Obgyn Revalida Review 2013 for Printing
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OBSTETRICS AND GYNECOLOGY REVALIDA REVIEW 2013
TOPICS OBSTETRICS ü First Prenatal Check-‐up
GYNECOLOGY ü Vaginal discharge ü Lesions on external genitalia ü Abnormal uterine bleeding ü Hypogastric pain
OBSTETRIC PRE-‐NATAL
S
CHECK UP
FIRST PRE-‐NATAL CHECK UP • Menstural History o LMP • Sexual History • Obstetric History • G P (TPAL) • Manner of delivery • Complications • Determine o Age of Gestation § LMP § Ultrasound o Estimated date of delivery § Naegele’s Rule ü +7, -‐3
PHYSICAL EXAMINATION • Weight in pounds • Breast examination • Abdomen: o Fundic Height § Start at 16-‐18 weeks AOG o Leopold’s Maneuver Start at 28-‐30 weeks § LM1 Fundal grip § LM2 Umbilical grip § LM3 Pawlik’s grip § LM 4 Pelvic grip o Fetal Heart Tone
Fundic Height
PHYSICAL EXAMINATION • Weight in pounds • Breast examination • Abdomen: o Fundic Height § Start at 16-‐18 weeks AOG o Leopold’s Maneuver Start at 28-‐30 weeks § LM1 Fundal grip § LM2 Umbilical grip § LM3 Pawlik’s grip § LM 4 Pelvic grip o Fetal Heart Tone
LM 1 – Fundal Grip
LM 2 – Umbilical Grip
LM 3 – Pawlik’s Grip
LM 4 – Pelvic Grip
FIRST PRE-‐NATAL CHECK UP Pelvic Examination • External genitalia o Lesions • Speculum examination o Describe the cervix and the vaginal discharge o Eg. Cervix is violaceous, smooth, with minimal whitish mucoid non-‐foul smelling discharge • Internal Examination o Describe the cervix, uterus and adnexa o Eg. Cervix soft, long, closed; uterus enlarged to 2 months size, no adnexal mass or tenderness o Adnexae cannot be evaluated if uterus is 3 months size
Danger Signs of Pregnancy • Persistent headache • Blurring of vision • Persistent nausea and vomiting • Fever and chills • Dysuria • Hypogastric pain • Bloody vaginal discharge • Watery vaginal discharge • Decreased fetal movement • Edema of the hands and feet
Presumptive Symptoms of Pregnancy • Nausea and vomiting • Disturbances in urination • Fatigue • Perception of fetal movement (quickening) • Breast symptoms
Presumptive Signs of Pregnancy o Cessation of menstruation o Anatomical breast changes • Breast enlargement and vascular engorgement • Hyperpigmentation of areola • Nipples become larger
o Change in vaginal mucosa – CHADWICK’s sign o Skin pigmentation – Chloasma, linea nigra,
striae gravidarum o Thermal signs – Increased temperature
Probable Signs of Pregnancy o Abdominal enlargement o Changes in uterus and cervix • HEGAR’s sign – softening of the uterine isthmus • GOODELL’s sign – cyanosis of the cervix (4 weeks) • Softening of the cervix (6-‐8 weeks) • Beaded pattern of cervical mucus (progesterone effect) o Braxton-‐Hicks contractions (28th week) o Ballotement (20th week) o Outlining of the fetus o (+) pregnancy test – β HCG • Onset: 8-‐9 days after ovulation • Peak: 60-‐70 days • Nadir: 14-‐16 weeks AOG
Positive Signs of Pregnancy o Fetal Heart Tone • TVS: 6-‐8 weeks • Doppler: 10-‐12 weeks • Stethoscope: 18 weeks
o Perception of active fetal movement by the
examiner
• 20 weeks
o Recognition of embryo or fetus by ultrasound • Gestational sac: 4-‐5 weeks • Fetal heart beat: 6-‐8 weeks • CRL predictive of gestational age up to 12 weeks
