Women's Health Keywords

Diagnostic Studies: Breast Carcinoma

Diagnostic tests: ○ Aspirate (if cystic) ○ Mammography - microcalcification ○ Ultrasound - best at delineating cysts ○ Breast biopsy - definitive diagnosis

Clinical Intervention: Hydatidiform Mole

Do ultrasonography during early pregnancy if uterine size is much larger than expected for dates, if women have s/sxs of preeclampsia, or if β-hCG levels are unexpectedly high ○ Measure β-hCG level, do pelvic USG, & if findings suggest gestational trophoblastic disease, confirm the diagnosis by biopsy ● Remove the tumor by *suction curettage*, then classify the tumor based on clinical criteria ○ If disease is persistent, treat pts w/ chemotherapy & prescribe post treatment contraception

Health Maintenance: Menopause

Average age 51.5 years (44-55 years old) ○ On avg women will spend 30+ yrs in the postmenopausal state ○ Onset < 40 years old = premature ovarian failure ● In nl healthy women > age 45 we dx menopause as 12 mos of amenorrhea in the absence of other biological or physiological causes. A high serum FSH is not required to make the dx. ● For health women 45 + ○ FSH & estradiol levels - FSH > 30 w/ ↓ estradiol ● Menopause is a retrospective dx based on 12+ mos of amenorrhea occurring at a mean age of 51 yrs ○ The dx is based on the appropriate age of a female pt for menopause (range, 45-55 years), sxs of frequent classic "hot flashes," night sweats, & the association of these sxs w/ the cessation of menses ● Women 40-45 yrs w/ irreg menstrual cycles & menopausal sxs may be in the menopausal transition ○ Same endocrine evaluation as for any woman w/ oligo/amenorrhea: serum human chorionic gonadotropin (hCG), prolactin, TSH, FSH ● Women under age 40 years w/ irregular menses & menopausal sxs, ○ Complete evaluation for premature ovarian failure ● *Hormonal Therapy*: Estrogen & Progesterone replacement - *Only indicated in symptomatic women* ● If uterus - HRT (estrogen + progesterone), if no uterus (ERT) ○ For women who have had a hysterectomy, estrogen is used alone ■ Oral, transdermal (patch, lotion, spray, or gel), or vaginal forms may be used. Treatment should start w/ the lowest dose; the dose is increased every 2-4 wk as needed. ■ Low doses include 0.3 mg PO once/day (conjugated equine or synthetic estrogens), 0.5 mg PO once/day (oral estradiol), and 0.025 mg once/day (estradiol patch) ○ Women who have a uterus should be given progestin in addition to estrogen because unopposed estrogen increases the risk of endometrial cancer. The progestin is taken w/ estrogen continuously (ie, daily) or sequentially (12 to 14 consecutive days of every 4 wks) ● Know the *contraindications for HRT* ○ ↑ triglycerides ○ Undiagnosed vaginal bleeding ○ Endometrial cancer ○ History of breast CA or estrogen-sensitive cancers ○ CVD History ○ DVT or PE history ● For vaginal dryness, recommend vaginal stimulation & OTC vaginal lubricants & moisturizers, & if they are ineffective, prescribe low-dose vaginal estrogen creams, tablets, or rings. ● Non-hormonal therapies: Cool temps, avoid hot, spicy foods or beverages, avoid ETOH, exercise, soy ○ Alternative drugs for vasomotor symptoms ■ SSRIs (paroxetine) ■ SNRIs ■ clonidine ■ gabapentin

Health Maintenance: Menstruation

Change your sanitary napkin every 4-6 hours Wash yourself properly Don't use soaps or vagina hygiene product Discard the sanitary napkin properly Stick to one method of sanitation

Clinical Therapeutics: Vaginitis in pregnancy

*Bacterial Vaginosis*: Metronidazole: 500 mg PO b.i.d. × 7 days (also used in pregnant women) *Candidal Vaginitis*: Fluconazole 150 mg PO X 1 repeat in 7 days *Trichomonas Vaginitis*: Metronidazole 2 g PO x 1 dose *Atrophic Vaginitis*: Conjugated estrogens vaginal cream (0.625 mg/g) 0.5-2 g vaginally daily for 3 wks, then tapered to lowest effective dose 2x weekly; administer cyclically (3 wks on, 1 wk off)

Clinical Therapeutics: Contraceptive Methods

*Barrier Methods*: Failure rates are as high as 40%, offer STI protection, safe for pts w/ contraindications to hormones Male condoms: 20% failure rate, offers STI protection Female condoms: 21% failure rate, offers STI protection Diaphragm: 15% failure rate, must remain in place 6-24 hours after intercourse, requires pelvic exam & fitting *Spermicides* Nonoxynol-9: Destroys sperm - often used w/ other forms of BCP such as condoms, 27% failure rate, Slightly increased risk for HIV *OCP's* - Prevents ovulation by inhibiting mid-cycle LH surge, thickens cervical mucus, thins endometrium 9% failure rate, 0.3% failure rate when used correctly. Improves dysmenorrhea & controls menstrual cycle. Protects against ovarian cysts, ovarian & endometrial cancer, improves acne. There is no convincing evidence that OCPs increase the risk of breast, cervical, or liver cancer, potential complications include thromboembolic events, HTN, hepatic adenoma, breakthrough bleeding, nausea & breast tenderness usually resolve w/in the first 3 cycles. *Combined estrogen & progesterone* - not used in women > 35 yo that are smokers, pts w/ h/o blood clots, breast cancer or migraines w/ aura. 35 & younger who smoke OK *Transdermal patch* - This method is very effective. The contraceptive efficacy of the transdermal patch is comparable to that of combined OCP's. The failure rate is 0.3 percent w/ perfect use & 9 % w/ typical use. Some evidence suggests that efficacy is slightly decreased in women who weigh > 198 lbs; however, the patch is still a very effective method for these women *NuvaRing*- Flexible plastic vaginal ring. 7% failure rate. Applied every week for 3 weeks then 1 week off. withdrawal bleeding *Progestin-only mini pill*. Failure rates similar to combined OCP'S - 9% failure rate, 0.3% failure rate when used correctly. *Safe in lactation* No estrogenic side effects (HA, nausea, HTN). Decrease ovarian & endometrial cancer risk. May cause menstrual irregularities. slightly less effective than combined OCP's *IUD* -*Most effective form* of birth control. Reversible. Copper IUD (Paragard) - 0.8% failure rate, women who cannot have hormones that want children later in life (replaced every 10 years). Progestin-only IUD (Mirena)- 0.2% failure rate, replaced every 3-5 years *Depo-Provera*: Long-acting progesterone injection. 5% failure rate. lasts 3 months. may cause menstrual irregularities *Nexplanon*- Long-acting progesterone implanted in the upper arm. 0.05% failure rate. lasts 3 years. may cause menstrual irregularities *Tubal ligation* - 0.5% failure rate, permanent. *Essure* - chemicals or coils to scar fallopian tubes - 0.5% failure rate, can be done in the office *Vasectomy* - 0.15% failure rate - vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing w/ the semen that is ejaculated from the penis.

History & Physical: Physiology of Pregnancy

*Cardiovascular* Plasma volume increases (10-15% per trimester). RBC mass incr's by 20-30%. So, even though there is more RBCs & a higher oxygen delivery, an still have a relative dilutional anemia. Despite there being more RBCs, even more plasma means the concentration of RBCs is lower. This lower concentration serves to reduce blood viscosity to improve placental perfusion. It also means mom can tolerate 1000cc of blood loss during delivery & not die. Cardiac output increases. While the ejection fraction shouldn't change, the HR incr's to accommodate a reduced systemic vascular resistance. Pregnant women are relatively volume expanded so have incr'd preload. They are also relatively vasodilated, so have a reduced systemic vascular resistance. HR incr's as well. Uterine blood flow accounts for 750cc/min (about 12% of cardiac output) by term. *Coagulation* Mom can tolerate blood loss at term bc of her incr'd volume. But mom also has defenses against blood loss built in - hypercoagulability. While it does save moms in developing countries from hemorrhaging to death, it also means that thrombosis in pregnancy is one of the leading causes of morbidity & mortality. Clotting factors increase (VII, VIII, X, von Willebrand) & anti-clotting factors decrease (Protein C, Protein S, & Antithrombin III). Of clinical significance are an ↑ Fibrinogen (meaning that a "normal" fibrinogen at delivery is an indicator for DIC) & an ↑ D-Dimer (meaning that the D-Dimer is always the wrong choice for evaluation of thrombosis in a pregnant woman). *Pulmonary* There's an ↑ minute ventilation by about 50%; it's achieved by ↑ tidal volume. RR doesn't change. This is important bc "as baby grows, it pushes on mom's diaphragm, so she can't take deep breaths." What that means is a ↓ Functional residual capacity by about 20%, but the FEV1 doesn't change & the tidal volume increases. *Genitourinary changes* There's an increased GFR, meaning that creatinine should be lower in pregnancy (0.4-0.8mg/dL). An incr'd GFR comes from an overall increased cardiac output & reduced systemic vascular resistance. Progesterone can dilate renal pelvises & calyceal systems. An enlarging uterus can compress the ureters at the pelvic brim (MC on the right). *Weight Gain* Weight gain is a sign of healthy development. There's amniotic fluid, the baby herself, & the increase in circulating volume. The "right amount of gain" is dependent on the starting BMI; it's obviously highly variable & is more than just the number. The learning point is that if mom starts underweight, she needs to gain more, & conversely, if mom is obese, she needs to gain less. "Classically normal" weight gain is between 0.5-1 pound per week. (15-35 lbs) *Gastrointestinal* There really isn't a pathology in the GI system; just things that make mom uncomfortable. Mom may not feel the other effects (despite how physiologically important they are). Mom often feels the constipation, GERD, & nausea, which are things that can be treated. Iron supplementation can worsen constipation. There is no "right choice" on the test for constipation. For life, the combination of a stool softener & a motility agent works well. Being fertile is one of the "5 Fs" of cholelithiasis. Pregnant women are also predisposed to it. *Endocrine* Estrogen & progesterone rise through pregnancy. Estrogen contributes to the hypercoagulable state. Prolactin increases as well - nipple discharge is considered normal.

