 140 mm Hg and/or diastolic BP weeks postpartum. ≥ 90 mm Hg documented on more than one occasion prior to the 20th week of gestation, HTN that existed before pregnancy, or HTN that persists > 12 weeks after delivery. Usually not associated with signifi cant proteinuria or end-organ damage if well controlled. 2. Gestational hypertension (most benign): Also called transient HTN and pregnancy-induced HTN. Obstetric Complications A sustained or transient systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg occurs after the 20th week of gesta- Superimposed tion. preeclampsia: No proteinuria or end-organ damage. Preeclampsia in the 3. Preeclampsia: presence of preexisting Defi ned as hypertension with proteinuria after the 20th week of gestation. chronic hypertension. Mild preeclampsia is defi ned by: Diagnosed with worsening A systolic BP ≥ 140 mm Hg or a diastolic BP ≥ 90 mm Hg twice blood pressures and > 6 hr apart at bed rest. proteinuria. Patients with Proteinuria: 1+ on dipstick or ≥ 300 mg/24 hr. chronic hypertension are at Usually no other subjective symptoms. ↑ risk of developing Severe preeclampsia is defi ned by: superimposed preeclampsia. A systolic BP ≥ 160 mm Hg or a diastolic BP ≥ 110 mm Hg twice 6 hr apart at bed rest with or without the following end organ fi ndings.

130 Neurologic: Frontal headaches, scotomata, eclampsia (seizure due to preeclampsia). Renal: Proteinuria (≥ 5.0 g/24 hr), oliguria (< 500 cc/24 hr). Gastrointestinal (GI): Epigastric or right upper quadrant (RUQ) pain (hepatocellular ischemia and edema that stretches Glisson’s capsule). ↑ aspartate transaminase (AST), alanine transaminase Symptoms of severe (ALT). preeclampsia include: Pulmonary: Edema, cyanosis. Headache Hematologic: Thrombocytopenia (< 100,000), microangiopathic Visual disturbances coagulopathy, hemolysis (↑ LDH). Epigastric/RUQ pain Fetal: IUGR or oligohydramnios. 4. Superimposed preeclampsia: Preeclampsia (mild or severe) in patients with chronic HTN in pregnancy. Twenty-ﬁ ve percent of patients with chronic HTN in pregnancy develop preeclampsia. Patients can have seemingly benign HTN (no proteinuria or evidence of end-organ damage) in early pregnancy and then develop pre- HIGH-YIELD FACTS eclampsia. Increasing proteinuria in the setting of HTN after the 20th week of gestation is preeclampsia, regardless of the timing of the onset of the Preeclampsia is usually HTN. asymptomatic; it is critical Often occurs earlier in pregnancy, has more severe fetal growth re- to pick it up during routine striction than preeclampsia without chronic HTN, and is also associ- prenatal visits. ated with ↑ risk of placental abruption.

PATHOPHYSIOLOGY Vasospasm in various organs (brain, kidneys, lungs, uterus) causes most of the signs and symptoms of preeclampsia; however, the cause of the vasospasm is unknown. Obstetric Complications

COMPLICATIONS The only deﬁ nitive Abruption. Eclampsia with intracranial hemorrhage, blindness. treatment for preeclampsia Coagulopathy. is delivery. Renal failure. Hepatic subcapsular hematoma. Uteroplacental insufﬁ ciency.

TREATMENT See Figure 8-1 for a management algorithm. Magnesium toxicity (7–10 The only cure for preeclampsia and its variants is delivery of the fetus. mEq/L) is associated with Preexisting HTN/transient HTN/chronic HTN in pregnancy: Antihy- loss of patellar reﬂ exes, pertensive medications vs. close observation. respiratory depression, and Antihypertensive medications have not been found to be helpful, and cardiac arrest. Treat with in some cases adversely affect fetal growth. calcium gluconate 10% Magnesium sulfate (MgSO4) is started for seizure prophylaxis when decision is made to deliver fetus. It is not a treatment for HTN. solution 1 g IV.

131 Diagnose HTN BP > 140/90 at rest, measured at least twice, and > 6 hours apart. (sustained ↑ in BP)

History of HTN before pregnancy

Yes No

HTN Check onset prior Baseline to 20 weeks? Labs

Yes No

Consider Molar Pregnancy

Chronic Hypertension BP > 160/110

If conditions worsen, Yes Like: ↑ HTN, Proteinuria, No DIC, Fetal growth retardation, other signs/symptoms

Severe HIGH-YIELD FACTS HIGH-YIELD Preeclampsia Magnesium sulfate prevents Check seizures in preeclampsia; 24-hr Urine Protein does not treat HTN. ≥ 5 g ≥ 0.3 g < 5 g

Deliver Baby

Consider Physical Exam When patients are put on Epigastric Pain MgSO4 for seizure Visual Disturbances, HA, Oliguria prophylaxis, they must be ≥ 37 Yes No closely monitored for weeks’ magnesium toxicity by gestation Obstetric Complications obtaining magnesium levels Mild Preeclampsia and watching for hyporeﬂ exia. Conservative Management < 37 weeks’ gestation Follow Blood Pressure

FIGURE 8-1. Management of hypertension in pregnancy.

(Reproduced, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and Gynecology. New York: McGraw-Hill, 1998: 60.)

Mild preeclampsia: HTN may be absent in 20% Preterm: Close monitoring for worsening disease. of women with HELLP Fetal testing (non-stress tests [NSTs] and biophysical proﬁ les syndrome and severe in [BPPs]) to ensure fetal well-being. 50%.

132 Bed rest is not necessary, although ↓ physical activity is recommended. Term: delivery. Vaginal delivery is usually attempted; cesarean delivery for other obstetrical reasons. Start MgSO4 for seizure prophylaxis. Severe preeclampsia: Very preterm (< 28 weeks): Close monitoring in hospital in select cases only. Preterm or term: Delivery. Delivery may not be in the best interest of the premature baby, but it is indicated to prevent worsening maternal disease. Objectives in management Vaginal delivery is usually attempted; cesarean delivery for other of severe preeclampsia: obstetrical reasons. 1. Prevent eclampsia which Start MgSO4 for seizure prophylaxis. can cause intracranial hemorrhage and

damage to other vital HIGH-YIELD FACTS HELLP Syndrome organs HELLP syndrome is a manifestation of severe preeclampsia with: 2. Deliver a healthy infant Hemolysis, Elevated Liver enzymes Low Platelets. It is associated with high morbidity, and immediate delivery is indicated. It may occur with or without HTN.

Eclampsia Diuretics are not used in pregnancy because they ↓ Deﬁ ned as seizure or coma without another cause in a patient with preec- → → plasma volume and this lampsia. Eclampsia hemorrhagic stroke death. may be detrimental to fetal Obstetric Complications growth. Salt restriction also TREATMENT ↓ plasma volume and is Airway, breathing, and circulation (ABCs). not recommended. Rule out other causes: Head trauma is a possible confounder; others include cerebral tumors, cerebral venous thrombosis, drug overdoses, epilepsy, and cerebrovascular accidents. Control seizures with magnesium sulfate (the only anticonvulsant used). Delivery is the only deﬁ nitive treatment. If diagnosis of eclampsia made, no expectant management regardless of gestational age. Vaginal delivery is recommended. Angiotensin-converting Women often go into spontaneous labor after onset of seizures, and/ enzyme (ACE) inhibitors are or have a shorter duration of labor. contraindicated because Control BP with hydralazine or labetalol. they are teratogenic. Use other classes of RISK FACTORS FOR HYPERTENSIVE DISEASES IN PREGNANCY antihypertensives to control Nulliparity. HTN in pregnancy. Age > 40 yr. African-American race. Family history of preeclampsia. Chronic HTN.

133 Chronic renal disease. Antiphospholipid syndrome. Diabetes mellitus. Multiple gestation. Angiotensinogen gene T235 (homozygous > heterozygous).

Antihypertensive Agents Used in Pregnancy

SHORT-TERM CONTROL Eclampsia: Hydralazine: IV or PO, direct vasodilator. Side effects: systemic lupus 25% of seizures are erythematosus (SLE)-like syndrome, headache, palpitations. before labor. β α Labetalol: IV or PO, nonselective 1 and 1 blocker. Side effects: head- 50% of seizures are ache and tremor. during labor. 25% of seizures are LONG-TERM CONTROL postdelivery (may be Methyldopa: PO, false neurotransmitter. Side effects: postural hypoten- encountered up to 10 sion, drowsiness, ﬂ uid retention. days postpartum). Nifedipine: PO, calcium channel blocker. Side effects: edema, dizziness.

GESTATIONAL DIABETES MELLITUS HIGH-YIELD FACTS HIGH-YIELD

A 33-year-old G4P3003 at 26 weeks gestation undergoes the 50-g glucose challenge test. The result is 160 mg/dL. What is the next step in management? Answer: She should undergo the 3-hr glucose tolerance test since her 1-hr result was > 140 mg/dL.

Pregestational diabetes (DM): Patient diagnosed with DM prior to pregnancy. What is a major fetal Gestational diabetes (GDM): Patient develops diabetes only during complication of gestational pregnancy. diabetes mellitus? White Classifi cation A1: Controlled with diet. Macrosomia White Classifi cation A2: Requires insulin. Obstetric Complications SCREENING When obtaining a patient’s history, look for signs of overt diabetes that has not yet been diagnosed. If these signs are present, the patient should not receive the routine screening during pregnancy. Signs of overt diabetes: Polydipsia. Polyuria. History of insulin or oral hypoglycemic agents between pregnancies. History of “touch of sugar” between pregnancies. Overt glycosuria. Frequent infections (vaginal candidiasis, cellulitis). If overt diabetes is suspected, perform a fi ngerstick (FS) glucose level without a glucose load.

134 If fasting FS is > 110 mg/dL or random > 150 mg/dL, diagnosis of diabetes. If fasting is > 140 mg/dL or random > 200 mg/dL, consider hospitalization for glycemic control. See Chapter 7 regarding Pregestational Diabetes. Risk factors: Early screen at 16 weeks when: Age > 30. Prior pregnancy with gestational diabetes. Diabetes is the most Family history of diabetes. Obesity (> 20% ideal body weight). common medical Previous infant > 4000 g (8¾ lb). complication of pregnancy. History of stillbirth or child with cardiac defects (poor obstetrical outcome). Race: Black, Hispanic, Native American. Glucose challenge test at 24–28 weeks: Give 50-g glucose load (nonfasting state). Gestational diabetes Draw glucose blood level 1 hr later. probably results from If ≥ 140, a 3-hr glucose tolerance test (GTT) is then required to diag- human placental HIGH-YIELD FACTS nose GDM. lactogen secreted during If > 200, patient is diagnosed with GDM type A1 and a diabetic diet pregnancy, which has large is initiated. glucagon-like effects. 3-hr GTT—if glucose challenge test is ≥ 140 and < 200: Unrestricted diet for 3 days, carbohydrate load prior to test. Fasting for 8–14 hr. Draw fasting glucose level. Give 100-g glucose load. Draw glucose levels at 1 hr, at 2 hr, and at 3 hr. Diagnosis of gestational diabetes made if two or more values are equal to or greater than those listed (see Table 8-1). Either criteria can be If a pregnant woman has used to make the diagnosis. an abnormal one hour

glucose challenge test, then Obstetric Complications MATERNAL EFFECTS check a 3-hr GTT. Four times ↑ risk of preeclampsia. ↑ risk of bacterial infections. Higher rate of C-section. ↑ risk of polyhydramnios. ↑ risk of birth injury. Thirty percent of women with gestational diabetes develop diabetes mellitus in TABLE 8-1. Diagnosis of Gestational Diabetes later life.

NATIONAL DIABETES PLASMA DATA GROUP CRITERIA (mg/dL) CARPENTAR/COUSTAN CRITERIA (mg/dL)

Fasting 105 95

1 hr 190 180

2 hr 165 155

3 hr 145 140

135 FETAL EFFECTS ↑ risk of perinatal death (A2 > A1). Fetal anomalies not ↑ in gestational diabetes (as opposed to pregestational diabetes). Two to three times ↑ risk of preterm delivery. Hyperinsulinemia → fetal macrosomia → birth injury (shoulder dystocia). Hyperglycemia affects most fetal organs except brain. Excessive fat on shoulders and trunk. Metabolic derangements at birth (hypoglycemia, hypocalcemia).

MANAGEMENT The key factors involved in successful management of these high-risk pregnancies include: The CNS anomaly most speciﬁ c to DM is caudal A glucose control log should be checked at each prenatal visit. regression. Maintain fasting glucose < 95 and 2-hr postprandial (breakfast, lunch, dinner) glucose < 120. If A1 with continued ↑ in glucose, start insulin. Oral hypoglycemic agents (glyburide, metformin) have been studied. If A2 with continued ↑ in glucose, ↑ insulin dose. Fasting glucose most important for fetal and maternal effects. At 32–34 weeks for A2 gestational diabetics: Fetal testing (BPP). HIGH-YIELD FACTS HIGH-YIELD US for growth every 4 weeks. Delivery: A1 gestational diabetics: Await labor. Fetal testing between 41 and 42 weeks. Consider delivery between 41 and 42 weeks. A2 gestational diabetics: Consider delivery at 39–42 weeks if good dating. If poor glycemic control, consider amniocentesis for fetal lung maturity and delivery at term. Maintain euglycemia during labor (insulin drip for A2). May offer cesarean delivery if fetal weight ≥ 4500 g.

SHOULDER DYSTOCIA

A 25-year-old G1P0 is delivering her ﬁ rst child. Her labor course was

Obstetric Complications protracted and she pushed for 3 hr. The head is seen to deliver and then retracts, forming the turtle sign. The infant’s shoulder does not deliver with gentle symmetric traction. What is the diagnosis? What is the next step in management? Answer: Shoulder dystocia. Calling for help is essential to perform the additional maneuvers.

Shoulder dystocia is diagnosed when the fetal shoulder is lodged behind the Shoulder dystocia = pubic symphysis after the fetal head has been delivered, and the delivery can- obstetric emergency not be completed. This is an obstetric emergency. If infant is not delivered quickly, it may suffer neurologic injury or death from hypoxia.

136 RISK FACTORS Maternal factors leading to ↑ fetal birth weight: Obesity Multiparity Gestational diabetes Shoulder dystocia Fetal: Post-term pregnancy (> 42 weeks). management— Intrapartum: Prolonged fi rst and/or second stage of labor. HELPERRR COMPLICATIONS Call for Help Brachial plexus nerve injuries. Episiotomy Fetal humeral/clavicular fracture. Legs up (McRobert’s Hypoxia/death. position) Pressure suprapubically TREATMENT Enter vagina for shoulder Several maneuvers can be done to dislodge the shoulder: rotation (Woods corkscrew) McRoberts maneuver: Maternal thighs are sharply fl exed against ma- HIGH-YIELD FACTS ternal abdomen. This fl attens the sacrum and the symphysis pubis and Reach for posterior arm may allow the delivery of the fetal shoulder. Rupture clavicle or pubic Suprapubic pressure slightly superior to the symphysis pubis and in the symphysis direction of the desired shoulder rotation. Return head into vagina Woods corkscrew maneuver: Pressure is applied against scapula of pos- for C-section (Zananelli). terior shoulder to rotate the posterior shoulder and “unscrew” the anterior shoulder. Posterior shoulder delivery: Hand is inserted into vagina and posterior arm is pulled across chest, delivering posterior arm and shoulder. This creates a shorter distance between the anterior shoulder and posterior axilla, allowing the anterior shoulder to be delivered. Break clavicle: Apply pressure with the fi ngers to the fetal clavicle. Zavanelli maneuver: If the above measures do not work, the fetal head Obstetric Complications can be returned to the uterus by reversing the cardinal movements of labor. At this point, a C-section can be performed. Do not apply fundal Maneuvers that do not require direct contact with the fetus should be pressure in shoulder done fi rst because they have lower morbidity for the fetus. Manipula- dystocia. It causes further tion of the fetus to accomplish a delivery in a shoulder dystocia has ↑ impaction of the shoulder morbidity. behind the symphysis pubis.

HYPEREMESIS GRAVIDARUM

Severe vomiting that results in: Weight loss. Dehydration. Metabolic derangements. Due to high levels of human chorionic gonadotropin (hCG), estrogens, or both. Psychiatric component present. Management: Rule out other causes (molar pregnancy, thyrotoxicosis, GI etiology). First line: Vitamin B6 with doxylamine. IV hydration, thiamine replacement, antiemetics. Parenteral nutrition.

137 ISOIMMUNIZATION

First step in management of isoimmunized pregnant A 29-year-old G2P1001 at 16 weeks gestation presents for prenatal care. patient: Check paternal Her blood type is A negative with a positive antibody screen. What is the erythrocyte antigen status. next step in management? Answer: Identify the antibody. Some can be dangerous for the fetus and some are benign.

In each pregnancy, a woman should have her blood type, Rh status, and antibody screen evaluated at the initial prenatal visit. If the antibody screen is positive, the next step is to identify the antibody. Some anti- Kell Kills, Duffy Dies, bodies pose no harm to the fetus (ie, anti-Lewis), while others can cause Lewis Lives. hemolytic disease of the newborn (HDN) and be fatal (ie, anti-D, anti- Kell, anti-Duffy). Along with antibodies to antigens on fetal red blood cells (RBCs), antibodies may be directed against fetal platelets. If the antibodies are not harmful to the fetus, no further workup needs to be done. If antibodies are known to cause harm to the fetus, next step is to determine the titer of the antibodies. A critical titer, usually 1:16 at most institutions, is the titer associated with a signiﬁ cant risk for HDN. Fetal surveillance with possible therapeutic interventions may be needed (see Figure 8-2). HIGH-YIELD FACTS HIGH-YIELD

Anti-D Isoimmunization An understanding of D (or Rho) RBC antigen compatibility is a crucial part of prenatal care. If a mother and developing child are incompatible, very serious complications can cause fetal death. This section will review the appropriate screening and therapy for anti-D isoimmunization.

WHAT IS RHOR D? The surface of the human RBC may or may not have a Rho (Rh) antigen. If a patient with blood type A has a Rho antigen, the blood type is A+. If that person has no Rho antigen, the blood type is A–. In the following discussion, the Rh antigen will be referred to as D. Half of all antigens on fetal RBCs come from the father, and half come from the mother. That means that the fetus may have antigens to which

Obstetric Complications the mother’s immune system is unfamiliar.

THE PROBLEM WITH D SENSITIZATION If the mother is D negative and the father is D positive, there may be a chance that the baby may be D positive. If the mother is D negative and her fetus is D positive, she may become sensitized to the D antigen and develop antibodies against the baby’s RBCs. These antibodies cross the placenta and attack the fetal RBCs, resulting in fetal RBC hemolysis. The hemolysis results in signiﬁ cant fetal anemia, resulting in fetal heart failure and death. This disease process is known as hemolytic disease of the newborn (HDN).

138 Antibody screen (+)

Identify antibody

Not cause HDN Causes HDN

Check paternal blood type Stop workup Check antibody titer and D status/genotype

Titer ≤ 1:8 (low) Titer ≥ 1:16 (critical titer)

Heterozygous Homozygous Antigen (-) Monitor titer monthly or unknown HIGH-YIELD FACTS Monitor for anemia Stop workup All children affected Historically: Spectral analysis with amniotic fluid bilirubin levels Fetal genotype (via Plot on graphs aminiocentesis Liley or Queenen and PCR)

Fetus (+) Fetus negative

Middle cerebral Obstetric Complications artery doppler (peak systolic velocity ↑ with anemia) Stop workup

Severe anemia Mild anemia 37–38 wks

Fetal transfusion Deliver

32 weeks

Deliver

Steroids

Deliver

FIGURE 8-2. Management of isoimmunization.

139 Sensitization is the development of maternal antibodies against D antigens on the fetus RBC. Sensitization may occur whenever fetal blood enters the maternal circulation. The fetus of the pregnancy when sensitization occurred usually suffers no harm because the maternal antibody titers are low. The subsequent pregnancies with a D-positive fetus are at signiﬁ cantly higher risk of HDN because the mother has already developed memory cells that quickly produce anti-D antibodies against the fetus RBCs. The following conditions can cause fetal-maternal bleeding, and lead to sensitization: Chorionic villus sampling. Amniocentesis. Spontaneous/induced abortion. Threatened/incomplete abortion. Ectopic pregnancies. Placental abruption/bleeding placenta previa. Vaginal or cesarean delivery. Abdominal trauma. Kleihauer-Betke test External cephalic version. determines the number of fetal RBCs in the maternal ANTI-D IMMUNE GLOBULINS (IGG) (BRAND NAME: RHOGAM) circulation (see section on Anti-D immune globulins are collected from donated human plasma. When RhoGAM). a mother is given a dose of anti-D IgG, the antibodies bind to the fetal RBCs that have the D antigen on them and clear them from the maternal circula- HIGH-YIELD FACTS HIGH-YIELD tion. The goal is to prevent the mother’s immune system from recognizing the presence of the D antigen and forming antibodies against it. Give to D-negative mothers, who have not formed antibodies against D antigen. The standard dose of Not indicated for patients who already have anti-D antibodies and are RhoGAM is 300 μg. It is sensitized. sufﬁ cient for 15 mL of Indicated for patients who might be sensitized to other blood group an- D-positive fetal RBCs (30 tigens. mL of whole fetal blood). Kleihauer-Betke (KB) test MANAGEMENT OF THE UNSENSITIZED D-NEGATIVE PATIENT (THE D-NEGATIVE PATIENT WITH A NEGATIVE ANTIBODY SCREEN) estimates the number of fetal RBCs that are present 1. Antibody screen should be done at the initial prenatal visit and at 28 in the maternal circulation. weeks. The dose of anti-D IgG is 2. If antibody screen negative, the fetus is presumed to be D positive, and Obstetric Complications based on the results of the one dose of anti-D IgG immune globulin is given to the mother at 28 KB test. weeks to prevent development of maternal antibodies. Anti-D immune globulins last for ~12 weeks, and the highest risk of sensitization is in T3. 3. At birth, the infant’s D status is noted. If the infant is D negative, no anti- D IgG is given to the mother. If the infant is D positive, anti-D IgG is given to the mother within 72 hr of delivery. The dose of anti-D IgG is determined by KB test. 4. Administration of anti-D IgG at 28 weeks gestation and within 72 hr of birth, reduces sensitization to 0.2%.

140 MANAGEMENT OF THE SENSITIZED D-NEGATIVE PATIENT (ANTIBODY SCREEN POSITIVE FOR ANTI-D ANTIBODY) Hemolytic Disease of A 35-year-old G4P2012 at 26 weeks gestation is diagnosed with anti-Kell the Newborn antibodies with the titer of 1:32. Amniocentesis shows that the fetus is Hemolytic disease of the positive for the Kell antigen. In addition to fetal testing with a biophysical newborn (HDN)/fetal profi le, what other testing is critical for this fetus? hydrops occurs when the Answer: The fetus should be monitored with middle cerebral artery Dopplers, mother lacks an antigen which indicate the severity of anemia. present on the fetal RBC → fetal RBCs in maternal circulation trigger an 1. If antibody screen at initial prenatal visit is positive, and is identifi ed as immune response → anti-D, maternal antibodies lyse 2. Check the antibody titer. Critical titer is 1:16. → fetal RBCs fetal anemia If titer remains stable at < 1:16, the likelihood of hemolytic disease of → the newborn is low. Follow the antibody titer every 4 weeks. fetal hyperbilirubinemia If the titer is ≥ 1:16 and/or rising, the likelihood of hemolytic disease + kernicterus + heart HIGH-YIELD FACTS of the newborn is high. Amniocentesis is done. failure, edema, ascites, 3. Amniocentesis: pericardial effusion → Fetal cells are analyzed for D status. death. Historically, amniotic fl uid was analyzed by spectral analysis, which measured the light absorbance by bilirubin. Absorbance measurements were plotted on a graph to predict the severity of disease. The preferred method now is to perform middle cerebral artery (MCA) Dopplers to assess for anemia. 4. Serial US monitoring for: Anatomy scan for hydrops fetalis. MCA Doppler for presence or severity of anemia (see Figure 8-3). Fetal hydrops = collection Consider blood transfusion to fetus if very premature. of fl uid in two or more

5. Delivery: body cavities: Obstetric Complications Mild anemia: Induction of labor at 37–38 weeks. Scalp edema Severe anemia: Deliver at 32–34 weeks. Pleural effusion Most babies > 32 weeks do well in the neonatal intensive care unit Pericardial effusion (NICU). Ascites

A B

FIGURE 8-3. Middle cerebral artery.

A. Doppler B. Waveform. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstet- rics, 23rd ed. New York: McGraw-Hill, 2010: 365.)

141 Weigh risks for continued cord blood sampling and transfusions with neonatal risks of preterm delivery. Administer steroids to mother to enhance fetal lung maturity.

Kell Isoimmunization With the use of anti-D immune globulin, there is an ↑ of isoimmunization caused by minor antigens acquired by incompatible blood transfusion. Some minor antigens cause HDN, and some do not. Those that do cause HDN are managed the same way as anti-D isoimmunized mothers. Kell isoimmunization is an exception because: It is less predictable and results in more severe anemia than alloimuni- zation due to other erythrocyte antigens. Maternal Kell antibody titers and amniotic ﬂ uid delta OD450 are not predictive of the severity of fetal anemia as with anti-D sensitization. MCA Dopplers are accurate in predicting severe anemia with Kell isoimmunization.

PRETERM LABOR

CRITERIA

HIGH-YIELD FACTS HIGH-YIELD Gestational age (GA) < 37 weeks with regular uterine contractions and: Progressive cervical change Braxton Hicks contractions (irregular, nonrhythmic, or usually painless contractions A cervix that is 2 cm dilated that begin at early or gestation and ↑ as term A cervix 80% effaced approaches) may make it or difﬁ cult to distinguish Ruptured membranes. between true and false labor. RISK FACTORS Previous history of preterm delivery. Hydramnios. Multiple gestations. Cocaine. Obstetric Complications Urinary tract infection (UTI). Vaginal infections. Abruption.

ASSESSMENT Evaluate for causes such as infection (gonococcus, bacterial vaginosis), abruption. Conﬁ rm GA of fetus (ie, by US). Predictors of preterm labor: Transvaginal cervical length measurement: > 35 mm: Low risk of preterm delivery. < 25 mm (especially with funneling): High risk of preterm delivery.

142 Fetal ﬁ bronectin assay: Vaginal swab of posterior fornix prior to digital exam. If negative, 99% predictability for no preterm delivery within 1 week.

Management of Preterm Labor Most infants born after 34 HYDRATION weeks GA will survive (the survival rate is within 1%

Not proven to reduce preterm labor, but hydration may decrease uterine irri- of the survival rate beyond tability. Dehydration causes antidiuretic hormone (ADH) secretion, and ADH 37 weeks). mimics oxytocin, which causes uterine contractions.

TOCOLYTIC THERAPY Tocolysis is the pharmacologic inhibition of uterine contractions. Tocolytic drugs have not been shown to decrease neonatal morbidity or mortality, but Tocolytics have not been may prolong gestation for 2–7 days to allow time for administration of steroids proven to prolong HIGH-YIELD FACTS and transfer to a facility with a neonatal ICU. It is used when fetus is < 34 pregnancy. weeks gestation.

TOCOLYTIC AGENTS Magnesium sulfate: Suppresses uterine contractions. Unknown mechanism of action: Competes with calcium, inhibits myosin light chain. Maternal side effects: Flushing, lethargy, headache, muscle weakness, diplopia, dry mouth, pulmonary edema, cardiac arrest. Toxicity is treated with calcium gluconate. Fetal side effects: Lethargy, hypotonia, respiratory depression. Contraindications: Myasthenia gravis.

Nifedipine: Oral calcium channel blocker. Obstetric Complications Maternal side effects: Flushing, headache, dizziness, nausea, transient hypotension. Fetal side effects: None yet noted. Contraindications to Contraindications: Maternal hypotension, cardiac disease; use with tocolysis— caution with renal disease. Avoid concomitant use with magnesium sulfate. BAD CHU β β Ritodrine, terbutaline, agonist: 2 receptor stimulation on myome- Severe Bleeding from trial cells →↑ cyclic adenosine monophosphate (cAMP) →↓ intracel- any cause lular Ca →↓ contractions: Severe Abruptio Maternal side effects: Pulmonary edema, tachycardia, headaches. placentae Fetal side effect: Tachycardia. Fetal Death/life- Contraindications: Cardiovascular disease, hyperthyroidism, uncon- incompatible anomaly trolled diabetes mellitus. Chorioamnionitis Indomethacin, prostaglandin inhibitors: For < 32 weeks. Maternal side effects: Nausea, heartburn. Severe pregnancy- Fetal side effects: Premature constriction of ductus arteriosus, pulmo- induced Hypertension nary HTN, reversible ↓ in amniotic ﬂ uid. Unstable maternal Contraindications: Renal or hepatic impairment, peptic ulcer disease. hemodynamics

143 CORTICOSTEROIDS Given to patients in preterm labor from 24 to 34 weeks unless they have Maternal corticosteroid an infection. administration with: Actions: Accelerate fetal lung maturity (↓ RDS), and reduce intraven- Preterm labor 24–34 tricular hemorrhage. weeks Preterm premature ASSESSING FETAL LUNG MATURITY rupture of membranes An amniocentesis may be performed to assess fetal lungs for risk of RDS. Fetal (PPROM) 24–32 weeks lungs are mature if: Fetal benefi ts: Phosphatidylglycerol is present in amniotic fl uid. ↓ respiratory distress Surfactant-albumin in amniotic fl uid at a ratio > 55. syndrome (RDS). Lecithin-sphingomyelin in amniotic fl uid at a ratio > 2. ↓ intraventricular hemorrhage. PREVENTION OF PRETERM LABOR 17α-hydroxyprogesterone is often given as weekly IM injections starting at 16–20 weeks to women with risk factors or history of preterm labor. Relaxes the myometrium. Prevents rejection of the fetus by suppressing lymphocyte production of cytokines.

HIGH-YIELD FACTS HIGH-YIELD PREMATURE RUPTURE OF MEMBRANES

A 24-year-old G3P1102 at 38 weeks presents to triage with a complaint of leakage of clear ﬂ uid from the vagina for the past 24 hr. She reports good fetal movement, no vaginal bleeding, no contractions. She is afebrile. On sterile speculum exam, pooling, ferning, and positive nitrazine is noted. Sterile vaginal exam is 1 cm, long cervix, –3 station, cephalic. Fetal heart rate (FHR) is reassuring, and no contractions are noted. What is the diagnosis? Answer: Premature rupture of membranes is diagnosed when the membranes rupture prior to the onset of labor. Rupture of membranes is conﬁ rmed by the sterile speculum exam. Based on the vaginal exam and the absence of contractions, the patient is not in labor. Considering that the fetus is term, the next step should be induction of labor in order to prevent chorioamnionitis. Obstetric Complications

Premature rupture denotes spontaneous rupture of fetal membranes before the onset of labor. This can occur at term (PROM) or preterm (PPROM). ROM: Rupture of membranes. PPROM: Most common PROM: Premature rupture of membranes (ROM before the onset of diagnosis associated with labor). preterm delivery. PPROM: Preterm (< 37 weeks) premature rupture of membranes. Prolonged rupture of membranes: Rupture of membranes present for > 18 hr.

144 ETIOLOGY Unknown but hypothesized: Vaginal and cervical infections. Prolonged rupture of Incompetent cervix. membranes may be due to Nutritional deﬁ ciencies. premature rupture (PROM) or an abnormally long COMPLICATIONS labor (not PROM). Prematurity: If PROM occurs at < 37 weeks, the fetus is at risk of being born prematurely with its associated complications. Pulmonary hypoplasia: If PROM occurs at < 24 weeks → oligohydramnios → pulmonary hypoplasia. Survival at this age is low. Chorioamnionitis. Placental abruption. Neonatal infection. Umbilical cord prolapse. Preterm labor. HIGH-YIELD FACTS

MANAGEMENT OF ALL PROM PATIENTS Avoid vaginal exams if possible to ↓ risk of chorioamnionitis. Evaluate patient for chorioamnionitis (common etiology of PROM): Fever > 100.4°F (38°C), leukocytosis, maternal/fetal tachycardia, uterine tenderness, malodorous vaginal discharge. If chorioamnionitis present, delivery is performed despite GA, and broad-spectrum antibiotics (ampicillin, gentamicin) are initiated.

SPECIFIC MANAGEMENT FOR PROM AT TERM Ninety percent of term patients go into spontaneous labor within 24 hr after rupture:

Obstetric Complications Patients in active labor should be allowed to progress. Nitrazine test may be If labor is not spontaneous, it should be induced. Cesarean delivery falsely positive if should be performed for other indications. contaminated with blood,

SPECIFIC MANAGEMENT OF PPROM semen.

An 18-year-old G1P0 at 30 weeks gestation presents to triage with complaints of clear ﬂ uid leaking from her vagina. Testing is positive for pooling, ferning, and nitrazine. The cervix is visually closed. FHR is reassuring. No contractions are noted on the monitor. The US shows a singleton, viable fetus, in the breech position. What is the next step in management? Answer: The patient has preterm premature rupture of membranes. She should be admitted to the hospital. Steroids should be administered to ↓ the risk of RDS in the fetus, and antibiotics should be given to ↑ the latency period.

Fifty percent of preterm patients go into labor within 24 hr after rupture. Generally, one needs to balance the risks of premature birth against the risk of infection (which ↑ with the time that membranes are ruptured before birth). Amniotic ﬂ uid assessment for fetal lung maturity from vaginal pooling. Consider delivery if mature. US to assess GA, anomalies, presentation of baby, and AFI.

145 Monitor in hospital for infection, abruption, fetal distress and preterm labor. If < 32 weeks gestation, give steroids to ↓ the incidence of RDS. Antibiotic coverage to prolong latency period (time between ROM and onset of labor) to give a premature fetus time to mature in utero. Fetal testing to ensure fetal well-being. Delivery: Golden rule: Never do a If infection, abruption, fetal distress noted. digital vaginal exam in At 34 weeks gestation. At this GA, most babies with little risk of RDS; third-trimester bleeding avoid the risk of other complications. until placenta previa is ruled out. THIRD-TRIMESTER BLEEDING

INCIDENCE Occurs in 2–5% of pregnancies.

Apt, Kleihauer-Betke, and WORKUP Wright’s stain tests History, including trauma. determine if blood is fetal, Vitals: Signs of hypovolemia include hypotension and tachycardia. maternal, or both. Labs: Complete blood count (CBC), coagulation proﬁ le, type and crossmatch, urinalysis, drug screen. US to look for placenta previa, as well as monitoring for fetal well-being. HIGH-YIELD FACTS HIGH-YIELD See Figure 8-4 for management of third-trimester bleeding. Determine whether blood is maternal, fetal, or both: Apt test: Put blood from vagina in tube with KOH: Turns brown for Whose blood is lost with a maternal; turns pink for fetus. ruptured vasa previa? Kleihauer-Betke test: Take blood from mother’s arm and determine Fetal-placental circulation percentage of fetal RBCs in maternal circulation: > 1% = fetal bleed- more than maternal ing. Maternal cells are washed out (ghost cells); fetal cells are bright red (due to fetal hemoglobin). Wright’s stain: Vaginal blood; nucleated RBCs indicate fetal bleed.

DIFFERENTIAL Obstetric causes: Placental abruption. Placenta previa. Vasa previa/velamentous insertion.

Obstetric Complications Uterine rupture. Circumvillate placenta. Extrusion of cervical mucus (“bloody show”). 2 most common causes of Nonobstetric causes: third-trimester bleeding = Cervicitis Polyp Placenta previa and Neoplasm abruption

146 Patient stable or unstable?

Stable Unstable

Is bleeding Sonogram No heavy?

> 36 Fetal < 36 No Previa weeks age weeks previa

Speculum exam Expectant IV access, IV access, Observation management HIGH-YIELD FACTS baseline labs, baseline labs, +/– Tocolysis Tocolysis as blood products blood products indicated

Still unstable? No Is FHR strip reassuring? No Repeat episodes? Yes Reposition mother, Yes check BP, IV, tocolytics Prompt delivery Is placenta Hospitalize low implant

Yes Is FHR strip No Yes reassuring? Obstetric Complications

Prompt Stabilize mother, DIC Abruptio Placenta delivery if acquire baseline panel placentae previa unstable; labs, DIC panel negative otherwise, cesarean at 36 weeks Conservative management/ DIC panel Consider observation positive uterine rupture

Prompt Consider vasa delivery previa No

FIGURE 8-4. Management of third-trimester bleeding.

147 Placental Abruption (Abruptio Placentae)

A 32-year-old G2P1001 at 34 weeks gestation is brought to triage after a motor vehicle crash. She was a restrained driver who was rear-ended Most nonobstetric causes while going 65 miles per hour on the freeway. The airbags were deployed. result in relatively little She has dark red vaginal bleeding and severe abdominal pain. Her vitals are blood loss and minimal stable. Abdomen is ﬁ rm all throughout and tender to palpation. FHR shows a threat to the mother and baseline of 130, ↓ variability, no accelerations, and late decelerations are present. fetus. Contractions are not well recorded. US shows a fundal grade 2 placenta. What is the most likely diagnosis? Answer: Placental abruption.

Premature separation of placenta from uterine wall before the delivery of baby (see Figure 8-5).

Pregnant woman + vaginal INCIDENCE bleeding + pain = 0.5–1.3%; severe abruption can lead to death (0.12%). abruption until proven otherwise. RISK FACTORS Trauma (usually shearing, such as a car accident). HIGH-YIELD FACTS HIGH-YIELD Previous history of abruption. Preeclampsia (and chronic HTN). Smoking. Cocaine abuse. High parity. Obstetric Complications

FIGURE 8-5. Placental abruption.

(Courtesy of SUNY at Buffalo School of Medicine, Residency Program in Emergency Medicine.)

148 CLINICAL PRESENTATION

A 28-year-old woman at 35 weeks gestation is brought in by ambulance following a car accident. She is complaining of severe abdominal pain, and on exam she is found to have vaginal bleeding. An US shows a fundal placenta and a fetus in the cephalic presentation. What is most likely the cause? Answer: Placental abruption. Microangiopathic hemolytic anemia seen on maternal blood smear. What is occurring? Disseminated intravascular coagulation (DIC). What is the next step? Transfuse blood products (PRBCs, platelets, FFP) and expedite a vaginal delivery. Want to avoid major surgery in the setting of DIC.

Vaginal bleeding (maternal and fetal blood present). Constant and severe abdominal pain. Irritable, tender, and typically hypertonic uterus. HIGH-YIELD FACTS Evidence of fetal distress (if severe). Maternal shock. Disseminated intravascular coagulation.

DIAGNOSIS US shows retroplacental hematoma or placental thickening only part of the time. Up to 20% of placental Clinical ﬁ ndings most important. abruptions can present without vaginal bleeding MANAGEMENT because bleeding is Correct shock (IV ﬂ uids, packed RBCs, fresh frozen plasma, cryopre- concealed. cipitate, platelets).

Maternal oxygen administration. Obstetric Complications Expectant management or induction of labor: Close observation of mother and fetus with ability to intervene immediately. If there is fetal distress, perform C-section.

A B C D

FIGURE 8-6. A. Normal placenta. B. Low implantation. C. Partial placenta previa. D. Complete placenta previa.

(Reproduced, with permission, from DeCherney AH, Nathan L. Current Obstetric & Gyneco- logic Diagnosis & Treatment, 9th ed. New York: McGraw-Hill, 2003.)

149 Placenta Previa A condition in which the placenta is implanted in the immediate vicinity of the cervical os. It can be classiﬁ ed into four types: Complete placenta previa: The placenta covers the entire internal cervical os (see Figure 8-6). Partial placenta previa: The placenta partially covers the internal cervical os. Marginal placenta previa: One edge of the placenta extends to the edge of the internal cervical os. Low-lying placenta: Within 2 cm of the internal cervical os.

INCIDENCE 0.5–1%.

ETIOLOGY Unknown, but associated with: High parity. Older mothers. Third trimester bleeding: Previous abortions. Painless bleeding = previa Previous history of placenta previa. Painful bleeding = Fetal anomalies. Five to ten percent associated with placenta accreta, especially if prior

HIGH-YIELD FACTS HIGH-YIELD abruption low transverse cesarean section.

CLINICAL PRESENTATION Painless, profuse bleeding in second or third trimester. US reveals that a baby is Postcoital bleeding. lying transversely. What are Spotting during ﬁ rst and second trimester that subsides, and then recurs later in pregnancy. you suspicious of? Placenta previa DIAGNOSIS Transabdominal US (95% accurate). Magnetic resonance imaging (MRI) ﬁ ndings: Placenta previa is diagnosed on MRI when it is low lying and partially or completely covering the internal os. It is best demonstrated on sagittal images. Double setup exam: Take the patient to the operating room and prep for a C-section. Do speculum exam: If there is local bleeding, do a C- Obstetric Complications section; if not, palpate fornices to determine if placenta is covering the os. The double setup exam is performed only on the rare occasion that the US is inconclusive and there is no MRI.

MANAGEMENT Cesarean delivery is indicated for placenta previa.

Fetal Vessel Rupture Two conditions cause third-trimester bleeding resulting from fetal vessel rupture: (1) vasa previa and (2) velamentous cord insertion. These two conditions often occur together and can cause fetal hemorrhage and death very quickly.

150 VASA PREVIA A condition in which the unprotected fetal cord vessels pass over the internal cervical os, making them susceptible to rupture when membranes are ruptured. Incidence: 0.03–0.05%. Sinusoidal heart rate pattern = fetal anemia VELAMENTOUS CORD INSERTION (from any cause). Fetal vessels insert in the membranes and travel unprotected to the placenta. This leaves them susceptible to tearing when the amniotic sac ruptures. The vessels are usually covered by Wharton’s jelly in the umbilical cord until they insert into the placenta. Incidence: 1% of singletons, 10% of twins, 50% of triplets.

CLINICAL PRESENTATION Vaginal bleeding with fetal distress. HIGH-YIELD FACTS MANAGEMENT Risk of uterine rupture in Correction of shock and immediate delivery (usually cesarean delivery). patients desiring trial of labor after cesarean (TOLAC): Uterine Rupture < 1% if previous low The disruption of the uterine musculature through all of its layers, usually transverse cesarean with part of the fetus protruding through the opening. × 1. < 2% if previous low COMPLICATIONS transverse cesareans Maternal: Hemorrhage, hysterectomy, death. × 2. Fetal: Permanent neurologic impairment, cerebral palsy, death. ~10% if previous

classical cesarean. Obstetric Complications RISK FACTORS Classical uterine scar is Prior uterine scar from a cesarean delivery is the most important risk factor: a contraindication for Vertical scar: 10% risk due to scarring of the active, contractile portion TOLAC. of the uterus. Low transverse scar: 0.5% risk. Can occur in the setting of trauma.

PRESENTATION AND DIAGNOSIS The biggest risk for uterine Nonreassuring fetal heart tones or bradycardia: Most suggestive of uter- rupture is a prior cesarean ine rupture. delivery. Sudden cessation of uterine contractions. “Tearing” sensation in abdomen. Presenting fetal part moves higher in the pelvis. Vaginal bleeding. Maternal hypovolemia from concealed hemorrhage.

MANAGEMENT Immediate laparotomy and delivery. May require a cesarean hysterectomy if uterus cannot be reconstructed.

151 Other Obstetric Causes of Third-Trimester Bleeding Extrusion of cervical mucus (“bloody show”): A consequence of effacement and dilation of the cervix, with tearing of the small vessels leading to small amount of bleeding that is mixed with the cervical mucus. Benign ﬁ nding. Often used as a marker for the onset of labor.

ABNORMALITIES OF THE THIRD STAGE OF LABOR

A 37-year-old G6P6006 with a history of asthma and chronic hypertension has just undergone a spontaneous vaginal delivery of a 5000-g infant. Her labor course was complicated by chorioamnionitis and preeclampsia. The placenta delivered spontaneously, but profuse vaginal bleeding is noted from the vagina. Pitocin is given, and fundal massage is performed, but the uterus feels soft and boggy. Large clots are removed from the uterus. No vaginal, cervical, or perineal lacerations are noted. Estimated blood loss is 700 cc. What is the most likely cause of the bleeding? What is the next best treatment for the patient? One unit of blood PRBCs contains ≈ 250 mL/unit Answer: Uterine atony is the most likely cause for this patient’s postpartum hemorrhage. Prostaglandin F2α (asthma) and methergine (hypertension) are contraindicated due to her medical conditions. The next best agent is misoprostol. HIGH-YIELD FACTS HIGH-YIELD

Early Postpartum Hemorrhage (PPH) Incidence of excessive Excessive bleeding that makes patient symptomatic and/or results in blood loss following vaginal signs of hypovolemia. delivery is 5–8%. Blood loss > 500 mL in vaginal delivery; > 1000 mL for cesarean delivery (difﬁ cult to quantify). During ﬁ rst 24 hr: “Early” PPH. Between 24 hr and 6 weeks after delivery: “Late” PPH. The most common cause of early PPH is uterine atony where the Most common cause of uterus does not contract as expected. Normally, the uterus contracts, early PPH = uterine atony. compressing blood vessels and preventing bleeding. Other causes of postpartum hemorrhage are summarized in the mnemonic CARPIT.

RISK FACTORS

Obstetric Complications Blood transfusion/hemorrhage during a previous pregnancy. Coagulopathy. Trial of labor after cesarean (TOLAC). High parity. Causes of postpartum Large infant/twins/polyhydramnios. hemorrhage— Midforceps delivery. Chorioamnionitis. CARPIT

Coagulation defect MANAGEMENT Atony of uterus 1. Manually compress and massage the uterus—controls most cases of hem- Rupture of uterus orrhage due to atony. Placenta retained 2. Start two large-bore IVs and infuse isotonic crystalloids. Type and cross Implantation site bleeding blood. Monitor vitals. Strict inputs and outputs. Trauma to genitourinary 3. Carefully explore the uterine cavity to ensure that all placental parts have tract been delivered and that the uterus is intact.

152 4. Inspect the cervix and vagina for trauma/lacerations. 5. If uterus is boggy, suspect atony: Give additional dilute oxytocin. Methergine—contraindicated: HTN. Prostaglandin F2α—contraindicated: Asthma. Misoprostol. Oxytocin should never be ↓ uterine pulse pressure: given as undiluted bolus Uterine artery embolization. because serious Hypogastric artery ligation. hypotension can result. Ligation of utero-ovarian ligament. Hysterectomy. 6. Consider coagulopathy if persistent bleeding with above management. Red top tube for clot retraction test. Normal coags if clot forms < 8 min. Coagulopathy if no clot >12 min. Uterine packing until fresh frozen plasma and/or cryoprecipitate The cause of the available. postpartum bleeding should Hysterectomy (additional surgery) should be avoided in setting of co- be sought out and treated HIGH-YIELD FACTS agulopathy. immediately.

Placental Attachment Disorders The abnormal implantation of the placenta in the uterus can cause retention of the placenta after birth and heavy bleeding.

TYPES Accreta = Attaches Placenta accreta: Placental villi attach directly to the myometrium Increta = Invades rather than to the decidua basalis (see Figure 8-7). Percreta = Penetrates Placenta increta: Placental villi invade the myometrium. Placenta percreta: Placental villi penetrate through the myometrium.

May invade the bladder. Obstetric Complications

FIGURE 8-7. Placenta accreta, increta, and percreta.

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 22nd ed. New York: McGraw-Hill, 2005: 831.)

153 ETIOLOGY Placenta accreta, increta, and percreta are associated with: Placenta previa. Previous cesareans (↑ number, ↑ risk). Previous dilation and curettage (D&C). Grand multiparity.

MANAGEMENT All of these conditions result in hemorrhage in the third stage of labor. Treat- ment of choice: hysterectomy.

Uterine Inversion This medical emergency most often results from an inexperienced person’s pulling too hard when delivering the placenta. It can also be a result of abnor- If a mass is palpated in the mal placental implantation. Morbidity results from shock and sepsis. vaginal canal immediately after the placental delivery, INCIDENCE uterine inversion is the One in 2200 deliveries. likely complication.

MANAGEMENT Administer anesthesia. HIGH-YIELD FACTS HIGH-YIELD Large-bore IV. Give blood PRN. Give uterine relaxants. Never pull on the cord to Replace inverted uterus by pushing on the fundus toward the vagina. deliver the placenta. Gentle Oxytocin is given after uterus is restored to normal conﬁ guration and traction will be sufﬁ cient in anesthesia is stopped. a normally implanted placenta. Obstetric Complications

154 CHAPTER 9 Infections in Pregnancy

Immune System in the Developing Embryo, Fetus, and Newborn 156 Varicella-Zoster 157 Inﬂ uenza 157 Parvovirus 158 Rubella (German Measles) 159 Cytomegalovirus 159 Group B Streptococcus 160 Toxoplasmosis 161 Bacterial Vaginosis 162 Candidiasis 163 Sexually Transmitted Infections 163 SYPHILIS 163

GONORRHEA 164

CHLAMYDIA 164

HERPES SIMPLEX VIRUS 164

HEPATITIS B VIRUS 165

HUMAN IMMUNODEFICIENCY VIRUS 165

HUMAN PAPILLOMAVIRUS 166

TRICHOMONIASIS 166

155 Infections in Pregnancy HIGH-YIELD FACTS b a TABLE 9-1. immunodeﬁ ciency virus; HSV, herpessimplexvirus;TB,tuberculosis. BStreptococcus;GC, gonococcus;HBV, group GBS, hepatitisBvirus;HIV, human membranes. ter birth(seeTable 9-1). acquired inuteroorduringdelivery. Infectionsafterthistimeareacquired af- 2 months.Infectionsdiagnosed inneonateslessthan72hrofageareusually mother. Afterbirth,breast-feeding providessomeprotectionthatwanes (IgM). Passive immunity crossingofIgGfromthe isprovidedbytransplacental responsetoinfectionistheproductionofimmunoglobulinThe initial fetal M Infant cell-mediated andhumoralimmunity beginstodevelopat9–15weeks. 156 Bacteria, viruses,orparasitesmaygainaccesstransplacentallycross theintact Organisms maycolonizeandinfect thefetusduringL&D. IMMUNE catheters Respirators and HSV Human transmission HSV Maternal exposure Varicella-zoster Transplacental contamination External sedn neto S GBS HSV Ascending infection I I RINE NTRAUTE NTRAPARTUM N EONATAL SYSTEM IN THE DEVELOPING EMBRYO, FETUS, AND N AND FETUS, EMBRYO, DEVELOPING THE IN SYSTEM Perinatal Infections b a HBV HIV Papillomavirus Hepatitis HIV Cytomegalovirus Rubella Parvovirus Coxsackievirus HSV V IRAL coliforms Staphylococcus Staphylococcus TB GBS Chlamydia Gonorrhea Syphilis Listeria Coliforms, GC/ coliforms Staphylococcus chlamydia B ACTERIAL Malaria Toxoplasmosis P ROTOZOAN EWBORN

