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Clinical Topics

Clinical Topics

Reviewed

Clinical Topic

Ambiguous Genitalia

1. Steroidogenesis Overview:

• Conversion of cholesterol to pregnenolone.

• Pathways for cortisol, aldosterone, and androgens.

• Enzyme deficiencies (e.g., 21-hydroxylase) can disrupt these pathways.

2. Workup for Ambiguous Genitalia:

• Detailed history and physical exam.

• Hormonal assays (e.g., 17-hydroxyprogesterone, testosterone).

• Genetic testing (e.g., karyotyping).

• Imaging (e.g., ultrasound, MRI).

3. Gender Determination:

• Chromosomal analysis (karyotyping).

• Hormonal levels for sex hormone profile.

• Phenotypic assessment.

4. Congenital Adrenal Hyperplasia:

• Autosomal recessive disorder, often 21-hydroxylase deficiency.

• Leads to excess androgen production.

• Can cause salt-wasting crisis in severe forms.

Amenorrhea

Gynecology

Open

Initial Evaluation: Begin with a thorough history and physical examination, followed by a pregnancy test, and assessment of serum LH, FSH, prolactin, and TSH levels. Utilize pelvic ultrasonography when indicated.

Excluding Pregnancy: Always rule out pregnancy as the first step in amenorrhea evaluation.

Treatment Tailoring: Base the treatment on the identified underlying cause; this may include surgery for anatomic causes, hormone replacement therapy for ovarian failure, and medications or lifestyle changes for chronic anovulation.

Surgical Intervention: When anatomic abnormalities are diagnosed, surgical correction is often the treatment of choice.

Lifestyle Adjustments: Address potential lifestyle factors contributing to chronic anovulation, such as those found in PCOS; changes may include diet, exercise, and weight management.

Ovulation Induction: For chronic anovulation, consider pharmacological options to induce ovulation, particularly when fertility is a concern.

Long-term Health Monitoring: Monitor for and manage complications of amenorrhea like infertility, osteoporosis, cardiovascular disease, and mental health issues.

Hormone Replacement Therapy: Utilize hormone replacement therapy to manage symptoms and prevent complications in cases of premature ovarian failure or other hormonal insufficiencies.

Amenorrhea as a Symptom: Recognize amenorrhea as a symptom that requires a diagnostic approach to identify and treat the underlying cause effectively.

1. Workup for Amenorrhea:

• History and physical exam.

• Pregnancy test.

• Hormonal assays (FSH, LH, prolactin, TSH).

• Imaging (e.g., ultrasound, MRI if central causes are suspected).

• Karyotyping if primary amenorrhea with atypical features.

2. Management of PCOS:

• Lifestyle modifications (diet, exercise).

• Oral contraceptives for cycle regulation.

• Metformin for insulin resistance.

• Clomiphene for ovulation induction if fertility desired.

Menstruation in Girls and Adolescents.pdf

pdf.pdf

pdf (1).pdf

p781.pdf

40618_2014_Article_169.pdf

Evaluation of Amenorrhea, Anovulation, and Abnormal Bleeding - Endotext - NCBI Bookshelf.pdf

Amniotic Fluid Embolism

Obstetrics

Open

Support Basic Life Functions: Immediate management of AFE involves supporting airway, breathing, and circulation (ABCs). This includes starting CPR if cardiac arrest occurs and preparing for a perimortem cesarean delivery if necessary.

Treat Coagulopathy and Hemorrhage: Post-resuscitation efforts should focus on hemodynamic stabilization and managing coagulopathy. This includes administering uterotonics, initiating a massive transfusion protocol, and using tranexamic acid if DIC or hemorrhage is present.

Address Pulmonary and Cardiac Complications: Management strategies should be employed for pulmonary hypertension and right ventricular failure, such as avoiding fluid overload, using vasopressors and inotropes, and considering pulmonary vasodilators.

Implement a Multidisciplinary Approach: Utilizing the Society for Maternal-Fetal Medicine's checklist can guide the initial management of AFE, ensuring that all aspects of care are covered and that the response is coordinated.

Regular Training and Simulations: To ensure the effectiveness of the AFE management checklist, regular training and simulations should be conducted to familiarize staff with the protocols and improve their response during actual AFE events.

AFE Guidelines.pdf

Checklist for AFE.pdf

Anemia

General

Open

Universal Iron Supplementation: The CDC recommends universal iron supplementation during pregnancy to address the increased iron requirements and prevent iron deficiency anemia.

Routine Screening Protocol: All pregnant women should be screened for anemia during the first trimester and again at 24-28 weeks of gestation using a complete blood count (CBC).

Serum Ferritin Testing: Serum ferritin level measurement is advocated as the most sensitive and specific test for diagnosing iron deficiency in anemic patients.

Consistent Screening Criteria: Apply consistent criteria across all populations for anemia screening to ensure appropriate identification and treatment.

Iron Supplementation Dosage: The recommended daily allowance of iron during pregnancy is 27 mg, with low-dose iron supplementation starting in the first trimester.

Management of Severe Anemia: Transfusion may be considered for severe anemia or maternal or fetal indications, such as hemoglobin levels less than 6 g/dL.

Parenteral Iron Usage: Intravenous iron should be considered for those who cannot tolerate oral iron, do not respond to oral iron, or have severe iron deficiency later in pregnancy.

Intraoperative Cell Salvage: This can be a valuable technique in cases of anticipated significant blood loss, such as with placenta previa or placenta accreta.

Evidence-Based Recommendations Summary: The presentation should close with a summary of recommendations from the ACOG Practice Bulletin, categorized by level of evidence to guide clinical practice.

Anemia in Pregnancy.pdf

Aneuploidy screening and prenatal diagnosis

Obstetrics

Open

Universal Screening Offer: All pregnant women should be presented with options for screening and diagnostic tests for fetal chromosomal abnormalities, irrespective of their age or initial risk factors.

Informed Decision-making: Proper counseling is vital to help patients understand chromosomal disorders, evaluate their risks, and comprehend the implications of test results.

Screening Options: Multiple screening methods are available, including cfDNA screening, serum screening, and ultrasound screening, each with specific time frames, sensitivities, and limitations.

Diagnostic Testing: CVS and amniocentesis are recommended for definitive diagnosis following a positive screening result, abnormal ultrasound, or other risk factors, with a small associated risk of miscarriage.

Comprehensive Analysis: Chromosomal microarray analysis can be utilized for a more detailed scan of chromosomal abnormalities beyond what traditional karyotyping can detect.

Twin Pregnancies: Adjustments in screening accuracy should be considered for twin gestations. cfDNA screening is feasible but with a higher rate of test failure.

Preimplantation Genetic Testing: Patients with prior preimplantation genetic testing should still be offered prenatal screening and diagnostic testing due to the potential for false negatives.

Interpretation and Counseling: Counsel patients on the meaning of positive and negative screening results, emphasizing the importance of diagnostic tests for confirmation and the concept of residual risk.

Incidental Findings: Awareness that screening can sometimes reveal incidental findings about maternal or fetal health that may require further attention.

Cell-free DNA Test Failures: A failed cfDNA test should prompt genetic counseling and potentially more comprehensive diagnostic approaches due to the associated increased risk of aneuploidy.

Screening for Fetal Chromosomal Abnormalities.pdf

Antibiotic prophylaxis in obstetrics

Obstetrics

Open

Cesarean Delivery Prophylaxis: Antibiotic prophylaxis recommended for all cesarean deliveries unless on equivalent treatment; administer within 60 minutes before surgery or ASAP if delayed.

Antibiotic Choice and Dosage: A single dose of a first-generation cephalosporin, like cefazolin, preferred; for allergies, use clindamycin plus an aminoglycoside. Weight-based dosing advised for obese patients.

Additional Dosing in Surgery: Extra intraoperative dose required for prolonged surgeries or significant blood loss.

Skin and Vaginal Cleansing: Use alcohol-based solution for skin and povidone–iodine or chlorhexidine gluconate for vaginal cleansing before cesarean delivery.

MRSA Colonization: Routine screening not advised, but vancomycin may be added for known MRSA-colonized patients undergoing cesarean delivery.

Obstetric Anal Sphincter Injuries (OASIS): A single dose of antibiotic at time of repair suggested.

Preterm Prelabor Rupture of Membranes (PROM): Antibiotic prophylaxis indicated to extend latency period for PROM under 34 weeks, with specified regimen avoiding amoxicillin–clavulanic acid.

Infective Endocarditis Prophylaxis: Not routinely recommended except for high-risk patients with specific heart conditions.

Cervical Cerclage and Postpartum Procedures: Insufficient evidence for antibiotic prophylaxis for cervical cerclage and no recommendation for postpartum procedures.

Early Pregnancy Loss: A single preoperative dose of doxycycline recommended to prevent infection after surgical management.

Hysterectomy: Single-dose prophylaxis with cefazolin recommended; adjust dosage for patient weight and consider additional dose for excessive blood loss.

Laparoscopic Procedures: Antibiotic prophylaxis not needed for laparoscopy without bowel or vaginal entry; may be considered for laparotomy.

Hysterosalpingography (HSG) and Chromotubation: No prophylactic antibiotics for patients without pelvic infection history; doxycycline regimen for dilated tubes or history of infection.

Sonohysterography and Hysteroscopy: Routine antibiotic prophylaxis not recommended.

Endometrial Ablation: Unclear role of antibiotic prophylaxis; one trial found no benefit.

IUD Insertion and Endometrial Biopsy: No routine prophylaxis recommended.

Uterine Evacuation: Antibiotic prophylaxis advised for induced abortion and early pregnancy loss.

Colporrhaphy and Vaginal Slings: Prophylaxis reasonable for these procedures.

Cystoscopy: No prophylaxis needed for women with negative urine cultures.

Cervical Tissue Excision: No antibiotic prophylaxis necessary for procedures like loop electrosurgical excision.

Vulvectomy and Oocyte Donation: The role of antibiotic prophylaxis not clear.

Embryo Transfer: Routine antibiotic prophylaxis not recommended.

Use of Prophylactic Antibiotics in Labor and Delivery.pdf

Prevention of Infection After Gynecologic Procedures _ ACOG.pdf

Antipartum Fetal Surveillance

Obstetrics

Open

Initiation of Surveillance: Surveillance is recommended for high-risk pregnancies to prevent fetal demise, generally starting at 32 weeks gestation, but earlier in severe cases.

Frequency of Surveillance: Testing frequency is typically weekly for persistent high-risk conditions using NST, BPP, or CST. Conditions of greater severity may necessitate more frequent surveillance.

Handling Abnormal Results: Abnormal results should prompt further testing or delivery, based on gestational age and the health status of the mother and fetus. Management is tailored to individual cases.

Antepartum Fetal Surveillance.pdf

Antiphospholipid syndrome

General

Open

Accurate Diagnosis: Ensure diagnosis of APS by satisfying both clinical and laboratory criteria, with antibody tests repeated at least 12 weeks apart.

Pregnancy Management with Thromboprophylaxis: Administer prophylactic heparin and low-dose aspirin during pregnancy for women with APS, especially with prior thrombotic events or recurrent pregnancy loss.

Postpartum Anticoagulation: Continue anticoagulation therapy for 6 weeks after childbirth to mitigate the risk of postpartum thrombosis.

Contraceptive Measures: Advise against estrogen-containing contraceptives for women with APS and recommend progesterone-only alternatives to reduce thrombosis risk.

Antiphospholipid Syndrome.pdf

Asthma

Obstetrics

Open

Asthma Medication During Pregnancy: It's essential to continue asthma medications throughout pregnancy to ensure good control and prevent maternal and fetal hypoxia.

Routine Pulmonary Function Monitoring: Regular assessment of lung function with PEFR or FEV1 is crucial to manage asthma effectively during pregnancy.

Step-Wise Therapy Management: Use a step-up or step-down approach in adjusting asthma therapy to maintain control, with cautious treatment reduction only after a period of stability.

Caution with Immunotherapy: Avoid initiating allergen immunotherapy in pregnant patients due to anaphylaxis risks. Existing maintenance therapy can continue if already well-tolerated.

Asthma in Pregnancy.pdf

Bariatric Surgery

Open

Preconception Counseling: Emphasize the importance of preconception counseling to address the elevated risk of pregnancy post-bariatric surgery, advising on the use of effective nonoral contraceptive methods due to possible malabsorption issues with oral contraceptives.

Nutritional Monitoring: Strongly recommend regular monitoring for micronutrient deficiencies from the onset of pregnancy, with trimester-specific evaluations to ensure proper nutrition and appropriate supplementation.

Gestational Diabetes Screening: Advise the consideration of alternative methods for gestational diabetes screening to avoid complications associated with the standard glucose load test, particularly in women with malabsorptive surgeries.

Bariatric Surgery and Pregnancy.pdf

Bartholin’s Abscess

Open

1. Treatment Decisions:

• Incision and drainage: For large, symptomatic abscesses.

• Marsupialization: For recurrent abscesses.

• Word catheter: To allow drainage and prevent recurrence.

• Excision: For chronic or recurrent cases not responding to other treatments.

Benign Breast Disorders

Open

Management of Benign Breast Disorders: Aim to alleviate symptoms, differentiate benign from malignant conditions, and identify women at higher risk of breast cancer for surveillance or preventive measures.

Breast Mass Evaluation: Use patient history, physical examination, and age-appropriate imaging such as ultrasonography (<30 years) or mammography (≥30 years).

Nipple Discharge Investigation: Assess for characteristics of discharge (bilateral vs. unilateral, expressed vs. spontaneous, non-bloody vs. bloody) to guide further evaluation and imaging.

Mastalgia Assessment: Distinguish between cyclic and noncyclic mastalgia and consider extramammary causes of breast pain in the evaluation.

Imaging with BI-RADS: Apply the BI-RADS system for classifying imaging findings to inform management decisions and identify the need for further testing or biopsy.

Histologic Sampling: Prefer core needle biopsy over fine-needle aspiration (FNA) for obtaining histologic samples and marker placement for future reference.

Simple Cyst Management: Manage conservatively unless symptomatic, in which case aspiration may be considered.