Diagnostic Studies: Prenatal Diagnosis & Care

*First Trimester Screen* - EGA 11-14 weeks *Ultrasound* for nuchal translucency *PAPP-A & hCG* ↑ levels are seen in chromosomal abnormalities Low levels of PAPP-A can be a/w Down's Syndrome *Cell Free Fetal DNA* - EGA ~10 weeks Analyze fetal DNA in maternal blood Screens for trisomies of 13, 18, & 21 Positive test results should be followed by CVS or amniocentesis *Chorionic Villus sampling (CVS)* - EGA 11-14 weeks Collect placental tissue to test for chromosomal & genetic abnormalities *Quadruple Screen* - EGA 16-18 weeks AFP, hCG, estriol, inhibin ↑ AFP = neural tube or abdominal wall defects ↑ hCG & inhibin and ↓ AFP & estriol = Down syndrome ↓ AFP, hCG, & estriol = Edwards syndrome *Amniocentesis* - EGA 15-20 weeks Collect amniotic fluid to diagnosis chromosomal abnormalities *Glucose Challenge Test* - EGA 24-28 weeks 1 hr glucose challenge test If abnormal followed by glucose tolerance test (3 hr) *Group B Strep Test* - EGA 35-57 weeks Swab the lower genital tract for colonization by GBS *Symptoms of pregnancy*: amenorrhea,↑ urine frequency, breast engorgement, nausea, bluish discoloration of vagina, vulva, & cervix due to vascular congestion (Chadwick's sign), softening of cervix *Urine Pregnancy Test (UPT)* detects hCG or B subunit sensitive to 1-2 weeks *Ultrasound* most accurate method to detect fetal size gestational Sac - 5 weeks fetal image detected at 6-7 weeks cardiac activity at 8 weeks

Health Maintenance: Normal Pregnancy

*First Trimester Screen* - EGA 11-14 weeks Ultrasound for nuchal translucency *PAPP-A & hCG* ↑ levels are seen in chromosomal abnormalities Low levels of PAPP-A can be a/w Down's Syndrome *Cell Free Fetal DNA* - EGA ~10 weeks Analyze fetal DNA in maternal blood Screens for trisomies of 13, 18, & 21 Positive test results should be followed by CVS or amniocentesis *Chorionic Villus sampling (CVS)* - EGA 11-14 weeks Collect placental tissue to test for chromosomal & genetic abnormalities *Quadruple Screen* - EGA 16-18 weeks AFP, hCG, estriol, inhibin ↑ AFP = neural tube or abdominal wall defects ↑ hCG & inhibin and ↓ AFP & estriol = Down syndrome ↓ AFP, hCG, & estriol = Edwards syndrome *Amniocentesis* - EGA 15-20 weeks Collect amniotic fluid to diagnosis chromosomal abnormalities *Glucose Challenge Test* - EGA 24-28 weeks 1 hr glucose challenge test If abnormal followed by glucose tolerance test (3 hr) *Group B Strep Test* - EGA 35-57 weeks Swab the lower genital tract for colonization by GBS

Clinical Therapeutics: Breast Cancer

*SERM: Tamoxifen or Raloxifene* can be used in postmenopausal or women > 35 w/ high risk - *tx x 5 yrs* ○ Anti-estrogen *Tamoxifen* is useful in tumors that are *ER-positive* - binds & blocks the estrogen receptor in the breast tissue. ○ *Aromatase inhibitors*: useful in *postmenopausal ER positive* patients w/ breast cancer - reduces the production of estrogen ○ *Monoclonal AB* tx: useful in pts w/ *HER2 positivity* (Human Epidermal Growth Factor Receptor)

Diagnosis: Fetal Distress

*V*-Variable ; *C*-Cord Compression *E*-Early ; *H*-Head Compression *A*-Accelerations ; *O*-Okay *L*-Late ; *P*-Placental Insufficiency ● Pt will present w/→*repetitive late decelerations in the presence of 2 contractions in 10 minutes* ● Normal fetal heart rate is between 120-160 bpm ○ > 160 for 10 minutes fetal tachycardia ○ < 120 for 10 minutes fetal bradycardia ● Nonstress testing - the nonstress test is a simple, noninvasive way of checking on the baby's health. The test records movement, heartbeat, & contractions. It notes changes in heart rhythm when the baby goes from resting to moving, or during contractions if the mother is in labor ○ GOOD- Reactive NST - > 2 accelerations in 20 mins defined by increased FHR of at least 15 bpm from baseline lasting > 15 secs, indicates fetal well being ○ BAD - Nonreactive NST - no FHR accelerations or < 15 bpm increase lasting < 15 secs, if this is the case then get a contraction stress test ● Contraction stress test - measures fetal response to stress at times of uterus contraction ○ GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 mins, indicates fetal well being, repeat CST as needed ○ BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 mins, worrisome especially if nonreactive NST, prompt delivery

Health Maintenance: Polycystic Ovary Syndrome

*Weight reduction* improves hirsutism, lipid & glucose parameters, & fertility Hirsutism is treated w/ androgen-lowering agents, including *oral contraceptives* Infertility is usually treated w/ *clomiphene citrate* to help induce ovulation Lipid abnormalities & insulin resistance should be managed medically Adding *metformin* increases ovulation & pregnancy rates & increases insulin sensitivity

Diagnostic Studies: Threatened Miscarriage

*bloody vaginal d/c* before 20 wks of gestation w/ or w/o uterine contractions in the presence of a *closed cervix*. Diagnose by *↓ βHG & classification based on USG findings* ○ Transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early pregnancy ■ The US demonstrates inappropriate development or interval growth, poorly formed/unformed fetal pole, fetal demise ○ The βHG should double every 48 hours in a viable intrauterine pregnancy ○ Blood type & Rh status necessary tests to preclude Rh sensitization in mother

History & Physical: Rectocele

A rectocele occurs when the supportive connective tissue separating the rectum & vagina weaken, leading to a prolapse of the rectal wall into the vagina ● This is usually due to any type of trauma that weakens the supportive tissue in this area, such as childbirth or repeated heavy lifting. In some women, the decrease in estrogen that occurs after menopause may cause laxity of these connective tissues, leading to a rectocele. Results in *PELVIC PRESSURE + BOWEL SXS* ○ Perceived or discovered bulge into the vagina ○ PELVIC PRESSURE ○ Defecatory dysfunction (constipation, straining, incomplete emptying) ○ Low back pain ● POP-Q (pelvic organ prolapse quantification): quantifies the extent & location of defects ○ Get a colonoscopy to rule out cancer & rectal studies if indicated

Scientific Concepts: Breech Presentation

A breech birth happens when a baby is born bottom first instead of head first. *Around 3-5% of pregnant women at term (37-40 weeks pregnant) will have a breech baby.* Prevalence decreases w/ increasing gestational age. 20-25% of fetuses under 28 wks are breech, but only 7-16% are breech at 32 wks, & only 3-4% are breech at term. Breech presentation may be frank, complete, or incomplete In most pregnancies, breech presentation is a chance occurrence. Risk increases w/ multiple gestations, uterine anomalies, hydrocephalus, & anencephaly The diagnosis of breech presentation is *based on PE, w/ ultrasound confirmation*, if the dx is uncertain. USG clearly identifies the fetal head in the fundus, buttocks in the lower uterine segment, extension or flexion of each hip & knee, & location of each foot Detection of fetal malpresentation (including breech, transverse lie, etc.) *prior to 37 weeks does not warrant intervention*. Observation & repeat ultrasound at 37 weeks is indicated In the US, clinician preference for women w/ the breech presentation is to offer external cephalic version at or near term, followed by a trial of vaginal delivery if the version is successful & planned cesarean delivery if breech presentation persists Some women may choose to undergo planned cesarean delivery if the breech persists w/o an attempt at external cephalic version Women w/ a low likelihood of successful version or at increased risk of fetal harm from the procedure may reasonably avoid the procedure Some women may choose to have a vaginal breech delivery There is a general consensus that these women should be at low risk of complications from vaginal breech delivery & their labor & delivery should be supervised by a clinician w/ experience in vaginal breech birth Both vaginal delivery & cesarean section have similar long-term maternal & childhood outcomes & some data suggest some long-term health benefits to being born vaginally