after HIGH-YIELD FACTS Infections in Pregnancy Varicella infection can cause infection Varicella maternal pneumonia in pregnancy. 157 (anti-varicella immunoglobulins) within 96 hr is (anti-varicella immunoglobulins) recommended for pregnant women or newborn. recommended for pregnant women Not ; treat with IV acyclovir. pneumonia She should be tested for the presence of varicella antibodies. Many antibodies. Many presence of varicella be tested for the She should rm presence of antibodies if immunity is uncertain. if immunity rm presence of antibodies A 25-year-old G1P0 at 15 weeks gestation reports weeks gestation con- that she came in at 15 G1P0 A 25-year-old ever She does not recall 2 days ago. child that had chickenpox tact with a is the next step? What having chickenpox. tibodies. for passive immunity. of protective maternal an- Much higher risk to infant due to absence that can be fatal. disease Neonates develop disseminated infant VZIG give infection 5 days before or after delivery, If maternal Chorioretinitis. Cerebral cortical atrophy. Hydronephrosis. Cutaneous and bony leg defects. FFECTS FFECTS tions. infection. indicated for those who are exposed and susceptible. for indicated Prevention with VZIG Answer: Antivirals: Amantadine and rimantadine recommended for prophylaxis. inhibitors for treatment and prophylaxis. Neuraminidase Category C drugs. Live attenuated: attenuated: Live so can give postpartum. Not secreted in breast milk, congenital Late pregnancy: Less risk of varicella infection. labor: Before/during Confi infection causes congenital malforma- Early pregnancy: Transplacental pregnancy. in adults; even more severe in More severe cause Can due to symptomatic or asymptomatic are immune Up to 90% of adults E E people are immune to chickenpox, but do not recall ever having it. If testing to chickenpox, but do not recall ever people are immune the varicella immuno- the antibodies, she should receive indicates that she lacks further If she has the varicella antibodies, nothing needs to globulin within 96 hr. be done. ACCINE INFLUENZA VARICELLA-ZOSTER REATMENT ETAL ETAL T F neural tube defects (NTDs) due to high fevers if exposed in early Possible pregnancy. Not usually life threatening, but pulmonary involvement can be serious. but pulmonary Not usually life threatening, V F Infections in Pregnancy HIGH-YIELD FACTS women atanyGA. given toallpregnant Infl uenzavaccineshouldbe M F V 158 None. P ETAL PARVOVIRUS (B19)PARVOVIRUS ACCINE REVENTION ANAGEMENT cause nonimmunehydropsandfetaldeath. tation forparvovirusinfection.The fetusisatriskforaplasticanemia,whichcan ings. What isthemostlikely diagnosis?What istherisktofetus? is afebrile;hasafi lacelikerashonherarms;andnootherfi ne erythematous, E Nonimmune aplasticane- hydrops:1%ofinfectedwomen, duetofetal death. Abortion,fetal IgGpresentseveraldaysafterIgMappears.persistsforlifeandof- IgMisproduced10–12daysafterinfectionandpersistsfor3–6months. Twenty tothirtypercentofadultsareasymptomatic. Flulikesymptomsarefollowed bybrightredrashontheface—slapped- Highest infectioninwomenwithschool-agedchildrenanddaycare Infectivityhighestbeforeclinical illness. Transmitted viarespiratoryorhand-to-mouthcontact. Causes Live attenuated intranasalvaccine notrecommendedforpregnant Inactivatedvaccine recommendedforallpregnantwomenatanygesta- DeliverybasedonGA. Consider transfusion. bloodfordegreeofanemia. Samplefetal evaluatesforanemia. Middlecerebralarteryresistance IfIgM+,thenperformultrasound (US)forhydrops. Afterexposure,checkIgMand IgG. Answer: Flulikesymptoms,slappedcheeks,andfi ne rashisaclassicpresen- mia. fers naturalimmunity againstsubsequent infections. extremities. cheek appearance.Rashmaybecomelacelike,spreading totrunkand workers (notteachers). women. tional age(GA)duringfl FFECTS of 100.4ºF 2daysago.Onphysicalexam,she (38ºC) andfeelinglethargic yesterday. afever red rashonbothofhercheeksthatstarted Shereports A 30-year-old G2P1001 at24 erythema infectiosumorfi u season. 6 / 7 weeksgestationpresentswithabright fth disease. nd- HIGH-YIELD FACTS Infections in Pregnancy Previous CMV infection does not confer immunity. Most common cause of perinatal infections: CMV. Most common fi nding in fi Most common congenital rubella syndrome: Deafness. 159 rm fetal cations. periodic reactivation and shedding. reactivation → virus latent → periodic NFECTION I IAGNOSIS NFECTION I Most common single defect. Deafness: Most common single D Congenital infection. Congenital strain. Infection from a different fetal in fetus. Primary infections cause severe morbidity Infections from reactivation have few sequelae. Recurrence. Reactivation. infection. Exogenous Cataracts, congenital (blindness!). glaucoma FFECTS pharyngitis, lymphadenopathy, polyarthritis). pharyngitis, lymphadenopathy, (breast-feeding). risk. tion. Chorioretinitis. calcifi Intracranial Microcephaly. Mental and motor retardation. does not prevent: Maternal immunity source of infection. Day care centers are common asymptomatic. Most symptoms (fever, Fifteen percent of adults have mononucleosis-type infection Primary Most common cause of perinatal developed world. infection in the person-to-person contact.uids and Spread via body fl infection infection via intrauterine, intrapartum, or postpartum Fetal infants and adults at virus for many months; susceptible Newborns shed during organogenesis. infections, worse of the most teratogenic One Congenital rubella syndrome: mental retarda- defects: Microcephaly, Central nervous system (CNS) E ATERNAL ONGENITAL RENATAL ACCINE CYTOMEGALOVIRUS (CMV) RUBELLA (GERMAN MEASLES) ETAL C Five percent of infected infants have this syndrome: M Live attenuated vaccine should be avoided 1 month before and during preg- should be avoided vaccine Live attenuated nancy. V P uid, fetal blood can confi fl villi, amniotic Rubella RNA in chorionic F infection. Mild infection in adults caused by an RNA virus. by an RNA in adults caused Mild infection Infections in Pregnancy HIGH-YIELD FACTS women! symptoms) inpregnant treat GBS(withorwithout onset GBSdisease.Always prophylaxis preventsearly- Intrapartum GBS C common. ofGBS(SagalactiaeAsymptomatic carrierstate )invaginaandrectumis treatmentorprophylaxis. No maternaltreatment.fetal T M P 160 N REATMENT GROUP B STREPTOCOCCUS (GBS) BSTREPTOCOCCUS GROUP OMPLICATIONS RENATAL EONATAL ANAGEMENT It istreatedwithIVantibiotics:ampicillin+gentamicin+/-clindamycin. is thegoldstandardfordiagnosis.MostcommoncauseGroupBstreptococcus. centa ordecidua—alsoknownasintra-amnioticinfection).Amnioticfl for diagnosis?What isthemostcommoncause?Howittreated? Prematureruptureofmembranes (PROM). Preterm labor. Ifmaternalprimaryinfectionconfi testing rmed, theninvasiveprenatal Measurementofmaternal serumIgMandIgGisusedtoconfi Routinematernalserologicscreenisnotrecommended. Polymerase chainreaction(PCR)detectsandquantifi es viralDNAin US canshow microcephaly, ventriculomegaly, intracranial calcifi Sensorineural defi Hemolytic anemia. Low-birth-weight andprematureinfantshaveworseoutcomethanterm Endometritis. Pyelonephritis. Fetal/neonatal infections. Chorioamnionitis. Answer: Chorioamnionitis(infectionoftheamnioticfl uid, membranes,pla- tions. with USandamniocentesis. amniotic fl blood. uid andfetal infants. Early-onset disease: tion. Sepsiscandevelopwithin6–12 hrofbirthwithsignsrespiratory Results fromverticaltransmission. Can preventwithintrapartumprophylaxis. infection <7daysafterbirth: Neonatal D distress syndrome(RDS),apnea, shock. S tenderness. What isthemostlikelydiagnosis?What isthegoldstandard of fever101ºF (38.3ºC), ruptureofmembranes,anddiffuseabdominal A 27-year-old womanat37 weeksgestationpresentswith a2dayhistory IAGNOSIS EPSIS cits. uid culture uid rm infec- ca- HIGH-YIELD FACTS Infections in Pregnancy All women should be All women should GBS at 35–37 screened for weeks. GBS Penicillin: First line for prophylaxis. 161 Intrapartum GBS prophylaxis. and clindamycin. for erythromycin risk is high, perform sensitivities If anaphylaxis If resistant to above, give vancomycin. or undercooked meat. Eating infected raw Infected cat feces. low. allergy: Cefazolin if anaphylaxis risk Penicillin women for GBS at 35–37 weeks. Culture all prophylaxis if GBS positive. Intrapartum birth. months after to 3 1 week Infection not preventable meningitis, Usually prophylaxis. with intrapartum nosocomial. or acquired community Infection vertical transmission. to CNS. nal primary infection. First-line agent. Penicillin: Late-onset disease: Late-onset pre-pregnancy infection almost eliminates Infection confers immunity; be localized Infected fetus clears the infection from organs, but it may of fetal Severity on the GA at the time of the mater- infection depends transmitted by: gondii transmitted Toxoplasma asymptomatic. Maternal infections are usually Culture-based approach: Culture-based the time of labor. GBS at unknown approach: For Risk-based REVENTION TOXOPLASMOSIS 22nd ed. New York, Obstetrics, 22nd ed. New York, FG, Leveno KJ, Bloom SL, et al. Williams from Cunningham (Reproduced, with permission, 2005: 1286.) McGraw-Hill, New York: FIGURE 9-1 P 9-1. See Figure Infections in Pregnancy HIGH-YIELD FACTS P T M 162 D vagina withanaerobicbacteria,Gardnerellavaginalis, Mycoplasmahominis . Clinical syndromethatresultsfromreplacementofnormalLactobacillusinthe REATMENT BACTERIAL VAGINOSIS (BV) VAGINOSIS BACTERIAL REVENTION IAGNOSIS ANAGEMENT bacterial vaginosis. The treatmentofchoiceinpregnancyisoralmetronidazole. bacterial vaginosis. the besttreatment? when KOH isaddedtothedischarge.What isthemostlikelydiagnosis?What is walls. Awetmountofthedischargeshowscluecells,andafi shy odorisnoted Wear gloveswhencleaning catlitterordelegatetheduty. Keepcatsin- Cleanandpeelfruitsvegetables. Practice goodhygienewhenhandlingraw meatandcontaminated No vaccines. Spiramycin. Sulfonamides +pyrimethamine, sulfonamides: Presumptivetreatment infection.Doesnoteliminate Preventsandreducescongenital therisk. Confi Routinescreening notrecommended. andblindness. retardation Canalsocausemental Answer: Symptoms anddiagnosisbasedonAmsel’scriteriaisconsistentwith doors utensils. in latepregnancy. Classic triadofnewborncomplications: Amsel clinical criteria: PCR for Avidity IgGtesting:Ifhigh-avidity IgGfound,infectioninthepreced- By seroconversionofIgGandIgMor>4-foldriseinpairedspeci- Hydrocephalus Intracranial calcifi Chorioretinitis Whiff testpositive:FishyodorwhenKOHadded to vaginaldis- Vaginal pH>4.5. Clue cellsonmicroscopy. Homogenous, whitedischarge thatcoats vaginalwalls. ing 3–5monthsisexcluded. men. charge. exam, a homogenous white discharge is noted to coat the vaginal side exam, ahomogenouswhitedischargeisnotedtocoatthevaginal discharge.She deniesitching,burning,orpain.Onphysical tory ofvaginal A 32-year-old G2P1001 at32 weeksgestationpresentswitha4-dayhis- rm diagnosis: T gondiiinamniotic fl cations uid. HIGH-YIELD FACTS Infections in Pregnancy Frontal bossing Frontal maxilla Short High palatal arch Saddle nose deformity teeth Malformed Penicillin is the only syphilis therapy in pregnancy that prevents congenital syphilis. What are late manifestations of congenital syphilis? Deafness with bone and teeth abnormalities 163 rmatory test: rmatory uconazole. rmatory tests: rmatory ndings: Edema, ascites, hydrops, thickened placenta. Edema, ascites, ndings: Fluorescent treponemal antibody absorption test (FTA-ABS) Microhemagglutination assay (MHA-TP) Rapid plasma reagin (RPR) Disease Reasearch Laboratory (VDRL) Venereal Confi Any stage of maternal syphilis may result in fetal infection. tests: Screening Chorioamnionitis Preterm birth Preterm PROM labor Preterm tis, pneumonia, myocarditis, nephrosis. myocarditis, tis, pneumonia, occurs with penicillin treatment. It in- Jarisch-Herxheimer reaction occurs with penicillin volves uterine contractions and late decelerations in the fetal heart rate as the dead spirochetes occlude the placental circulation. for all stages is the treatment of choice of syphilis (same as Penicillin be allergic, then she must nonpregnant patients). If patient is penicillin desensitized and still treated with penicillin. Treponema pallidum spirochetes cross the placenta and cause congeni- Treponema tal infection. US fi US skin lesions, rhini- hepatosplenomegaly, Newborns can have jaundice, by one confi test should be followed One screening Can give oral fl preferred. treatment with antifungals Topical improve perinatal Does not outcome. for symptoms. Oral metronidazole recommended. of partners not routinely Treatment stain. Gram criteria: Nugent used. of BV—not diagnosis for the sensitivity low have smears Pap complications: risk of antepartum Increased IAGNOSIS SEXUALLY TRANSMITTED INFECTIONS (STIs) INFECTIONS TRANSMITTED SEXUALLY CANDIDIASIS REATMENT REATMENT Syphilis See Chapter 18 for additional information on STIs. See Chapter 18 for additional T D Pseudohyphae seen on wet prep microscopy. Yeast infection on the vulva and in the vagina usually caused by Candida albi- on the vulva and in the vagina infection Yeast cans. T Infections in Pregnancy HIGH-YIELD FACTS of verticaltransmission. be performedto↓ must a cesareandelivery present atthetimeoflabor, prodromal symptomsare If herpeslesionsor Chlamydia trachomatis. ophthalmia neonatorum: Most commoncauseof preterm delivery: Infections associatedwith Bacterial vaginosis Trichomoniasis Gonorrhea the risk Herpes SimplexVirus Chlamydia Gonorrhea 164 Inpregnancy, usuallylimited tolower tract(cervix,urethra,peri- genital Treatment: Signsandsymptoms:Numbness,tingling,pain(prodromalsymptoms), Treatment: Erythromycin, amoxicillin, azithromycin. screen:Screenatthefi Prenatal visit.RepeatinT3ifathigh rst prenatal Diagnosedwithnucleic acid PCR. Cancausedelayedpostpartumuterineinfection. Mostpregnantpatientsareasymptomatic. Gonorrheacancauseconjunctivitisandblindnessinneonates.Allnew- Treat withceftriaxone. Diagnosedwithnucleic acid PCR. screenshouldbedoneatthefi Prenatal visit.Repeatlaterin rst prenatal Chlamydiainfection. Often,thepatienthasconcomitant Canbreast-feed,evenwhenonantivirals.Avoid breast-feeding ifherpes Whenpatientpresentsinlabor: Newborninfectionwiththree forms: infections canoccurviaintrauterine(5%),peripartum(85%), Neonatal nated. toms andamountofviralshedding. Shedding notcompletelyelimi- nancy. urethral glands,andvestibularglands).Acutesalpingitisisrareinpreg- vesicles witherythematousbasethathealwithoutscarring. risk. borns aregivenprophylaxisagainstconjunctivitis. pregnancy ifhighriskfactors. lesions on breast that can come in contact withinfant. lesions onbreastthatcancome incontact (10%). and postnatal infections: Neonatal Complications: Suppression with acyclovir starting at36weeksisindicated Suppressionwithacyclovirstarting forthose Safeinpregnancy. Pneumonia. Ophthalmia neonatorum:Conjunctivitis,blindness. Postpartum infections Chorioamnionitis PROM Preterm delivery Septic abortion Ifprodromalsymptoms or lesionsarepresent,patientshouldbeof- Examine perineum,vagina, cervixforlesions. Askaboutprodromalsymptoms. Disseminated disease withmultiple organinvolvement. CNSdisease withencephalitis. Skin,eye,mouthwithlocalized involvement. with ahistoryofherpes. fered acesareandeliveryto ↓theriskofverticaltransmission. Acyclovir andvalacyclovircanshorten the lengthofsymp- HIGH-YIELD FACTS Infections in Pregnancy Antiretroviral therapy Antiretroviral delivery Cesarean With antiretrovirals and vertical cesarean delivery, transmission of HIV is reduced from 25% to 2%. HIV Testing Opt-in approach: Patient must consent to receive the test. is Opt-out approach: Test routinely done on all patients; patient must decline the test if she does not want it. main strategies to ↓ Two vertical transmission of HIV: 165 upon delivery. rst of three hepatitis B vaccines The infant should receive the fi rst of the hepatitis vaccine series and vaccine series and rst of the hepatitis the fi infant should receive The Western blot and/or PCR. rmatory: Western A 30-year-old G1P0 at 39 weeks gestation is admitted for active labor. Her for active labor. gestation is admitted weeks at 39 G1P0 A 30-year-old B. chronic hepatitis by an infection with is complicated prenatal course takes place? once the delivery the infant be treated How should if viral load > 1000 copies. vals. patient is on ZDV. nant women regardless of CD4+ count and viral load in order to reduce vertical transmission. Enzyme-linked immunosorbent assay (ELISA). Enzyme-linked immunosorbent Screening: Confi Reduce duration of ruptured membranes. Recommend cesarean delivery before labor or rupture of membranes breast-feeding. Avoid syrup to newborn for 6 weeks. Give ZDV at regular inter- CD4+ counts and viral loads should be monitored monthly while Blood counts and liver functions should be monitored Give maternal IV ZDV. preg- Antiretroviral therapy should be encouraged in all HIV-infected Give fi Give prophylaxis. Can breast-feed if infant given (HBIG) to infant upon delivery. Give hepatitis B immunoglobulin Cirrhosis carcinoma Hepatocellular period can reduce risk of vertical transmission to 2%. period can reduce risk of vertical transmission transmission from mother to fetus. transmission is re- to neonate, risk of transmission ing antepartum, intrapartum, and duced to 8%. a repeat test in T3. Opt-out approach used for HIV testing. a repeat test in T3. Opt-out approach partum or with breast-feeding. gen (HBsAg). to: ↑ risk of infectivity with ↑ levels of hepatitis B early antigen (HBeAg). Prevention of neonatal infection: If mother with hepatitis B: ↑ risk of preterm delivery. Answer: Reduce vertical transmission: started therapy (HAART) in the antenatalCombination antiretroviral Reduce maternal viral load: are secondary to vertical AIDS The vast majority of cases of pediatric is given dur- (ZDV) Risk of perinatal ~25%. If zidovudine transmission HIV screening recommended at fi rst prenatal visit. Some states require recommended at fi HIV screening Most neonatal infection due to ingestion of infected fl uid in the peri- Most neonatal infection due to ingestion of infected fl can be given during pregnancy. Vaccine Screen at fi rst prenatal with hepatitis B surface anti- visit and at delivery Screen at fi pregnancy. treatment not recommended during Antiviral Small amount of transplacental passage. leading in 70–90% of acutely infected infants infection occurs Chronic hepatitis immune globulin soon after birth.hepatitis immune globulin Human Immunodefi (HIV)ciency Virus Human Immunodefi Hepatitis B Virus Hepatitis Infections in Pregnancy HIGH-YIELD FACTS papillomatosis infetus. HPV cancauselaryngeal Trichomoniasis the larynx. Juvenile-onset respiratorylaryngealpapillomatosis:Rarebenign neoplasmof N T and vulvarcancer. Chronic condyloma,cervical,vaginal, viralinfectionthatcancausegenital Human Papillomavirus (HPV) 166 REATMENT EONATAL Treat withoralmetronidazole. Complications: Diagnosismadewhenfl DuetoHPV-6 and-11. Hoarseness,respiratorydistress. Notrecommendedforpregnancy: Laser. Cryotherapy. Trichloroacetic orbichloroaceticacid appliedweeklyforexternalwarts. Cesareandeliverynotroutinelyrecommended. afterdelivery. Lesionsregressspontaneously Ifsizeandlocationoflesionsobstructvaginaldelivery, mayneedtoper- warts,↑ externalgenital Condylomaacuminata, Clearanceofvirusslower duringpregnancy. pregnancy. form acesareandelivery. Pretermprematurerupturedmembranes. Preterm delivery. Interferon Imiquimod 5-fl Podofi Podophyllin resin I NFECTION uorouracil lox agellated organisms seenonwet prep. in number andsizein CHAPTER 10 Twin Gestation

Maternal Adaptations 168 Types of Twins 168 Prenatal Diagnosis 169 Diagnosis and Management of Twins 169 Twin-Twin Transfusion 170

167 Multiple gestation or twins continues to ↑ in the United States secondary to assisted reproductive techniques and an advancing maternal age at childbirth. Maternal and perinatal morbidity are ↑ in multiple gestations, as well as congenital anomalies. Prenatal visits are more frequent with multiple gestations, since they are at increased risk for complications. Many of these women re- Gain 24 pounds by 24 quire care by a trained specialist. In twins, normal physiologic changes are weeks in a multiple increased, compared with a singleton pregnancy. There is an increase in car- gestation pregnancy. diac output, iron requirements, plasma volume, blood volume, glomerular ﬁ l- tration rate, and caloric requirements.

When did cell division MATERNAL ADAPTATIONS occur? Chorionicity is important to determine Maternal physiologic changes are more exaggerated compared to a singleton early in the pregnancy— pregnancy. can be done with Cardiac: ultrasound. ↑ heart rate, ↑ stroke volume, ↑ cardiac output is more secondary to the ↑ myometrial contractility and blood volume. ↑ in uterine volume/weight. Respiratory: Further ↑ in tidal volume and oxygen consumption. Renal: ↑ GFR and ↑ in renal size. Number of twin Nutrition: pregnancies is on the rise Calories: Average to consume 3000–4000 kcal/day compared to 2400

HIGH-YIELD FACTS HIGH-YIELD ↑ due to use of assisted kcal/day in singletons. reproduction techniques. Weight gain: Avg/week is 1–1.5 pounds; total gain: 35–45 pounds.

TYPES OF TWINS

Multiple-gestation A 22-year-old P2012 at 15 weeks gestation, consistent with LMP, presents pregnancy has a high for the ﬁ rst antenatal visit. She reports that fetal movement is present. On incidence of preterm labor. physical exam, her fundal height is 20 cm, at the level of the umbilicus. A bedside ultrasound, reveals a twin gestation. Management of her antenatal care should include what important tests/procedures? Answer: An ultrasound to determine chorionicity and serial ultrasounds to Twin Gestation Twin check for fetal growth restriction/discrepancy. Serial US assessments are the only reliable way to A zygote is the result of fertilization of an ovum with a spermatozoan. document adequate fetal growth and fetal growth Dizygotic twins are the result of two ova fertilized by two different restriction. sperm. Risk factors include fertility drugs, race, advanced maternal age, and parity. These are fraternal twins. Monozygotic twins are the result of a single ovum fertilized by one sperm which subsequently divides. The frequency of 1 in 250 pregnancies (see Figure 10-1). These are indentical twins. The timing of cell division within the monozygotic twin determines the amnionicity and chorionicity of twins. A size/date discrepancy Division of the ovum between days 0 and 3: Dichorionic, diamniotic when measuring uterine monozygotic twins. fundal height of > 3 cm Division between 4 and 8 days: Monochorionic, diamniotic monozy- should prompt US gotic twins. assessment.

168 HIGH-YIELD FACTS

FIGURE 10-1. Mechanism of monozygous twinning.

(Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 22nd ed. New York: McGraw-Hill, 2005: 914.)

Division between 9 and 12 days: Monochorionic, monoamniotic monozygotic twins. Division after 13 days: Conjoined twins. Monochorionic twins have more complications than dichorionic. Monoamniotic twins have more complications than diamniotic. Twin Gestation

PRENATAL DIAGNOSIS

Diagnosis and genetic counseling is important because of the ↑ risk of congenital anomalies. Both monozygotic and dizygotic twins are at ↑ for structural anomalies. Multiple gestation have an increased risk of aneuploidy. Vaginal delivery of twins First-trimester serum markers not as valid for multiple gestation. Nuchal translucency is the preferred ﬁ rst-trimester marker. can be performed but requires an obstetrician skilled in vaginal twin deliveries; otherwise, DIAGNOSIS AND MANAGEMENT OF TWINS cesarean delivery is recommended. Physical exam may show a uterine size/gestational age (GA) difference with size greater than expected from GA. Ultrasound is used for the following in multiple gestations: Conﬁ rm diagnosis. Determine chorionicity. Detect fetal anomalies.

169 Measure cervical length. Evaluate for fetal growth. Differential diagnoses for a Guide invasive procedures. Conﬁ rm fetal well-being. size/date discrepancy in Determining chorionicity is important: pregnancy include: Chorionicity can best be determined in the ﬁ rst or early second tri- Twins mester by ultrasound (US). Adnexal mass Monochorionic twins should undergo US examination to look for fe- Distended bladder tal growth every 4 weeks, while dichorionic twins can be scanned ev- Fetal macrosomia ery 6–8 weeks for growth. Hydramnios Growth restriction rates are higher among the monochorionic in Maternal obesity comparison to the dichorionic twin gestation. Uncertain LMP Monochorionic twins may also be at risk for twin-twin transfusion Molar pregnancy syndrome. Induction of labor of twins should be strongly considered when 38 weeks gestation has been reached, as the rate of stillbirth and growth restriction ↑ after this GA. Determining the route of delivery (vaginal versus cesarean) should be Multiple gestation based on the experience of the obstetrician and the presentation of both pregnancies are at twins. increased risk for Breech presentation of Twin A and cephalic presentation of Twin B complications, such as may causes interlocking twins, and cesarean delivery should be under- diabetes mellitus, taken in this causes. hypertension, congenital HIGH-YIELD FACTS HIGH-YIELD anomalies, and growth restriction TWIN-TWIN TRANSFUSION

A serious complication of monochorionic multifetal gestation in which blood/intravascular volume is shunted from one twin to another. The major risk is intrauterine fetal demise, in which one twin develops Dizygotic twins are more complications of due to underperfusion and the other due to over perfusion. common that monozygotic The theoretical cause is unbalanced vascular anastomoses. twins. US is needed for diagnosis. Treatment is laser coagulation of the anastomoses. Twin Gestation Twin Monochorionic twins have higher complication rates than dichorionic twins, and require more frequent surveillance.

TWINS Twin-twin transfusion: Deadly complication in monochorionic twin gestations.

170 CHAPTER 11 Abortions and Fetal Death

First-Trimester Bleeding 172 Spontaneous Abortions 172 Types of Spontaneous Abortion 174 THREATENED ABORTION 174

INEVITABLE ABORTION 175

INCOMPLETE ABORTION 175

COMPLETE ABORTION 176

MISSED ABORTION 176

SEPTIC ABORTION 177

RECURRENT ABORTION 178 Induced Abortion 178 ASSESSMENT OF THE PATIENT 179

INDICATIONS FOR THERAPEUTIC ABORTION 179

METHODS OF ABORTION 179 Fetal Death 180 CAUSES OF FETAL DEATH BASED ON TRIMESTER 181

171 Abortions and Fetal Death HIGH-YIELD FACTS chromosomal abnormalities. trimester areadueto abortions inthefi rst Majority ofspontaneous “abortus.” weighing <500g=an weeks GAorafetusborn Loss ofafetus<20 pregnant patientsthat: should begiventoall An anti-Dantibodyinjection negative. immunoglobulin ifRh bleeding. Giveanti-D patients withvaginal and Rhonallpregnant Always checkbloodtype spontaneous abortion. pregnancies resultin Approximately 30%of D(Rh)antibody screen D(Rh)antigen Havevaginalbleeding. negative. negative. atomic, endocrine,immunologic, factors. andenvironmental abortion arenumerous, including chromosomalabnormalities,infections,an- abortionsareaccidents ofpregnancy.Spontaneous Etiologyofspontaneous W D be relatedtothepregnancy. Bleeding inthefi rst trimestercanbefrommanycausesthatmayornot 172 E TIOLOGIES SPONTANEOUS ABORTIONS FIRST-TRIMESTER BLEEDING IFFERENTIAL ORKUP Chromosomal Abnormalities Completed spontaneous abortion is the spontaneous expulsionofallfe- abortionisthespontaneous Completedspontaneous Abortion=intentionalorunintentional termination ofapregnancy Diagnostic tests: Physical: History:Vaginal bleeding +/-abdominal pain. Trauma. Benign andmalignantlesions(ie,choriocarcinoma, cervicalcancer). Hydatidiform mole. Ectopic pregnancy. Spontaneous abortion. Majorityofabnormalkaryotypesare numeric abnormalitiesasaresult Mostareunrecognized becausetheyoccurbeforeoratthetimeof Occursin30%ofallrecognized pregnancies. tion. tissuefromtheuterinecavitybefore20weeksgesta- andplacental tal orweight of<500 g. < 20gestation fertilized ovum. of errorsduringgametogenesis, fertilization,orthefi rst division ofthe next expectedmenses(70–80%). Ultrasound (US) assesses fetal viabilityandcontentsoftheuterus. Ultrasound(US)assessesfetal BloodtypeandRh.Ananti-Dimmunoglobulin injection shouldbe Completebloodcount(CBC). Quantitive Pelvic exam(notethesourceofbleeding andcervicaldilation). signs(ruleoutshock/sepsis). Vital given toallpregnantpatientsthat: Prevents maternalisoimmunization (generation ofantibodies D(Rh)antibodyscreennegative. D(Rh)antigennegative. Havevaginalbleeding. against fetal redbloodcellsincurrentorfuturepregnancies). against fetal D IAGNOSIS β-human chorionic gonadotropin (hCG)level. HIGH-YIELD FACTS Abortions and Fetal Death abnormalities Top etiologies of Top abortion: spontaneous 1. Chromosomal 2. Unknown 3. Infection defects 4. Anatomic factors 5. Endocrine 173 ciency. 14 cigarettes/day ↑ abortion rates. ≥ 14 cigarettes/day Trisomy: 50–60%. Trisomy: 7–15%. (45,X): Monosomy 15%. Triploidy: 10%. Tetraploidy: Tobacco: Tobacco: Alcohol. Irradiation. Environmental toxin exposure. > 5 cups/day. Caffeine: Trauma. Diabetes—uncontrolled. anticoagulant. Lupus antibody (antiphospholipid syndrome). Anticardiolipin Cervical incompetence. Cervical submucosal). (especially Leiomyomas from previous curettage). Intrauterine adhesions (ie, defi Progesterone ovarian syndrome (PCOS). Polycystic Mycoplasma hominis Mycoplasma monocytogenes Listeria Chlamydia Gonorrhea 25–30%. Septate/bicornuate uterus: Toxoplasma gondii Toxoplasma simplex Herpes urealyticum Ureaplasma Frequency: Infections abor- uid can cause fl or seminal uterine cavity, agents in cervix, Infectious may be asymptomatic: tions. These infections Immunologic Factors Immunologic Environmental Factors Endocrine Abnormalities Structural Abnormalities Abortions and Fetal Death HIGH-YIELD FACTS (Reproduced, withpermission,from Toy EC, etal.CaseFiles:ObstetricsandGynecology, 3rded.NewYork: McGraw-Hill,2009: 96.) TABLE 11-1. etcaoto Fever, abdominal/ Septic abortion isdaoto osmtm oCoe Nonviable Closed No symptoms No Missed abortion abortion Complete abortion Incomplete abortion Inevitable abortion Threatened T ERMINOLOGY Types ofSpontaneousAbortions membranes ruptured pelvic pain, but nowsubsided bleeding previously Cramping, going) bleeding (on Cramping, bleeding Cramping, Vaginal Bleeding No Closed Uncertain; upto Uncertain; Closed No Vaginal Bleeding H ISTORY Threatened Abortion See Table 11-1. 174 TYPES OF SPONTANEOUS ABORTION incomplete/septic abortion. Many patientshaveanormalpregnancycourse;othersmaycomplete/ her condition? cardiac activitypresent.What isthelikelydiagnosis?What isthebesttreatmentfor showsan8-weekgestationwith bleeding. The cervixisclosed, thick,andhigh.US vaultwithnoactive Sterile speculumshows5ccofdarkbloodinthevaginal Threatened abortion. TheAnswer: Threatened patientshouldbemanagedexpectantly. abortion. l isepse lsdNnibeFollow hCG levels Nonviable Closed All tissuepassed tissue passed Some butnotall hemodynamically stable.Physicalexamrevealsanontenderabdomen. bleeding. Shedeniescramping,trauma,orintercourse.isafebrileand A 34-year-old G1P0at8weeks gestationpresentstotheEDwithvaginal P Passed/not SAEOF ASSAGE T passed ISSUE No Open Abortion is Abortion Open No ?C pncoe ibentval IVantibiotics Viable/not viable Open/closed ERVICAL pnNnibeD&C Nonviable Open OS ultrasound) (diagnosed on inevitable 50% willmiscarry P V REGNANCY AIIYOF IABILITY ?M management D&C vsexpectant to negative D&C management D&C vsexpectant Expectant hCG levels Transvaginal US management ANAGEMENT HIGH-YIELD FACTS Abortions and Fetal Death 175 An 18-year-old G1P0 at 8 weeks gestation presents to the ED complaining An 18-year-old of worsening cramping and vaginal spotting. She denies passage of tissue. cervical os and a cervical dilation Physical exam shows bleeding from the out amniotic fl uid or products of conception (POC) in the endocer- uid or products of conception (POC) fl out amniotic vical canal. serial can follow If uncertain of diagnosis, activity. fetus with cardiac pregnancy of 60% every 48 hr if normal hCGs; should ↑ by a minimum (peaks at ~10 weeks). nancy. Vaginal bleeding before 20 weeks gestation, open cervical os, and no weeks gestation, open cervical bleeding before 20 Answer: Vaginal a blood transfusion. requiring bleeding Ongoing infection, septic abortion. Ascending from an open cervical os. coming Speculum exam reveals blood activity may or may not be present on US. cardiac Fetal Surgical evacuation of the uterus if fetal activity is absent. cardiac Expectant management if fetal activity is present. cardiac cramps. Presence of menstrual-like with- from a closed cervical os, Speculum exam reveals blood coming uterus if gestation gestational an empty US will show early, sac, or very result in loss of preg- up to 50% may although may continue, Pregnancy labor and delivery. increases the risk of preterm It of 3 cm. There are no palpable adnexal masses. Ultrasound shows an intrauterine are no palpable adnexal masses. Ultrasound of 3 cm. There likely diagnosis? is the most gestational sac with a viable fetus. What an inevitable abortion.expulsion of products of conception is ANAGEMENT ANAGEMENT IAGNOSIS IAGNOSIS Incomplete AbortionIncomplete Incomplete abortion is the passage of some, but not all, POC from the uterine cavity before 20 weeks gestation. Increased risk of: M D Inevitable abortion is vaginal bleeding, cramps, and cervical dilation at < 20 Inevitable abortion is vaginal bleeding, gestation expulsion of POC. Expulsion of POC is imminent. without weeks Inevitable Abortion Observation, pelvic rest. Observation, pelvic M D is uterine bleeding from a gestation from weeks is < 20 that bleeding is uterine abortion Threatened of tissue. passage or dilation cervical without Abortions and Fetal Death HIGH-YIELD FACTS abortions. inevitable andincomplete isseenwith Dilated cervix M D closed Complete abortionisthecompletepassageofPOC.Thecervicalos Complete Abortion M D 176 D sion ofanyPOC. without expul- demiseMissed abortionisfetal before20weeksofgestation Missed Abortion IAGNOSIS IAGNOSIS IAGNOSIS ANAGEMENT ANAGEMENT empty uterus. vault, andthecervixisclosed.Anultrasoundshowsan dark bloodinthevaginal Vitals arenormal.Onphysicalexamshedeniesabdominalpain,thereis5ccof Observepatientforfurtherbleeding andsignsofinfection. isoftenperformeddueto↑ Between8and14weeks,curettage SendPOCtopathologyverifyintrauterinepregnancy. USshows emptyuterus. Uterusiswellcontracted.Cervicalosmaybeclosed. Pain hasceased. KaryotypePOCifrecurrentabortion. Suction dilation(D&C)toremovethePOCfrom andcurettage (IVfl andstabilize Assesshemodynamic status uids, bloodtransfusion). intheuterusmaybeseenwithUS. POCretained POCpresentintheendocervicalcanalorvagina. Enlarged,boggyuterus;dilated internalos. Continued crampingandbleeding. US confi Quantitative Intermittent vaginalbleeding/spotting/brown discharge andafi Thepregnantuterusfailstogrow, andsymptomsofpregnancy havedis- Answer: Completeabortion. closed cervix. uterus. SendPOCtopathology. appeared. hood thattheabortionwasincomplete. after theabortioniscompleted. pregnant andanultrasounddone3dayspriorshowedaviablefetus. thatsheis9weeks ing andcrampingthatisnowdecreased.Shereports bleed- A 24-year-old womanpresents totheEDwithcomplaintsofvaginal rms absent fetal cardiacsac. rms absentfetal activityoremptygestational β-hCG maydecline,platue, orcontinue to↑. likeli- rm, HIGH-YIELD FACTS Abortions and Fetal Death Low platelets Low PT/PTT Prolonged If POC are not removed in a septic abortion, severe sepsis often occurs. Consumptive coagulopathy (DIC) is an uncommon but serious complication of septic abortion. Low-normal range Low-normal Early sign brinogen level: fi of consumption especially: coagulopathy, 177 suppositories. 1 A 25-year-old G3P1011A 25-year-old at 9 LMP weeks gestation by to the ED presents discharge. She abdominal pain, and foul-smelling lower with fever, reported of clear vaginal having a copious amount discharge 2 days prior. fetal T3. in T2 and demise weeks. for delivered. More so dead fetus is not coagulopathy if Concern for Most women will spontaneouslyMost women deliver a fetal within 2 demise a D&C. that may require or septic abortion of incomplete Risk serum electrolytes, liver function tests (LFTs), blood urea nitrogen serum electrolytes, liver function tests (LFTs), blood urea nitrogen and coagulation panel. (BUN), creatinine, tenderness, signs of peritonitis. parametrium and sometimes to peritoneum. Infected POC are present. The patient has a septic abortionAnswer: The and should receive broad-spectrum (UA), culture, blood culture, check CBC, urinalysis discharge Vaginal Broad-spectrum IV antibiotics that has anaerobic bacteria coverage. uterine hypotension, tachycardia, generalized pelvic discomfort, Fever, Speculum exam: Malodorous vaginal and cervical discharge. Leukocytosis. retained US shows POC. Can be threatened, inevitable, of abortion. or incomplete type The infection is usually polymicrobial. to Infection can spread from endometrium, through myometrium, Septic shock may occur. Suction D&C. Suction prostaglandin E with dilators Cervical Expectant management. management. Expectant Her temperature is 101.1ºF (38.4ºC), blood pressure 110/70, pulse 100, and respi- 100, pulse blood pressure 110/70, (38.4ºC), Her temperature is 101.1ºF She appears lethargic tender to palpation in the lower and ill. She is ratory rate 18. a copious amount of foul-smelling dis- abdomen. Sterile speculum exam shows charge in the vagina. Bimanual exam reveals uterine tenderness and no adnexal Complete blood count (CBC) cervix is dilated 1 cm, thick, and high. masses. The US of 20K. shows a white blood cell count (WBC) shows a 9-week intrauterine is the uid around it. What and minimal fl pregnancy with cardiac activity present for her condition? is the best treatment most likely diagnosis? What IV antibiotics and a D&C. ANAGEMENT ANAGEMENT IAGNOSIS M D Septic Abortion M Abortions and Fetal Death HIGH-YIELD FACTS that aredetectablebyUS. subsequent pregnancies 23% chanceofabortionin recurrent abortionhavea Women of withahistory more successiveabortions. Recurrent abortionistwoor Investigate possibleetiologies.Potentially usefultestsinclude: M E Recurrent Abortion 178 D TIOLOGY INDUCED ABORTIONINDUCED EFINITIONS ANAGEMENT Lupusanticoagulant(antiphospholipid workup). Anticardiolipin andantiphosphatidylserineantibodies. Luteal-phaseendometrialbiopsynotveryhelpful. Sonohysterogram,hysteroscopy:Evaluateuterinecavity. Parentalkaryotypes:Balancedtranslocationinparentsmayresultun- Karyotypeofabortus. Maternal thrombophilia(geneticmutationsthatincreasetheriskof Unexplainedinamajorityofcases. Autoimmune conditions (classically, antiphospholipidsyndrome[APA] Infections: Endocrinologic abnormalities. Cervical incompetence:Painless cervicaldilation leadstosecond-tri- Acquired defects:Intrauterinesynechiae(Ashermansyndrome),leio- Anatomic abnormalities:Uterinedidelphys,uterus,bicornuate, septate Parental chromosomalabnormalities(balancedtranslocationisthe Women abortionshavearecurrence withtwosuccessivespontaneous Two ormoresuccessiveclinically recognized pregnancylossespriorto Hysterectomyifunabletoevacuatetheinfecteduterinecontents. D&Cafteradequate tissuelevelofantibiotics(2hr)inahemodynami- Therapeutic abortion: termination performed Elective termination ofpregnancy: Intentional abortion: Induced Factor VLeiden. maternal health. weeks gestation. balanced translocationinthefetus. thrombi formation). demise). in whichthrombosisresultsfetal or syphilis. mester abortions.Treat withcervicalcerclage. myomas. and unicornuate uterus. most common). risk of25–30%. 20 weeksGAconstitutesrecurrentabortion. antibiotics; performD&Cwhenpatientadequately stabilized. IVfl start patient.Ifhemodynamically unstable, cally stable based onthewoman’s desire. Chlamydia, Ureaplasma,Listeria,Mycoplasma,Toxoplasma, Intentional termination ofpregnancy, before20 Intentional termination performed to maintain termination performedtomaintain Intentional ud and uids HIGH-YIELD FACTS Abortions and Fetal Death lesions/lacerations Spontaneous abortion Spontaneous pregnancy Ectopic pregnancy Molar Vaginal/cervical placenta Abruptio previa Placenta Rupture of vasa previa rupture Uterine Ninety percent of all abortions are performed in rst trimester. the fi Differential diagnosis for T1 bleeding: Differential diagnosis for T3 bleeding: 179 α: 2 , F 1 E 2, Easy to use, can be safely used in women with prior ce- GENTS A (8–9 weeks). (7 weeks). prostaglandin. (GA) can lead to complications. (GA) can Advantages: Disadvantages: Diarrhea, fever. sarean delivery. Seventy-seven percent successful for pregnancy 57–63 days gestation Given every 2–6 hr until uterus evacuated. 48 hours later. by misoprotol is followed Antiprogestin mifepristone Ninety-two percent successful for pregnancy < 49 days gestation Can be administered orally or vaginally, depending on the type of depending orally or vaginally, Can be administered of gestational abortions for dating—miscalculation Critical for T2 age during the procedure. Can help size. dates and uterine between there is a discrepancy If suspected. pregnancy Ectopic Leiomyomata may feel bigger. present—uterus [TTP]). ulins should be administered prophylactically. ulins should be administered Mifepristone (RU 486) and misoprostol: Prostaglandin E Abortions in T1 and T2 can be performed with pharmacologic agents. used. cavity: Infrequently solution instilled in the amniotic Hypertonic agents. Induction of labor with pharmacologic methods. Surgical Intrauterine infection. Intrauterine preeclampsia/eclampsia. Severe Major malformation (eg, anencephaly). atrophy). Genetic (eg, spinal muscular Hematologic disease (eg, thrombotic thrombocytopenic purpura (eg, thrombotic thrombocytopenic Hematologic disease retinopathy). Metabolic (eg, proliferative diabetic mother needs prompt chemotherapy). Neoplastic (eg, cervical cancer; cerebrovascular malformation). Neurologic (eg, berry aneurysm; disease. Renal Cardiovascular disease. Cardiovascular Genetic syndrome (eg, Marfan). anti-D immunoglob- type: If patient is Rh negative, Blood type and Rh counseling should be performed. Careful patient Important in confi gestationrming age. US: Important confi in ATERNAL HARMACOLOGIC ETAL Methods of Abortion Indications for Therapeutic AbortionIndications for Therapeutic (Not an Exhaustive List) M P F Assessment of the Patient Assessment Abortions and Fetal Death HIGH-YIELD FACTS contraction. induces smoothmuscle use inasthmatics,asit anomalies. abortions: Congenital Most commonreasonforT2 PGF the fi rst49days. abortions arebestusedin Medical methodsof United StatesisD&C. of inducedabortioninthe The mostcommonmethod giving birth. than theriskofdeathfrom but itis10timesless Death isariskofabortion, Establishing GAiscritical. than T1abortions. higher forT2abortions Complications are4times Suction curettage: Safestsurgicalabortion Mostcommonprocedure method. for abortioninT1. 2α iscontraindicatedfor Three main classes are fetal, placental, andmaternalcauses. placental, Three mainclassesarefetal, E abortion. abortionoramissedtraction fromthemother. Itcanresultinaspontaneous prior tocompleteexpulsionorex- Death ofthefetus>20weeks gestation, C S 180 TIOLOGY URGICAL FETAL DEATH MLCTOSOF OMPLICATIONS Placental Fetal Fetal growth restriction:Signifi Death. Riskofanesthesia. Psychological sequelae. Uterine perforation/rupture. Cervical laceration. Hemorrhage. Disseminated intravascularcoagulation(DIC). IncompleteremovalofPOC. Infection:Mostcommoncomplication. Hysterectomy:Considerifpatienthasconcurrentfi Hysterotomy. Placental abruption is a common cause of fetal death. abruption isacommoncauseoffetal Placental Multiple gestation. Chromosomal andgeneticabnormalities:Found inupto8–13%offe- in situofthecervix. ated with: tal death. tal partsusingvariousinstruments. lation ofcervixandextractionfetal Dilation andevacuation(D&E):UsedmostofteninT2.Itinvolvesdi- of theuterus. lating thecervixandusingasuctionapparatustoremovecontents (D&C):UsedmostofteninT1.Itinvolvesdi-Dilation andcurettage Maternal smoking Fetal infection Fetal aneuploidies Preeclampsia. Hypertension. Smoking. Maternal cocaineandotherillicit druguse. Diabetes Obesity Autoimmune disease Hypertension /R NeedtechnicalDisadvantages: expertise,traumatothecervix. greater convenience. Advantages: M ISK ETHOD F ACTORS S URGICAL Less emotional stress for patient, avoid hospitalization, Less emotionalstressforpatient,avoid hospitalization, A BORTIONS cant ↑ intheriskofstillbirth.Itisassoci- broids orcarcinoma HIGH-YIELD FACTS Abortions and Fetal Death Up to 35% of fetal deaths are associated with the presence of congenital malformation. The frequency of The frequency chromosomal abnormalities in fetal deaths is 10 times higher than that in live births. A carefully performed autopsy is the single most useful step in identifying the cause of fetal death. 181 ) rst sign. rst ) ) ERM EEKS –T EEKS EEKS Hypertension Diabetes ONSPECIFIC usually the fi centa previa, abruptio placentae). centa previa). diabetes). showing absent fetalReal-time US showing heart movement is the diagnostic method of choice. Absent fetal heart tones by Doppler. hypertension). (eg, diabetes, disease Maternal systemic Maternal infection (eg, chorioamnionitis). Substance abuse (eg, cocaine). absent fetalIn late pregnancy, movement detected by the mother is parvovirus). CMV, Infections (eg, toxoplasmosis, Trauma. accident. Cord Anticardiolipin antibodies. Anticardiolipin placentation, (eg, circumvallate Placental pla- pathological conditions Anticardiolipin antibodies. Anticardiolipin antibodies. Antiphospholipid abnormalities. Chromosomal defects of uterus and cervix. Anatomic Erythroblastosis. placentation, (eg, circumvallate Placental pla- pathological conditions smoking, toxins). Environmental factors (eg, medications, defects (eg, müllerian defects). Maternal anatomic dysfunction, thyroid ciency, insuffi Endocrine factors (eg, progesterone Unknown. Chromosomal abnormalities. Chromosomal Nulliparity. age. maternal Advanced Obesity. smoking. Drugs, alcohol, comorbidities: Medical Placental infarction. Placental Placental infection. or membrane transfusion syndrome. Twin-twin black race. Non-Hispanic N Maternal IAGNOSIS IME D Causes of Fetal Death Based on Trimester Causes of Fetal T1 (1–13 W T T3 (28 W T2 (14–27 W Abortions and Fetal Death HIGH-YIELD FACTS M 182 ANAGEMENT Thepatientshouldbeencouragedtoseekcounselingdueemotional Everyattemptshouldbemadetoavoid ahysterotomy. deathoccursinT3.Inductionoflaborwith Labor inductioniffetal deathoccursinT2.D&Ehas↓ D&E maybeusediffetal agnosis anddelivery. stress causedbydiagnosisdeathandlengthoftimebetweendi- offetal sarean deliverywithalow transverseuterinescar. vaginal misoprostol issafeandeffectiveeveninpatientswithapriorce- uterine perforation. mortality comparedtoPGE mortality 2 laborinduction,butalsohastheriskof maternal CHAPTER 12 Ectopic Pregnancy

Epidemiology 184 Risk Factors 184 Exam 185 Differential Diagnosis 185 Diagnostic Studies 186 Management 187 GENERAL 187

MEDICAL 187

SURGICAL 188

183 Ectopic pregnancy is a pregnancy that is located outside the uterine cavity. The most common site is the fallopian tubes (97%), followed by the abdominal cavity, ovary, and cervix. Within the fallopian tubes, the ampulla is the most common site, followed by the isthmus and ﬁ mbria. Cornual pregnancies that occur in the intramural portion of the fallopian tube are the most danger- Ectopic pregnancy is the ↑ leading cause of ous due to risk of uterine rupture (see Figure 12-1). Rupture of the ectopic pregnancy can lead to rapid bleeding and death. pregnancy-related maternal death during T1. Diagnose and treat before rupture occurs to ↓ the risk of EPIDEMIOLOGY death! Rate of occurrence: 2% of reported pregnancies. Increased risk of recurrance. Three to four times more common in women over age 35 compared to those in the 15- to 24-year-old age group. Most common site of ectopic pregnancy: Ampulla of fallopian tube RISK FACTORS

A 20-year-old G1P1001 whose last menstrual period (LMP) was 7 weeks ago presents to the ED with right lower quadrant (RLQ) pain and vaginal Biggest risk factor for spotting. She reports that her menses have been regular, except that she HIGH-YIELD FACTS HIGH-YIELD ectopic pregnancy: Prior is currently 3 weeks late. She has a history of pelvic inﬂ ammatory disease, and she ectopic pregnancy smokes one pack of cigarettes per day. Review of systems is positive for nausea and vomiting, Physical exam shows blood pressure 100/70, heart rate 90, and temperature 98.8ºF (37.1ºC). She has RLQ tenderness without rebound or guarding. Pelvic exam shows 5 cc of dark blood in the vault and right adnexal tenderness. Quantitative β-human chorionic gonadotropin (β-hCG) is 3000 mIU/mL. Ultrasonography (US) shows an empty uterus. What is the most likely diagnosis? Answer: Ectopic pregnancy. All reproductive-age women who present with abdominal pain and bleeding should have a β-hCG done. The quantitative β-hCG is at a level where an intrauterine pregnancy should be visualized in the uterus. Since the uterus is empty, the pregnancy must be in an ectopic location. Ectopic Pregnancy Pelvic inﬂ ammatory disease (PID)/history of sexually transmitted infections (STIs) is a major risk factor. This can create scarring of the fallopian tubes. Previous ectopic pregnancy. Tubal scarring from surgery or tuberculosis. Current intrauterine device (IUD) use. Congenital malformations of the uterus: Septate uterus. Ectopic pregnancy is the Current smoking. leading cause of Assisted reproduction technology: Ovulation-inducing drugs and in pregnancy-related deaths vitro fertilization. (6%). In utero diethylstilbestrol (DES) exposure.

184 Abdominal Isthmic Cornual (2%) (< 1%) (12%)

Ampullary (78%)

Fimbrial (5%) Cervical Ovarian (1%) (4%)

FIGURE 12-1. Sites of ectopic pregnancy.

(Reproduced, with permission, from Pearlman MD, Tintinalli JE, eds. Emergency Care of the Woman. New York: McGraw-Hill, 1998: 22.) HIGH-YIELD FACTS

EXAM

Pelvic exam may reveal normal or slightly enlarged uterus. Always check a pregnancy Vaginal bleeding. test on all reproductive age Pelvic pain. women with abdominal Palpable adnexal mass. pain and/or vaginal Signs of ruptured ectopic: bleeding. Hypotension. Tachycardia. Abdominal exam with rebound and guarding.

DIFFERENTIAL DIAGNOSIS Ectopic Pregnancy

Think of anything that can cause abdominal, adnexal pain, or bleeding in a premenopausal woman: Threatened abortion Ovarian torsion PID Acute appendicitis Ruptured ovarian cyst Tubo-ovarian abscess Degenerating uterine leiomyoma

185 DIAGNOSTIC STUDIES

A 26-year-old G2P0010 at 6 weeks gestation by LMP presents to the ED with left-sided abdominal pain and vaginal bleeding. She denies chest pain, dizziness, or shortness of breath. She had performed a urine pregnancy test at home 2 weeks ago, and it was positive, but has not received prenatal care yet. She was treated for pelvic infl ammatory disease 1 year ago. The serum β-hCG is 2000 mIU/mL. What is the next step that will help to confi rm or exclude the diagnosis of ectopic pregnancy? Answer: Transvaginal ultrasound is the modality of choice and should be done next. The presence of an intrauterine pregnancy makes the risk of ectopic very low If the quantitative β-hCG is (not zero). The TVUSG may show an empty uterus or fi ndings consistent with an > 1200 mIU/mL, and there ectopic pregnancy. is no evidence of an IUP, suspect ectopic pregnancy. Urine pregnancy test (UPT) to confi rm pregnancy: The UPT will be positive, with β-hCG levels > 25 mIU/mL, approximately 1 week after conception. Quantitative serum β-hCG: Should ↑ by at least 66% every 48 hr in the fi rst 6–7 weeks of gestation after day 9. Value of serial β-hCGs: Stable reliable patients can be followed with HIGH-YIELD FACTS HIGH-YIELD β-hCG of 25 will have a serial β-hCG levels. Inadequate rise in β-hCG is suggestive of ectopic positive urine pregnancy or nonviable pregnancy. test. Progesterone: Results often not available immediately. β-hCG of 1200–2000: > 25 ng/mL: Suggests normal intrauterine pregnancy (IUP). IUP detectable with < 5 ng/mL: Suggests abnormal pregnancy (either ectopic or nonvia- TVUS. ble pregnancy). β-hCG of 5000: IUP 5–25 ng/mL: Unclear. Unfortunately, many results fall in this range detectable with and are not helpful. US: Diagnostic modality of choice: abdominal US. Transvaginal sonography (TVUS) is more sensitive than transabdominal approach. Ectopic pregnancy is suspected if a gestational sac is not seen within the uterine cavity with a serum pregnancy test at a threshold value. Threshold for detecting an IUP on TVUS is β-hCG = 1200 mIU/mL Ectopic Pregnancy (see Figure 12-2). US fi ndings suggestive of ectopic pregnancy: β-hCG levels do not Absence of intrauterine gestational sac. correlate with: Ectopic gestational sac or cardiac activity. Size of ectopic Complex adnexal mass. Fluid in the cul de sac: Fluid in the dependent portion of the pel- Potential for rupture vis can represent blood from the ruptured ectopic pregnancy. Location of ectopic Gestational age of ectopic

186 FIGURE 12-2. Transvaginal ultrasound demonstrating an ectopic pregnancy.

Note the large amount of free ﬂ uid (FF) in the pelvis. No intrauterine pregnancy was seen. A large complex echogenic mass (EM) was seen in the left adnexa, consistent with an ectopic pregnancy. A simple cyst (SC) is also seen, in the right adnexa. HIGH-YIELD FACTS

MANAGEMENT

A 30-year-old G2P1001 at 6 weeks gestation presents to the ED with vaginal spotting and right lower quadrant pain. She denies any medical conditions, any prior surgeries, or any substance abuse. She is afebrile with stable vital signs. She is tender in the right lower quadrant without rebound or guarding. Serum β-hCG is 4000 mIU/mL. US shows an empty uterus with a 2.5-cm hyperechoic ring consistent with an ectopic in the right adnexa. There is a small amount of ﬂ uid in the cul de sac. What is the best treatment for this

patient? Ectopic Pregnancy Answer: Methotrexate. This hemodynamically stable patient has ﬁ ndings consistent with an ectopic pregnancy. She should undergo additional blood work to ensure there are no blood dyscrasias and be able to have regular follow-up. With methotrexate, she avoids risks of surgery and can preserve the fallopian tube.

General Determine if the patient is hemodynamically stable. Determine if the ectopic pregnancy is ruptured. Administer Anti-D immunoglobulin if patient is D negative.

Medical Methotrexate (MTX) an option if early ectopic pregnancy and unruptured. Antimetabolite. Inhibits dihydrofolic acid reductase. Interferes with DNA synthesis. Treatment of certain neoplastic diseases, rheumatoid arthritis, psoriasis, and ectopic pregnancies.

187 Indications: Hemodynamically stable patient. Ectopic pregnancy < 3.5 cm. Patient compliant for follow-up. Intrauterine pregnancy ruled out. Relative contraindications: Fetal cardiac activity of ectopic pregnancy. Quantitative β-hCG > 15,000 mIU/mL. Ectopic pregnancy > 3.5 cm. Absolute contraindications: Hemodynamically unstable patient: MTX requires time to work. Leukopenia: MTX can further suppress immune system. Do not coadminister a Thrombocytopenia (< 100K). Active renal/hepatic disease. nonsteroidal anti- Active peptic ulcer disease. inﬂ ammatory drug (NSAID) Possibility of concurrent viable intrauterine pregnancy. with MTX, as it can Presence of ruptured ectopic pregnancy. potentiate nephrotoxicity. Breast-feeding.

Surgical Laparotomy if patient is hemodynamically unstable: Enter into the peritoneal cavity via a large incision on abdominal wall. Place two large bore IVs to administer normal saline and type HIGH-YIELD FACTS HIGH-YIELD and cross for blood. Most commonly used for hemodynamically unstable patient. Fast access and minimal equipment needed. Laparoscopy if patient is hemodynamically stable: Entry into peritoneal cavity via small incisions and visualization of abdominal and pelvic organs with a small camera. Can be diagnostic (only visualize) or operative (perform surgical procedures). Salpingectomy: Removal of the tube: Partial salpingectomy: Removal of part of the tube. Complete salpingectomy: Removal of the whole tube. Salpingostomy: A partial salpingectomy Incision on the antimesenteric portion of the tube. may cause a future ectopic Used for unruptured distal tubal ectopic pregnancy. Ectopic Pregnancy pregnancy. Allows pregnancy to be removed while sparing the tube. Should follow the β-hCG down to zero as some pregnancy tissue may be left behind and continue to grow, which can cause a chronic ectopic.

188 SECTION III

᭤ Contraception and High-Yield Facts in Sterilization ᭤ Menstruation Gynecology ᭤ Premenstrual Syndrome/ Premenstrual Dysphoric Disorder ᭤ Infertility ᭤ Amenorrhea ᭤ Hyperandrogenism ᭤ Hyperprolactemia and Galactorrhea ᭤ Abnormal Uterine Bleeding ᭤ Pelvic Pain ᭤ Endometriosis/ Adenomyosis ᭤ Differential Diagnoses of Pelvic Masses ᭤ Cervical Dysplasia ᭤ Cervical Cancer ᭤ Endometrial Hyperplasia and Endometrial Cancer ᭤ Ovarian Cancer and Fallopian Tube Cancer ᭤ Vulvar Dysplasia, Vular Cancer and Vaginal Cancer ᭤ Vulvar Disorders ᭤ Gestational Trophoblastic Disease ᭤ Sexually Transmitted Infections/Vaginitis ᭤ Breast Disease ᭤ Women’s Health Maintenance ᭤ Female Sexuality ᭤ Ethics ᭤ Menopause ᭤ Pelvic Relaxation ᭤ Urinary Incontinence