Fibroadenoma Treatment: Monitor asymptomatic fibroadenomas; consider excision if they cause significant symptoms or exhibit growth.

Excisional Biopsy for Suspicious Lesions: Perform excisional biopsy for radial scars and atypical hyperplasia to confirm diagnosis and exclude malignancy.

Enhanced Screening for High-Risk Women: Offer women with atypical hyperplasia or LCIS enhanced screening and risk-reducing strategies, including chemoprophylaxis with medications like tamoxifen or raloxifene.

LCIS Management: Recommend surgical excision to exclude associated carcinoma and ensure ongoing surveillance with mammography and clinical breast exams.

Diagnosis and Management of Benign Breast Disorders.pdf

BRCA

Gynecology

Open

Genetic Risk Evaluation: All patients with ovarian, fallopian tube, or peritoneal carcinoma should have a genetic evaluation to inform treatment and family testing.

BRCA1/BRCA2 Testing: Testing for germline mutations in BRCA1 and BRCA2 is crucial as they account for most cases of hereditary breast and ovarian cancer (HBOC).

Inclusive Cancer Definition: Ovarian cancer in medical literature often encompasses fallopian tube and primary peritoneal cancers due to their similarities.

Additional Genetic Factors: Besides BRCA mutations, other genes contribute to HBOC and should be included in risk evaluations.

Risk Communication: Patients must be informed of their specific cancer risks associated with BRCA mutations to guide personal and familial healthcare decisions.

Genetic Counseling Importance: Genetic counseling should be routine in obstetrics and gynecology, especially for women with personal or familial cancer histories.

Testing Protocols: Genetic testing should start with the family member affected by cancer and be followed by appropriate counseling and informed consent.

Risk-Reducing Surgeries: Offer risk-reducing bilateral mastectomy and salpingo-oophorectomy to women with mutations that increase the risk of breast and ovarian cancers, respectively.

Breast Mass 1. Breast Self-Assessment vs. Self-Examination:

• Self-assessment: Awareness of any breast changes.

• Self-examination: Systematic palpation and visual inspection.

2. Screening Protocol for Breast Carcinoma:

• Regular mammograms based on age/risk.

• Clinical breast exams.

• Self-awareness of changes.

3. Role of Imaging and Biopsy in Breast Mass Workup:

• Mammography: Initial imaging, especially for screening.

• Ultrasound: Further evaluation, especially in younger women.

• Aspiration: Differentiates cystic from solid masses.

• Needle localization: Assists in precise biopsy.

• Excision biopsy: Confirms diagnosis when non-invasive biopsy inconclusive.

4. Breast Cyst Aspiration:

• Clear fluid: Typically discarded.

• Bloody or turbid fluid: Sent for cytology.

5. Significance of Menopause, Receptor, and Nodal Status in Breast Cancer:

• Menopausal status: Affects hormone therapy.

• Receptor status (ER/PR/HER2): Determines targeted therapy.

• Nodal status: Influences staging and treatment intensity.

Hereditary Breast and Ovarian Cancer Syndrome.pdf

Breast disease and breast cancer screening

Open

Mammography Initiation: Offer mammography starting at age 40 and make it mandatory by age 50 for women at average risk.

Screening Frequency: Provide options for annual or biennial mammography based on patient preferences and risk factors.

Continuation of Screening: Recommend continuing screening until at least age 75, with further continuation based on overall health and longevity.

Clinical Breast Examination (CBE): Offer CBE every 1-3 years for women aged 25-39 and annually from age 40, especially for women at high risk.

Breast Self-Awareness: Encourage women to be aware of the normal look and feel of their breasts and report any changes, but routine self-examination is not recommended for average-risk women.

Breast Cancer Risk Assessment and Screening in Average-Risk Women.pdf

Breastfeeding

Obstetrics

Open

Engorgement Management: Mild symptoms may require expectant management and adequate infant latch. Severe cases need minimal milk expression to relieve symptoms, early and frequent breastfeeding, and reverse pressure softening techniques.

Persistent Pain Management: Address underlying causes such as infant latch issues or maternal infections. Provide nipple care, pain relief, lactation support, and specialist referrals when necessary.

Low Milk Supply Management: Reassure patients with adequate milk supply indicators. Encourage frequent feeding or expression to stimulate production and address any underlying conditions. Use supplementation if needed for infant well-being.

Galactagogues Use: Assess and optimize breastfeeding practices before considering galactagogues. Inform patients about potential benefits and risks.

Mastitis Management: Ensure frequent and effective milk removal. Treat infections with appropriate antibiotics and provide pain relief. Investigate resistant infections or abscess if no improvement.

Management for Late Preterm and Early Term Infants: Offer proactive lactation support, focus on milk supply development, and encourage frequent hand expression.

Medication Use During Lactation Guidance: Engage in open communication about medication use, provide accurate information, and encourage continued breastfeeding unless contraindicated.

Substance Use Disorder and Breastfeeding Recommendations: Advise against breastfeeding with illicit drug use and marijuana. Support breastfeeding for stable patients on medication-assisted treatment for opioid use. Discourage tobacco smoking but recognize it's not a strict contraindication.

Palpable Breast Mass Evaluation and Management: Prompt evaluation of any breast mass during lactation with appropriate imaging and biopsy if needed. Provide lactation support throughout the process.

Breastfeeding Challenges.pdf

Breech

Obstetrics

Open

Shift Towards Planned Cesarean: An increasing trend towards cesarean deliveries for term singleton breech presentations is observed, driven by concerns over safety and a decline in vaginal breech delivery expertise.

External Cephalic Version (ECV) Promotion: ECV is recommended to reduce cesarean deliveries, provided there are no contraindications and cesarean delivery services are available in case of complications.

Planned Vaginal Breech Delivery with Caution: While generally not the first option, planned vaginal breech delivery may be considered with strict eligibility criteria, hospital-specific protocols, and thorough informed consent.

Incorporation of Patient Preferences: Shared decision-making is stressed, taking into account the healthcare provider's capability to perform vaginal breech deliveries and the patient's individual preferences.

Acknowledgment of Updated Research: Recognition of recent studies finding no long-term neurodevelopmental differences between children born via planned cesarean or vaginal breech delivery, impacting the discussion on delivery mode.

Adherence to ACOG Guidelines: Current recommendations call for a collaborative approach to the delivery mode decision, supporting ECV and considering planned vaginal breech delivery with proper protocols and informed consent.

Mode of Term Singleton Breech Delivery.pdf

BSO

Gynecology

Open

Optimal BSO Timing: The study recommends performing BSO at age 50 or older during hysterectomy for benign conditions to avoid increasing overall mortality.

Estrogen Therapy for Younger Women: Women under 50 who undergo BSO should receive postoperative estrogen therapy to significantly reduce mortality risks, particularly from cardiovascular diseases and stroke.

Cancer Risk Reduction: BSO lowers ovarian cancer risk across all ages and additionally reduces breast cancer risk for women over 50, without negatively impacting colorectal or lung cancer mortality.

Cardiovascular Risk Update: Contrary to previous beliefs, there is no increased cardiovascular disease risk associated with BSO after age 50, based on the updated model findings.

Hormone Therapy Post-BSO: For women under 50, hormone therapy after BSO is advised to counteract the risks associated with premature loss of estrogen, such as increased cardiovascular mortality.

Green Journal 5-2022 Age for BSO at time of hysterectomy.pdf

Cardiac disease in pregnancy

Obstetrics

Open

Prepregnancy Counseling: Women with known cardiovascular disease should consult with a cardiologist before pregnancy to optimize health and assess risks.

Pregnancy Heart Team: A multidisciplinary team should manage moderate to high-risk cardiovascular conditions during pregnancy, delivery, and postpartum.

Risk Assessment: Use of specific risk stratification models and assessment tools is recommended to differentiate between pregnancy symptoms and those suggestive of cardiovascular disease.

Diagnostic Testing: Appropriate testing based on symptoms and existing cardiovascular conditions should be conducted, including echocardiograms, stress tests, and monitoring devices.

Management of Preexisting Cardiac Diseases: Specialized care and monitoring are required for women with high-risk cardiac diseases, including mechanical valve prostheses and cardiomyopathies.

Peripartum Cardiomyopathy: Prompt evaluation and management of symptoms such as shortness of breath and chest discomfort are crucial for women with peripartum cardiomyopathy.

Acute Coronary Events: Pregnant or postpartum women with chest pain should be evaluated for acute coronary syndrome, prioritizing maternal condition management.

Antepartum Management: Deliveries should occur at hospitals with appropriate care levels, and specific management plans should be in place for women with cardiac disease.

Intrapartum Management: Delivery plans should be established by 20–30 weeks of gestation, with careful management of anticoagulation around delivery.

Obstetric Anesthesia: Consultation with an anesthesiologist antepartum is recommended, and epidural labor analgesia should be offered under supervision.

Immediate Postpartum Management: Awareness of the increased risk of cardiovascular events in the early postpartum period is necessary, with appropriate monitoring and care.

Postpartum Follow-up: Early follow-up visits with healthcare providers are recommended for women with hypertensive disorders or heart disease/cardiovascular disorders.

Long-Term Considerations: Continuity of care postpartum should address long-term cardiovascular risks and include counseling and intervention strategies.

Ongoing Care and Education: Postpartum care should include education on individualized cardiovascular risks and planning for future pregnancies.

Pregnancy and Heart Disease.pdf

Cerclage

Obstetrics

Open

Progesterone Supplementation: Vaginal progesterone is recommended for women with a short cervix and no history of preterm birth, potentially considering it for those with a history of preterm birth and a shortened cervix. It is most commonly administered as a 200 mg daily dose from early to late second trimester.

Intramuscular 17-OHPC: Not recommended for primary prevention of preterm birth, especially after the FDA withdrew approval of Makena due to lack of evidence supporting its effectiveness.

Cervical Cerclage: Indicated primarily for women with a history of second-trimester pregnancy losses attributed to painless cervical dilation. The procedure is also considered in cases of advanced cervical dilation in the second trimester or for women with a prior spontaneous preterm birth before 34 weeks and a short cervical length.

Cerclage Techniques: Both McDonald and Shirodkar transvaginal techniques are used, with no clear superiority of one over the other. Transabdominal cerclage is reserved for cases where transvaginal cerclage isn't feasible or has failed.

Cerclage Management: Antibiotics and tocolytics have not shown to improve cerclage efficacy. Routine ultrasound surveillance post-cerclage is unnecessary. Timing for removal of transvaginal cerclage is typically around 36–37 weeks, unless cesarean delivery is planned at or beyond 39 weeks.

Management of Complications: The approach to preterm labor and preterm premature rupture of membranes (PPROM) in the context of cerclage is based on clinical judgment, with recommendations varying on whether to retain or remove the cerclage.

Non-Surgical Management: Activity restriction, bed rest, and pelvic rest are discouraged as they have not proven effective. Vaginal pessary has limited evidence of benefit and is not widely recommended.

Shared Decision-Making: Critical in managing cervical insufficiency, considering individual risk factors, clinical presentation, and patient preferences.

Guidelines and Resources: Providers should refer to ACOG Practice Bulletin No. 142, SMFM guidelines, and other relevant organizational recommendations for comprehensive management guidelines and updates on cerclage and progesterone use.

Cerclage for the Management of Cervical Insufficiency.pdf

Updated Clinical Guidance for the Use of Progesterone Supplementation for the Prevention of Recurrent Preterm Birth _ ACOG.pdf

Cervical Cancer Screening

Gynecology

Open

Endorsement of USPSTF Guidelines: ACOG now supports the USPSTF cervical cancer screening recommendations, moving away from its own and ASCCP's previous guidelines.

HPV Testing for Ages 30+: The preferred screening for individuals aged 30 and over is now primary high-risk HPV testing every 5 years, replacing the need for concurrent cytology.

Screening Commencement: Cervical cancer screening should start at the age of 21 years.

Young Adults' Screening Protocol: For those aged 21-29, the guidelines continue to advise cytology alone every 3 years.

Post-65 Screening: Screening guidelines after age 65 have not changed.

Handling Abnormal Screenings: Abnormal screening results should be managed according to the ASCCP's current guidelines.

Consideration for Ages 25-29: For individuals aged 25-29, primary HPV testing is a consideration every 5 years, subject to FDA approval and proven effectiveness.

ACS's Preference for HPV Testing: The ACS suggests primary HPV testing as the best option, foreseeing a gradual transition away from cytology-based screening.

Investigational HPV Self-Sampling: HPV self-sampling is being explored as a means to increase screening access.

Implications of HPV Vaccination: The rise in HPV vaccination rates may lead to future modifications in screening recommendations, possibly increasing the age at which screening begins.

Uniform Screening Adherence: Consistent adherence to screening guidelines is emphasized as more critical than the specific screening method used.

Health Disparities: There is a call to address the ongoing health inequities in cervical cancer care.

Promotion of HPV Vaccination: Obstetrician-gynecologists are encouraged to strongly advocate for HPV vaccination due to its effectiveness in preventing cervical cancer.

• Carcinoma Evaluation Post-Hysterectomy:

• Hysterectomy does not completely rule out carcinoma; further pathological examination of the uterus is necessary.

Cervical Cancer Screening.pdf

Updated Cervical Cancer Screening Guidelines _ ACOG.pdf

Updated Guidelines for Management of Cervical Cancer Screening Abnormalities _ ACOG.pdf

Cesarean hysterectomy

Cesarean Hysterectomy

Open

Preoperative Planning: Ensure thorough preoperative evaluation, including hematologic and coagulation status assessment, to prepare for potential complications.

Surgical Team Experience: Select experienced surgeons and assistants for the procedure, especially in cases involving abnormal placentation or previous uterine surgeries.

Optimal Incision Choice: Use a vertical abdominal incision for better exposure in most cases, unless a transverse incision is deemed sufficient.

Visualization of Ureters: Directly visualize ureters during surgery to prevent urinary tract injuries.

Meticulous Hemostasis: Employ meticulous clamping, ligation, and suturing techniques to manage intraoperative hemorrhage effectively.