History & Physical: Cystocele

A cystocele occurs when the supportive connective tissues separating the bladder & vagina weaken, leading to a prolapse of the bladder into the *superior* end of the vagina ● This results in a *bulge* of the bladder into the vaginal wall (bladder hernia) + *urinary symptoms* ● This can occur after childbirth or after lifting heavy objects for a period of time. A chronic cough can repeatedly strain these connective tissues, leading to a cystocele. Obese women are more likely to develop a cystocele. ○ Can result from childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain ○ Perceived or discovered BULGE IN THE VAGINA ○ Pelvic pressure, urinary dysfunction (urgency, frequency, incomplete voiding, urinary retention, urinary incontinence)

Scientific Concepts: Prenatal Care

A recommended prenatal care schedule consists of the following: ○ Monthly visits to a healthcare professional for weeks 4-28 of pregnancy ○ Visits twice monthly from 28 to 36 weeks ○ Weekly after week 36 (delivery at week 38-40) ● Recommendations for use of dietary supplements in pregnancy: ○ All pregnant women should receive a prenatal vitamin. ○ Folic acid supplementation (0.4-0.8 mg) prior to conception; 4 mg for secondary prevention ○ Calcium: 1,000-1,300 mg/day; supplement may be beneficial for women w/ high risk for gestational hypertension or communities w/ low dietary calcium intake. ○ Iron: Screen for anemia (Hgb/Hct) & treat if necessary. Recommend 30 mg/day of iron in pregnant women. ○ Vitamin A: Pregnant women in industrialized countries should limit to <5,000 IU/day. ○ Vitamin D: Consider supplementation in women w/ limited exposure to sunlight. ● A full physical exam should be performed at the 1st prenatal appointment. ● At each subsequent prenatal visit, the following should be recorded: ○ Weight: Total wt gain range should be 25-35 lb, except in obese women, where wt gain should be <15 lb ○ ACOG defines hypertension as BP >140 mm Hg systolic or >90 mm Hg diastolic ○ Monitor BP especially closely in pts w/ chronic hypertension (predating pregnancy), preeclampsia/eclampsia, or gestational hypertension. ○ UA for glucose & protein; 24-hour protein excretion is the gold standard but not practical. ○ Fundal height ○ Fetal heart rate: usually audible by 12 weeks' GA w/ a Doppler instrument ○ Fetal position by abdominal palpation at 36 weeks ○ Pelvic/cervical exam if indicated ● Advanced maternal age is 35 & each mother should be offered testing for genetic abnormalities ● Expectant date of confinement can be calculated by Naegele's rule ○ What was the first day of bleeding? = 1'st day of the last menstrual period ■ 1'st day of last menstrual period + 7 days - 3 months + 1 year ● Initial visit should be 6 weeks after LMP ● Each visit assess: ○ Fetal heart tones, blood pressure, fundal height, fetal movement & urinalysis ○ Ultrasound should be able to detect fetal heart activity 1-2 wks after 1st missed cycle (around 5-6 wks) ● Triple screen: AFP, HCG, Estriol ● Quad Screen: AFP, HCG, Estriol, Inhibin A ● Chorionic villus sampling: between 10-12 weeks (end of first trimester) ● Amniocentesis: between 15-18 wks (beginning of the 2nd trimester) - esp for women > 35 yo in the high-risk group ● 75 g 2-hour oral glucose tolerance test at 26-28 weeks ● Group B strep test between 35-37

Diagnosis: Leiomyoma

AKA Uterine Fibroids: benign smooth muscle cell tumors, also called fibroids & leiomyomas. May cause *infertility & iron deficiency anemia* May be single or multiple, described by location, most myomas involve more than one layer of the uterus Subserosal: Projects into the pelvis, may be pedunculated Intramural: Within the uterine wall Submucosal: Projects into the uterine cavity Sxs: *Polymenorrhea, menorrhagia, intermenstrual bleeding &/or metrorrhagia. Uterine mass* ** The best diagnostic study of uterine fibroids is by ultrasound ** The dx of uterine fibroids is likely if bimanual pelvic examination detects an enlarged, mobile, irregular uterus that is palpable. Confirmation requires imaging, which is usually indicated. Diagnosis w/ ultrasound &/or MRI

History & Physical: APGAR Score

APGAR score: ○ Activity (2=active movement) ○ Pulse (2= >100 BPM) ○ Grimace (2= pulls away, sneeze) ○ Appearance (2=pink) ○ Respiration (2=crying) ■ Score > 6 is good. ■ A score of 4 necessitates resuscitation.

History & Physical: Secondary Amenorrhea

Absence of menses for 3 mos in a woman w/ previously nl menstruation or 6 mos in a woman w/ a h/o irregular cycles ○ The MCC is *pregnancy* ○ Endometrial atrophy Asherman's syndrome caused by scarring of the endometrium after early termination of pregnancy or a D&C, Radiation ○ Premature ovarian failure - FSH is high > 40 ○ Pituitary dysfxn - Sheehan's syn - hemorrhage causes bleeding into the posterior pituitary stalk ○ Drug use, herbals, hormonal medications, stress, extreme changes in wt, eating disorders, excessive exercise (w/ a low percentage of body fat) ● *Labs* ○ check a quant βHCG ○ TSH ○ Prolactin if > 200 CT of sella ○ *Progesterone challenge* - give prolactin for 10 days if no bleed repeat HCG ○ FSH - if > 40 ovarian failure if low or nl HPO abnormality ● Treat underlying cause ○ If no desire to become pregnant may use OCPs ○ Cyclic progesterone 10 mg for 10 days, Ovulation inducers if the patient would like to become pregnant

Diagnosis: Toxic Shock Syndrome

Acute illness characterized by *high fevers* which may quickly lead to *hypotensive shock & multisystem failure.* Caused by exotoxins from S. Aureus. Menstruating women between age 12-24 who use super absorbent tampons. Postpartum women, use of diaphragm, post surgical procedures. Abrupt onset of high fevers, vomiting, diarrhea. W/in 48 hrs signs of shock occur (temp, dehydration, tachycardia, hypotension) & a diffuse "sunburn-like" rash appears over the face, trunk, & proximal extremities. Desquamation (palms/soles) may occur 1-2 wks after onset. Involvement of 3+ organ systems (GI, CNS, GU, mucous membranes, skin, CV, Hepatic) is essential for dx

Diagnosis: Chancroid

An acute, curable, sexually transmitted disease caused by *H. ducreyi*. It is uncommon in the US but is a predominant cause of genital ulcer disease in sub-Saharan African ● Presentation: 1-3 extremely *painful ulcers* around the perilabial area that are deep, purulent, & have ragged edges. ○ a/w *unilateral, suppurative, painful swollen inguinal lymph nodes*, that in 25% of cases will rupture, releasing a heavy foul discharge that is contagious (suppurative adenopathy = *bubo*) ○ Systemic sxs (fever, myalgias) are typically not present ● R/O: syphilis, HSV, lymphogranuloma venereum (LGV), & granuloma inguinale ● Laboratory tests ○ Culture on selective media isolates H. ducreyi ○ Gram stain of a specimen from the ulcer base of bubo aspirate: reveals *gram-negative rods in a chain*; referred to as a "school of fish: pattern ○ PCR ● TX: Azithromycin (PO) or Ceftriaxone (IM) - treat both partners

History & Physical: Bacterial Vaginosis

Bacterial Vaginosis: ■ FISHY, grey, scant, THIN, STICKY ■ pH > 4.5 (BACTERIA = BASIC) ■ Wet-prep shows epithelial cells w/ bacteria coating on surface = "clue cells" ■ KOH testing causes a release of amine odor (+ whiff test)

Clinical Therapeutics: Premature Rupture of Membranes

Bed rest & imminent delivery of the baby. Vaginal delivery can be performed if the baby & mother are stable. *Pitocin* may be needed to start contractions if they have not started w/in 24 hours after rupture. ● Treatment depends on gestational age ○ > 34 weeks - induce ○ 32-34 weeks collect fluid & check for lung maturity - then induce ○ < 32 weeks stop contractions & start 2 doses of *steroid injection* then deliver the baby - give *antibiotics*

Health Maintenance: Premature Rupture of Membranes

Bed rest & imminent delivery of the baby. Vaginal delivery can be performed if the baby and mother are stable. *Pitocin* may be needed to start contractions if they have not started w/in 24 hours after rupture. ● Treatment depends on gestational age ○ > 34 weeks - induce ○ 32-34 weeks collect fluid & check for lung maturity - then induce ○ < 32 weeks stop contractions & start 2 doses of *steroid injection* then deliver the baby - give *antibiotics*