189 This page intentionally left blank CHAPTER 13 Contraception and Sterilization

Contraception 192 BARRIER METHODS 194

HORMONAL AGENTS 196

INTRAUTERINE DEVICE 200

POSTCOITAL/EMERGENCY CONTRACEPTION 201 Sterilization 201 VASECTOMY 201

BILATERAL TUBAL OCCLUSION 202

OTHER METHODS OF STERILIZATION 204 Abstinence 204 CONTINUOUS ABSTINENCE 204

NATURAL FAMILY PLANNING 204

191 Contraception and Sterilization HIGH-YIELD FACTS TABLE 13-1. oral Progestin-only progestin) (estrogen and hormonal Combined Barrier C ATEGORY ComparisonofContraceptiveAgents Condoms Cervical caps Diaphragm Minipill Vaginal ring patch Contraception contraceptives Combined oral A GENTS efi method willbeinfl uenced bypersonalconsiderations,noncontraceptiveben- time ofintercourse,orafterintercourse.Apatient’s choice ofcontraceptive abstinence. Contraceptivescanbeusedregularlypriortointercourse,atthe Contraception isawaytopreventpregnancyusingmedications, devices,or 192 CONTRACEPTION ts, effi cacy, safety, cost,andcontraceptivemethod(seeTable 13-1). endometrium Thins fallopian tubes of uterusand Alters motility penetration inhibit sperm mucus to Thickens cervical Inhibits ovulation endometrium Thins fallopian tubes of uterusand Alters motility penetration inhibit sperm mucous to Thickens cervical obstruction Mechanical M ECHANISM ↓ STIs Not desiringhormones Breast-feeding irritation anddischarge but mayhavevaginal Ring—less toremember, have morenausea remember butmay Patch—less to day OCP—take pillevery Endometriosis Ovarian cysts Dysmenorrhea Iron defi B EST S ciency anemia ciency UITED F OR associated withmoreUTIs Diaphragm maybe tomaterials Allergies Lack ofspontaneity placing devicesongenitals with Patient discomfort Pelvic organprolapse remember totakepill Patient needsto each dayatsametime Dependent ontakingpill pregnancy Known orsuspected disease, liverfailure liver tumors,active Benign ormalignant withaura Migraines bleeding Undiagnosed vaginal vascular disease nephropathy, peripheral Diabetic retinopathy, Uncontrolled hypertension of 35 Cigarette smokeroverage disease coronary artery Cerebrovascular or Prior thromboembolic mutations Known thrombogenic event D C ONTRAINDICATIONS SDATGSAND ISADVANTAGES HIGH-YIELD FACTS Contraception and Sterilization broids distorting ↑ irregular vaginal ISADVANTAGES AND ONTRAINDICATIONS C D Uterine fi endometrial cavity Undiagnosed abnormal vaginal bleeding Known or suspected carcinoma of the breast or personal history of breast cancer Hypersensitivity to any of the components May bleeding or recent PIDCurrent STI Unexplained vaginal bleeding Malignant gestational trophoblastic disease Untreated cervical or endometrial cancer Current breast cancer Anatomical abnormalities distorting the uterine cavity ↑ Depression ↑ Osteopenia/ gain Weight Current or past history of thrombosis or thromboembolic disorders Hepatic tumors (benign or malignant), active liver disease osteoporosis 193 OR F UITED ciency anemia ciency anemia S EST B Dysmenorrhea Ovarian cysts Endometriosis Desires long-term reversible contraception (5 yr) Stable, mutually monogamous relationship Menorrhagia Dysmenorrhea Breast-feeding Desires long-term contraception Iron defi Sickle cell disease Epilepsy Dysmenorrhea Ovarian cysts Endometriosis Breast-feeding Desires long-term contraception (lasts 3 yr) Iron defi ECHANISM M Thickens cervical Thickens mucous Thins endometrium Inhibits ovulation Thins endometrium cervical Thickens mucous to inhibit sperm penetration Inhibits ovulation Thins endometrium Alters cervical mucous to inhibit sperm penetration GENTS A Levonorgestrel IUD Etonorgestrel Depo-medroxy progesterone acetate (progestin) (continued) Agents of Contraceptive Comparison ATEGORY C Injectables IUD Implants (subdermal in arm) TABLE 13-1. TABLE Contraception and Sterilization HIGH-YIELD FACTS (Reprinted, withpermission,fromToy EC, etal.CaseFiles:ObstetricsandGynecology,3rded.NewYork: McGraw-Hill,2009: 283.) pelvicinfl intrauterinedevice;PID, IUD, ammatory disease;STI, sexuallytransmittedinfection;UTI,urinarytractinfection. TABLE 13-1. sterilization Permanent IUD C ATEGORY ComparisonofContraceptiveAgents(continued) occlusion Bilateral tubal Copper-T A GENTS M General methodsofpreventingpregnancyinclude: 194 T F Barrier Methods YPES EMALE ALE Abstinence Sterilization Intrauterinedevice(IUD) Hormonal Barrier Polyurethane (newest,sensitive, expensive). Latex (mostcommon,inexpensive). Effi Itofferslabialprotection,unlike themalecondom. Rarelyusedbecauseofexpenseandinconvenience (itmust notbere- C moved for6–8hrafterintercourse). C ONDOM ONDOM cacy: 79%. tubes obstruction of Mechanical Damages ovum of ovum speed transport Changes viability and migration Inhibits sperm M ECHANISM contraceptive steroids Contraindication to relationship monogamous Stable, mutually (10 yr) reversible contraception Desires long-term children Does notdesiremore B EST S UITED F OR endometrial cavity Uterine fi cavity theuterine distorting Anatomical abnormalities Current breastcancer endometrial cancer Untreated cervicalor trophoblastic disease Malignant gestational bleeding Unexplained vaginal months withinpast2 Current PID Current STI future May wantchildreninthe surgery Contraindications to or dysmenorrhea May causemorebleeding Wilson disease D C ONTRAINDICATIONS SDATGSAND ISADVANTAGES briods distorting distorting briods HIGH-YIELD FACTS Contraception and Sterilization contraceptive only contraceptive Hormonal patch may be less effective in obese (≥ 200 lbs) women. Effi cacy rates for Effi spermicides are much higher when combined with other barriers (eg, condoms, diaphragms). P450 inducers will decrease cacy of oral the effi contraceptives (OCPs) (eg, phenytoin, rifampin, griseofulvin, carbamazepine, alcohol, barbiturates) due to increased clearance. The protects method that is the male and against STIs female condoms. Inconsistent condom use accounts for most failures. 195 ↑ risk of urinary tract infection (UTI). AP C ). (which may cause toxic shock syndrome fections [STIs]). fections ↓ sensation. birth: 80–90%. In women who have not given birth: 60–70%. In women who have given infection If left in for too long, may result in Staphylococcus aureus May properly before genital Must be placed contact. rupture. May in- transmitted sexually against least protection (sensitive, skins Animal IAPHRAGM ERVICAL RAWBACKS OMPLICATIONS PONGE PERMICIDE FFICACY FFICACY FFICACY FFICACY FFICACY YPES C E 84%. S A polyurethane sponge containing nonoxynol-9 that is placed over the cervix. discon- It can be inserted up to 24 hr before intercourse. Production has been States. in the United tinued E 74–94%. T which dis- of spermicide, Nonoxynol-9 and octoxynol-3 are active ingredients rupt the sperm cell membrane; effective for only about 1 hr. Foams, gels, creams placed in vagina up to 30 min before intercourse. Do not gels, creams placed in vagina up to 30 min Foams, reduce the risk of STIs. E A smaller version of a diaphragm that fi ts directly over the cervix. It is more ts directly that fi A smaller version of a diaphragm States.popular in Europe than in the United C E 80–94%. A fl exible ring with a rubber dome that must be fi It cre- tted by a gynecologist. fi be must exible ring with a rubber dome that A fl vagina. It must portion of the the cervix and the lower ates a barrier between hr. left in place after intercourse for 6–8 and be inserted with spermicide 86–97%, depending on proper use. on depending 86–97%, D E S D Contraception and Sterilization HIGH-YIELD FACTS Main mechanisms: progesterone combined. COC: Estrogenand results inmenses. menstrual cycle,which withdrawal ofthenormal simulate hormone The inactivepillsintheCOC contraception. combination hormonal in patientswhotake aura can↑ Migraine headacheswith contraceptive agents. a contraindicationfororal Tension headachesarenot Estrone: Menopause Estriol: Pregnancy Estradiol: Reproductivelife Types ofestrogens: Causes endometrial mucus Thickenscervical Altersuterineand Prevents ovulation atrophy penetration to preventsperm fallopian tubemotility risk ofstroke S M E C Hormonal Agents Toxic shocksyndrome. R 196 B IDE FFICACY ISK ENEFITS OMBINATION CAIMOF ECHANISM history ofbreastcancer, andpregnancy. withaura,andbenignormalignantlivertumors,disease, disease, migraines include: femalesmokers>35 yearsold,uncontrolledHTN,diabeteswithvascular developing venousthromboembolismandstrokes.ContraindicationsforOCPuse pills (COCs). Howdoyoucounsel thispatient? tive withahistoryofbreastcancer. Sherequestscombinationoralcontraceptive E Progesteronepreventsluteinizing hormone(LH)surgeandtherefore Estrogensuppressesfollicle-stimulating hormone (FSH)andtherefore estrogenandprogestin;typesincludefi Contain xed dosingandphasic 95–99.9%(variabilityduetocompliance). Reducestheriskofpelvicinfl ammatory disease (PID)(thickermucus), Regulates menses. Bloating. Headache. Nausea. Answer: FFECTS inhibits ovulation. ofendometrium. stability prevents follicularemergence.Maintains dosing: acne, andhirsutism. fi ↓ riskofanemia. ↓ bleeding anddysmenorrhea. ↓ riskofendometrialcancerby50%. ↓ riskofovariancancerby75%. brocystic breast change,ovariancysts,ectopicpregnancy, osteoporosis, Causesendometrialatrophy. Altersmotilityoffallopiantubeanduterus. Thickenscervicalmucus toposeasabarrierforsperm. changes inthelevelofestrogen. Phasic dosing:Gradual↑ Fixed dosing:Requires thesamedoseeverydayofcycle. auras, has uncontrolled hypertension (HTN),andhasafi auras, hasuncontrolledhypertension with Her historyrevealsthatshesmokescigarettes,suffersfrommigraines A 37-year-old G2P2womandesiresareversibleformofcontraception. O A The patientshouldnotbeplaced onCOCs duetoherriskfactorsfor CTION RAL C ONTRACEPTIVES (COC in amountofprogestinaswellsome S ) rst-degree rela- rst-degree HIGH-YIELD FACTS Contraception and Sterilization inhibits FSH. Estrogen inhibits LH. Progestin Oral contraception mechanism in a nutshell: Estrogen suppresses breast milk, so combination pills are not used for nursing mothers. Progestin-only pills are used. Always check a β-hCG to Always check before rule out pregnancy the acne prescribing medicine isotretinin (very teratogenic!). What is the treatment for idiopathic hirsutism? OCP 197 ONTRACEPTIVES C RAL O CTION NLY A -O milk). tumors). (but not released). A mature follicle is formed No placebo is used. Lactating does not suppress breast women (progestin, unlike estrogen, (eg, estrogen-sensitive is contraindicated for whom estrogen Women lation. The main differences from combination pills are: lation. The main differences risk of venous thromboembolism/stroke (3/10,000). thromboembolism/stroke of venous ↑ risk > 35 years old). (in smokers infarction ↑ risk of myocardial FFECTS Breakthrough bleeding. Breakthrough Nausea (10–30% of women). for: Progestin-only pills are best to prevent sperm penetration. Thickens mucous fallopian tubes. Alters motility of uterus and of endometrial glands. Causes thinning Contain progestin: There is LH suppression and therefore no ovu- only Uncontrolled HTN. Uncontrolled peripheral vascular disease. nephropathy, retinopathy, Diabetic breast or endometrial cancer. or suspected Known bleeding. vaginal Undiagnosed with aura. Migraines liver failure. liver tumors, active liver disease, or malignant Benign or suspected pregnancy. Known mutations. thrombogenic Known events. Prior thromboembolic (current or remote). or coronary artery disease Cerebrovascular smoking over age 35. Cigarette in some. Depression Migraines. E ECHANISM OF ONTRAINDICATIONS ISKS IDE FFICACY ROGESTION S M E be takenbut must at same time each day Comparable to COCs (95–99%), (within 3 hr). C P R Contraception and Sterilization HIGH-YIELD FACTS the same time every day.the sametimeevery requires takingthepillat strict complianceand Progestin-only pillrequires antithrombin III. factors VIIandX↓ procoagulant? Estrogen↑ Why isestrogena Side effectsofprogestin: Side effectsofestrogen: proven. an Oral contraceptives’linkto Irregular bleeding Weight gain Acne Depression Headache Nausea Breast tenderness ↑ in breastcancerisnot I S I suppression. Thicker mucus andendometrialatrophy alsocontribute.ThereisnoFSH highprogesteroneleveltoblockLHsurge(andhenceovulation). Sustained M 99.7%. E (DMPA)Medroxyprogesterone acetate IMinjectiongivenevery3months. I 198 of thearm.Itshouldbereplaced every3years. tissue rodinsertedinthesubcutaneous Etonorgestrel (progestin) containing C NJECTABLE MPLANTABLE NDICATIONS IDE FFICACY ONTRAINDICATIONS CAIMOF ECHANISM tive methodforher? and and improvessymptomsofendometriosis. with sicklecelldisease.Itimprovesanemia,↓ E Weight gain. Mood changes. Unknown whenmenstruation/fertility willresumeaftertreatmentcessa- Bleeding irregularity/spotting. DMPA canprovidenoncontraceptivebenefi forwomenwhoeither Especially cannottolerateCOCsorwho suitable Osteoporosis/osteopenia. Liver disease. Breast cancer. Undiagnosed vaginalbleeding. Known/suspected pregnancy. Osteopenia/osteoporosis. Reversewhenstopusing DMPA. Answer: FFECTS tion (canremaininfertileforupto9months). COCsasprescribed. are unabletotake ↓ libido. ↓ high-densitylipoprotein (HDL). ↑ hairshedding. ↓ Sicklecelldisease: ↓thenumber ofsicklecellcrises. Seizure disorder: the numberofseizures.Italso↓ H still hasseizuresonceaboutevery6months.What isthebestcontracep- malseizuresforwhichshetakesananticonvulsant.She history ofgrand A 20-year-old G0desireslong-term reversiblecontraception.Shehasa H ORMONAL A ORMONAL Medroxyprogesterone acetateinjectioncan↑ CTION A A GENTS GENTS ↓ thenumber ofseizure episodes. the numberofsicklecellcrisesinpatients dysmenorrhea andovariancysts, ts in: the seizurethreshold HIGH-YIELD FACTS Contraception and Sterilization 199 ) ) VRA ING E R cult removal cult UVA RTHO CTION (N A (O ING to COC. cacy similar R effi cacy if out > 3 hr. ↓ effi ↓ libido FFECTS Better compliance. Better May come off and need replacement. Must be changed every 3 weeks. time. Must be inserted at the same Liver disease/cancer Liver cancer Breast Concomitant therapy anticonvulsant Effi Adnexal enlargement Adnexal diffi Possible Thrombophlebitis/embolism pregnancy Known/suspected (CAD). mellitus, HTN, coronary artery disease diabetes with Women bleeding Irregular Acne Thickened mucus. Thickened atrophy. Endometrial to oral contraceptives. Contraindication/intolerance > 35 years old. Smokers of ovulation. surge and inhibition of LH Suppression E ECHANISM OF AGINAL ONTRAINDICATIONS IDE FFICACY RANSDERMAL NDICATIONS C S I 99.8%. M V T E Contraception and Sterilization HIGH-YIELD FACTS failure ratesthanOCPs. injections havelower subdermal implant,and methods liketheIUD, Non-user-dependent is an↑ upper genitaltract,sothere access forbacteriatothe The IUDfi lamentprovides multiple sexpartners placement: Women with Contraindication forIUD risk forinfection. I M 97–99.1%. E ment protruding removal. throughthecervixintovaginatofacilitate Insertion ofaT-shaped deviceintotheendometrialcavitywithanylonfi Intrauterine Device 200 C C NDICATIONS FFICACY OMPLICATIONS ONTRAINDICATIONS CAIMOF ECHANISM years after the IUD placementmaybeduetoSTIs. years aftertheIUD placementareduetocontamination. Infectionsmonthsto mal tothetimeofIUD patient’s symptoms? stringsatthecervicalos.What isthemostlikelycausefor discharge andIUD abdominal pain,nausea,vomiting,andfever. Speculumexamrevealsmalodorous without anyapparentcomplications.The patientpresents4dayslaterwith LevonorgestrelIUDcanbe used formenorrhagia. Smokers>35yearsold. Oralcontraceptivescontraindicated/not tolerated. Levonorgestrel IUD: Copper T: Uterine perforation. PID. Absolute contraindications: Currentorsuspected pregnancy, undiag- Copper allergy. Wilson disease. Known/suspected pregnancy. Immunocompromised (eg,HIV, sicklecelldisease). RecenthistoryofPID. Multiplesexualpartners. Answer: nosuppressed patients,severe anatomical uterine distortion. acute infection(cervical,uterine, orsalpingeal),historyofPID,immu- nosed abnormalvaginalbleeding, suspectedgynecologicmalignancy, Spermicidal Usedfor5yr Thins endometrium Thickenscervicalmucous Usedfor10yr. Damagesovum,changesovumtransportspeed. Inhibitsspermmigration andviability. Coppercausesasterileinfl ammatory reaction,creatingahostileen- vironment. STIs or other medical conditions. She undergoes the insertion of an IUD ofanIUD STIs orothermedicalconditions. Sheundergoestheinsertion along-term,monogamousrelationship.Shedenieshistoryof reports A 25-year-old G1P1,whodelivered afull-terminfant6monthspreviously, A Endometritis due to contamination during insertion. Infectionsproxi- Endometritis duetocontaminationduringinsertion. CTION la- HIGH-YIELD FACTS Contraception and Sterilization Tubal occlusion is twice as Tubal common as vasectomy. What are the two methods of emergency postcoital contraception? Up to 3 days after intercourse: levonorgestrel (plan B). Up to 5 days after: Copper T IUD. What are options for emergency contraception? IUD within 5 days or low- dose progesterone within 72 hr. Ectopic pregnancy is a Ectopic pregnancy of dangerous complication IUD use. Copper and levonorgestrel IUD reduce the risk of ectopic pregnancy compared to no contraceptives, but not as much as OCPs. 201 cacy: 89%. cacy: NTERCOURSE NTERCOURSE I I infection. cacy:100%. Nearly FTER FTER A A AYS AYS A 19-year-old G0P0 woman presents to the offi that she may ce concerned woman presents to the offi G0P0 A 19-year-old after engaginghave an undesired pregnancy her in unprotected sex with boyfriend not remember the date of her last patient does 2 days ago. The rility one must use contraception for 12 weeks or 20 ejaculations and rility one must then have two consecutive negative sperm counts. the proximal and distal cut ends (offi ce procedure done under local an- the proximal and distal cut ends (offi esthesia). Ejaculation still occurs. 25% of women who undergo tubal ligations may experience regret after 25% of women who undergo tubal ligations may experience regret after in women permanent sterilization. Higher regret rate is associated tubal liga- younger than age 25, women not married at the time of their tion, or women whose tubal ligation was performed less than a year after delivery. 3 D 5 D Emergency contraception is effective when initiated within 72 hr of 72 is effective when initiated within Answer: Emergency contraception to the surgical site, so to ensure ste- Sperm can still be found proximal by sealing of of a small section of both vas deferens, followed Excision and 13– is estimated that 10–12% of men who undergo vasectomies It Male type: Vasectomy. occlusion. type: Tubal Female Ectopic pregnancy. Ectopic T. with Copper Menorrhagia expulsion. IUD Actinomyces menstrual period. What therapy can you offer this patient? therapy menstrual period. What or insertion of high-dose progestin, high-dose OCPs, intercourse. It consists of a Copper T IUD. PTO PTO STERILIZATION Vasectomy U that leaves a male or female unable to re- Sterilization is an elective surgery States, procedures per year in the United ster- produce. With about 1 million birth control. There are 1–4 pregnancies ilization is the most popular form of per 1000 sterilizations. Can be left in the uterine cavity and provide contraception Copper T IUD: Can be left in the uterine cavity and Effi for up to 10 yr. Levonorgestrel (Plan B): One 0.75-mg tablet takenA within 72 hr of coitus. rst dose. Effi second 0.75-mg tablet is taken 12 hr after the fi U Postcoital/Emergency Contraception Postcoital/Emergency Contraception and Sterilization HIGH-YIELD FACTS (Reproduced, withpermission, fromCunningham G,etal.Williams21st ed.NewYork: Obstetrics, McGraw-Hill, 2001:1556.) 13-1. FIGURE Tubal occlusionfacts: States. laparoscopy intheUnited frequent indicationfor Tubal ligationisthemost Clippingmethod ismost methodis Electrocautery the mostlikelytofail. easily reversedbutalso diffi cult toreverse. most popularand Irving alnrKroener Madlener Various techniques fortubalsterility. fallopian tube. band, orFallope ring,isplacedaroundthebaseofdrawn-up portionof A lengthofisthmus isdrawn upintotheendoftrocar,andasilicone B has thehighestfailurerate. 90-degree angleontheisthmus. Itisthe mosteasilyreversedmethodbutalso isappliedata The Hulka-Clemensclip(alsoFilshieclip),similar toastaple, C popular method(veryeffectivebutmostdifficult toreverse). This involvesthecauterizationofa3-cmzoneisthmus. Itisthemost E methods occludethefallopiantubesbilaterally. Eighty toninety percentoftubalocclusionsaredonelaparoscopically. All L ble pregnancy. phase ofthemenstrualcycleinordertoavoid thetimeofovulationandpossi- pregnancy). Anintervaltubalocclusionshouldbeperformedinthefollicular ean sectionorimmediately aftervaginaldelivery)orinterval(remotefroma Procedures canbeperformed(Figure13-1)either postpartum(duringcesar- Bilateral Tubal Occlusion 202 APAROSCOPIC LECTROCAUTERY ANDING LIPPING T UBAL O Pomeroy CCLUSION Parkland HIGH-YIELD FACTS Contraception and Sterilization pelvic adhesions cant PID signifi to no history Little of to no history Little of habitus Body Selection of patient for tubal ligation is important: Essure is the most effective Essure is the method of permanent available sterilization Be sure to follow-up on tubal pathology report after ligation to ensure that tissue excised was fallopian tubes. 203 mbriae follow- cacy. Similar to the Pomeroy but without the excision, a the excision, but without to the Pomeroy Similar CCLUSION A segment of isthmus is lifted and a suture is tied is lifted A segment of isthmus (Essure) A window is made in the mesosalpinx and a segment is made in the mesosalpinx A window Resection of the distal ampulla and fi Resection of the distal ampulla and Epinephrine is injected beneath the serosa of the isth- Epinephrine is injected beneath the O BSTRUCTION O CCLUSION UBAL ALPINGECTOMY T O CCLUSION UBAL S REGNANCY T O UBAL P OTAL T T HASE Pregnancies after tubal ligation reversal are ectopic until proven oth- Pregnancies after tubal ligation reversal are ectopic ian cyst. procedure is performed on the fallopian tubes < 2–3 cm from the uterus. of isthmus is tied proximally and distally and then excised. is tied proximally and of isthmus is lifted and crushed and tied at the base. segment of isthmus myometrium and the distal end buried in the mesosalpinx. myometrium and the distal end buried of ected off the tube, and the proximal end is refl The mesosalpinx mus. The meso- The distal end is not excised. the tube is ligated and excised. salpinx is reattached proximal stump, while the long dis- to the excised tal end is left to “dangle” outside of the mesosalpinx. around the approximated base. The resulting loop is excised, leaving a excised, base. The resulting loop is around the approximated the most popular proximal and distal ends. This is gap between the method. terosalpingogram 3 months after implant placed. 3 months terosalpingogram to enter the fallopian tube. and prevents sperm mal fallopian tube. mal fallopian ing ligation around the proximal ampulla. -P Infection. Operative complications most commonly from anesthesia. still fertile). of procedure (patient Failure pain/dysmenorrhea, menorrhagia, ovar- syndrome: Pelvic Poststerility if the stulas can occur, especially formation: Uteroperitoneal fi Fistula Madlener method: Madlener is cut, with the proximal end buried in the method: The isthmus Irving method: Kroener method: Uchida Pomeroy method: Pomeroy method: Parkland hys- proved by until tubal occlusion needed Alternative contraception implant over 3 months of action: Scarring forms around Mechanism proxi- is placed in the implant coil polyester/nickel/titanium/steel Small invasive. Minimally data effi 99.8% shows Two-year YSTEROSCOPIC OMPLICATIONS OF EVERSIBILITY OF ARTIAL OR OSTPARTUM UTEAL C erwise. Around one-third of tubal ligations can be reversed such that pregnancy can Around one-third of tubal ligations can be reversed such that pregnancy result. R L but A luteal-phase pregnancy is a pregnancy diagnosed after tubal sterilization It is prevented by ei- conceived before. Occurs around 2–3/1000 sterilizations. sensitive pregnancy tests prior to the procedure or performing ther performing phase. the procedure during the follicular Removal of part or all of the fallopian tube. Removal of part or all of the fallopian H P P Contraception and Sterilization HIGH-YIELD FACTS patient compliance. pregnancy, dependingon rate inpreventing NFP hasa75–99%success stain fromsexatthefistain rst signsmucus until4daysafterthepeakday. again andgoaway. Ifcoupledoesnotdesirepregnancy, theyareadvisedtoab- as the“peakday”offertility. Afterthepeakday, themucus willbecomethick cus becomesmoreclear,profuse,wet,stretchy, andslippery, andisreferredto mucus astheymoveclosertoovulation.Attimeofovulation,awoman’s mu- opening ofthevaginatodetermine ifsheisfertile.Mostwomenwillsecrete The womanchecksforthepresenceandchange of cervicalmucus atthe O they aretryingtoconceive. iftheydonotdesirepregnancyorhaveintercourse The couplecanabstain tive dayswhenshehasaprogesteronesurge,indicating thatsheisovulating. as soonshewakesup.Hertemperatureshould↑by0.3–1ºFfor3consecu- The womanmustandrecordherbasalbodytemperatureeverymorning take B 4. Lactational amenorrhea 3. Symptothermal method Ovulation/cervical mucus method 2. Basal bodytemperaturemethod 1. There arefourmethodsofNFP: period. fromhavingsexoruseanotherformofcontraceptionduringthefertile stain patient’s abilitytorecognize thesignsthatovulationisabouttooccurandab- wanted pregnancy. Thesuccessorfailure ofthismethodswilldependonthe strual cycle.Itcanbeaneffective,low-cost, andsafewaytopreventanun- A formofbirthcontrolbasedonthetiming ofsexduringawoman’s men- Natural Family Planning(NFP) way topreventpregnancy. fromvaginalintercourseatanytime.Itistheonly100%effective Abstaining Continuous Abstinence ectopic pregnancy= sterilization purposes.Failure rateis<1%.Pregnancyafterhysterectomy= Removal oftheuterus,either vaginallyorabdominally; rarelyperformedfor H in laparoscopyandlaparotomy. cludes thefallopiantubesbyemployingmethodssimilar tothoseperformed Utilizes entrythroughthevaginalwallnearposteriorcul-de-sacandoc- C Other MethodsofSterilization 204 ASAL ABSTINENCE OLPOTOMY YSTERECTOMY VULATION B ODY /C T EMPERATURE ERVICAL M emergency. UCUS M ETHOD (B ILLINGS M ETHOD ) HIGH-YIELD FACTS Contraception and Sterilization 205 ETHOD NFP M MENORRHEA NFP A mal cycle. ity status to her partner. impact on libido. awareness. time to learn fertility Takes risk to baby. No impact on breast-feeding—no Abstinence isn’t always easy. and cooperative couple. a committed Requires No protection against STIs. Low cost. Low Reversible. fertility and nor- and understanding of woman’s knowledge Improved her fertil- should communicate The woman Improve communication: bloating, or hormonal No side effects, allergies, breakthrough bleeding, ISADVANTAGES OF DVANTAGES OF YMPTOTHERMAL ACTATIONAL D A The use of breast-feeding to space pregnancies through exclusive breast- space pregnancies to The use of breast-feeding on demand. This ers, no bottles, and nursing which means no pacifi feeding, as reliable for child working mothers, so it may not be cult for may be diffi spacing. L Combination of previous two methods. In addition to taking the temperature two methods. In addition of previous Combination signs checks for other the woman day, changes every for mucus and checking position and changes in the spotting, pain or cramps, abdominal of ovulation: that you abstain sex from requires the cervix. This method rmness of and fi after the eleva- the third day signs of fertility until rst notice day you fi from the of the either more effective than method can be This tion in temperature. because it uses a variety of signs. other two methods S NOTES HIGH-YIELD FACTS HIGH-YIELD Contraception and Sterilization Contraception

206 CHAPTER 14 Menstruation

Puberty 208 SECONDARY SEX CHARACTERISTICS 208

TANNER STAGES 208

PRECOCIOUS PUBERTY 208 Menstrual Cycle 208 DAYS 1–14: FOLLICULAR PHASE 210

DAY 14: OVULATION 210

DAYS 14–28: LUTEAL PHASE 210

207 PUBERTY

Puberty is the transition from childhood to the ﬁ nal stage of maturation What is the order of that allows for reproduction. Puberty is believed to begin with disinhibition of the pulsatile gonado- pubertal landmarks? tropin-releasing hormone (GnRH) secretion from the hypothalamus Thelarche, pubarche, (mechanism is unknown). menarche

Secondary Sex Characteristics Development of the secondary sexual characteristics proceeds in the following

CHARACTERISTIC AGE HORMONE order: Thelarche 10 Estradiol 1. Thelarche (breast budding). Average age 10 years. Due to increase in estradiol. Pubarche 11 Adrenal 2. Pubarche (axillary and pubic hair growth). Average age 11 years. Due to hormones increase in adrenal hormones. Menarche 12 Estradiol 3. Menarche (ﬁ rst menses). Average age 12 years. Due to increase in estradiol.

Tanner Stages The Tanner stages of development refer to the sequence of events of breast and pubic hair development. Stage 1: Prepubertal child. HIGH-YIELD FACTS HIGH-YIELD Stages 2–4: Development stages. Stage 5: Adult.

A female age 13 or older Precocious Puberty without any breast development has estrogen Appearance of the secondary sexual characteristics before 8 years of age is re- defi ciency and needs ferred to as precocious puberty and requires investigation into the etiology. evaluation. ETIOLOGY (NOT AN EXHAUSTIVE LIST) Idiopathic: Most common. Tumors of the hypothalamic-pituitary stalk: Prevent negative feedback. Infl ammation of the hypothalamus: ↑ GnRH production. Menstruation 21-hydroxylase defi ciency. Estrogen-secreting tumors. Excess exogenous estrogen.

MENSTRUAL CYCLE

The menstrual cycle is the cyclical changes that occur in the female reproductive system (see Figure 14-1 and Table 14-1). The hypothalamus, pituitary, ovaries, and uterus interact to allow ovulation approximately once per month (average 28 days [+/–7 days]). The following description is based on a 28-day menstrual cycle. Many follicles are stimulated by follicle-stimulating hormone (FSH), but the follicle that secretes more estrogen than androgen will be released.

208 TABLE 14-1. Summary of Menstrual Cycle

Menstruation: Withdrawal of progesterone causes endometrial sloughing.

Follicular phase: FSH causes follicle maturation and estrogen secretion. Estrogen causes endometrial proliferation.

Ovulation: LH surge causes oocyte to be released.

Luteal phase: Corpus luteum secretes progesterone, which causes: Endometrial maturation. ↓ FSH, ↓ LH.

This dominant follicle releases the most estradiol so that its positive HIGH-YIELD FACTS feedback causes an LH surge. Average menses = 4 days. More than 7 days is abnormal. Blood loss in menstruation averages 30–50 mL and should not form clots; > 80 mL is an abnormally high amount of blood loss. Prostaglandins released from the endometrium cause dysmenorrhea.

Follicular phase Luteal phase

Ovulation

P Endocrine cycle E2 Menstruation LH

FSH

Ovarian histology Follicular Corpus recruitment Dominant follicle luteum

Menses Endometrial histology

37.0 Body temperature 36.5 (° C) 36.0

20 4 6 8 10 12 14 16 18 20 22 24 26 28 Days

FIGURE 14-1. The menstrual cycle.

(Modiﬁ ed, with permission, from Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison’s Prin- ciples of Internal Medicine, 14th ed. New York: McGraw-Hill, 1998: 2101.)

209 Days 1–14: Follicular Phase The follicular phase begins on the ﬁ rst day of menses. All hormone levels are low. Without any negative feedback, GnRH from the hypothalamus causes FSH release from the pituitary. Ovulation takes place FSH stimulates maturation of granulosa cells in the ovary. The granu- 24–36 hr after LH surge losa cells secrete estradiol in response. and 12 hr after LH peak. Estradiol inhibits luteinizing hormone (LH) and FSH due to negative feedback. In the meantime, the estradiol secretion also causes the endometrium to proliferate. LH acts on the theca cells to ↑ secretion of androgens (which are converted to estradiol), prepare the cells for progesterone secretion, and cause further granulosa maturation.

The follicular phase is highly variable. The luteal Day 14: Ovulation phase is usually about 11 A critical level of estradiol triggers an LH surge. days due to the length of The LH surge causes the oocyte to be released from the follicle. The time the corpus luteum ruptured follicle then becomes the corpus luteum, which secretes pro- is able to secrete gesterone. progesterone.

Days 14–28: Luteal Phase

HIGH-YIELD FACTS HIGH-YIELD The corpus luteum secretes progesterone for only about 11 days in the absence of human chorionic gonadotropin (hCG). Progesterone causes the endometrium to mature in preparation for pos- The corpus luteum is sible implantation. It becomes highly vascularized and ↑ glandular se- maintained after cretions (see Table 14-2). fertilization by hCG, Progesterone also causes inhibition of FSH and LH release. released by the embryo. If fertilization does not occur, the corpus luteum involutes, progesterone and estradiol levels fall, with subsequent endometrial sloughing (menses). The hypothalamic-pituitary axis is released from inhibition, and the cycle begins again.

TABLE 14-2. Ovarian Hormone Effect on Uterus Menstruation

OVARIAN PHASE DOMINANT HORMONE UTERINE PHASE

Before ovulation Follicular Estrogen Proliferative

After ovulation Luteal Progesterone Secretory

210 CHAPTER 15 Premenstrual Syndrome/ Premenstrual Dysphoric Disorder

Deﬁ nition 212 Premenstrual Syndrome Diagnostic Criteria 212 Premenstrual Dysphoric Disorder Diagnostic Criteria 213 Tests 213 Treatment 213

211 Premenstrual Syndrome/ HIGH-YIELD FACTS Dysphoric Disorder HIGH-YIELD FACTS phase. Symptoms duringluteal Pathognomonic forPMS: cur inthelutealphaseforbothconditions. symptoms ofPMDDdoaffecttheactivitiesdailyliving.Theoc- toms. ThesymptomsofPMSdonotimpairdailyactivities;however, the PMDD bothhavesimilar symptoms,butPMDDhasmarkedlyseveresymp- tion shouldbemadebecauseeachhasadifferent treatment.PMSand have manysymptomsthatoverlapwithanxietyanddepression.Adifferentia- Premenstrual syndrome(PMS)andpremenstrualdysphoricdisorder (PMDD) 212 PREMENSTRUAL SYNDROME DIAGNOSTIC CRITERIA DEFINITION Best diagnosticmethodiskeepingaprospectivesymptomdiaryfor2months. with menses.Sheisabletocontinueherdailyactivitiesdespitethesymptoms. likely diagnosis.What isthebestwaytomakediagnosis? menses,she nolongerhasthesesymptoms.What isthemost Once shebegins Atleastoneofthefollowing affectiveandsomaticsymptomsduringthe Monitor for2–3monthsbecausesymptomscanbevariablemonthto Symptomsfollowed byasymptom-freeperiod. Mayinterferewithworkandpersonalrelationships. Occurinlutealofthemenstrualcycle. Bothphysicalandbehavioral. Referstoagroupofmild tomoderatesymptoms. Exclude otherdiagnoses—depression andanxietymaypresentall Symptoms occurintwoprospectivelymonitored cycles. No recurrenceuntilcycleday13. Relievedwithin4daysofonset ofmenses. PMS. This patienthasaffectiveandsomaticcomplaintsthatresolve Answer: PMS. 5 daysbeforemenses: month. throughout thecycle. Affective symptoms: Somatic symptoms: Irritability Angry outburst Depression Extremity swelling Headache Abdominal bloating Breast tenderness Social withdrawal Confusion Anxiety when sheisalone,butabletoworkandtakecareofher2children. havingheadaches andbreastpain.Shefeelsbetter menses. Shereports A 26-year-old womancomplainsoffeelingsadandconfusedbeforeher Premenstrual Syndrome/ HIGH-YIELD FACTS Dysphoric Disorder Calcium and aerobic exercise help PMS/PMDD symptoms. The therapy with most evidence for effectiveness for PMS/PMDD: SSRIs and ovulation blocking agents. Diagnosis of PMS should be made from recording symptoms on a prospective calendar. 213 uid retention. uid icts. ↑ tryptophan, a precursor to serotonin. ammatory drugs (NSAIDs). SPHORIC DISORDER DIAGNOSTIC CRITERIA DIAGNOSTIC DISORDER SPHORIC ↓ mastalgia. A 17-year-old G0 complains of being sad 4 days right before she starts right before she of being sad 4 days G0 complains A 17-year-old She reportsmenstruating. hopelessness, anxiety, fatigue, low energy, and sleep distur- tenderness, headache, bloating, breast mood swings, symptoms during the last 2 weeks of the cycle. Spironolactone: Diuretic helps with the symptoms of fl anti-infl Nonsteroidal Vitamin E Vitamin foods Carbohydrate-rich to help. and shown Fluoxetine and sertraline have been well studied the menstrual cycle or just with throughout Can be administered Reassurance and information counseling. to help. Relaxation therapy for severe symptoms has been shown is helpful. Calcium sad, hopeless, or having self-deprecating thoughts. Feeling Anxiety or tension. Mood lability and crying. irritability, anger, ↑ interpersonal confl Persistent (SSRIs): reuptake inhibitors Selective serotonin Other: Supportive therapy: depression. Aerobic exercise reduces affective symptoms, especially Dietary supplementation: Answer: PMDD. with PMS, patient has symptoms consistent This but with one affective symptom: Five symptoms of PMS including cycles. monitored Symptoms with prospectively bances during these days. These symptoms disappear 2 days after the start symptoms disappear 2 days after days. These bances during these of basis. She reports occur on a monthly menses. They a that she misses school on is the most What she cannot get out of bed for 3 days. monthly basis because rm the diagnosis? objective test to confi is the best likely diagnosis? What should monitor her that affect daily activities. She markedly severe symptoms to her menses and record them prospectively. symptoms in relation TREATMENT TESTS (DSM-IV CRITERIA) PREMENSTRUAL DY PREMENSTRUAL No drugs are currently FDA approved for the treatment of PMS or PMDD, No drugs are currently FDA approved used off label. There are also some dietary but several drugs are helpful when can be recom- been helpful. Treatment cations that have and lifestyle modifi mended based on severity of symptoms. Prospective calendar of symptoms in relation to menses. Prospective calendar of symptoms in Premenstrual Syndrome/ HIGH-YIELD FACTS Dysphoric Disorder HIGH-YIELD FACTS 214 Bilateralsalpingo-oophorectomy:Reservedforthosewhoaretherapeu- Gonadotropin-releasinghormone(GnRH)agonists: SeverePMS. Oral contraceptives: agonists onadailybasis,andwantdefi tic withGnRHagonists only, anddonotwanttocontinueGnRH taking Monophasic,continuous best. Mayhelpwithphysicalsymptoms,butnotmood. nitive treatment. CHAPTER 16 Infertility

Deﬁ nition: Infertility 216 Types 216 Female Factors Affecting Infertility 216 Male Factors Affecting Infertility 216 Infertility Workup 216 MALE FACTOR 216

OVULATORY FACTOR 217

UTERINE FACTORS 218

TUBAL FACTOR 219

PERITONEAL FACTORS 219 Assisted Reproductive Technologies 219 DEFINITION 220

INTRAUTERINE INSEMINATION 220

IN VITRO FERTILIZATION AND EMBRYO TRANSFER 220

INTRACYTOPLASMIC SPERM INJECTION 220

GAMETE INTRAFALLOPIAN TRANSFER 220

ZYGOTE INTRAFALLOPIAN TRANSFER 220

ARTIFICIAL INSEMINATION WITH DONOR SPERM 220

215 The monthly conception rate is 20% in a group of normal fertile couples. In- fertility ↑ with increasing age of the female partner. Female factors account for 40–50% of infertile couples. Male factors account for 23% of infertile couples. In 40% of infertile couples, there are multiple causes.

DEFINITION: INFERTILITY

Infertility is deﬁ ned as a The inability to conceive after 12 months of unprotected sexual inter- failure to conceive after course. 1 yr of unprotected Affects 15% of couples. intercourse.

TYPES

Primary infertility: Infertility in the absence of previous pregnancy. Secondary infertility: Infertility after previous pregnancy.

FEMALE FACTORS AFFECTING INFERTILITY

HIGH-YIELD FACTS HIGH-YIELD Multifactorial: 40%. Unexplained: 28%. Anovulation: 18%. Tubal disease: 14%. Endometriosis: 9%.

MALE FACTORS AFFECTING INFERTILITY

Abnormal sperm function. Abnormal sperm production. Obstruction of ductal system (seminiferous tubules to urethral oriface). Infertility

INFERTILITY WORKUP

See Table 16-1.

Calcium channel blockers and furantoins can impair Male Factor sperm number and SEMEN ANALYSIS function. Performed after at least 48 hr of abstinence, with examination of the sperm within a maximum of 2 hrs from time of ejaculation (for those who prefer to collect at home). Two properly performed semen analyses should be obtained at least 4 weeks apart. The analysis reﬂ ects sperm production that occurred 3 months ago.

CHARACTERISTICS Volume: Normal > 2 mL. Semen count: Normal > 20 million/mL.

216 TABLE 16-1. Evaluation of Infertile Couple

Male factor: Semen analysis.

Ovulation factor: Serum progesterone, day 3 FSH, prolactin, endometrial biopsy.

Cervical factor: Postcoital test.

Uterine factor: Ultrasonography, hysterosonogram, hysterosalpingogram, hysteroscopy.

Tubal factor: Hysterosalpingogram, laparoscopy.

Endometriosis: Laparoscopy.

Motility: Normal > 50% with forward movement. Morphology: Normal > 40%. HIGH-YIELD FACTS

TREATMENT FOR ABNORMAL SEMEN ANALYSIS Depends on the cause. Most male infertility is Refer to urologist. idiopathic. Smoking and alcohol cessation. Avoid lubricants with intercourse. Clomiphene 25 mg/day for 25 days, with 5 days of rest (for the male partner). Artiﬁ cial insemination (with partner or donor sperm): Intrauterine insemination: Sperm injected through cervix. Intracytoplasmic sperm injection. If semen analysis is normal, continue workup of other factors.

Ovulatory Factor Infertility A 28-year-old woman G0 has been unable to conceive with her husband over the last year. Her periods are irregular. She has a BMI of 30, displays coarse facial hair and a dark velvety pigmentation on the back of her neck. What is the likely diagnosis in this patient? What is the reason she is unable to conceive? Answer: Polycystic ovarian syndrome (PCOS) affects approximately 5% of all women, and is a leading cause of infertility. The patient is anovulatory and will need clomiphene, an ovulation induction agent, in order to conceive.

METHODS OF ASSESSING OVULATION History of regular monthly menses is a strong indicator of normal ovulation. ° ° Basal body temperature (BBT): Body temperature rises about 0.5 –1 F Initial workup for infertility: during the luteal phase due to the ↑ level of progesterone. Elevation of BBT BBT is a good indicator that ovulation is taking place. Serum progesterone: May be low if the corpus luteum is not producing Semen analysis enough. Hysterosalpingogram Day 3 FSH: Elevated if patient is anovulatory. Endometrial biopsy: Determines histologically the presence/absence of ovulation. 217 POSSIBLE CAUSES AND TREATMENTS OF ANOVULATION Pituitary insufﬁ ciency: Treat with intramuscular luteinizing hormone/ follicle-stimulating hormone (LH/FSH) or clomiphene. Hyperprolactinemia: Administer bromocriptine, a dopamine agonist, which supresses prolactin. PCOS: Treat with clomiphene +/– metformin, weight loss. Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation, galactorrhea, stress.

Uterine Factors

A 30-year-old female G0 is undergoing an evaluation of her uterus as part of the workup for infertility. What procedure is diagnostic and therapeutic in the evaluation of the uterus? Answer: Hysteroscopy is diagnostic and therapeutic.

If ovulation analysis and semen analysis are normal, analysis of the internal architecture of the uterus and fallopian tubes is performed to determine if there is an anatomic obstruction causing infertility. In most cases, an internal architecture study is part of the initial workup. Hysteroscopy: HIGH-YIELD FACTS HIGH-YIELD A hysteroscope is an telescope that is connected to a video unit with a fi ber-optic light source. It is introduced through the cervix and allows visualization of the uterine cavity. It is diagnostic and therapeutic. It can view the abnormality and treat it at the same time. Hysteroscopy is useful in: Asherman syndrome (lyse intrauterine adhesions). Endometrial polyps (polypectomy). Congenital uterine malformations (eg, excise a uterine septum). Submucosal fi broids (resect). Hysterosalpingogram: Radiopaque dye is injected into the cervix and uterus. Dye passes Infertility through the fallopian tubes to the peritoneal cavity. It should outline the inner uterine contour and both fallopian tubes when imaged with fl uoroscopy. Allows visualization of uterus and fallopian tubes. Performed during follicular phase (avoid possibility of pregnancy). There is a risk of salpingitis from the injection. An interventional radiologist can use catheters to open the fallopian tubes that are occluded proximally. Sonohysterogram: Fluid is instilled in the endometrial cavity concurrently with a pelvic ultrasound. Outlines intrauterine pathology (ie, polyps, submucosal fi broids). Can be done with an ultrasound in an offi ce setting. Ultrasound: In offi ce study. Laparoscopy: A telescope is placed through the skin of the abdominal wall into the peritoneal cavitiy.

218 Can visualize outside of the uterus to assist in diagnosis of some mul- lerian malformations.

CAUSES AND TREATMENTS FOR UTERINE FACTOR INFERTILITY Submucosal ﬁ broid: Resection, myomectomy. Intrauterine septum: Hysteroscopic resection of septum. Uterine didelphys: Metroplasty—a procedure to unify the two endometrial cavities. Asherman syndrome: Hysteroscopic lysis of intrauterine adhesions.

Tubal Factor

A 30-year-old female G0 has been having unprotected intercourse for 18 months without getting pregnant. She reports regular menstrual cycles. She had two episodes of pelvic inﬂ ammatory disease (PID) in the past. HIGH-YIELD FACTS What is the best diagnostic modality to evaluate this patient? What will be the best treatment for her infertility? Answer: Hysterosalpingogram will help determine if there is tubal blockage due to PID. If tubal blockage is present, the most effective treatment is in vitro fertilization. Damage from tubal surgery can result in ectopic EVALUATION pregnancy. Most reproductive Hysterosalpingogram Laparoscopy endocrinologists recommend in vitro CAUSES AND TREATMENTS FOR TUBAL FACTOR INFERTILITY fertilization if tubal factor is present. Adhesions: Lysis of adhesions via laparoscope.

Microsurgical tuboplasty. Infertility Neosalpingostomy (blocked tubes are opened). Tubal reimplantation for intramural obstruction. In vitro fertilization (IVF). Tubal blockage: Tubal ﬂ ushing. If the evaluation up to this point is within normal limits, then a diagnostic laparoscopy should be done.

Peritoneal Factors Laparoscopy is diagnostic and therapeutic.

CAUSES AND TREATMENTS FOR PERITONEAL FACTOR INFERTILITY Adhesions: Lysis of adhesions via laparoscopy. Endometriosis: Excision or ablation of implants.

ASSISTED REPRODUCTIVE TECHNOLOGIES

Assisted reproductive technologies (ARTs) include clinical and laboratory techniques that are used to achieve pregnancy in infertile couples. ARTs are employed when correction of the underlying cause of infertility is not feasi- ble. 219 Deﬁ nition Directly retrieving eggs from ovary followed by manipulation and replacement. Generally employed for inadequate spermatogenesis. The following are examples. Aside from intrauterine insemination, ARTs can utilize patient or donor egg and /or sperm.

Intrauterine Insemination Washed sperm is injected into the uterus. Must have a normal tube for fertilization to take place.

In Vitro Fertilization (IVF) and Embryo Transfer Egg cells are fertilized by sperm outside the uterus. Consists of ovarian stimulation, egg retrieval, fertilization, selection, and embryo transfer into uterus. IVF ↑ the chances of Success rate of IVF is about 20%. multiple gestation. Expensive.

Intracytoplasmic Sperm Injection (ICSI) Subtype of IVF.

HIGH-YIELD FACTS HIGH-YIELD Injection of spermatozoan into oocyte cytoplasm. Revolutionized treatment of infertility in men with severe oligospermia (low number), azoospermia (absence of live sperm), asthenospermia (low motility), teratospermia (abnormal morphology). Pregnancy rate: 20% per cycle. Multiple pregnancy rate: 28–38%. Not inﬂ uenced by cause of abnormal sperm. Can use spermatozoa from testicular biopsies. Expensive.

Gamete Intrafallopian Transfer (GIFT)

Infertility Egg and sperm are placed in a normal fallopian tube for fertilization. Success rate is about 25%.

Zygote Intrafallopian Transfer (ZIFT) Zygote created via fertilization in vitro and placed in fallopian tube, where it proceeds to uterus for natural implantation. Success rate is about 30%.

Artiﬁ cial Insemination with Donor Sperm Success rate is 75% in six cycles. Donor sperm is used for ARTs.

220 CHAPTER 17 Amenorrhea

Primary Amenorrhea 222 BREASTS ABSENT, UTERUS PRESENT 222

BREASTS PRESENT, UTERUS ABSENT 223

BREASTS ABSENT, UTERUS ABSENT 224

BREASTS PRESENT, UTERUS PRESENT 224 Secondary Amenorrhea 226 CAUSES 226

EVALUATION 228

221 Amenorrhea HIGH-YIELD FACTS amenorrhea. common causeofprimary gonadal dysgenesis.Most elevated plasmaFSH= amenorrhea+ Primary breasts anduterus. note presence/absenceof amenorrhea, with primary When evaluatingapatient oligomenorrhea. months isdefi nedas more than35daysto6 Absence ofmensesfor fertility. todistinguishportant thedisease processes becauseitcanhaveanimpacton Patients withoutbreastsandwithauterus havenoovarianestrogen.Itisim- Breasts Absent,Uterus Present cate thediagnostic teststhatwillbemost helpful. tients, butnotingbreastanduterusdevelopmentonphysicalexamcanindi- arenormalforthesepa- are presentorabsent.Theexternalfemalegenitalia (uterus) ondary sexualcharacteristics(breasts)andfemaleinternalgenitalia useful togroupthecausesofprimaryamenorrheaonbasiswhethersec- placealongtheHPOaxis.Itismoreclinically where theabnormalitytakes The causesofprimaryamenorrheahavebeentraditionally classifi result willbeamenorrhea. menstrual blood.Ifthereisanabnormalityinanyoneofthesecomponents,the sponds totheHPOaxis,andnormalcervixvaginaallow theoutfl (HPO) axisisinvolvedintheregulationofmenstrualcycle,uterusre- The causesofamenorrheaarequite varied.Thehypothalamic-pituitary-ovarian 222 PRIMARY AMENORRHEA 17α Gonadal dysgenesis(hypergonadotropic hypogonadism):Mostcom- Primary amenorrhea: Absenceofmensesbyage16withnormalgrowth Turner syndrome (45,X):Inaddition toprimaryamenorrheaandab- hypernatremia, andhypokalemia duetoexcessmineralocorticoid. These sol andadrenal/gonadalsex steroid secretion. They havehypertension, female. arephenotypically regression, sotheinternalandexternalgenitalia gen isnotnecessaryformüllerianductdevelopment orwolffi cause the↓ (FSH) andluteinizing hormone(LH)levelsaremarkedlyelevatedbe- breast developmentdoesnotoccur. Follicle-stimulating hormone there isnosynthesisofovariansteroids. Duetolow levelsofestrogen, tissue calledgonadalstreak.Duetotheabsenceofovarianfollicles, somal deletionordisorder. Ovariesarereplacedbyabandoffi mon causeofprimaryamenorrhea.Mostcommonlyduetochromo- sexual characteristics. causes. Also,absenceofmensesbyage14inagirlwithnosecondary and secondarysexualcharacteristics.Usuallygeneticoranatomic hormone. low forsecondarysexualcharacteristics.Patients alsoreceive growth roidism. At puberty, thepatientisgivenestrogen andprogesteronetoal- cubitus valgus,cardiac abnormality, renalabnormalities,andhypothy- and ure (mostprevalent),webbingoftheneck,shortfourth metacarpal, sent breasts,thesepatientshaveothersomaticabnormalities: shortstat- ical condition. who previouslyhadnormalmenses.Usuallycausedbyunderlyingmed- Secondary amenorrhea:Absenceofmensesfor ties asTurner syndromepatients. Structurally abnormalXchromosome:Mayhavethesameabnormali- -hydroxylase defi levels ofestrogendonotprovidenegativefeedback.Estro- ciency:Canoccurin46,XX.Patients have ≥ 6monthsinawoman edbasedon an duct an ↓ ow of of ow brous corti- HIGH-YIELD FACTS Amenorrhea Androgen insensitivity: Patients look female No pubic hair. externally. Remove gonads after puberty to avoid risk of malignancy (gonadoblastoma or dysgerminoma). hydroxylase 17α hydroxylase ciency: defi absent, 46,XX: Breast uterus present Breast absent, 46,XY: uterus absent. 223 -hydroxylase α oor. Low levels of estrogen are due to are due to levels of estrogen Low Will have normal levels of gonadotropins ifWill have normal Androgen insensitivity. Breasts are present; uterus and axillary/pubic Androgen insensitivity. risk of developing a malignancy (gonadoblastoma or dysgermi- Anosmia associated with low gonadotropins. with low associated Kallmann syndrome: Anosmia giomas. An 18-year-old G0, presents with complaints of never having started An 18-year-old She denies use of drugs, menses. Her siblings started menses at age 12. lb. Her blood cant weight loss. She is 5′5″ and 130 heavy exercise, or signifi ↑ Prepubertal hypothyroidism. Prepubertal Kernicterus. encephalitis. Mumps major: Iron deposits in the pituitary. Thalassemia pigmentosa. Retinitis fl absence of sellar Congenital: Stenosis of aqueduct, adenoma, craniopharyn- Prolactinoma, chromophobe Acquired: with: disease): Associated ciency (pituitary defi Isolated gonadotropin Anatomic lesions of the hypothalamus or pituitary can result of the hypothalamus lesions Lesions: Anatomic gonadotropin production. in low hormone (GnRH) release (hypogo- Inadequate gonadotropin-releasing hypogonadism): nadotropic estrogen-progester- should receive with GnRH. These patients stimulated one supplementation for epiphy- and allow to induce breast development GnRH is menopausal gonadotropins or pulsatile seal closure. Human levels of due to low does not work Clomiphene for fertility. administered endogenous estrogen. low gonadotropin release. gonadotropin low noma), usually after age 20. The gonads should be removed after pu- Es- bone growth. adequate for breast development and berty to allow trogen is then given. These patients are raised as females. defi female internal genitalia. no breasts or will have ciency defi from the absence of androgen receptors or lack of responsiveness to an- These patients have an XY karyotype and normally drogen stimulus. male levels of testoste- male gonads that produce normal functioning The müllerian ducts regress due to the rone and dihydrotestosterone. an ducts do not de- presence of antimüllerian hormone, and the wolffi with this by testosterone. Patients velop because they are not stimulated have no male or female internal genitalia, have normal fe- condition a short or absent vagina. male external genitalia, and have either These patients have normal breasts and scant or absent axillary and testes or those in the inguinal canal have Intra-abdominal pubic hair. an patients need replacement with sex steroids and cortisol. Despite low lev- low Despite cortisol. and sex steroids with replacement need patients fertiliza- in vitro with been achieved have pregnancies sex steroids, els of and 17 karyotype 46,XY Those with transfer. tion/embryo Answer: results This condition insensitivity (testicular feminization): Androgen Hypothalamic-pituitary disorders: Hypothalamic-pituitary pressure is 110/60. She has Tanner stage IV breasts, but no axillary or pubic hair. IV breasts, but no axillary or pubic hair. stage She has Tanner pressure is 110/60. She has a blind vaginal is the most likely diagnosis? pouch. What hair is absent in androgen insensitivity. Breasts Present, Uterus Absent Breasts Present, Uterus Amenorrhea HIGH-YIELD FACTS imperforate hymen. hematocolpos from mass attheintroitus= pelvic pain+bulgingblue hair +nomensescyclic Normal breastandpubic amenorrhea. of primary Second mostcommoncause Müllerian agenesis: uterus. müllerian failure?Absent What istheresultof type 46,XX,willhavenobreasts,butauterusbepresent. There isinsuffi cient estrogentoallow breastdevelopment. Thosewithkaryo- testosterone levelsdonotallow thedevelopmentofinternalmalegenitalia. lia. Antimüllerianhormonecausestheregressionofmüllerianducts.Low enzyme neededtosynthesizesexsteroids. Theyhavefemaleexternalgenita- Breasts Present,Uterus Present 17α-hydroxylase defi Breasts Absent,Uterus Absent 224 TABLE 17-1. Further evaluation Further Testosterone Pubic/axillary hair Uterus Breast Karyotype Imperforatehymen;transversevaginalseptum.Thesepatientspresent Thisisthesecondlargestcategoryofindividuals withprimaryamenor- syndrome):In Müllerian agenesis(Mayer-Rokitansky-Kuster-Hauser exam. Thetreatmentistoexcise obstruction. massonphysical imperforate hymen)canbepalpatedasaperirectal hematocolpos (accumulation ofmenstrual bloodinthevaginafroman with cyclicpelvicpainduetomenstrualbloodnothavinganegress.A evaluated similar tothose withsecondaryamenorrhea. rhea (chromosomal/gonadaldysgenesis#1).Thesewomenshouldbe vaginal dilators tomakethevaginafunctional(seeTable 17-1). mones. Theymayundergosurgicalreconstructionofthevaginaoruse hor- They havenormalendocrinefunctionanddonotneedsupplemental abnormalitiesandshouldbescreenedwithanultrasound or MRI. etal mal axillaryandpubichair. Thesepatientshaveassociated renalandskel- but havenormallyovulatingovaries,normalbreastdevelopment,andnor- this condition, thepatientshavenouterusandashortenedvagina, ComparisonofAndrogenInsensitivityandMüllerianAgenesis ciency: edgndcoyRenal/skeletalabnormalities Normal Female levels Absent Need gonadectomy Present XX Normal malelevels Absent Absent Present XY These patientsareXY, havetestes,butlackthe A NDROGEN R ESISTANCE M ÜLLERIAN A GENESIS HIGH-YIELD FACTS Amenorrhea Check FSH to distinguish between gonadal failure and hypogonadotropic hypogonadism. FSH is high with gonadal failure and low with hypogonadotropic hypogonadism. Ovarian failure may be due to hypothalamus not producing GnRH or ovaries not responding to FSH. - 225 -hydroxyprogesterone. 17α ndings: -hydroxylase defi ciency—(46, XX) electrolytes, ↑ ciency—(46, -hydroxylase defi deoxycorticosterone, ↓ ↑ MENORRHEA A RIMARY P rm presence of uterus: Ultrasound, rarely MRI. ary amenorrhea. Remove testes if Y chromosome present. progesterone, drome (46,X); 17α ciency, hypothalamic/pituitary disorders. Head CT or MRI to evalu- Head CT or MRI to hypothalamic/pituitary disorders. ciency, Prolactin, thyroid-stimulating or adenoma. ltrative disease ate for infi and dehydroepiandrosterone sulfate hormone (TSH). Testosterone (DHEA-S) if signs of hyperandrogenism. XAM workup on second- Normal: With normal breast and uterus. Focus Low/normal: Functional hypothalamic amenorrhea, GnRH defi amenorrhea, Functional hypothalamic Low/normal: syn- of primary ovarian failure. Karyotype: Turner High: Indicative β-hCG to rule out pregnancy. E FSH staging of pubic hair. Tanner Hymen. depth. Vaginal or rectal exam to evaluate internal organs. Vaginal syndrome with coarctation of aorta. Turner disorders. Adrenal size. Clitoral have 46,XX with normal female levels of testosterone. Androgen insen- have 46,XX with normal female levels testosterone. sitivity has 46,XY with male levels of nipples. trogen action. lamic/pituitary disorders. perprolactinemia. suggests ovarian/pituitary cause. fi Uterus present. No other anatomic Confi absent: Karyotype, serum testosterone: Müllerian anomalies Uterus vitiligo. acanthosis nigracans, Skin: Hirsutism, acne, striae, stigmata: chest, widely spaced hairline, web neck, shield Low Turner Blood pressure: Blood staging): Marker of ovary function and es- (Tanner Breast development exam: Genital Headaches, vision problems, fatigue, polyuria, polydipsia: Hypotha- polyuria, polydipsia: vision problems, fatigue, Headaches, span. chart, arm growth weight, Height, members. family compared to other Height Neonatal/childhood health problems. of virilization. Symptoms change, exercise. weight Recent stress, can affect hypothalamus. Drugs: Heroin/methadone hy- can cause Reglan (metoclopramide) Galactorrhea: Antipsychotics, stagesOther of any pubertal reached? Lack of puberty development history. Family ISTORY HYSICAL VALUATION OF TUDIES S P H E Amenorrhea HIGH-YIELD FACTS girls isanorexianervosa. amenorrhea inadolescent The mostcommoncauseof terms oftheHPOaxis. Think aboutthecausesin reproductive-age woman. pregnancy testina pregnancy. Alwayschecka amenorrheais secondary The mostcommoncauseof P H terone. Low levelsofgonadotropins, estrogen,absentwithdrawal bleedwithproges- Causes 226 ITUITARY SECONDARY AMENORRHEA YPOTHALAMIC does notpreventpregnancy100% ofthetime. is pregnancy, soaurineorserumβ-hCG shouldbechecked.Contraception use any pillsrecently. What isthenextstepinmanagementofthispatient? She usescombinationoralcontraceptivepills(OCPs)regularly, andhasnotmissed history. deliveries. medical orsurgical She hashadtwotermspontaneousvaginal Functional hypothalamic amenorrhea: Weight loss/anorexia nervosa: Thosewhoaremalnourishedhavea↓ exercise. Stress and Drugs:OCPsactatthelevelofhypothalamus andpituitary.Postpill Lesions:Craniopharyngiomas, granulomatous disease, encephalitisse- Other(1%):Cervical,endocrine. Uterus (5%). Ovary (40%). Pituitary (19%). Hypothalamus (35%). Pregnancy. The pituitary glandcanbedamagedfromanoxia,thrombosis, Lesions:Thepituitary Neoplasms: Answer: The mostcommoncauseof amenorrhea inareproductive-agewoman tion (prolactinomas)orexcision. in alatersection.Treatment mayinvolvesuppressionwithmedica- tumors.Prolactinomaswillbediscussedprolactin-secreting pituitary other causes. reproductive ability. Weight gainwillallow mensestoresume. amenorrhea canoccurupto6monthsafterstoppingthepill. quelae. FSH. Thepatientsmayhavehypothyroidism andadrenalinsuffi hormones likeadrenocorticotropichormone(ACTH), TSH,LH,and or hemorrhage.Maybeassociated with↓secretionofotherpituitary (H Pituitary damageunrelatedtopregnancy.Simmonds disease:Pituitary rhage). Treatment hormones. includes replacementofpituitary hemor- sive episodeduringpregnancy(usuallyduetocatastrophic cell destruction occursduetohypoten- Sheehan syndrome:Pituitary has mensesregularlyevery28 days,lastingfor5days.Shedeniesany weeks agocomplainsofnomensesforthepast2months.Sheusually A 30-year-old 8 HispanicG2P2002, withlastmenstrualperiod(LMP) YPOESTROGENIC Chromophobe adenomasarethemostcommon non- A MENORRHEA ) ↓ GnRH secretion,without ciency. HIGH-YIELD FACTS Amenorrhea Age < 40 Amenorrhea FSH Elevated PCOS is the most common cause of hirsutism. of choice for Treatment PCOS: OCPs Progestin challenge test: Give oral progestin for 10 days. If the endometrium has been primed with estrogen from ovaries or peripheral fat, the withdrawal of progestin after 10 days will cause endometrial sloughing with resultant menses. No menses indicates absence of ovaries, estrogen ow or outfl ciency, defi obstruction. Premature ovarian failure: 227 ashes ) of 20 lb in her weight over the last year. over the last year. lb in her weight of 20 YPOGONADISM risk for endometrial hyperplasia or cancer if left risk for endometrial H Hyperandrogenism. Hyperandrogenism. rmatory test. Polycystic ovarian syndrome (PCOS). Diagnosis of PCOS is established of PCOS Diagnosis ovarian syndrome (PCOS). Polycystic YPERGONADOTROPIC most commonly on neck and axilla). and vaginal dryness. Her serum FSH menopausal is very high and in the is the most likely diagnosis? range. What A 35-year-old G2P2002 with LMP G2P2002 one year ago presents with hot fl A 35-year-old Acne. Oligomenorrhea/amenorrhea. Obesity. present velvety skin discoloration brown (gray, nigricans Acanthosis puberty. Premature pubarche and/or precocious on ultrasound. ovaries Polycystic Signs of androgen excess (hirsutism, acne). Oligomenorrhea/amenorrhea. Hirsutism. A 35-year-old G3P3003 complains of absence of menses for 8 months. of menses for 8 months. of absence complains G3P3003 A 35-year-old until days menses every 40–50 with She reports at age 12 menarche ↑ complains of an She recently. (H Vaniqa [efl ornithine]) and infertility (ovulation induction with clomi- ornithine]) [efl Vaniqa phene). Start OCPs/hormone therapy to prevent continuous cyclic or endometrial hyperplasia/endometrial cancer and regulate menses. bone protection. Signs: Diagnosis: Established are pres- if two out of three of the following ent: hirsutism (cosmetic methods, spironolactone, Aim treatment toward X permutation. Fragile syndrome. Turner include hormone replacement. Need strategies for may Treatment chemotherapy. or systemic May be due to radiation can be present. conditions Autoimmune amenorrhea before the age of 40. Premature ovarian failure. Symptoms are similar to those in menopause are similar to Answer: Premature ovarian failure. Symptoms Answer: Surgical: Bilateral salpingo-oophorectomy. ovaries: Polycystic Premature ovarian failure (POF): Depletion of oocytes resulting in and FSH a comfi is She denies any family history or use of medications or drugs. She used or drugs. or use of medications any family history She denies She is 5′4″, pregnant with her last two pregnancies. clomiphene to become and chin. She has acne She has hair on her upper lip lb, BP 120/80. weight 220 what is the most likely diagnosis? If left untreated, face. What and oily skin on her is this patient at ↑ risk for? of the following: a history of oligomenorrhea/amenorrhea, with two out of three cysts seen on (acne, hirsutism), and multiple features of hyperandrogenism ↑ patient is at ultrasound. This untreated. VARIAN O Amenorrhea HIGH-YIELD FACTS thereafter. pregnancy orshortly curettage performedduring Asherman syndromeis The mostcommoncauseof amenorrhea. secondary scarring. Itcancause tocurettageand secondary (IUAs) orfi brosis, intrauterine adhesions Asherman syndromeis C H Evaluation Can causesecondaryamenorrhea. E cone. Treat withcervicaldilation. Stenosis U 228 NDOCRINE ERVICAL TERINE ISTORY Symptomsofestrogendefi disease: Symptomsofhypothalamic-pituitary Acne,hirsutism,deepening ofvoice. Recentstress,weight change,newdiet orexercise habits, illness. Hyperandrogenism (neoplasm,exogenousandrogens). Diabetes mellitus. Hyper/hypothyroidism. Infection: Endometrial ablation: Asherman syndrome: Medications: Obstetricemergencywith hemorrhage (Sheehansyndrome). menorrhagia. metrial cavityandcauseamenorrhea. Hot fl Polyuria, polydipsia. Fatigue. Visual fi Galactorrhea. Headaches. Treat viahysteroscopicresectionofadhesions.Estrogensadminis- Confi Adhesionsmayformaftermyomectomy, metroplasty, orcesareande- Most frequentassociated withpreg- causeisendometrialcurettage Metoclopramide, antipsychotics:cause↑ High-dose progestins. Androgenic drugs. Initiation ordiscontinuation ofOCPs. Poor sleep. Vaginal dryness. orrhea. copy. tered tostimulate regrowth ofendometrium. livery. nancy. ↓ libido. due toloopelectrosurgicalexcision procedure(LEEP)orcold-knife ashes. rm thediagnosis withhysterosalpingogram(HSG)orhysteros- eld defects. Endometritis ortuberculosis. Intrauterine adhesionscanobliteratetheendo- This proceduremayhavebeenperformedfor ciency: prolactin leading toamen- HIGH-YIELD FACTS Amenorrhea Absence of vaginal bleeding Absence of after progesterone challenge is due to very low levels of estrogen. Premature ovarian failure is idiopathic. 229 ciency: POF. ciency: in women with PCOS. with in women 2 XAM for 10 days. If bleeding occurs, then adequate estrogen is present in then adequate occurs, for 10 days. If bleeding the body. E Serum estradiol. Serum mg Provera (medroxyprogesterone) 10 test with Progestin withdrawal PCOS. acne, acanthosis nigricans: Hirsutism, disorders. skin, thickened skin: Thyroid Thin/dry Consider karyotype. POF. TSH, FSH. FSH is high in Serum prolactin, and testosterone if signs of hyperandrogenism. DHEA-S status: Estrogen Neurologic exam for visual fi Pituitaryelds: adenoma. for visual fi exam Neurologic Skin: (BMI): > 30 kg/m mass index Body anorexia. illness/cachexia, of systemic Signs Genital defi with signs of estrogen tissue exam for galactorrhea. Breast HYSICAL TUDIES REATMENT T etiology of amenorrhea. based on the is individualized Treatment S P NOTES HIGH-YIELD FACTS HIGH-YIELD Amenorrhea

230 CHAPTER 18 Hyperandrogenism

Deﬁ nitions 232 Sources of Androgens 232 ADRENAL PRODUCTION OF ANDROGENS 232

OVARIAN PRODUCTION OF ANDROGENS 232 Idiopathic Hirsutism (Peripheral Disorder of Androgen Metabolism) 233 Adrenal Etiologies 233 CUSHING SYNDROME AND CUSHING DISEASE 233

CONGENITAL ADRENAL HYPERPLASIA 233 Ovarian Etiologies 234 POLYCYSTIC OVARIAN SYNDROME 234

STROMAL HYPERTHECOSIS 234

THECA LUTEIN CYSTS 235

LUTEOMA OF PREGNANCY 235

ANDROGEN-SECRETING OVARIAN NEOPLASMS 235 History 235 Physical Exam 235 Studies 236 Treatment 236

231 DEFINITIONS

Hirsutism: Presence of hair in locations where it is not normally found in a woman, speciﬁ cally in the midline of the body (upper lip, chin, back, intermammary region). Virilization: Presence of signs of masculinization in a woman (temporal balding, deeper voice, clitoral enlargement, ↑ muscle mass). Hypertrichosis: A generalized ↑ in the amount of body hair in its normal location. Vellus hairs: Fine hairs found on most parts of the body. They are barely visible. Terminal hairs: Coarse, darker hairs found, for example, in the axilla and pubic region. Androgens facilitate the conversion of vellus to terminal hairs.