Prompt Hemorrhage Management: Be prepared for immediate surgical intervention and blood transfusions in cases of severe hemorrhage, and consider interventional radiology procedures if necessary.

Early Recognition of Complications: Monitor closely for signs of infection, thromboembolism, and urinary complications in the postoperative period.

Postoperative Care: Administer broad-spectrum antibiotics for infections, manage urinary tract injuries with catheterization and antibiotics, and apply anticoagulation therapy for thromboembolism prophylaxis.

Interdisciplinary Approach: Coordinate with anesthesiologists, interventional radiologists, and other specialists for comprehensive care during and after cesarean hysterectomy.

Cesarean Hysterectomy _ GLOWM.pdf

Chorioamnionitis

Obstetrics

Open

Infection Prevention and Prophylaxis: Emphasizing the use of prophylactic antibiotics to prevent surgical site infections and Group B streptococcal infection in newborns is crucial. Also, special attention should be given to infection risk management in obese pregnant patients.

Multidisciplinary Care: The concept of a coordinated care team, such as a Pregnancy Heart Team, for managing high-risk pregnancies could be adapted to include specialists focused on intra-amniotic infections.

Individualized Management: Tailoring the management of conditions like thrombocytopenia in pregnancy suggests that a similar approach should be taken for managing intra-amniotic infections, considering the individual patient's circumstances.

Fetal and Neonatal Considerations: Management of infections during pregnancy should take into account the well-being of both the mother and the newborn, as exemplified by the guidelines for breastfeeding in hepatitis B and neonatal care in immune thrombocytopenia.

Prompt Diagnosis and Treatment: It's imperative to quickly recognize and treat intra-amniotic infection to prevent serious outcomes for both mother and child.

Antibiotic Therapy: Using broad-spectrum antibiotics as initial treatment for intra-amniotic infection is recommended, adjusting based on culture results when possible.

Delivery: Expedited delivery may be necessary to control the infection, with the mode of delivery assessed by gestational age, fetal condition, and maternal health.

Supportive Care: Essential supportive care includes managing fever and pain, and maintaining fluid and electrolyte balance.

Monitoring: Constant monitoring of mother and fetus is important to evaluate treatment response and identify any complications.

Intrapartum Management of Intraamniotic Infection.pdf

CHTN (non-pregnant)

Gynecology

Open

None

CHTN (Pregnancy)

Obstetrics

Open

Increasing Prevalence of Chronic Hypertension: The growing rates of chronic hypertension among pregnant women are attributed to the obesity epidemic and rising maternal age.

Diagnostic Criteria: The definition of chronic hypertension in pregnancy has been updated to align with ACC/AHA guidelines, which introduce lower thresholds for diagnosis than previously used.

Essential Hypertension Predominance: The majority of chronic hypertension cases during pregnancy are of unknown cause, highlighting the importance of a thorough history and physical exam to detect less common secondary forms.

Measurement Protocol: Accurate blood pressure readings require the patient to be at rest, without recent caffeine or tobacco use, and with the correct cuff size and positioning.

Preexisting Hypertension Complications: Chronic hypertension can lead to the development of superimposed preeclampsia, which complicates diagnosis and management.

White Coat Hypertension: Ambulatory blood pressure monitoring is recommended to confirm suspected white coat hypertension and guide treatment decisions.

Maternal and Fetal Risks: Chronic hypertension significantly increases maternal and fetal risks, including maternal mortality, gestational diabetes, cesarean delivery, and adverse perinatal outcomes.

Prepregnancy Counseling and Evaluation: Optimizing maternal health and understanding medication safety prior to pregnancy are crucial for women with chronic hypertension.

Initial Evaluation and Secondary Hypertension Screening: Early pregnancy care should include testing for end-organ damage, especially renal function, and consideration of secondary hypertension diagnostics if indicated.

Antihypertensive Therapy: The initiation and selection of antihypertensive drugs during pregnancy are debated, with labetalol and nifedipine being preferred options for chronic and acute management.

Low-dose Aspirin Recommendation: Daily low-dose aspirin is advised for women with chronic hypertension starting between 12 and 28 weeks of gestation to reduce the risk of preeclampsia.

Fetal Surveillance and Third-trimester Ultrasound: Antenatal fetal testing and growth assessments are recommended for pregnant women with chronic hypertension due to increased risks.

Delivery and Anesthesia Considerations: Neuraxial anesthesia is preferred over general anesthesia for women with severe hypertension, and delivery timing should be carefully determined based on the presence of maternal or fetal complications.

Postpartum Monitoring and Medication: Postpartum women with chronic hypertension require close blood pressure monitoring and may need antihypertensive medications, which are generally safe for breastfeeding.

Chronic Hypertension in Pregnancy.pdf

Clomid

Open

1. Mechanism of Action:

• Selective estrogen receptor modulator (SERM), increasing FSH and LH for ovulation induction.

2. Dosage:

• Typically 50 mg daily for 5 days, starting on day 2-5 of the menstrual cycle.

3. Side Effects:

• Hot flashes, ovarian enlargement, visual disturbances.

4. Monitoring:

• Ultrasound for follicular development.

• Hormone levels (e.g., estradiol) as needed.

5. Multiple Gestation Risk:

• Clomid: 5-10%.

• Pergonal: Higher due to multiple follicles stimulated.

CMV, parvovirus, VZV, toxo in pregnancy

Obstetrics

Open

CMV Management: No routine serologic screening; research protocols might use antiviral medications; CMV-specific hyperimmune globulin is being investigated but not yet effective.

Parvovirus B19 Management: Monitor for fetal anemia and hydrops fetalis; consider intrauterine transfusion for severe fetal anemia.

VZV Management: Administer oral acyclovir for maternal varicella; use Varicella-Zoster Immune Globulin for exposed pregnant women without immunity.

Toxoplasmosis Management: Perform serologic testing for diagnosis; use spiramycin to reduce vertical transmission and a combination of drugs for confirmed fetal infection; routine serologic screening is not advised during pregnancy.

Cytomegalovirus Parvovirus B19 Varicella Zoster and Toxoplasmosis.pdf

Condyloma Acuminata (CHPV)

Open

• Caused by HPV (human papillomavirus).

• Appears as genital warts.

Congenital abnormalities of the reproductive tract

Open

None

1. Embryology of Internal and External Genitalia:

• Development from the Müllerian ducts.

• Fusion and canalization processes form uterus, fallopian tubes, and upper vagina.

2. Types of Uterine Anomalies:

• Septate uterus: Incomplete septum resorption.

• Bicornuate uterus: Partial Müllerian duct fusion.

• Didelphys uterus: Complete fusion failure, double uterus.

Contraceptive Counseling

Gynecology

Open

Individualized Contraceptive Choice: Emphasize the importance of personalizing contraceptive selection based on individual preferences, medical history, and lifestyle needs. Discuss all available options, their benefits, risks, and proper use with the patient.

Risks and Benefits of Hormonal Contraceptives: Counsel patients on both the risks, such as venous thromboembolism with CHCs, and the benefits, including highly effective pregnancy prevention and menstrual cycle regulation. Use the US MEC for guidance on medical conditions.

Emergency Contraception Accessibility: Ensure patients are informed about the availability and effectiveness of emergency contraception, and provide clear instructions on use, particularly the time-sensitive nature of these methods.

Advantages of LARC: Highlight the effectiveness, longevity, and convenience of Long-Acting Reversible Contraception (IUDs and implants), and discuss potential side effects to assist in informed decision-making.

Sterilization Considerations: Present sterilization as a permanent method of contraception, discuss the risks of surgery, and address the potential for regret, especially among younger individuals, to support a thoughtful choice.

Comprehensive Patient Counseling: Engage in shared decision-making, considering patient values and preferences, and offer comprehensive counseling that includes addressing misperceptions and concerns about contraception.

Special Populations Consideration: Tailor counseling and contraception management to special populations, such as adolescents, breastfeeding women, those with mental health or physical disabilities, and patients with medical comorbidities, following specific guidelines like the US MEC.

Follow-Up and Ongoing Care: Establish regular follow-up visits to assess satisfaction and adherence, provide ongoing education, and integrate STI prevention counseling into contraceptive care.

Use of Hormonal Contraception in Women With Coexisting Medical Conditions.pdf

Criteria for dating

Open

First Trimester Ultrasound: Use ultrasound measurement before 13 6/7 weeks with crown-rump length for the most accurate estimation of gestational age and due date.

Adjusting Due Date: If first-trimester ultrasound differs from last menstrual period (LMP) dating by more than 7 days, revise the EDD accordingly.

Ultrasound Over Second-Trimester Adjustments: Do not adjust gestational age based on second-trimester ultrasound if a first-trimester ultrasound is consistent with LMP dating.

Assisted Reproductive Technology (ART) Pregnancies: Determine EDD using the embryo age and transfer date for pregnancies resulting from ART.

Second and Third Trimester Ultrasound Accuracy: Recognize decreased accuracy in ultrasound dating as pregnancy progresses, with the third trimester being the least precise.

Suboptimally Dated Pregnancies: Consider a pregnancy suboptimally dated if no confirming or revising ultrasound is performed before 22 0/7 weeks.

Third Trimester Discrepancies: Adjust the EDD if the first ultrasound in the third trimester suggests a discrepancy greater than 21 days.

Clinical Decision Making: Use caution when making management decisions based on third-trimester ultrasound due to potential misdating; consider the full clinical picture and possibly repeat ultrasounds.

Documentation and Communication: Discuss and document gestational age and EDD with the patient early in the pregnancy, ensuring it is recorded in medical records and on the birth certificate.

Methods for Estimating the Due Date.pdf

Critical Care in Pregnancy

Open

Early Antibiotic Therapy for Sepsis: It is advised to initiate antibiotic treatment early in cases of sepsis to lower the risk of mortality.

Resuscitative Hysterotomy Guidelines: Perform resuscitative hysterotomy for maternal benefit when a pregnant woman's uterus is at or above the umbilicus (20 weeks gestation or more) if cardiac arrest resuscitation is unsuccessful.

Timing for Resuscitative Hysterotomy: Consider resuscitative hysterotomy immediately upon maternal cardiac arrest and be prepared to perform it if spontaneous circulation does not resume within the initial minutes of resuscitation.

Cesarean Delivery Post-Cardiac Arrest: While injury-free survival rates are 50% with perimortem cesarean delivery up to 25 minutes after cardiac arrest, prioritize more rapid resuscitative hysterotomy to potentially improve survival outcomes.

Critical Care in Pregnancy.pdf

Decreased FM

Obstetrics

Open

Reduction of Stillbirth Risk: Antenatal fetal surveillance is utilized primarily to lower the risk of stillbirth, especially in high-risk pregnancies, although its effectiveness across all conditions linked to stillbirth is not established.

Challenges in Prescription: Crafting a definitive list of indications for antenatal fetal surveillance is difficult due to unknown pathways to increased stillbirth risk, limited evidence for efficacy, and reliance on expert opinion and observational studies rather than robust clinical trials.

ACOG Guidance on Surveillance: The American College of Obstetricians and Gynecologists (ACOG) recommends antenatal fetal surveillance for conditions with a stillbirth rate higher than 0.8 per 1,000 and a relative risk or odds ratio for stillbirth greater than 2.0, with specific timing and frequency suggestions outlined in their documentation.

Importance of Shared Decision-Making: Critical to the process is shared decision-making between the patient and clinician to tailor the surveillance strategy to the patient's unique circumstances and preferences, especially in the context of fetal anomalies or imminent viability thresholds.

Timing and Frequency of Surveillance: Surveillance is generally recommended to start at 32 weeks gestation or later but may begin earlier for severe high-risk conditions. The frequency is often set at weekly intervals, with adjustments made for additional high-risk factors or changing maternal conditions.

Individualized Care Approach: Due to the lack of strong evidence, antenatal fetal surveillance should be individualized based on expert consensus, available observational studies, and the patient's specific situation.

Call for Research: There is a need for research to refine the understanding of stillbirth risks, develop evidence-based surveillance recommendations, address the consequences of false positives, and improve surveillance methods to detect possible underlying causes of stillbirth such as placental dysfunction.

Indications for Outpatient Antenatal Fetal Surveillance.pdf

Differential diagnosis of fetal hydrops

Open

None

Dysmenorrhea

Gynecology

Open

Empiric Treatment for Primary Dysmenorrhea:

Initiate treatment based on patient history suggesting primary dysmenorrhea.

Use NSAIDs as first-line treatment, starting 1–2 days before the onset of menses and continue through the first few days of bleeding.

Individualize dosage and educate on correct usage and timing to maximize efficacy.

Hormonal Agents in Management:

Consider hormonal agents when NSAIDs are insufficient or as an alternative first-line option.

Combine with NSAIDs as needed, and choose based on patient preference, weighing benefits and side effects.

Complementary and Alternative Therapies:

Encourage exercise and heat treatment due to their low risk and general health benefits.

Be cautious with dietary supplements and alternative therapies due to limited evidence and unclear safety data.

Follow-Up and Monitoring:

Regularly assess treatment response using visual analog scales or numerical rating scales.

Investigate secondary causes if no improvement after 3–6 months of treatment and ensure adherence to treatment.

Pelvic Imaging for Secondary Dysmenorrhea:

Utilize ultrasonography as the initial imaging modality for potential causes.

Consider MRI for further evaluation if necessary, but be mindful of cost-effectiveness.

Laparoscopy for Endometriosis:

Consider laparoscopy for persistent dysmenorrhea unresponsive to medical treatment, with biopsy confirmation of endometriosis.

Excise or ablate visible lesions during initial laparoscopy.

Managing Endometriosis in Adolescents:

Aim for symptom relief, suppression of disease progression, and protection of future fertility.

Use suppressive hormonal therapy continuously unless conception is desired.

Reserve GnRH agonist therapy for refractory pain, with add-back therapy to prevent bone loss and menopausal symptoms.

Long-term Management and Support:

Provide ongoing education and support, incorporating multidisciplinary services when needed.

Monitor long-term impacts on fertility and offer resources for additional information and support.

Dysmenorrhea

• Conservative Treatments:

• NSAIDs, hormonal contraceptives, heat therapy.