Clinical Intervention: Breast Abscess

Breast ultrasound & mammography may be necessary in non lactating women ● Treatment is by *incision & drainage + antibiotics* ○ Regimen: Nafcillin/oxacillin IV or cefazolin PLUS metronidazole ○ Alternative is Vancomycin ○ Milk must continue to be expressed to reduce engorgement & aid in healing ○ Decision to continue breastfeeding vs. pump & dump is related to antibiotics used and decision of the surgeon. It is common to stop breast feeding from the affected breast

Diagnostic Studies: Cystocele

Bulge of the bladder into the vaginal wall (bladder hernia) + urinary sxs Diagnosed w/ *voiding studies, urodynamic studies*

Scientific Concepts: Turner Syndrome

Can cause *amenorrhea* (Primary Ovarian Failure) Turner Syndrome (*45, X*) - characterized by short stature, streak gonads, mild MR, & other abnormalities such as webbed neck, lymphedema, pigmented nevi, & congenital heart defects (coarctation of the aorta) Can manifest w/ *IUGR*

Health Maintenance: Uterine Prolapse

Caucasian women, after labor/delivery, chronic cough. Vaginal fullness, abd pain worse late in day, after prolonged standing. Relieved by lying down. Prolapse of the uterus into the vaginal canal - graded by uterine descent: 0 degree: No descent 1st degree: To the upper vagina / descent btn normal & ischial spine 2nd degree: To the introitus/btn ischial spines & hymen 3rd degree: Cervix is outside the introitus/within hymen 4th degree (sometimes referred to as procidentia): Uterus & cervix entirely outside the introitus/through hymen Prolapse of the bladder into the front wall of the vagina (cystocele) - leads to a "reservoir effect" where the bladder is not completely emptied when the urine is passed Prolapse of the rectum into the back wall of the vagina (rectocele) - complain of a sensation of bulging in the vagina when they strain to open their bowels. Diagnosis is by Pelvic examination Dx is confirmed by speculum or bimanual pelvic examination. Vaginal ulcers are biopsied to exclude CA Simultaneous urinary incontinence requires evaluation Asymptomatic 1st- or 2nd-degree uterine prolapse may not require treatment Symptomatic 1st/2nd-degree prolapse can be tx'd w/ a *pessary* if the perineum can support a pessary Severe or persistent sxs & 3rd/4th-degree prolapse require *surgery*, usually hysterectomy w/ surgical repair of the pelvic support structures (colporrhaphy) & suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby). Surgical options include a vaginal approach (vaginal repair) & an abdominal approach.

Diagnosis: Cervical Dysplasia

Caused by sexual transmission of high risk types of *HPV* ○ Know the Risk Factors! ■ Early age of intercourse ■ Early childbearing ■ Multiple sex partners ■ History of STI ■ Low socioeconomic status ■ Smoking ● HPV DNA is found in virtually all cervical carcinomas & precursor lesions worldwide. ○ 16 & 18 cause cancer, 6 & 11 cause warts ○ High-risk HPV types: 16, 18, 31, 33, 35, 45, 52, & 58 are common oncogenic virus types ○ *HPV16* is the most carcinogenic HPV genotype & accounts for 55-60% of all cervical cancers. ○ HPV18 is the next most carcinogenic HPV genotype. HPV18 causes a greater proportion of glandular cancers, adenocarcinoma, & adenosquamous carcinoma, than squamous cell carcinoma. ○ Most HPV infections are transient, becoming undetectable w/in 1-2 yrs. Persistent infections are what place women at significant risk for developing precancerous lesions. ○ Low-risk types: HPV viral types 6, 11, 42, 43, & 44 are considered common low-risk types & may cause genital warts. HPV 6 & 11 (cause 90% of benign anogenital warts) can lead to low-grade squamous intraepithelial lesion (LSIL) & CIN 1. ○ Transformational zone most commonly affected ● Cervical Cancer Screening ○ First PAP at the *age of 21 regardless of sexual activity* (no pap indicated prior to that) ○ Age less than 30: do not screen w/ HPV testing ○ Age 21-65: Screen w// PAP every 3 years ○ Age 30-65: Screen w/ PAP and Cytology every 5 years ○ Age > 65: Screen w/ adequate prior screening: do not screen ● Evaluating PAP results: KEEP IT SIMPLE ○ *** ASC-US & up - require reflex HPV testing for high-risk types - if negative HPV then you can repeat in 12 months if + then send for colposcopy - this will work for all age groups

Diagnosis: Incompetent Cervix

Diagnosed w/ *ultrasound - funneling of the cervix* ○ Unfortunately, an incompetent cervix is usually diagnosed after a second or third-trimester miscarriage occurs. The incompetent cervix can usually be detected on prenatal ultrasound or pelvic exam. ○ S/ S: pts may or may not have some bleeding in the second or third trimester.

Clinical Intervention: Cervical Dysplasia

Cervical Cancer Screening ○ *First PAP at the age of 21 regardless of sexual activity* (no pap indicated prior to that) ○ Age less than 30: do not screen w/ HPV testing ○ Age 21-65: Screen w// PAP q 3 years ○ Age 30-65: Screen w/ PAP and Cytology q 5 years ○ Age > 65: Screen w/ adequate prior screening: do not screen ● Evaluating PAP results: KEEP IT SIMPLE ○ *** ASC-US & up - require reflex HPV testing for high-risk types - if negative HPV then you can repeat in 12 months if + then send for colposcopy - this will work for all age groups ● Vaccination ○ Quadrivalent HPV vaccine (Gardasil) targets HPV types 6, 11, 16, & 18. ○ 9-valent vaccine (*Gardasil 9*) targets the same HPV types as the quadrivalent vaccine (6, 11, 16, & 18) as well as types 31, 33, 45, 52, & 58. Protects against 90% of warts 73% of cervical cancers ○ Bivalent vaccine (Cervarix) targets HPV types 16 and 18. ● In the US, only the 9-valent vaccine is available ○ Females - HPV vaccine is recommended at 11-12 yrs. It can be administered starting at 9 yo & catch-up vaccination is recommended for females aged 13-26 yrs who have not been previously vaccinated or who have not completed the vaccine series. ○ Males - HPV vaccine is recommended at 11-12 years. It can be administered as starting at 9 yo, & catch-up vaccination is recommended for males aged 13-21 yrs who have not been previously vaccinated or who have not completed the vaccine series. ○ Among males 22-26 yo, catch-up HPV vaccination is recommended if they are men who have sex w/ men or immunocompromised (including HIV-infected males). ● *Dosing: ○ < 15 yo: administer a two- rather than a three-dose vaccine series. In such pts, the 2 doses are administered at least 6 months apart ○ > 15 yo: the HPV vaccine is administered in 3 doses at 0, at 1 to 2 mos, & at 6 mos ○ Immunocompromised pts should also receive a three dose series

Scientific Concepts: Cervicitis

Cervicitis is inflammation or infection of the cervix. This usually occurs due to *STDs*, such as chlamydia or gonorrhea. *Chemical irritation* from lubricants, spermicides, or douching may also cause cervicitis. Bacterial vaginosis may also cause a *bacterial infection* of the cervix. ○ Can be an infectious or inflammatory cause ○ Infectious cause is most likely an STI: chlamydia, gonorrhea, herpes, HPV, trichomonas ○ Inflammation caused by allergy to spermicide or chemical exposure ○ Most women are asx ○ May have bloody clear/grey vaginal d/c, postcoital bleeding, dyspareunia or pelvic pain ○ dx'd w/ Pap smear, wet prep, cervical swab for gonorrhea & chlamydia ○ Treatment based on cause ■ Inflammatory: remove the offending agent ■ Infectious - appropriate antibiotic therapy Appropriate abx should be started to prevent spreading of the infection, which could lead to PID or a pelvic abscess. If the irritation is chemical in nature, pts should stop using the causative agent.

History & Physical: Vulvovaginal Candidosis

Clumpy or cheesy vaginal d/c, pruritus, dysuria, burning, dyspareunia, vaginal or vulvar edema & erythema. ■ pH < 4.5 ■ KOH branching hyphae ■ Treatment: Topical antifungals (Diflucan) Fluconazole 150 mg PO x 1 then repeat in 7 days

Clinical Therapeutics: Cystocele

Conservative therapy includes Kegel exercises, pelvic floor retraining, & behavioral modification ● A *pessary* can be inserted to provide extra support to these connective tissues & prevent the bladder from prolapsing into the vagina ● If symptoms are very bothersome & not relieved w/ more conservative measures, *surgical repair w/ mesh augmentation* may be necessary to strengthen the support underneath the bladder.