SOURCES OF ANDROGENS

Androgens are produced in the ovary and the adrenal gland. The ovary primarily makes testosterone. It also secretes androstenedione and dehydroepiandrosterone (DHEA) to a smaller degree. Androstenedione and DHEA are Ovary makes testosterone. converted to testosterone in peripheral tissue. The adrenal gland makes dehy- Adrenal gland makes droepiandrosterone sulfate (DHEA-S) and DHEA. To produce a biologic effect,

HIGH-YIELD FACTS HIGH-YIELD DHEA-S. the enzyme 5α-reductase in the peripheral tissue converts testosterone to more potent 5α-dihydrotestosterone (DHT).

Adrenal Production of Androgens The zona fasciculata and the zona reticularis of the adrenal cortex produce androgens, as well as cortisol. ACTH regulates production. A third layer of the adrenal cortex, the zona glomerulosa, produces aldosterone and is regulated by the renin-angiotensin system. All three hormones––cortisol, androgens, and aldosterone––are derived from cholesterol. Androgen products from the adrenal are found mostly in the form of DHEA and DHEA-S. Elevation in these products represents ↑ adrenal androgen production. Hyperandrogenism Ovarian Production of Androgens In the ovaries, ﬁ rst, luteinizing hormone (LH) stimulates the theca cells to produce androgens (androstenedione and testosterone). Then, follicle-stimulating hormone (FSH) stimulates granulosa cells to convert these androgens to estrone and estradiol. When LH levels become disproportionately greater than FSH levels, androgens become elevated.

232 IDIOPATHIC HIRSUTISM (PERIPHERAL DISORDER OF ANDROGEN METABOLISM)

A 35-year-old G3P3003 complains of increasing facial hair that began 2 years ago. She reports menses every 30 days lasting for 4 days, denies taking any medications. She reports her sister has similar symptoms. On physical exam, the patient is normotensive. She has moderately dark hair on her upper lip and chin. No other abnormal distribution of hair. She has normal female genitalia. Serum levels of testosterone and DHEA-S are normal. What is the most likely diagnosis? Answer: Idiopathic hirsutism. Gradual onset of hirsutism with normal menses, testosterone and DHEA-S indicate idiopathic hirsutism.

This condition manifests with signs of hirsutism, regular menses, and normal levels of testosterone and DHEA-S. This disorder is due to ↑ activity of HIGH-YIELD FACTS 5α-reductase activity in the periphery. Antiandrogens that block the peripheral activity of testosterone or inhibit the enzyme 5α-reductase can be used to treat the hirsutism.

ADRENAL ETIOLOGIES

Cushing Syndrome and Cushing Disease Cushing syndrome: An adrenal tumor produces ↑ levels of cortisol with clinical fi ndings—hirsutism, menstrual irregularity, central obesity, moon face, buffalo hump, abdominal striae, weakness, and muscle wasting. Exogenous or endogenous cortisol can be the cause. Rapid onset of hirsutism or Confi rm diagnosis with dexamethasone suppression test. virilization = tumor Hyperandrogenism Cushing disease (pituitary disease) is a subset of Cushing syndrome. (ovarian or adrenal). A benign pituitary adenoma causes an ↑ in the secretion of adreno- corticotropic hormone (ACTH) which results in ↑ cortisol levels. It accounts for 70% of Cushing syndromes. Virilization and hirsutism are associated with this condition because the ACTH stimulates androgen production as well. Paraneoplastic syndromes, in which tumors (usually small cell lung cancer) produce ectopic ACTH, also cause ↑ cortisol. These account for 15% of Cushing syndromes. Adrenal tumors (adenoma or carcinoma) account for the remaining 15% of Cushing syndromes. In general, adenomas produce only cortisol, so no hirsutism or virilization is present. Carcinomas, by contrast, often produce androgens as well as cortisol, so they may present with signs of hirsutism and virilization. DHEA-S is markedly elevated, and hirsutism and virilization has a rapid onset. Computed tomography (CT) or magnetic resonance imaging (MRI) can confi rm the diagnosis. A baby with ambiguous genitalia, dangerous Congenital Adrenal Hyperplasia (CAH) hypotension, and elevated Caused by a congenital defect in an enzyme that produces cortisol. 17-hydroxyprogesterone. 21-hydroxylase defi ciency: The most common form of congenital ad- Think: 21-Hydroxylase renal hyperplasia. The condition has various levels of severity. Affected defi ciency

233 individuals lack an enzyme crucial to cortisol and mineralocorticoid production. Therefore, the ↑ precursors of cortisol are shunted to androgen production. Elevated serum 17-hydroxyprogesterone is used as a marker for establishing the diagnosis of 21-hydroxylase defi ciency. In the severe form, affected females have ambiguous genitalia at Most common cause of birth, along with severe salt wasting and cortisol insuffi ciency. Late- ambiguous genitalia in a onset 21-hydroxylase defi ciency presents with varying degrees of viril- newborn: CAH due to ization and hirsutism in females after puberty. 21-hydroxylase defi ciency. 11β-hydroxylase defi ciency: Associated with ↓ cortisol, but ↑ mineral corticoids and androgens. A typical patient with this enzyme defi - ciency has severe hypertension with virilization/hirsutism (which results in pseudohermaphroditism of female babies). 11-deoxycortisol levels are high in 11β-hydroxylase defi ciency (see Table 18-1).

OVARIAN ETIOLOGIES

Polycystic Ovarian Syndrome (PCOS) PCOS is a common condition (affecting 5% of reproductive-age women) and is diagnosed by the presence of two out of three clinical ﬁ ndings: hyperandrogenism, oligomenorrhea/amenorrhea, and multiple cysts on ultrasound. An abnormal release of gonadotropin-releasing hormone (GnRH) causes HIGH-YIELD FACTS HIGH-YIELD a persistently elevated LH. The LH:FSH ratio is often > 3:1. There are ↑ levels of androgens produced from the adrenal gland and the ovary. These women also have higher levels of estradiol that is not bound to sex hormone–binding globulin (SHBG), although the total estradiol level is not elevated. There is ↑ estrone due to adipose conversion of androgens. The most common cause of These patients also have acanthosis nigricans, obesity, insulin resistance, ↑ hirsutism and irregular and infertility. In the future, they are at risk for diabetes mellitus, hyper- menses is PCOS. tension, cardiovascular disease, endometrial cancer, and ovarian cancer. The risk of endometrial and ovarian cancer is reduced with the use of oral contraceptive pills (OCPs).

Stromal Hyperthecosis LH stimulates theca cells in the ovary resulting in stromal hyperplasia. Hyperandrogenism A 24-year-old obese woman Theca cells produce large amounts of testosterone. with facial hair complains Presents with gradual onset, anovulation, amenorrhea, and hirsutism. of amenorrhea. LH:FSH Testosterone secretion is progressively ↑ as a woman ages, resulting in ratio is elevated. Think: virilization and bilaterally enlarged ovaries up to 5-7 cm in diameter. PCOS.

TABLE 18-1. Clinical Findings in Congenital Adrenal Hyperplasia

21-HYDROXYLASE DEFICIENCY 11β-HYDROXYLASE DEFICIENCY

Androgens High High

Cortisol Low Low

Mineralacorticoids Low → hypotension High → hypertension

Marker ↑ 17-hydroxyprogesterone ↑ 11-deoxycortisol

234 Theca Lutein Cysts Theca cells produce androgens, and granulosa cells transform the androgens to estrogens. Theca lutein cysts produce abnormally high levels of androgens, in excess of the amount that can be converted to estrogens. Diagnosis is made by ovarian biopsy. A baby with ambiguous Luteoma of Pregnancy genitalia is born to a mother who complains of ↑ A benign tumor that grows in response to human chorionic gonadotro- facial hair growth over last pin (hCG). few months. Think: Virilization may occur in both the mother and the female fetus. Luteoma of pregnancy. The tumor usually disappears postpartum, as do maternal clinical features.

Androgen-Secreting Ovarian Neoplasms HIGH-YIELD FACTS

A 25-year-old G0 complains of dark hair on her upper lip and chin, thinning hair on her head, and deepening of her voice that took place over 2 months. She denies medications. She is normotensive. She has hair growth as stated above and has temporal balding. Her pelvic exam is within normal limits except for clitoromegaly. What is the most likely diagnosis? What is the next step in management? Answer: Due to the rapid presentation of virilization, this is most likely an adrenal or ovarian tumor. Drawing serum total testosterone and DHEA-S will help differentiate the source. Pelvic US will conﬁ rm the presence of an ovarian mass. A CT or MRI will conﬁ rm the presence of an adrenal mass. Hyperandrogenism Sertoli-Leydig cell tumors and hilar (Leydig) cell tumors are rare conditions in which the neoplasms secrete androgens. Sertoli-Leydig cell tumors are distinguished from hilar cell tumors in that Sertoli-Leydig tumors usually present in young women with palpable masses and hilar cell tumors are found in postmenopausal women with nonpalpable masses. Neoplasms present with rapid signs of virilization.

HISTORY

Pregnancy: Theca lutein cysts, luteoma of pregnancy. Timing of hirsutism, virilization: Rapid onset suggestive of ovarian or adrenal tumors. Gradual suggestive of idiopathic etiology.

PHYSICAL EXAM

Note distribution of terminal hair. Note signs of virilization. Bimanual exam: Pelvic mass.

235 Hirsutism, menstrual irregularity, central obesity, moon face, buffalo hump, abdominal striae, weakness, and muscle wasting: Cushing syndrome.

STUDIES

If cortisol levels are low Serum total testosterone (ovarian), DHEA-S (adrenal): Distinguish after an overnight ovarian vs. adrenal source. dexamethasone suppression Ultrasound: Confi rm ovarian mass. test, Cushing syndrome is CT/MRI: Confi rm adrenal mass. excluded from the Dexamethasone suppression test: Distinguish the etiology of the ACTH differential. stimulation. Serum 17-hydroxyprogesterone: Elevated in 21-hydroxylase defi ciency. Serum 11-deoxycortisol: Elevated in 11β-hydroxylase defi ciency.

TREATMENT

Ovarian and adrenal tumors: Sertoli-Leydig cell tumors: Unilateral salpingo-oophorectomy if not completed childbearing. Hilar cell tumors: Usually in postmenopausal women. Total abdomi- HIGH-YIELD FACTS HIGH-YIELD nal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO). Adrenal adenoma or carcinoma: Surgical removal. Stromal hyperthecosis: TAH, BSO. Late onset 21-hydroxylase defi ciency: Androgen excess and menstrual irregularities can be treated as PCOS. Infertility: Supplement with glucocorticoids to suppress androgens and allow ovulation. PCOS: Weight loss. OCPs for acne and menstrual irregularity. Estrogen component in the OCP ↑ SHBG; SHBG binds androgens; free androgen levels are then ↓. Progestins in the OCP inhibits 5α-reductase activity in the skin. Hyperandrogenism Cyclic progesterone for menstrual irregularity. Infertility: Ovulation induction with clomiphene and metformin. Skin disorders: Peripheral antiandrogens: Spironolactone, fi nasteride, cyproterone acetate. Androgenic acne responds quickly to treatment. Hirsutism moderately responsive; alopecia least responsive to treatment. Idiopathic hirsutism: Peripheral androgen activity inhibitor. May take 3 months to work (length of hair life cycle). Electrolysis. OCPs, medroxyprogesterone acetate. Treatment of choice for Ketoconazole: Risk of hepatitis. idiopathic hirsutism: Spironolactone: Blocks androgen receptors, ↓ ovarian testosterone Spironolactone. production, inhibits 5α-reductase. Finasteride (5α-reductase inhibitor), fl utamide (nonsteroidal antian- drogen): Similar effectiveness to spironolactone.

236 CHAPTER 19 Hyperprolactinemia and Galactorrhea

Deﬁ nitions 238 Etiology 238 Prolactinoma 239

237 DEFINITIONS

Hyperprolactinemia: Elevated levels of the hormone prolactin (PRL). Galactorrhea: Watery or milky ﬂ uid secreted from the breast that is not Physiologic stimuli for in relation to pregnancy. PRL release: Prolactinoma: Prolactin-secreting pituitary tumor. Breast and nipple palpation. Exercise. ETIOLOGY Stress. Sleep. A 35-year-old G2P2002 complains of milky discharge from her breasts for Noonday meal. 6 months. She also reports no menses for 6 months. She used to have menses every 28 days, lasting for 4 days. She has started to have hot ﬂ ashes in the last 4 months. She denies the use of any medications. She is normotensive. No masses are palpated on the breast exam, but a milky discharge is expressed from both breasts. Her vagina is dry. Her serum β-human chorionic Stress is the most common gonadotropin (β-hCG) is negative. What is the most likely diagnosis? What studies cause of mildly elevated should be ordered next? PRL. Answer: This patient has galactorrhea, amenorrhea, and low estrogen most likely due to hyperprolactinemia. Serum prolactin and thyrotropin-stimulating hormone (TSH) should be drawn to initiate the evaluation. HIGH-YIELD FACTS HIGH-YIELD

PRL is a peptide hormone produced by the anterior pituitary gland and is important for lactation. The main function of PRL is to stimulate Conﬁ rm galactorrhea by growth of mammary tissue as well as produce and secrete milk into the visualizing fat droplets with alveoli. ↑ secretion of prolactin, hyperprolactinemia, may lead to galac- microscope. torrhea. PRL secretion is stimulated by thyrotropin-releasing hormone (TRH) and serotonin; it is inhibited by dopamine. Hyperprolactinemia inhibits the pulsatile release of gonadoropin-releasing hormone (GnRH), resulting in amenorrhea/oligomenorrhea, anovulation, Medications are the most inappropriate lactation and galactorrhea. Causes of hyperprolactinemia: common cause of Drugs: Tranquilizers, tricyclic antidepressants (TCAs), antipsychotics, galactorrhea and antihypertensives, narcotics, oral contraceptive pills (OCPs). hyperprolactinemia. ↓ and Galactorrhea Hypothyroidism: negative feedback of thyroxine (T4) on the hypo- Hyperprolactinemia thalamic-pituitary axis causing an ↑ in TRH. TRH stimulates PRL secretion. Hypothalamic: Craniopharyngioma, sarcoidosis, histiocytosis, leuke- The most common pituitary mia. Interferes with portal circulation of dopamine. adenoma associated with Pituitary: Prolactinoma. Microadenoma (< 1 cm), macroadenoma hyperprolactinemia is (> 1 cm). See the following section on prolactinoma. prolactinoma. Hyperplasia of lactotrophs: Present very similarly to those having microadenomas. Empty sella syndrome: Intrasellar extension of subarachnoid space which causes compression of the pituitary gland and an enlarged sella turcica. Acromegaly: Pituitary gland secretes growth hormone as well as PRL.

238 Acute/chronic renal disease: ↓ metabolic clearance of PRL. Chest surgery or trauma: Breast implants, herpes zoster at breast dermatome.

Fifty percent of women with PROLACTINOMA hyperprolactinemia will have a prolactinoma. If PRL One-tenth of people in the general population have an incidental pro- is > 200 ng/mL, nearly lactinoma. 100% will have Fifty percent of women with hyperprolactinemia have a prolactinoma. prolactinoma. Most prolactinomas are microadenomas. Majority of microadenomas do not enlarge. Hyperprolactinemia with or without a microadenoma follows a benign clinical course and treatment is not necessary unless estrogen levels are low or pregnancy is desired. Microadenoma growth is not stimulated by:

Pregnancy Most macroadenomas HIGH-YIELD FACTS OCPs enlarge with time. Most Hormone replacement microadenomas do not.

HISTORY Amenorrhea/oligomenorrhea. Galactorrhea. The most common Headaches. symptoms of Bitemporal visual fi eld defi cit. hyperprolactinemia are galactorrhea and PHYSICAL EXAM amenorrhea. Visual fi eld testing if macroadenoma is present. Macroadenomas can exert pressure on the optic chiasm. Breast exam. Hyperprolactinemia and Galactorrhea

STUDIES PRL level. Sixty percent of women with galactorrhea have TSH, triiodothyronine (T3), T4: Evaluate for hypothyroidism if PRL is elevated. hyperprolactinemia. Ninety Magnetic resonance imaging (MRI): Most sensitive for diagnosis of pi- percent of women with tuitary masses and empty sella syndrome due to greater soft tissue con- galactorrhea, amenorrhea, trast. and low estrogen have hyperprolactinemia. TREATMENT Drugs: Stop the suspected drug, and repeat PRL after 1 month. If medication cannot be stopped and PRL level above 100 ng/mL, image the sella turcica to determine the presence of macroadenoma. MRI: Modality of choice to Patient with galactorrhea and normal menses: No further therapy if diagnose pituitary normal PRL, normal TSH. adenomas or empty sella syndrome.

239 Bromocriptine: Dopamine receptor agonist. For patients with macroadenoma: Can reduce tumor mass. Bromocriptine is the drug For those that desire to conceive, are anovulatory, with hyperprolactinemia: Discontinued after conception as it crosses the placenta. of choice for women with Not known to be teratogen. PRL-secreting For those with galactorrhea only: Inhibits secretion of PRL. microadenoma who want to Side effects: Severe orthostatic hypotension (fainting, dizziness), nau- conceive. sea, vomiting. Administered orally or vaginally (reduced side effect of nausea and vomiting). Long-term treatment is required. Cabergoline is the drug of Cabergoline: Long-acting dopamine receptor agonist. Less frequent choice for reducing PRL and less severe side effects. levels and shrinking Transsphenoidal microsurgical resection: tumors. Recommended only if macroadenoma and fail medical therapy. Risk of diabetes insipidus, iatrogenic hypopituitarism. Fifty percent cure for microadenomas, 25% cure for macroadenoma. Radiation: Adjunctive treatment following incomplete removal of large ↑ tumors. Pregnancy the likelihood Osteoporosis treatment/prophylaxis: Low levels of estrogen resulting ↓ that PRL levels will or from hyperprolactinemia can result in bone loss. become normal overtime. HIGH-YIELD FACTS HIGH-YIELD Bromocriptine induction of pregnancy is not associated with ↑ congenital abnormalities, spontaneous abortion, or multiple gestation.

Cabergoline is more

and Galactorrhea effective and better Hyperprolactinemia tolerated than bromocriptine.

240 CHAPTER 20 Abnormal Uterine Bleeding

Deﬁ nitions 242 Abnormal Uterine Bleeding: Reproductive Age 242 Postmenopausal Bleeding 245

241 DEFINITIONS

Menorrhagia: Bleeding Menstrual abnormalities include: too long or too much. Polymenorrhea: Uterine bleeding occurring at regular intervals of < 21 History of clots most days. consistent with diagnosis of Menorrhagia: Prolonged (> 7 days) or excessive (> 80 mL) uterine anemia. bleeding occurring at regular intervals (synonymous with hypermenor- rhea). Oligomenorrhea: Uterine bleeding occurring at intervals > 35 days. Metrorrhagia: Bleeding occurring at frequent, irregular intervals. Menometrorrhagia: Combination of both menorrhagia and metror- How much blood loss is rhagia; uterine bleeding that is prolonged or excessive, frequent, and ir- necessary to deﬁ ne regular. menorrhagia? > 80 mL Dysfunctional uterine bleeding: Bleeding that occurs after organic, systemic, and iatrogenic causes have been ruled out. Two types: anovulatory and ovulatory.

ABNORMAL UTERINE BLEEDING: REPRODUCTIVE AGE Two main mechanisms for hemostasis during A 24-year-old G0P0 presents to the ofﬁ ce with a menstrual period every menstruation are 3–4 months. Her periods are heavy, lasting 7–9 days. Her body mass index HIGH-YIELD FACTS HIGH-YIELD hemostatic plug formation (BMI) is 40. She complains of severe acne since puberty. Recently, she and vasoconstriction. was diagnosed with diabetes mellitus type 2. Her genitourinary (GU) exam was normal, with no palpable masses. What initial lab tests should be ordered in the evaluation of this patient? Answer: β-hCG, follicle-stimulating hormone (FSH), thyrotropin-stimulating Metrorrhagia: The metro hormone (TSH), prolactin (PRL). These tests cover the top differential diagnosis of never comes according to pregnancy, premature ovarian failure, thyroid dysfunction, and hyperprolactinemia schedule (bleeding at as the cause of abnormal uterine bleeding (AUB). If all of the results are normal, frequent, irregular further workup can be done. intervals).

A normal menstrual cycle occurs every 21–35 days (28 ± 7 days) with menstruation for 2–7 days. The normal blood loss is less than 80 mL total (average 35 cc), which represents 8 or fewer soaked pads per day with usually no more than 2 heavy days. AUB is any disturbance of the above. It can occur at any Abnormal Uterine Bleeding age and has many causes. Patient with postcoital Most cases of reproductive age bleeding are related to pregnancy, struc- bleeding should be tural uterine pathology, anovulation, coagulopathy or neoplasia. Less com- evaluated for cervical mon causes include trauma and infection. cancer and cervicitis. ETIOLOGY Organic: Reproductive tract disease. Accidents of pregnancy (threatened, incomplete, missed abortion; ectopic pregnancy; trophoblastic disease). Malignancy: Most commonly endometrial and cervical cancers. Es- trogen producing ovarian tumors like the granulosa-theca cell tumors may present with excessive uterine bleeding.

242 Infection: Endometritis presents with episodic intermenstrual spotting. Cervicitis and severe vaginal infections can present with bleeding. Structural causes (ﬁ broids, polyps, adenomyosis). Foreign bodies: Tampons retained in the vagina or intrauterine devices for contraception can cause bleeding. Most common cause of Endometriosis: Occasionally presents as premenstrual spotting. hospital admission for Traumatic vaginal lesions. menorrhagia in adolescents Systemic: = von Willebrand disease. von Willebrand disease can cause ↑ bleeding due to coagulopathy. Prothrombin deﬁ ciency. Leukemia. Sepsis. Idiopathic thrombocytopenic purpura. Hypersplenism. Thyroid dysfunction: Hypothyroidism causes anovulation and is fre- Tumors (benign and quently associated with menorrhagia and intermenstrual bleeding.

malignant) often present HIGH-YIELD FACTS Cirrhosis: Excessive bleeding secondary to the reduced capacity of the with menorrhagia or liver to metabolize estrogens. metrorrhagia. Iatrogenic: Anticoagulation medications. Oral or injectable steroids used for contraception. Hormone replacement therapy (HRT). Tranquilizers and psychotropic drugs: Interfere with neurotransmit- ters responsible for inhibition and release of hypothalamic hormones, leading to anovulation and AUB. Dysfunctional uterine bleeding (DUB): DUB is a diagnosis of Ovulatory: After adolescence and before perimenopausal years. Usu- exclusion—not regular, not ally menorrhagia and/or intermenstrual bleeding. Due to abnormal predictable, and not

endometrial hemostasis for any reason. The diagnosis of ovulatory associated with PMS. It is Abnormal Uterine Bleeding DUB is made by endometrial biopsy (EMB). On the fourth day of diagnosed only when all ﬂ ow, the EMB reveals both proliferative and secretory endometrium. organic causes are ruled Anovulatory: Predominant cause of DUB. There is continuous estra- out. diol production without corpus luteum formation or progesterone production. This steady state of estrogen stimulation results in constant endometrial proliferation without progesterone-mediated maturation and shedding. Fragments of overgrown endometrium sheds sporadi- cally. Anovulation can manifest in: Polycystic ovarian syndrome (PCOS). Obesity. Signs of PCOS Adolescents (perimenarchal). Perimenopause. Oligomenorrhea Hirsutism HISTORY Obesity Ask the patient about the frequency, interval, duration, and amount of Cystic ovaries bleeding. Ask the patient if and when the menstrual pattern changed. Ask about the presence of clots. Provide the patient with a calendar to record her bleeding episodes and its duration. Ask the patient how many full sanitary napkins she uses on average. This is very subjective so beware. Irregular bleeding is often Menorrhagia present since menarche? associated with anovulation.

243 Family history of bleeding? Epistaxis, gum bleeding, postpartum bleeding, surgical bleeding. Cold intolerance.

PHYSICAL EXAM Bimanual may reveal bulky uterus/discrete fi broids. Obesity, hirsutism, acanthosis nigricans (PCO). Exopthalmos, goiter, delayed DTRs, dry skin/hair (thyroid disorder). Visual fi eld defi cits, galactorrhea (hyperprolactinemia). Petechia (coagulopathy).

DIAGNOSTIC TESTS Pap smear. Pregnancy test: Sensitive hCG. Hysteroscopy can be used Hemoglobin, serum Fe, serum ferritin. to diagnose and treat the TSH. uterine abnormality at the FSH. same time. Prolactin. Coagulation panel: von Willebrand factor for adolescents with menorrhagia. EMB for women ≥ 35 yrs of age or with history of unopposed estrogen. Pelvic ultrasound. Sonohysterogram (pelvic US combined with intrauterine saline infusion to outline the uterine cavity). HIGH-YIELD FACTS HIGH-YIELD Hysteroscopy

TREATMENT

A 28-year-old G2P2002 presents to the ED complaining of excessive uterine bleeding for the past week that has worsened over the past 24 hr, shortness of breath, and dizziness. She appears pale; HR 110, BP 90/65. She is sweating profusely and is very restless. Sterile speculum exam shows active bright red bleeding and a normal cervix. What is the best treatment for this patient? Answer: Dilation and curettage (D&C) is the treatment of choice for a patient with heavy bleeding and hemodynamic instability. Its effect is immediate.

Address organic, systemic, iatrogenic causes as indicated. Abnormal Uterine Bleeding Medical management: First-line treatment. Used for women who desire future fertility or those who will reach menopause within a short period of time. Nonsteroidal anti-inﬂ ammatory drugs (NSAIDs) (tranexamic acid/ mefenamic acid). Iron supplements. Hormones: OCP is the mainstay for anovulatory bleeding. Combina- tion pill or estrogens are used in the acute management of DUB. Pro- gestin intrauterine device (IUD) can be used for DUB.

244 D&C: Indicated mainly for women with heavy bleeding leading to hemodynamic instability. Once the acute episode of bleeding is controlled, the patient can be placed on medical management. Endometrial ablation: Used as an alternative to hysterectomy when other medical modalities fail or when there are contraindications to their use. It should not be used in women who wish to maintain their reproductive capacity. Myomectomy. Hysterectomy: Reserved for women with other indications for hysterectomy, such as leiomyomas or uterine prolapse. Hysterectomy should be used to treat persistent ovulatory DUB only after all medical therapy has failed.

POSTMENOPAUSAL BLEEDING (PMB) HIGH-YIELD FACTS A 55-year-old female with LMP 5 years ago presents with a chief complaint of vaginal spotting. She reports painful intercourse and burning in the vagina. Her spotting is not related to sexual activity. She denies any medical conditions and is not on any medications. Pelvic exam reveals a dry vagina with ↓ rugae. What is the most likely diagnosis for this patient? Answer: Bleeding due to atrophy is the most common cause for postmenopausal bleeding.

Postmenopausal bleeding is defi ned as bleeding that occurs after 1 year of amenorrhea. All vaginal bleeding in postmenopausal women must be evalu- Most common cause of ated. Postmenopausal bleeding can be due to atrophy or endometrial carci- Abnormal Uterine Bleeding postmenopausal bleeding: noma, along with various other causes. atrophy of genital tract. ETIOLOGY Most common lethal cause: endometrial cancer. Vaginal/endometrial atrophy (most common): Hypoestrogenism causes atrophy of the endometrium and vagina. In the uterus, the collapsed, atrophic endometrial surfaces contain little or no fl uid to prevent intracavitary friction. This results in microerosions of the surface epithelium which is prone to light bleeding or spotting. Postmenopausal HRT: Many postmenopausal women who take HRT develop vaginal bleeding; the frequency depends upon the regimen HRT for menopausal used. woman with uterus must Endometrial hyperplasia: contain progestin with Endogenous estrogen production from ovarian or adrenal tumors or exogenous estrogen therapy are possible causes. estrogen to prevent Obese women have high levels of endogenous estrogen due to the endometrial hyperplasia / conversion of androstenedione to estrone and the aromatization of carcinoma. androgens to estradiol, both of which occur in peripheral adipose tissue. Adenomyosis: Confi rmed by pathologic examination following hysterectomy. Symptomatic adenomyosis occurs after menopause only in the presence of postmenopausal HRT. Post radiation therapy:

245 A late effect of radiation therapy. Radiation devascularizes tissue, causes sloughing, and bleeding. Vaginal vault necrosis causes uncontrolled bleeding and pain. Iatrogenic anticoagulant effect. Neoplasia: Postmenopausal bleeding = Endometrial cancer. endometrial cancer until Cervical cancer. Vaginal bleeding occurs because the cancer out- proven otherwise by tissue grows its blood supply. The necrotic and denuded tissue bleeds easily biopsy. and causes a malodorous discharge. Vulvar cancer. Estrogen-secreting ovarian tumor. Leiomyomata uteri. The diagnosis of a uterine sarcoma should be considered in postmenopausal women with rapidly growing leiomyomata. Polyps: Endometrial growths of unknown etiology. Growth of polyps Vaginal bleeding + foul- can be stimulated by estrogen therapy or tamoxifen. They may be smelling discharge = benign, premalignant, or malignant. cervical cancer. Infection: Uncommon cause of postmenopausal bleeding. Trauma.

HISTORY Ask the patient about the frequency, duration, and amount of bleeding, and when it started. Ask the patient about any associated signs/symptoms like weight loss, fe- HIGH-YIELD FACTS HIGH-YIELD ver. Differential diagnosis for History of trauma. thickened endometrial Ask the patient which medications she takes—hormones, anticoagu- stripe in a postmenopausal lants, tamoxﬁ en, over the counter, herbal supplements. woman: Ask the patient about her past medical history. History of bleeding in relation to sexual activity. Endometrial cancer Family history of bleeding, gynecologic cancer, breast cancer. Endometrial hyperplasia Leiomyoma PHYSICAL EXAM Polyp Note any suspicious lesions, lacerations, discharge, or foreign bodies. Classic signs of atrophy include pale, dry vaginal epithelium that has lost its rugae. Assess the size, contour, and tenderness of the uterus.

STUDIES

Abnormal Uterine Bleeding Vaginal probes and wet mount for infections. Pap smear for cervical dysplasia, neoplasia. Endometrial biopsy for endometrial hyperplasia or cancer. Transvaginal ultrasound to assess endometrial stripe. If endometrial Endometrial stripe > 4–5 stripe is < 4 mm, endometrial sampling may be deffered unless the pa- mm in a patient with PMB tient has persistent bleeding. Rationale is thin lining due to atrophy. should prompt an Diagnostic D&C. evaluation. Hysteroscopy.

246 TREATMENT

A 65-year-old overall healthy woman, menopausal for 15 years, presents with vaginal bleeding. She reports 3 days of dark red spotting that has now resolved. An ofﬁ ce endometrial biopsy shows endometrial hyperplasia with atypia. What is the best treatment for this patient? Answer: Hysterectomy with possible staging. Hyperplasia with atypia is thought of as a precursor to endometrial cancer. The cancer may have been missed due to sampling error. The safest procedure for this patient is a hysterectomy, which will allow the pathologist to evaluate the full extent of the uterine disease.

Treatment of postmenopausal bleeding is dependent on the cause: Local estrogen cream is used to treat vaginal atrophy and postradiation effect limited to the vaginal region. Hysteroscopy, endometrial ablation, or hysterectomy can be offered if HIGH-YIELD FACTS symptoms are due to benign lesions like polyps and ﬁ broids. Endometrial hyperplasia without atypia can be managed with progestin and ongoing monitoring. Endometrial hyperplasia with atypia should be treated as if there is underlying cancer. Small chance that cancer was missed due to sampling error. Hysterectomy is the treatment of choice. If carcinoma, consult gynecologic oncology to determine the best treatment (chemotherapy, radiation, or surgery). Abnormal Uterine Bleeding

247 NOTES HIGH-YIELD FACTS HIGH-YIELD Abnormal Uterine Bleeding

248 CHAPTER 21 Pelvic Pain

Chronic Pelvic Pain 250 Acute Pelvic Pain 251

249 Pelvic Pain HIGH-YIELD FACTS Gastrointestinal Neoplasia Infections otherthanPID Pelvic infl ammatory Adhesions/denomyosis Endometriosis/ndometritis Leiomyoma Think ofLEAPINGpain Chronic pelvicpain— released fromtheovary. occurs atthetimeaneggis associated withovulation.It ispelvicpain Mittelschmerz repeat offi cevisits. laparoscopies, and40%of 20% ofdiagnostic 12% ofhysterectomies, Pelvic painaccountsfor disease (PID) E D system involved. longer. Thediagnosis totheorgan andmanagementforthepainistailored Chronic pelvicpain (CPP) isdiscomfort inthepelvislastingfor6monthsor 250 W TIOLOGIES CHRONIC PELVICCHRONIC PAIN FNTO AND EFINITION ORKUP despite medicaltherapy, interventionmaybeconsidered. asurgical Medical therapyisinstitutedfi rst, asconservativemanagement.Ifpainpersists, pelvic ultrasound.Treatment: nonsteroidalanti-infl ammatory drugs(NSAIDs). ormedicaltreatment? ordered? Would youofferthe patientsurgical is negative.What ishermost likelydiagnosis?What diagnostictestshouldbe the uterus.Hercervixandadnexaarenontendertopalpation.pregnancytest uterus tobeenlarged,about16 weeks,insize.Shehastendernessdirectlyover Musculoskeletal. Psychological/psychiatric. LEAPING: Pain thatisbelow theumbilicus,butbetweenhips. Symptoms causesignifi cant distress orimpairmentinsocial, occupa- Pelvic discomfort thatisnoncyclicandlasts>6months. Detailed Detailed history (focusingonaboveetiologies): Mittelschmerz. Urinarytractinfection(UTI)/interstitial cystitis. Fibromyalgia. Answer: bound, depression,sexualdysfunction). areasoffunctioning (eg,missedtional, orotherimportant work,home- Lastmenstrual period(LMP)andmenstrual history. Past surgeries:Adhesionsform afterprevioussurgeries.Adhesionsare Associated symptoms/relieving factors:Pain maybeassociated with Pain characteristics:Painintermittent, orwithmonthly maybeconstant, Temporal pattern:Timing anddurationofsymptoms. source ofpain. fi positional changes,fever,or nausea/vomiting. menses (cyclic). ble bowel syndrome(IBS). Gastrointestinal (infl ammatory bowel disease, diverticulosis, orirrita- Neoplasia. Infections otherthanPID. Pelvic inflammatory disease (PID). Adhesions/denomyosis. Endometriosis/ndometritis. Leiomyoma. brous tissuethatformsbetween two internalorgansandmaybea She takesTylenol forthepainwithminimalrelief. The examrevealsthe lasting 20 minutes,threetofour timesaweek.The painbegan1yearago. A 35-year-old G2P2,witha history ofuterinefi broids, complainsofpain The mostlikelydiagnosisisfibroid uteruswithdegeneration.Imaging: C RITERIA HIGH-YIELD FACTS Pelvic Pain Abortion Laparoscopy is the fi nal, Laparoscopy is the fi conclusive step in diagnosing pelvic pain, but it should only be done once psychogenic and gastrointestinal etiologies have been evaluated. Differential for acute pelvic pain— A ROPE Appendicitis/Abscess/ Ruptured ovarian cyst Ovarian torsion PID (tubo-ovarian abscess) Ectopic pregnancy PID is the most common PID is the most pelvic pain cause of chronic that 30 in women less is years old. Endometriosis in the most common cause women greater than 30 years old. 251 stula. rmatory test such as a VDRL or FTA-ABS, rmatory test such as a VDRL or FTA-ABS, Look for: broid. A 22-year-old G0, with an LMP 13 days ago, presents to the ED complain- G0, with an LMPA 22-year-old 13 ing of right lower quadrant pain in the past 2 days. She reports that Advil is no longer relieving the pain. She is afebrile, with a pulse of 80 and a broids. sis, irritable bowel syndrome, or infl disease. ammatory bowel sis, irritable infl syndrome, or bowel sion. fi masses for abdominopelvic nance imaging (MRI)—best to evaluate or malignancies. tender on palpation. an infection. blood cell count (WBC) may indicate or a uterine fi In some cases, may reveal endometriosis. as PID or endometritis. or constipation associated with the pain. with associated or constipation with to be associated been known pain has abuse): Pelvic or sexual sexual abuse. factors and childhood psychiatric HIV, gonorrhea/chlamydia cultures. gonorrhea/chlamydia HIV, to evaluate for diverticulo- Gastroenterology referral for colonoscopy interstitial cystitis. Cystoscopy to evaluate for evaluate for psychosomatic pain and for depres- Psychiatry referral to to evaluate ovarian cyst/neoplasms or uterine sonogram: Best Pelvic tomography (CT)/magnetic reso- further evaluation: Computed For Pregnancy test. Pregnancy RPR, if positive then a confi culture. Urinalysis (UA) and urine occult blood. Fecal or a fi abscesses, May suggest hemorrhoids, Anal tenderness: vagina may be suggest interstitial cystitis; anterior Bladder pain: May elevated white An blood count (CBC) with differential: Complete suggest an enlarged ovary and pelvic exam may on abdominal Masses such an infection, tenderness: If present may indicate Cervical motion may suggest vulvodynia. Vulva-tenderness diarrhea, vomiting, as nausea, such complaints (GI) Gastrointestinal history: Dyspareunia. Sexual of physical stress, history depression, history (marital Social discourse, Referrals Imaging studies: Labs: Answer: A ruptured corpus luteal cyst is the diagnosis. She recently ovulated, Mittelschmerz. Physical exam: exam: Physical temperatur of 98.2. Her abdomen is soft, but very tender with rebound and guarding. A pregnancy test is negative. An ultrasound reveals a normal-size left ovary uid in the cul-de-sac (pouch of with a small amount of fl and a 4-cm right ovary, is her diagnosis? How will you treat her? Douglas). What since her period was 2 weeks ago. She needs surgical is acute treatment. This pain, with signs of an acute abdomen on exam. Since she is hemodynamically stable, she should have a diagnostic laparoscopy to diagnose and treat, instead of a laparotomy. ACUTE PELVIC PAIN PELVIC ACUTE Pelvic Pain HIGH-YIELD FACTS corpus lutealcyst. diagnosis? Aruptured ultrasound. Whatisthe echogenic adnexalmasson pregnancy testhasan pelvic painandanegative A femalewithnew-onset acute pelvicpain. the mostcommoncauseof An ovarianrupturedcystis abdominal orpelvicpain. during evaluationof undergo apregnancytest contraception, should or sexual history age, regardlessofreported All womenofreproductive PID, orappendicitis. a degeneratingleiomyoma, related toadnexaltorsion, infl ammation/necrosis appendicitis), due toinfection(PIDor An elevatedWBCmaybe T W E Acute pelvicpainisanyinthecavitythatlasts<6months. 252 REATMENT TIOLOGIES ORKUP Surgicaltherapy:Considerifacutepain(signs ofanacuteabdomen)or withconservativemanagement,ifnotacute,NSAIDs(ie,motrin, Start Dependsontheetiologyofpain. Pelvic sonogram:Lookforovariancysts/neoplasm, torsion,an Labs: Physical exam: Lookforlocalized/point tenderness,cervicalmotion History:Includetemporalcharacteristics(cyclic,intermittent, ornon- GI/genitourinary (GU): Obstetric: Gynecologic—mayrequire surgery, ifpainissevere: Surgery:Mayconsistofadiagnostic laparoscopyoranexploratory lapa- eliminating anGIorpsychiatricetiology). if workupofchronic painpersistsdespiteathoroughworkup(after naproxen). scess. intrauterine/ectopic pregnancy, uterine fi broids, oratubo-ovarianab- guarding, rebound,orseveretenderness. three maybesignsofPID.Lookforanacuteabdomensuchas tenderness, adnexalandabdominal tenderness.Thelatter cyclic), location,andseverityofpain. rotomy. Cultures (nucleic acid DNAamplifi cation) testsforchlamydia and UAandculture,ifindicated. CBCwithdifferential. Pregnancy test. UTI. Infl Appendicitis. Diverticulitisordiverticulosis. Abortion. Ectopic pregnancy. Dysmenorrhea. Endometriosis. Tubo-ovarian abscess,PID. Adnexal torsion. Rupturedovariancyst. gonococcus. ammatory bowel diseasebowel syndrome(IBS). (IBD),orirritable CHAPTER 22 Endometriosis and Adenomyosis

Endometriosis 254 Adenomyosis 257 Adenomyosis Versus Endometriosis 258

253 ENDOMETRIOSIS

A 32-year-old G0P0 presents to the infertility clinic with a 3-yr history of infertility. She states that her menses began at age 13 and occurs on regular 28-day intervals. She complains of severe monthly pain 1 week before each menses and pain with intercourse. She denies a history of sexually transmitted diseases. Her husband has a child from a previous marriage. On rectovaginal exam, she has uterosacral nodularity and a fi xed, retrofl exed uterus. What diagnostic test would be the most appropriate at this point to make the diagnosis? What fi ndings would you see on a tissue biopsy? Answer: The patient has classical symptoms of endometriosis, especially dysmenorrhea and dyspareunia. Endometriosis is a common condition associated with infertility. Laparoscopy is the diagnostic test of choice. The tissue biopsy would show endometrial glands, stroma, and hemosiderin-laden macrophages. Most common site: ovary and pouch of Douglas.

DEFINITION Ectopic endometrial glands and stroma ectopically growing outside of the uterus, often causing pain and/or infertility.

HIGH-YIELD FACTS HIGH-YIELD INCIDENCE Ten to fi fteen percent of reproductive-aged women. Endometriosis is the most Occurs primarily in women in their 20s and 30s. Common in nullipa- likely cause of infertility in rous woman. a menstruating woman Accounts for 20% of chronic pelvic pain. over the age of 30, without One-third to one-half of women affected with infertility, have endo- a history of pelvic metriosis. infl ammatory disease. PATHOPHYSIOLOGY The ectopic endometrial tissue is physiologically functional. It responds to hormones and goes through cyclic changes, such as menstrual bleeding. The result of this ectopic tissue is “ectopic menses,” which causes bleeding, peritoneal infl ammation, pain, fi brosis, and, eventually, adhesions. A 37-year-old woman complains of hemoptysis SITES OF ENDOMETRIOSIS Endometriosis and Adenomyosis during the menstrual period. Think: Common Ovary (bilaterally): 60%. Endometriosis of the Peritoneum over uterus. nasopharynx or lung. Anterior and posterior cul-de-sacs. Broad ligaments/fallopian tubes/round ligaments. Uterosacral ligaments. Bowel. Pelvic lymph nodes: 30%.

254 Less Common Rectosigmoid: 10–15%. Cervix. Vagina. Bladder. Severity of symptoms does Rare not necessarily correlate Nasopharynx. with quantity of ectopic Lungs. endometrial tissue, but may Central nervous system (CNS). correlate with the depth of Abdominal wall. Abdominal surgical scars or episiotomy scar. penetration of the ectopic Arms/legs. tissue.

THEORIES OF ETIOLOGY Though the mechanisms and etiology are unknown, there are four theories commonly cited. It is likely that multiple theories may explain the diverse nature of this disorder: HIGH-YIELD FACTS Retrograde menstruation: Endometrial tissue fragments are retrogradely transported through the fallopian tubes and implant there or intra- Long-term complications abdominally with a predilection for the ovaries and pelvic peritoneum. of endometriosis: Mesothelial (peritoneal) metaplasia: Under certain conditions, peritoneal tissue develops into functional endometrial tissue, thus responding Prolonged bleeding to hormones. causes scarring Vascular/lymphatic transport: Endometrial tissue is transported via (adhesions). blood vessels and lymphatics. This can explain endometriosis in loca- Adhesions cause tions outside of the pelvis (ie, lymph nodes, pleural cavity, kidneys). infertility, and small Altered immunity: There may be deﬁ cient or inadequate natural killer bowel obstruction, pelvic (NK) or cell-mediated response. This can explain why some women de- pain, and difﬁ cult Endometriosis and Adenomyosis velop endometriosis, whereas others with similar characteristics do not. surgeries. Iatrogenic dissemination: Endometrial glands and stroma can be implanted during a procedure (eg, c-section). Endometriosis can be noted in the anterior abdominal wall.

GENETIC PREDISPOSITION A woman with a ﬁ rst-degree relative affected with endometriosis has a 7% chance of being similarly affected as compared with 1% in unrelated persons. Congenital anomalies that With a positive family history, a patient may develop endometriosis at promote retrograde an earlier age than the family member. menstruation may be a common associated ﬁ nding CLINICAL PRESENTATION in adolescents. Pelvic pain (that is especially worse during menses, but can be chronic): Secondary dysmenorrhea (pain begins up to 48 hr prior to menses). Dyspareunia (painful intercourse) as a result of implants on pouch of Douglas; occurs commonly, with deep penetration. Dyschezia (pain with defecation): Implants on rectosigmoid. Infertility. Intermenstrual bleeding. Cyclic bowel or bladder symptoms (hematuria). Chronic pelvic pain may be Up to one-third of women may be asymptomatic. a result of endometriosis associated with adhesions.

255 SIGNS Fixed retrofl exed uterus, with scarring posterior to uterus. Classic fi ndings of Tender uterus or presence of adnexal masses. endometriosis: “Nodular” uterosacral ligaments or thickening and induration of utero- Dysmenorrhea, sacral ligaments. dyspareunia, and Ovarian endometriomas: Tender, palpable, and freely mobile implanted masses that occur within the ovarian capsule and bleed. This dyschezia. creates a small blood-fi lled cavity in the ovary, classically known as a “chocolate cyst.” Blue/brown vaginal implants (rare).

DIAGNOSIS Laparoscopy or laparotomy: Ectopic tissue must be biopsied for defi nitive diagnosis. The gold standard for diagnosis is laparoscopy with biopsy proven hemosiderin laden macrophages. The colors of endome- The classic fi ndings on trial implants vary widely: physical exam are Red implants—new. nodularities on the Brown implants—older. uterosacral ligament and a White implants—oldest (scar tissue). fi xed retroverted uterus. Tissue biopsy (cardinal features): Positive fi ndings contain endometrial glands, stroma, and hemosiderin-laden macrophages. Maximum time on estrogen suppression should be 6 months due to adverse effects. HIGH-YIELD FACTS HIGH-YIELD CLINICAL COURSE Thirty-fi ve percent are asymptomatic. Symptomatic patients may have increasing pain and possible bowel pain and possible bowel complications. Often, there is improvement with pregnancy secondary to temporary cessation of menses. May be associated with infertility.

TREATMENT Medical (temporizing). The primary goal is to induce amenorrhea and cause regression of the endometriotic implants. The pulsatile fashion of All of these treatments suppress estrogen: endogenous GnRH Gonadotropin-releasing hormone (GnRH) agonists (leuprolide): Sup- stimulates FSH secretion. press follicle-stimulating hormone (FSH); create a pseudomeno- GnRH agonists cause down pause. regulation of pituitary Depo-Provera (progesterone [+/– estrogen]): Creates a pseudopreg- Endometriosis and Adenomyosis receptors and supress FSH nancy (amenorrhea). secretion. This creates a Danazol: An androgen derivative that suppresses FSH/luteinizing pseudo-menopause state. hormone (LH), thus also causing pseudomenopause. Oral contraceptives (OCPs): Used with mild disease/symptoms. Surgical Conservative (if reproductivity is to be preserved): Laparoscopic lysis and ablation of adhesions and implants. Deﬁ nitive: Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO). A GnRH agonist can be used in conjunction with surgical treatment. It is associated with osteoporosis and should be used for only six months.

256 ADENOMYOSIS

A 39-year-old G4P4 comes to the clinic complaining of increasing menorrhagia, dysmenorrhea, and an enlarging uterus. On physical exam, the Ectopic endometrial tissue uterus is 14 weeks in size, boggy, slightly tender, and mobile. What would does not function like be the next best step in management? normal uterine Answer: Unfortunately there is no proven medical therapy for adenomyosis. endometrium. Thus, it is GnRH agonists can be used to cause a menopause-like state with complete ces- nonresponsive to hormones sation of ovarian function and menses, causing the abnormal tissue to shrink. in the normal manner as NSAIDs and OCPs improve dysmenorrhea and regulate the heavy menses. compared to endometriosis.

DEFINITION

Ectopic endometrial glands and stroma are found within the myometrium, re- HIGH-YIELD FACTS sulting in a symmetrically enlarged and globular uterus. Pelvic ultrasounds should INCIDENCE be performed to Occurs in 30% of women. differentiate between Usually in parous women in their 30s to 50s. Rare in nulliparous adenomyosis and uterine women. ﬁ broids. Often coexists with uterine ﬁ broids and to a lesser extent with endometriosis.

SIGNS AND SYMPTOMS

Common Endometriosis and Adenomyosis Pelvic pain (usually noncyclical). Symmetrical uterine enlargement. The diagnosis of Dysmenorrhea that progresses with duration of disease. Dysmenorrhea adenomyosis is suggested in adenomyosis doesn’t occur as cyclically as it does in endometriosis. by characteristic clinical Menorrhagia: 50% of women are asymptomatic. The diagnosis is usu- manifestations after ally made incidentally by the pathologist, when examining a surgical endometriosis and specimen. leiomyomas have been ruled out. DIAGNOSIS Either ultrasound or MRI can be used to differentiate between adenomyosis and uterine ﬁ broids.

TREATMENT Adenomyosis is described as No proven medical therapy for treatment. an enlarged, globular, GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding. “boggy” uterus on physical Hysterectomy: Deﬁ nitive therapy if childbearing is complete. The diagnosis is usually conﬁ rmed after histologic examination of the hysterec- exam. tomy specimen. Endometrial ablation will not improve adenomyosis symptoms.