Dysmenorrhea and Endometriosis in the Adolescent.pdf

Dyspareunia

Open

1. Causes:

• Infections, endometriosis, pelvic floor dysfunction.

2. Workup:

• History, physical exam, imaging, lab tests.

3. Treatment Options:

• Pelvic floor therapy, lubricants, addressing underlying causes.

Dysplasia

Open

1. Cone vs. LEEP for Cervical Dysplasia:

• Cone biopsy: For larger or glandular lesions.

• LEEP: For smaller, squamous lesions.

2. Counseling for CIN 1, 2, and 3:

• CIN 1: Observation and follow-up.

• CIN 2: LEEP or cryotherapy.

• CIN 3: LEEP or cone biopsy.

3. Colposcopic Features of CIN 1, 2, and 3:

• CIN 1: Mild acetowhite.

• CIN 2: Moderate acetowhite, mosaic pattern.

• CIN 3: Dense acetowhite, punctation.

Early Pregnancy Loss

Obstetrics

Open

Misoprostol for Medical Management: Recommended initial treatment with 800 mcg vaginally, possibly repeated if necessary. Combining with mifepristone (200 mg orally) 24 hours prior may increase effectiveness.

Ultrasonography for Diagnosis: The preferred method to confirm a viable intrauterine pregnancy.

No Surgical Intervention for Asymptomatic Women: Those with a thickened endometrial stripe post-treatment typically do not need surgery.

Management Options: Expectant, medical, and surgical management are all viable; patient preference should inform the decision.

Doxycycline to Prevent Infection: Prophylaxis recommended post-surgical management.

Rh D Immune Globulin for Rh D-negative Women: Especially important in later first-trimester losses to prevent Rh alloimmunization.

Early Pregnancy Loss.pdf

Eclampsia

Obstetrical Emergencies

Open

Confirming Severe Preeclampsia: The text recommends validating the diagnosis of severe preeclampsia by repeating blood pressure measurements and initiating prompt treatment.

Implementing Initial Treatment: Start with antihypertensives and magnesium sulfate to manage the patient's condition. Informing the patient, alerting staff, and preparing equipment are critical initial steps.

Positioning and Monitoring: Emphasizes placing the patient in the left lateral position if fetal distress is observed and continuously monitoring the patient's and fetus's vital signs.

Convulsion Management: During a convulsion, the patient should be placed in a lateral recumbent position, airway management should be prioritized, and magnesium sulfate should be administered.

Continuous Post-Seizure Care: Following a seizure, the patient requires ongoing monitoring and treatment, including maintaining antihypertensive therapy and magnesium sulfate administration for 24 hours post-seizure or delivery.

Magnesium Sulfate Protocol: Provides specific dosing instructions for magnesium sulfate, both for initial treatment and maintenance.

Handling Recurrent Seizures: Outlines the continued use of magnesium sulfate and the addition of benzodiazepines or other anticonvulsants if seizures persist.

Magnesium Toxicity Precautions: Identifies signs of magnesium toxicity and recommends immediate treatment with calcium gluconate if toxicity is suspected.

Low-Dose Aspirin Use During Pregnancy.pdf

Ectopic pregnancy

Gynecology

Open

Laparoscopic Surgery and Methotrexate: Both are deemed safe and effective for stable women with nonruptured ectopic pregnancies.

Surgical Intervention Necessity: Mandatory for patients with hemodynamic instability, symptoms of a ruptured ectopic mass, or signs of intraperitoneal bleeding.

hCG Discriminatory Level: A conservatively high hCG level, such as 3,500 mIU/mL, should be used to guide diagnosis.

Salpingostomy vs. Salpingectomy: The choice should be based on the patient's clinical status, fertility desires, and the extent of tubal damage.

Methotrexate Protocol Selection: Should be informed by the initial hCG level and thorough patient discussion of the associated benefits and risks.

Methotrexate Treatment Failure: Likely if there's less than a 15% decrease in hCG from day 4 to day 7 post-treatment.

Fertility After Methotrexate: No adverse effects on subsequent fertility or ovarian reserve have been observed.

Expectant Management: May be an option under specific conditions, especially when hCG is below 200 mIU/mL.

Diagnostic Evaluation: Should at least include transvaginal ultrasound and confirmation of pregnancy.

Medical Management with Methotrexate: Advisable for stable patients with a confirmed or suspected ectopic pregnancy, unruptured mass, and no absolute contraindications.

hCG Monitoring After Methotrexate: It is essential to monitor hCG levels until they return to a non-pregnant state.

Patient Counseling Post-Methotrexate: Patients should be informed about the risk of ectopic pregnancy rupture and advised on substance avoidance and the importance of postponing pregnancy until resolution.

Tubal Ectopic Pregnancy.pdf

Emergency Contraception

Gynecology

Open

Awareness and Education: Clinicians should inform all women, especially adolescents, those of low socioeconomic status, and foreign-born women, about the availability, safety, and proper use of emergency contraception (EC) to improve awareness and dispel misconceptions.

Access Improvement: Healthcare providers should advocate for policies that facilitate better access to EC, ensuring over-the-counter availability without age restriction and addressing any barriers that pharmacies or other entities might impose.

Identification of Candidates: All women who have had unprotected or inadequately protected intercourse and do not desire pregnancy should be identified as candidates for EC, with an emphasis on the absence of any medical contraindications to its use.

Streamlining Provision: EC should be provided without unnecessary clinical examinations or pregnancy tests, and clinicians should not delay administration based on the timing of intercourse within the menstrual cycle.

Counseling on Repeat Use: Women should be counseled that EC can be used more than once in a menstrual cycle if necessary, but it should not be used as a regular form of contraception, and discussions should include long-term contraceptive options.

Follow-Up Guidance: Clinicians should advise women that no specific follow-up is necessary after using EC. However, they should seek medical evaluation if they experience a delay in menses beyond one week or persistent abdominal pain.

Emergency Contraception.pdf

Endometrial ablation

Gynecology

Open

Exclusion of Concurrent Carcinoma: Gynecologists should exclude concurrent carcinoma when diagnosing EIN-AEH, using hysteroscopic examination with endometrial sampling as the most accurate method.

Definitive Surgical Treatment: Hysterectomy is recommended as the definitive treatment for EIN-AEH, while supracervical hysterectomy and endometrial ablation are not advised due to risks of incomplete treatment.

Non-Surgical Management Options: For patients who cannot undergo hysterectomy, progestational agents, particularly intrauterine administration, are suggested, with continuous oral therapy being more effective than cyclic.

Follow-Up Protocol: Patients treated non-surgically should have a histologic assessment within 3-6 months and may require long-term maintenance therapy with progestational agents if risk factors for endometrial cancer persist.

Lifestyle Modifications Counseling: Patients should be counseled on lifestyle changes like weight loss and glycemic control to reduce the risk of EIN-AEH and endometrial cancer.

Areas for Future Research: Further studies are needed on the effectiveness of progestational agents, repeat sampling for malignancy exclusion, non-surgical management outcomes, lifestyle modification impacts, molecular classification in treatment, and disparities in EIN-AEH treatment and mortality.

Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia.pdf

Endometrial Cancer

Gynecology

Open

Surgical Management: For endometrial cancer, the standard management is a total hysterectomy with bilateral salpingo-oophorectomy and lymph node assessment to determine the extent of disease spread.

Radiation Therapy: Radiation is recommended for reducing local recurrence in patients with intermediate to high-risk features, with vaginal brachytherapy preferred over whole pelvic irradiation to enhance quality of life.

Chemotherapy: Advanced or recurrent endometrial cancer is treated with chemotherapy, often using a regimen that includes carboplatin and paclitaxel, and for advanced-stage disease, a combination of doxorubicin, cisplatin, and paclitaxel may improve survival.

Fertility-Sparing Options: Selected young patients with early-stage, low-grade endometrioid carcinoma who wish to preserve fertility may be treated with high-dose progestins, but must be counseled on the variable response rates and high risk of recurrence.

Surveillance: After treatment, patients should undergo regular follow-up exams semiannually for the first 2 years and then annually, with imaging studies being performed only if recurrence is suspected.

Endometrial Cancer.pdf

Endometriosis

Gynecology

Open

Diagnosis with Imaging: Begin with transvaginal ultrasound for initial evaluation of suspected endometriosis. A laparoscopy is required for a definitive diagnosis.

Hormonal Therapy as First-line Treatment: Use oral contraceptives, GnRH agonists, or progestins to effectively reduce pain associated with endometriosis, keeping in mind the potential for symptom recurrence after stopping treatment.

Surgical Treatment for Symptom Relief and Fertility: Offer laparoscopic excision of lesions to alleviate symptoms and possibly improve fertility. Consider definitive surgeries like hysterectomy when conservative treatments fail and fertility is not a concern.

Tailored Management Strategy: Adopt a personalized approach to treatment, factoring in the patient's symptom severity, fertility aspirations, and preferences, and weigh both medical and surgical options.

Management of Endometriosis.pdf

Endometritis - Postprocedural

Gynecology

Open

None

External cephalic version

Obstetrics

Open

Offer ECV to Eligible Women: ECV should be offered to all eligible women with breech presentations who are near term, as it increases the chances of vaginal delivery and reduces cesarean birth rates.

Patient Selection at 37 Weeks: Pregnant women at or after 37 weeks of gestation are preferred candidates because spontaneous version is less likely, and emergency cesarean delivery can be performed safely if needed.

Assessment of Fetal Presentation: Healthcare providers should assess and document fetal presentation beginning at 36 weeks gestation to determine eligibility for ECV.

Utilize Tocolysis: Parenteral tocolysis is recommended during ECV to relax the uterus and improve the success rate of the procedure.

Consider Neuraxial Analgesia: Neuraxial analgesia in combination with tocolysis may be considered to increase comfort and possibly the success rate of ECV, although evidence is limited.

Ensure Cesarean Delivery Capabilities: ECV should only be performed in settings where cesarean delivery services are readily available in case of complications or emergency.

Perform Pre- and Post-Procedure Assessments: Fetal well-being and contraction patterns should be monitored before and after ECV to ensure the safety of both the mother and fetus.

Administer Rh Immune Globulin: Rh-negative patients should receive Rh immune globulin if delivery is not anticipated within 72 hours post-ECV to prevent Rh sensitization.

Cost-Effectiveness of ECV: ECV is generally cost-effective, especially considering the reduced hospital charges and length of stay associated with vaginal deliveries compared to cesarean sections.

External Cephalic Version.pdf

Fecal incontinence

Gynecology

Open

Initial Management and Non-Surgical Treatments: Non-surgical treatments, such as dietary modifications, fiber supplementation, and stool-modifying medications, are advocated as the first-line management for fecal incontinence, with the aim to decrease the frequency and severity of episodes.

Effectiveness of Conservative Measures: Conservative interventions, while offering short-term relief, are not typically seen as long-term solutions for fecal incontinence. Pelvic floor muscle training and anal sphincter tissue bulking injections may provide additional relief if initial conservative treatments are ineffective.

Surgical Treatment Considerations: Surgical options are considered when conservative and non-surgical treatments fail. They are specifically indicated for conditions like fistulae or rectal prolapse.

Screening and Evaluation: Proactive screening for fecal incontinence is recommended for women with risk factors. A thorough initial evaluation should include medical history, symptom assessment, and physical examination, while routine laboratory tests are not necessary unless infectious diarrhea is suspected.

Ancillary Testing and Referrals: Routine use of ancillary diagnostic tests is not recommended unless an anatomical defect or dysfunction is suspected. Obstetrician-gynecologists can manage initial conservative treatments, but should refer to specialists for surgical management or when conservative treatments fail.

Non-Surgical Intervention Efficacy: Non-surgical treatments show modest short-term effectiveness with low risk, but long-term effectiveness data is lacking. Injectable bulking agents can reduce fecal incontinence episodes for up to 6 months, although long-term effects are uncertain.

Surgical Treatment Risks and Benefits: Surgical treatments are not advised as the first step, except for specific conditions, due to their short-term improvement and higher complication risks. Referral to a specialist is recommended for potential surgical candidates.

Fecal Incontinence.pdf

Female Sexual Dysfunction

Gynecology

Open

Initiate Conversations: Obstetrician-gynecologists should proactively engage in conversations about sexual function during routine visits to identify FSD and make the topic more approachable.

Use Self-Report Checklists: Employ brief sexual function self-report checklists to facilitate discussions about sexual health and identify potential issues.

Comprehensive Evaluation: Conduct a thorough evaluation comprising a detailed history, physical examination, and sexual history to identify possible gynecologic causes of FSD.

Psychological Interventions: Integrate psychological therapies like sexual skills training, cognitive-behavioral therapy, and couples therapy for all types of FSD, and consider referral to mental health specialists.

Hormonal Therapy for GSM: Employ low-dose vaginal estrogen or alternatives like ospemifene for genitourinary syndrome of menopause-related FSD, avoiding hormone therapy for non-hypoestrogenic FSD.

Selective Androgen Therapy: Consider short-term transdermal testosterone for postmenopausal women with sexual interest/arousal disorders, but not for premenopausal women or systemic DHEA as it is ineffective.

Flibanserin for Pre-Menopausal Women: Flibanserin may be an option for premenopausal women with hypoactive sexual desire disorder, with caution regarding alcohol interaction.

Non-Hormonal Medication Options: Bupropion may be beneficial for antidepressant-induced sexual dysfunction, but sildenafil is not recommended outside of clinical trials.

Addressing Genito-Pelvic Pain: Recommend pelvic floor physical therapy, appropriate use of lubricants, topical anesthetics, and moisturizers for genito-pelvic pain, but advise against using vaginal CO2 fractional laser treatment outside of research settings.

Evidence-Based Recommendations: Follow the evidence grading methodology to apply treatment recommendations, with Level A being based on consistent evidence, Level B on limited evidence, and Level C on consensus and expert opinion.

Female Sexual Dysfunction.pdf

Fetal growth restriction

Obstetrics

Open

Serial Ultrasonography: Regular monitoring of fetal growth and amniotic fluid volume via ultrasound is essential in the management of FGR to track the progression and make timely decisions.