Diagnostic Studies: Endometriosis

Definitive diagnosis is made by *laparoscopy* (definitive study) & confirmed by biopsy ○ Imaging tests (ultrasonography, barium enema, IV urography, CT, MRI) are not specific or adequate for diagnosis. However, they sometimes show the extent of endometriosis & thus can be used to monitor the disorder once it is diagnosed

Health Maintenance: Rubella Vaccination

Due to vaccinations, congenital rubella is extremely rare in the US. *Testing for all pregnancy women is recommended in first trimester or prior to pregnancy*. Vaccination should *not* be given during pregnancy bc it is a live, attenuated virus. Mother should be given MMR postpartum Women who are planning to become pregnant should check with their doctor to make sure they are vaccinated before they get pregnant. Because MMR vaccine is an attenuated (weakened) live virus vaccine, pregnant women who are not vaccinated should wait to get MMR vaccine until after they have given birth. Adult women of childbearing age should *avoid getting pregnant for at least 4 weeks* after receiving MMR vaccine. Pregnant women should NOT get MMR vaccine.

Diagnosis: Dysmenorrhea

Dysmenorrhea: *Pain w/ menses or precede menses by 1-3 days*. Pain tends to peak 24 h after the onset of menses & subsides after 2-3 days ○ Lower abd cramping, HAs, N/V, diarrhea ○ Up to 95% of menstruating females have experienced primary dysmenorrhea. Up to 42% lose days of school/work monthly due to dysmenorrhea. ● Primary Dysmenorrhea - Begins early after menarche ○ Crampy, lower abd pain occurring during menses w/o any clear dz - a/w *prostaglandins* ● Secondary Dysmenorrhea - new-onset in an older women ○ New-onset in older women, a/w a *secondary pathologic (structural) cause* - adenomyosis, endometriosis, fibroid, PID, IUD

Clinical Therapeutics: Dysmenorrhea

Dysmenorrhea: Pain w/ menses or precede menses by 1-3 days. Pain tends to peak 24 h after the onset of menses & subsides after 2-3 days An NSAID or an NSAID plus a low-dose OCP is usually effective ○ *1'st line - NSAIDs* ○ *2'nd line - hormonal contraception* ● NSAIDs are the most effective treatment, w/ the addition of OCPs when necessary. About 10% of affected women do not respond to these measures. In these cases, it is important to consider secondary causes of dysmenorrhea in affected women. Acupuncture is also used as an alternative treatment.

Clinical Intervention: Eclampsia

ECLAMPSIA = HTN, + PROTEINURIA + SEIZURES or COMA ○ Pt meets all criteria for preeclampsia + Seizures or Coma this is life-threatening for mother & fetus ○ Same diagnostic criteria as pre-eclampsia ○ TREAT w/ *MAGNESIUM SULFATE* for seizures ○ *Delivery of fetus once the pt is stabilized* ○ BP meds: *HYDRALAZINE* Delivery is the only cure for preeclampsia & eclampsia - The decision to induce depends on the stage of pregnancy & severity of the disease ○ "If both mom & fetus are stable induction of labor is warranted if not then C-section is indicated." ○ Bed rest may be recommended, which includes a left side-lying position as this increases placental blood circulation ○ Magnesium sulfate for seizure prophylaxis ○ Treat extremely high BP w/ IV antihypertensives (Labetalol or Hydralazine) ○ If *less than 34 weeks antenatal steroids* promote fetal lung development

Clinical Intervention: Pyelonephritis

Outpt tx: FQ or trimethoprim-sulfamethoxazole x 10-14 days; if enterococcus is suspected, add amoxicillin until cultures return. Inpt tx indicated if pt is noncompliant, can't tolerate PO, is severely ill or is *pregnant;* initial tx is *ceftriaxone, ampicillin, & gentamicin or aztreonam*

Diagnosis: Gestational Diabetes

Glucose intolerance of diabetes mellitus during pregnancy *Fasting glucose is > 92* is diagnostic of gestational DM Consider amnio for fetal lung maturity & induction At 18 wks get a level 2 US - worried about fetal cardiac abnormalities Most pts can be managed w/ dietary modification Obtain a random glucose on all pregnant women during the first prenatal visit to check for preexisting diabetes, then conduct a repeat screening at 24-28 wks. *Screening* consists of administering a *nonfasting 50-g glucose challenge test*, followed by a serum glucose level 1 hour later. If the 1-hour serum glucose value is > 130 mg/ dL, a *3-hour glucose tolerance test* is performed. *3-hour glucose tolerance test*: Glucose concentration greater than or equal to these values at 2 or more time points are generally considered a positive test Fasting: 95 One hour > 180 Two hour > 155 Three hour > 140

Clinical Intervention: Melasma

Hyperpigmentation of the face Commonly used topical agents for the treatment of melasma include hydroquinone, azelaic acid, kojic acid, glycolic acid, salicylic acid and tretinoin. Of these treatments, *hydroquinone* remains the gold standard . Second-line treatments, such as chemical peels and lasers, are efficacious in some patients Sun protection

History & Physical: Normal Postpartum uterus

Immediately after delivery, the uterus is at the level of the umbilicus ■ After 2 days, the uterus shrinks or involutes ■ After 2 weeks, it descends into the pelvic cavity ■ By 6 weeks, it is back to its antenatal size Uterus: at the level of the umbilicus after delivery, involution (shrinks) after 2 days, descents into the pelvic cavity ~ 2 wks. *Nl size around 6 wk postpartum*

History & Physical: Endometritis

Infection of the uterine endometrium. Chorioamnionitis (fetal membrane infection) Usually polymicrobial (often vaginal flora, aerobic & anaerobic bacteria) RF: Postpartum or postabortal uterine infection: C-section biggest RF, prolonged rupture of membranes > 24 hrs, vaginal delivery, dilation & curettage (or evacuation) S/sxs: *Fever, tachycardia, abd pain & uterine tenderness after c-section, 2-3 days postpartum or postabortal* (may present later). Mainly a clinical dz May have vaginal bleeding/discharge (may have *foul smelling lochia*)

Scientific Concepts: Pelvic Inflammatory Disease

Inflammation of the *upper genital tract* caused by infection or iatrogenic cause ○ Will have cervical motion tenderness on exam = *chandelier sign* ● Causative agents = N. gonorrhea, C. trachomatis, anaerobes, gram-neg bacteria & streptococci ○*Risk Factors*: ■ Sexually active & age <25 yrs ■ First sexual activity at a young age (<15 yrs) ■ New/multiple sexual partners ■ Non Barrier contraceptive methods (OCPs) ■ Previous h/o PID; 20-25% will have a recurrence ■ Cervical ectopy ■ H/o C. trachomatis; 10-40% will develop PID ■ H/o gonococcal cervicitis; 10-20% will develop PID ■ Gynecologic procedures such as endometrial bx, curettage, & hysteroscopy break the cervical barrier, predisposing women to ascending infections ● PAs must consider PID in the ddx in women 15-44 yo who present w/ lower abd or pelvic pain & cervical motion or pelvic tenderness, even if these sxs are mild. ● What is the *classic triad* of s/sx in PID? *Pelvic pain, incr'd vaginal d/c, & fever* ● Clinical findings suggested by direct abd tenderness, cervical motion tenderness, & adnexal tenderness plus 1 or more of the following: ○ Temperature > 38°C, ○ WBC count > 10,000/mm3, or ○ Pelvic abscess found by manual examination or ultrasonography ● The CDC recommends empiric treatment for PID if ≥ 1 of the following minimum criteria are present on the pelvic exam in an at-risk pt: ○ Cervical motion tenderness ○ Uterine tenderness ○ Adnexal tenderness in the presence of lower abd or pelvic pain ● First-line treatment of PID ○ Inpatient regimen: ■ IV cefotetan or IV cefoxitin plus doxycycline (orally or IV) ■ IV clindamycin & IV gentamicin ○ Outpatient regimen: ■ *IM ceftriaxone plus oral doxycycline w/ or w/o oral metronidazole* ■ IM cefoxitin & oral probenecid plus oral doxycycline w/ or w/o oral metronidazole ■ Other parenteral 3rd gen cephalosporin plus doxycycline w/ or w/o oral metronidazole ● Situations that may require *hospitalization* for inpatient treatment include the following: ○ observation for potential surgical emergencies that cannot be excluded ○ pregnancy ○ failed outpatient treatment ○ severe illness, such as high fever, N/V ○ the pt is unable to follow or to tolerate an oral regimen & ○ the presence of a tubo-ovarian abscess

Diagnosis: Normal Labor & Delivery

Labor is defined as *regular uterine contractions causing cervical change* ● WHO defines normal birth as "spontaneous in onset, low-risk at the start of labor & remaining so throughout labor & delivery. The infant is born spontaneously in the vertex position between 37 & 42 completed weeks of pregnancy. After birth, mother & infant are in good condition." ● Cervical examination: ○ Dilation - up to 10 cm ○ Effacement (softening) - up to 100% ○ Station (position of the baby the head) - 0 is at ischial spine. ● Stages of labor: ○ Stage 1: Onset contractions to full dilation (primi- 6-20 hours ) (multi- 2-14 hours) ○ Stage 2: Full dilation to baby delivery (primi- 30 mins-3 hours) (multi- 5-6 minutes) ○ Stage 3: After baby delivery to expulsion of placenta (0-30 mins) ■ Placenta should have 2 arteries & 1 vein