257 ADENOMYOSIS VERSUS ENDOMETRIOSIS

Adenomyosis: Found in older, multiparous women. Tissue is not as responsive to hormonal stimulation. Noncyclical pain. Endometriosis: Found in young, nulliparous women. Tissue is responsive to hormonal stimulation. Cyclical pain. HIGH-YIELD FACTS HIGH-YIELD Endometriosis and Adenomyosis

258 CHAPTER 23 Differential Diagnoses of Pelvic Masses

Diagnostic Tests for Various Causes of Pelvic Masses 260 Functional Ovarian Cysts 260 FOLLICULAR CYSTS 260

LUTEIN CYSTS 262 Tubo-ovarian Abscess 262 Endometriomas 263 Benign Cystic Teratomas 264 Malignancies 264 Leiomyomas (Fibroids) 266

259 Differential Diagnoses HIGH-YIELD FACTS treated surgically. ratherthan observed, asymptomatic areoften malignancy and that arenotsuspiciousfor Ovarian masses<5cm exam. pelvic massonphysical reproductive agewitha done inallwomenof Pregnancy testsshouldbe masses. common causeofpelvic Leiomyomas arethemost ative pregnancytest. The primarydiagnostic testsare:Physicalexam,pelvicultrasound,andaneg- D originate fromthecervix,uterus,oradnexa,otherorgansystems. Masses inthepelvismaybecysticorsolidandcanoccuratanyage.They 260 acleartoyellow estrogen-richfl contains cyst. Just like theoriginalfollicle,ovariancystisgranulosa celllinedand Failure ofruptureorincomplete resorptionoftheovarianfollicleresultsina P Follicular cystsarethemost commonfunctionalovariancysts. Follicular Cysts FUNCTIONAL OVARIAN CYSTS FUNCTIONAL DIAGNOSTIC TESTS FOR VARIOUS CAUSES OF PELVIC MASSES HYSIOLOGY IFFERENTIAL ruptured ovarian cyst, which may require surgical intervention. ruptured ovariancyst,whichmayrequiresurgical should beyournextstepinmanagement? TOA: Endometrioma neoplasm(discussed below): Endocervicalcurettage Endometrial Ovarian neoplasm Leiomyoma(discussed below): Physicalexam(+US,hysteroscopyif Ovarian cysts: Pregnancy:Pregnancytest. Malignant:Ovaries,fallopiantubes,colon,cervix,metastatic. Benign: Fibroid, ovarianneoplasms(mostcommon—cysticteratoma), Infection/infl Pregnancy(ectopicpregnancy). Physiologic/functionalcyst(follicular,corpusluteal,orthecalutein). Answer: exal massonexam(Figure23-1). (ECC), dilation(D&C). andcurettage age, family history. scan, CA-125level,surgicalexplorationifhighlevelofsuspicion dueto needed forconfi endometriomas. scess, appendicitis). mation). of feeling“weak”anddizziness.Aurinepregnancytestis negative. What complaints ofsuddensevereright-sidedpelvicpain.Shealsocomplains with ED oneweek prior,A 24-yearold G0withaLMP presentstothe D History ofpelvicinflammatory disease (PID)withapalpableadn- IAGNOSES Ultrasound. This patientpresentswithsymptomscommonfora ammation (tubo-ovarianabscess[TOA],diverticular ab- Physical exam(+ultrasound[US]ifneededforconfi rmation). (discussed below): Laparotomy/laparoscopy. (discussed below): US,computedtomography(CT) uid. r- HIGH-YIELD FACTS Differential Diagnoses 261 ammatory disease disease ammatory Tubo-ovarian abscess. Tubo-ovarian rms the diagnosis and is also helpful to see whether the cyst is and is also helpful to see whether the diagnosis rms YMPTOMS S underlying cause (eg, neoplasia) is found. taneously within 2 months. cyst, in the symptomatic patient. cated to evaluate/rule out neoplasia/endometriosis. ruptured. May show an ovarian cyst or fl uid in the cul-de-sac, which is uid in the cul-de-sac, which an ovarian cyst or fl ruptured. May show consistent with a ruptured cyst. the ovarian cyst. more pain they cause and the higher the risk of ovarian torsion. more pain they cause and the higher symptomatic cysts can be managed with OCPs if no other Chronically No treatment is necessary for most cysts, since they usually resolve spon- Oral contraceptives (OCPs) may aid in the resolution of the ovarian If the cyst is unresolved after 2 months, laparotomy/laparoscopy is indi- exams. and abdominal Physical exam: Pelvic confi US Polymenorrhea/oligomenorrhea. and pelvic pain. abdominal Unilateral of es rupture often signifi (ie, rebound and guarding) Acute pelvic pain cm). The larger the size, the Usually asymptomatic when small (< 5 IAGNOSIS IGNS AND REATMENT T D and was successfully treated with antibiotics. (Reproduced, with permission, from Callen PW. from Callen PW. (Reproduced, with permission, and was successfully treated with antibiotics. Saunders; 2007. , 5th ed. Philadelphia, PA: Ultrasonography in Obstetrics and Gynecology Callen.) Photo courtesy of P. Endovaginal sonogram of a patient with pelvic pain, vaginal discharge, and fever. The sono- and fever. pain, vaginal discharge, Endovaginal sonogram of a patient with pelvic with internal uid (F) in the cul-de-sac and a large cystic mass fl gram demonstrates echogenic have pelvic infl to in the left adnexa. This patient was known echoes (arrows) FIGURE 23-1. S Differential Diagnoses HIGH-YIELD FACTS organisms). negative, andanaerobic gram positive, (includes coveragefor spectrum antibiotics process. Treat withbroad- A TOAisapolymicrobial elevated BHCGlevels. pregnancies, dueto usually areseeninmolar Bilateral thecaluteincysts T eral. stimulation andleadtothecalutein cysts,whichareoftenmultiple andbilat- ↑ levelsofhumanchorionic gonadotropin(hCG)cancause T History andpelvicexam,US. D S C cysts. There aretwotypesoflutein cysts:corpusluteumcystsandthecalutein Lutein Cysts 262 P consequence ofpelvicinflammatory disease (PID). An abscessinvolvingtheovaryandfallopiantubethat mostoftenarisesasa HECA REATMENT GSAND IGNS TUBO-OVARIAN ABSCESS (TOA) ABSCESS TUBO-OVARIAN HYSIOLOGY IAGNOSIS ORPUS Ifsymptomatic:Analgesics,OCPs,laparotomy/laparoscopy ifruptured, OCPs. Observefor2months.Canstart Poly/oligomenorrhea. Unilateral adnexaltendernessandpain. Thesecystsrarelygrow >5cm. Ifthisruptures,thepatientwillpresentwithacute lower-quadrant pain Corpus hemorrhagicum isformedwhentherehemorrhageintoa Thecorpusluteumisenlargedandcanproduceprogesteroneforweeks Largeovariancysts(>5cm)increase Surgicalresectioncanbeconsideredforsymptomaticcysts>5cmor TOA canalsodevelopinassociation withpelvicsurgeryormalignancy. SecondaryTOAmaydevelop asaresultofbowel perforation (appendi- PrimaryTOAmayariseasacomplicationofan ascending infectionof L is amedical emergency. with anacuteabdomen. neum. and vaginalbleeding andmaydevelop signsofshockandhemoperito- corpus luteumcyst. longer thannormal,andmaydelaymenses. cyst rupture. for clinical evidenceofacutepain,mostlikelysecondarytoanovarian citis, diverticulitis) fromintraperitoneal spreadofinfection. the reproductivetract. L UTEIN UTEUM S YMPTOMS C YST C YST the riskofovariantorsion,which follicular over- HIGH-YIELD FACTS Differential Diagnoses An endometrioma = chocolate cyst. TOA are different from TOA are different in that they other abscesses to antibiotic respond quickly treatment. 263 rms the diagnosis and allows the opportunity to assess for other to assess for other the opportunity and allows rms the diagnosis YMPTOMS YMPTOMS nitive surgery (oophorectomy): Alternative to cystectomy. Endo- (oophorectomy): Alternative to cystectomy. surgery nitive nitive diagnosis is made by laparoscopy and a biopsy containing he- diagnosis nitive S S can be excised by laparoscopy of laparotomy. Aspiration has proven to by laparoscopy of laparotomy. can be excised be ineffective. and it is a good metriomas are less likely to recur after oophorectomy, option for women who have completed childbearing. sis, pelvic pain, and an ovarian cyst. As many as 50% of women with en- sis, pelvic pain, and an ovarian cyst. dometriosis will develop an endometrioma. mosiderin laden macrophages. abscesses. Only surgical; medical therapy is not effective treatment for an endometrioma. (endometrioma) Conservative surgery (ovarian cystectomy): Entire cyst Defi Defi Pelvic pain Pelvic Dysmenorrhea Dyspareunia made in women with a history of endometrio- can be diagnosis Clinical Antimicrobial therapy. Antimicrobial or US-guided drainage Laparoscopic if no response to antibiotics. Palpable mass. Palpable exam: Physical . and abdominal Pelvic confi US pain. abdominal and/or Pelvic Leukocytosis. Fever. discharge. Vaginal IAGNOSIS IAGNOSIS HYSIOLOGY ENDOMETRIOMAS IGNS AND IGNS AND REATMENT REATMENT T D S P have endometriosis. Endometriosis is a Endometriomas arise in women who which endometrial glands and stroma occur outside the uterine in condition cavity and are located on the ovary. Endometriomas arise as a result of ectopic endometrial tissue in the ovary. ectopic endometrial tissue in the ovary. Endometriomas arise as a result of “chocolate cysts” due to the thick, brown, They are commonly referred to as uid that they contain. tarlike fl T D S Differential Diagnoses HIGH-YIELD FACTS the ovary can be preserved. canbepreserved. the ovary an oophorectomy—and with acystectomyandnot dermoid cystcanbetreated A youngwomanwitha T D P 264 is tract cancer. Thelifetimeriskofdevelopingovarian canceris1.6%.Thisrisk Malignant ovariantumorsaretheleading causeofdeathfromreproductive REATMENT BENIGN CYSTIC TERATOMAS MALIGNANCIES HYSIOLOGY IAGNOSIS ↑ to5%withoneaffectedfi ovarian cystectomy. best treatmentforthispatient? calcifi formed intheoffi ce revealsa5-cm,lefthypoechoicunilocularcystcontaining tenderness, andtherightovaryisnormalsizenontender. Anultrasoundper- An ovariancystectomyis preferred inpremenopausalfemales,<40 Excision oftheteratomabylaparotomyorlaparoscopy. Cysticteratomascanhaveaconsistencyrangingfromcompletelycystic USistheprimaryimagingtoolusedfordiagnosis. Malignanttransformationdevelopsinonly1–3%ofcases. Almostallmaturecysticteratomashavea46,XXkaryotype. Oocytesthatareabletodevelopintoteratomasundergoanarrestinde- Thediverse tissuefoundwithinateratomaisbelievedtodevelopfrom tissueofectodermal, mesodermal,andendo- Cysticteratomascontain OGCTs ariseprimarilyinyoungwomenage12–30andaccountfor (dermoid cysts)arethemostcommon Benign maturecysticteratomas Ifthereisnoviableovariantissue,orifthepatient>40,thenanoo- Answer: Diagnosis—benigncysticteratoma.Treatment—laparoscopy withan years old. to completelysolid. velopment aftermeiosis I. and mayincludeskin,bone,teeth,hair. the geneticmaterialinasingleoocyte.Thetissueismature(benign) bone, teeth,andhair. dermal origin.Thetissueismature(benign) andmayincludeskin, 70% oftumorsintheagegroup. ovarian germcelltumor(OGCT). phorectomy canbeused. cations andinternaldebris.What isthemostlikelydiagnosis?What isthe afebrile andonexamination,herleftovarypalpatesto5-cmwithmild that withinthelast3months,shehashadintermittent,dullpain.Sheis A 25-year-old G1P1presents foranannualwell-womanexam.Shereports rst-degree relative. HIGH-YIELD FACTS Differential Diagnoses Ovarian cancers present with vague GI symptoms (fullness, early satiety, bloating) at a more advanced cancer stage, at the time of the initial diagnosis. 265 likelihood that an ↑ rst-degree relative. rst-degree matted bowels, enlarged nodes matted with hormone replacement after menopause. with hormone replacement Sonographic Findings Suggestive of Malignancy Pelvic ↑ YMPTOMS nitive diagnosis is tissue biopsy. is tissue biopsy. diagnosis nitive S ovarian tumor is malignant. improves survival. even in the presence of distant metastasis is helpful. ian cancer. ian cancer. lymphadenectomy, omentectomy, with bilateral salpingo-oophorectomy, and peritoneal washings would be performed. be malignant and benign (see Table 23-1). (see Table be malignant and benign bryonal choriocarcinoma. epithelium is hypothesized to result in malignant transformation. These transformation. to result in malignant is hypothesized epithelium cell, and transi- clear endometrioid, serous, mucinous, tumors include tional cell. and steroid. ACTORS aggressive removal of all visible disease With more advanced disease, cancer is one of the few cancers in which “surgical debulking” Ovarian surgical staging be conducted for all women with ovar- Complete must In a woman with early-stage hysterectomy ovarian cancer an abdominal between masses that are likely to distinguishing Ultrasound is helpful in Defi pressure, fullness, swelling, or bloating. GI symptoms: Abdominal urgency. Urinary or pain. discomfort Pelvic asymptomatic. Often ovarian neoplasms are history in fi Family Age (> 50). Nulliparity. breast cancer. History of Slight yolk-sac, and em- dysgerminoma, Germ cells: These include teratoma, of the ovarian surface (ie, ovulation) stimulation Repeated Epithelium: an indicates An elevated serum CA-125 (> 35 units) cell, Sertoli cell, Sertoli-Leydig, include granulosa Sex-cord stroma: These F Solid component of mass, not hyperechoic, nodularity uid trapped in different compartments) Multiloculated (fl septations (thick walls between compartments)Thick Presence of ascites masses, Peritoneal IAGNOSIS ISK ATHOLOGY IGNS AND REATMENT TABLE 23-1. TABLE T D S R Origins of the three main types of ovarian tumors: of ovarian types three main of the Origins P Differential Diagnoses HIGH-YIELD FACTS torsion. present withacutepainand become pedunculated,may Subserosal fi broids,which present asmenorrhagia. types offi broidsusually Submucosal andintramural = aleiomyosarcoma A rapidlyenlargingmyoma (leiomyosarcoma). to malignancy (fi broids) progress Rarely doleiomyomas type. commonly ofthesubserous Leiomyomas aremost early disease. in only50%ofwomenwith ovarian canceroverallbut of womenwithepithelial CA-125 iselevatedin80% Changes inuterinefibroids overtimeinclude: S E which arehormonallyresponsive. Leiomyomas arelocalized, benign, smoothmuscle tumorsoftheuterus, P 266 U EQUELAE PIDEMIOLOGY LEIOMYOMAS (FIBROIDS) LEIOMYOMAS ROGNOSIS TERINE such as US willhelptoconfisuch asUS rm thediagnosis. What isyournextstepinmanagement? sures 16 weeksinsize,irregular, andinthemidline.The adnexaarenotpalpable. Red degeneration(painfulinterstitialhemorrhage,oftenwithpreg- Calcifi Hyaline degeneration. Themostcommonindication forhysterectomy. Theyarealmostalwaysmultiple. Clinically foundin25–33% ofreproductive-agewomenandinupto Overall5-yrsurvival: Seventy-fi Postoperative platinum-based chemotherapyisindicated inallhigh- Cervical:Inthecervix. Subserous: Intramural: Withintheuterinewall. Submucous: Just below endometrium; tendtobleed. Cysticdegeneration—mayrupture intoadjacentcavities. Answer: This patientlikelyhasuterinefi broids. Apelvicexamandimaging nancy). 50% ofblackwomen. haveoccurred. ter regionalordistantmetastases grade ovariancancer. Interligamentous: Thefibroid grows laterally intothebroadligament. omentum). Parasitic: Thefi bloodsupplyfromanotherorgan(ie, broid obtains L 89%withearlydisease. 36%withlocalspread. 17%withdistantmets. CTOSOF OCATIONS She alsocomplainsofpelvicpainandpressure.Onexam,theuterusmea- that areverypainful.Occasionally, shehasbleedinginbetweenperiod. A 40-year-oldwomanpresentscomplainingofheavymenstrualperiods cation. ve percentofwomenarediagnosed withadvanceddisease af- Just below the serosa/peritoneum. L EIOMYOMAS HIGH-YIELD FACTS Differential Diagnoses fi broids at fi relative risk: ↑ 1.82 1.85 Abruption: 3.87 Abruption: bleeding: First-trimester labor: Dysfunctional 3.98 Breech: 6.39 C-section: About one-third of fi broids About one-third of fi recur following myomectomy. The treatment for asymptomatic 11 weeks’ size is observation. nitive treatment for Defi broids = hysterectomy fi Pregnancy with fi broids fi Pregnancy with carries The most common location broid = for a uterine fi subserosal 267 broids. Some fi broids may grow in size may grow broids Some fi May be due to enlarging fi May be due to enlarging is indicated for asymptomatic women, as this hormonally for is indicated +/− anemia: One-third of cases present with bleeding. Bleed- with bleeding. of cases present One-third +/− anemia: with no other reason for infertility. A myomectomy is for women who with no other reason for infertility. desire to retain childbearing. uterus for their pleted childbearing. lifestyle. Symptoms limit patients in infertile broid Myomectomy: Surgical removal of the fi symptomatic women who have com- for Hysterectomy: Indicated is > 14 weeks’ gestation size. Tumor falls. Hematocrit compresses adjacent structures. Tumor Pressure ulceration. Pressure covering. endometrial Abnormal blood supply. Abnormal to 6 months to shrink tumors (ie, before surgery) and control bleeding: to 6 months to shrink tumors (ie, before sensitive tumor will likely shrink with menopause/pregnancy/not men- sensitive tumor will likely shrink with struating. usually midline, enlarged, irregularly shaped, and mobile. enlarged, usually midline, [HSG], hysteroscopy. hysterosalpingogram ing [MRI], CT, rule out malignancy. ing is usually menorrhagia, caused by: menorrhagia, ing is usually during pregnancy. Bed rest and narcotics are indicated for pain with red for pain Bed rest and narcotics are indicated during pregnancy. degeneration. be given for up can hormone (GnRH) agonists Gonadotropin-releasing when: is usually initiated Treatment No treatment No Pregnancy is usually uncomplicated. (bimanual pelvic and abdominal exams): Fibroids are Fibroids exams): pelvic and abdominal exam (bimanual Physical magnetic resonance imag- by x-ray, Sonography (may also be visualized and D&C can be done to hysteroscopy, endometrial biopsy, ECC, Pap, Secondary dysmenorrhea. Pain: pressure: Pelvic Infertility. in > 50% of cases. in > Asymptomatic Bleeding IAGNOSIS YMPTOMS REATMENT T D S NOTES HIGH-YIELD FACTS HIGH-YIELD Differential Diagnoses Differential

268 CHAPTER 24 Cervical Dysplasia

Cervical Dysplasia 270 Risk Factors for Cervical Dysplasia and Cervical Cancer 270 Human Papillomavirus 270 Squamocolumnar Junction 271 Pap Smear 271 Colposcopy with Cervical Biopsy 273 Cone Biopsy and LEEP 274 Cryotherapy 275 Laser Therapy 275 Prevention of Cervical Dysplasia 275 GARDASIL 275

CERVARIX 276

269 CERVICAL DYSPLASIA

Cervical dysplasia describes abnormal cells of the cervix that can be precursors to cancer. Papanicolaou (Pap) smears are performed regularly to assess for cervical dysplasia. Further workup and treatments include colposcopy, cone biopsy, and the loop electrosurgical excision procedure (LEEP) as well as cryotherapy or laser therapy. Approximately 80% of cervical dysplasia is related to human papillomavirus (HPV) infection, and a new vaccine against this virus Squamous cell carcinoma of can be offered to young women. the cervix is nonexistent in Cervical dysplasia and cervical cancer lie on a continuum of conditions. Cer- women who have had no vical dysplasia can take one of three paths: sexual contact. 1. Progress to cancer. 2. Remain the same and not progress. 3. Regress to normal.

RISK FACTORS FOR CERVICAL DYSPLASIA AND CERVICAL CANCER

Human papillomavirus (HPV) infection: Eighty percent of cases. Risk highest if infected > 6 months. Types 16, 18, 31, 33, 45––high oncogenic potential.

HIGH-YIELD FACTS HIGH-YIELD ↑ sexual activity (↑ risk of viral/bacterial infections): Multiple sexual partners. Intercourse at early age (< 17 yr). Low socioeconomic status. Genetic predisposition. HPV typical associations: Cigarette smoking (cocarcinogen substances). Types 6 and 11: Alcohol, 2–4 drinks/wk, can ↑ sexual behavior which leads to HPV infec- Anogenital warts tion. ↓ Types 16 and 18: Oral contraceptives (OCPs), particularly with use > 5 yr (condoms Cancer risk in these women). Young women whose mothers took diethylstilbestrol (DES) during pregnancy. Immunodeﬁ ciency. Cervical Dysplasia HUMAN PAPILLOMAVIRUS (HPV) Risk factors for cervical dysplasia— HPV is a sexually transmitted infection. Infection can occur through infected intact skin, mucous membranes, or bodily ﬂ uids from an infected OSHA Ends Dirt, Garbage, partner. and Chemicals: Abstinence, condoms, and decreasing the number of sexual partners Oral contraceptives can lower the risk of contracting HPV. Sex Most HPV infections are subclinical (asymptomatic), but many can HPV manifest by causing cervical abnormalities, such as cervical intraepithe- Alcohol lial lesions (I, II, and III). Education/poverty There are more than 100 genotypes of HPV. Diethylstilbestrol (DES) HPV types 16 and 18 cause 70% of cervical cancers. Genetics Cigarettes

270 Columnar epithelium

SquamousSCJ Ectropion Transformation zone

FIGURE 24-1. Sites of cervical cancers.

SQUAMOCOLUMNAR JUNCTION (SCJ)

Located on the cervix, this is the border between the squamous lining of the vagina and the columnar cells of the uterus. Most cervical cancers arise at this site. Cervical dysplasia almost HIGH-YIELD FACTS Position is variable (see Figure 24-1). always occurs at the TZ or In nulliparous women, it is usually located at the external cervical os. SC J. In pregnancy, it migrates out and is visible to the naked eye. The area near the ectocervix where, columnar cells undergo metaplasia and become squamous cells, is referred to as the transformation zone (TZ). The TZ is the area between the columnar and squamous epithelium. The TZ must be biopsied to rule out cancer or precancer.

PAP SMEAR The adolescent cervix is more susceptible to carcinogenic stimuli.

A 21-year-old G2P2 female desires contraception. She has been sexually Cervical Dysplasia active for 4 yrs, with three lifetime partners. Her monthly menses are irregular. Before prescribing oral contraceptive pills, what tests need to be performed? Answer: A pregnancy test, then a Pap smear.

A cytologic screening test for cervical neoplasia.

TECHNIQUE A speculum is placed in the vagina to expose the uterine cervix (no digital exams or lubricants in the vagina prior to the Pap). Cells are scraped from the ectocervix with a spatula, then from the endocervix using an endocervical brush. The cells are smeared on a glass slide, ﬁ xative spray is applied, and the cells are examined. New technique: Cervix is scraped and swabbed as above, but the sample is placed in liquid medium (thin prep).

SUCCESS RATE ↓ incidence and mortality rate of invasive cervical cancer by 90%. Eighty percent sensitivity. Ninety percent speciﬁ city.

271 SCREENING GUIDELINES According to the American College of Obstetricians and Gynecologists (ACOG) recommendations released December 2009: Routine annual screening Pap tests should begin at age 21; women be- Two things to remember tween the ages of 21 and 29 should receive screening Pap tests every 2 yr. about a Pap smear: If three consecutive Pap smears and pelvic exams 1 yr apart are normal 1. It is a screening tool. in women > 30 yr who have no risk factors, the screening interval can 2. It provides cytologic be lengthened to every 3 yr. information, not Lengthening of interval is not recommended if the patient or her sexual histologic. partner has more than one other sexual partner, or a history of a recent abnormal Pap smear. A pelvic examination should be performed yearly.

MICROSCOPIC ANALYSIS Cytologic analysis of cells taken from a Pap smear will indicate cervical dysplasia if there is: Clumping of chromatin. ↓ cytoplasm resulting in a higher nucleus-to-cytoplasm ratio.

CLASSIFICATION OF ABNORMALITIES Remember, Pap smear gives information about cervical cytology. Two different systems exist that describe the possible ﬁ ndings of a Pap smear:

HIGH-YIELD FACTS HIGH-YIELD 1. Modern classiﬁ cation system (cervical intraepithelial neoplasia An abnormal screening test [CIN]): Describes the degree of abnormality of the cells. (pap smear) needs a 2. Bethesda staging system (squamous intraepithelial lesion [SIL]) diagnostic test for describes three things: conﬁ rmation (colposcopy, The adequacy of the Pap test performed. biopsies). The degree of abnormality. A description of the cells. Table 24-1 correlates the Bethesda staging with the CIN staging. All the terms are possible results of a Pap smear.

FINDINGS AND WORKUP Atypical squamous cells of undetermined signiﬁ cance (ASCUS): Three options: Adolescents should not 1. Repeat Pap every 6 months until two consecutive negative smears. Cervical Dysplasia receive a Pap smear until 2. Perform colposcopy. 3. Perform HPV testing. If positive, will need to proceed with age 21, regardless of colposcopy. sexual activity. Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H): Colposcopy with indicated biopsy. Atypical glandular cells of undetermined signiﬁ cance (AGUS): Col- poscopy and endometrial sampling + endocervical curettage (ECC). Low-grade squamous intraepithelial lesion (LGSIL): Colposcopy with (ECC) and biopsies. High-grade squamous intraepithelial lesion (HGSIL): Colposcopy with ECC and biopsies. If there is a discrepancy between the cytology and the biopsy, then an excisional procedure should be performed (LEEP-loop electrosurgical excision procedure or cold knife conization- CKC). Very complex, many algorithms. Protocols available online at www.as- ccp.org.

272 TABLE 24-1. Modern Classiﬁ cation System vs. Bethesda Staging System

MODERN CLASSIFICATION SYSTEM (CIN) BETHESDA STAGING

Squamous Normal Normal lesions Benign cellular changes

Atypical cells, possible inﬂ ammatory Reactive cellular changes ASCUS

CIN I—mild dysplasia: Neoplastic cells conﬁ ned to lower one-third of LSIL epithelium (60% spontaneously regress)

CIN II—moderate dysplasia: Involvement of two-thirds of epithelium ASC-H

(43% regress) HSIL HIGH-YIELD FACTS

CIN III—severe dysplasia (carcinoma in situ): Involvement up to the HSIL basement membrane of the epithelium (33% regress, 12% advance to invasive cancer)

Squamous cell carcinoma Squamous cell carcinoma

Glandular Atypical glandular cells AGUS lesions Atypical glandular cells favor neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma Cervical Dysplasia

AGUS, atypical glandular cells of undetermined signiﬁ cance; ASC-H, Atypical squamous cells, cannot exclude HSIL; ASCUS, atypical squamous cells of undetermined signiﬁ cance; CIN, cervical intraepithelial neoplasia; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion.

FOLLOW-UP All treatment methods have a ﬁ rst-time success approaching 95%. A Pap smear should be performed every 4–6 months after treatment for at least 12 months. If any Pap smear returns abnormal, a coloscopy should be performed.

COLPOSCOPY WITH CERVICAL BIOPSY

Both colposcopy and A 45-year-old G4P4 African-American female’s Pap smear returns with a biopsies are needed for a report of ASCUS. Her Pap smears have always been normal in the past. histologic diagnosis. What is the next best step to evaluate her cancer risk? Answer: HPV DNA testing. If HPV DNA testing is “positive,” indicating the presence of high-risk HPV DNA, then a colposcopy and biopsy should be performed.

273 DEFINITION A procedure that utilizes staining and a low-magniﬁ cation microscope, mounted on a stand, for the viewing of the cervix, vagina, and vulva. Provides illuminated, magniﬁ ed view, which aids in identifying lesions On biopsy, 5–17% of cases and biopsying suspicious areas to obtain histologic diagnosis. of ASCUS and 24–94% of INDICATIONS FOR A COLPOSCOPY ASC-H demonstrate CIN II–III. Done after any abnormal Pap smear! Except with ASCUS, you have the option of repeating a Pap instead. ASCUS with high-risk HPV subtypes. ASC-H. Atypical glandular cells. LGSIL. HGSIL.

PROCEDURE 1. Speculum is inserted for visualization of the cervix and the Pap smear is repeated. 2. Acetic acid is applied. After 30 sec, the acetic acid dehydrates cells and causes precipitation of nucleic proteins in the superfi cial layers. The neoplastic cells appear whiter because of a higher nucleus/cytoplasm ratio. Ninety percent of women 3. Colposcopy: Then a low-power microscope (colposcope) is used to look with abnormal cytologic for dysplasia. Signs of dysplasia include whiteness and abnormal vessels. HIGH-YIELD FACTS HIGH-YIELD fi ndings can be adequately The transformation zone must be visualized in its entirety. If the TZ or the evaluated with colposcopy. entire extent of the lesion is not entirely visualized, then the colposcopy is considered inadequate. 4. Cervical biopsy: Neoplastic and dysplastic areas are then biopsied under colposcopic guidance. Contraindications include acute pelvic infl ammatory disease (PID) and cervicitis. Pregnancy is not a contraindication. 5. ECC: A curette is used to scrape the cervical canal to obtain endocervical cells for cytologic examination. An ECC is contraindicated in pregnancy.

What must be completely INFORMATION PROVIDED BY COLPOSCOPY AND ECC visualized for adequate If biopsy results or ECC is positive for CIN II or III, then a cone biopsy or a colposcopic evaluation? LEEP should be performed for further diagnosis or treatment. 1. TZ. 2. Extent of lesion in its

Cervical Dysplasia entirety. CONE BIOPSY AND LEEP

Cold knife cone biopsy: A procedure performed in the operating room in which a cone-shaped biopsy is removed with a scalpel, including part of the endocervical canal. Requires use of general anesthesia. Done less often now. LEEP: A procedure performed in an ofﬁ ce setting or in an operating room. A small wire loop with an electric current is used to excise the TZ and the endocervix. This is the cone biopsy specimen. Local anesthesia/analgesia is required.

INDICATIONS FOR CONE BIOPSY/LEEP Inadequate view of TZ on colposcopy. Positive ECC. ≥ 2 grade discrepancy between colposcopic biopsy and Pap.

274 Treatment for with CIN 1–III, and CIS (carcinoma in situ). Treatment for adenocarcinoma-in-situ. When cancer cannot be excluded after colposcopy, biopsy, and ECC.

LEEP Evaluation of biopsy LEEP can also be used to diagnose and treat CIN. margins may be difﬁ cult with LEEP, because of GUIDELINES FOR LEEP TREATMENT thermal artifact. Never treat during pregnancy. Never treat without excluding invasive carcinoma. When treating, excise entire TZ. Always excise keratinizing lesions.

CRYOTHERAPY HIGH-YIELD FACTS

An outpatient procedure that uses a probe cooled with nitrous oxide (N2O to −70°F) to ablate lesions.

INDICATIONS Treatment of LSIL or HSIL only if it is a lesion completely visualized on colposcopic exam.

COMPLICATIONS AND SIDE EFFECTS Profuse, watery, vaginal discharge and failure of therapy for HSIL. Long-term complications include cervical stenosis and a small ↑ in preterm labor.

LASER THERAPY Cervical Dysplasia

Light ampliﬁ cation by stimulated emission of radiation (LASER): A high-energy photon beam generates heat at impact and vaporizes tissue. Causes less tissue destruction of the TZ compared to other methods. Very expensive.

INDICATIONS Excision or ablation of CIN.

PREVENTION OF CERVICAL DYSPLASIA

Gardasil Licensed in 2006 by the FDA as the ﬁ rst quadrivalent HPV vaccine. Administered as three doses: 0.5 mL intramuscularly given at intervals of 0, 2, and 6 months. Contains virus-like particles from four HPV genotypes: 6, 11, 16, and 18.

275 Cervarix Licensed in 2010 by the FDA, as the ﬁ rst bivalent HPV vaccine. Administered in three doses: .5 ml intramuscularly given at intervals of 0, 1, and 6 months. Contains virus-like particles from two HPV genotypes: 16 and 18.

SUCCESS RATE What HPV genotypes are Gardasil: Protects against 70% of cervical cancers and 90% of genital warts. Cervarix: Protects against 75% of cervical cancers caused from types 16 and 18. contained in the Gardasil vaccine? INDICATIONS Answer: Types 6, 11, 16, 18 Gardasil: Give to females age 9–26 yr; Cervarix: Give to females 10–25 yr. Routinely given at age 11–12. Pregnancy Class B; not recommended for pregnant women. Can be given to breast-feeding women. Efﬁ cacy for previously exposed individuals has not been established.

SIDE EFFECTS Pain Redness Allergic reaction HIGH-YIELD FACTS HIGH-YIELD FOLLOW-UP Routine cervical cancer screening still necessary. The need for booster dose at 5 yr has not been established. Cervical Dysplasia

276 CHAPTER 25 Cervical Cancer

Epidemiology 278 Symptoms 278 Differential Diagnosis 278 Types of Cervical Cancer 279 SQUAMOUS CELL CANCER 279

ADENOCARCINOMA 279

MESTASIS OF CERVICAL CANCER 279 Clinical Staging of Invasive Cervical Cancer 279 Treatment of Invasive Cervical Cancer 281 Treatment of Bulky Central Pelvic Disease 281 Follow-up of Cervical Carcinoma 282 Recurrent Cervical Carcinoma 282 Cervical Cancer in Pregnancy 283 Adenocarcinoma of Cervix 284

277 Cervical Cancer HIGH-YIELD FACTS moderate size. lesionsareof when cervical cancer becomeevident Symptoms ofcervical R A erations, butoverallhavesimilar survivalratesasnonpregnantpatients. ofdisease.on thestage Women diagnosed whilepregnantfaceunique consid- clinically,sure. Cervicalcancerisstaged, notsurgically. Treatment depends comprise 20%andcanberelatedtomaternaldiethylstilbestrol (DES)expo- are relatedtohumanpa pillomavirus (HPV)infectionwhileadenocarcinomas tract. Eightypercentofcervicalcancersaresquamous cellcarcinomas. They Cervical canceristhethirdmostfrequent malignancyofthefemalegenital 278 SYMPTOMS EPIDEMIOLOGY DIFFERENTIAL DIAGNOSIS DIFFERENTIAL ACE GE A P Avne stages: Advanced stages: Middle Early stages: rateistwotimesgreaterthanwhites. African-Americanmortality More prevalentinAfrican-American womenandurbanHispanic ofwomendiagnosed Increasingpercentage beforeage20(perhapsdue Fifteenpercentofwomendevelopitbeforeage30. Peak incidence betweenages45and55. Infections. Tuberculosis, syphiliticchancres,and granuloma inguinalecanalso Vaginal malignancies. Papillary endocervicitis/papillomas/infl Polyps, nabothian cysts. FFECTED women thanwhitewomen. to earlyscreening orchangesinsexualpatterns). cause cervicallesions. REVALENCE Weight loss,lossofappetite. Dysuria/hematuria. Postvoid bleeding. Postcoital bleeding (brownish discharge). Irregular/prolongedvaginalbleeding/pink discharge. None. Legswelling(secondarytoblockage oflymphatics). Severepain,duetospread sacralplexus. Bloody, malodorousdischarge. some painduringintercourse.What isthenextstep? A 50-year-old G3P3womanfeelswell,butnoticespostcoitalbleedingand Answer: SpeculumexamwithaPap smearorbiopsyifalesionisvisible. ammation. HIGH-YIELD FACTS Cervical Cancer ye steak ectal ladder ndometrial ntra-abdominal Cervical cancer is staged clinically. Adenocarcinoma of the cervix is relatively resistant to radio- and chemotherapy compared to squamous cell carcinoma. Metastasis of cervical cancer to: RIB E R I B E In keratinizing type of In keratinizing cells create cervical cancer, with foci of keratinization ed “pearls” that can cornifi be visible. Small-cell carcinoma: Small, round, or spindle-shaped ned cell with poorly defi borders. tumor-stromal 279 Well-demarcated tumor-stromal borders. Well-demarcated of all invasive cervical cancers. 10–20% of all invasive cervical A 55-year-old G1P1 female presents to clinic with a complaint of A 55-year-old smear and follow-up colposcopy patient’s Pap postcoital bleeding. The rm a diagnosis of squamous cell cervical carcinoma. with biopsy confi ladder. ndometrial. ectal. ntra-abdominal. 80%. fi ned tumor borders. fi Breast. Lung. Bone. Liver. Answer: A computed tomography (CT) scan of the abdomen/pelvis and a R I B E with maternal DES exposure. May be associated Accounts for Accounts canal and glands. the endocervical columnar cells lining Arises from smear is rate with Pap cult; the false-negative is diffi Early diagnosis Keratinizing. Nonkeratinizing: poorly de- round spindle shape cells with small Small cell carcinoma: of cervical cancer. for 80–85% Accounts with HPV infection. Associated What is the next best step in staging is the What cancer? this patient’s cervical is done prior to the chest x-ray to evaluate for metastases to lymph nodes. This clinical staging of the cancer. CLINICAL STAGING OF INVASIVE CERVICAL CANCER CERVICAL INVASIVE OF STAGING CLINICAL TYPES OF CERVICAL CANCER CERVICAL OF TYPES YPES Clinical stagingClinical of cervical cancer is important for prognosis and treatment 25-1 and 25-2). (see Tables Mestasis of Cervical Cancer A. extension: By direct Adenocarcinoma T Squamous Cell Cancer Squamous B. By hematogenous spread: Cervical Cancer HIGH-YIELD FACTS 280 TABLE 25-1. THE M S S U S S S TAGE TAGE TAGE TAGE TAGE Stage IVB—Spreadofcancertodistantorgans(outsidepelvis). Stage IVA—Spread ofcancertoadjacentpelvicorgans(bladder/rectum). tothepelvicsidewall;hydronephrosis oranonfunctioningkidney. IIIB—Extension extensiontothepelvicsidewall,butinvolveslowerthirdof vagina. IIIA—No involvement. IIB—Parametrial IIA2—Clinically visible lesion >4cm. IIA1—Clinically visible lesion <4cm. parametrialinvolvement. IIA—No IB2—Lesion confi IB1—Lesion confi visiblelesionconfiIB—Clinically ned tothecervixorlesions>IA. IA2— than3mmindepthandnowider7mm. IA1—Invasionofstromanogreater IA—Invasive canceridentifi ed onlymicroscopically. GrosslesionsarestageIB. PPER CS FTHE OF UCOSA V AGINA IV—C III—C II—C I—C 0—C V AGINA no widerthan7mm. than3mmandlessorequalto5indepth,but Invasion ofstromagreater ANCER ; H RIOAIN ARCINOMA ANCER ANCER ANCER , B FIGO Staging, Revised2009 Staging, FIGO DOEHOI RA OR YDRONEPHROSIS B C UT E ADROR LADDER T E NIE OTHE TO ONFINED N XTENDS ned tocervix>4cm. ned tocervixuteri≤4cm. HAT TNE OTHE TO XTENDED TTHE OT H S ITU AS B R L E EYOND (CIN3) OWER XTENDED CU OR ECTUM C U N T P ERVIX TERUS ONFUNCTIONING HIRD ELVIC B B YN THE EYOND O OTH S , B NLY IDEWALL UT N TT THE TO OT T ; T K RUE IDNEY UMOR P ELVIS P I ELVIC VLE THE NVOLVES ; I NVOLVES S IDEWALL E L TE THE ITHER OWER ; I VLE THE NVOLVES T IDOF HIRD HIGH-YIELD FACTS Cervical Cancer Uterus Cervix tissue Parametrial vagina Upper Radical hysterectomy requires removal of: How does cervical cancer spread? Direct extension and lymphatic spread. nodes involved are Lymph external, internal, common iliac, and para-aortic nodes. 281 nitive nitive DENOCARCINOMA A nuclear atypia of solid growth Small component and Mild to moderate pattern Solid predominate Severe nuclear atypia UMOR T High-dose delivery to the cervix and vagina, and High-dose delivery to the cervix and Radical hysterectomy with lymph node dissection. with lymph node dissection. hysterectomy Radical QUAMOUS S NVASIVE I Carcinoma of Cervical Grading cantly larger doses of radiation to surface of cervix. cantly larger doses of radiation TAGING S nifi External-beam whole pelvic radiation. sig- allow applicators intracavitary cesium: Transvaginal Transvaginal minimal dosing to the bladder and rectum: dosing minimal Done only in patients with low-stage disease (IB–IIA). Done only in patients with low-stage disease guided biopsies. inspect pelvis. or computed tomography (CT) with intravenous contrast dye. or computed tomography (CT) with treatment with radiation or radical surgery. or radical treatment with radiation therapy. neoadjuvant radiation hysterectomy with adjuvant or Radical defi cytoreduction: Use of cytotoxic chemotherapy before Tumor Radiation therapy: Radiation Proctoscopy. Radical surgery: Chest x-ray. Chest Liver function tests. CT- Evaluate lymph node enlargements or abnormalities with external and rectal exam (under anesthesia). It is important Pelvic to palpate and ECC, and biopsy. Colposcopy, uterine lining. Hysteroscopy to evaluate the (IVP) intravenous pyelogram tract via cystoscopy, Evaluate genitourinary RADE 23 Moderately differentiated differentiated Poorly 4 Intermediate-grade differentiation Undifferentiated X1 be assessed Cannot differentiated Well G ODES OF TREATMENT OF BULKY CENTRAL PELVIC DISEASE TREATMENT OF INVASIVE CERVICAL OF INVASIVE TREATMENT CANCER M TABLE 25-2. TABLE Cervical Cancer HIGH-YIELD FACTS uremia. cancer patientsinclude Causes ofdeathincervical recurrence. indication ofpelvic swelling isoftenan orunilateralleg nerve distribution ofthesciatic Leg painfollowingthe T tients). Uremia isthemajorcauseofdeathincervicalcancer(found50%pa- C Look for: S 282 REATMENT REIGFOR CREENING RECURRENT CERVICAL CARCINOMA CERVICAL RECURRENT CARCINOMA CERVICAL OF FOLLOW-UP UEOF AUSE Generalprinciples oftreatment: Treatment ofcervicalcancerbystage: Costovertebralangleandfl Sacralbackacheorpaininsciatic distribution. Fistulas(inbladderorbowel). Pelvic andlegpain. Constipation/melena. Hematuria/dysuria. Vaginal bleeding. Recurrenceofcancercanoccur anywhere,butoccurmainlyinthepel- Thirtypercentofpatientstreatedforcervicalcancerwillhavearecur- Achestx-rayandCTscanofabdomenareperformedannually. Anexamconsistsofahistory, physical,andPap. Patients areexamined every3monthsforthefi rst 2yr,thenevery6 Chemotherapy: vis (vagina,cervix,orlateralpelvicwall). rence. months inyr3–5,andyearlythereafter. Response rates:50–70%for4–6monthsoflife. Most combinationsincludeplatinum. Responseratesarehigherwith combinationtherapy. Patients previouslytreatedwithradiotherapy aretreatedonlybyradi- Patients withlocalrecurrenceafterradical hysterectomyaretreated Patients mayundergo defi nitive treatmentonlyifdisease isconfi Excretory urogramcanidentifyperiureteralcompressionbytumor. D to pelvis. cal pelvicsurgery. with 2b–4b: Chemotherapy(cisplatin) andradiation. para-aortic lymphadenectomy. 1a–2a: Radical hysterectomyorradiation, pelviclymphadenectomy, uterus). or cryo(ifpatientwantstoretain dominal hysterectomy (TAH; ifcompletedchildbearing),conization ab- procedure (LEEP)orcoldknife conebiopsy(ectocervix);total 0–1: Laserorcryotherapy(endocervix);loopelectrosurgicalexcision EATH R radiation. ECURRENCE ank pain. ned HIGH-YIELD FACTS Cervical Cancer Radical hysterectomy, Radical hysterectomy, pelvic lymphadenectomy, para-aortic lymphadenectomy and radiation ned to cervix: If confi If beyond cervix: Chemo An ECC (endocervical curretting) is contraindicated in pregnancy. What is the basic treatment What is the basic treatment for invasive cervical cancer? 283 gestational age, tumor stage, and met- uenced by uenced is incompatible with pregnancy continuation. treatment nitive lymphadenectomy after high classic cesarean delivery. stage I disease. be done if the patient has a Stage If the stage IA1 cancer. is > Stage treatment can be instituted. IA2, then after delivery, for fetal prolongation of pregnancy apies, which would allow matu- severe during pregnancy can lead to conization A cold knife rity. complications such as hemorrhage and loss of pregnancy. hysterectomy and pelvic Third-trimester treatments include radical Delays in treatment have not been reported to ↑ recurrence rates in can conization) CKC (cold-knife early-stage a diagnostic In disease chemother- Second-trimester treatments can include platinum-based evaluation. If the patient chooses to continue the pregnancy, ther- the pregnancy, astatic continue evaluation. If the patient chooses to or the pregnancy can be ter- apy can be postponed until after delivery treatment. Radiation to begin A pregnancy can be terminated minated. only chemotherapy. cannot be given during pregnancy, should replace CT scans. partum visit. is reserved for patients in whom an invasive lesion is sus- tic conization rmed by biopsy and the results will alter the pected but cannot be confi is performed postpar- Otherwise, conization or mode of delivery. timing second tri- should be performed in the if necessary, tum. Cone biopsy, and pre- hemorrhage Complications are common including mester. term labor. nant patient, although colposcopy may be deferred until 6 weeks post- colposcopy may be deferred nant patient, although partum. (HG- intraepithelial lesion high-grade squamous lial lesion (ASC-H), colposcopy with bi- require glandular cells (AGCs) SIL), and atypical opsy (endocervical curettage [ECC] contraindicated). > 21 years old). Defi staging Clinical except magnetic resonance imaging (MRI) unchanged, at 6-week post- If antepartum colposcopy is negative, repeat colposcopy Diagnos- during pregnancy. is contraindicated Therapeutic conization old managed as in nonpreg- and LGSIL in patients > 21 years ASCUS intraepithe- high-grade squamous cells with possible Atypical squamous are asymptomatic. cervical cancer patients with of pregnant One-third and discharge. in pregnancy include vaginal bleeding Symptoms obstetric visit (if performed at the initial Cervical cytology should be Therapy should be infl CERVICAL CANCER IN PREGNANCY CANCER CERVICAL CREENING YMPTOMS REATMENT T S S Three percent of all invasive cervical cancers occur during pregnancy. cervical cancers of all invasive Three percent Cervical Cancer HIGH-YIELD FACTS breast cancer. 1.35% during pregnancyhavea Women whotookDES ↑ relative riskof D T S cer diagnosed inpregnancycomparedtononpregnantpatients. suggestsnodifferenceinprognosisofpatientswithcervicalcan- Limited data P D 284 REATMENT REIGOF CREENING ADENOCARCINOMA OF CERVIX ROGNOSIS ISEASE ELIVERY PatientsIA1cancer,require with>Stage acesareansectionfordelivery, Episiotomies shouldbeavoided duetocasereportsofcancerimplanta- PatientsIAtumors maybecandidates withsmall-volumestage forvaginal common;yearly Pulmonary andsupraclavicularnodalmetastasis MostDES-relatedclearcellcarcinomas recurafter≤3yrofinitial treat- Vaginectomy ifvaginaisinvolved. Preferredtreatmentisradical hysterectomyandpelviclymphnodedis- Similar totreatmentofsquamous cellcarcinoma ofcervix. Carefulpalpationofvaginalwallstoruleoutadenosisormasses. Annual Pap smear. Idisease: Five-yearsurvivalrateforstage >90%. Overallsurvivalrate:80%. Carcinomas mainlyarisefromtheendocervix;lesionsare“endophytic.” Affectswomenaged16–27;median age—19yr. Makesup10–15%ofcervicalcancers. Consideration of possibletumorhemorrhageandsize/shapeinfl and thentreatment. tion atsuchsites. delivery. screening chestx-rayrecommended. ment. IBorIIA. section forstage delivery method. R ECURRENCE DES-E XPOSED W OMEN uence CHAPTER 26 Endometrial Hyperplasia and Endometrial Cancer

Endometrial Hyperplasia 286 Epidemiology of Endometrial Cancer 286 Clinical Presentation 287 Differential Diagnosis of Postmenopausal Bleeding 287 Additional Workup for Endometrial Cancer 288 HISTOLOGIC SUBTYPES 288 Staging of Endometrial Cancer 288 Grading 289 Treatment 289 Uterine Sarcoma 290

285 ENDOMETRIAL HYPERPLASIA

A precancerous condition. Types include: Simple (cystic hyperplasia without atypia): An endometrial thickness of Glandular and stromal proliferation. < 5 mm in a One percent progress to cancer (most well differentiated). postmenopausal woman Complex (adenomatous hyperplasia without atypia): with vaginal bleeding has a Only glandular proliferation of the endometrium. negative predictive value of Three percent progress to cancer. 99% for endometrial Atypical: cancer. Simple atypical (10% progress to cancer). Complex atypical (29% progress to cancer). Proliferation with cytologic atypia.

DIAGNOSIS OF ENDOMETRIAL HYPERPLASIA Endometrial biopsy (gold standard). Atypical hyperplasia is Pap smear: If endometrial cells are found on a pap suspect endometrial pa- more likely to progress to thology. cancer in older women Other procedures might pick it up: compared with younger Endocervical curettage (ECC). Transvaginal ultrasound to evaluate the endometrial stripe in a post- women. menopausal woman. Hysterocopy with uterine curettage if endometrial biopsy is inadequate. HIGH-YIELD FACTS HIGH-YIELD

TREATMENT Women with Lynch syndrome (hereditary Simple hyperplasia with abnormal bleeding: Cyclical progestin therapy. nonpolyposis colorectal Complex hyperplasia or simple atypical hyperplasia: Cyclical or continuous progestin therapy (or hysterectomy if uterine preservation is not desired). cancer, or HNPCC) have a Complex atypical hyperplasia: Continuous high-dose progestin therapy 40–60% lifetime risk of if uterine preservation is desired; hysterectomy if uterine preservation is developing endometrial not desired. cancer, which is equal to their risk of developing colorectal cancer. EPIDEMIOLOGY OF ENDOMETRIAL CANCER

Endometrial carcinoma is a malignancy arising from the lining of the Any factor that lowers the uterus. It is the most common gynecologic malignancy in the United States, level or time of exposure to and is diagnosed in over 35,000 women annually. It is 1.3 times more estrogen ↓ the risk of

Endometrial Hyperplasia & Cancer common than ovarian cancer and twice as common as cervical cancer. endometrial cancer. Because endometrial cancer usually presents with obvious symptoms, it is most often diagnosed at an early stage. Lifetime risk is 3%. Age at diagnosis: < 40 yr: 5% 40–50 yr: 15% Side effects of > 50 yr: 80% progestins: Two types: Weight gain Type I (most common): An estrogen-dependent neoplasm that be- Edema gins as proliferation of normal tissue. Over time, chronic proliferation Thrombophlebitis becomes hyperplasia (abnormal tissue) and, eventually, neoplasia. Type II: Unrelated to estrogen or hyperplasia. Tends to present with Headache higher-grade or more aggressive tumors. Hypertension

286 CLINICAL PRESENTATION

Endometrial cancer is the A 55-year-old G0P0 woman presents with a 2-month history of intermittent most common gynecologic vaginal bleeding. She completed menopause 3 yr ago. She is obese and cancer. she has never been pregnant. What is the most likely diagnosis? Answer: Endometrial cancer.

Abnormal bleeding is present in 90% of cases: Bleeding in postmenopausal women (classic). Meno/metrorrhagia (in premenopausal cases). Abnormal Pap smear: 1–5% of cases. Pap smears are not diagnostic, but a ﬁ nding of abnormal glandular cells of unknown signiﬁ cance (AG- CUS) warrants further investigation. HIGH-YIELD FACTS DIFFERENTIAL DIAGNOSIS OF POSTMENOPAUSAL BLEEDING

A 59-year-old G2P2 postmenopausal woman comes in with 2 months of spotting in her underwear. She says that the bleeding is minimal but still requires wearing pads occasionally. She has no pain and still has regular sexual intercourse. She weighs 300 pounds. She is single and has no children. What is the next step? Answer: Endometrial biopsy. The most likely diagnosis is endometrial cancer.

Her risk factors are nulliparity, obesity, and prolonged estrogen exposure. Endometrial Hyperplasia & Cancer A postmenopausal woman

DIFFERENTIAL DIAGNOSES has bleeding. What is next step? Endometrial biopsy. Exogenous estrogens. Atrophic endometritis/vaginitis. Endometrial cancer. Endometrial/cervical polyps. Coagulopathy. Endometrial hyperplasia.

RISK FACTORS Endogenous unopposed estrogen (ie, polycystic ovarian syndrome [PCOS]). Estrogen-producing tumors (ie, granulosa cell tumors). Liver disease (a healthy liver metabolizes estrogen). Previous radiation (↑ sarcomas). Obesity (2–5 times ↑ risk). Early menarche/late menopause. Nulliparity (2–3 times ↑ risk; most likely when associated with anovulation). PCOS (chronic unopposed estrogen stimulation). Diabetes mellitus (2.8 times risk). Any factor that raises the Hypertension. level or time of exposure to Endometrial hyperplasia (highest risk is with complex atypia). estrogen increase the risk Tamoxifen treatment for breast cancer (2–3 times ↑ risk). for endometrial cancer.

287 Unopposed estrogen stimulation (eg, menopausal estrogen replacement: 4–8 times ↑ risk). Familial predisposition. Caucasian race.

PROTECTIVE FACTORS Regular ovulation. Combined oral contraceptives. Cigarette smoking. Multiparity.

DIAGNOSIS FOR POSTMENOPAUSAL BLEEDING Endometrial biopsy. D&C hysteroscopy, if endometrial biopsy, is inadequate.

ADDITIONAL WORKUP FOR ENDOMETRIAL CANCER

After diagnosis of endometrial cancer is made, the following should be performed to evaluate for possible metastasis: Physical exam. Pathology of the endometrial biopsy of D&C specimen. HIGH-YIELD FACTS HIGH-YIELD Chest x-ray. Complete metabolic panel, cbc, type and screen. Abdominal and pelvic computed tomography (CT).

Histologic Subtypes Endometrioid (ciliated adenocarcinoma): 75–80%. Hyperplasia without atypia Papillary serous: 5–10%: has the lowest risk of Poor prognosis. progressing to cancer, and No history of elevated estrogen. hyperplasia with atypia has More common in blacks. the highest risk. Acts like ovarian cancer. Typically presents in late stage (stage IV). Clear cell: < 5%. Poor prognosis. Sarcomas (covered below). Poorly differentiated carcinomas (Poor prognosis). Endometrial Hyperplasia & Cancer STAGING OF ENDOMETRIAL CANCER

Endometrial cancer is staged surgically. Surgical staging is both The stage of an endometrial cancer is determined by: diagnostic and therapeutic. 1. The spread of tumor in the uterus. 2. The degree of myometrial invasion. 3. The presence of extrauterine tumor spread. This assessment is accomplished through a surgical staging operation (similar to ovarian cancer). The staging of a patient’s disease directs treatment and predicts outcome (see Table 26-1).

288 TABLE 26-1. Staging of Endometrial Cancer FIGO Revised 2009

STAGE DESCRIPTION

*I: Tumor conﬁ ned to the uterus IA: No or less than half of myometrium IB: Invasion equal to or more than half of the myometrium

*II: Tumor invades cervical stroma, but does not extend beyond uterus**

*III: Local and/or regional spread IIIA: Invasion of uterine serosa and/or of the tumor adnexa IIIB: Invasion of vagina and/or parametrial involvement

IIIC: Mets to pelvic/para-aortic lymph HIGH-YIELD FACTS nodes IIIC1: Positive pelvic nodes IIIC2: Positive para-aortic lymph nodes with or without positive pelvic lymph nodes

*IV: Tumor invades bladder and/ IVA: Invasion of bladder and/or bowel or bowel mucosa, and/or distant mucosa mets IVB: Distant invasion, including intra-abdominal mets and/or inguinal Endometrial Hyperplasia & Cancer lymph nodes

* Endocervical gland involvement is Stage I. ** Positive peritoneal cytology does not change the stage and is reported separately.

GRADING

Grading is determined by the tumor histology: Grade is the most important G1 Well differentiated < 5% solid pattern prognostic indicator in G2 Moderately differentiated 5–50% solid pattern endometrial cancer. G3 Poorly differentiated > 50% solid pattern

TREATMENT

Basic treatment for all stages (surgical staging is always the ﬁ rst step): Total abdominal hysterectomy (TAH). Grade 3 tumors usually do Bilateral salpingo-oophorectomy (BSO). not have steroid hormone Pelvic and para-aortic lymphadenectomy. receptors, whereas grade 1 Peritoneal washings for cytology (“loose or free cancer cells”). tumors usually do.

289 ADJUVANT THERAPY After the above steps in treatment, adjuvant therapy depends on the stage. Stages I–II Adjuvant radiation therapy (includes internal and external radiation). Stages III–IV External beam radiation Hormone therapy: Progestin therapy is often used as adjuvant hormonal therapy: Side effects: If the cancer is progesterone receptor positive—70% Doxorubicin: have a 5-yr survival. Cardiotoxicity If the cancer is progesterone receptor negative—15–20% have a 5-yr survival. Cisplatin: Nephrotoxicity Adjuvant chemotherapy: Doxorubicin Cisplatin Carboplatin and paclitaxel (Taxol)

UTERINE SARCOMA

A 53-year-old G1P1 postmenopausal woman presents with complaints of vaginal bleeding and pelvic pain. For the past 3 months, she has noticed that her abdomen has enlarged rapidly. What is the most likely HIGH-YIELD FACTS HIGH-YIELD diagnosis? Answer: Leiomyosarcoma.

Uterine sarcoma is classifi ed separately from endometrial cancer: < 5% of uterine malignancies (a rare cancer). Presents as a rapidly enlarging mass with bleeding. < 1% of fi broids progress to cancer. Poor prognosis. Risk factors are similar. Most cases are diagnosed with exploratory surgery for what was thought to be a uterine myoma (fi broid).

TYPES A. Homologous (mesenchymal tissue that normally forms in the uterus). B. Heterologous (foreign tissue to the uterus). Endometrial Hyperplasia & Cancer Leiomyosarcoma (LMS): Homologous. One-third of uterine sarcomas. Presents with rapidly growing pelvic mass +/– pain or vaginal bleeding. Endometrial stromal sarcoma (ESS): Homologous. Ten percent of uterine sarcomas. Low-grade, indolent course. Peak incidence in ﬁ fth decade. Tumors contain estrogen and progesterone receptors which are sensitive to hormone therapy.

290 Carcinosarcoma (malignant mixed müllerian tumors): Heterologous. Usually found in older patients (> 60). Presents with postmenopausal bleeding and large uterus. Undifferentiated sarcomas: High-grade, aggressive tumors with poor prognosis.

DIAGNOSIS > 10 mitosis/10 high-powered ﬁ elds with cytologic atypia. Usually diagnosed from specimen sent after hysterectomy. Staged just like endometrial cancer.