Doppler Velocimetry: Utilization of umbilical artery Doppler helps in assessing the placental function and in identifying fetuses at high risk of adverse outcomes, which is critical in managing FGR.

Antenatal Surveillance: Implementation of nonstress tests and biophysical profiles to monitor fetal well-being, with the initiation of these tests at a gestational age where delivery would be beneficial.

Timing of Delivery: Decision-making regarding the optimal time for delivery should take into account the cause of FGR, gestational age, and fetal surveillance outcomes, with general recommendations provided for various scenarios.

Preterm Delivery Considerations: In cases of preterm delivery, the presence of a neonatal intensive care unit and the use of antenatal corticosteroids and potentially magnesium sulfate are recommended for improving neonatal outcomes and neuroprotection.

Mode of Delivery: The presence of FGR alone is not an indication for cesarean delivery; delivery mode should be determined by other clinical factors.

Fetal Growth Restriction.pdf

Fetal heart rate abnormalities

Obstetrics

Open

Routine Monitoring for Normal FHR: In case of Category I FHR, which is normal, it is advised to conduct routine monitoring with reviews at set intervals during the labor stages.

Increased Surveillance for Indeterminate FHR: The presence of Category II FHR tracings calls for heightened observation and potential corrective interventions like maternal repositioning or oxygen administration to improve fetal conditions.

Urgent Interventions for Abnormal FHR: Category III tracings, indicative of a high risk of fetal acidemia, require immediate intrauterine resuscitative measures and consideration for expedited delivery.

Management of Variable Decelerations: Intermittent variable decelerations are usually benign, but recurrent ones suggest cord compression and necessitate interventions like maternal repositioning or amnioinfusion.

Addressing Late Decelerations: Late decelerations point towards uteroplacental insufficiency and are managed by improving maternal perfusion, administering fluids, and adjusting uterotonic drugs.

Treating Fetal Tachycardia: Fetal tachycardia often stems from maternal or fetal factors, and management involves identifying the underlying cause and treating it accordingly.

Response to Bradycardia and Prolonged Decelerations: These patterns are critical and require immediate evaluation and response due to potential severe underlying conditions like cord prolapse or placental abruption.

Tachysystole Assessment and Management: For tachysystole associated with non-reassuring FHR patterns, it is crucial to reevaluate uterine activity and administer treatments to reduce it if necessary.

Management of Intrapartum Fetal Heart Rate Tracings.pdf

Intrapartum Fetal Heart Rate Monitoring Nomenclature Interpretation and General Management Principles.pdf

GBS +

Obstetrics

Open

Universal Screening Timing: Pregnant women should be screened for GBS between 36 0/7 and 37 6/7 weeks of gestation to ensure valid culture results up to at least 41 0/7 weeks gestation.

Screening Method: Vaginal-rectal culture is the standard for GBS screening, with a single swab for both sites, while NAAT is an alternative that does not replace routine prenatal screening.

First-line Treatment: Intravenous penicillin is the preferred treatment for intrapartum antibiotic prophylaxis, with intravenous ampicillin as an alternative.

Managing Penicillin Allergies: Severity assessment of penicillin allergy is crucial; first-generation cephalosporins are for low-risk allergies, clindamycin for susceptible GBS isolates, and vancomycin for resistant cases.

Antibiotic Timing Relative to Birth: Obstetric interventions need not be delayed to complete 4 hours of antibiotic administration, but efforts should be made to maximize the antibiotic exposure before birth.

Procedures in GBS-colonized Women: The opinion provides guidance on various obstetric procedures in GBS-colonized women, ensuring safe and effective care without unnecessary delays.

Prevention of Group B Streptococcal Early-Onset Disease in Newborns.pdf

Gestational Diabetes

Obstetrics

Open

Universal Screening: Screening for GDM is recommended between 24–28 weeks gestation, with earlier testing for women at high risk for pregestational diabetes.

Nutrition and Exercise Counseling: Women diagnosed with GDM should receive immediate advice on diet and physical activity to manage their condition.

Blood Glucose Monitoring: Regular monitoring of fasting and postprandial glucose levels is crucial to assess and maintain glycemic control.

Lifestyle Interventions: Limiting carbohydrate intake to 33–40% of total calories and distributing it throughout the day along with regular moderate-intensity exercise improves insulin sensitivity.

Pharmacological Treatment: Insulin is the first-line medication, with Metformin as an alternative in specific cases, acknowledging the absence of long-term safety data.

Postpartum Management: Postpartum screening for diabetes is recommended, followed by continued monitoring and lifestyle interventions to prevent type 2 diabetes.

Gestational Diabetes Mellitus.pdf

Gestational Hypertension and Preeclampsia

Obstetrics

Open

Assess and Stabilize:

Monitor vital signs and fetal heart rate, check for any signs of organ dysfunction, and assess the patient's overall condition. Obtain consent for treatment with magnesium sulfate or antihypertensives if necessary.

Lab Work and Monitoring:

Conduct liver function tests, complete blood count, and renal function tests. Continuously monitor vital signs and fetal heart rate, adjusting monitoring intervals as the condition progresses.

Differentiate Hypertension Types:

Distinguish between gestational hypertension and preeclampsia using criteria such as proteinuria levels and severe features like low platelets or elevated liver enzymes.

Administer Medications:

Start with antihypertensive treatments such as nifedipine, hydralazine, or labetalol to control blood pressure, and begin magnesium sulfate protocol for seizure prophylaxis.

Decision-Making for Delivery:

Consider immediate delivery if the patient is at or beyond 34 weeks gestation and showing signs of instability, or administer betamethasone if preterm delivery is anticipated.

Postpartum Care:

Monitor patients closely for at least 48 hours postpartum, particularly for signs of HELLP syndrome, which may worsen or peak in severity during this time.

Address HELLP Syndrome:

Evaluate for HELLP syndrome using criteria like LDH, AST/ALT levels, and platelet count. Manage with delivery, corticosteroids, and close monitoring of lab values and potential complications.

Gestational Hypertension and Preeclampsia.pdf

Headache in pregnancy

Obstetrics

Open

Primary Headache Prevention: Obstetricians should review and adjust medications for headache prevention, with a focus on nonpharmacologic interventions such as trigger avoidance, lifestyle modifications, cognitive behavioral therapy, acupuncture, and biofeedback. Calcium channel blockers and antihistamines are considered safe pharmacologic options.

Acute Headache Treatment at Home: Acetaminophen is the first-line treatment for primary headaches during pregnancy. Combination therapy with caffeine is permissible but should be limited due to potential fetal effects. NSAIDs can be used only in the second trimester for intractable migraines.

Treatment in Medical Facilities: Metoclopramide with or without diphenhydramine is recommended for persistent headaches. Other options like prednisolone, intravenous magnesium, or sumatriptan may be used with caution. Avoid butalbital-containing products, opioids, and ergot alkaloids.

Management During Lactation: Safe medications include acetaminophen, NSAIDs (except standard-dose aspirin), caffeine, and metoclopramide. Opioids and ergot alkaloids should be used with caution due to potential adverse effects in infants.

Secondary Headache Treatment: Management strategies depend on the underlying condition, with specific treatments such as magnesium sulfate for preeclampsia and an epidural blood patch for postdural puncture headache.

Patient Counseling: Emotional support and counseling are crucial for women experiencing severe or persistent headaches during pregnancy and postpartum.

Headaches in Pregnancy and Postpartum.pdf

HELLP Syndrome

Obstetrical Emergencies

Open

None

Hemoglobinopathies

Open

Preventive Screening: High-risk individuals, notably from African, Southeast Asian, or Mediterranean backgrounds, should be provided with carrier screening for hemoglobinopathies.

Genetic Counseling: Couples identified as carriers through screening should receive genetic counseling to understand the risks and implications for offspring.

Comprehensive Testing: Initial screening with CBC and hemoglobin electrophoresis is recommended, with DNA testing reserved for prenatal diagnosis.

Folic Acid Supplementation for SCD: Pregnant women with SCD should take 4 mg of folic acid daily to compensate for increased red blood cell turnover.

Pain Management in SCD: Address painful crises with adequate analgesia and hydration, while avoiding teratogenic drugs like hydroxyurea.

Selective Transfusion Therapy: In SCD pregnancies, use transfusions judiciously to manage severe complications, aiming to reduce Hb S levels to 40% and maintain total hemoglobin around 10 g/dL.

Monitoring in Thalassemias: Ensure proper transfusion and iron chelation in β-thalassemia major, and monitor fetal growth via serial ultrasounds.

Multidisciplinary Care Team: Manage pregnant women with hemoglobinopathies with a team approach involving obstetricians skilled in high-risk pregnancies and hematologists.

Hemoglobinopathies in Pregnancy.pdf

Hepatitis Vaccination

Obstetrics

Open

Universal Screening: All pregnant individuals should be screened for hepatitis B at the first prenatal visit, using the HBsAg test and a triple panel test at least once in adulthood to assess immunity, active infection, or susceptibility.

Antiviral Therapy for High Viral Loads: Pregnant individuals with HBV DNA levels greater than 200,000 IU/mL should be offered antiviral therapy with tenofovir to reduce the risk of perinatal transmission, starting in the third trimester.

First-Line Treatment with Tenofovir: Tenofovir, either as tenofovir disoproxil fumarate or tenofovir alafenamide, is recommended as the first-line antiviral therapy due to lower resistance and safety concerns.

Importance of Neonatal Prophylaxis: Newborns of HBsAg-positive mothers must receive hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth to prevent transmission, irrespective of maternal antiviral therapy.

Breastfeeding Safety: Breastfeeding is considered safe for individuals with chronic hepatitis B if the infant has received immunoprophylaxis at birth.

No Hepatitis C Treatment in Pregnancy: There are currently no treatments approved for hepatitis C during pregnancy, and women should be referred to a specialist for care after delivery.

Vaccination During Pregnancy: Vaccinations for hepatitis A and B are recommended during pregnancy for susceptible individuals to prevent these infections.

Management of Acute Hepatitis: Severe acute hepatitis in pregnancy requires hospitalization and supportive care, while less severe cases may be managed as outpatients with precautions to prevent transmission.

Viral Hepatitis in Pregnancy _ ACOG.pdf

Hepatitis B.pdf

Hirsutism/Congenital adrenal hyperplasia

Open

Clinical Evaluation for Diagnosis: Initial assessment should involve a detailed medical history and physical examination to identify symptoms of androgen excess, such as acne and hirsutism.

Longitudinal Monitoring for PCOS: Adolescents suspected of having PCOS should undergo a longitudinal evaluation over 1-2 years post-menarche before confirming the diagnosis to differentiate from normal pubertal changes.

Early Symptom Management: Treatment for symptoms like acne and hirsutism should begin promptly, regardless of the ongoing evaluation for underlying conditions such as PCOS.

Laboratory Testing: Recommended tests include total and free testosterone levels and a 17-hydroxyprogesterone test, with additional tests for rapid virilization cases.

Hirsutism Treatment Approaches: Combining lifestyle changes, hair removal methods, and medications that suppress or block androgen action is advocated for managing hirsutism.

Acne Management Strategies: A multimodal approach using topical therapies, hormonal therapy such as CHCs, and oral antibiotics or isotretinoin for more severe cases.

Follow-Up and Counseling: Emphasize the importance of regular follow-up to monitor treatment effectiveness and side effects, and provide counseling about long-term management and realistic expectations.

Screening and Management of the Hyperandrogenic Adolescent.pdf

HIV in Pregnancy

Obstetrics

Open

Early HIV Identification: Initiating cART to HIV-infected pregnant women is crucial as it can drop the risk of mother-to-child transmission to below 1–2% if viral load is managed properly.

Regular Viral Load Monitoring: Initial testing at the first prenatal visit, then after starting or changing cART, followed by monthly tests until undetectable, and quarterly thereafter ensures proper management and reduces transmission risks.

Labor and Delivery Screening: Rapid HIV screening during labor or postpartum for untested/unknown-status women ensures timely initiation of prophylactic measures to prevent transmission.

Viral Load Determines Delivery Method: For low viral load (≤1,000 copies/mL), vaginal delivery is suitable, while high viral load (>1,000 copies/mL) warrants a pre-labor cesarean at 38 weeks and IV zidovudine prophylaxis.

Informed Patient Autonomy: Regardless of viral load, respecting the mother’s informed decision about the delivery method is vital.

Pre-labor Rupture of Membranes (PROM) Management: For low viral load, PROM duration doesn't increase transmission risk, while high viral load cases require individualized care to decide on the urgency of cesarean delivery.

Special Considerations: Avoid invasive procedures even with undetectable viral load, and prefer certain medications over others for postpartum hemorrhage in HIV-infected women due to drug interactions.

pdf.pdf

Hypercholesterolemia and dyslipidemias

General

Open

Heart-Healthy Lifestyle Emphasis: Across all ages, prioritizing a heart-healthy lifestyle can mitigate the risk of ASCVD, with young adults benefiting from lifestyle changes to prevent the development of risk factors.

High-Intensity Statins for Clinical ASCVD: For patients with clinical ASCVD, high-intensity statin therapy is recommended to achieve a greater reduction in LDL-C and subsequent risk reduction.

Combination Therapy for Very High-Risk ASCVD: In very high-risk patients, considering non-statin medications in addition to statins is reasonable when LDL-C levels remain above 70 mg/dL despite therapy.

Severe Primary Hypercholesterolemia Management: For patients with LDL-C levels ≥190 mg/dL, initiate high-intensity statin therapy without the need for 10-year ASCVD risk calculation, and consider adding other lipid-lowering agents if LDL-C remains high.

Diabetes Mellitus and Statin Therapy: In diabetic patients aged 40 to 75 with LDL-C ≥70 mg/dL, start moderate-intensity statin therapy. For those at higher risk, high-intensity statins may be considered.

Clinician-Patient Risk Discussion Prior to Statin Therapy: Before starting statin therapy for primary ASCVD prevention in adults aged 40 to 75, a thorough risk discussion should take place to review risk factors and treatment options.

Moderate-Intensity Statin for Certain Adults: In adults without diabetes and with LDL-C ≥70 mg/dL and ASCVD risk ≥7.5%, initiate moderate-intensity statin therapy after weighing treatment options.