What to Request? Ultrasound o TVS – to determine fetal viability and aging (13 weeks) Laboratory examinations o CBC o Physiologic anemia:
• 1st trimester: 92 mg/dL 1st Hour > 180 mg/dL 2nd Hour > 153 mg/dL GDM
Maternal Nutrition during Pregnancy o 2000 kcal/day, add 300 kcal/day in 2nd and 3rd trimester o Normal weight gain: 25-‐35 lbs § 1 lb/week
1. IRON: 1 g entire pregnancy § 300 mg: fetus and placenta § 500 mg: expanding maternal hemoglobin mass § 200 mg: excreted
ü No supplementation in 1st trimester ü 30 mg of elemental iron everyday as supplied by ferrous
sulfate, gluconate or fumarate
2. CALCIUM § 30 g deposited in fetus § 400-‐900 mg Calcium supplementation
Maternal Nutrition during Pregnancy 3. Iodine – due to prevalence of GOITER § for a 49 kg woman = 100 micro g + 25 micro /day
4. Zinc § essential for enzymatic activity required for growth, brain dev’t, sexual maturation & immune function § 12 mg/day 5. Phosphorus § essential for bone calcihication § absorption impaired by antacid intake
6. Folate § Contributing factor for anemia § 350 mcg/day
NUTRITION DURING PREGNANCY o Calories – 300 kcal/day (2nd to 3rd tri) o CHON – 9 g/day o CHO – 50 to 100 g/day o Fats – 15 – 25 g//day
Dietary Computation Ht in cm – 100 =? 10% = DBW x 35 (activity) IBW IBW + 300 kcal = TCR x .6 CHO / 4 TCR x 1.5 CHON / 4 TCR x .25 Fats / 9
Pre-‐natal Check up o Frequency • Monthly until 28 weeks • Every 2 weeks until 36 weeks • Weekly 37 weeks onwards
GYNECOLO
GY
o GYN OPD FORM
ü Menstrual history o Menarche o Interval o Duration o Intensity o Symptoms ü Sexual History o Onset o # partners o Dyspareunia o Post coital bleeding o Contraception
o GYN OPD FORM
ü Breast Examination ü Abdominal
examination ü Pelvic Exam § External genitalia § Speculum § IE
* Ask patient to void hirst
ü If no sexual contact:
RECTAL EXAMINATION, DON’T DO SPECULUM EXAM ü Do Pap Smear if sexually active
Speculum Exam
Internal Examination – Cervix and Uterus
Internal Examination – Adnexa
Rectovaginal Examination
GYNECOLOGY Pelvic Examination • External genitalia o Lesions • Speculum examination o Describe the cervix and the vaginal discharge o Eg. Cervix is pink, smooth with minimal whitish mucoid non-‐foul smelling discharge • Internal Examination o Describe the cervix, uterus and adnexa o Eg. Cervix hirm, long, closed; uterus normal-‐sized anteverted, movable, nontender; no adnexal mass or tenderness • Rectovaginal exam: if indicated • RECTAL EXAM: cervix hirm, long (cannot assess if cervix is closed or dilated)
GYNECOLO
GY
VAGINAL D ISCHARGE
Vaginal Discharge o Physiologic
The Vaginal Ecosystem estrogen lactobacilli
glycogen Promotes growth of lactobacilli; inhibits growth of pathogenic organisms
lactic acid
pH 3.8-4.2*
Infective Vaginitis: Signs and Symptoms
o Vaginal discharge o Pruritus o Odor o Burning sensation o Dysuria o Dyspareunia
Bacterial Vaginosis o Syndrome of unknown cause
characterized by depletion of the normal lactobacillus population and an overgrowth of vaginal anaerobes (Gardnerella vaginalis) accompanied by loss of usual vaginal acidity.