TREATMENT Surgical (TAH/BSO, +/– lymphadenectomy, and peritoneal washings). Adjuvant therapy (chemotherapy) may decrease recurrence. Radiation may enhance local control after surgery. Unknown survival beneﬁ t. HIGH-YIELD FACTS Multiagent chemotherapy is prescribed for metastatic sarcomas. Com- plete responses are rare. Endometrial Hyperplasia & Cancer

291 NOTES HIGH-YIELD FACTS HIGH-YIELD Endometrial Hyperplasia & Cancer

292 CHAPTER 27 Ovarian Cancer and Fallopian Tube Cancer

Epidemiology 294 Epithelial Cell Ovarian Cancer 294 Hereditary Ovarian Cancer Syndromes 295 Ovarian Cancer Workup 296 Screening Recommendations 296 Staging 296 Nonepithelial Ovarian Cancer 297 OVARIAN GERM CELL TUMORS 298

OVARIAN SEX-CORD STROMAL TUMORS 300 Fallopian Tube Carcinoma 300

293 Ovarian & Fallopian Tube Cancer HIGH-YIELD FACTS peritoneal fl uid. cancerous cellsintothe spreads byexfoliationof Ovarian cancertypically for ovariancancer. ascites. Itispathognomonic mass whenassociatedwith pelvic andupperabdominal Omental cakingisafi xed all ovariancancers. cancer accountsfor85%of Epithelial cellovarian diagnosed atstageIIIorIV. ovarian cancerare Seventy percentofcases gynecologic cancer. second mostcommon dissemination. Itisthe to detectbefore cancer becauseitisdiffi cult deadliest gynecologic Ovarian canceristhe stage. stage. gynecologic malignancybecauseitismostoftendiagnosed atanadvanced ian cancerareepithelialandnonepithelial.Ovarianisthemostdeadly or thecellsofovaryitself.Assuch,twobasichistologicaltypesovar- Ovarian cancerisamalignancyarisingfromtheepitheliallining oftheovary 294 Six subtypesarisingfromepithelialtissue: H The majorityofovariancancersareepithelial. EPITHELIAL CELL OVARIAN CANCER CELL EPITHELIAL EPIDEMIOLOGY ISTOLOGIC CA-125. Defi nitive diagnosis:biopsy/surgery. and paclitaxel.The patientwillgetserialCA-125 levelsonfollow-upexaminations. omentectomy,oophorectomy (BSO), andthenchemotherapywithcarboplatinum be inmanagement? seems tobeeatingless.What isthesuspecteddiagnosis? today isnegative.Shedoesn’tunderstandwhyherpantsaretoosmallwhenshe vomiting. Shestatesthatshehasneverbeenpregnant,andherpregnancytest Median ageatdiagnosis is63yr. Lifetimeriskis1in70. SeventypercentofpatientsarediagnosedIIIorIV. asstage Thedeadliestgynecologicmalignancy. Fifthmostcommoncancerforwomen. Secondmostcommongynecologicmalignancy. Undifferentiated: 5% Brenner: 4% Clear cell:6% Endometrioid: 10% Mucinous: 25% Serous: 50% Answer: Total abdominalhysterectomy(TAH) withbilateralsalpingo- Answer: have 6cmbilateralovarianmassesandascites.What wouldthenextstep presented withabdominalbloating.Onpelvicultrasoundsheisfoundto A 61-year-old G2P2femaleisdiagnosedwithovariancanceraftershe bleeding,nausea,or ofbreathevenatrest. Shedeniesvaginal shortness increasing waistsizeandabloatingsensation.Shecomplainsofoccasional A 65-year-oldG0whitefemalepresentswitha4-monthhistoryof S UBTYPES Ovarian cancer. ultrasoundand Initialstepsindiagnosis:transvaginal HIGH-YIELD FACTS Ovarian & Fallopian Tube Cancer In a postmenopausal woman with a pelvic mass, CA-125 is much more c for ovarian cancer specifi compared to a premenopausal woman. Ovarian cancer spread is normally through the uid, which peritoneal fl carries cancer cells to other abdominal structures. Ovarian cancer metastasis to the umbilicus is “Sister nodule.” This Mary Joseph’s is a palpable nodule. More than 5 yrs of OCP use More than 5 cancer by ↓ risk of ovarian 25–50%. This protection lasts 15 yrs after discontinuation. The serous type of epithelial ovarian cancer is the most common type of ovarian cancer and is bilateral 65% of the time. 295 ACTORS YMPTOMS F EMINDER S to treatment. R conditions. premenopausal medical It may be elevated in many tool. It is not effective as a screening in 80% of cases. A tumor marker that is elevated and the response the disease It is useful in tracking the progression of these). from metastasis other organs. to ACTORS Oral contraceptives Oral Multiparity ligation Tubal Hysterectomy Breast-feeding CA-125: Late childbearing. Late Advanced age (50–70). history of ovarian cancer. Family of breast cancer. history or family Personal race. Caucasian fertility drugs (data diet, inconclusive on high-fat powder, Talcum Nausea/vomiting. habits. bowel Change in girth. of abdominal Widening late menopause. Early menarche, Nulliparity. Pelvic mass/pain. Pelvic (“omental mass Abdominal caking”). (dyspnea). Pleural effusion Ascites. pressure). to ↑ intra-abdominal (due hernia Ventral satiety. Early Initial stagesInitial usually are Signs/symptoms asymptomatic. usually are F and is linked to the mutation of BRCA-1 and BRCA-2 genes in 90% of and is linked to the mutation of BRCA-1 and BRCA-2 genes in 90% HOC. BRCA is a tumor suppressor gene that is located on chromosome 17. ORKUP ROTECTIVE ISK LINICAL HEREDITARY CANCER OVARIAN SYNDROMES IGNS AND Ten to fi fteen percent of cases occur in association with genetically predis- fteen percent of cases occur in association to fi Ten posed syndromes called hereditary cancer (HOC) syndromes. In ovarian There are age of 50 yr. at a median these patients, ovarian cancer is diagnosed three types: 1. Breast-ovarian cancer syndrome: Involves cancer of the breast and ovary P W R S C Ovarian & Fallopian Tube Cancer HIGH-YIELD FACTS tract. from thegastrointestinal cancer,primary usually metastatic fromanother ovarian tumorsthatare Krukenberg tumorsare metastases. enlargement andliver retroperitoneal lymphnode the disease,including to evaluatetheextentof abdomen/pelvis ishelpful CT scanofthechest/ Before astagingsurgery, a symptoms. other gastrointestinal cause bowelobstructionand Large ovariantumorscan that cause↑CA-125: Malignant conditions cause Benign conditionsthat Liver disease Hemorrhagic ovarian Pregnancy Leiomyoma Pelvic infl ammatory Endometriosis Pancreatic cancer Breast cancer Lung cancer Endometrial cancer cyst disease (PID) ↑ CA-125: cludes: surgically(seeTableOvarian cancerisstaged surgeryin- 27-1).Thestaging 3. Site-specifi Lynch nonpolyposiscoloncancer(HNPCC): IIsyndrome—hereditary 2. 296 To achieve“optimalcytoreduction”ofthedisease,2. whichmeansremoving To thepatient’s accuratelystage disease. 1. The purposeofsurgeryinpatientswithovariancancer istwofold: T REATMENT STAGING SCREENING RECOMMENDAT W OVARIAN CANCER Involves sitesthatmayincludebreast,ovaries,uterus,andcolon. genetic link.Usually, twoormorefirst-degree relativeshavethedisease. stage ovariancancer. stage bulking surgeryhasbeen shown toimprovesurvival in patientswithany tumor>1cminsize.Thiskindofde- all sitesofprimaryormetastatic CA-125:Tumor markerforepithelialovariancancer(notverysensitiveor BSO. TAH. Peritoneal washings(forcytology). Ifhighrisk,perform: Women with Women with Defi Aswithanypelvicmass,thefirst stepofevaluationisultrasound. Unfortunately, ovariancancerisoftendiagnosed afterthedisease has Pelvic andpara-aorticlymphadenectomy. Omentectomy. Genetic testingandcounseling. specifi lows. sidered amother,sister,ordaughter. cer): Noroutinescreening recommended.A fi spread beyondtheovary(advancedstage). Consider BRCAscreening. Considerprophylacticoophorectomyif Annual pelvicexam. Annual transvaginal ultrasound. Annual CA-125 (poortoolforscreening). positive. nitive identifi c). Accounts for < 1% and has an extremely strong c ovariancancer:Accountsfor<1%andhasanextremelystrong high risk( standard risk(<2fistandard rst-degree relativeswithovariancan- ORKUP cation ofadnexalmassbylaparoscopy/laparotomyfol- IONS > 2fi rst-degree relativeswithovariancancer): rst-degree relativeiscon- HIGH-YIELD FACTS Ovarian & Fallopian Tube Cancer CA-125 is elevated in 80% of cases of ovarian cancer, but only in 50% of stage I cases. It is most useful as a tool to gauge progression/ regression of disease. Surgical staging: Ovarian, endometrial, vulva, and fallopian tube cancers Clinical staging: Cervical and vaginal 297 ESCRIPTION D IA: One ovary, capsule intact capsule IA: One ovary, IB: intact Both ovaries, capsules on ovary surface, ruptured, ascites with capsule IC: Tumor or positive peritoneal washings malignant cells, IIB: Involvement of other pelvic structures IIC: IIA or IIB ovary surface, plus tumor on capsule with malignant cells, or positive ruptures, ascites washings peritoneal IIIA: (indicates abdominal peritoneal washings Positive seeding) microscopic IIIB: on abdominal peritoneal surface < 2 cm implants IIIC: abdominal peritoneal surface > 2 cm implants on and/ or positive retroperitoneal or inguinal nodes Pleural effusion, skin or supraclavicular nodes NDICATORS I Staging (FIGO) Cancer of Ovarian TAGE S ANAGEMENT ROGNOSTIC M germinomas, choriocarcinomas. germinomas, tumors. theca cell tumors, Sertoli-Leydig boplatin: free intervals. Germ cell tumors: 8% of all ovarian cancers; include teratomas, dys- 1% of all ovarian cancers; include granulosa- Sex-cord stromal tumors: sites. Multiple disease CA-125. High/rising or paclitaxel Paclitaxel and cisplatin First-line chemotherapy: and car- interval. Short disease-free or clear cell tumor. Mucinous can improve survival and disease- In selected patients, chemotherapy P I: Tumor limited to I: Tumor ovaries II: spread Pelvic IIA: of uterus/tubes Involvement III: Spread to the abdominal cavity IV: Distant metastasis liver/spleen spread Parenchymal OOR OSTOP NONEPITHELIAL CANCER OVARIAN Account for 15% of ovarian cancers. Histologic types include: P P TABLE 27-1. TABLE Ovarian & Fallopian Tube Cancer HIGH-YIELD FACTS usually aftermenopause. malignant degeneration, teratoma canundergo A benign(mature)cystic malignant. women <21yearsoldare germ celltumorsfoundin Approximately one-thirdof complications. treatment topreventseptic prophylactic antibiotic cells/μL requires neutrophil count<500 neutropenia. Anabsolute Chemotherapy cancause cancer. promise intreatingovarian administration hasshown IV, intraperitoneal(IP) traditionally administered While chemotherapyis D T E C Most arebenign. cells thatnormallyareabletodifferentiate intothethreegermcelltissues. ovarian cancerinwomen<30yearsold.Theyarisefromtotipotentialgerm Eight percentofovariancancersareGCTs.Theytheprimarycause Ovarian GermCellTumors (GCTs) 298 ERATOMA NDODERMAL LINICAL YSGERMINOMA Contains tissuefromectoderm,mesoderm,andendoderm. Contains Characteristic MostaggressiveGCT. Ten percentofGCTs. Arisesfromextraembryonic tissues(resemblesayolksac). Very chemoandradiation sensitive. Twenty percentareassociated withpregnancy. Ten percentarebilateral. Affects Most common (45%ofmalignantgermcelltumors);arisesfromundif- Usuallyfoundinchildrenoryoungwomen. Vaginal bleeding. Fever. Acute abdomen. Abdominal painwithrapidlyenlargingpalpablepelvic/abdominal Contains hair,teeth,skin,sebum,andbone. Contains Answer: Dysgerminoma. ferentiated totipotentialgermcells. mass. α-fetoprotein (AFP)is the tumormarker(seeTable 27-2). Lactic dehydrogenase(LDH)isthetumormarker(seeTable 27-2). Carcinoid: Rare. Struma ovarii: Mature solidand/orcystic(alsocalleddermoid): mesoderm, andendoderm. Immature (malignantteratoma):Haphazardtissuefromtheectoderm, May causehyperthyroidism. Mostly thyroid tissue. Benign teratoma. Benign: Canleadtotorsion>5cm. Ninety-fi P RESENTATION biopsy. What isthemostlikely pathology? adnexal mass.Sheundergoesanexploratorylaparotomyandexcisional A 7-year-old complainsofabdominalpain,andaworkuprevealsan girl S young INUS ve percentofteratomas. T women (<30yearsold). UMOR Schiller-Duval bodies. HIGH-YIELD FACTS Ovarian & Fallopian Tube Cancer Granulosa cell tumors are very chemosensitive. Know tumor markers cold for the wards. Up to 80% survival with complete resection. 299 ARKER M UMOR T LDH AFP AFPβ-hCG, CA-125 Inhibin Testosterone ERUM S brosis may be elevated. S Nephrotoxicity (extreme nausea and vomiting) Nephrotoxicity GCT β-hCG UMOR T and -human chorionic gonadotropin, GCT, germ cell tumor; LDH, lactic GCT, β-human chorionic gonadotropin, β-hCG, salpingo-oophorectomy and complete surgical stag-Unilateral ALIGNANT VARIAN ARCINOMA O Markers Serum and Their Tumors Ovarian M S C stage teratomas. Stage IA, grade I immature IA, grade 1 immature tera- is tomas have a high cure rate with surgery alone. The BEP regimen the standard of care: bination. syncytiotrophoblasts (extraembryonic tissues). syncytiotrophoblasts (extraembryonic (see Table 27-2). (see Table β-hCG and AFP are the tumor markers -human chorionic gonadotropin (β-hCG) is the tumor marker. gonadotropin β-human chorionic ing. GCT LDH, AFP, AFP, LDH, Surgery: Recommended for all malignant GCTs except Adjuvant chemotherapy: percent of GCTs. Ten tumor is the most common com- sinus and endodermal Dysgerminoma embryonal cells. Rare; composed of primitive Affects females age 4–28 yr. may cause sexual precocity or abnormal uterine bleeding. Tumors Rare nongestational and arises from cytotrophoblasts choriocarcinoma; malignant. Highly Affects women < 20 years old. leomycin Pulmonary fi dyscrasias BEP Regimen Pulmonary Bleomycin Etoposide Blood Side Effects CisPlatin Dysgerminoma Endodermal sinus tumor Endodermal Embryonal and choriocarcinoma Epithelial ovarian tumor Granulosa cell tumor Sertoli-Leydig cell tumor IXED HORIOCARCINOMA MBRYONAL REATMENT OF E T C TABLE 27-2. TABLE AFP, α-fetoprotein; AFP, dehydrogenase. M Ovarian & Fallopian Tube Cancer HIGH-YIELD FACTS gynecologic malignancy. the leastcommon Fallopian tubecarcinomais chemo/radiation therapy. and, treatment issurgery secretes testosterone.Its found inyoungwomenand arrhenoblastoma. Leydig tumoris A raretypeofSertoli- ovary. occur withafi bromaofthe (hydrothorax, ascites)can Meig syndrome is afi broma. benign tumoroftheovary The mostcommonsolid This is S G T Ovarian Sex-CordStromalTumors endodermal sinus tumors. vival is85%fordysgerminomas, 75%forimmatureteratomas,and65% Prognosis isgenerallygoodbecausemostarediscovered early. Five-yearsur- P 300 ETETOF REATMENT ERTOLI FALLOPIAN TUBE CARCINOMA FALLOPIAN TUBE ONSSOF ROGNOSIS RANULOSA Frequently presentswithvirilization,hirsutism, and menstrualdisorders. Testosterone isthetumormarker. Secretes Inhibinisthetumormarker. Characteristic Call-Exner bodies (eosinophilicbodies surroundedby Association withendometrialcancerin5%ofcases. Canpresentwithfeminization, precociouspuberty, menorrhagia,or Secretes Theybehaveaslow-grade malignancies andusuallyaffectolderwomen. Someofthesetumorsarefunctionalandsecreteestrogenortes- Arisefromthesexcordsandspecialized stromaoftheembryonic go- Itisaveryraretypeofcancer thatcanaffectanyage. Theyspreadthroughtheperitonealfl Themostcommonhistologic subtypeispapillary serous(90%). Fallopian tubecarcinomas usuallyareadenocarcinomas. cancer. granulosa cells). postmenopausal bleeding. tosterone. nads (beforetheydifferentiate intoovariesortestes). with stage II–IVdiseasewith stage andthoserecurrence. Idiseaseused inpatientswithstage butisrecommendedforall Adjuvant therapy:Chemotherapyandradiation arenot commonly Surgical: Classic presentingtriad: -L TAH-BSO in womenwhohavecompletedchildbearing. Watery vaginal discharge Vaginal bleeding Pain grade neoplasia. Unilateral salpingo-oophorectomyinyoungwomenwithlow-stage/ EYDIG -T O O HECA C VARIAN VARIAN testosterone. estrogens. ELL C T UMOR ELL S GCT EX T -C UMOR S ORD S TROMAL T UMORS uidinasimilar fashiontoovarian HIGH-YIELD FACTS Ovarian & Fallopian Tube Cancer In any woman with In any woman bleeding postmenopausal wateryor a profuse discharge, fallopian tube carcinoma should be considered. 301 nding, defi ned ned nding, as defi is the pathognomonic fi pathognomonic is the uens ROGNOSIS P AND , REATMENT , T Hydrops tubae perfl tubae Hydrops cramping pain relieved with watery discharge. pain relieved with cramping other indications. for a laparotomy during are diagnosed Many TAGING S cancer. to ovarian All similar NOTES HIGH-YIELD FACTS HIGH-YIELD Ovarian & Fallopian Tube Cancer Tube Ovarian & Fallopian

302 CHAPTER 28 Vulvar Dysplasia, Vulvar Cancer, and Vaginal Cancer

Vulvar Intraepithelial Neoplasia 304 Vulvar Cancer 305 Vaginal Cancer 307

303 Vulvar dysplasia describes precancerous lesions. Dysplasia simply describes cellular changes, characterized by changes in size, shape, hyperchromasia, and presence of mitotic ﬁ gures.

The most common VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) complaint in vulvar cancer is itching and burning of Dysplastic lesions of the vulva that have potential to progress to carci- the vulva. noma. Etiology is unknown, although human papillomavirus (HPV) has been implicated because of similarity in pathology and often concomitant presence of cervical intraepithelial neoplasia (CIN).

RISK FACTORS A precursor to vulvar Like cervical cancer, vulvar cancer risk factors include HPV types 16, cancer can be: 18, 31, and 33, and the precancerous lesions are classiﬁ ed as intraepithelial neoplasia (termed VIN as opposed to CIN). A lump or wart-like HPV types 6 and 11 are commonly found in vulvar warts. lesion HPV(human papillomavirus). Lichen sclerosis History of vulvar skin disease. Lichen planus PRESENTATION Pruritus and/or irritation (recent or long-standing), raised white lesions. HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD Pruritus and/or irritation (recent or long-standing). Raised white lesions.

Gardasil, the vaccine for DIAGNOSIS HPV, protects against strains Biopsy (most important for diagnosis). 6, 11, 16, and 18. Lower- Colposcopic exam (must include vulva, vaginal, cervix, perineal, and pe- numbered strains generally rianal). cause condylomas, whereas higher-numbered strains STAGING generally cause dysplasia As in cervical dysplasia, VIN is based on degree of epithelial spread: and cancer with time. VIN I: Involvement of less than one-half of epithelium. VIN II: Involvement of more than one-half of epithelium. VIN III: Full-thickness involvement (carcinoma-in-situ). and Vaginal Cancer and Vaginal

TREATMENT Vulvar Dysplasia and Cancer

Vulvar Dysplasia, Vulvar Cancer, Vulvar Dysplasia, Cancer, VIN lesions are multifocal, thus requiring treatment of many areas. Treatment is according to the size of the lesion: Small, well-circumscribed VIN: Wide local excision. Multifocal lesions: Laser vaporization. Extensive (large) lesions: Skinning vulvectomy.

304 VULVAR CANCER

A 64-year-old G3P3 woman presents with vaginal itching. She has been Condyloma acuminata: to her dermatologist and tried numerous topical treatments without relief. Genital warts associated She has a 1-cm white lesion on her labia that, upon palpation, begins to with HPV, which have a bleed. What is the fi rst step in diagnosis? What other fi ndings in her medical and pearly, and plaque-like or social history might put her at ↑ risk for cancer? caulifl ower appearance. Answer: The fi rst step in diagnosis is biopsy! Other fi ndings that might put her Vs. at ↑ risk for cancer include age, itching, and bleeding on exam. Condyloma lata: Genital warts in secondary syphilis, which are nonpainful, Most often found in women age 60–70. raised, grayish-white Unlike the cervix, the vulva does not have a transformation zone. Vulvar intraepithelial lesions are less likely than cervical intraepithelial lesions. lesions to become high grade or cancers. Vulvar cancer is the fourth most common gynecologic cancer (4–5% of HIGH-YIELD FACTS HIGH-YIELD FACTS all gynecologic cancers) and can arise as carcinoma of various types: Squamous (90%). Adenocarcinoma (Paget disease, Bartholin’s gland). Basal cell carcinoma. Remember that a dark- Melanoma (4–5%). pigmented lesion could be a Metastasis. Sarcoma. melanoma, even in the Verrucous carcinoma. vulvar region. The vulva includes the external genital structures. Vulvar cancers are not common cancers. Most are squamous cell carcinoma. Vulvar Dysplasia, Cancer,

SIGNS AND SYMPTOMS Vulvar Dysplasia and Cancer Pruritus (most common). Ulceration. and Vaginal Cancer Mass (often exophytic). Most common site of vulvar Bleeding. dysplasia is labia majora.

RISK FACTORS Postmenopausal. Smoking. Immunodeﬁ ciency syndromes. Other risk factors: Age Pruritus is the most HPV common symptom of vulvar VIN HIV cancer. Always biopsy itchy, Vulvar skin disease (dystrophy) white lesions on exam. Melanoma Atypical moles

DIAGNOSIS Biopsy of the suspicious lesion.

STAGING See Table 28-1. Vulvar cancer is surgically staged. Most common vulvar cancer is squamous cell.

305 TABLE 28-1. Vulvar Cancer Staging, FIGO Revised 2009

STAGE I: TUMOR CONFINED TO THE VULVA

IA: Lesions < 2 cm in size, conﬁ ned to the vulva or perineum, stromal invasion < 1.0 mm. No nodal invasion IB: Lesions > 2 cm in size or with stromal invasion > 1.0 mm, conﬁ ned to the vulva or perineum. No nodal metastasis

STAGE II: TUMOR OF ANY SIZE WITH EXTENSION TO ADJACENT PERINEAL STRUCTURES 1 1 ( /3 LOWER URETHRA, /3 LOWER VAGINA, ANUS); NEGATIVE NODES

STAGE III: TUMOR OF ANY SIZE WITH OR WITHOUT EXTENSION TO ADJACENT PERINEAL 1 1 STRUCTURES ( /3 LOWER URETHRA, /3 LOWER VAGINA, ANUS) WITH POSITIVE INGUINO-FEMORAL LYMPH NODES

IIIA: (i) With lymph node metastasis (> 5 mm), or (ii) 1–2 lymph node metastasis(es) (< 5 mm), or IIIB: (i) With 2 or more lymph node metastases (> 5 mm), or (ii) 3 or more lymph node metastases (< 5 mm) IIIC: With positive nodes with extracapsular spread

2 2 STAGE IV: TUMOR INVADES OTHER REGIONAL ( /3 UPPER URETHRA, /3 UPPER VAGINA), OR HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD DISTANT STRUCTURES

IVA : Tumor invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or ﬁ xed to pelvic bone, or (ii) ﬁ xed or ulcerated inguino-femoral lymph nodes IVB: Any distant metastasis including pelvic lymph nodes

Clear cell adenocarcinoma TREATMENT of the vagina often Stages I–II: Radical vulvectomy and lymphadenectomy (wide local ex- correlates with in utero cision is sometimes possible for certain small lesions < 1 cm). diethylstilbestrol exposure Stages III–IV: As above, plus removal of affected organs and adjunct ra- (DES); these patients often diation therapy. and Vaginal Cancer and Vaginal present young. Vulvar Dysplasia and Cancer Vulvar Dysplasia, Vulvar Cancer, Vulvar Dysplasia, Cancer,

TABLE 28-2. Staging of Vaginal Cancer

STAGE

I: Limited to vaginal mucosa

II: Beyond mucosa but not involving pelvic wall

III: Pelvic wall involvement

IV: Involvement of bladder, rectum, or distant mets

306 VAGINAL CANCER

A 72-year-old G4P4 female presents to the ofﬁ ce complaining of a “large ball” on the inside of the vagina. She notices that it bleeds on occasion. What is the next step in managing this patient? Answer: Biopsy the lesion.

Primary cancer arises in vagina. A rare gynecologic malignancy (2% of gynecologic cancers). Vulvar cancer: Surgically Usually presents in postmenopausal women. staged. Increased risk in premenopausal women exposed to DES in utero. Vaginal cancer: Clinically Most common type is squamous cell carcinoma (other types are the staged. same as vulvar cancer types). Having CIN or VIN is a risk factor for development of vaginal cancer. HIGH-YIELD FACTS HIGH-YIELD FACTS SIGNS AND SYMPTOMS Ulcerated mass Exophytic mass Abnormal vaginal discharge Bleeding Asymptomatic Pain in advanced cases

DIAGNOSIS Biopsy of suspicious lesion. Vulvar Dysplasia, Cancer,

STAGING Vulvar Dysplasia and Cancer See Table 28-2. Vaginal cancer is clinically staged. The stage of tumor is the most important predictor of prognosis. and Vaginal Cancer

TREATMENT Stages I–II: Surgical resection and radiation. Stages III–IV: Radiation only.

307 NOTES HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD and Vaginal Cancer and Vaginal Vulvar Dysplasia and Cancer Vulvar Dysplasia, Vulvar Cancer, Vulvar Dysplasia, Cancer,

308 CHAPTER 29 Vulvar Disorders

Vulvar Dystrophies 310 PAGET DISEASE OF THE VULVA 310

LICHEN SIMPLEX CHRONICUS 311

LICHEN SCLEROSUS 311

LICHEN PLANUS 312 Psoriasis 312 Vestibulitis 312 Cysts 313 BARTHOLIN’S ABSCESS 313

SEBACEOUS CYSTS (EPIDERMOID CYST) 313

HIDRADENOMAS 313

OTHER RARE CYSTS 314

309 Vulvar Disorders HIGH-YIELD FACTS P Paget DiseaseoftheVulva biopsied toruleoutmalignancy. characterized byvariouspruritic,whitelesionsofthevulva.Lesionsmust be help toidentifythesedisorders. Vulvar dystrophiesareagroupofdisorders fi Vulvar disorders encompassawiderangeofconditions, fromisolatedlocal 310 T Direct biopsyoflesion.Willvisualizepagetcellsunder themicroscope. D ndings tosystemic illnesses.Agoodunderstandingofthevulvaranatomywill REATMENT VULVAR DYSTROPHIES RESENTATION IAGNOSIS yearly screening. frequently associatedwithothercancers.Recurrenceisfairlycommon;continue need widelocalexcisiondowntosubcutaneousfat.Paget diseaseofthevulvais solitary lesion?Isthereariskofrecurrenceaftertreatment? her vulva.Shehasa10-yr historyofbreastcancer. Howwouldyoumanagethis appearance issecondarytolichenifi vulvar carcinomaisassociatedwithlichenplanusandsclerosus.The white malignancy? What microscopic changescontributetothewhiteappearance? next stepwillbemosthelpfulindiagnosingthisrash?Ispatientat stop scratchingthem.Examinationshowsirritated,raised,whitelesions.What Recurrences arefrequent aftertreatment. lesionwithoutmalignancy: Wideexcision tosubcutaneous If solitary Canbeassociated withotherunderlyinglocalinvasivecarcinomas or Postmenopausal Caucasianfemales. Pruritic,erythematous,eczematoid lesion. Answer: BiopsyofthelesionrevealsPaget diseaseofthevulva.Solitarylesions Answer: The nextstepindiagnosingthisrashispunchbiopsy. An↑riskof fat. adenocarcinoma ofthegastrointestinal (GI)tractorbreast. for almost2yr. Onexam,itappearsthereisaredeczematouslesionon foranitchygenitallesion.Ithasbeenpresent yr comestohergynecologist A 65-year-oldG3P3Caucasianwomanwhohasbeenmenopausalfor10 thatshecan’t previously effectiveultraviolet(UV)treatment.Shereports thatarenotrespondingtoher but hasnewlesionsonhervulvarregion A 60-year-oldG1P1womanhasahistoryofraised,silver-coloredrash cation. ↑ riskfor HIGH-YIELD FACTS Vulvar Disorders ↑ risk of malignancy. Wickham striae are fi ne, Wickham striae are fi white, lacy lesions, found in oral lichen planus (commonly on the gingiva). Lichen simplex chronicus Lichen simplex chronicus carries If an itch-scratch cycle is mentioned, choose LSC! 311 Current 10th ed. New York: McGraw-Hill, 2007: 617.) McGraw-Hill, 10th ed. New York: Vulvar lichen sclerosus. Vulvar UP - of the vulva and epidermal contracture leads to loss of vulvar architec- of the vulva and epidermal contracture ture. cells (see Figure 29-1). There is ammatory and infl below mogenization also loss of the rete ridges. in the raised, white, thickened lesions. in the raised, white, An atrophic lesion characterized by paperlike appearance on both sides with a layer of ho- reveals epithelial thinning Microscopic examination itching and scratching. by chronic characterized disorder It is a skin also appear red and irritated Lesions may due to itching. reveals acanthosis and hyperkeratosis. examination Microscopic irritation by chronic a hypertrophic dystrophy caused LSC is resulting Breast exams. Breast vulva. of the cervix and evaluation Cytologic for GI disease. Screening OLLOW Diagnosis & Treatment: Obstetrics & Gynecology, Diagnosis & Treatment: Notice the paper-thin appearance, bilateral distribution, and pale color, with a loss of Notice the paper-thin appearance, bilateral distribution, in the posterior fourchette.ssures can occur architecture. In severe cases, contractures and fi from DeCherney AH, Nathan L, Goodwin TM, et al. (Reproduced, with permission, FIGURE 29-1. Lichen Sclerosus Lichen Simplex Chronicus (LSC) Lichen Simplex Chronicus Patients with Paget disease of the vulva will need to be followed annually with: annually followed to be will need of the vulva disease Paget with Patients Patients with Paget disease are at increased risk of cancer. at increased risk of are disease with Paget Patients F Vulvar Disorders HIGH-YIELD FACTS dermatitis. such asacontact more commondiagnoses dystrophy, alwaysruleout Before diagnosingvulvar Polygonal Purple Planar Pruritic 4 P’s oflichenplanus: T T Keyes 3-to5-mmpunchbiopsyofvulva. D Lichen Planus 312 T nosis ismadeifthistouchproducesseverepain. Lightly touchthevulvarvestibulewithacotton-tipped applicator. The diag- D REATMENT REATMENT OF REATMENT VESTIBULITIS PSORIASIS ANSSOF IAGNOSIS IAGNOSIS Etiologyisunknown. Infl Vulvar painisacommongynecologicproblem. Topical D. vitamin Steroid cream—goalistodecreasescratchingandrubbing. Pruritusisvariable. Althoughitcommonlyoccursoverthekneesand/orelbows, lesionscan A common dermatologiccondition characterizedbyredplaques cov- Ultravioletlightforcontinued scratching. Diphenhydramine atnight topreventitchingduringsleep. oralsteroids Steroid insevere cream(testosterone,clobetasol/temovate); Maypresentasvulvo-vaginal-gingivalsyndrome. Skinbecomesverythickened(hypertrophied)andmaycausescarring. Mostlesionsarefoundintheinnervulvaandvagina. Arecurrentrashduetoinfl Theremaybeshiny, purplelesionsvisualizedonthevulva. Anuncommoncondition. Surgery—if lesionsareunresponsivetotreatment,vestibulectomy is Xylocaine jellyforanesthesia. Trichloroacetic acid. Temporary sexual abstinence. Although theaffectedareaturnswhitewithaceticacid undercolpo- pain). pain associated with coitus (insertionaldyspareunia and/orpostcoital be foundonthevulvaaswell. ered bysilverscales. cases. possible, thoughwithrisk of recurrence. scopic examination, theselesionsarenotdysplastic. ammation ofthevestibularglands→tenderness,erythema,and V V ULVAR ULVAR D D YSTROPHIES YSTROPHIES ammation. HIGH-YIELD FACTS Vulvar Disorders Bartholin’s gland cysts are Bartholin’s often asymptomatic, unilateral, 1–8 cm in size, tense, and nonpainful. Bartholin’s glands are Bartholin’s analogous to the male gland Cowper’s (bulbourethral gland). It secretes a thick, alkaline uid during coitus. fl The vestibular glands glands) are (Bartholin’s located at the 5 and 7 o’clock positions of the inferolateral vestibule (area between the labia minora). abscess tends to Bartholin’s develop rapidly over 2–4 days. Symptoms include acute pain, dyspareunia, and pain with walking. They are usually unilateral and can rupture on their own in 5 days. The pain is improved after the cysts ruptures. 313 Hidradenitis suppurativa is most commonly found in intertriginous A 30-year-old G3P3 overweight African-American woman presents with A 30-year-old On line. She can’t keep her skin dry. ammation of her bikini painful infl is the diag- exam, there are draining sinuses and scarring of the skin. What A 35-year-old G0 woman calls to make an appointment for a tender nod- an appointment for calls to make G0 woman A 35-year-old vaginathe opening of the 3 days ago at ule she found the right. She on had some discomfort dis- night during intercourse but didn’t the other ammatory symptoms generally arise from infection and can be ducts become occluded. atic. incised cyst to prevent reocclusion) or incised 14 days to aid healing). treated with antibiotics. and 7 o’clock position. which usually occurs due to infection. gland is occluded, Answer: Answer: Bartholin’s abscess. any treatment. Most cysts do not require and drainage. If it becomes infected, it can be treated with incision cyst. The most common vulvar Cysts are mainly asymptomatic. when pilosebaceous (rarely minora) Occur beneath the labia majora the palpable, smooth mass, patients are generally asymptom- Besides thick, cheesy material is extruded. If expressed, yellow, Infl also be prescribed. Antibiotics and sitz baths may and drainage and marsupialization (suturing the edges of the Incision atable tip left in the gland for 10– an infl catheter (a catheter with Ward located at the 5 o’clock glands are two pea-sized glands, Bartholin’s The gland cannot be palpated. A normal Bartholin’s draining abscesses occur when the main duct Bartholin’s nosis? such as the mons pubis, the genitocrural folds, buttocks, and areas of the body, are four times more likely than men to develop hidradenitis sup- axillae. Women purativa. cover anything morning. Now she says it’s uncomfortable until yesterday to walk. is the most likely diagnosis? What CYSTS REATMENT Hidradenomas Sebaceous Cysts (Epidermoid Cyst) T Bartholin’s Abscess Vulvar Disorders HIGH-YIELD FACTS fi stulas. that becomedraining thick, palpablesinustracts glands canevolveinto surrounding theapocrine Subcutaneous involvement Other RareCysts 314 Treatment: Treatment: Topical steroid creamsandlong-term,oralantibiotics.Se- Diagnosisismadebybiopsy. Thesecyststendtobepruritic. Astheinfectiongrows overtime,scarringandpitscanform. Hidradenomas(apocrinesweatglandcysts)alsooccurbeneaththelabia Thiscondition isachronic infectionoftheapocrineglands,foundin vere casesarealsotreatedbyexcision oftheinfectedskin. occlusion. majora asaresultofductal exam. reproductive-age women.Afoulsmellingdischarge maybepresenton Skene’s ductcyst: peritonealfl contains Cyst ofcanalNuck:Ahydrocele(persistentprocessusvaginalis); Ifsymptomatic,excision ofcyst. Ifasymptomatic,supportivetreatment occlusionandcysticformationoftheSkene’s Ductal (paraurethral) Very rareandverysmall. glands occurs,andpatientshavediscomfort. uid. CHAPTER 30 Gestational Trophoblastic Disease

Deﬁ nition 316 Hydatidiform Mole 316 COMPLETE MOLE 316

PARTIAL MOLE 317

INVASIVE MOLE 317 Choriocarcinoma 319 Placental Site Trophoblastic Tumor 321

315 Gestational trophoblastic disease (GTD) is a general term that encompasses a spectrum of interrelated conditions originating from the placenta. In GTD, there is abnormal growth that continues beyond the end of pregnancy. These conditions include complete and partial hydatidiform moles, invasive moles, gestational choriocarcinomas, and placental site trophoblastic tumors.

DEFINITION DNA of complete mole is GTD are entities arising from placental syncytiotrophoblasts and cy- always a paternal. totrophoblasts. It refers to a spectrum of abnormalities of the trophoblast associated with pregnancy. They represent an aberrant fertilization event. The four tumors are: Hydatidiform mole (complete or partial). Persistent/invasive trophoblastic disease. Choriocarcinoma. Placental site trophoblastic tumor.

HYDATIDIFORM MOLE

Complete Mole HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD

A 22-year-old G1P0 at 12 weeks by dates presents with vaginal bleeding and an enlarged-for-dates uterus on exam. Her blood pressure is 160/90, there are no fetal heart sounds, and an ultrasound shows a snowstorm pattern. After dilation and curettage (D&C), what would most likely be the karyotype? Answer: 46,XX in a complete mole.

DNA of a partial mole is both maternal and A placental (trophoblastic) tumor forms when a maternal ova devoid of deoxy- paternal. ribonucleic acid (DNA) “empty egg” is “fertilized” by the paternal sperm (see Disease Figure 30-1): Neoplasia Gestational Trophoblasic Gestational Trophoblasic

FIGURE 30-1. Complete mole on ultrasonography.

316 KARYOTYPE Most have karyotype 46,XX, resulting from sperm penetration and subsequent DNA replication. The treatment for partial Some have 46,XY, believed to be due to two paternal sperms simultaneously penetrating the ova. and complete molar The BHCG value may be higher as compared to a partial mole. pregnancy is prompt removal of intrauterine EPIDEMIOLOGY contents with D&C. Incidence is 1 in 1,500 pregnancies in the United States, 1 in 200 in Mexico, 1 in 125 in Taiwan.

Partial Mole Partial mole may contain a A mole with a fetus or fetal parts (see Figure 30-2). fetus or fetal parts. Women with partial (incomplete) molar pregnancies tend to present

later than those with complete moles. HIGH-YIELD FACTS

KARYOTYPE Usually 69,XXY, and contains both maternal and paternal DNA.

EPIDEMIOLOGY One in 50,000 pregnancies in the United States.

A young woman who passes Invasive Mole grape-like vesicles from her A variant of hydatidiform mole that invades the myometrium or blood vagina should be diagnosed vessels. with hydatidiform mole. It is by deﬁ nition, malignant trophoblastic disease and can spread to extrauterine sites. Twenty percent of patients will develop malignant se- Gestational Trophoblasic quelae after a complete hydatidiform mole. The treatment involves complete metastatic workup and appropriate

malignant/metastatic therapy (see below). A D&C is not recommended Disease for treatment, because of the increased risk of uterine perforation. Che- motherapy is the usual treatment.

FIGURE 30-2. Partial mole on ultrasonography.

317 HISTOLOGY OF HYDATIDIFORM MOLE Trophoblastic proliferation. Hydropic degeneration (swollen villi). Lack/scarcity of blood vessels. The development of preeclampsia before 20 weeks SIGNS AND SYMPTOMS is suspicious for the The most common symptom is abnormal painless bleeding in the ﬁ rst presence of a molar trimester. pregnancy. Passage of villi (vesicles that look like grapes). Preeclampsia < 20 weeks. Uterus large for gestational age. High human chorionic gonadotropin (hCG) level for gestational age.

MEDICAL COMPLICATIONS OF MOLAR PREGNANCY Preeclampsia. Hyperemesis gravidarum. GTD secrete hCG, lactogen, Hyperthyroidism. and thyrotropin. Anemia. Pulmonary trophoblastic embolization.

DIAGNOSIS Elevated hCG (usually > 100,000 mIU/mL). 15-25% theca lutein cysts visualized (secondary to the high BHCG levels). HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD Absence of fetal heartbeat. Ultrasound: “Snowstorm” pattern. Pathologic specimen: Grapelike vesicles. Histologic specimen (see above).

TREATMENT OF COMPLETE OR PARTIAL MOLES Dilation and curettage (D&C) to evacuate and terminate pregnancy. Total abdominal hysterectomy (TAH) can be performed in women who have completed childbearing. Twenty percent of complete Follow up with the workup to rule out invasive mole (malignancy): moles will be malignant. Chest x-ray (CXR) to look for lung mets. < 5% of partial moles will Liver function tests to look for liver mets. Disease

Neoplasia be malignant. hCG monitoring: Weekly until negative for 3 weeks, then monthly until negative for 6 months; yearly for 1–3 yr. If the hCG level rises, does not fall, or falls and then rises again, the molar pregnancy is considered

Gestational Trophoblasic Gestational Trophoblasic persistent/malignant. Contraception should be used during the 1-yr follow-up. Administer RhoGAM for RH negative patients.

METASTATIC WORKUP Any of the following on CXR, computed tomography (CT) of brain, lung, liver, kidneys. exam indicates molar Labs: CBC, Comprehensive metabolic panel, clotting studies, and blood pregnancy: type, Rh, and antibody screen. Passage of grapelike TREATMENT (FOR NONMETASTATIC MOLAR PREGNANCIES) villi Preeclampsia early in Chemotherapy methotrexate or Actinomycin D (as many cycles as pregnancy needed until hCG levels return to negative) or Snowstorm pattern on Total abdominal hysterectomy + chemotherapy (fewer cycles needed). Treatment for metastatic molar pregnancy is the same as for choriocar- ultrasound cinoma (see below).

318 RECURRENCE RISK One to two percent in subsequent pregnancy.

TREATMENT (METASTATIC MOLAR PREGNANIES) Same as choriocarcinoma (see below).

CHORIOCARCINOMA

A 31-year-old G2P2 woman, 5 months after a vaginal delivery reports to the ED complaining of nausea, vomiting, and abnormal vaginal bleeding. Her pregnancy test is positive. A D&C was performed and the histology revealed sheets of trophoblastic cells and no chorionic villi. What is her diagnosis? What is the next step in management? Answer: Diagnosis is Choriocarcinoma. The workup should be initiated to HIGH-YIELD FACTS determine if there is metastatic or nonmetastic choriocarcinoma.

HISTOPATHOLOGY Choriocarcinoma has characteristic sheets of trophoblasts with extensive hemorrhage and necrosis, and unlike the hydatidiform mole, choriocarcinoma has no villi. These tumors metastasize early. Common sites for metastasis include vagina, lung, liver, and brain.

EPIDEMIOLOGY Incidence is about 1 in 16,000 pregnancies. Gestational Trophoblasic

DIAGNOSIS Increasing or plateauing β-hCG levels. Nonmetastatic malignancy Absence of fetal heartbeat. has almost a 100% Disease Uterine size/date discrepancy. remission rate following Specimen (sheets of trophoblasts, no chorionic villi). chemotherapy. A full metastatic workup is required when choriocarcinoma is diagnosed.

TREATMENT AND PROGNOSIS OF NONMETASTATIC CHORIOCARCINOMA Chemotherapy: Methotrexate or Actinomycin D (as many cycles as needed until hCG levels return to negative) or; give 1–2 additional cy- Sheets of trophoblasts = cles after ﬁ rst negative β-hCG. choriocarcinoma. Total abdominal hysterectomy (TAH) + chemotherapy (fewer cycles needed). Remission rate is near 100%.

TREATMENT OF METASTATIC CHORIOCARCINOMA, METASTATIC INVASIVE MOLE, OR METASTATIC HYDATIDIFORM MOLE Treatment is determined by the patient’s risk (high or low) or prognostic score. Low-risk patients (score < 7), can be treated with single-agent chemotherapy for 5 days and a hysterectomy.

319 High-risk patients (score > 7), can be treated with multiagent chemotherapy, in addition to radiation. Chemotherapy is continued until after the hCG levels have negative. hCG levels are monitored for 1 yr after normalization. All patients are placed on reliable contraception during this time of monitoring. Serial β-hCG’s are every 2 weeks until negative; then every 3 months, then monthly for 1 year. Give 1–2 additional cycles after ﬁ rst negative β-hCG. Risk of recurrence: < 1%.

PROGNOSTIC GROUP CLINICAL CLASSIFICATION See Table 30-1 and Table 30-2.

TABLE 30-1. FIGO Prognostic Scoring System (2000)

SCORE

RISK FACTOR 0124

Age (yr) ≤ 39 > 39

Pregnancy Hydatidiform Abortion Term mole HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD

Interval from pregnancy event < 4 4–6 7–12 > 12 to treatment (in months)

hCG (pre-treatment) (IU/mL) < 1000 1000- 10,000– > 100K 10,000 100K

Largest tumor size uterus 3–4 5–6 (in cm)

Site of metastases Lung Spleen GI Brain Vagina Kidney Liver Disease Neoplasia

Number of metastasis 0 1–4 4–8 > 8

Gestational Trophoblasic Gestational Trophoblasic Prior chemotherapy agent – – Single Two or more drug agents

Scores are added to give the prognostic score.

320 TABLE 30-2 Treatment According to Score/Prognostic Factors

Low risk (score < 7) Single-agent therapy (methotrexate)

High risk (score > 7) Multiple-agent therapy (EMACO therapy—etoposide, MAC, and vincristine)

PLACENTAL SITE TROPHOBLASTIC TUMOR (PSTT)

A rare form of GTD. Characterized by inﬁ ltration of the myometrium by intermediate trophoblasts, which stain positive for human placental lactogen. There are no chorionic villi present. Unlike other GTDs, hCG is only slightly elevated. HIGH-YIELD FACTS TREATMENT TAH: Prognosis is poor if there is tumor recurrence or metastasis. These tumors (most are cured by TAH) are not sensitive to chemotherapy. Gestational Trophoblasic Disease

321 NOTES HIGH-YIELD FACTS HIGH-YIELD FACTS HIGH-YIELD Disease Neoplasia Gestational Trophoblasic Gestational Trophoblasic

322 CHAPTER 31 Sexually Transmitted Infections and Vaginitis

Pelvic Inﬂ ammatory Disease 324 Gonorrhea 325 Chlamydia 326 SEROTYPES A–K 326

SEROTYPES L1–L3 327 Syphilis 327 Genital Herpes 328 Human Immunodeﬁ ciency Virus and Acquired Immune Deﬁ ciency Syndrome 329 Human Papillomavirus 330 Chancroid 330 Pediculosis Pubis (Crabs) 331 Vaginitis 332 Toxic Shock Syndrome 334

323 Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS chandelier. patient jumpstothe is somuchpainthatthe there you touchthecervix, Chandelier sign:When is aclinicaldiagnosis. fordiagnosis.PID necessary Positive labtestsarenot 3. 2. Adnexal tenderness 1. Abdominal tenderness PID: clinical diagnosisof Requirement fora are mostcommon). and gonorrheafi rst(these always thinkofchlamydia responsible forPID,but Rarely isasingleorganism years. women inreproductive PID. PIDaffects10%of episode ofsymptomatic United Statesexperiencean million womeninthe Each yearapproximately1 tenderness motion Cervical D C ments) causedbyascending infectionfrom thevaginaandcervix. Infl D nis, rectum,mouth,throat,respiratorytract,oreyes. Transmissioncontact. occursviamucous membranesofthevulva,vagina,pe- bacteria, viruses,parasites,andprotozoaninfectionsthataretransmitted byclose ally transmitted infections,areamajorsourceofmorbidity. Thegroupincludes Sexually transmitted infections(STIs),alsoknown asvenerealdiseases orsexu- 324 PELVIC INFLAMMATORY DISEASE (PID) OMMON IAGNOSIS EFINITION admission includevomitingandfever. You What treatmentshouldbegiven? diagnoseherwithPID. cervical motiontenderness,uterineandbilateraladnexaltenderness. tract(uterus,tubes,ovaries, liga- ammation ofthefemaleuppergenital Lab ResultsandOtherPossible ExamSigns Laparoscopy Physical Exam Purulentcervicalorvaginal discharge. Oraltemperature>101ºF(38.3ºC). Cervicalmotiontenderness. Adnexal tenderness. Abdominal tenderness. Gardnerellavaginalis, Peptostreptococcus, and Streptococcus. Escherichia coli. trachomatis. Chlamydia Neisseria gonorrhoeae. Ten percentofwomenwithacutePIDwilldevelopperihepatic infl fordiagnosis,The “goldstandard” butitisusuallyemployedonlyin Revealspusdraining fromthefallopian tubes;collectedinthecul-de- CultureevidenceofNgonorrhoeae orCtrachomatis. ElevatedWBCcount,erythrocytesedimentation rate(ESR),C-reactive Pelvic abscess. Presenceofabundantwhitebloodcells(WBCs) onmicroscopy ofvagi- ofdischarge Gramstain with gram-negativediplococci. Answer: mation, known asFitz-Hugh–Curtissyndrome. cases unresponsivetomedical treatment. sac. protein (CRP). nal secretions. C and vomiting.Hertemperatureis101.4ºF (38.6ºC). Examinationconfi dischargeforthepast10and vaginal days.Additionally, nausea shereports A sexuallyactive21-year-old G1P1complainsoflowerabdominalpain AUSATIVE Inpatient cefoxitin/cefotetan+doxycycline.Criteriaforhospital O RGANISMS Bacteroides. rms am- Sexually Transmitted Infections

HIGH-YIELD FACTS and Vaginitis - 2 Treat gonorrhea in a Treat patient allergic to penicillin with specitinomycin. Gonorrhea of the throat is cult to particularly diffi treat. A swab at 72 hr after starting treatment is necessary; retreat if this swab is positive. In what media does Neisseria gonorrhea grow? in CO Thayer-Martin Criteria for hospitalization for PID— GU PAP GI symptoms Uncertain diagnosis Peritonitis Abscess Pregnancy enriched environment. 325 + metronidazole. axacin Perform the culture and treat the patient empirically. Since she Perform the culture and treat the patient empirically. oxacin/ofl OSPITALIZATION H A 19-year-old G2P2 female presents with known exposure to gonorrhea 7 A 19-year-old She reports but an ↑ in vaginaldays prior. discharge for the past day, denies any other symptoms. On physical exam, you notice minimal vaginal Levofl +/– metronidazole. Ceftriaxone/cefoxitin + doxycycline be treated empirically. Sexual partners should also Cefoxitin/cefotetanchlamydia). + doxycycline (preferred for for abscess). (preferred + gentamicin Clindamycin treatment. copy with this syndrome. with this copy ACTORS Answer: Inpatient: Outpatient: be excluded. Surgical emergency cannot tolerate oral antibiotic Outpatient failure within 48 hr or unable to Lack of compliance. Immunocompromised. High fever > 100.9ºF (38.3ºC). Pregnancy. Peritonitis. (GI) symptoms (nausea, vomiting). Gastrointestinal or pelvic). Abscess (tubo-ovarian diagnosis. Uncertain sexual partners. Multiple sex partner(s). New intercourse. Unprotected Concomitant history of STD. of intrauterine contraceptive device. Presence Nulliparity. laparos- on liver capsule at the be seen can adhesions string” “Violin < 35 years. Age F admits to a recent exposure to gonorrhea, there is no need to wait for the culture admits to a recent exposure to gonorrhea, there is no need to wait for the culture to come back. In women, asymptomatic infection is common and symptoms may not begin days after infection. until 7–21 discharge. You obtain a swab for gonorrhea culture. What is the next step? obtain a swab for gonorrhea culture. What discharge. You RITERIA FOR ISK GONORRHEA REATMENT An infection of the urethra, cervix, pharynx, or anal canal, caused by the An infection of the urethra, cervix, pharynx, or anal canal, caused Neisseria gonorrhoeae. gram-negative diplococcus, T C R Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS by gonorrheaorchlamydia. vomiting. Itcanbecaused fever, nausea,and right upperquadrantpain, perihepatitis presentsas Fitz-Hugh–Curtis common asgonorrhea. Chlamydia istwiceas also given. chlamydial coinfectionis empirical treatmentof When treatinggonorrhea, untreated. progress toPIDif women withgonorrheawill Ten tofi fteenpercentof exposure togonorrhea. of transmissionafterone There isa50–90%chance “Violinstring”adhesions laparoscopy visualized on ↑ liverfunctiontests bacteria. tiva, nasopharynx,causedbyChlamydiatrachomatis, anobligateintracellular Chlamydia isaninfectionofthegenitourinary (GU)tract,GIconjunc- T D P 326 Serotypes A–KofCtrachomatis canhavethefollowing presentation: Serotypes A–K P REATMENT CHLAMYDIA RESENTATION RESENTATION IAGNOSIS chronic pelvicpain. syndrome,Reiter trachoma-conjunctivitis,pelvicadhesions,and Curtis complications arepreventedbytreatingthispatient? TheLserotypescauseasystemic disease (lymphogranuloma venereum). Sexualpartnersshouldalsobetreated. Ifcoinfection withchlamydia isnotruledout: Levofl Ofl Ciprofl Cefi Ceftriaxone125mgIMsingledoseor DNA/polymerasechainreaction(PCR)amplification (goldstandard). Gonozyme(enzymeimmunoassay). CultureinThayer-Martinagar. PID. Vaginal discharge. Endocervicitis. Dysuria. Asymptomatic. PID. Urethritis. Cervicitis. Mucopurulent discharge. Asymptomatic. SerotypesA–Kcausemore localizedGUmanifestations. Therearenumerous serotypesofchlamydia. Answer: Doxycycline100mgPObid×7days. Azithromycin 1gPOsingledoseor oxacin 400mgPOsingledoseor cervicitis isnoticed.Chlamydiatrachomatisinfectionsuspected.What unprotected sexualintercourse.Onphysicalexam,amucopurulent A 16-year-old discharge5daysafter G0P0femalepresentswith↑vaginal xime 400mgPOsingledoseor oxacin 250mgPOsingledose. oxacin 500mgPOsingledoseor infection include PID, Fitz-Hugh– Complications foraChlamydiainfectionincludePID, Sexually Transmitted Infections

HIGH-YIELD FACTS and Vaginitis Physicians often treat both gonorrhea and chlamydia even if diagnosing only one. Syphilis is the most likely diagnosis for a woman with painless genital lesions who then later develops hand, foot, and mouth rashes. Reiter Syndrome of Classic triad urethritis, conjunctivitis, arthritis: and reactive can’t pee, Can’t see, can’t climb a tree. Use azithromycin rather than doxycycline for pregnant women with chlamydia. Doxycyline causes discoloration of the fetal teeth, if used during pregnancy. 327 uorescent Order a specifi c serologic test, such as the fl Order a specifi Answer: A 22-year-old G1P1 woman has a positive rapid plasma reagin G1P1 woman has a positive rapid plasma A 22-year-old (RPR) with is the next step in the workup? a titer of 1:4. What appetite. tual blindness from corneal abrasions. from corneal blindness tual Tertiary syphilis:Tertiary of the skin and Presents years later with granulomas lesions (eg, aortic aneurysms), neuro- bones (gummas), cardiovascular syphilis (eg, tabes disease). paresis, and meningovascular dorsalis, Secondary syphilis: Generalized rash (often macular or papular on the palms and soles of the feet), condyloma lata, patches with mucous fever, malaise, usually appearing 1–6 months after lymphadenopathy, primary chancre. Spontaneous after about 1 month. regression with serologic proof of infection. Asymptomatic disease Latent syphilis: within the past ed as early latent if syphilis was acquired Further classifi over a year prior. year or late latent if acquired Primary syphilis: hard chancre of the vulva, vagina, or cervix Painless ngers), usually appearing 1 month after ex- tongue, or fi (or even anus, posure. Spontaneous after 1–2 months. healing 1 g PO single dose. Doxycycline 100 mg bid × 7 days or azithromycin venereum: Doxycycline 100 mg BID × 21 days. Lymphogranuloma Tertiary stage: Rectovaginal fi rectalstulas, strictures. stage: Rectovaginal fi Tertiary papule on genitals. Painless Primary lesion: stage: Secondary of with fever, malaise, and loss Inguinal lymphadenitis even- and eyelash hypercurvature in resulting Conjunctivitis Trachoma: syndrome. Fitz-Hugh–Curtis syndrome. Reiter treponemal antibody absorption test (FTA-ABS) or microhemagglutination test for or microhemagglutination treponemal antibody absorption test (FTA-ABS) A false-positive RPR pallidum (MHA-TP). can be seen with certain viral Treponema hepatitis, varicella, measles), lymphoma, tuberculosis, infections (Epstein-Barr, disease, and pregnancy. malaria, endocarditis, connective tissue IAGNOSIS RESENTATION SYPHILIS REATMENT Syphilis has various stages ways: of manifestation that present in different Treponema pallidum. spirochete Treponema Syphilis is an infection caused by the P T D PCR). cation testing of the cervix (NAAT, Nucleated amplifi This venereum. cause lymphogranuloma of C trachomatis Serotypes L1–L3 several forms: that can present in disease is a systemic Serotypes L1–L3 Serotypes Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS recurrence. that predisposetoherpes defi ciencyaresomefactors Stress, illness,andimmune medication. treat withanantiviral positive forgenitalherpes, lesion. Iftheresultis painful vaginal/vulvar Perform aviralcultureon positive RPR. Pregnancy maygivefalse- Screening testsforsyphilis: treatment forsyphilis. Penicillin Gisthebest syphilis: Confi testsfor rmatory MHA-TP FTA-ABS VDRL RPR ing: Patients withherpescanbeasymptomatic, butmaypresentwiththefollow- P T D 328 D C REATMENT GENITAL HERPES OMPLICATIONS RESENTATION IAGNOSIS IAGNOSIS lab testsshouldbeobtained? Primary infection: Eightypercentofadultshaveantibodies toHSV-2, mostwithouthistory HSVisaDNAvirus. Infection causedbyherpessimplexvirustype2(HSV-2) in85%of Treatment, duringpregnancy, isonlyBenzathinePenicillin G.Itcrosses Doxycycline. thoughindiffering Benzathine penicillin Gforallstages, doses. Visualizationofspirochetesondarkfield microscopy isanadditional test Cytologicsmear—multinucleated giant cells(Tzancktest). Grossexamination ofvulvafortypical lesions. Nonprimary fi Recurrent infection: Recurrencefromviralstoresinthesacralganglia, Answer: milder. preexisting antibodies toHSV-1 ofHSV-2 canmakethepresentation in thepresenceofpreexistingantibodiestoHSV-1 orviceversa.The of infection. cases, andbytype1(HSV-1) in15%ofcases. penicillin, adesensitizationmust bedone. topreventcongenital syphilis. Ifapatientisallergicto the placenta available. ofprimaryinfectionincludingresulting inamilderversion vesicles. exposure. thematous basethatprogresstopainfululcers,usually 1–3weeksafter pruritus, followed bymultiple painfulgenital vesicleswithanery- tests, performedifRPR/VDRLispositive,forconfi Treponemal tests:FTA-ABS andMHA-TPareveryspecifi sults formanyconditions. Laboratory test(VRDL).Thesearenonspecific andcangivepositivere- Screening: nontreponemaltestsareRPRorVenereal DiseaseResearch risk of neonatal infection ↑ riskofneonatal ↑ riskofcervicalcancer large numberofsymmetricallyplacedulceratedlesionsonthevulva.What withurination.Onphysicalexam,shehasa of vulvarpainanddiscomfort A 17-year-old G1P1femalepresentstoyouroffi ce complainingof5days Viral culturesorTzanck smear todiagnoseherpessimplexvirus. rst episode: Thisisdefi Malaise, myalgias,fever,vulvarburning, orvulvar ned as initial infectionbyHSV-2 rmation. c diagnostic c Sexually Transmitted Infections

HIGH-YIELD FACTS and Vaginitis Treatment of AIDS is Treatment palliative and not curative. Always biopsy an undiagnosed suspicious a lesion in order to obtain nitive diagnosis. defi Cesarean delivery is indicated for active herpes infection. c. 329 5 days; valtrex 500 mg TID × 5 days; valtrex 500 Acyclovir 400 mg rmatory test. rmatory Acyclovir 400 mg BID; valtrex 500 mg daily beginning at at BID; valtrex 500 mg daily beginning Acyclovir 400 mg A 30-year-old G3P3 female presents for a follow-up visit after initial STD visit after initial STD G3P3 female presents for a follow-up A 30-year-old enzyme-linked immunosorbent screening. Her test results include a positive is the next step in the workup? What assay (ELISA) for HIV. c. This is a screening test. This is a screening This is a confi cifi after exposure—fatigue, weight loss, lymphadenopathy, night sweats. night loss, lymphadenopathy, after exposure—fatigue, weight by a long asymptomatic period lasting months to years. This is followed wasting. used in pregnancy. BID for 7–10 days. daily for 7 days. 36 weeks of pregnancy. ACTORS Order a Western blot to confi rm antibodies against HIV. blot to confi Answer: Order a Western Vertical transmission. Vertical It is sensitive but not as specifi to HIV. ELISA: Detects antibodies rmation if ELISA is positive. It is very spe- blot: Done for confi Western Intravenous drug use. Blood transfusions between 1978 and 1985. Prostitution. Multiple sex partners/unprotected sex. Bisexual or homosexual partners. Mononucleosis-like illness occurring weeks to months infection: Mononucleosis-like Initial infections, dementia, depression, Kaposi sarcoma, AIDS: Opportunistic development. is under A vaccine and can be that is dosed less frequently, is another antiviral Famciclovir 7–10 days; valtrex 500 mg valtrex 500 mg 7–10 days; 400 mg TID × Acyclovir outbreak: Primary infection: Recurrent Pregnancy: Viral cultures of fl vesicle/ulcer. unroofed from an uid of fl cultures Viral PCR. against HSV. for antibodies blot assay Western An alternative means of testing if the Western blot is indeterminate. blot is indeterminate. PCR: An alternative means of testing if the Western F IAGNOSIS ISK RESENTATION CIENCY VIRUS (HIV) AND (HIV) HUMAN VIRUS IMMUNODEFICIENCY (AIDS) SYNDROME DEFICIENCY IMMUNE ACQUIRED REATMENT D R P HIV is an RNA retrovirus that causes AIDS. The virus infects CD4 lympho- HIV is an RNA retrovirus that causes cytes and other cells and causes ↓ cellular immunity. T not curative. is palliative and for HSV Treatment Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS T D perineum,anus,external genitalia, vagina,andcervix. Warts ofvarioussizes(sometimesdescribedascauliflower-like papules)onthe P T 330 REATMENT REATMENT CHANCROID (HPV) PAPILLOMAVIRUS HUMAN RESENTATION IAGNOSIS can bedonetoconfi special media, that requires special growth conditions. special media,thatrequiresgrowth stain returnsaschancroid.What isthecausativeorganism? Highlyactiveantiretroviraltherapy(HAART) isused.Itconsistsofvarying SeeChapter24fortreatmentofcervicaldysplasia. aretreatedwithcryosurgery, acuminata laserablation, Condylomata CervicaldysplasiacausedbyHPVinfectionisscreenedviaPap smear. Warts arediagnosed onphysicalexam.Biopsycanbedoneforconfi Subtypes16,18,31,and33areassociated withcervicalandpenile can- Subtypes 6and11areassociated warts(condylomata withgenital CD4 T-cell countsandplasmaHIV-RNA viralloadaremeasuredto Answer: Condylomataacuminatacanbediagnosedonphysicalexam.Biopsy Answer: electrocautery, trichloroaceticacid, andaldaracream. cer. acuminata). monitor patient’s responsetotherapy. nonnucleoside inhibitors,andproteaseinhibitors. reversetranscriptase combinations ofnucleoside/nucleotide inhibitors, reversetranscriptase mation. What testcanhelptomake a defi her vulva.Onexam,numerousirregular, colored,raisedlesionsarenoted. on A 16-year-old G0P0femalepresentscomplainingofpainlessgrowths gray basealongwithinguinallymphadenopathy.gray The cultureandgram vulva. Onexam,thereisanirregulardeep,well-demarcated ulcerwitha A 21-year-old G1P1femalepresentswithapainfulgenitalulceronthe Haemophilus ducreyi,thediagnosisisconfi rmed withaculturein rm. nitive diagnosis? nitive r- Sexually Transmitted Infections

HIGH-YIELD FACTS and Vaginitis Herpes: Multiple base red. painful ulcers, Chancroid: 1–3 painful ulcers, base yellow gray. Syphilis: 1 painless indurated. ulcer, Lymphogranuloma venereum: 1 painless not indurated. ulcer, Granuloma inguinale: elevated, rolled, Ulcer, rough. Distinguishing painful Distinguishing lesions ulcerating genital with vesicles: 331 sh.” A 26-year-old female presents after unprotected sexual intercourse with female presents after unprotected A 26-year-old suspect pediculosis pubis. How do you intense genital pruritus. You rm the diagnosis? confi a painful ulcer (unlike syphilis, which is hard and painless) with a gray, a gray, and painless) with which is hard ulcer (unlike syphilis, a painful with ragged edges. base, nonindurated, which has a crablike appearance Answer: By visualizing the mite Phthirus pubis, Pyrethrin, permethrin (Nix) cream, or lindane (Kwell) shampoo. is also necessary. of clothing and bedding Proper cleaning in pregnancy. Lindane is contraindicated Reevaluate after 7 days. History of pruritus. Visualization of crabs or nits. Pruritus in the genital area from parasitic saliva. seen in the pubic hair. Ninety percent are commonly month. The incubation period is 1 is 1 week. period Incubation genitalia on external soft, papule as a presents becomes that Chancroid bubo, also is possible. or lymphadenopathy, Inguinal under microscopy. IAGNOSIS IAGNOSIS RESENTATION RESENTATION PEDICULOSIS PUBIS (CRABS) PEDICULOSIS TIOLOGY TIOLOGY REATMENT REATMENT T D E by Phthirus pubis. The louse is transmitted Blood-sucking parasitic crab louse, close sexual contact. P T or azithromycin. oxacin, Ceftriaxone, ciprofl D Gram stain gram-negative rods in showing of ulcer or inguinal node aspirate fi chains—“school of E rod. a small gram-negative Haemophilus ducreyi, P Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS TABLE 31-1. bacteria tosurvive. Raising thepHallowsother kills mostotherbacteria. an acidicenvironmentthat fl orainthevagina,creates Lactobacillus, thenormal Treatment “Whiff” test partners? Treat sexual fi Microscopic pH discharge Quality of complaints Clinical ndings Vaginitis Negative (nosmell) Normal bacteria Epithelial cells 3.8–4.2 odor, vault invaginal Clear orwhite, no None colonic fl as smallamountsof Streptococcus aswell epidermidis, Streptococcus, Lactobacillus, with include mostly P (N HYSIOLOGIC ORMAL ora 332 VAGINITIS often seenonthecervixduringexam(commonlycalledstrawberry). addition totheclassicfrothy, malodorousdischarge,petechiaeare yellow-green discharge showsmotileprotozoa.What isthetreatmentofchoice? )B Answer: Metronidazoleisthetreatmentofchoicefortrichomoniasis.In discharge andmultiplepetechiaeonthecervix.The wetmountofthe discharge.Onphysicalexam,younoticeafrothy, vaginal yellow-green A 25-year-old G2P2femalecomplains ofalargeamountfoul-smelling Positive (fi topical metronidazole; oralor Oral ortopical Bacteria include Clue cells(epithelial Visualize withsaline o eesr Notnecessary Not necessary > 4.5 adherent to vaginal walls adherent tovaginal or Homogenous intercourse especially aftermenses, Malodorous discharge, Mycoplasma (Haemophilus) and/or Gardnerella surface) attached totheir cells withbacteria white, thin,sticky, ACTERIAL clindamycin shy smell) shy V gray AGINOSIS eaiePositive ornegative Negative Budding yeastand In 10% KOH antifungals) (or othervarious suppository Oral, topical,or 4–4.5 to vaginal walls to vaginal cheese–like,” adherent White, “cottage discharge, dyspareunia edema, odorless Pruritus, erythema, pseudohyphae C ANDIDIASIS imidazole Motile, fl In saline Yes metallic taste) like reactionandhasa has potentialdisulfi (Note: Metronidazole Oral > 4.5 “bubbly” or“frothy” Green toyellow,sticky, pruritus, urethritis discharge, malodorous, Copious, frothy protozoa metronidazole T RICHOMONIASIS agellated, ram- Sexually Transmitted Infections

HIGH-YIELD FACTS and Vaginitis Trichomonas Trichomonas The most common complaint of a patient with candidiasis (yeast infection) is itching. If a woman has a If a woman eld strawberry fi of the cervix,appearance most likely what is the diagnosis? vaginitis. Clinical diagnosis depends the on the examination of vaginal secretions under the microscope and measurement of the vaginal pH. e 333 ceptiv Gardnerella lood discharge and/or discharge , or others (listed in male) ammation. emale F aginal, tampon, contra sponge V ora. e culture site and b sitiv Staphylococcus aureus? Staphylococcus Po e r y FB*; . ndings. e an e , nasal, etc. ound, Mal teria not met, Remov ection or colonization) pursue alternativ If cri diagnoses y potential site fo uma site (Inf An Surgical w tra ed? volv erent . ° C h . The distinguishing features are features are . The distinguishing Candida, and Trichomonas . Suspect TSS er > 38.9 er v e Toxic shock syndrome (TSS) workup. shock syndrome (TSS) Toxic –CNS –Mucous membranes –GI –Liv –Renal –Skin –Cardiac –Muscular –Hematologic –Skin ras –F Are at least three diff organ systems (listed) in ycin Combining vaginal secretions with 10% KOH: Amines vaginal secretions with 10% KOH: Amines “Whiff” test: Combining ycin is based on microscopic fi Diagnosis is based on microscopic Clinical characteristics. Clinical Quality of discharge. pH of dis- to test strip of pH paper, reveal pH: Secretions applied charge. released will give a fi shy odor, indicating a positive test. shy odor, indicating released will give a fi described with the following characteristics. following described with the (bacterial), .g., nafcillin 1–2 g q4h) enous antibiotics Destabilize Antibiotics: of fl normal balance the Douche: Raises the pH. Intercourse: Raises the pH. of infection and/or infl body: Serves as a focus Foreign that cause vaginitis: organisms There are several common indam v l ancom Anti-staph beta-lactam ammation of the vagina and cervix, often resulting in ↑ resulting often and cervix, vagina of the ammation . C reign body * Fo (e b a. c. V c. EFINITION TIOLOGY 1. Assess hemodynamics 1. me and electrolytes Replace volu 2. 3. Intra 3. (Modifi ed, with permission, from Pearlman MD, Tintinalli JE, eds. Emergency Care of the MD, Tintinalli from Pearlman ed, with permission, (Modifi 1998: 615.) McGraw-Hill, . New York: Woman FIGURE 31-1. E Infl pruritus, and usually caused by an identifi able microbe (see Table 31-1). The (see Table able microbe by an identifi and usually caused pruritus, is trichomoniasis. is sexually transmitted that only vaginitis D Sexually Transmitted Infections

and Vaginitis HIGH-YIELD FACTS rod, (likefungi). granules, grampositive+ Actinomyces: sulfa infection withanIUD? What isthemostcommon 334 TOXIC SHOCK SYNDROME SeeFigure31-1. Notasexuallytransmitted infection. CausedbythepreformedStaphylococcusaureustoxin. Arare,acuteillnesscharacterizedbymultiple organinvolvement,hypotension, asunburnrash,andconstitutionalsymptoms. CHAPTER 32 Breast Disease

Breast Anatomy 336 Approach to Breast Complaints 336 Common Breast Complaints 337 BREAST MASS 337

NIPPLE DISCHARGE 338

BREAST PAIN 338

BREAST SKIN CHANGES 339

335 Benign breast disease and breast lumps may be encountered after a physical exam or noted on imaging studies. The following will provide you with a basic guide in the initial evaluation of breast complaints.