Risk-Enhancing Factors for Statin Initiation: In adults with intermediate ASCVD risk and certain risk-enhancing factors, the initiation of statin therapy may be favored.

Coronary Artery Calcium (CAC) Score to Guide Therapy: For adults with uncertain statin therapy decisions and intermediate ASCVD risk, a CAC score can inform treatment, with a score ≥100 Agatston units strongly indicating statin therapy.

Monitoring Treatment Response: After initiating or adjusting statin therapy, lipid levels should be reevaluated within 4 to 12 weeks, and then every 3 to 12 months, to assess the efficacy and adherence to treatment.

1. What are the normal values for a lipid profile?

Total Cholesterol: Desirable is less than 200 mg/dL; 200-240 mg/dL is borderline, and above 240 mg/dL is high risk.

LDL (Low-Density Lipoprotein): Desirable is less than 100 mg/dL; 100-160 mg/dL is moderate risk, and greater than 160 mg/dL is high risk.

HDL (High-Density Lipoprotein): Desirable is greater than 60 mg/dL; 40-60 mg/dL is moderate risk, and less than 40 mg/dL is high risk.

Triglycerides: Desirable is less than 150 mg/dL; 150-885 mg/dL is moderate risk, and above 885 mg/dL is high risk.

2. When would you treat with diet alone, and when would you add pharmacological treatment?

Diet Alone: Recommended as an initial approach for individuals with slightly elevated lipid levels who are at low to moderate cardiovascular risk and do not have additional high-risk factors (such as diabetes, significantly high LDL, or existing cardiovascular disease).

Diet Plus Pharmacological Treatment: Indicated for:

Patients with LDL > 190 mg/dL.

Individuals with clinical cardiovascular disease.

Adults aged 40-75 with diabetes and LDL levels between 70-189 mg/dL, even without clinical cardiovascular disease.

Individuals with an LDL level of 70-189 mg/dL and a calculated 10-year cardiovascular risk greater than 7.5%.

3. List the risk factors for cardiovascular disease.

General Risk Factors:

Age

Family history of premature cardiac disease

Hypertension

Diabetes

Current smoking

Alcohol consumption

Obesity

Sedentary lifestyle

Low HDL levels

Female-Specific Risk Factors:

Premature menopause

Primary ovarian insufficiency

Adverse pregnancy outcomes (e.g., preterm delivery, preeclampsia, abruption)

History of metabolic syndrome

Polycystic Ovary Syndrome (PCOS)

Cholesterol Screening - StatPearls - NCBI Bookshelf.pdf

Hysterectomy

Open

Vaginal Hysterectomy as First Option: Vaginal hysterectomy should be the first choice when suitable, due to better outcomes such as shorter hospital stays and fewer complications.

Laparoscopic over Open Abdominal: If vaginal hysterectomy isn't possible, laparoscopic hysterectomy is preferred over open abdominal due to it being less invasive.

Consideration of Individual Factors: The selection of hysterectomy method should take into account personal patient factors, the specifics of the disease, and surgical considerations including surgeon expertise and resources.

Opportunistic Salpingectomy: This procedure can be done during a vaginal hysterectomy without altering the surgical approach, unless prophylactic measures for genetic risk are necessary, which may require laparoscopic or abdominal routes.

Risk Assessment with Morcellation: The benefits of minimally invasive morcellation must be weighed against the potential risk of spreading malignant tissue, and patients must be thoroughly informed.

Evaluating Robot-Assisted Surgery: Robot-assisted laparoscopic hysterectomy is an option that requires surgeon proficiency in other hysterectomy techniques, with ongoing research into its specific benefits.

Shared Decision-Making Imperative: The route of hysterectomy should be decided jointly by the patient and the physician, considering all risks and benefits and the patient's personal situation, with referrals as needed to accommodate patient choice.

Choosing the Route of Hysterectomy for Benign Disease.pdf

Immunizations

Obstetrics

Open

Immunization Prioritization: Emphasize the significance of vaccinations for pregnant women, ensuring they receive recommended vaccines like influenza and Tdap for the health of both the mother and fetus.

Vaccine Safety Assurance: Reassure pregnant women of the safety of inactivated virus, bacterial, or toxoid vaccines and recommend only approved vaccines, such as Pfizer's Abrysvo for RSV.

Vaccination Schedule Compliance: Adhere to the recommended timelines for administering vaccines, like the Tdap vaccine between 27 and 36 weeks, to maximize the health benefits for the newborn.

Healthcare Provider Influence: Utilize the influence of obstetricians in promoting vaccine uptake through direct recommendations and patient counseling, considering patient preferences in vaccination decisions.

Concurrent Vaccine Administration: Encourage the coadministration of all recommended vaccines to simplify the vaccination process and reduce the number of healthcare visits for pregnant women.

Meticulous Record-Keeping: Maintain meticulous documentation of vaccine administration or refusal in patient medical records and state immunization systems, with particular attention to RSV vaccination due to its implications for infant monoclonal antibody administration.

Educational Resource Utilization: Direct patients and healthcare providers to authoritative resources like the ACOG website for comprehensive information on maternal immunization.

Maternal Immunization.pdf

Maternal Respiratory Syncytial Virus Vaccination _ ACOG.pdf

Induction of labor

Open

Indications for Induction: Ensure induction is done for valid maternal or fetal reasons or logistical concerns, and take into account the gestational age and cervical readiness.

Cervical Ripening Methods: Use prostaglandins or mechanical devices to prepare the cervix if it's not favorable for induction.

Management of Tachysystole: Monitor and manage tachysystole by adjusting oxytocin dosage, repositioning the mother, hydrating intravenously, or using tocolytics if necessary.

Cautious Misoprostol Use: Administer misoprostol carefully, starting with a low dose of 25 mcg, avoiding frequent dosing, and never use in women with prior cesarean section or uterine surgery.

Induction of Labor.pdf

Infertility

Open

Hormonal Therapy Initiation: Hormonal therapy for adolescents with POI should mimic natural ovarian hormone production, beginning gradually and increasing to higher doses than used for menopausal women.

Long-term Hormonal Management: Continual hormonal therapy is required for overall health, including bone and cardiovascular health, using transdermal, oral, or transvaginal estradiol, with cyclic progesterone to protect the endometrium.

Fertility and Contraception: Spontaneous pregnancy is possible in 5-10% of cases, so contraceptive counseling is essential. Barrier methods or IUDs are preferred over oral contraceptives, which may interfere with the hormonal therapy needed to maintain bone density.

Bone Health Monitoring: There are no specific guidelines for DEXA scanning in adolescents with POI, but regular monitoring for bone density is important due to the risk of early bone loss.

Cardiovascular Health: Annual blood pressure checks and lifestyle counseling for cardiovascular health are recommended, with lipid level assessments every 5 years.

Thyroid and Autoimmune Screening: Thyroid function and adrenal autoimmunity should be assessed after POI diagnosis, with regular monitoring due to the increased risk of related endocrine disorders.

Psychological Support: Psychological counseling for the patient and education for the family are important to manage the emotional impact of the condition and support the patient's well-being.

Specialist Referrals: Referral to a reproductive endocrinologist and infertility specialist may be necessary for fertility concerns, and to explore options such as in vitro fertilization with donor oocytes, except in high-risk cases such as Turner syndrome.

Primary Ovarian Insufficiency in Adolescents and Young Women.pdf

Influenza and pregnancy

Obstetrics

Open

Annual Influenza Vaccination: Pregnant individuals are advised to get an annual inactivated or recombinant influenza vaccine, which can be administered during any trimester and in conjunction with other vaccines like Tdap, RSV, or COVID-19.

Vaccine Timing: Vaccination should optimally occur by the end of October, but anytime during the flu season is beneficial. The vaccine's protective effect extends to both the pregnant individual and their newborn.

Safety of Influenza Vaccine: Extensive research, including clinical trials and safety-reporting systems, has established the safety and efficacy of the influenza vaccine during pregnancy.

Clinician's Role in Vaccination: Health care professionals, especially obstetrician–gynecologists, are instrumental in increasing vaccine acceptance through strong recommendations and offering the vaccine during office visits.

Mask Use: Wearing a well-fitting mask is safe during pregnancy and is recommended to prevent respiratory infection transmission, especially when community virus levels are high.

Assessment and Treatment of Respiratory Illness: Pregnant individuals with respiratory symptoms should be assessed for both influenza and SARS-CoV-2, and treatment should be initiated promptly with oseltamivir for suspected influenza and Paxlovid for confirmed SARS-CoV-2 infection, without awaiting test results.

Postexposure Chemoprophylaxis: For pregnant individuals exposed to influenza, oseltamivir is recommended as chemoprophylaxis to prevent infection.

Addressing Vaccination Disparities: To combat racial and ethnic disparities in influenza-related outcomes and vaccination rates, health care professionals should employ culturally sensitive communication, address vaccine misconceptions, and partner with community organizations.

Importance of Health Care Professional Counseling: Trust-based counseling by obstetrician–gynecologists on the benefits and safety of influenza vaccination is crucial for patient compliance and can significantly impact maternal and neonatal health outcomes.

Influenza in Pregnancy Prevention and Treatment.pdf

Inherited Thrombophilias in Pregnancy

Obstetrics

Open

Thrombophilia Types and Diagnosis: Management should include knowledge of common thrombophilias such as Antithrombin deficiency, Factor V Leiden mutation, prothrombin 20210A, and Protein C and S deficiencies. It's crucial to understand the mutations, their prevalence, and the appropriate tests required for diagnosing each type of thrombophilia.

Risk Assessment for Thrombophilia: When managing patients with thrombophilia, it's important to consider risk multipliers associated with heterozygous and homozygous states, especially for conditions like Protein C, Protein S, and antithrombin deficiencies. This information is vital for risk stratification and treatment planning.

Antiphospholipid Antibody Syndrome Management: Clinicians should be aware of the prevalence of antiphospholipid antibody syndrome, especially its association with lupus, and ensure the use of proper diagnostic criteria including tests for lupus anticoagulant, beta-2 glycoprotein, and anticardiolipin antibodies.

Indications for Thrombophilia Evaluation: Management recommendations include performing a thrombophilia workup in patients with a family history of thrombophilia, recurrent thrombosis, or arterial thrombosis. However, evaluation is not typically indicated in thrombosis due to malignancy, Heparin-Induced Thrombocytopenia (HIT), and other specific conditions.

Inherited Thrombophilias in Pregnancy.pdf

Intraoperative complications

Gynecology

Open

None

IUFD (intrauterine fetal demise)

Open

None

IUGR

Open

None

Labor management

Obstetrics

Open

Introduction to Labor Management

The presentation aims to optimize labor management, reduce risks, and guide cesarean delivery decisions, focusing on managing dystocia.

Active Labor Threshold

Recommends recognizing active labor commencement at 6 cm dilation, with variable transitions between 4 cm and 6 cm.

Active Phase Arrest

Defines active phase arrest as no dilation for 4 hours with adequate contractions or 6 hours with oxytocin, suggesting cesarean delivery may be necessary.

Management of Latent Labor

Advises against cesarean for prolonged latent phase if maternal and fetal conditions are stable, promoting patience and continued observation.

Oxytocin Augmentation Extension

Supports extending oxytocin augmentation to at least 4 hours before considering cesarean delivery in cases of slow but progressive labor.

Second-Stage Labor Extension

The 2014 guidelines recommend extending the second stage by 1 hour, provided there's fetal descent, and encourage individualized decision-making.

Epidural Analgesia

Suggests offering neuraxial anesthesia at any labor stage without increasing cesarean risk, as per ACOG.

Active Management of Labor

Advocates for active management, including standardized diagnosis, early amniotomy, and oxytocin for protracted labor, along with personalized care.

Amniotomy and Labor Induction

Recommends early amniotomy to reduce induction-to-delivery interval, with no significant increase in complications.

Low- vs. High-Dose Oxytocin

Both dosing strategies are acceptable, with high-dose potentially reducing cesarean rates in nulliparous women.

Continuous Support

Encourages continuous support during labor to improve outcomes, including increased vaginal birth and reduced cesarean rates.

Position Changes and Ambulation

Promotes upright positions and movement to potentially shorten the first stage of labor and decrease cesarean likelihood.

Manual Rotation

Manual rotation of fetal head might reduce cesarean and operative vaginal delivery rates and is advised when appropriate.

Operative Vaginal Delivery

Recommends considering operative vaginal delivery before cesarean for second-stage arrest, based on clinician expertise and patient factors.

Decision-Making in Arrest Scenarios

Emphasizes shared decision-making and patient preference when considering interventions for labor arrest.

Conclusion

Stresses the importance of evidence-based recommendations tailored to individual needs for effective labor dystocia management.

First and Second Stage Labor Management.pdf

Laparoscopy

Open

None

Lichen Sclerosis

Open

None

Liver diseases

Open

None

Long-Acting Reversible Contraception Implants and Intrauterine Devices

Open

Management of LARC in Various Medical Conditions: Utilize the US MEC to guide safe and effective LARC use even in patients with complex medical conditions, as most women have few contraindications to LARC methods.

Timing for LARC Insertion: Follow US SPR recommendations for optimal timing of LARC insertion, including immediate postabortion and postpartum scenarios, to enhance contraceptive efficacy and continuation rates.

Emergency Contraception with Copper IUD: Consider copper IUDs for emergency contraception due to their high effectiveness, offering a dual benefit of immediate contraception and long-term LARC protection.

Counseling on Menstrual Changes: Inform and reassure patients about potential menstrual changes due to LARC use, and ensure they understand that these changes are generally not harmful.

Expulsion Risks and Follow-Up: Educate patients about the possibility of IUD expulsion, especially in higher-risk groups such as adolescents and nulliparous women, and stress the importance of follow-up checks.

Ectopic Pregnancy Awareness: Despite low pregnancy rates with LARC, inform patients about the possibility of ectopic pregnancy and the need for prompt medical attention if they suspect pregnancy.