History & Physical: Fibroadenoma

MC breast tumor in young adolescent women - 10-20% of women. MC in late teens to early 20's. Composed of glandular & fibrous tissue *Painless, firm solitary (rubbery feeling) well defined mobile mass. Gradually grows over time & does not usually wax & wane w/ menstruation*. No axillary involvement or nipple discharge. Usually found in reproductive age women Diagnosed w/ ultrasound &/or mammogram +/- biopsy The TOC for a suspected fibroadenoma is either a fine-needle bx or an excision bx

Scientific Concepts: Mastitis

Mastitis is a condition in which *bacteria (S. Aureus)* enter the breast tissue through a milk duct or a fissure in the skin, caused by breastfeeding. Mastitis usually occurs w/in the *first few weeks of breastfeeding* but may occur later on. ○ Mastitis occurs mainly in *BREASTFEEDING WOMEN*. Rarely, this condition occurs in women who are not breastfeeding. ○ Infectious vs. congestive mastitis (unilateral vs. bilateral) ■ Infectious (unilateral) - Unilateral, fever, chills & color change ■ Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas ● ***Inflammatory breast cancer presents w/ breast tenderness & color change, but fever & chills are not usually present*** ● Diagnosis is clinical - if an abscess is suspected & ultrasound may be warranted ● Tx w/ dicloxacillin 250 mg QID x 10 days for staphylococcus ○ Pts should be encouraged to continue breastfeeding & apply warm/cold compresses to the infected area along w/ oral NSAIDs

History & Physical: Mastitis

Mastitis is a condition in which bacteria enter the breast tissue through a milk duct or a fissure in the skin, caused by breastfeeding. Mastitis usually occurs w/in the first few weeks of breastfeeding but may occur later on. ○ Mastitis occurs mainly in *BREASTFEEDING WOMEN*. Rarely, this condition occurs in women who are not breastfeeding. ○ Infectious vs. congestive mastitis (unilateral vs. bilateral) ■ *Infectious (unilateral) - Unilateral, fever, chills & color change* ■ Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas

History & Physical: Shoulder Dystocia

Shoulder Dystocia: failure of the shoulders to deliver spontaneously after delivery of the fetal head ○ One or both shoulders lodged at pubic symphysis w/ delivery of the head ○ This is an obstetric emergency ● *Turtle Sign* - retraction of the delivered head against the maternal perineum

Scientific Concepts: Menstruation

Menstruation (1st day of follicular phase) ■ If the egg isn't fertilized, the *corpus luteum soon deteriorates* (causing a *fall of progesterone & estrogen* levels) ● The endometrium is no longer maintained & sloughs off, leading to menstruation ● The negative feedback of GnRH subsides, causing ↑pulsatile GnRH secretion. This leads to *↑FSH & LH*, which starts the follicle maturation process all over again GnRH pulses >1 an hour favor LH secretion; less frequent pulses favor FSH secretion

Clinical Therapeutics: Preterm Labor

Mgmt: admission to the hospital & observe for signs of infection ○ *Antenatal steroids*: enhances fetal lung maturity (L:S ratio < 2:1, < 34 wks). *Betamethasone* ○ *Tocolytics*: suppresses uterine contraction. May be given for 48 h to delay delivery so steroids can take full effect on the fetus. Don't delay labor if intrauterine infection is detected. ■ *Indomethacin*: inhibits prostaglandin-mediated uterine contraction (ex 24-32 wks) ■ *Nifedipine* (CCB) (ex 32-34 wks or 2nd line during 24-32 wks) ■ *Magnesium Sulfate*: must be admitted if administered. Not used w/ Nifedipine ■ *Beta2 Agonists*: Terbutaline (2nd line 32-34 wks). S/E: maternal pulmonary edema ○ *Antibiotic prophylaxis*: included GBS: ex Ampicillin followed by PO Amoxicillin & Azithromycin. PCN allergy: Cefazolin followed by PO cephalexin & azithromycin

Health Maintenance: Cervical Cancer

Most caused by HPV (High risk types, 16 & 18, 31, 33) ○ *HPV 16* is the most carcinogenic HPV genotype & accounts for 55-60% of all cervical cancers. ○ Worldwide, cervical cancer is the 3rd MC malignancy among women. ○ *Squamous cell* is the MC type ○ Risk factors: early sex, multiple sex partners, cigarette smoking ■ In the developed world, it is the 10th MC malignancy among women. In the US, it is the 3rd MC gynecologic cancer. ○ The dz has a bimodal distribution, w/ the highest risk among women age 40-59 yrs & >70. ○ Women w/ cervical cancer may be asx & have a normal PE. The MC sx is vaginal bleeding, often post-coital, vaginal discharge ● Cervical Cancer is prevented & diagnosed through PAP screening ○ ***ASCUS & up - require reflex HPV testing for high-risk types - if negative HPV then you can repeat in 12 months if + then send for colposcopy - this will work for all age groups***

Diagnosis: Syphilis

Syphilis is caused by the *spirochete Treponema pallidum* & has incr'd in incidence over the last 10 yrs; it is a/w risk taking behavior such as drug use. ● The dz has 3 phases, w/ an incubation period of about 3 wks: ○ *Primary syphilis*: presents as a painless chancre in the genital or groin region persisting 3-6 wks. ○ *Secondary syphilis*: presents as an erythematous rash involving the palms & soles or a condyloma lata which is similar to the lesions of 1° syphilis in its infectivity but differs in appearance ○ *Tertiary syphilis (latent)*: Affects about 30% & is a representation of widespread systemic involvement & can present w/ major vessel changes, such as in the aorta, permanent CNS changes (neurosyphilis), or even benign mucosal growths called gummas. ● *Congenital syphilis*: Hutchinson teeth (notches on teeth). Saddle-nose deformity, ToRCH syndrome. ● Any reference to *dark field microscopy* should make you think of what organism? Treponema pallidum ● The rash of secondary classically affects what part of the body? Palms & soles ● In suspected acquired syphilis, the traditional approach has been to first perform nontreponemal serology screening using the *VDRL, rapid plasma reagin (RPR)*, or ICE Syphilis recombinant antigen test ○ The sensitivity of the VDRL & RPR tests is estimated to be 78%-86% for detecting primary syphilis, 100% for secondary syphilis, & 95%-98% for tertiary syphilis ○ *Treponemal antibody-absorption test (FTA-ABS)* is commonly used as a confirmatory test after pos results on the VDRL or RPR test ● Some conditions may cause a false + test, including: ○ IV drug use ○ Lyme disease ○ Certain types of pneumonia ○ Malaria ○ Pregnancy ○ SLE & some other autoimmune disorders ○ Tuberculosis (TB) ● Lumbar puncture should be performed in pts suspected of having neurosyphilis w/ no CI ○ No single test is available for the definitive dx of neurosyphilis; rather, the clinical sxs, serology, & cerebrospinal fluid (CSF) values (CSF cell count or protein & a reactive CSF-VDRL) must be used in combination to determine the dx

History & Physical: Polyhydramnios

Polyhydramnios is defined as a *pathological increase of amniotic fluid volume* in pregnancy & is a/w increased perinatal morbidity & mortality. Common causes of polyhydramnios include gestational diabetes, fetal anomalies w/ disturbed fetal swallowing of amniotic fluid, fetal infections & other, rarer causes. The dx is obtained by ultrasound. The prognosis of polyhydramnios depends on its cause & severity. Typical sxs of polyhydramnios include *maternal dyspnea, PPROM, abnormal fetal presentation, cord prolapse & postpartum hemorrhage*. Due to its common etiology w/ gestational diabetes, polyhydramnios is often a/w fetal macrosomia. To prevent the above complications, there are two methods of prenatal tx: amnioreduction & pharmacological treatment w/ NSAIDs. In addition to conventional management, experimental therapies which would alter fetal diuresis are being considered.