Amsel’s Criteria (3 out of 4) ü thin green or gray-‐white
homogenous discharge ü clue cells ü pH > 4.5 ü Amine odor with 10% KOH (Whiff
Test)
Treatment o Metronidazole 500mg/tab 1 tab BID x 7 days
Alternative regimens o Metronidazole 2 g orally as single dose o Clindamycin 300 mg BID x 7 days
Trichomoniasis • copious yellow-‐green frothy
discharge • pH > 4.5 • strawberry cervix • burning sensation • dyspareunia
• Wet mount (NSS) – motile
trichomonads • Whiff test (+)
Treatment Recommended Regimen 0 Metronidazole 500 mg twice daily for 7 days
Alternative Regimens
0 Metronidazole 2 g orally in a single dose 0 Tinidazole 2 g orally in a single dose
Treat sexual partner
Candidiasis o Candida albicans o Other pathogenic species 0 Candida glabrata 0 Candida parapsilosis 0 Candida tropicalis 0 Candida krusei
o Common among diabetics,
pregnant women, patients on chronic steroids or broad-‐ spectrum antibiotics and OCP users
Candidiasis o Severe vulvar pruritus o Curd-‐like, whitish vaginal
discharge adherent to vaginal walls o No odor o pH < 4.5
Candidiasis
10% KOH Smear
TREATMENT ü Clotrimazole vaginal tablet o 100 mg/tab 1 tab ODHS x 7 days o 200 mg/tab 1 tab ODHS x 3 days o 500mg/tab 1 tab ODHS single dose
ü Fluconazole 150mg/tab 1 tab OD ü Miconazole 100 mg vag supp x 7 days
Clinical Features of Vaginal Discharge Bacterial Vaginosis
Candidiasis
Trichomoniasis
S/Sx
Foul smelling vaginal White thick vaginal discharge discharge; pruritus, burning, dysuria
Yellowish foul smelling vaginal discharge, pruritus, dysuris
PE hindings
Thin whitish gray homogenous discharge
Thick curd-‐like discharge adherent to vaginal walls, vaginal erythema
Yellow, frothy discharge with or without cervical erythema
pH
>4.5
4.5
Wet Mount
Clue cells Amine odor on KOH (Whiff test)
Hyphae or spores
Motile trichomonads
Organism
Gardnerella vainalis
C. albicans
Trichomonas vaginalis
Clotrimazole
Metronidazole
Treatment Metronidazole
Mixed Vaginal Infection ü Miconazole + metronidazole (Neopenotran)
vaginal suppository ODHS x 7 days ü Nystatin + Metronidazole (Flagystatin)
vaginal supposory ODHS x 7 days
Mucopurulent Cervicitis Criteria § gross visualization of
yellow mucopurulent material on a white cotton swab
§ ≥ 10 per microscopic
hield (magnihication × 1000) on Gram-‐ stained smears obtained from the endocervix
Mucopurulent Cervicitis Signs and symptoms
§ hypertrophic and edematous cervix § vaginal discharge, deep dyspareunia, and
postcoital bleeding Pathogens
§ Chlamydia trachomatis § Neisseria gonorheae
Treatment Gonorrhea • •
Cehixime 400 mg po OD Ceftriaxone 125mg IM
PLUS Chlamydial therapy if not ruled out
Chlamydia • Azithromycin 1 gm single dose • Doxycycline 100 mg bid x 7days
GYNECOLO
GY
LESIONS O N EXTERNAL GENITALIA
Condyloma Acuminata o HPV 6 & 11 – benign, warts o HPV 16 & 18 – premalignant and malignant
lesions o Sexual transmission or autoinoculation o Conditions that predispose to HPV
§ Immunosuppression, diabetes, pregnancy, local
trauma
o Signs and symptoms § Asymptomatic § Pain, itching, bleeding when friable § Foul odor if secondarily infected
Condyloma Acuminata
Treatment
MOA Dose
Podocilox 0.5% solution or gel
Imiquimod 5% cream (aldara)
Antimitotic BID for 3 days then 4 days off up to 4 cycles
Immune enhancer Daily and HS, 3x a week up to 16 weeks Wash 6-‐10 min after
Side effects Mild to moderate pain Mild to moderate local Local irritation inhlammation Pregnancy
NO
NO
Treatment Cryotherapy
Trichloroacetic acid