Pre-Procedure Regret Prevention: Conduct thorough counseling before LARC procedures, particularly sterilization, to reduce the likelihood of regret, emphasizing the permanence and full range of contraceptive options.

Patient-Centered Decision-Making: Engage in shared decision-making by respecting patient preferences and providing comprehensive information on all contraceptive options, especially highlighting the long-term and reversible nature of LARC.

Adolescent-Specific Considerations: Create a supportive environment for adolescent patients, addressing misconceptions and providing tailored counseling that considers their unique needs and barriers.

Long-Acting Reversible Contraception Implants and Intrauterine Devices.pdf

Lupus

Obstetrics

Open

Pre-Pregnancy Risk Stratification: Women with stable or low SLE activity may consider pregnancy, whereas those with severe organ damage should explore alternatives. Monitoring and adjusting medications before conception is critical for safety.

Medication Management: Essential medications should be reviewed for compatibility with pregnancy, particularly avoiding teratogenic drugs like MMF and ensuring continued use of safe options like hydroxychloroquine.

Multidisciplinary Antenatal Care: Coordination between obstetricians, rheumatologists, and other specialists is key, alongside regular monitoring for disease activity and complications such as preeclampsia.

Monitoring Disease Activity: Use validated tools and laboratory tests for SLE activity throughout pregnancy and adjust treatment accordingly to manage flares.

Management of Flares: Mild flares may be treated with safe pain relief options, while more severe ones require compatible DMARDs and careful use of glucocorticoids.

Distinguishing Preeclampsia: Differentiate between lupus flares and preeclampsia with the help of laboratory tests, as misdiagnosis can have critical implications for management.

Postpartum Care: Increased vigilance for SLE flares and thrombosis is necessary after childbirth, with continued use of most pregnancy-compatible medications during lactation.

Laboratory Testing: Regular tests including FBC, U&E, creatinine, LFTs, serological profile, and urinalysis are recommended to monitor health and disease activity, with interpretation mindful of pregnancy-related changes.

Tailored Testing Based on Symptoms: Additional tests may be warranted for those with specific symptoms or complications, with frequent monitoring for those with active or severe SLE.

Lynch Syndrome

Open

Colonoscopy Schedule: Individuals with Lynch syndrome should undergo colonoscopy every 1-2 years starting at the age of 20-25, or 2-5 years earlier than the youngest cancer diagnosis in their family.

Endometrial Cancer Monitoring: Recommended to have an endometrial biopsy every 1-2 years beginning at age 30-35, along with vigilant menstrual tracking to detect any abnormal bleeding patterns.

Ovarian Cancer Surveillance: No agreed-upon surveillance method; however, ovarian cancer screening has been found ineffective for early detection in Lynch syndrome.

Prophylactic Surgery: Women may consider a hysterectomy and bilateral salpingo-oophorectomy after childbearing to significantly lower the risk of endometrial and ovarian cancers.

Chemoprevention Options: Usage of oral contraceptives may cut the risk of endometrial cancer by up to 50%, while high-dose aspirin taken for a minimum of two years may reduce the risk of colorectal cancer.

Importance of Genetic Counseling: At-risk individuals should undergo genetic counseling to understand their genetic risks, testing outcomes, surveillance options, and implications for relatives.

Lynch Syndrome.pdf

Macrosomia

Obstetrics

Open

Exercise During Pregnancy: Encouraging exercise can be beneficial in managing the risk of macrosomia by potentially reducing maternal weight gain and improving glucose metabolism.

Low Glycemic Diet for GDM: Implementing a low glycemic diet in women diagnosed with gestational diabetes mellitus may help control blood sugar levels and reduce the risk of fetal overgrowth.

Prepregnancy Bariatric Surgery: For women with class 2 or class 3 obesity, considering bariatric surgery before pregnancy can be a significant intervention to decrease the likelihood of macrosomia.

Macrosomia.pdf

Magnesium sulfate for fetal neuroprotection

Open

Administration Timing: Magnesium sulfate should be given to women at risk of preterm delivery before 32 weeks for fetal brain protection.

Meta-Analysis Conclusion: Although individual studies were inconclusive, a meta-analysis suggests magnesium sulfate reduces cerebral palsy risk.

Pregnancy Duration: Treatment with magnesium sulfate for neuroprotection does not extend pregnancy duration.

Maternal Safety: Minor complications increase with magnesium sulfate use, but serious maternal complications do not.

Treatment Guidelines: Development of specific guidelines is recommended for magnesium sulfate administration, drawing on data from large trials.

Dosage Regimens: Dosage regimens must be consistent with those from larger trials, such as a 6g load followed by 2g/hour.

Secondary Treatment: Magnesium sulfate can be used for persistent pregnancy headaches, with careful monitoring due to potential side effects.

Contraindications: Intravenous magnesium sulfate is contraindicated in conditions like myasthenia gravis and moderate to severe renal failure.

Oral Magnesium Caution: Oral magnesium may prevent headaches but is associated with an increased risk of neonatal death based on a Cochrane Review.

Neuroprotective Effects: No evidence suggests magnesium sulfate's neuroprotective benefits for newborns with meconium-stained amniotic fluid.

Magnesium Sulfate Before Anticipated Preterm Birth for Neuroprotection.pdf

Management of Alloimmunization During Pregnancy

Obstetrics

Open

Paternal and Fetal Antigen Testing: Determining the father's and fetus's erythrocyte antigen status is crucial. If the father is antigen negative and is the biological father, no further action is needed. If he is positive, the fetal antigen type should be assessed via PCR on amniocytes or maternal plasma.

Non-Invasive Fetal Anemia Assessment: Middle cerebral artery (MCA) Doppler testing is recommended to noninvasively monitor the fetus for anemia, with a sensitivity of 100% for predicting moderate or severe anemia when peak systolic velocity values exceed 1.5 times the median for gestational age.

Management of Non-D Antigen Alloimmunization: Care for pregnancies affected by antibodies to minor antigens generally parallels Rh D alloimmunization management, with specific attention to Kell alloimmunization due to its unpredictability and potential severity.

Timing of Delivery: The timing should balance prolonging pregnancy for fetal maturity and the risks of invasive procedures. Mild cases may warrant delivery at 37-38 weeks, while severe cases may require earlier interventions with considerations for fetal lung maturity and neonatal intensive care.

Training for MCA Doppler Testing: Correct technique and proper training are essential for accurate MCA Doppler testing, especially as the false-positive rate increases after 34-35 weeks of gestation. This tool is particularly useful in Kell alloimmunization cases.

Prevention of Rh D Alloimmunization.pdf

Management of Alloimmunization During Pregnancy.pdf

Management of Genital Herpes in Pregnancy

Obstetrics

Open

Diagnosis and Confirmation: Pregnant individuals with suspected genital herpes should have the diagnosis confirmed using type-specific laboratory tests, with no need for repeat testing in those with a known history of HSV.

Antiviral Medication: Oral antiviral medications, specifically acyclovir or valacyclovir, are recommended for treatment, with dosages adjusted due to enhanced renal clearance in pregnancy.

Suppressive Therapy: Starting suppressive therapy at 36 weeks of gestation is advised to reduce the risk of an outbreak during delivery.

Delivery Management: Cesarean delivery is recommended for active genital lesions or prodromal symptoms at labor; however, it's not indicated for women with a history of HSV but no active symptoms.

PPROM and HSV: In cases of PPROM with active genital HSV lesions, a careful balance between the risks of prematurity and neonatal HSV is necessary, with antiviral treatment recommended if expectant management is chosen.

Breastfeeding and HSV: Breastfeeding is safe unless there is an active lesion on the breast. Valacyclovir and acyclovir are considered safe for nursing mothers.

Patient Education: It's crucial to maintain open communication for informed decision-making, patient education, and optimal management of genital herpes in pregnancy.

Management of Genital Herpes in Pregnancy (1).pdf

Meconium Stained Fluids

Obstetrics

Open

Shift in Management Practice: The practice of managing newborns with meconium-stained amniotic fluid has shifted away from routine intrapartum suctioning to a more individualized approach based on the vigor of the newborn.

Current Guidelines for Vigorous Newborns: Vigorous newborns with meconium-stained amniotic fluid should receive initial care with the mother and may have their mouth and nose cleared with a bulb syringe if necessary.

Updated Approach for Nonvigorous Newborns: Nonvigorous newborns should be taken to a radiant warmer for tailored resuscitation steps, with intubation and suctioning performed only if there is airway obstruction.

Readiness for Neonatal Resuscitation: A skilled neonatal resuscitation team, including personnel skilled in endotracheal intubation, should be notified and available when meconium-stained amniotic fluid is present.

Protocols for Resuscitation: The resuscitation protocols for infants with meconium-stained amniotic fluid should be the same as those for infants with clear amniotic fluid.

Delivery of a Newborn With Meconium Stained Amniotic Fluid.pdf

Multiple gestations

Obstetrics

Open

Early Determination of Chorionicity: Vital for pregnancy management, with first-trimester ultrasonography being most accurate for assessing chorionicity.

Avoidance of Routine Prophylactic Interventions: Cerclage, bed rest, and similar interventions are not recommended without specific indications, as they do not decrease neonatal morbidity or mortality in twins.

Use of Tocolytic Therapy: Considered for short-term delay of preterm labor to administer antenatal corticosteroids or transfer to a tertiary care center.

Administration of Antenatal Corticosteroids: Recommended between 24 and 34 weeks gestation to reduce the risk of neonatal death and prematurity complications.

Magnesium Sulfate for Fetal Neuroprotection: Advised for expected preterm delivery before 32 weeks to lower the risk of cerebral palsy.

Screening for Fetal Chromosomal Abnormalities: Offered to all twin pregnancies, with various screening methods available despite reduced accuracy compared to singletons.

Management of Discordant Fetal Growth: Regular monitoring is important, with special attention to growth-restricted fetuses, which increase neonatal morbidity risks.

Handling of Single Fetal Death: Requires individualized care, particularly in monochorionic pregnancies due to the increased risk to the surviving twin.

Antenatal Fetal Surveillance Strategy: Tailored according to the type of twin pregnancy, with more frequent monitoring in monochorionic pregnancies for complications like TTTS.

Intervention for TTTS: Includes laser coagulation, amnioreduction, or selective reduction, depending on the severity and gestational age.

Delivery Planning: Uncomplicated twin pregnancies have recommended delivery times based on chorionicity and amnionicity, with cesarean birth suggested for monoamniotic twins.

Postpartum Care: Acknowledges the elevated risk of uterine atony, hemorrhage, and emergency hysterectomy, suggesting preparedness for potential complications.

Multifetal Gestations Twin Triplet and Higher-Order Multifetal Pregnancies.pdf

Nausea and Vomiting of Pregnancy

Open

Early Intervention: Early treatment of NVP is crucial to prevent its progression to HG, with the aim to manage symptoms before they become severe.

Nonpharmacologic Therapies: Implementing lifestyle changes such as taking prenatal vitamins before conception, eating frequent small meals, and considering the use of ginger and acupressure as beneficial practices to reduce the incidence and severity of NVP.

First-Line Pharmacotherapy: Vitamin B6 (pyridoxine), alone or in combination with doxylamine, is recommended as the initial pharmacological treatment for NVP.

Additional Pharmacologic Options: When first-line treatments are not effective, other pharmacologic agents like dopamine antagonists, antihistamines, and serotonin 5-HT3 receptor antagonists can be considered, although the safety of some, such as high-dose ondansetron, is still under scrutiny.

Advanced Treatment for Refractory Cases: Corticosteroids are suggested as a last resort for refractory NVP due to their risk profile, and should only be used when other therapies have failed.

Intravenous Hydration and Nutritional Support: For individuals with severe NVP or HG, intravenous hydration is recommended, while enteral tube feeding is the preferred method of nutritional support. Total parenteral nutrition and PICCs are considered last-resort options.

Hospitalization: Hospitalization should be reserved for patients with severe symptoms who have not improved with outpatient care, especially if there are changes in vital signs or mental status, continued weight loss, or if they are refractory to outpatient treatment.

Behavioral Interventions: Mindfulness-based cognitive therapy may offer a new avenue for symptom improvement, despite limited evidence for traditional behavioral interventions.

Nausea and Vomiting of Pregnancy.pdf

Neural Tube Defects

Obstetrics

Open

Folic Acid Supplementation: All women capable of becoming pregnant should take 400 micrograms of folic acid daily before conception and during the first trimester to prevent NTDs.

Prenatal Screening: Utilize maternal serum alpha-fetoprotein (MSAFP) screening and second-trimester ultrasonography to detect NTDs. First-trimester ultrasound and fetal MRI may assist in unclear cases.

Referral to Specialists: Refer suspected or confirmed cases of NTDs to a maternal-fetal medicine unit for comprehensive evaluation and management planning.

Counseling on Management Options: Provide thorough counseling regarding the nature of the NTD, anticipated outcomes, and management options, including pregnancy termination, expectant management with neonatal repair, and in utero fetal repair for eligible candidates.

Antenatal Fetal Surveillance: Consider serial ultrasound examinations to monitor fetal growth, head size, and hydrocephalus progression, although routine surveillance's role is unclear.

Delivery Planning: Plan delivery at a tertiary care center, with timing and mode of delivery individualized based on fetal condition and maternal factors. Latex precautions during delivery are imperative due to the risk of latex allergy.

Fetal Surgery: Offer fetal surgery to suitable candidates based on the “two-hit hypothesis" to repair myelomeningocele in utero and potentially minimize further neurologic damage.

Neural Tube Defects.pdf

No/Late prenatal care

Open

Gestational Age Estimation: ACOG redefines a suboptimally dated pregnancy as one without an ultrasound before 22 0/7 weeks of gestation. Accurate dating is crucial for management decisions, with the first trimester ultrasound being the most reliable for establishing gestational age.

Indicated Delivery Timing: For medically necessary deliveries, use the best clinical estimate of gestational age. Elective deliveries are not recommended due to potential risks of neonatal morbidity from misdated gestational age.

Antenatal Corticosteroids: Administer based on the best clinical estimate of gestational age, especially for women at risk of preterm delivery between 24 and 34 weeks, and potentially up to 36 6/7 weeks.