History & Physical: Preeclampsia

Preeclampsia - Classic triad: *HTN, (+) PROTEINURIA & edema* after 20 wks GA *Mild Preeclampsia* BP 140/90 - 160/110 Proteinuria - > 300 mg/24 hours or > +1 on dipstick Edema of face hands and feet Delivery is the only cure performed at 34-36 wks - schedule for elective vaginal delivery - A C-section is not necessary unless complications develop Steroids to mature lungs at 26-30 wks daily weights, BP & dipstick weekly, bed rest *Severe Preeclampsia* BP > 160/110 Proteinuria > 5g in 24 hours or no urine or 3 +on dipstick Cerebral visual change Pulmonary edema ***HELLP SYNDROME*** - Hemolysis, elevated liver enzymes, & low platelets DELIVERY IS ONLY CURE - performed at 24-26 wks Hospitalization & START MAGNESIUM SULFATE to prevent eclampsia BP MEDS: started if BP > 180/110 - HYDRALAZINE

Scientific Concepts: Premature Rupture of Membranes

Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins in a pt who is ≥ 37 wks gestation ○ If PROM occurs before 37 wks of pregnancy, it is called preterm premature rupture of membranes (PPROM) ○ No clear cause affects *10% of pregnancies* ○ Presents as a gush or slow leak of fluid from the vagina. ● Determine if fluid is indeed amniotic fluid ○ Nitrazine test to determine if this is amniotic fluid: pH > 7.1 means it is pos ○ Fern test: take a specimen of the fluid put it on a slide & let it air dry will see "fern pattern" crystallization of the amniotic fluid (crystallization of estrogen & amniotic fluid) ○ Sterile speculum exam: look for *infection* ○*Incr Risk of infection after 24 hrs*

Clinical Therapeutics: Major Depressive Disorder with Peripartum Onset

Psychotherapy = 1st line SSRI Breastfeeding: ACOG guideline lists fluvoxamine, nortriptyline (Pamelor), and sertraline

Clinical Intervention: Sexual Assault

Rape constitutes both a psychiatric emergency & a legal situation; all procedures should be documented, clothing saved, & samples taken ○ *Explain to the pt the purpose of all procedures*, & inform him/her of what is being done before doing it. This provides the pt w/ a feeling of some control ○ *A rape kit*, which has instructions regarding questions to include in the Hx, how specimen samples are to be collected & under what conditions, & how samples should be handled after collection, is valuable & ensures that the proper evidence is secured. ○ *Cultures from the vagina, the anus, & usually, the pharynx for gonorrhea & Chlamydia, RPR for syphilis, hepatitis antigens, HIV, urinalysis, pregnancy test* for menstrual-aged women ● *Prophylactic antibiotic therapy* should be initiated ○ IM Rocephin 250 mg & PO doxycycline BID x 7 days ○ *Tetanus toxoid* if indicated ○ The pt should be given the option of *emergency contraception* ○ *Counseling*: As soon as possible after the event, & preferably before leaving the ED, the pt should talk to a mental health professional & f/u counseling should be scheduled ● F/u w/in 24-48 hours after discharge, all victims should be contacted by phone ○ One-week visit - a general review of the pt's progress ○ Six-week visit - repeat cultures for STIs & repeat RPR ○ 12-18 week visit may be indicated for repeat HIV titers

Scientific Concepts: Breast Physiology

The epithelial component of the tissue consists of lobules, where milk is made, which connect to ducts that lead out to the nipple. Most cancers of the breast arise from the cells which form the lobules and terminal ducts. These lobules and ducts are spread throughout the background fibrous tissue and adipose tissue (fat) that make up the majority of the breast. The male breast structure is nearly identical to the female breast, except that the male breast tissue lacks the specialized lobules, since there is no physiologic need for milk production by males. The nipple is stimulated when the baby sucks; muscular tissue surrounding the nipple causes it to become erect. When the nipple is stimulated, the brain's pituitary gland secretes the hormone *prolactin*, which triggers the breast's milk gland cells to produce milk. This does not occur until the baby and placenta are delivered. The hormone *oxytocin* is then released, helping to relax the mother, and causing the milk gland to contract and push milk out of the nipple. This is called letdown or milk ejection reflex. Letdown may take several minutes, especially when the mother is tired or tense.

Clinical Therapeutics: Premature Rupture of membranes

Treatment depends on gestational age > 34 weeks - induce 32-34 weeks collect fluid & check for lung maturity - then induce < 32 weeks stop contractions & start 2 doses of steroid injection then deliver the baby - give antibiotics

Clinical Therapeutics: Dysfunctional Uterine Bleeding

Treatment is aimed at causing cyclic bleeding & protection of the endometrium ○ *Progesterone therapy* (oral or IUD), OCPs, Estrogen therapy, GnRH agonists ■ A very good treatment involves 14 days of Provera 10 mg orally followed by the initiation of a monophasic BCP (such as Alesse) ■ (Mirena or Liletta) is also very effective & provides long term contraception ○ Hysteroscopy, endometrial curettage, polypectomy, endometrial ablation ○ NSAIDs: Naproxen 500 mg at onset & 3-5 hours later, then 250-500 mg BID ■ Ibuprofen 600 mg once per day

Clinical Intervention: Tubo-ovarian abscess

Treatment modalities for TOA include *antibiotic therapy, minimally invasive drainage procedures, invasive surgery*, or a combination of these interventions. The large majority of small abscesses (<7 cm in diameter) resolves w/ antibiotic therapy alone. *Inpt* IV cefotetan or IV cefoxitin plus doxycycline (orally or IV) or IV clindamycin & IV gentamicin

Diagnosis: Edward Syndrome

Trisomy 18 *↓ AFP, hCG, & estriol* Major features: severe mental retardation, prominent occiput, micrognathia, flexed fingers, congenital heart disease, horseshoe kidney, meckel diverticulum or malrotation, most trisomy 18 infants die before term 1 week of life & vast majority die w/in 1 yr IUGR

Clinical Therapeutics: Lymphogranuloma Venereum

Tx: *PO Doxycycline or erythromycin for 3 weeks* ○ *Lymph node aspiration* if needed Causative agent: Chlamydia trachomatis; serotypes L1, L2, & L3 MC ● H&P: Recent Travel & unprotected sex in tropical regions or regions where LGV is endemic (Africa, SE Asia, India); anal sex ● PE findings: ○ *Stage 1*: small, painless papules/shallow ulcerations typically on the vaginal wall ○ *Stage 2*: painful unilateral inguinal lymphadenopathy (groove sign). In women: bubo (matted nodes adherent to overlying skin) & lower back/abd/pain due to deep pelvic node involvement ■ Groove sign (inguinal buboes w/ nonsignificant ulcers) = pathognomic ○ *Stage 3*: rupture of the bubo leads to genitorectal syndrome (strictures & fistulas in the anogenital tract): constitutional sxs; proctocolitis; abscesses ■ Most women present in stage 3

Diagnosis: Complete Breech Presentation

Types of breech presentation: ■ Frank breech (flexed hips & extended knees) MC ■ *Complete breech (flexed hips & knees)* ■ Footling breech (one knee flexed, one extended) The Dx of breech presentation is based on *PE, w/ USG confirmation*, if the dx is uncertain ● USG clearly identifies the fetal head in the fundus, buttocks in the lower uterine segment, extension or flexion of each hip & knee, & location of each foot ● Detection of fetal malpresentation (including breech, transverse lie, etc.) prior to 37 wks does not warrant intervention. Observation & repeat USG at 37 wks is indicated

Clinical Therapeutics: Urinary Tract Infection

Uncomplicated: Trimethoprim-sulfamethoxazole x 3 days Nitrofurantoin x 3-5 days FQ x 3 days Complicated: FQ x 7-14 days *Pregnant: Nitrofurantoin x 3-7 days*

Diagnosis: Postpartum Hemorrhage

Uterine atony (inability of uterus to contract down) is the MCC of postpartum hemorrhage & is characterized by a *soft/boggy uterus* Other causes include cervical or vaginal tears, placenta accreta & uterine rupture & bleeding dyscrasias *Defined as > 500 ml w/ vaginal delivery or > 1000 ml if C-section* Common cause of maternal death w/in 24 hours of delivery This is a clinical diagnosis uterus is soft & boggy on examination Ultrasound may aid in the diagnosis

History & Physical: Postpartum Hemorrhage

Uterine atony (inability of uterus to contract down) is the MCC of postpartum hemorrhage & is characterized by a soft/boggy uterus ● Other causes include cervical or vaginal tears, placenta accreta & uterine rupture & bleeding dyscrasias ○ *Defined as > 500 ml w/ vaginal delivery or > 1000 ml if C-section* ○ Common cause of maternal death w/in 24 hours of delivery ● This is a clinical diagnosis *uterus* is *soft & boggy* on examination ○ Ultrasound may aid in the diagnosis

Health Maintenance: Incompetent Cervix

Weakening of the cervix which causes premature shortening or dilation & miscarriage - causes *recurrent 2nd trimester miscarriages* ○ An incompetent cervix refers to a cervix that will not remain completely closed during pregnancy, placing the baby at risk for premature birth. ○ This can be due to past trauma to the cervix, such as from sgy or D& C. ○ Previous deliveries that were traumatic to the cervix may lead to an incompetent cervix, as can genetic anomalies that cause a malformed cervix. ● Diagnosed w/ USG - funneling of the cervix ○ Unfortunately, an incompetent cervix is usually diagnosed after a second or third-trimester miscarriage occurs. The incompetent cervix can usually be detected on prenatal USG or pelvic exam. ○ S/ S: pts may or may not have some bleeding in the second or third trimester. ● Treated w/ *cervical cerclage* which involves placing purse string sutures in the cervix to draw it closed. Placed at 14-16 wks & removed at 36 wks to allow for delivery ○ This effectively sutures the cervix closed to prevent premature dilation. These sutures are usually removed in the last few wks of pregnancy to prevent tearing of the cervix as it tries to dilate.