BREAST ANATOMY

A 34-year-old G3P3 woman presents with 3 months of pain in her right breast. She reports that her mother had breast cancer at the age of 64, for which she received surgery and chemotherapy. Examination reveals a 2-cm cystic mass to the right of her areola, mobile, somewhat tender. Ultrasound (US) reveals a cystic structure, not complex in nature. Aspiration of the mass yields clear ﬂ uid and relieves her pain. The cyst resolves with aspiration. What is your next management step? Answer: Reassure the patient that the mass is benign in nature. Continue routine clinical breast exams (CBE), annually.

Screening mammogram The breasts: should be performed every Large sebaceous glands located in the anterior chest wall; weigh 1–2 yr beginning at age 200–300 grams (in premenopausal yrs). HIGH-YIELD FACTS HIGH-YIELD 40–49, and annually at Composed of 20% glandular tissue and 80% fat/connective tissue. age 50. CBE should be Lymphatic drainage: performed by a health care Drains to regional nodes in axilla and the clavicle. Blood supply: provider annually. Internal thoracic artery Lateral thoracic artery Posterior intercostal artery Thoracoacromial artery

Rule of 3s: APPROACH TO BREAST COMPLAINTS 3 minute breast exam 3 middle fi ngers used Approach to complaints: for breast exam Biopsy, and take a history of complaint. Breast Disease Breast 3 palpation pressures Record the location of the breast complaint. during exam Examine each breast systematically for at least 3 min. (superfi cial, Age: Document age of the patient—biggest risk factor for develop- intermittent, deep) ment of breast cancer. Screening mammogram: Every 1–2 yr from the age of 40 to 49; after 50, annually. Timing of complaints in relation to menstrual cycle. A breast self-examination (SBE) should be encouraged, and a yearly clinical breast examination (CBE), by a health care provider, is recommended. A SBE should begin at 18 years old and a CBE by a health care provider should begin at age 21. It should take 3–5 minutes to per- Two methods to perform a form a CBE, by a health care provider. breast exam: CBE: Concentric pattern Inspect for skin changes and breast asymmetry. (circular) Exam in supine and sitting position. Vertical (lawnmower Use systemic palpation method. type) Use three middle fi ngers to palpate the breasts. Apply pressure to the breast with the pads of the fi ngers.

336 Flatten the breast against the chest wall during palpation. Apply gentle pressure to the nipple to look for a nipple discharge. Examine for lymph node enlargement in the axillary and supraclavicular area. Examine lymph nodes: Supraclavicular COMMON BREAST COMPLAINTS Infraclavicular Medially Breast Mass Inferiorly Breast mass workup. Laterally (axillary line) History and physical exam: Imaging (ultrasound/MMG/MRI). Aspiration for ﬂ uid. Excisional biopsy (if needed). Suspicious ﬁ ndings (for a If a patient palpates a breast mass that the clinician does not palpate, cancer) on exam:

imaging studies should be ordered (see Figure 32-1). Re-examine and/ Fixed, hard, irregular HIGH-YIELD FACTS or refer to a breast surgeon in 2–3 months if nothing is appreciated on mass clinical examination. Always report detection of a breast mass by its Mass > 2 cm quadrant location (see Figure 32-1). Palpated masses should be aspirated or biopsied. US may help to local- ize deep masses and assist in aspiration and/or biopsy. Over the age of 40, diagnostic mammogram should be the initial imaging modality of choice for a breast lump. If a woman is < 40, evaluation of a breast mass should begin with US (ultrasound) the breast tissue is Suspicious fi ndings (for a more dense. cancer) on mammogram: Ultrasound is the initial imaging modality in women < 40 years of age. Clusters of calcifi cations. US helps to differentiate a cystic versus a solid breast mass. ↑ Aspirate the mass if it is cystic. breast density. Aspiration: Irregular margins of If fl uid is cloudy/bloody, → excisional biopsy and imaging. mass (spiculations). If fl uid is clear and resolution of cyst, then monitor. Breast Disease If cyst remains after aspiration, then excisional biopsy. A palpable mass not detected on US or mammogram requires surgical referral for biopsy/excision. A solid, dominant, persistent mass requires a tissue diagnosis, by aspira- Risk factors for breast tion or biopsy. cancer: A nonpalpable mass, found on an imaging study, requires either follow- Personal hx of breast ing with further imaging or immediate biopsy, depending on how suspi- cancer. cious it appears on the image (“spiculated” masses are very suspicious). Early menarche. The differential diagnoses of benign breast masses: Nulliparity. Fat necrosis is usually a result of trauma to the breast with subse- Alcohol intake. quent bleeding into the breast tissue. It is rare but often confused with Obesity. cancer. The breast may contain a fi rm, tender, ill-defi ned mass that Decreased physical requires surgical excision. activity. Fibroadenoma is a common lesion seen in patients in the age range Use of prolonged HRT of 20–40. They are rubbery, fi rm, freely mobile, solid, and well cir- (> 5 yrs) during cumscribed. Imaging with US can guide biopsy, and if the pathology returns fi broadenoma, it can be followed clinically. menopausal years. Phylloides tumors usually occur in older women and are typically larger than fi broadenomas. They should be removed completely. Fibrocystic breast changes are a pathologic diagnosis and should not be used to describe clinical fi ndings. The classic symptoms include cyclic bilateral breast pain. The signs include ↑ engorgement, pain,

337 and excessive nodularity. These lesions do not place the patient at ↑ risk for cancer but should be completely excised. Risk factors for hereditary Atypical hyperplasia is usually discovered after mammogram-directed biopsy. Complete excision of this mass is warranted, and these lesions breast cancer: ↑ the risk of future breast cancer anywhere in the breasts (not just at Ashkenazi Jew the site of the lesion). Personal hx of breast/ ovarian cancer < 40 yrs old Nipple Discharge Two or more relatives This complaint may represent either benign or malignant breast dis- with breast cancer ease. (< 50 yrs) Bilateral milky discharge from multiple ducts is galactorrhea and may be normal, although it can be associated with hypothyroidism, prolactin-producing tumor, or medications. Medications that can cause a nipple discharge include antipsychotics, antidepressants, gastrointestinal drugs, and some antihypertensives. If galactorrhea persists more than 6 months from the time of breast- feeding, thyroid function tests and prolactin level are warranted. Nipple discharge that is spontaneous and bloody, from a single duct, persistent, and stains the clothes is more likely to be an intraductal carcinoma or papilloma—requires investigation with imaging and biopsy. Imaging begins with mammogram and US. Surgery referral for abnormal ﬁ ndings. Differential diagnoses, in addition to cancer, include the following: HIGH-YIELD FACTS HIGH-YIELD Intraductal papillomas Duct ectasia Galactorrhea

Breast Pain History and physical exam, noting the cyclicity and duration of the pain. Inquire about menstrual history, hormone use, dietary habits (caffeine, tea, sodas, chocolate), and the presences of breast implants Oral contraceptives trauma. commonly cause breast Cyclical pain is bilateral in nature. Pain is ↑ during the luteal phase pain. dissipating with menses onset. Fibrocystic breast changes and cyclical mastalgia may require more than just reassurance if the exam is nega- Breast Disease Breast tive. Noncyclical pain is more likely unilateral, in the following instances: Large breasts, ductal ectasia, inﬂ ammatory breast cancer, pregnancy, and some medications. If clinical exam is negative and the pain is cyclical, reassurance is reasonable. If negative for masses, reassure patient. If positive for masses, order imaging studies. Treatment may consist of reducing intake of caffeine, treatment with nonsteriodal anti-inﬂ ammatory drugs (NSAIDs), acetaminophen, and a “support” bra.

338 E 12

A D 9 3

C B HIGH-YIELD FACTS 6

FIGURE 32-1. Female Breast Quadrants

A: UIQ (upper inner quadrant); B: LIQ (lower inner quadrant); C: LOQ (lower outer quadrant; D: UUQ (upper outer quadrant), majority of breast cancers are detected in this quadrant; E: Tail of Spence (outer portion of breast toward the axilla).

Breast Skin Changes On exam, the skin is inspected for any edema, erythema, or retraction. Ulceration, eczema, and redness around the nipple can be Paget disease. Mammogram and surgery referral is warranted. Erythema, tenderness, and a mass is suspicious for inﬂ ammatory breast cancer (also referred to as “peau d’orange”). Mammogram and surgery referral is warranted. Breast Disease Warmth, tenderness, induration, and erythema may also be mastitis or a breast abscess even in the nonlactating woman. If ﬂ uctuance is appreciated, a breast US and drainage with antibiotics are the treatment of choice.

339 NOTES HIGH-YIELD FACTS HIGH-YIELD Breast Disease Breast

340 CHAPTER 33 Women’s Health Maintenance

Screening Tests 342 PAP SMEAR 342

BREAST EXAMS 342

MAMMOGRAPHY 342

COLON CANCER SCREENING 342

LABORATORY TESTING 343 Immunizations 344 Health Education 344 NUTRITION AND EXERCISE 345 Substance Abuse 345 ALCOHOL 346

TOBACCO 346 Seat Belt Use 346 Safe Sex Practices 347 Physical Abuse 347 DOMESTIC VIOLENCE 347

SEXUAL ASSAULT 348

RAPE-RELATED POSTTRAUMATIC STRESS DISORDER 348

341 Women’s Health Maintenance HIGH-YIELD FACTS Mammography Breast Exams Pap Smear(ACOG, December2009) ous medical conditions anddiseases. patients. Thesetoolsareusedforthepreventionand/orearlydetectionofseri- Obstetricians/gynecologists must beaware ofscreening testssuggestedfortheir 342 Colon CancerScreening SCREENING TESTS pneumococcal vaccine. creatinine, hemoglobin,infl uenza vaccine,tetanus-diphtheria(Td) booster, and glucose, completebloodcount(CBC),urinalysis,ureanitrogen(BUN), coloncancerscreening,cholesterol/lipidfasting mammogram, Annually beginning atage50. Screening beginsatage40.Orderamammogramevery1–2yr. Allfemalesshouldperform breastself-examsoncepermonthbeginning Anannual clinical breast exam(CBE)shouldbeperformed,byahealth This appliestolow-risk women.High-riskwomenrequire morefre- BeginPap testingatage21.Atages21–29,Pap testisevery2years.Af- High-risk patientsincludethosewithinfl ammatory bowel disease, co- Beginscreening atage50inlow-risk patients.Oneoffi ve screening op- Answer: Fecal occultbloodtesting(FOBT),followed bycolonoscopyfor 1. Colonoscopyevery10yr. 5. Double-contrast bariumenemaevery5yr. 4. FOBTwith fl 3. Flexiblesigmoidoscopy every 5 yr. 2. week aftertheir menstrual period). at age18(eg,premenopausalwomenshouldexamine their breastsone care provider,onallwomenbeginning atage21. quent screening. ter 30,Pap testingcanbeevery3years. should beginscreening earlierandmorefrequently. cancer,orcancerpredispositioncolorectal syndrome.Thesepatients lonic polyps,coloncancer,orafamily historyoffamilial polyposiscoli, tions shouldbeselected: positiveresults. screening andhealthmaintenancetestswillsheneed? woman exam.Shehasnotseenaphysicianforseveralyears.What A 65-year-old,postmenopausalwomancomestoyourclinicforawell- This patientwillneedaPap smear, annualclinicalbreastexam, exible sigmoidoscopy. HIGH-YIELD FACTS Women’s Health Maintenance Routine screening for chlamydial and gonorrheal infection is recommended for all sexually active adolescents and high-risk females, even if they are asymptomatic. These tests are done simultaneously as the presence of one of these infections is a high risk for the presence of the other. 343 ESTING T (TSH) ciency virus (HIV): HIV-positive people should be virus (HIV): HIV-positive ciency ESTING ORMONE T NFECTION I H KIN (TB) S LUCOSE RANSMITTED TIMULATING diabetes mellitus (DM), or multiple coronary heart disease risk factors heart disease coronary mellitus (DM), or multiple diabetes obesity). (tobacco, hypertension, coronary artery disease. T G -S History of vascular disease. Family history of DM (one fi two second-degree relatives). rst- or history of DM (one fi Family Obese. History of gestational DM. Hypertension. syndrome. History of polycystic ovarian 55 yr), (CAD) (< of premature coronary artery disease history Family cholesterol. Elevated ≥ 240 mg/dL. parent or sibling with blood cholesterol History of with premature (< 55 yr) History of sibling, parent, or grandparent lipid disorder. Familial American). group (Hispanic/African-American/Native High-risk ethnic tested regularly. risk factors: or if autoimmune disease. or if autoimmune with developmental disabilities. Women who exchange sex for drugs or money. Women who use IV drugs. Women who are in a detention facility. Women sexual partners. History of multiple sexual contacts. History of sex with a partner who has multiple infection (STI). partner has a sexually transmitted whose Persons History of STI. for all sexually active females under age 25. screening Annual testing. requires Exposure to TB-infected person populations. underserved/low-income Medically persons. Immunocompromised Intravenous (IV) drug user. Resident of a long-term care facility. Recent TB skin test converter. Regular testing for teens. immunodefi Human at age 45. every 3 yr beginning Test in a patient with age or more frequent can begin at a younger Screening at age 45. beginning Every 5 yr yr between ages 65 and 75. Every 3–5 if: screening Periodic 50, then every 5 yr. begins at age Screening disease history of thyroid strong family (age 19–64) if screening Periodic HOLESTEROL EXUALLY ASTING UBERCULOSIS HYROID T F T S C Laboratory Testing Laboratory Women’s Health Maintenance HIGH-YIELD FACTS B Periodically forwomenwithDMandwhoareage65orolder. HIV T 344 all must beconsidered bythephysician. factors thatdetermine eachindividual’s diet andexercise requirements, which Good diet and exercise arecrucial forleading ahealthylife.Therearemany ACTERIURIA IMMUNIZAT HEALTH EDUCATION Pneumococcalvaccine ifage65,orsoonerforwomen with: Meningococcal vaccine beforeentering highschoolforthosenotim- Infl HepatitisAvaccine ifathighrisk(suchaschronic liverdisease, illegal Varicella vaccine, oneseries,forthosenotimmunized. HepatitisBvaccine onceforthosenotpreviouslyimmunized. Measles,mumps, rubella(MMR)forallnonimmune women. Tdboosteroncebetweenages11and18,thenevery10yr. Whoareinadetentionfacility. Whoarepregnantorplanning tobecomepregnant. Whohaveinvasivecervicalcancer. tractdisease. Withrecurrentgenital WhoareinanareawithhighprevalenceofHIVinfection. Whoweretransfusedbetween1978and1985. Whosepartnersaremenwhohavesexwith(MSM). WithahistoryofsexwithanHIV-positive partner. Withahistoryofprostitution/IVdrugabuse. Whohavemorethanonesexualpartner. SeekingtreatmentforSTIs. Aged13–65yearsoldannually. Herpeszostervaccine: Singledoseinadultsage 60orolder. Humanpapillomavirusvaccine (HPV):Oneseries forthoseage9–26. SIGIN ESTING munized. of becoming ill.Also for high-riskconditions suchas: drug user,individuals travelingtoendemic countries). Healthcareprovider. Cardiovascular disease. Renal disease. Asthma. Diabetes. Hemoglobinopathy. Immunosuppression. Residentofachronic carefacility. Revaccination after5yrinthesegroups. Infl Alcoholism/cirrhosis. Asplenia. Sicklecelldisease. uenza vaccine annually foranyonewishingtoreducetheir chance T uenza vaccine riskfactors. ESTING IONS W OMEN /U RINALYSIS HIGH-YIELD FACTS Women’s Health Maintenance the body’s the body’s about your GUILTY GUILTY drinking? ANNOYED when people criticize your drinking? you should CUT BACK on your drinking? a drink fi rst thing in a drink fi the morning to steady your nerves or “cure” a hangover (EYE OPENER)? Exercise will ↑ metabolic rate and prevent the storage of fat. CAGE Questionnaire for Alcoholism Have you ever felt like C— Have you ever been A— Have you ever felt G— Have you ever needed E— High-fat diets have adverse High-fat diets have adverse effects on lipid metabolism, body and insulin sensitivity, composition. 345 in resting metabolic rate and loss of lean tis- Using the CAGEeffective in questionnaire has been shown to be very activity. to physical Predisposition Resting metabolic rate. Appetite. Satiety. Body fat distribution. A 53-year-old G1P1 female presents to your offi ce for a well-woman ce for a well-woman G1P1 female presents to your offi A 53-year-old asked about alcohol use, she informs you that she drinks exam. When several glasses of wine every evening. How should you screen for sue. sue and can maintain their weight with higher caloric intake.sue and can maintain weight their milk products). milk pasta). tis- Older women who are physically active are less likely to lose lean Eat 2.5 cups of vegetables vegetables). daily (eat more dark green fruit juices. frozen, or canned). Limit Eat 2 cups of fruit daily (fresh, yogurt, or other for milk, fat or fat free daily (low Drink 3 cups of milk or grilled). daily (baked, broiled, Eat 5.5 oz of meat and beans As one ages, there is a ↓ or Eat 6 oz of grains every day (whole bread, breads, crackers, rice patient’s life. The role of an OB/GYN physician is to provide universal is to provide universal life. The role of an OB/GYN physician patient’s for substancescreening abuse. This can be accomplished by direct or via questionnaire. questioning erate intensity for 30 min on most days of the week. erate intensity for 30 min daily life. Persons should eat from the fi ve food groups daily. The fol- ve food groups daily. should eat from the fi daily life. Persons recommended: are lowing stead of 2–3). the three major transitional periods in a woman’s life: periods in a woman’s major transitional the three 1. control: which and heredity, Genetics 1. Puberty 2. Pregnancy 3. Menopause 2. Nutrition. 3. activity and exercise. Physical Answer: that can affect every aspect of a Substance abuse is a serious condition Physical activity during all stages at mod- of life should include exercise Adjust caloric intake level: for age and physical activity Utilize the Food Guide Pyramid as a tool in making food choices in choices as a tool in making food Guide Pyramid Utilize the Food small meals (ie, 4–6 in- Maintain consisting of frequent a healthy diet factors: by three major determined is body weight One’s during be emphasized should and body weight of nutrition The issues alcoholism? screening for problem drinking. OALS SUBSTANCE ABUSE ABUSE SUBSTANCE G Nutrition and Exercise and Nutrition Women’s Health Maintenance HIGH-YIELD FACTS adolescents. common causeofdeathfor Accidents arethemost 400,000 deaths/yr. death inwomen.Relatedto common causeofcancer Lung canceristhemost Alcohol: Whencomparedtomen, Excessiveusefor Accountsfor100,000 unmetabolized alcohol. which todistribute have lessbodywaterin alcohol metabolismand dehydrogenase tobegin gastric alcohol reduced activityof women haverelatively men. considered excessivefor half thequantity women isaboutone- United States. deaths peryearinthe Tobacco excessive alcoholthanmen(aphenomenoncalledtelescoping): Women experiencemoreacceleratedandprofoundmedical consequences of Alcohol 346 SEAT BELT USE Obstetric effects: Reducedfertility, ↑ Endocrine effects: Smokersreachmenopauseearlierandhave Most commonfactorinchronic obstructivepulmonarydisease Linkedtolungcancer,coronaryarterydisease (CAD),andrespiratory causeofprematuredeath Cigarette smokingisthemostpreventable Fetal alcohol syndrome: Whencombinedwithcigarette smoking,itcancauseoralandesopha- Malignancies. Stroke. Early menopause. Menstrual disorders. Stroke. Cardiomyopathy. Myopathy. Peptic ulcersthatrequire surgery. Cirrhosis. Anexampleofscreening wouldbetheCAGE questionnaire. Two “yes” Accidents causemore deathsthaninfectiousdiseases, pulmonary dis- Deathsduetoaccidents areleading causeofdeath infemalesage13– Childrenwhogrow up exposedtosecondhandsmokehavehigherrates (COPD). diseases. 5As toscreening women: toapply the and avoidable Itisimportant illness intheUnited States. geal cancers. answers hasasensitivityof93%andspecificity of76%foralcoholism. eases, diabetes, andliverkidneydisease. 18. of respiratoryandmiddle earillness. osteoporosis. and placental abruption. and placental premature delivery, low-birth-weight growth restriction, infants,fetal Includes growth retardation, facial anomalies, and mental retarda- facialIncludes growth anomalies,andmental retardation, Teratogenic effectsaredoserelated. tion. Arrange forfollow-up. Assist inquit attempt. Assess willingnesstoquit. Advise toquit. Ask abouttobacco. rates of spontaneous abortion, rates ofspontaneous ↑ riskof HIGH-YIELD FACTS Women’s Health Maintenance Any injury during especially one pregnancy, to the abdomen or breasts, is suspicious for abuse. 347 ndings. IOLENCE V ICTIMS V 33-1) OMESTIC chance of death and serious injury by > 50%. death and serious ↓ chance of ABLE D T EE BLIGATION TO (S peated complaints are often seen in abused pregnant women. tic violence, during the pregnancy. O re- and multiple Late entry into prenatal appointments, care, missed Pregnant women, in general, are at highest risk to experience domes- her fault, nor does she deserve the abuse. sought. fi clinical physician’s and con- private conversation, side to allow refusal to leave the patient’s trol of victim. occur with any woman, in any situation. timized (physically, psychologically, or emotionally) by a current or past psychologically, (physically, timized intimate partner. one they know. gency contraception and side effects of various contraceptive methods. and side effects of various contraceptive gency contraception lion injuries per yr. injuries per lion Listen in a nonjudgmental the patient that it is not fashion, and assure Assess the safety of the patient and her children. general somatic complaints. for The patient calls or visits frequently Pregnant women: at which treatment is A delay between the time of injury and the time of the injuries and the explanation between the patient’s Inconsistencies A history of repeated trauma. perpetrator may exhibit signs of control over the health care team, The violence because it can Every woman should be screened for domestic injuries. Bilateral or multiple is vic- an individual Domestic violence refers to a relationship in which States, women are abused by some- Each year in the United 2 million on safe sex practices. Education to postpone sexual involvement. Encouragement emer- about contraceptive options, including Provision of information mil- and 4–5 per yr deaths for 50,000 account accidents Motor vehicle belts Seat head, eyes, neck, torso, breasts, abdomen, and/or genitals. Injuries to the EDICAL IAGNOSIS ECOGNITION OF PHYSICAL ABUSE PHYSICAL SAFE SEX PRACTICES SEX SAFE M D questionnaire. Use screening R Domestic Violence Improved and successful prevention of pregnancy and STIs by more adoles- prevention of pregnancy and Improved and successful includes: counseling that cents requires Women’s Health Maintenance HIGH-YIELD FACTS during EACHtrimester. be questionedaboutabuse All pregnantwomenshould physical abuse. relationships involving approximately two-thirdsof Sexual abuseoccursin TABLE 33-1. 5. Are you afraid of your partner oranyoneyoulistedabove? Areyouafraidofyourpartner 5. 4. Within thepastyear, hasanyoneforcedyoutohavesexualactivities?Hasin thepastforcedyoutohave bysomeone? Sinceyou’vebeenpregnant,haveyouhit,slapped,kicked,orotherwisephysicallyhurt 3. Within thepastyear, bysomeone? have youbeenhit,slapped,kicked,orotherwisephysicallyhurt 2. toyou? orsomeoneimportant Haveyoueverbeenemotionallyorphysicallyabusedbyyourpartner 1. sexual activities? AbuseAssessmentScreen S stress ofbeing raped. A “rape-trauma”syndromeresultingfromthepsychologicalandemotional Rape-Related Posttraumatic StressDisorder(RR-PTSD) Sexual Assault 348 GSAND IGNS stat, then2tabs12 600mg×1dose. hrlater;(3)mifepristone(RU486) Acute phase: Rapeisdefi ned assexualintercoursewithouttheconsentofoneparty, Sexual assault occurswhenanysexualactisperformedbyoneperson Carefullydocumentallsubjectiveandobjectivefi ndings. Therecords Ifthepatientisnotreadytoleave,discuss asafetyorexitplanandpro- Ifthepatientisreadytoleaveabusiverelationship,connectherwith Reorganization phase: Answer: physical or mental condition.physical ormental whether fromforce,threatoforincapacity toconsentdue on anotherwithoutthatperson’s consent. abuse. can beusedinalegalcasetoestablish vide thepatientwithdomesticviolenceinformation. resources suchasshelters,police,publicagencies, andcounselors. Gynecologic complaints Nightmares Flashbacks Phobias Anxiety/depression. Generalized physicalcomplaints andpains(ie,chestpain,back- Vaginal itch,pain,anddischarge. Eatingandsleepdisorders. aches, andpelvicpain). S contraception? raped thenightbefore.What areheroptionsifshedesiresemergency A 27-year-old G0P0female presentstoyouroffi ce statingthatshewas YMPTOMS (1) PlanB:0.75 mglevonorgestrelq12h ×2doses;(2)Oral:tabs HIGH-YIELD FACTS Women’s Health Maintenance The annual incidence of sexual assault is 73 per 100,000 females. ve percent of Seventy-fi rape victims know their perpetrator. Physicians are not obligated Physicians are procedures if to perform they are morally opposed. There is an obligation to refer patients as necessary. The greatest danger for spousal abuse to occur involves a threat or an attempt to leave the relationship. 349 then 2 more tabs 12 hr later; single dose. Plan B (levonorgestrel): Consists of two tablets, each 0.75 mg taken rate is 1%. 12 hr apart. Failure Ovral (50 μg ethinyl estradiol, Combined estrogen-progestin pills: 0.5 mg norgestrel): 2 tabs PO STAT, 75% effective. 1 g PO in a single dose or azithromycin Ceftriaxone 125 mg IM + 2 g PO in a Doxycycline 100 mg PO BID × 7 days + metronidazole seal and store safely. of photographs, and reporting of the incident to the authorities. reporting of the incident of photographs, and hepatitis B/C). hepatitis (even if the health care provider is female). health care provider (even if the Gonorrhea, chlamydia, and trichomonal infec- Infection prophylaxis: Gonorrhea, chlamydia, tions: when indicated. Td toxoid Administer regimen: Postcoital Offer the hepatitis B vaccine. Offer anti-virals for HIV prophylaxis. and clothing. Collect appropriate samples Maintain the chain of command. name; with the patient’s Label photographs, clothing, and specimens and psychological counseling. care medical follow-up Arrange for Obtain taking for treatment, collection of evidence, informed consent record events. Accurately Accurately describe injuries. syphilis, (HIV, Obtain bloodwork for STI’s cultures; check appropriate patient and provide STI prophylaxis. Counsel therapy for unwanted pregnancy. Provide preventive and emotional status. Assess psychological intervention. Provide crisis history. and gynecologic Obtain complete medical female chaperone the presence of a injuries in Assess and treat physical Physician’s Legal Responsibilities Legal Physician’s Physician’s Medical Responsibilities Physician’s ANAGEMENT REATMENT T M Women’s Health Maintenance HIGH-YIELD FACTS 350 NOTES CHAPTER 34 Female Sexuality

Female Sexual Response 352 FEMALE RESPONSE CYCLE 352

SEXUALITY: FETUS TO MENOPAUSE 352

SEXUAL DYSFUNCTION 353

351 FEMALE SEXUAL RESPONSE

It is important to consider every aspect of a woman’s health, including her sexuality. Evaluation of sexual function should be a basic part of any well- woman exam.

Female Response Cycle Desire: Begins in the brain with perception of erotogenic stimuli via the special senses or through fantasy. After somatosensory Arousal: stimulation, orgasm is an Clitoris becomes erect. adrenergic response. Labia minora become engorged. Blood ﬂ ow in the vaginal vault triples. Upper two-thirds of the vagina dilate. Lubricant is secreted from the vaginal surface. Lower one-third of vagina thickens and dilates. Plateau: Unlike men, women can The formation of transudate (lubrication) in the vagina continues in experience multiple conjunction with genital congestion. orgasms without a time lag Occurs prior to orgasm. in between. Orgasm: Rhythmic, involuntary, vaginal smooth muscle and pelvic contractions, leads to pleasurable cortical sensory phenomenon (“or-

HIGH-YIELD FACTS HIGH-YIELD gasm”).

Sexuality: Fetus to Menopause

PRENATAL AND CHILDHOOD Sexual development begins prenatally when the fetus differentiates into a male or female. Sexual behavior, usually in the form of masturbation, is common in childhood. It is normal for children As children grow older, they are socialized into cultural emphasis on under age 6 to be curious privacy and sexual inhibition in social situations. about their own or others’ Between ages 7 and 8, most children engage in childhood sexual bodies. games, either same-gender or cross-gender play. Female Sexuality Female ADOLESCENCE Gender identity and sexual preferences begin to solidify as puberty begins.

MENSTRUAL CYCLE The menstrual cycle can affect sexuality (ie, in some women, there is a peak Sexual intercourse should in sexual activity in the midfollicular phase). be avoided in high-risk pregnancies, such as PREGNANCY placenta previa, placental For some women, intercourse is avoided during pregnancy due to fear abruption, preterm labor, of harming the baby or a self-perception of unattractiveness. and preterm ruptured Coitus is safe until 36 weeks in normal pregnancies. membranes.

352 POSTPARTUM Women often experience sexual problems within the ﬁ rst 6 weeks of delivery, including: Perineal soreness. Excessive fatigue. Disinterest in sex. This is secondary to changing hormone levels.

MENOPAUSE A ↓ in sexual activity is most frequently observed. Advancing age is associated with ↓ in: Intercourse frequency. Orgasmic frequency. Enjoyment of sexual activity: Sexual enjoyment may also be ↓ with the ↑ duration of the relationship and with the partner’s increasing HIGH-YIELD FACTS age. ↓ sexual responsiveness may be reversible if caused by reduction in functioning of genital smooth muscle tissue. Psychosocially, middle-aged women often feel less sexually desirable. Hormonal changes: Low estrogen levels lead to less vaginal lubrication, thinner and less elastic vaginal lining, and depressive symptoms, resulting in ↓ sexual desire and well-being.

Sexual Dysfunction It is important to ﬁ rst clarify whether the dysfunction reported is: Lifelong or acquired. Global (all partners) or situational. Female Sexuality EVALUATION STRATEGIES Look for possible etiologies: Medical illnesses. Menopausal status. Medication use (antihypertensives, cardiovascular meds, antidepressants, etc.). Rule out other psychiatric/psychological causes: Life discontent (stress, fatigue, relationship issues, traumatic sexual history, guilt). Major depression. Drug abuse. Anxiety. Obsessive-compulsive disorder.

MANAGEMENT STRATEGIES Medical illnesses need evaluation and speciﬁ c treatment. Screen for and treat depression with psychotherapy or medication. Reduce dosages or change medications that may alter sexual interest (ie, switch to antidepressant formulations that have less of an impact on sexual function). Address menopause and hormonal deﬁ ciencies.

353 FEMALE SEXUAL DYSFUNCTION DISORDERS Hypoactive sexual desire disorder: Persistent or recurrent absence or deﬁ cit of sexual fantasies and desire for sexual activity. Sexual aversion disorder: Persistent or recurrent aversion to and avoid- Sexual arousal disorders ance of genital contact with a sexual partner. are accompanied by Sexual arousal disorder: complaints of dyspareunia, Partial or total lack of physical response as indicated by lack of lubri- lack of lubrication, or cation and vasocongestion of genitals. orgasmic difﬁ culty. Persistent lack of subjective sense of sexual excitement and pleasure during sex. Female orgasmic disorder: Persistent or recurrent delay in, or absence of, orgasm following a normal excitement phase. Vaginismus: Persistent involuntary spasm of the muscles of the outer Lack of orgasm during third of the vagina, which interferes with sexual intercourse. intercourse is a normal variation of female sexual EVALUATION FOR A SEXUAL DYSFUNCTION DISORDER response if the woman is Take sexual experience into account. Women often become more or- able to experience orgasm gasmic with experience. with a partner using other, Physical factors that may interfere with neurovascular pelvic dysfunc- noncoital methods. tion (ie, surgeries, illnesses, or injuries). Psychological and interpersonal factors are very common (ie, growing up with messages that sex is shameful and for men only). Partner’s lack of sexual skills.

HIGH-YIELD FACTS HIGH-YIELD Sildenaﬁ l citrate (Viagra) and other vasodilators are TREATMENT FOR SEXUAL DYSFUNCTION currently undergoing Treatment varies and in general involves the couple. Therapy should be insti- clinical trials with women tuted for both partners, in addition to the following: for sexual dysfunction Treat the ↓ lubrication with the application of lubricants, such as KY treatment. Jelly or Astroglide. Menopausal symptoms may respond to oral or topical estrogen. For lifelong, generalized orgasmic disorder, there is rarely a physical cause. Treat with masturbation programs and/or sex therapy.

SEXUAL PAIN DISORDERS Exogenous administration Dyspareunia: Recurrent genital pain before, during, or after inter- of estrogen improves course. Female Sexuality Female vaginal lubrication, atrophic Evaluation: Differentiate between physical disorder, vaginismus, lack conditions, hot ﬂ ashes, of lubrication. headaches, and insomnia. Management: If due to vaginal scarring/stenosis due to history of episiotomy or vaginal surgery, vaginal stretching with dilators and massage. If postmenopausal, vaginal estrogen cream to improve vaginal pli- ability. Low-dose tricyclic antidepressants may be helpful. Pelvic ﬂ oor physical therapy (Kegel exercises). Menopause and Sexual Coital position changes. Dysfunction Vaginismus: Recurrent involuntary spasm of the outer third of the va- Menopause → vaginal gina (perineal and levator ani muscles), interfering with or preventing atrophy and lack of coitus. adequate lubrication → painful intercourse →↓ sexual desire.

354 Evaluation: Obtain history. Rule out organic causes (ie, vaginitis, endometriosis, pelvic inﬂ am- Many antidepressants matory disease, irritable bowel syndrome, urethral syndrome, inter- worsen the sexual response stitial cystitis, etc.). Examine the pelvis for involuntary spasm. by increasing the Rule out physical disorder or other psychiatric disorder. availability of serotonin Management: and decreasing dopamine. Treat organic causes. Psychotherapy. Provide reassurance. Physical therapy (ie, Kegel exercises, muscle relaxation massage, and gradual vaginal dilatation). The woman controls the pace and Estrogen use, in a duration. postmenopausal female, improves sexual desire. HIGH-YIELD FACTS Female Sexuality

355 NOTES HIGH-YIELD FACTS HIGH-YIELD Female Sexuality Female

356 CHAPTER 35

EthicsETHICS

End-of-Life Decisions 358 Life-Sustaining Treatment 358 Reproductive Issues 358 Informed Consent 359 Patient Conﬁ dentiality 359 EXCEPTIONS 359

357 Ethics HIGH-YIELD FACTS conditions. the spousecannotdefy durable powerofattorney, another persontobea living willorhasappointed If amarriedpersonhas It isthephysician’s responsibilityto: outcomes ofthedecision being made. sions easierbutwilllikelycausethephysician tomorecloselyconsiderthe derstanding thevariousaspectsofforensicmedicine maynotmakethesedeci- Physicians inallfi elds ofmedicine encounterdiffi cult ethicaldecisions. Un- 358 The ethicalresponsibilityofthephysician is: medical condition. Any treatmentthatservestoprolonglifewithout reversing theunderlying LIFE-SUSTAINING TREATMENT DEC END-OF-LIFE REPRODUCTIVE ISSUES REPRODUCTIVE someone asherdurablepowerofattorneytomakedecisionsonbehalf. In a Thepatient’s legalspouseisthedefacto durablepower ofattorney for In a Advance directives(livingwillanddurablepower ofattorneyfor Honorthepatient’s wishes,whenthepatientcannolongerspeakfor Determine thepatient’s preferences. To explainhisor herpersonalviewstothepatientandhow thoseviews To behonest andfairtotheir patients whentheyseekadviceorservices To identifyhis orherown opinions ontheissueathand. Answer: Shecaneitherwritealivingwill(dictatesherpreferences)orappoint petent tomakesuchadecision. systems intheeventthatinjuryorillnessrendersindividual incom- and provideavalidconsenttothewithholding/withdrawal oflife-support pointed durablepower ofattorney. tions ofalivingwillormakedecisions ifanotherpersonhasbeenap- health careifnootherisappointed; thespousecannotdefycondi- participate intheconsent process. someone toactasasurrogatedecision makerwhenthepatientcannot ment iffacedwithapotentiallyterminal illness. health care)allow patientstovoice their preferencesregarding treat- herself. may influence theservice oradvicebeing provided. in thisarea. speak forherself. What options doesshehave? to delineatepreferencesforhercare,intheeventthatsheisunable A 35-year-old G2P2femaleis scheduledformajorsurgery. Shewouldlike living will,acompetent,adultpatientmay, inadvance, formulate durable power ofattorney forhealthcare,apatientappoints ISIONS HIGH-YIELD FACTS Ethics 359 of the procedure are discussed. ts of the procedure ed. voluntary. age minors to involve their parents. to involve their age minors care and should not notify to consent to medical a competent minor consent. the parents without the patient’s and there is reason to believe will face a serious health threat, the minor the problem to the parents is that the parents will be helpful, disclosing justifi equally person. questions the patient has. questions Risks and benefi discussed. Alternatives to procedure are are discussed. the procedure Consequences of not undergoing When minors request confi dential services, physicians should encour- dential services, physicians confi request When minors should permit otherwise, the physician does not require Where the law parental feels that without If the physician involvement and guidance (ie, HIV). diseases Communicable wounds. Gunshot wounds. Knife A patient threatens to infl ict serious bodily harm to herself or another ict serious bodily threatens to infl A patient and answer any to discuss the procedure and answer any be willing must Physician ever, minors may give their own consent for certain own treatments, such as al- may give their ever, minors diseases. cohol detox and treatment for venereal INORS PATIENT CONFIDENTIALITYPATIENT INFORMED CONSENT XCEPTIONS E 3. be competent. The patient must Exceptions The information disclosed to a physician during his or her relationship with during his or to a physician The information disclosed should not reveal information or dential. The physician the patient is confi to unless required without the express consent of the patient, communications do so by law. The following are certainThe following consent need not be ob- cases in which informed tained: 1. emergency. Lifesaving medical prevention. 2. Suicide have consent obtained parents. How- from their must minors Normally, 3. 2. Information: A legal document that requires a physician to obtain to a physician treatment consent for that requires A legal document procedures. diagnostic or many an operation performed, rendered, be met: conditions the following consent requires Informed be 1. Must M Ethics HIGH-YIELD FACTS 360 NOTES CHAPTER 36 Menopause

Deﬁ nitions 362 Factors Affecting Age of Onset 362 Physiology During the Perimenopausal Period 362 OOCYTES DIE 362

OVULATION BECOMES LESS FREQUENT 363

ESTROGEN LEVELS FALL 363 Physiology During the Menopausal Period 363 Treatment of Menopausal Adverse Effects 364 ESTROGEN REPLACEMENT THERAPY 365

HORMONE REPLACEMENT THERAPY 365

361 Menopause signiﬁ es the depletion of oocytes and manifests as the absence of menses. The changes in female hormones can have signiﬁ cant morbidity for a woman. A variety of symptoms can occur, that can require medical treatment. The treatment may have adverse effects in some women, so its use should be considered carefully.

DEFINITIONS

Menopause is the permanent cessation of menstruation caused by failure of ovarian estrogen production, in the presence of elevated gonado- Average age of menopause tropin levels (diagnosed after 6–12 months of amenorrhea). in the United States is Menopause is preceded by the climacteric or perimenopausal period, about 51 years. the multiyear transition from optimal menstrual condition to menopause. The postmenopausal period is the time after menopause. See Figure 36-1.

Cigarette smoking is a factor shown to signiﬁ cantly FACTORS AFFECTING AGE OF ONSET reduce the age of menopause (3 yr). Genetics. Smoking (↓ age by 3 yr). HIGH-YIELD FACTS HIGH-YIELD Chemo/radiation therapy.

PHYSIOLOGY DURING THE PERIMENOPAUSAL PERIOD

Oocytes Die Women’s immature eggs, or oocytes, begin to die precipitously (via apoptosis) and become resistant to follicle-stimulating hormone (FSH), the pituitary hormone that causes their maturation. Menopause

FIGURE 36-1. The STRAW staging system.

(Reproduced, with permission, from Soules MR et al. Executive Summary: Stages of Repro- ductive Aging Workshop [STRAW]. Fertil Steril 2001;76[5]: 874–878.)

362 Menopause is characterized by an elevated FSH due to: 1. ↓ inhibin (inhibin inhibits FSH secretion; it is produced in smaller amounts by the fewer oocytes). 2. Resistant oocytes require more FSH to successfully mature, triggering greater FSH release. FSH levels double to 20 mIU/mL in perimenopause Ovulation Becomes Less Frequent and increase to 40 in menopause. Women ovulate less frequently: Initially 1–2 fewer times per year, and eventually, just before menopause, only once every 3–4 months. This is due to a shortened follicular phase. The length of the luteal phase does not change.

Estrogen Levels Fall Oligo/anovulation leads to abnormal bleeding in A 51-year-old female G4P4 complains of new onset of pain with inter- perimenopause. HIGH-YIELD FACTS course and occasional vaginal itching that started in the past 6 months. Workup for sexually transmitted infections (STIs) is negative, and on wet mount you note very few epithelial cells consistent with atrophic vaginitis. What is the major hormonal change implicated in these symptoms? Answer: There is a decline in estrogen that causes atrophic vaginitis.

Estrogen (estradiol-17β) levels begin to decline, resulting in hot fl ashes (which may also be due to ↑ luteinizing hormone [LH]). There is a major reduction in ovarian estrogen production at 6 months before menopause. Hot fl ashes can occur for 2 yr after the onset of estrogen defi ciency begins and can last up to 10 or more years. Hot fl ashes usually occur on the face, neck, and upper chest and last a When menopause occurs few minutes, followed by intense diaphoresis. Women often complain after age 55, it is

of sleep disruption, because of the diaphoresis. considered late menopause. Menopause

PHYSIOLOGY DURING THE MENOPAUSAL PERIOD

↓ in estradiol level. FSH and LH levels rise secondary to absence of negative feedback. Androstenedione is aromatized peripherally to estrone (less potent than estradiol), which is the major estrogen in postmenopausal women. Androstenedione and testosterone levels fall. These two hormones are produced by the ovary. The most important physiologic change that occurs with menopause Premature ovarian failure is the decline of estradiol-17β levels that occurs with the cessation of is deﬁ ned as menopause follicular maturation. Table 36-1 lists the organ systems affected by the occurring before age 40. ↓ estradiol levels.

363 TREATMENT OF MENOPAUSAL ADVERSE EFFECTS

A 50-year-old G1P1 female complains of hot ﬂ ashes for 3 months during the day and night sweats so bad she has to change her shirt. On further questioning, she reports that she has ↑ irritability and a lack of libido for that same period of time. What is this woman’s problem and what treatment could you offer her? Answer: This woman is experiencing menopause. If her symptoms are distressing, she could be offered hormone replacement therapy to alleviate some of her symptoms.

Hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) has been shown to counteract some of the side effects of estrogen loss listed in Table 36-1.

TABLE 36-1. Physiologic Effects of Menopause

ORGAN SYSTEM EFFECT OF DECREASED ESTRADIOL AVAILABLE TREATMENT

Cardiovascular ↑ LDL, ↓ HDL. After two decades of menopause, the risk of HIGH-YIELD FACTS HIGH-YIELD myocardial infarction (MI) and coronary artery disease is equal to that in men.

Bone Osteoporosis. Estrogen receptors found HRT/ERT becoming second line on many cells mediating trabecular bone Calcitonin maintenance (ie, ↓ osteoblast activity, Raloxifene ↑ osteoclast activity) due to ↓ estrogen Etidronate (a bisphosphonate osteoclast levels. inhibitor) Exercise Calcium supplementation 50% reduction in death from hip fracture with

Menopause normal estrogen levels

Vaginal mucous Dryness and atrophy, with resulting HRT/ERT pill or cream membranes dyspareunia, atrophic vaginitis.

Genitourinary Loss of urethral tone, dysuria. HRT/ERT

Psychiatric Lability, depression. +/– HRT/ERT, antidepressants

Neurologic Preliminary studies indicate there may be a link HRT/ERT between low levels of estradiol and Alzheimer disease.

Hair and skin Skin: Less elastic, more wrinkled. HRT/ERT pill or cream Hair: Male growth patterns.

ERT, estrogen replacement therapy; HDL, high-density lipoprotein; HRT, hormone replacement therapy; LDL, low-density lipoprotein.

364 Estrogen Replacement Therapy (ERT) ERT—estrogen alone: Indicated in women status post hysterectomy. Although HRT recommendations changed Hormone Replacement Therapy (HRT) with the WHI study, there HRT—estrogen + progesterone: The progesterone component is are many fl aws in the needed to protect the endometrium from constant stimulation and re- design. Recommendations sultant ↑ in endometrial cancer. It is indicated for women who still will likely change in the have their uterus. near future. The Women’s Health Initiative (WHI) and the Heart and Estrogen/ Progestin Replacement Study (HERS) have prompted great changes in the understanding and recommendations of HRT. Cardiovascular: HRT does not seem to protect against cardiovascular disease. In fact, it could make it worse. Osteoporosis: Controversial because they protect against osteoporosis but there are other medications, such as bisphosphonates and ralox- Menopause wreaks HIGH-YIELD FACTS ifene, that can do the same thing. HAVOC: Breast cancer: Seen to ↑ the risk of breast cancer. Hot fl ashes Atrophy of the INDICATIONS FOR HRT IN MENOPAUSE Vagina Presence of hot fl ashes. Osteoporosis Prevention of atrophic vaginitis. Coronary artery disease

RECOMMENDATIONS Short-term therapy (< 5 yr) is acceptable for menopausal symptom relief. Prescribe the lowest dose that relieves the symptoms. Order a mam- Estrogen creates a mogram before initiating therapy and yearly thereafter. hypercoagulable state due Osteoporosis can be prevented with HRT; however, other medications to ↑ production of hepatic are as effective and can be used as ﬁ rst-line therapy. coagulation factors. HRT should not be used to prevent cardiovascular disease.

RISKS OF HRT/ERT Menopause ↑ risk of breast cancer. ↑ incidence in endometrial cancer (ERT only). Thromboembolism, myocardial infarction (MI), stroke. Cholecystitis/cholelithiasis.

CONTRAINDICATIONS TO HRT/ERT Unexplained vaginal bleeding. Breast carcinoma (relative contraindication, not absolute). Metastatic endometrial carcinoma/ovarian carcinoma. Liver disease. History of thromboembolic disease. History of MI or stroke. May worsen hypertension or migraines.

365 NOTES HIGH-YIELD FACTS HIGH-YIELD Menopause

366 CHAPTER 37 Pelvic Relaxation

Anatomy of Pelvic Floor Support 368 Prolapse 368

367 Pelvic Relaxation HIGH-YIELD FACTS through thevagina. introitus, orprotruding the uppervagina,to prolapse aseitherlimitedto In general,thinkof and coccygealmuscles. made upofthelevatorani The pelvicdiaphragmis ture: anterior,apical,andposterior. Prolapses canbeclassifi ed according tothelocationofprotruding struc- T their normalposition. Thereareseveraltypes. Prolapse isthefailureofpelvicmusculatureorgansin tomaintain turbance ofanythefollowing canresultinprolapse: Several crucial structuresmakeupthesupportoffemalepelvicfl surgery orapessarydevice. standing. Whenprolapsebecomessymptomatic,treatmentiswarrantedwith pressure. Diagnosismust bemadeexamining thepatientwhensupineand can occurinvariousorgansandisusuallyassociated withasensationof↑ will nolongerbeabletokeeppelvicorgansintheir properposition.Prolapse With agingand↑pelvicpressure,thereisariskthatthemusculature 368 YPES PROLAPSE ANATOMY OF PELVIC FLOOR SUPPORT of theprolapse. patient inboththesupineandstandingpositiontohelpdetermineseverity unia. What isyournextstepinmanagementofthispatient? Perineum. Urogenital diaphragm. Pelvic diaphragm. Endopelvic fascia. Cardinal broadandroundligaments. Bony structure. Posterior: Apical: Anterior: Answer: Enterocele(intestine):SeeFigure 37-1 Rectocele:SeeFigure37-1 Vaginal prolapse Uterocele Cystourethrocele Cystocele (bladder) vagina thatisworsewhencoughing, andhasarecentonsetofdyspare- vagina dren comestoyouroffi ce complainingofpressureandabulgeinher A 57-year-old G8P8overweightwoman(250 lbs)whohashadthreechil- Perform acompletepelvicexamtoassessforprolapse.Examine the Perform oor. Dis- HIGH-YIELD FACTS Pelvic Relaxation Advancing age Advancing obstruction Chronic Constipation predisposition Genetic Menopause Parity surgery Prior disease Pulmonary Tumor/mass Risk factors for developing prolapse: 369 da, myelomeningocele. da, ) LASSIFICATION C ALKER Types of prolapse. Types -W YMPTOMS ADEN S abdominal pressure: Obesity, cough (eg, chronic obstructive pulmo- cough (eg, chronic pressure: Obesity, abdominal (B tiple sclerosis. ↑ heavy lifting. nary disease), ACTORS To the level of the ischial spines: To Between ischial spines and introitus: Up to introitus: introitus: Grade II Past Grade I Grade III Grade IV upon exertion. Organ protrusion, especially Incontinence. pain. Groin Dyspareunia. Spotting. Splinting to defecate. Loss of connective tissue: Spina bifi after menopause. Atrophy of supporting tissues: Aging, especially of “pressure.” Feeling function: Postpartum. Loss of levator ani of supporting tissue: Postsurgical. Transection paralysis, mul- Loss of innervation: Amyotrophic lateral sclerosis (ALS), F RADING ISK IGNS AND S Many conditions can cause prolapse: Disturbing the anatomical supports can cause prolapse: Disturbing the anatomical Many conditions pressure. the innervations, or increasing abdominal (childbirth), disrupting Examples include: R Organ displacement: Benson & Pernoll’s Handbook of Obstetrics ML. Benson & Pernoll’s from Pernoll (Reproduced, with permission, 2001: 807–808.) McGraw-Hill, and Gynecology, 10th ed. New York: FIGURE 37-1. FIGURE 37-1. Symptom alleviation/exacerbation is often related to pelvic effort (ie, better Symptom alleviation/exacerbation is often related to pelvic effort (ie, with standing, worse in evening). worse when prone, better in the morning, G Pelvic Relaxation HIGH-YIELD FACTS organ prolapse: Complications ofpelvic is contraindicated. population orwhensurgery useful intheelderly Pessaries areespecially and standingpositions. patient inboththesupine Remember toexaminethe Vaginal bleeding Ulcerations tractinfections Urinary Constipation Urinary retention T D 370 REATMENT IAGNOSIS Surgical Nonsurgical There areseveraltypesofsurgicalrepairsforeachtypeprolapse. Indications forsurgery:Childbearingiscompletedand/orsymptomsare Symptomatic prolapse: Canbetreatedwithapessaryorsurgically. A Asymptomatic prolapse: Patient shouldbeexamined inthesupine position. andstanding Diagnosis ismadebydirect visualizationofprolapsedorganduring New, minimally invasivetechniques arebeing developed. cal treatment. interfering withpatient’s functioning anddoesnotrespondtononsurgi- supportofthepelvicorgans.Typeshelp maintain include: pessary isanobject(prosthetic)placedintheuppervaginadesignedto complete pelvicexamination. Uterineprolapse:Hysterectomy—auterineprolapseoftenoccursin Gehrung (U-shaped). Infl Doughnut (ring). Smith-Hodge (ovalring). Pelvic-strengthening exercises (ie,Kegelmaneuvers)and/orhor- Usually requires performed. conjunction withanotherprolapse,socombinedrepairsareusually mone/estrogen replacementtherapymaybebenefi performed withanytypeofprolapse. nal inafemalewhoisNOTsexuallyactive.Thisprocedure canbe LeFort procedure/colpoclesis:Surgicalobliterationofthevaginalca- terocele. Similar transvaginal repairexists. and uterosacralligamentsviaabdominal approachtopreventanen- Moschovitzrepair—approximationofendopelvicfascia Enterocele: with levatorani muscles viavaginalapproach. Rectocele: Posterior repair—posteriorvaginalwallreinforcement Cystocele: forcement viavaginalapproach. Kelly plication(anteriorvaginalrepair):Endopelvicfascial rein- the bladderneck. Anterior colporrhaphy:Bladderbuttressbasesuturesproximalto atable. follow-up, butnoimmediate interventionneeded. cial. CHAPTER 38 Urinary Incontinence

Deﬁ nition 372 Causes 372 REVERSIBLE 372

IRREVERSIBLE 372 Evaluation 373 Treatment 373 STRESS INCONTINENCE 373

URGE INCONTINENCE 374

OVERFLOW INCONTINENCE 374

TOTAL INCONTINENCE 374

371 Urinary incontinence is an involuntary loss of urine that can be due to a variety of conditions. It can cause social embarrassment. Cystometrics and Urodynamic studies can help to differentiate between the different types of urinary incontinence. Distinguishing between the types of incontinence is important because management is drastically different. Reversible causes of urinary incontinence— DIAPPERS DEFINITION Delirium Infection Involuntary loss of urine that is a symptom of a pathological condition. Incon- Atrophic vaginitis tinence can be due to reversible or irreversible (but treatable) causes. It inhib- Pharmacologic causes its the patient socially. Psychiatric causes Excessive urine production Restricted mobility CAUSES Stool impaction Reversible Delirium, infection, atrophic vaginitis, drug side effects, psychiatric illness, excessive urine production, restricted patient mobility, and stool impaction are reversible causes of urinary incontinence. Causes of urinary It is helpful to explore these easily correctable causes before moving on incontinence— to the more expensive and invasive workup for the irreversible causes. HIGH-YIELD FACTS HIGH-YIELD This Urine Flow is So Outrageous Irreversible

Total STRESS INCONTINENCE Urge Loss of urine (usually small amount) only with ↑ intra-abdominal Functional pressure (ie, with coughing, laughing, exercise). Stress Caused by urethral hypermotility and/or sphincter dysfunction that Overﬂ ow maintains enough closing pressure at rest but not with exertion.