MOA
Thermal-‐induced cytolysis
Chemical coagulation of proteins
Dose
Weekly every 1-‐2 weeks
Weekly
Side effects Pain, necrosis, blistering
Pain
Pregnancy
NO
YES
Electrocautery or Surgical Excision
HPV o Advise CERVICAL CANCER
VACCINATION
§ CERVARIX – HPV 16 & 18 § GARDASIL – HPV 6, 11, 16 and 18
o Age group: 13-‐26 y/o o Males can be given HPV vaccination
Genital Ulcers • Syphilis • Genital herpes • Chancroid • Granuloma inguinale (donovanosis) • Lymphogranuloma venereum
Clinical Features of Genital Ulcers Syphilis
Herpes
Chancroid
Incubation
2-‐4 weeks (1-‐12 weeks) 2-‐7 days
1-‐14 days
10 lesion
Papule
Vesicle
Papule or pustule
# lesions
Usually ONE
Multiple
Multiple
Edges
Sharply demarcated, elevated, round or oval
Erythematous
Undermined, ragged, irregular
Depth
Superhicial or deep
Superhicial
Excavated
Base
Smooth, nonpurulent
Serous, erythematous
Purulent
Induration
Firm
None
Soft
Pain
Unusual
Common
Very tender
Lymphadeno-‐ pathy
Firm, nontender, bilateral
Firm, tender, bilateral
Tender, may suppurate, unilateral
Clinical Features of Genital Ulcers Syphilis
Herpes
Chancroid
Causative organism
Treponema pallidum
HSV 1 and 2
Haemophilus ducreyi
Diagnosis
Screening: VDRL and Tzanck smear RPR Viral culture Validation: FTA-‐ABS and Serology MHA-‐TP
Gram stain Culture
Treatment
Primary (Chancre) PEN G 2.4 M units/IM single dose
Azithromycin 1 g/tab single dose Ceftiaxone 250 mg IM single dose Ciprohloxacin 500 mg BID x 3 d Erythromycin 500 mg q 6 hrs x 7 d
Acyclovir 200mg 5 x day / 400 mg tid Famciclovir 250 mg tid Valacyclovir 1000 mg bid 7-‐10 days
Clinical Features of Genital Ulcers Lymphgranuloma Venereum
Donovanosis
Incubation
3 days-‐6 weeks
1-‐4 weeks (up to 6 months)
10 lesion
Papule, pustule or vesicle
Papule
# lesions
Usually One
Variable
Edges
Elevated, round or oval, irregular
Elevated, regular
Depth
supervicial, or deep
Elevated
Base
Variable
Red and rough “beefy”
Induration
Occasionally hirm
Firm
Pain
Variable
Uncommon
Lymphadeno-‐ pathy
Tender, may suppurate, loculated, usually unillateral
Pseudoadenopathy
GYNECOLO VAGINAL B
GY
LEEDING
Dehinitions Oligomenorrhea
Bleeding occurs at intervals of > 35 days and usually is caused by a prolonged follicular phase.
Polymenorrhea
Bleeding occurs at intervals of < 21 days and may be caused by a lutealphase defect.
Menorrhagia
Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow (>=80 mL) or duration (>=7 days).
Menometrorrhagia
Bleeding occurs at irregular, noncyclic intervals and with heavy flow (>=80 mL) or duration (>=7 days).
Amenorrhea
Bleeding is absent for 6 months or more in a nonmenopausal woman. Irregular bleeding occurs between ovulatory cycles; causes to consider
Metrorrhagia or bleeding include cervical disease, intrauterine device, endometritis, polyps, intermenstrual submucous myomas, endometrial hyperplasia, and cancer. Midcycle spotting
Spotting occurs just before ovulation, usually because of a decline in the estrogen level.
Postmenopausal bleeding
Bleeding recurs in a menopausal woman at least 1 year after cessation of cycles.
Acute emergent abnormal uterine bleeding
Bleeding is characterized by significant blood loss that results in hypovolemia (hypotension or tachycardia) or shock.
Dysfunctional uterine bleeding
This ovulatory or anovulatory bleeding is diagnosed after the exclusion of pregnancy or pregnancy-related disorders, medications, iatrogenic causes, obvious genital tract pathology, and systemic conditions.