Clinical Therapeutics: Polycystic Ovarian Syndrome

Weight reduction improves hirsutism, lipid & glucose parameters, & fertility ○ Hirsutism is treated w/ androgen-lowering agents, including *oral contraceptives* ○ Infertility is usually treated w/ *clomiphene citrate* to help induce ovulation ○ Lipid abnormalities & insulin resistance should be managed medically ○ Adding *metformin* increases ovulation & pregnancy rates & increases insulin sensitivity

Clinical Therapeutics: Premenstrual Syndrome

imbalance of estrogen & progesterone along w/ excess prostaglandin production ○ Sxs during the luteal phase (1-2 wks before menses)-Bloating, irritability. Exercise & stress reduction are beneficial in general & should be recommended on this basis ○ *SSRIs are 1st-line* options for mod-severe premenstrual sxs who *do not desire contraception* ■ Can be administered as continuous daily therapy or may be used cyclically 2 wks prior to the menstrual cycle ○ *Combined estrogen-progestin oral contraceptive as first-line therapy if contraception is a high priority* (stops ovulation & stabilizes hormone levels) ■ Start w/ a 3 mg drospirenone (DRSP)/20 mcg ethinyl estradiol (EE) COC (Yazmin) w/ a 4-day pill-free interval as the first-line pill ■ If sx relief w/ the COC monotherapy is incomplete, an SSRI can be added ○ GnRH agonist therapy: For women who have not responded to or cannot tolerate SSRIs or OCs & continue to experience severe sxs ○ Surgery (bilateral oophorectomy/bilateral salpingo oophorectomy [surgical menopause]) is considered only as a last resort

Health Maintenance: Chlamydia Cervicitis

■ Clear vaginal discharge ■ often have dysuria, dyspareunia or postcoital bleeding ■ Nucleic acid amplification test (NAAT) is the gold standard ■ Azithromycin 1 g PO single dose or Doxycycline 100 mg PO BID × 7 days PLUS Ceftriaxone 250 mg IM in a single dose

Clinical Therapeutics: Bacterial Vaginosis

■ First Line Treatment: ● Metronidazole: 500 mg PO b.i.d. × 7 days ● Metronidazole gel 0.75%: 5 g intravaginally daily × 5 days ● Clindamycin 2% cream: 5 g intravaginally qhs × 7 days ■ Second Line Treatment ● Clindamycin ● Tablets: 300 mg PO b.i.d. × 7 days ● Ovules: 100 g intravaginally qhs × 3 days ● Bioadhesive cream 2%: 5 g × 1 dose

Clinical Intervention: Ovarian Torsion

● *Ultrasonography* is the imaging modality of choice ○ A neg pregnancy test in conjunction w/ the presence of spikes along the Doppler flow graph is diagnostic for ovarian torsion ○ Doppler flow is not always absent in torsion & the *GS for the dx of ovarian torsion is laparoscopy* ● Surgical treatment of ovarian torsion includes laparoscopy to uncoil the torsed ovary & possibly oophoropexy to fixate the ovary which is likely to twist again ○ In severe cases, where blood flow is cut off to the ovary for an extended period of time, necrosis of the ovary can occur. In these cases the ovary must be surgically removed

Clinical Therapeutics: Prenatal Care

● A recommended prenatal care schedule consists of the following: ○ Monthly visits for weeks 4-28 of pregnancy ○ Visits twice monthly from 28 to 36 weeks ○ Weekly after week 36 (delivery at week 38-40) ● Recommendations for use of dietary supplements in pregnancy: ○ All pregnant women should receive a prenatal vitamin. ○ Folic acid supplementation (0.4-0.8 mg) prior to conception; 4 mg for secondary prevention ○ Calcium: 1,000-1,300 mg/day; supplement may be beneficial for women w/ high risk for gestational HTN or communities w/ low dietary calcium intake. ○ Iron: Screen for anemia (Hgb/Hct) & treat if necessary. Recommend 30 mg/day of iron in pregnant women. ○ Vitamin A: Pregnant women in industrialized countries should limit to <5,000 IU/day. ○ Vitamin D: Consider supplementation in women w/ limited exposure to sunlight. ● A full physical exam should be performed at the 1st prenatal appointment. ● At each subsequent prenatal visit, the following should be recorded: ○ Weight: Total wt gain range should be 25-35 lb, except in obese women, where wt gain should be <15 lb ○ ACOG defines hypertension as BP >140 mm Hg systolic or >90 mm Hg diastolic ○ Monitor BP especially closely in pts w/ chronic HTN (predating pregnancy), preeclampsia/eclampsia, or gestational hypertension. ○ UA for glucose & protein; 24-hour protein excretion is the gold standard but not practical. ○ Fundal height ○ Fetal heart rate: usually audible by 12 weeks' GA w/ a Doppler instrument ○ Fetal position by abdominal palpation at 36 weeks ○ Pelvic/cervical exam if indicated ● Advanced maternal age is 35 & each mother should be offered testing for genetic abnormalities

History & Physical: Fibrocystic Disease

● Fibrocystic breast disease is a condition in which women develop *lumps in the breasts that come & go* ○ Painful, swollen, lumpy breasts bilaterally, intermittent to constant pain. Usually multiple, mobile well-demarcated areas in the breast ○ Breast cysts may incr or decr in size w/ menstrual hormonal changes ○ Pain before menses which usually resolves w/ the start of the menstrual cycle ○ Ovarian hormones are the causative agent ● Dx is breast cyst aspiration supplemented by USG &/or mammogram. Straw colored fluid w/ no blood

Scientific Concepts: Normal Physiology

● Follicular phase: days 1-14; the endometrium thickens under the influence of estrogen. In the ovaries, a dominant follicle matures, leading to ovulation ● Luteal phase: after ovulation, the ruptured follicle becomes the corpus luteum, secreting progesterone (& some estrogen). ○ Progesterone enhances the lining of the uterus to prepare it for implantation. If there is no implantation, the corpus luteum degenerates, leading to a steep decrease in both estrogen & progesterone. Leading to menstruation ● Phase 1: Follicular (Proliferative): Day 1-12 ○ *Estrogen* Predominates ■ Pulsatile GnRH from the hypothalamus → ↑FSH & LH from the pituitary gland to stimulate the ovaries ○ Ovaries: ■ ↑FSH causes follicle & egg maturation in the ovary ■ ↑LH stimulates the maturing follicle to produce estrogen ○ Endometrium (Uterus) ■ Estrogen builds up the endometrium (proliferative) ○ Estrogen causes *negative feedback* in HPO system: (hypothalamus-pituitary-ovarian) ■ The ↑'ing levels of estrogen inhibits hypothalamic GnRH release as well as pituitary release of LH & FSH (no new follicles start maturing) ● Ovulation: Days 12-14 ○ ↑estrogen being releases from the mature follicle switches from *NEGATIVE to POSITIVE FEEDBACK* on GnRH causing mutual ↑'s in estrogen, FSH, & LH ○ The sudden LH surge causes ovulation (egg release) ● Phase 2: Luteal (Secretory): Days 14-28 ○ *Progesterone* predominates ■ The LH surge also causes the ruptured follicle to become the corpus luteum. Which secretes progesterone & estrogen to maintain the endometrial lining. Estrogen & progesterone switches back to negative feedback ○ If pregnancy occurs: ■ The blastocyst (maturing zygote) keeps the corpus luteum functional (to prevent the endometrium from sloughing) ● Menstrual Cycle ○ Menstruation (1st day of follicular phase) ■ If the egg isn't fertilized, the corpus luteum soon deteriorates (causing a fall of progesterone & estrogen levels) ● The endometrium is no longer maintained & sloughs off, leading to menstruation ● The negative feedback of GnRH subsides, causing ↑pulsatile GnRH secretion. This leads to ↑FSH & LH, which starts the follicle maturation process all over again ■ GnRH pulses >1 an hour favor LH secretion; less frequent pulses favor FSH secretion

Diagnosis: Normal labor & delivery

● Labor is defined as *regular uterine contractions causing cervical change* ● The World Health Organization (WHO) defines normal birth as "spontaneous in onset, low-risk at the start of labor & remaining so throughout labor & delivery. The infant is born spontaneously in the vertex position between 37 & 42 completed weeks of pregnancy. After birth, mother & infant are in good condition." ● Cervical examination: ○ Dilation - up to 10 cm ○ Effacement (softening) - up to 100% ○ Station (position of the baby the head) - 0 is at ischial spine. ● Stages of labor: ○ Stage 1: Onset contractions to full dilation (primi- 6-20 hours ) (multi- 2-14 hours) ○ Stage 2: Full dilation to baby delivery (primi- 30 mins-3 hours) (multi- 5-6 minutes) ○ Stage 3: After baby delivery to expulsion of placenta (0-30 mins) ■ Placenta should have 2 arteries & 1 vein

Clinical Intervention: Incompetent Cervix

● Treated w/ *cervical cerclage* which involves placing purse string sutures in the cervix to draw it closed. Placed at 14-16 weeks & removed at 36 weeks to allow for delivery ○ This effectively sutures the cervix closed to prevent premature dilation. These sutures are usually removed in the last few weeks of pregnancy to prevent tearing of the cervix as it tries to dilate.