URGE INCONTINENCE

A 52-year-old G4P4 active female complains of sudden urgency to go to the bathroom followed by loss before she makes it to the bathroom. The

Urinary Incontinence urges are not precipitated by laughing or coughing, nor is she constantly Total incontinence is leaking throughout the day. What is the underlying cause of her incontinence? continuous urinary and/or Answer: This woman has an urge incontinence that is caused by unopposed fecal leakage due to a detrusor muscle contraction. ﬁ stulous tract. This occurs as a result from: Sudden feeling of urgency followed by emptying of bladder. Prior pelvic surgery Caused by unopposed detrusor contraction. Obstetric trauma Radiation OVERFLOW INCONTINENCE Constant dribbling +/– urgency with inability to completely empty the bladder. Caused by detrusor underactivity (due to a neuropathy) or urethral obstruction.

372 MIXED INCONTINENCE Combinations of above.

EVALUATION Functional incontinence: A person can recognize the

HISTORY need to urinate, but cannot make it to the bathroom Ask about aforementioned symptoms, medications, medical history (diabetes because of immobility. mellitus, neuropathies).

PHYSICAL Pelvic exam: Check for cystoceles, urethroceles, atrophic changes, and Q-tip test. Rectal exam: Check for impaction and rectocele; assess sphincter tone. Neurological exam: Assess for neuropathy. HIGH-YIELD FACTS

LABS Urinalysis and culture to rule out urinary tract infection.

Q-TIP TEST A cotton swab is placed in the urethra. The change in angle between Q-tip test: ↑ upward the Q-tip and the woman’s body is measured upon straining. motion of the Q-tip is Normal upward change is < 30 degrees, and a positive test is one with caused by loss of support > 30-degree change. from the urethrovesicular A positive test indicates stress incontinence. junction, indicating stress incontinence. CYSTOMETRY Cystometry provides measurements of the relationship of pressure and volume in the bladder. Urinary Incontinence Catheters that measure pressures are placed in the bladder and rectum, while a second catheter in the bladder supplies water to cause bladder fi lling. Measurements include post residual volume, volumes at which an urge to void occurs, bladder compliance, fl ow rates, and capacity. Diagnoses: Stress, urge, and overfl ow incontinence.

URODYNAMIC STUDIES A set of studies that evaluate lower urinary tract function. Stress incontinence treated Studies may include cystometry (see above), bladder ﬁ lling tests, cys- with α-adrenergic agonists toscopy, uroﬂ owmetry, and leak-point pressure tests. Can help diagnose and differentiate between types of incontinence. and surgical repair.

TREATMENT

Stress Incontinence Kegel exercises strengthen urethral muscles. Estrogen therapy. α-adrenergic agonists (eg, phenylpropanolamine, pseudoephedrine).

373 Surgical repair. Burch is the gold standard. Suburethral slings are more popular due to ease of placement. A suburethral sling is the treatment for stress incontinence. Urge Incontinence Medications: Anticholinergics. Calcium channel blockers. Tricyclic antidepressants. Urge incontinence treated Timed voiding: Patient is advised to urinate in prescribed hourly inter- with medications, timed vals before the bladder ﬁ lls. voiding, and dietary Surgery is rarely used to treat urge incontinence. changes. Avoid stimulants and diuretics (ie, alcoholic beverages, coffee, carbon- ated beverages).

Overﬂ ow Incontinence Due to obstruction: Relieve obstruction. Due to detrusor underactivity: Treat possible neurological causes—diabetes mellitus, B12 deﬁ ciency.

HIGH-YIELD FACTS HIGH-YIELD Total Incontinence Surgical repair for ﬁ stulas. Urinary Incontinence

374 SECTION IV: CLASSIFIED Medical Student Information of Interest ᭤ AwardsOpportunities and Opportunities ᭤ Web Sites of Interest ᭤ Web Sites of Interest

375 OPPORTUNITIES

AMA-MSS Councils AMA-MSS Committee AMA POLITICAL ACTION The Medical student section of Application COMMITTEE (AMPAC) the AMA (AMA-MSS) has sev- Medical students are sought to AMPAC is a bipartisan group eral councils for which it seeks serve on the following AMA- that serves to advance the inter- medical students. MSS committees: est of medicine within Congress, specifi cally by supporting candi- Application involves a current Committee on Computers and curriculum vitae, an essay on dates for offi ce that are friendly Technology (formerly Com- why you want to be a member to medicine. They also provide of an AMA Council, which puter Projects Committee) numerous programs to educate Council(s) you prefer, what you Committee on Long Range physicians, medical students, and consider to be your major Planning their families on political activ- ism. The Board directs the pro- strengths and qualifi cations for Legislative Affairs Committee grams and activities of this ex- the position, and what benefi ts Minority Issues Committee you feel are likely to result from tremely important political Ad Hoc Committee on Com- your participation. action committee. Adding medi- munity Service and Advocacy cal students to the leadership of Council on Constitution and Ad Hoc Committee on Mem- this group will provide for better Bylaws bership Recruitment and Re- medical student representation within the group, as well as Council on Ethical and Judi- tention greater student involvement in cial Affairs Ad Hoc Committee on MSS this important process. Terms are Council on Legislation Programs and Activities for two years. Council on Long Range Plan- Ad Hoc Committee on Scien- ning and Development tifi c Issues Committee (CSI) Council on Medical Educa- Ad Hoc Committee on Inter- tion national Health and Policy Council on Medical Service All applications must be com- Council on Scientifi c Affairs pleted and submitted with a CV to American Medical Associa- tion, Department of Medical Student Services, 515 North State Street, Chicago, IL 60610. Fax: (312) 464-5845. CLASSIFIED Opportunities 376 WEB SITES OF INTEREST

ACOG.org Subscription to the Journal of USP Drug Information for the American Medical Wom- the Health Care Professional ACOG.org is the offi cial Web en’s Association (JAMWA), a (free 1998 benefi t for three site for the American Congress quarterly peer-reviewed scien- and four multiyear member- of Obstetricians and Gynecolo- tifi c publication ship options) gists. The Web site has several AMWA Connections, a bi- Discounts up to 35% in items of interest to medical stu- monthly newsletter keeping AMA’s Medical Student Cata- dents, including a career guide you connected to your col- log for medical students interested leagues PaperChase—discounted on- in the specialty. Women’s health projects and line subscription to MED- innovative “Train-the-Trainer” LINE searches (free access af- Medical student membership programs ter 5 P.M.) in ACOG Discounts for AMWA publi- Policy Promotion Grants for cations such as The Women’s chapter and community proj- ACOG publications Complete Healthbook, The ects Reduced meeting fees Women’s Complete Wellness Educational loans consolida- Entry into their member-only Book, and Developing a Child tion Care Program Web site Advanced access and reduced Updates in the specialty fees to AMWA’s Career De- velopment Institute medscape.com Members-Only sections on This site’s medical student sec- JOIN AMWA (American the AMWA Web site tion includes features such as Medical Women’s “today’s headlines,” a medical ms4c.org student discussion forum to vent Association) and exchange study tips, a Medical Students for Choice Become a medical student life weekly “focus” story from a med (MSFC) is dedicated to ensuring member of AMWA. Member- student’s perspective, free tools that women receive comprehen- ship benefi ts include: for your palm pilot, test-taking sive reproductive health care, Networking opportunities at skills, study tips, and a “clerk- including abortion. One of the the national and local lev- shop clues” section that summa- greatest obstacles to safe, legal els—60 physicians branches rizes the latest advances relevant abortion is the absence of and 120 student branches to OB/GYN, Medicine, Surgery, trained providers. The more Continuing Medical Educa- and other clerkships. CLASSIFIED than 6,000 medical students and tion (CME) programs residents of are Leadership and mentoring committed to ensuring that opportunities medical practitioners are pre- Professional and personal de- pared to provide their patients velopment programs with the full range of reproduc- AMWA’s legislative network tive health care choices. AMWA’s Annual, Interim, and Regional Meetings offer- ing career and personal devel- www.ama-assn.org opment curricula FREIDA Online—computer Gender Equity Information access to graduate training pro- Line to assist you with con- gram data (members receive cerns on sexual harassment, up to 30 free mailing labels)

gender bias, racial discrimina- Airline discounts for travel to Opportunities tion, and other matters residency interviews (graduat- Women’s Health Advocacy ing seniors only)

377 NOTES CLASSIFIED Opportunities 378 Index

A Abuse assessment screen, 348 comparison of müllerian agen- Acquired immune defi ciency esis and, 224 Abortion, 172–180 syndrome (AIDS), Androgens, sources of, 232 fi rst-trimester bleeding, 172 329–330 adrenal production, 232 induced, 178–180 Acromegaly, 238 ovarian production, 232 assessment of patient, 179 Actinomyces, 334 Androstenedione, 232 methods, 179–180 Acute abdomen, differential Anemia, in pregnancy, 125 therapeutic, indications for, diagnosis of, 121 Anencephaly, 54 179 Adenocarcinoma of cervix, 279, Anti-D isoimmunization, 138, spontaneous, 172–173, 174 284 140–142 anatomical abnormalities, Adenomyosis, 245, 257–258 immune globulins (RhoGam), 173 versus endometriosis, 258 140 chromosomal abnormalities, Adrenarche, 208 sensitized D-negative patient, 172–173 Advance directives, 358 management of, 141–142 classifi cation, 174 AIDS. See Acquired immune unsensitized D-negative pa- endocrine abnormalities, defi ciency syndrome tient, management of, 140 173 Alcohol abuse, 346 Antihypertensive agents used in environmental factors, 173 Amenorrhea, 222–229 pregnancy, 134 immunologic factors, 173 primary, 222–225 Antiphospholipid syndrome, infections, 173 breasts absent, uterus absent, 125–126 structural abnormalities, 173 224 Antithrombin III defi ciency, 124 types of, 174–178 breasts absent, uterus pres- Aortic stenosis, in pregnancy, 118 complete, 174, 176 ent, 222–223 Appendicitis, in pregnancy, 121 incomplete, 174, 175–176 breasts present, uterus ab- Apt test, 146 inevitable, 174, 175 sent, 223–224 Arrhenoblastoma, 300 missed, 174, 176–177 breasts present, uterus pres- Artifi cial insemination with do- recurrent, 178 ent, 224–225 nor sperm, 220 septic, 174, 177–178 secondary, 226–229 Asherman syndrome, 178, 228 threatened, 174–175 cervical, 228 Asthma, in pregnancy, 119 Abruptio placentae (placental endocrine, 228 B abruption), 148–149, 179 evaluation, 228–229 Abstinence, 204–205 hypothalamic, 226 Backache during pregnancy, 62 continuous, 204 ovarian, 227 Bacterial vaginosis natural family planning (NFP), pituitary, 226 in pregnancy, 162–163 204–205 uterine, 228 not in pregnancy, 332 basal body temperature, 204 Amniocentesis, 55–56, 141 Bacteriuria lactational amenorrhea, 205 differences between CVS and, asymptomatic, 120 ovulation/cervical mucus 56–57 laboratory testing for, 344 method (Billings method), Amsel clinical criteria, 162 Bacteroides, 324 204 Androgen insensitivity (testicular Bacteroides bivius, 100 symptothermal method, 205 feminization), 223, 224 Bacteroides disiens, 100

379 Bacteroides fragilis, 100 mass, 337 Cervarix, 276 Baden-Walker classifi cation, nipple discharge, 338 Cervical cancer, 277–284 369 pain, 338 adenocarcinoma, 284 Bartholin’s abscess, 313 skin changes, 339 bulky central pelvic disease, Bartholin’s glands, 16, 313 postpartum, 104–107 treatment of, 281 Basal body temperature method breast fever, 105–106 clinical staging of, 279–280 of contraception, 204 breast-feeding, 106–107 FIGO staging, revised 2009, Benign cystic teratomas, 264 lactation suppression, 105 280 Bethesda staging system, 272, mature milk and lactation, differential diagnosis, 278 273 104–105 epidemiology, 278 Bilateral tubal occlusion, 202– milk development, 104 follow-up of, 282 203 milk-secreting machinery, grading of, 281 banding, 202 development of, 104 in pregnancy, 283–284 clipping, 202 during pregnancy, 34 recurrent, 282 complications of, 203 Breech presentations, 76–77 symptoms, 278 electrocautery, 202 Bromocriptine, 240 treatment of, 281 hysteroscopic, 203 types of, 279 laparoscopic, 202 adenocarcinoma, 279 luteal-phase pregnancy, 203 C metastasis, 279 postpartum, 203 squamous cell cancer, 279 reversibility of, 203 CA-125, 295, 296, 297 Cervical cap, 195 salpingectomy, partial or total, Cabergoline, 240 Cervical dysplasia, 270–276 203 Caffeine in pregnancy, 60 and cervical cancer, risk factors Billings method of contraception CAGE questionnaire for alcohol- for, 270 (ovulation/cervical mucus ism, 345, 346 colposcopy with cervical bi- method), 204 Canal of Nuck, cyst of, 314 opsy, 273–274 Biophysical profi le (BPP), 49 Cancer therapy during preg- cone biopsy and LEEP, 274– Bishop score, 72 nancy, 127 275 Bladder, during pregnancy, 38 chemotherapy, 127 cryotherapy, 275 “Bloody show” (cervical mucus, radiation, 127 human papillomavirus (HPV), extrusion of), 152 surgery, 127 270 Body weight, postpartum changes Candida, 333 laser therapy, 275 in, 98 Candida albicans, 163 Pap smear, 271–273 Bowel function, postpartum, 99 Candidiasis, during pregnancy, classifi cation of abnormali- Braxton Hicks contractions, 33, 163 ties, 272 68, 142 Caput succedaneum, 92 screening guidelines, 272 Breast cancer, hereditary, risk fac- Carcinosarcoma, 291 prevention of, 275 tors for, 338 Cardiovascular disease, in preg- Cervarix, 276 Breast exam, 342 nancy, 118–119 Gardasil, 275, 276 Breast-feeding, 106–107 aortic stenosis, 118 squamocolumnar junction benefi ts, 106 Eisenmenger syndrome and (SCJ), 271 contraindications to, 106–107 conditions with pulmo- Cervical exam during labor, recommended dietary allow- nary hypertension, 119 71–72 ances, 106 mitral stenosis (MS), 118 consistency, 72 Breast-ovarian cancer syndrome, mitral valve prolapse, 118 dilation, 71 295 Cardiovascular system during effacement, 71 Breasts, 34, 104–107, 335–339 pregnancy, 37 position, 72 anatomy, 336 Cephalohematoma, 92 station, 71 complaints, 336–339 Cephalopelvic disproportion, Cervical mucus, extrusion of approach to, 336–337 90 (“bloody show”), 152

380 Cervix, 18, 34, 97 Colposcopy, 18, 273–274 male condom, 194–195 blood supply, 18 with cervical biopsy, 273–274 spermicide, 195 components, 18 Colpotomy, 204 sponge, 195–196 epithelium, 18 Conception, 31–33 comparison of agents, 192–194 nerve supply, 18 embryology, 31–32 hormonal agents, 196–199 postpartum, 97 fertilization, 31 combination oral contracep- during pregnancy, 34 implantation, 31 tives (COCs), 196–197 Cesarean delivery, 90–91, 101– ovulation, 31 implantable, 198–199 102 placenta, 33 injectable, 198 basic types, 90 placentation, 31 progestin-only oral contra- discharge from hospital follow- postimplantation, 33 ceptives, 197 ing, 102 preimplantation, 31 transdermal (Ortho Evra), indications, 90–91 Condoms 199 surgical site infection, 101– female, 194 vaginal ring (NuvaRing), 199 102 male, 194–195 intrauterine device, 200–201 Chadwick’s sign, 25, 324 Condyloma acuminata, 305, 330 postcoital/emergency, 201 Chancroid, 330–331 Condyloma lata, 305 postpartum, 103 Chandelier sign, 324 Cone biopsy and LEEP, 274–275 depo-medroxyprogesterone, Chemotherapy during pregnancy, Congenital adrenal hyperplasia 103 127 (CAH), 233–234 implanon, 103 Chlamydia, 156, 164, 173, 178, clinical ﬁ ndings in, 234 intrauterine device, 103 326–327, 343 Congenital anomalies, screening lactational amenorrhea in pregnancy, 164 for, 50–58 method, 103 routine screening for, 343 amniocentesis, 55–56 oral contraceptive pills, 103 serotypes A–K, 326–327 differences between CVS Contraction stress test (CST), 48 serotypes L1–L3, 327 and, 56–57 Copper T intrauterine device, trachomatis, 100, 164, 324, chorionic villus sampling 200, 201 326–327 (CVS), 56–57 Cordocentesis, 57–58 “Chocolate cysts,” 263 differences between amnio- Corpus luteal cyst, ruptured, Cholelithiasis and cholecystitis, centesis and, 56–57 251–252 in pregnancy, 122 cordocentesis, 57–58 Coxsackievirus, 156 Cholesterol, laboratory testing of, ﬁ rst-trimester screen (FTS), 51 Crown-rump length, measure- 343 genetic testing, 58 ment of, 54 Choriocarcinoma, 299, 319–321 human chorionic gonadotro- Cryotherapy, 275 FIGO prognostic scoring sys- pin (hCG), 53 Cushing syndrome, 233 tem, 320 inhibin A, 53 Cushing disease, 233 treatment according to score/ maternal serum α-fetoprotein Cystic teratomas, benign, 264 prognostic factors, 321 (MSAFP), 52–53 Cystocele, 368, 370 Chorionic villus sampling (CVS), quad screen, 51–52 treatment of, 370 56–57 ultrasound, specialized (level Cystourethrocele, 368 differences between amniocen- II), 53–55 Cytomegalovirus, 156, 159–160 tesis and, 56–57 unconjugated estriol (uE3), 53 Cigarette smoking, 346, 362 Constipation during pregnancy, 61 D Cleft lip, 54 Consumptive coagulopathy Clostridium, 100 (DIC), 177 Deep vein thrombosis (DVT), in Coccyx, 22 Contraception, 103, 192–201 pregnancy, 122–123 Colon cancer screening, 342 barrier methods, 194–196 Dehydroepiandrosterone Colostrum, 104, 105 cervical cap, 195 (DHEA), 232 Colpoclesis, 370 diaphragm, 195 Dehydroepiandrosterone sulfate Colporrhaphy, anterior, 370 female condom, 194 (DHEA-S), 232

381 Delivery Dyspareunia, 354 uterine sarcoma, 290–291 normal spontaneous vertex Dystocia, 86–87 workup for, 288 vaginal, 79–81 histologic subtypes, 288 episiotomy, 81 Endometrial hyperplasia, 245, E head, delivery of, 79 286 infant, delivery of, 79–80 Eclampsia, 133–134 Endometrial neoplasm, 260 inspection, 80 Ectopic pregnancy, 183–188 Endometrial stripe, 246 nuchal cord, checking for, diagnostic studies, 186 Endometrial stromal sarcoma 79 differential diagnosis, 185 (ESS), 290 perineal lacerations, 80 epidemiology, 184 Endometrioma, 260, 263 placenta, delivery of, 80 exam, 185 Endometriosis, 254–256 postdelivery hemostasis, 81 management, 187 classic fi ndings of, 256 shoulders, delivery of, 79 general, 187 long-term complications of, pain control during, 92–94 medical, 187–188 255 general anesthesia, 94 surgical, 188 Endometritis, 100, 101 intravenous analgesia and risk factors, 184 Enterocele, 368, 369, 370 sedation, 92–93 sites of, 185 treatment of, 370 local anesthesia, 93 tests, 186 Enzyme-linked immunosorbent lower genital tract innerva- Edwards syndrome (trisomy 18), assay (ELISA), 164, 329 tion, 92 51, 53 Epidural analgesia, 94 nonpharmacological meth- Eisenmenger syndrome and con- Episiotomy, 81 ods, 92 ditions with pulmonary infection, 102 regional anesthesia, 93–94 hypertension, 119 Erythema infectiosum, 158 Depo-medroxyprogesterone, post- Embryo transfer, 220 Escherichia coli, 100, 101, 120, partum use of, 103 Embryology, 31–32 324 Diabetes mellitus Embryonal carcinoma, 299 Essure (hysteroscopic tubal gestational, 134–136 Emergencies during pregnancy, occlusion), 203 diagnosis of, 135 63 Estradiol-17β, 363 pregestational, 113–114, 134 Employment during pregnancy, Estrogen, 196, 363–365 classifi cation of, 113 62 levels in perimenopausal pe- Diaphragm, 195 Empty sella syndrome, 238 riod, 363 Diethylstilbestrol (DES), 306 End-of-life decisions, 358 replacement therapy (ERT), Dilation and curettage (D&C), Endocrine system, 39 364, 365 180 parathyroid gland, 39 Ethics, 358–359 Dilation and evacuation (D&E), pituitary gland, 39 end-of-life decisions, 358 180 thyroid gland, 39 informed consent, 359 Dizygotic twins, 168 Endodermal sinus tumor, 298, life-sustaining treatment, 358 Domestic violence, 347–348 299 patient confi dentiality, 359 abuse assessment screen, 348 Endometrial changes in puer- exceptions to, 359 Doppler velocimetry, 50 perium, 96 minors, 359 Double-bubble sign, 54 Endometrial cancer, 286–291 reproductive issues, 358 Down syndrome (trisomy 21), 51, clinical presentation, 287 Exercise during pregnancy, 60 53, 54 epidemiology of, 286 Duodenal atresia, 54 grading, 289 F Durable power of attorney for postmenopausal bleeding, health care, 358 differential diagnosis of, Factor V Leiden mutation, 124 Dysfunctional uterine bleeding, 287–288 Fallopian (uterine) tubes, 19–20, 243 staging of, 288–289 300–301 Dysgerminoma, 298, 299 FIGO revised 2009, 289 anatomic sections, 19 Dysmenorrhea, 209 treatment, 289–290 blood supply, 20

382 carcinoma, 300–301 Doppler velocimetry, 50 Gamete intrafallopian transfer nerve supply, 20 fetal movement counts, 47 (GIFT), 220 Family planning. See Contracep- modifi ed biophysical profi le Gardasil, 275, 304 tion; Natural family plan- (mBPP), 49–50 Gardnerella vaginalis, 100, 162, ning non-stress test (NST), 47–48 324, 333 Fasting glucose test, 343 ultrasound (US), 48–49 Gastrointestinal disorders, in Fat necrosis, 337 Fetal vessel rupture, 150–151 pregnancy, 121–122 Fecal occult blood test (FOBT), vasa previa, 151 acute abdomen, differential 342 velamentous cord insertion, 151 diagnosis of, 121 Female orgasmic disorder, 354 Fetus, assessment of, 73–77 appendicitis, 121 Female sexual response, 352–355 Leopold maneuvers, 73–74 cholelithiasis and cholecystitis, response cycle, 352 attitude and posture, 74 122 sexual dysfunction, 353–355 lie, 74 Gastrointestinal tract, 38–39 disorders, 354 position, 74 gallbladder, 39 pain disorders, 354–355 presentation/presenting part, liver, 39 sexuality, fetus to menopause, 74 Gastroschisis, 55 352–353 malpresentations, 75–77 Genetic testing, 58 adolescence, 352 breech presentations, 76–77 Genital herpes, 328–329 menopause, 353 brow presentation, 75 Germ cell tumors (GCTs), ovar- menstrual cycle, 352 face presentation, 75 ian, 297, 298–300 postpartum, 353 normal presentation, 74 choriocarcinoma, 299 prenatal and childhood, vertex presentation (occiput dysgerminoma, 298 352 presentation), 74 embryonal carcinoma, 299 Fertilization, 31 Fibroadenoma, 337 endodermal sinus tumor, 298 Fetal alcohol syndrome, 346 Fibrocystic breast changes, mixed, 299 Fetal death, 180–182 337–338 teratoma, 298 causes of, based on trimester, Fifth disease, 158 German measles (rubella), 156, 181–182 First-trimester bleeding, 172 159 Fetal descent, average pattern First-trimester screen (FTS), 51 Gestational diabetes mellitus, of, 68 Fitz-Hugh–Curtis syndrome, 324, 134–136 Fetal heart rate (FHR), 27 326 diagnosis of, 135 monitoring during labor, 82 Fluorescent in situ hybridization Gestational trophoblastic disease, patterns, 82–86 (FISH), 58 315–321 beat-to-beat variability Fluorescent treponemal antibody choriocarcinoma, 319–321 (BTBV), 86 absorption test (FTA- FIGO prognostic scoring decelerations, 83–85 ABS), 163, 328 system, 320 defi nitions, 83 Folic acid, requirements during treatment according to fetal tachycardia, 85 pregnancy, 59 score/prognostic factors, long-term variability (LTV), Follicular phase of menstrual 321 86 cycle, 210 defi nition, 316 short-term variability (STV), Forceps delivery, 91 hydatidiform mole, 316–319 86 Functional incontinence, 373 complete, 316–317 Fetal hydrops, 141 Fundal height during pregnancy, invasive, 317 Fetal lung maturity, assessing, 144 25, 47 partial, 317 Fetal maturity, confi rmation of placental site trophoblastic tu- 89 mor (PSTT), 321 G dating criteria, 89 Gonadal dysgenesis (hyper- Fetal surveillance, 47–50 Galactorrhea, 237–239, 338 gonadotropic hypogonad- biophysical profi le (BPP), 49 Gallbladder, during pregnancy, ism), 222, 227 contraction stress test (CST), 48 39 Gonadotropin defi ciency, 223

383 Gonorrhea, 156, 164, 173, 325– Hormone replacement therapy physical exam, 235–236 326, 343 (HRT), 364, 365 studies, 236 in pregnancy, 164 Hot fl ashes, 363 treatment, 236 routine screening for, 343 Human chorionic gonadotropin Hyperemesis gravidarum, 137 Granuloma inguinale, 325, 331 (hCG), 26–27, 53, 186 Hypoestrogenic amenorrhea, 226 Granulosa-theca cell tumor, 300 overview, 26 Hypergonadotropic hypogonad- Gravidity, 43 pregnancy test using, 26–27 ism (gonadal dysgenesis), plasma hCG, 27 222, 227 urine hCG, 27 Hyperhomocysteinemia, 124 H in screening for congenital ab- Hyperplasia with atypia, 247, 338 Haemophilus ducreyi, 330–331 normalities, 53 Hyperprolactinemia, 218, 237– Hashimoto’s thyroiditis, 116 Human immunodefi ciency virus 239 Health education, 344–345 (HIV), 156, 165, 329–330, defi nitions, 238 nutrition and exercise, 345 344 etiology, 238–239 Heart and Estrogen/Progestin laboratory testing for, 344 prolactinoma, 238–239 Replacement Study in pregnancy, 165 Hypertension, chronic, 117–118 (HERS), 365 Human papillomavirus (HPV), Hypertensive diseases of preg- Heartburn during pregnancy, 61 166, 260, 270, 275–276, nancy, 130–133 HELLP syndrome, 124, 133 304, 330, 344 eclampsia, 133 Hematologic changes, 36–37, 97 in pregnancy, 165 gestational, 130 postpartum, 97 vaccine, 344 management of, 132 during pregnancy, 36–37 Hydatidiform mole, 316–319 preeclampsia, 130–131 blood volume, 36 complete, 316–317 preexisting or chronic, 130 coagulation, 37 invasive, 317 superimposed preeclampsia, immunology, 36 partial, 317 131 iron, 36 Hydronephrosis, 120 Hyperthyroidism, 115–116 Hemolytic diseaes of the new- Hydrops tubae perfl uens, 301 Hypertrichosis, 232 born (HDN), 141 11β-Hydroxylase defi ciency, 234 Hypoactive sexual desire disor- Hemorrhoids during pregnancy, 17α-Hydroxylase defi ciency, der, 354 61 222–223, 224 Hypothalamic-pituitary disorders, Hemostasis, postdelivery, 81 21-Hydroxylase defi ciency, 233– 223 Hepatitis, 156 234, 236 Hypothyroidism, 109, 116 Hepatitis A vaccine, 344 Hyperandrogenism, 231–236 postpartum, 109 Hepatitis B virus, in pregnancy, adrenal etiologies, 233–234 in pregnancy, 116 165 congenital adrenal hyperpla- Hysterectomy, 204, 247, 370 Hereditary nonpolyposis colorec- sia (CAH), 233–234 Hysterosalpingogram, 218, 219 tal cancer (HNPCC), 286, Cushing syndrome and Hysteroscopy, 218, 244 296 Cushing disease, 233 Herpes simplex virus (HSV), 156, androgens, sources of, 232 I 164, 173, 325, 328–329 adrenal production, 232 genital herpes, 328–329 ovarian production, 232 Immune system in the develop- in pregnancy, 164, 173 defi nitions, 232 ing embryo, fetus, and Herpes zoster vaccine, 344 hirsutism, idiopathic, 233 newborn, 156 Hidradenomas, 313–314 history, 235 Immunizations, 63, 344 Hilar (Leydig) cell tumors, 235, ovarian etiologies, 234–235 during pregnancy, 63 236 luteoma of pregnancy, 235 Imperforate hymen, 224 Hirsutism, 232, 233 polycystic ovarian syndrome Implanon, postpartum use of, 103 idiopathic, 233, 236 (PCOS), 234 Implantation, 31 HIV. See Human immunodefi - stromal hyperthecosis, 234 In vitro fertilization (IVF) and ciency virus theca lutein cysts, 235 embryo transfer, 220

384 Indomethacin, 143 J cesarean delivery, 90–91 Induced abortion, 178–180 basic types, 90 Jarisch-Herxheimer reaction, assessment of patient, 179 indications, 90–91 163 methods, 179 delivery, normal spontaneous pharmacologic agents, 179 vertex vaginal, 79–81 surgical method, 180 K episiotomy, 81 therapeutic, indications for, 179 head, delivery of, 79 Kallmann syndrome, 223 Infant care, postpartum, 104 infant, delivery of, 79–80 Karyotyping, 58 inspection, 80 Infertility, 215–220 Kegel exercises, 354, 355, 370, nuchal cord, checking for, 79 assisted reproductive technolo- 373 gies (ART), 219–220 Kell isoimmunization, 142 perineal lacerations, 80 artifi cial insemination with Kelly plication, 370 placenta, delivery of, 80 donor sperm, 220 Kidneys, during pregnancy, 38 postdelivery hemostasis, 81 defi nition, 220 Klebsiella, 100 shoulders, delivery of, 79 gamete intrafallopian trans- Kleihauer-Betke test, 99, 140, 146 fetal heart rate patterns, 82–86 fer (GIFT), 220 Kroener method (tubal occlu- beat-to-beat variability in vitro fertilization (IVF) sion), 203 (BTBV), 86 and embryo transfer, 220 Krukenberg’s tumor, 296 decelerations, 83–85 intracytoplasmic sperm in- defi nitions, important, 83 jection (ICSI), 220 fetal tachycardia, 85 intrauterine insemination, L long-term variability (LTV), 220 Labor 86 zygote intrafallopian transfer abnormal labor patterns, 86–87 short-term variability (STV), (ZIFT), 220 dystocia, 86–87 86 defi nition, 216 abnormalities of third stage, fetus, assessment of, 73–77 female factors affecting, 216 152–154 Leopold maneuvers, 73–74 male factors affecting, 216 early postpartum hemor- malpresentations, 75–77 types, 216 rhage (PPH), 152–153 normal presentation, 74 workup, 216–219 placental attachment disor- induction of, 88–90 male factor, 216–217 ders, 153–154 confi rmation of fetal matu- ovulatory factor, 217–218 uterine inversion, 154 rity, 89 tubal factor, 219 assessment of patient in, 69 contraindications, 89 uterine factors, 218–219 history, 69 indications, 88–89 Infl ammatory breast cancer (peau vaginal exam (VE), 69 methods, 89 d’orange), 339 Bishop score, 72 management of patients in, Infl uenza cardinal movements of, 77–79 81–82 in pregnancy, 157–158 descent, 77, 78 maternal vital signs, 82 vaccine, 158, 344 engagement, 77, 78 oral intake, 82 Informed consent, 359 expulsion, 79 vaginal exams, 81 Inhibin A, 53 extension, 77, 78 monitoring during, 82 Insemination, intrauterine, 220 external rotation (restitu- fetal heart rate (FHR), 82 Intracytoplasmic sperm injection tion), 78, 79 uterine contractions, 82 (ICSI), 220 fl exion, 77, 78 operative vaginal delivery, Intrauterine device, 103, 200–201 internal rotation, 77, 78 91–92 Copper T, 200, 201 cervical exam, 71–72 forceps delivery, 91 postpartum use of, 103 consistency, 72 vacuum delivery, 92 Intrauterine insemination, 220 dilation, 71 pain control during, 92–94 Irving method (tubal occlusion), effacement, 71 general anesthesia, 94 203 position, 72 intravenous analgesia and Ischial spines, 22 station, 71 sedation, 92–93

385 Labor (Continued) Living will, 358 effect on sexuality, 353, 354 pain control during Lochia, 96 factors affecting age of onset, (Continued) Loop electrosurgical excision pro- 362 local anesthesia, 93 cedure (LEEP), 274–275, perimenopausal period, physi- lower genital tract innerva- 282 ology during, 362–363 tion, 92 Luteal phase of menstrual cycle, estrogen levels, 363 nonpharmacological meth- 210 oocytes, 362–363 ods, 92 Luteoma of pregnancy, 235 ovulation, 363 regional anesthesia, 93–94 Lymphogranuloma venereum, physiology during, 363 pelvic shapes, 87–88 325, 327, 331 Menstrual cycle, 208–210, 352 preterm, 142–144 Lynch syndrome, 286, 296 effect on sexuality, 352 management of, 143–144 follicular phase, 210 rupture of membranes, 69–70 luteal phase, 210 M stages of, 67–68 ovulation, 210 fi rst, 67 Madlener method (tubal occlu- summary of, 209 second, 68 sion), 203 Metabolic changes during preg- third, 68 Magnesium sulfate, 143 nancy, 34–35 trial of labor after cesarean Magnesium toxicity, 131 carbohydrate metabolism, 35 (TOLAC), 91 Malaria, 156 water metabolism, 35 candidates for, 91 Mammography, 342 Methotrexate, 187 contraindications to, 91 Mastitis, 105 Metrorrhagia, 242 true versus false, 68 Maternal serum α-fetoprotein Microhemagglutination assay Labor-inducing agents, 72 (MSAFP), 52–53 (MHA-TP), 163, 328 Lactation suppression, 105 Mayer-Rokitansky-Kuster-Hauser Mifepristone (RU 486), 179 Lactational amenorrhea method syndrome (Müllerian Minerals, requirements during of contraception, 103, agenesis), 224 pregnancy, 59 205 McRoberts maneuver, 137 Misoprostol, 179 Lactobacillus, 162, 332 Measles, mumps, rubella (MMR) Mitral stenosis (MS), in preg- Laparoscopy, 218, 219 vaccine, 344 nancy, 118 LeFort procedure, 370 Meconium, 70 Mitral valve prolapse, in preg- Leg cramps during pregnancy, Meconium aspiration syndrome nancy, 118 62 (MAS), 70 Mittelschmerz, 250, 251 Leiomyoma, 260, 266–267 Medical student information of Modifi ed biophysical profi le Leiomyosarcoma (LMS), 290 interest, 375 (mBPP), 49–50 Leopold maneuvers, 73–74 opportunities, 376 Monozygotic twins, 168–169 attitude and posture, 74 web sites, 377 Müllerian agenesis (Mayer- lie, 74 Meigs syndrome, 300 Rokitansky-Kuster-Hauser position, 74 Menarche, 208 syndrome), 224 presentation/presenting part, Meningococcal vaccine, 344 Mycoplasma, 173 74 Menometrorrhagia, 242 Mycoplasma hominis, 100, 162, Levonorgestrel, 201, 348–349 Menorrhagia, 242 173 Leydig cell tumors, 235, 236 Menopause, 353, 354, 361–365 Lichen planus, 312 adverse effects, treatment of, N Lichen sclerosus, 311 364–365 Lichen simplex chronicus (LSC), estrogen replacement ther- Naegele’s rule, 24 311 apy (ERT), 364, 365 Natural family planning (NFP), Listeria, 156, 178 hormone replacement ther- 204–205 Listeria monocytogenes, 100, 173 apy (HRT), 364, 365 basal body temperature, 204 Liver, during pregnancy, 39 defi nitions, 362 lactational amenorrhea, 205

386 ovulation/cervical mucus third stage of labor, abnormali- Orgasmic disorder, female, 354 method (Billings method), ties of, 152–154 Ortho Evra (transdermal contra- 204 early postpartum hemor- ceptive), 199 symptothermal method, 205 rhage (PPH), 152–153 Osteoporosis, 364, 365 Nausea and vomiting during placental attachment disor- Ovarian cancer, 264–266, 294– pregnancy, 60–61 ders, 153–154 300 Neisseria gonorrhoeae, 324, 325, uterine inversion, 154 epidemiology, 294 329 third-trimester bleeding, epithelial cell, 294–295 Neural tube defects (NTDs), 51, 146–152 hereditary syndromes, 295 59 cervical mucus, extrusion of nonepithelial, 297–298 Nifedipine, 143 (“bloody show”), 152 germ cell tumors (GCTs), Nipple discharge, 338 fetal vessel rupture, 150–151 297, 298–300 Nitrazine test, 145 management of, 147 sex-cord stromal tumors, Non-stress test (NST), 47–48 placenta previa, 150 297, 300 Nuchal translucency measure- placental abruption (abrup- screening recommendations, ment, 52 tio placentae), 148–149 296 Nugent criteria, 163 uterine rupture, 151 staging, 296–297 Nutritional needs, during preg- Obstetric visits, frequency of, FIGO, 297 nancy, 58–60 43–44 workup, 296 diet, 59 fi rst visit, 44–45 Ovarian cysts, 260 folic acid, 59 physical exam, 45 functional, 260–262 minerals, 59 subsequent visits, 45–46 follicular, 260–262 pica, 60 history, 45 lutein, 262 vegetarians, 59 physical exam, 46 Ovarian failure, premature weight gain, 58–59 routine initial tests, 46 (POF), 227 NuvaRing (vaginal ring contra- routine timed tests 46 Ovarian neoplasm, 260 ceptive), 199 Obstetrics and gynecology clerk- Ovaries, 20 ship, succeeding in, 1–11 blood supply, 20 clinical clerkship and USMLE histology, 20 O Step 2 exam, preparing nerve supply, 20 Obstetric complications, 129–154 for, 6–7 Overfl ow incontinence, 374 gestational diabetes mellitus, sample delivery note, 9 Ovral, 348, 349 134–136 sample discharge orders post– Ovulation, 31, 210, 363 hyperemesis gravidarum, 137 cesarean section, 11 in perimenopausal period, hypertension, 130–134 sample obstetric admission his- 363 antihypertensive agents used tory and physical, 8–9 Ovulation/cervical mucus in pregnancy, 134 sample post-cesarean section method of contraception eclampsia, 133–134 note, 10–11 (Billings method), 204 HELLP syndrome, 133 sample post-NSVD discharge Oxytocin, 39, 81, 89, 105 hypertensive diseases of preg- orders, 10 nancy, 130–133 sample postpartum note, 10 P isoimmunization, 138–142 terminology, 7 anti-D, 138, 140–142 wards, 2–5 Paget disease of the vulva, 310– Kell, 142 Oligohydramnios, 49 311 management of, 139 Oligomenorrhea, 222, 242 Pap smear, 271–273, 342 premature rupture of mem- Omphalocele, 55 classifi cation of abnormalities, branes, 144–146 Ophthalmia neonatorum, 163 272 preterm labor, 142–144 Oral contraceptive pills, 103 screening guidelines, 272 management of, 143–144 postpartum use of, 103 Papillomavirus, 156 shoulder dystocia, 136–137 Orgasm, 352 Paracervical block, 93

387 Parathyroid gland, during preg- Phylloides tumors, 338 mature milk and lactation, nancy, 39 Physical abuse, 347–349 104–105 Parity, 43 domestic violence, 347–348 milk development, 104 Parkland method (tubal occlu- abuse assessment screen, 348 milk-secreting machinery, sion), 203 rape-related posttraumatic development of, 104 Parvovirus, 156 stress disorder (RR- care, routine, 98–99 B19, 158 PTSD), 348–349 fi rst few days, 99 Patau syndrome (trisomy 13), 53 sexual assault, 348 fi rst several hours, 98 Patient confi dentiality, 359 Pica, 60 immediately after labor, 98 exceptions to, 359 Pituitary gland, during preg- coitus in, 102–103 minors, 359 nancy, 39 contraception, 103 Peau d’orange (infl ammatory Pituitary insuffi ciency, 218 discharge from hospital, 102 breast cancer), 339 Placenta, 33 cesarean delivery, 102 Pediculosis pubis (crabs), 331 delivery of, 80 instructions, 102 Pelvic diaphragm, 21 Placenta accreta, 153 vaginal delivery, 102 Pelvic infl ammatory disease Placenta increta, 153 fever, causes of, 101 (PID), 251, 324–325 Placenta percreta, 153 infant care, 104 Pelvic masses, differential diagno- Placenta previa, 150, 179 infection, 100–102 ses of, 259–267 Placental abruption (abruptio endometritis, 101 benign cystic teratomas, 264 placentae), 148–149, 180 episiotomy, 102 diagnostic tests, 260 Placental attachment disorders, surgical site (cesarean deliv- endometrioma, 260, 263 153–154 ery), 101–102 leiomyomas, 260, 266–267 Placental separation, signs of, 68 urinary tract, 101 malignancies, 264–266 Placental site involution, 96 puerperium of normal labor ovarian cysts, 260–262 Placental site trophoblastic tumor and delivery, 96–98 follicular, 260–262 (PSTT), 321 body weight, changes in, 98 lutein, 262 Placentation, 31 cervix, 97 tubo-ovarian abscess (TOA), Plan B (levonorgestrel), 348, 349 hematology/circulation, 97 260, 261, 262–263 Pneumococcal vaccine, 344 peritoneum and abdominal Pelvic pain, 249–252 Pneumonia, in pregnancy, wall, 97 acute, 251–252 119–120 urinary tract, 97 chronic, 250–251 Polycystic ovarian syndrome uterus, 96 Pelvic relaxation, 367–370 (PCOS), 217, 218, 227, sexual problems in, 353 pelvic fl oor support, anatomy 234, 236 Postpartum hemorrhage, 81, 96, of, 368 Polyhydramnios, 50 152–153 prolapse, 368–370 Polymenorrhea, 242 early, 152–153 Pelvic viscera, ligaments of, Polymerase chain reaction Poststerility syndrome, 203 20–21 (PCR), 164 Posttraumatic stress disorder, Pelvimetry, 22 Pomeroy method (tubal occlu- rape-related (RR-PTSD), Pelvis, 22 sion), 203 348–349 shapes, 22, 87–88 Postimplantation, 33 Precocious puberty, 208 Peptostreptococcus, 324 Postmenopausal bleeding (PMB), Pregestational diabetes, 113–114 Perinatal infections, 156 245–247, 287–288 classifi cation of, 113 Perineal body, 21 differential diagnosis of, Pregnancy Pericutaneous umbilical blood 287–288 complications in. See Obstetric sampling (PUBS), 57–58 Postpartum, 95–109, 353 complications Peritoneum and abdominal wall, breasts, 104–107 diagnosis of, 24–27 postpartum, 97 breast fever, 105–106 fetal heart rate (FHR), 27 Pessaries, 370 breast-feeding, 106–107 human chorionic gonadotro- Phthirus pubis, 331 lactation suppression, 105 pin (hCG), 26–27

388 Naegele’s rule, 24 seizure disorder, 122 fi rst visit, 44–45 signs and symptoms 24–25 sickle cell disease, 124–125 fundal height, 47 ultrasound (US), 27 systemic lupus erythemato- subsequent visits, 45–46 ectopic, 183–188 sus, 126 reproductive history, terminol- diagnostic studies, 186 thromboembolic disorders, ogy of, 43 differential diagnosis, 185 122–124 Preterm labor, 142–144 epidemiology, 184 thyroid disease, 115–116 management of, 143–144 exam, 185 physiology of, 29–39 assessing fetal lung maturity, management, 187 cardiovascular system, 37 144 risk factors, 184 conception, 31–33 corticosteroids, 144 sites of, 185 endocrine system, 39 hydration, 143 tests, 186 gastrointestinal tract, 38–39 tocolytic agents, 143 effect on sexuality, 352 hematologic changes, 36– tocolytic therapy, 143 emergencies during, 63 37 prevention of, 144 infections in, 155–166 metabolic changes, 34–35 Progesterone, 105, 186, 196, 210, bacterial vaginosis (BV), 162 reproductive tract, 33–34 226 candidiasis, 163 respiratory system, 37 Progestin challenge test, 227 cytomegalovirus, 159–160 urinary system, 38 Prolactin, 39, 105 group B streptococcus psychiatric disorders, 107– Prolactinoma, 238–239 (GBS), 160–161 108 Propylthiouracil (PTU), 115 immune system in the devel- maternity/postpartum blues, Prostaglandins, 90, 119, 209 oping embryo, fetus, and 107 Protein C defi ciency, 124 newborn, 156 postpartum depression, 108 Protein S defi ciency, 124 infl uenza, 157–158 postpartum psychosis, 108 Proteus, 100 parvovirus (B19), 158 thyroid dysfunction, 109 Prothrombin G20210A mutation, rubella (German measles), twin gestation, 167–170 124 159 diagnosis and management Pruritic dermatologic disorders sexually transmitted infec- of, 169 unique to pregnancy, 35 tions (STIs), 163–166 twin-twin transfusion, 170 Pruritic urticarial papules and toxoplasmosis, 161–162 types of twins, 168 plaques of pregnancy varicella-zoster, 157 Preeclampsia, 130–133 (PUPPP), 126–127 medical conditions in, 111–127 superimposed, 131 Psoriasis, vulvar, 312 anemia, 125 Preimplantation, 31 Psychiatric disorders, postpartum, antiphospholipid syndrome, Premature ovarian failure (POF), 107–108 125–126 227 maternity/postpartum blues, cancer therapy, 127 Premature rupture of membranes 107 cardiovascular disease, (PROM), 144–146 postpartum depression, 108 118–119 Premenstrual syndrome (PMS)/ postpartum psychosis, 108 gastrointestinal disorders, premenstrual dysphoric Pubarche, 208 121–122 disorder (PMDD), 212– Puberty, 208 hypertension, chronic, 214 precocious, 208 117–118 defi nition, 212 secondary sex characteristics, pregestational diabetes, diagnostic criteria, 212–213 208 113–114 tests, 213 Tanner stages, 208 pruritic urticarial papules treatment, 213–214 Pudendal block, 93 and plaques of pregnancy Prenatal care, 43–47. See also Pudendal nerve, 92 (PUPPP), 126–127 Pregnancy Puerperium of normal labor and pulmonary disease, 119–120 defi nitions, 43 delivery, 96–98 renal and urinary tract disor- obstetric visits, frequency of, uterus, 96–97 ders, 120–121 43–44 endometrial changes, 96

389 Puerperium of normal labor and epithelium, 18 S delivery (Continued) nerve supply, 18 Sacrum, 22 uterus (Continued) fallopian (uterine) tubes, Safe sex practices, 347 involution of uterine corpus, 19–20 Salpingectomy, 188, 203 96 anatomic sections, 19 partial or total, 203 placental site involution, 96 blood supply, 20 Salpingostomy, 188 uterine vessels, changes in, nerve supply, 20 Schiller-Duval bodies, 298 97 muscles, 21–22 Screening tests, 342–344 blood supply, 22 Pulmonary disease, in pregnancy, breast exam, 342 119–120 nerve supply, 22 colon cancer screening, 342 asthma, 119 ovaries, 20 laboratory testing, 343–344 pneumonia, 119–120 blood supply, 20 bacteriuria/urinalysis, 344 Pulmonary embolism (PE), in histology, 20 cholesterol, 343 pregnancy, 124 nerve supply, 20 fasting glucose, 343 Pulmonary hypertension, in preg- pelvic viscera, ligaments of, HIV, 344 nancy, 119 20–21 thyroid-stimulating hormone Pyelonephritis, in pregnancy, pelvis, 22 (TSH), 343 120–121 shapes, 22 sexually transmitted infec- uterus, 19 tion, 343 blood supply, 19 Q tuberculosis (TB) skin test- components, 19 ing, 343 Q-tip test, 373 histology, 19 mammography, 342 Quad screen, 51–52 nerve supply, 19 Pap smear, 342 vagina, 17 Seat belt use, 346–347 blood supply, 17 R Sebaceous (epidermoid) cyst, vul- nerve supply, 17 var, 313 Radiation during pregnancy, 127 vulva, 16–17 Seizure disorder, in pregnancy, Rape, 348 blood supply, 16 122 Rape-related posttraumatic stress lymph, 16 Sertoli-Leydig cell tumors, 235, disorder (RR-PTSD), nerve supply, 17 236, 299, 300 348–349 Reproductive issues, ethics and, Sex-cord stromal tumors, ovarian, Rapid plasma reagin (RPR), 163, 358 297, 300 327, 329 Reproductive tract, 33–34 granulosa-theca cell, 300 Rectocele, 368, 369, 370 breasts, 34 Sertoli-Leydig cell tumor, 300 treatment of, 370 cervix, 34 Sexual assault, 348 Regional anesthesia during labor skin, 34 Sexual arousal disorder, 354 and delivery, 93–94 uterus, 33 Sexual aversion disorder, 354 epidural analgesia, 94 vagina, 34 Sexual dysfunction, 353–355 paracervical block, 93 Respiratory system, during preg- disorders, 354 pudendal block, 93 nancy, 37 pain disorders, 354–355 spinal (subarachnoid) block, 93 RhoGam, 140 Sexual intercourse Reiter syndrome, 327 Ritodrine, 143 postpartum, 103 Renal and urinary tract disorders, Round ligament pain during contraception, 103 in pregnancy, 120–121 pregnancy, 62 during pregnancy, 62 bacteriuria, asymptomatic, 120 Rubella (German measles), 156, Sexual pain disorders, 354–355 pyelonephritis, 120–121 159 Sexual response, female, 352–355 Reproductive anatomy, 15–22 Rule of 3s, 336 response cycle, 352 cervix, 18 Rupture of membranes, 69–70, sexual dysfunction, 353–355 blood supply, 18 144–146 disorders, 354 components, 18 premature (PROM), 144–146 pain disorders, 354–355

390 sexuality, fetus to menopause, Squamocolumnar junction Teratoma, 298 352–353 (SCJ), 271 Terbutaline, 143 adolescence, 352 Squamous cell carcinoma Terminal hairs, 232 menopause, 353 cervical, 279 Testicular feminization (andro- menstrual cycle, 352 vaginal, 307 gen insensitivity), 223 postpartum, 353 Staphylococcus, 156 comparison of müllerian agen- prenatal and childhood, 352 Staphylococcus aureus, 105, 334 esis and, 224 Sexually transmitted infections methicillin-resistant, 120 Theca lutein cysts, 235 (STIs), 163–166, 324–333, Sterilization, 201–204 Thelarche, 208 343 bilateral tubal occlusion, Third-trimester bleeding, 146– acquired immune defi ciency 202–203 152 syndrome (AIDS), 329 banding, 202 cervical mucus, extrusion of bacterial vaginosis (BV), clipping, 202 (“bloody show”), 152 162–163 complications of, 203 fetal vessel rupture, 150–151 chancroid, 330–331 electrocautery, 202 vasa previa, 151 chlamydia, 164, 326–327 hysteroscopic (essure), 203 velamentous cord insertion, serotypes A–K, 326 laparoscopic, 202 151 serotypes L1–L3 luteal-phase pregnancy, management of, 147 genital herpes, 328–329 203 placenta previa, 150 gonorrhea, 164 postpartum, 203 placental abruption (abruptio hepatitis B virus, 165 reversibility of, 203 placentae), 148–149 herpes simplex virus, 164, salpingectomy, partial or uterine rupture, 151 328–329 total, 203 Thromboembolic disorders, in human immunodefi ciency vi- colpotomy, 204 pregnancy, 122–124 rus (HIV), 165, 329 hysterectomy, 204 deep vein thrombosis (DVT), human papillomavirus (HPV), vasectomy, 201 122–123 166, 330 Streptococcus, 100, 324 pulmonary embolism (PE), laboratory testing for, 343 group B, 156, 160–161 124 pediculosis pubis (crabs), 331 intrapartum prophylaxis, 161 thrombophilias, 124 pelvic infl ammatory disease Streptococcus viridans, 105 Thyroid, 39, 109 (PID), 324–325 Stress incontinence, 372, 373– disease, 115–116 syphilis, 162–163, 327–328 374 hyperthyroidism, 115–116 toxic shock syndrome, 333 Stromal hyperthecosis, 234, 236 hypothyroidism, 116 trichomoniasis, 166 Struma ovarii, 298 dysfunction, postpartum, 109 vaginitis, 331–333 Substance abuse, 345–346 during pregnancy, 39 Sheehan syndrome, 105, 226 alcohol, 346 Thyroid storm, 116 Shoulder dystocia, 136–137 tobacco, 346 Thyroid-stimulating hormone Sickle cell disease, in pregnancy, Suburethral sling, 374 (TSH), laboratory testing 124–125 Symptothermal method of con- of, 343 Sildenafi l citrate (Viagra), 354 traception, 205 Thyrotoxicosis, 109, 115 Simmonds disease, 226 Syphilis, 156, 162–163, 325, Tobacco abuse, 346 “Sister Mary Joseph’s nodule,” 327–328, 331 Tocolytic agents, 143 295 in pregnancy, 162–163 Tocolytic therapy, 143 Sitz bath, 98 Systemic lupus erythematosus, in Toxic shock syndrome (TSS), Skene’s duct cyst, 314 pregnancy, 126 333, 334 Skin, during pregnancy, 34 workup, 333 Sonohysterogram, 218 Toxoplasma, 173 T Spermicide, 195 Toxoplasma gondii, 161–162, Spinal (subarachnoid) block, 93 Tanner stages, 208 173 Sponge, contraceptive, 195–196 Telescoping, 346 Toxoplasmosis, 156, 161–162

391 Transdermal contraceptive Ultrasound (US), 218 Uterus, 19, 33, 96–97, 154, 210 (Ortho Evra), 199 in pregnancy, 27, 48–49, blood supply, 19 Transformation zone (TZ), 271 53–55, 186 components, 19 Transvaginal sonography indications, 27 histology, 19 (TVUS), 186, 187 limitations, 27 inversion of, 154 Transverse vaginal septum, 224 specialized (level II), 53–55 nerve supply, 19 Travel, during pregnancy, 62 transvaginal (TVUS), 186, ovarian hormone effect on, Treponema pallidum, 162, 327 187 210 Trial of labor after cesarean Umbilical cord insertion, 54 postpartum, 96–97 (TOLAC), 91 Unconjugated estriol (uE3), 53 endometrial changes, 96 candidates for, 91 Ureaplasma, 178 involution of uterine corpus, contraindications to, 91 Ureaplasma urealyticum, 173 96 Trichomonas vaginalis, 69, 333 Uremia, 282 placental site involution, 96 Trichomoniasis, during preg- Ureters, during pregnancy, 38 uterine vessels, changes in, nancy, 166 Urge incontinence, 372, 374 97 Trisomy 13 (Patau syndrome), 53 Urinalysis, 344 during pregnancy, 34 Trisomy 18 (Edwards syndrome), Urinary incontinence, 371–374 51, 53 causes, 372 V Trisomy 21 (Down syndrome), irreversible, 372–373 51, 53 reversible, 372 Vacuum delivery, 92 Tubal occlusion, bilateral, defi nition, 372 Vagina, 17, 34, 97 202–203 evaluation, 373 blood supply, 17 banding, 202 treatment, 373–374 nerve supply, 17 clipping, 202 overfl ow incontinence, 374 postpartum, 97 complications of, 203 stress incontinence, 373–374 during pregnancy, 34 electrocautery, 202 total incontinence, 374 Vaginal cancer, 306–307 hysteroscopic, 203 urge incontinence, 374 staging of, 306 laparoscopic, 202 Urinary system, during preg- Vaginal delivery, 79–81, 91–92, luteal-phase pregnancy, 203 nancy, 38 102 postpartum, 203 bladder, 38 discharge from hospital follow- reversibility of, 203 kidneys, 38 ing, 102 salpingectomy, partial or total, ureters, 38 normal spontaneous vertex, 203 Urinary tract, 79–81 Tuberculosis (TB), 156 postpartum, 97 episiotomy, 81 skin testing, 343 infection, 101 head, delivery of, 79 Tubo-ovarian abscess (TOA), disorders, in pregnancy, 120– infant, delivery of, 79–80 260, 261, 262–263 121 inspection, 80 Turner syndrome, 51, 222 bacteriuria, asymptomatic, nuchal cord, checking for, Twin gestation, 167–170 120 79 diagnosis and management of, pyelonephritis, 120–121 perineal lacerations, 80 169–170 Urogenital diaphragm, 21 placenta, delivery of, 80 maternal adaptations, 168–169 Uterine bleeding, abnormal, postdelivery hemostasis, 81 prenatal diagnosis, 169 241–247 shoulders, delivery of, 79 twin-twin transfusion, 170, 181 defi nitions, 242 operative, 91–92 types of twins, 168 postmenopausal, 245–247 forceps delivery, 91 reproductive age, 242–245 vacuum delivery, 92 Uterine inversion, 154 Vaginal prolapse, 368 U Uterine prolapse, 370 Vaginal ring contraceptive Uchida method (tubal occlu- Uterine sarcoma, 290–291 (NuvaRing), 199 sion), 203 Uterocele, 368 Vaginismus, 354–355

392 Vaginitis, 332–333 Vulva, 16–17 Vulvar intraepithelial neoplasia Varicella vaccine, 344 blood supply, 16 (VIN), 304 Varicella-zoster, 156, 157 lymph, 16 Varicosities during pregnancy, 61 nerve supply, 17 W Vasa previa, 151 Vulvar cancer, 305–306 Vasectomy, 201 staging, FIGO revised 2009, Weight gain, during pregnancy, Vegetarians, nutritional deﬁ cien- 306 58–59 cies in, 59 Vulvar disorders, 309–314 Western blot, 164, 329 Velamentous cord insertion, 151 cysts, 313–314 “Whiff” test, 333 Vellus hairs, 232 Bartholin’s abscess, 313 Wickham striae, 311 Venereal Disease Research Labo- of canal of Nuck, 314 Women’s Health Initiative ratory (VDRL) screening hidradenomas, 313–314 (WHI), 365 test, 163, 327 sebaceous (epidermoid), 313 Woods corkscrew maneuver, Vernix, 70 Skene’s duct, 314 137 Vertex presentation (occiput pre- dystrophies, 310 Wright’s stain, 146 sentation), 74 lichen planus, 312 Vestibulitis, 312 lichen sclerosus, 311 Z Viagra (sildenaﬁ l citrate), 354 lichen simplex chronicus “Violin string” adhesions, 324, (LSC), 311 Zavanelli maneuver, 137 326 Paget disease, 310–311 Zidovudine (ZDV), 164–165 Virilization, 232 psoriasis, 312 Zygote intrafallopian transfer von Willebrand disease, 243 vestibulitis, 312 (ZIFT), 220

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