Abnormal Uterine Bleeding ANOVULATORY o Infrequent,
irregular o Menstrual bleeding that varies in amount, duration and character and not preceeded by premenstrual molimina
OVULATORY o Regular, monthly
periods that are heavy or prolonged o Usually secondary to a systemic or an organic pelvic pathology
Abnormal Uterine Bleeding Anovulatory cycles
• Dysfunctional uterine bleeding • Endocrine disorders
Ovulatory cycles
• Systemic causes o Blood dyscrasia, hypothyroidism, liver or
renal disorder
• Reproductive tract
o Accidents of pregnancy o Endometrial polyp o Submucous myoma o Adenomyosis o Neoplasia – endometrial, cervical, vaginal
Abnormal Uterine Bleeding P A L M
Polyp Adenomyosis Leiomyoma Malignancy and Hyperplasia
C O E I N
Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not classicied
CASE o An 18 year old nulligravid, no sexual contact, consulted
because of irregular menses. She had menarche at 11 years old. Her menses were coming every 30-‐60 days, 3 to 5 days duration, moderate in amount. From age 15 years, she started to have her menses every 2-‐3 months. She was also noted to have gained weight for the past 2 years. BMI 26, with moderate hair on the upper lip and chin, excessive hair on the chest, infraumbilical area, upper and lower back and the thighs. o Rectal exam: cervix hirm, long; uterus normal-‐sized, anteverted; no adnexal mass or tenderness • Assessment: Abnormal uterine bleeding probably anovulatory • Plan: TVS
POLYCYSTIC OVARIAN SYNDROME 1990 National Institutes of Health Criteria (NIH): Requires both criteria 1 Chronic anovulation
2
2003 ESHRE/ASRM (Rotterdam): Requires 2 of 3 criteria 1
Clinical and/or 2 biochemical signs of hyperandrogenism 3
2006 Androgen Excess Society (AES): Requires all 3 criteria
Oligo-and/or anovulation
1 Ovarian dysfunction (oligo-ovulation and/or polycystic ovaries)
Clinical and/or biochemical signs of hyperandrogenism
2
Hyperandrogenism (hirsutism and/or hyperandrogenemia)
Polycystic ovaries
3
Exclusion of other androgen excess disorders
Exclusion of other androgen excess disorders
POLYCYSTIC OVARY o 12 or more follicles
measuring 10 cm3)
o only one ovary fitting the
definition is required for diagnosis
MANAGEMENT
Lifestyle modification, targeting a weight loss of 5-10% of initial body weight, significantly improve menstrual regularity and rate of ovulation. Target BMI 20-25
MANAGEMENT
Metformin should be used as an adjunct to general lifestyle modification but not as a replacement for weight loss, improved diet and increased exercise in treating abnormal uterine bleeding in women with PCOS.
Metformin 500mg/tab 1 tab BID-‐TID
MANAGEMENT -‐ TVS Thickened endometrium Progesterone challenge o Medroxyprogesterone acetate (MPA) 10mg/tab 1 tab OD x 5 days o Come back on Day 1 or Day 2 of menses o MPA 10 mg/tab 1 tab OD on Days 16-‐25 of menses x 6 cycles o Repeat TVS after treatment
MANAGEMENT -‐ TVS o Thin Endometrium
OCPs • Cyproterone acetate + ethinyl estradiol • Levonorgestrel + ethinyl estradiol
The use of oral contraceptive pills for 21-day period followed by a 7-day pill free interval improves menstrual regularity among women with PCOS, regardless of body mass index.
MANAGEMENT
The use of oral contraceptives is the first choice in the treatment of hirsutism in PCOS. Estrogenic component of OCPs ↓ Suppresses LH ↓ Decreased ovarian androgen production
CASE o An 30 y/o G2P2 (2002) consulted because of
prolonged and profuse menses of 3 months duration. No other symptoms. o SE: cervix pink, smooth, with minimal bleeding per os o IE: cervix hirm, long, closed. Uterus normal-‐sized anteverted, no adnexal mass or tenderness
Assessment: Abnormal uterine bleeding t/c endometrial pathology Plan: TVS
Endometrial Polyp o Symptoms § Intermenstrual spotting § Heavy menstrual bleeding § No pain o PE hindings § Can be normal § SE: pinkish to reddish smooth polypoid mass protruding out of the cervical os
Myoma Symptoms o Only submucous myoma will cause AUB o Intramural, subserous § Pelvic heaviness,
hypogastric mass, voiding symptoms § Will present with pain only if with degeneration
Myoma PE hindings o Subserous or Intramural § IE: uterus nodularly enlarged
to 3 months size, hirm, movable, nontender
o Submucous § May be normal § SE (prolapsed): Reddish,
meaty tissue protruding out of the cervical os; with minimal vaginal bleeding
Adenomyosis Symptoms o Heavy menstrual bleeding o Progressive dysmenorrhea PE hindings o IE: uterus symmetrically enlarged, doughy, tender
Endometrial Cancer Patient Prohile o Menopause o Nulligravid o Obese o Hypertensive PE hindings o May be normal Management o TVS: thickened endometrium > 5mm o Endometrial biopsy or curettage
Treatment of heavy menstrual bleeding Medical
Surgical
Non-‐hormonal
Hormonal
Dilatation/curettage
NSAIDs
COCs
Endometrial ablation
Tranexamic acid
Estrogens
Hysterectomy
Oral progestins Depot progestins Danazol GnRH agonists LNG-‐IUS
GYNECOLO
GY
HYPOGAST RIC PAIN
Frequency of Acute Pelvic Pain Diagnosis
Hypogastric Pain • UTI • Endometriosis • Pelvic inhlammatory disease • Ovarian newgrowth with complication –
twisting or leaking or ruptured
Endometriosis o Symptoms § Progressive dysmenorrhea § Dyspareunia § Dyschezia § Infertility
o PE hindings § IE: hixed retroverted uterus § RVE: nodularities in cul de sac § Adnexal mass – if with endometrial
cyst
Pelvic Inhlammatory Disease
N. gonorrhea has a rapid onset, and the pelvic pain usually begins a few days after the onset of a menstrual period.
C. trachomatis alone often may have an indolent course with slow onset, less pain, and less fever.
Risk Factors Age at first Douching intercourse
Lack of contraception
Coitus during menses
Multiple partners
High frequency of sex
Risk Factors
Lower genital tract infections
Previous PID 25%
Smoking / substance abuse
IUD – occurs only at the time of insertion and in the first 3 weeks after placement
CDC Guidelines for Diagnosis of Acute PID Clinical Criteria for Initiating Therapy Empiric treatment should be initiated • if one or more of the minimum criteria are present and no other cause(s) for the illness can be identified • Sexually active young women and those at risk for STDs if they present with lower abdominal pain
Minimum criteria • Cervical motion tenderness • Uterine tenderness • Adnexal tenderness
Additional Criteria to Increase Specihicity of Diagnosis
Temperature >38.3°C (101°F) Abnormal cervical or vaginal mucopurulent discharge WBCs on saline wet prep Elevated ESR Elevated CRP Gonorrhea or chlamydia test positive
Management Medical • Out patient • In patient
Surgical • Conservative • Radical
Outpatient Regimen A Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg orally twice a day for 14 days, with or without Metronidazole 500 mg orally twice a day for 14 days.
Criteria for Hospitalization
Surgical emergencies
Pregnancy
Non-response to oral therapy
Inability to tolerate an outpatient oral regimen
Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess
HIV infection with low CD4 count
Inpatient Regimens Parenteral Regimen A • Cefotetan 2 g IV q 12 hour • Cefoxitin 2 g IV q 6 hours PLUS • Doxycycline 100 mg orally/ IV q 12 hrs
Inpatient Regimens Parenteral Regimen B • Clindamycin 900 mg IV q 8 hour PLUS • Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.
Continue either of these regimens for at least 24 hours after substantial clinical improvement Complete a total of 14 days therapy with Doxycycline (100 mg orally twice a day) OR Clindamycin (450 mg orally 4 times a day
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