Amniocentesis for Lung Maturity: Routine amniocentesis to assess fetal lung maturity is not advised due to its unreliability in predicting newborn outcomes and the increased risk of morbidities even with mature lung profiles.

Delivery at 41 Weeks: Initiate delivery at 41 weeks using the best clinical estimate due to increased risks of unrecognized postmaturity. Antepartum fetal surveillance may be considered starting at 39-40 weeks.

Trial of Labor After Cesarean (TOLAC): Base delivery decisions on the best clinical estimate for women with previous cesarean deliveries. For repeat cesareans, delivery is recommended at 39 weeks using the best clinical estimate.

Follow-up Ultrasonography: An interval ultrasound 3-4 weeks after the initial one can support gestational age estimates and might identify fetal growth restriction, prompting reconsideration of delivery timing.

Counseling on Risks: Patients should be informed about the increased risk of neonatal morbidity associated with the limitations of accurately determining gestational age and the rationale behind delivery timing decisions.

Management of Suboptimally Dated Pregnancies.pdf

OB Emergency

Obstetrical Emergencies

Open

Emergency Preparedness Imperative: Obstetrician-gynecologists must prioritize emergency preparedness to handle severe maternal morbidity effectively.

Risk Identification and Assessment: Regular risk assessment and proactive planning are critical to identifying potential emergencies in obstetrics and gynecology.

Resource Availability: Centralizing emergency supplies and maintaining specialized kits for specific emergencies can significantly reduce response times.

Empowered Response Activation: Staff at all levels should be empowered to activate emergency protocols when early warning signs are detected.

Effective Rapid Response Teams: The composition and training of rapid response teams are key to their effectiveness in improving patient outcomes during emergencies.

Drills and Simulation Training: Conducting emergency drills and simulations enhances teamwork, communication, and the standardization of care during obstetric emergencies.

Continuous Training and Feedback Loop: Ongoing training, coupled with a process for debriefing and feedback, is essential for improving emergency response systems.

Preparing for Clinical Emergencies in Obstetrics and Gynecology.pdf

Obesity - non-pregnant

Open

Lifestyle Interventions: Emphasizes a four-stage approach including healthy eating, physical activity, and minimized screen time, with progression to more intensive support and behavioral strategies.

Medical Therapies: Mentions the FDA-approved drug Tetrahydrolipstatin for adolescents with obesity and Metformin for cases involving PCOS and insulin resistance, while advising against unproven weight loss supplements.

Surgical Interventions: Describes bariatric surgery as an option for those with severe obesity and related comorbidities, highlighting the need for a multidisciplinary team for pre- and postoperative care.

Prevention Strategies: Focuses on education by healthcare providers, advocating for physical activity and nutrition programs, and employing behavioral modification techniques.

Parental Involvement: Stresses the importance of parents as role models and the creation of a supportive environment for healthy behaviors.

Psychosocial Support: Recommends that healthcare providers screen for and address the psychosocial effects of obesity, including depression and bullying, and provide appropriate referrals.

Obesity in Adolescents.pdf

Obesity - non-pregnant

Obstetrics

Open

Individualized Patient Counseling: Tailor counseling to each patient's specific risks, the indication for surgery, and the surgeon's experience; discuss potential need to convert to open surgery.

Less Invasive Approach: Consider less invasive options due to higher complication risks associated with obesity; alternatives to surgery or minimally invasive procedures are preferred.

Comprehensive Preoperative Assessment: Evaluate comorbid conditions such as coronary artery disease, hypertension, diabetes, obstructive sleep apnea, and venous thromboembolism; consult with an anesthesiologist; consider preoperative imaging like MRI.

Venous Thromboembolism Prophylaxis: Provide prophylaxis for patients undergoing surgery exceeding 45 minutes using low molecular weight heparin or intermittent pneumatic compression if not at high risk for bleeding.

Antibiotic Prophylaxis: Consider increased dose of antibiotics in obese patients to ensure adequate tissue concentration; ongoing research is refining specific dosage recommendations.

Surgical Positioning and Equipment: Ensure proper positioning to maximize exposure and minimize injury; select suitable operating table and stirrups for patient weight and comfort.

Postoperative Care: Individualize care focusing on comorbidities; consider extended venous thromboembolism prophylaxis, manage respiratory morbidity, utilize multimodal pain management, and employ strategies to reduce wound complications.

Minimally Invasive Surgery Preference: Favor vaginal hysterectomy for its better outcomes; if not suitable, laparoscopic hysterectomy is less invasive than open abdominal surgery, though more challenging and with a higher conversion rate in obese patients.

Gynecologic Surgery in the Obese Woman.pdf

Obesity - pregnant

Obstetrics

Open

Preconception Weight Management: Encourage weight loss before pregnancy through surgical or nonsurgical means to improve outcomes, but avoid weight loss medications due to safety concerns.

IOM Weight Gain Guidelines: Adhere to the Institute of Medicine's recommendations for gestational weight gain: 15-25 lb for overweight and 11-20 lb for obese women.

Dietary and Lifestyle Interventions: Provide nutrition counseling focusing on healthy eating and portion control, and recommend regular moderate-intensity exercise with behavioral counseling.

Early and Regular Screening: Conduct early screening for gestational diabetes and OSA; offer detailed fetal anomaly ultrasound, understanding obesity may limit visibility.

Antenatal Fetal Surveillance: Consider starting weekly fetal surveillance at 37 weeks for BMI 35-39.9, and at 34 weeks for BMI ≥ 40, to monitor for stillbirth risks.

Intrapartum Care Considerations: Arrange for early anesthesiology consultation, apply mechanical prophylaxis for venous thromboembolism, and allow a longer first stage of labor before cesarean for labor arrest.

Postpartum Support and Counseling: Support postpartum weight management through diet and exercise interventions and provide contraceptive counseling to aid interpregnancy weight management.

Multidisciplinary Approach: Emphasize the need for a comprehensive, individualized care plan involving a team of healthcare providers to address the complexities of obesity in pregnancy.

Obesity in Pregnancy.pdf

Obstetric Analgesia and Anesthesia

Open

Neuraxial Analgesia and Cesarean Rates: Strong evidence supports that neuraxial analgesia does not increase cesarean delivery rates, countering a common misconception.

Opioid Monitoring: Due to the risk of respiratory depression, both the mother and neonate must be carefully monitored when opioids are administered for pain relief.

Emergency Cesarean Delivery: In emergencies where an epidural is not in place, spinal anesthesia, combined spinal-epidural, or general anesthesia are recommended despite limited evidence.

Thrombocytopenia Considerations: There is no established safe lower limit for platelet count in women considering neuraxial blockade; this decision should be individualized.

Maternal Request for Pain Relief: A woman's request for pain relief during labor, in the absence of medical contraindications, is a sufficient reason to provide analgesia.

Platelet Count for Neuraxial Analgesia: Epidural and spinal analgesia are considered safe for patients with platelet counts ≥ 70 x 10^9/L under specific conditions, although this is based primarily on expert opinion.

Obstetric Analgesia and Anesthesia Labor Causes.pdf

Obstetrical vaginal lacerations

Open

Classification and Identification: Lacerations are classified from first to fourth degree, with third- and fourth-degree lacerations being severe and termed OASIS. Proper identification requires adequate lighting, exposure, analgesia, and a digital rectal examination for OASIS.

Prevention of Lacerations: Interventions like antepartum/intrapartum perineal massage, warm compresses, and potentially manual perineal support may reduce the risk of perineal trauma. However, evidence is inconclusive for some methods, such as the effectiveness of birthing position and delayed pushing.

Management of Episiotomy: Routine episiotomy is not supported by current evidence, and its rates have declined. Continuous suturing is preferred for episiotomy and second-degree lacerations for better outcomes.

Repair Techniques: Specific repair techniques are recommended depending on the type and severity of the laceration. For OASIS, detailed repair techniques are provided, including suture types and methods.

Antibiotic Use: A single dose of antibiotics is recommended during the repair of OASIS to prevent infection.

Postpartum Care: Emphasizes pain management, preventing constipation, and monitoring for potential complications like bleeding, infection, wound breakdown, and fistula formation. Long-term care includes pelvic floor exercises and monitoring for complications like anal incontinence.

Counseling for Future Deliveries: Women with a history of OASIS should receive counseling on the risks and benefits of vaginal versus cesarean delivery in future pregnancies. Cesarean delivery can be offered based on patient preferences after thorough discussion of risks.

Prevention and Management of Obstetric Lacerations at Vaginal Delivery.pdf

100

Oligohydramnios

Open

Individualized Delivery Timing: Management should be based on individual patient circumstances, with delivery timing decisions made case-by-case.

Avoiding Non-Medically Indicated Early Delivery: Non-medically indicated deliveries before 39 weeks are discouraged due to neonatal risks.

Accurate Gestational Age Assessment: Precise knowledge of gestational age is critical for informed decision-making regarding the timing of delivery.

Non-reliance on Fetal Lung Maturity Tests: Lung maturity tests via amniocentesis should not dictate the timing of delivery when there are clear medical indications for early delivery.

Use of Antenatal Corticosteroids: A single course of antenatal betamethasone is advised for late-preterm deliveries unless delivery is imminent and medically indicated.

Condition-Specific Delivery Recommendations: Management includes condition-specific recommendations for delivery timing, such as for placenta previa, fetal growth restriction, multiple gestations, hypertensive disorders, and diabetes.

Navigating Competing Indications: ACOG provides resources, such as an applet, to assist clinicians in cases with multiple competing indications for early delivery.

Medically Indicated Late-Preterm and Early-Term Deliveries.pdf

101

Operative vaginal delivery

Obstetrical Emergencies

Open

Counseling and Consent: The patient should be fully informed about the reasons for operative vaginal delivery, the options available (vacuum or forceps), associated risks, and the possibility of requiring a cesarean delivery if these methods fail. Informed consent must be obtained prior to proceeding.

Patient Evaluation: Prior to the delivery, confirm indications such as prolonged labor or fetal distress, ensure the cervix is fully dilated, the fetal head is at an appropriate station and position, and there are no contraindications, such as incomplete cervical dilation or suspected cephalopelvic disproportion.

Conditions for Vacuum-Assisted Success: Choose the correct vacuum device, apply the cup properly to the fetal head, gradually increase suction, and apply traction in coordination with contractions. If no progress is made, or if complications arise, the procedure should be abandoned.

Conditions for Forceps-Assisted Success: Select the correct type of forceps for the fetal head position, insert blades gently and correctly, apply traction in line with the maternal pelvis, and abandon the procedure if there's no descent of the fetal head or if resistance suggests potential trauma.

Post-Delivery Management: Following delivery, both the mother and newborn should be examined for any signs of trauma from the operative delivery. Provide postpartum care, monitor for delayed complications, and offer counseling and reassurance to the patient and family.

Operative Vaginal Birth.pdf

102

Osteoporosis

Gynecology

Open

Diagnosis of Osteoporosis: Utilize Dual-energy X-ray absorptiometry (DXA) to measure BMD, with a T-score ≤ -2.5 indicating osteoporosis and a T-score between -1.0 and -2.5 indicating osteopenia. Fragility fractures also diagnose osteoporosis, even with normal BMD.

Candidates for Pharmacotherapy: Recommend pharmacologic treatment for patients with a T-score ≤ -2.5, those with a history of fragility fractures, or those with a T-score between -1.0 and -2.5 and increased fracture risk based on assessment tools.

Pharmacotherapy Options: First-line therapy includes bisphosphonates (Alendronate, risedronate, zoledronic acid), with drug holidays after 5 years of oral or 3 years of intravenous treatment for certain patients. Denosumab, raloxifene, hormone therapy, calcitonin, and anabolic agents like teriparatide, abaloparatide, and romosozumab are additional options.

Nonpharmacologic Interventions: Ensure adequate daily intake of Calcium and Vitamin D, promote fall prevention strategies, encourage regular aerobic and weight-bearing exercises, and support smoking cessation and alcohol reduction.

Treatment Monitoring: Perform DXA testing every 1-3 years to monitor bone loss, check renal function, serum calcium, and vitamin D levels every 1-2 years, and consider vertebral fracture assessment in certain clinical situations.

Referral: Refer patients to specialists for T-scores < -3.0, new fragility fractures, normal BMD with fragility fractures, recurrent fractures or bone loss despite treatment, unusual or unresponsive osteoporosis, or secondary osteoporosis due to endocrine or metabolic causes.

osteoporosis_prevention,_screening,_and_diagnosis_.30.pdf

management_of_postmenopausal_osteoporosis__acog.36.pdf

103

Ovarian cyst

Open

None

Ovarian Cysts Cover.jpg

104

Pap Smear Guidelines

Gynecology

Open

Age-Specific Screening Protocols: Women under 21 do not require screening; those between 21 and 29 should have a Pap test every 3 years, with HPV testing being an option for those 25 to 29. Women aged 30 to 65 have the choice of co-testing every 5 years, Pap test every 3 years, or HPV test every 5 years. Women over 65 with a history of negative tests may not need further screening.

Screening Post-HPV Vaccination: Women who have received the HPV vaccine should continue to follow the recommended screening schedule.

Screening After Hysterectomy: Women who have had a hysterectomy may still require screening if the cervix was not removed, especially if they have a history of cervical cancer or pre-cancerous changes.

Increased Screening for Certain Populations: More frequent screenings are advised for women with HIV, compromised immune systems, a history of cervical cancer, or prenatal exposure to diethylstilbestrol.

Necessity of Regular OB-GYN Visits: Regular visits to an OB-GYN are vital for comprehensive reproductive health care, even when a woman is not due for a cervical cancer screening.

Cervical Cancer Screening.pdf

105

PCOS

Gynecology

Open

Combination Hormonal Contraceptives: Primary treatment for menstrual irregularities in PCOS, with additional benefits for endometrial protection.

Lifestyle Modifications: Weight loss and exercise are initial recommendations for managing infertility due to PCOS.

Letrozole: Considered the first-line therapy for ovulation induction in PCOS patients, surpassing clomiphene citrate in effectiveness.

Metformin: While not the most effective for inducing live birth, it may improve outcomes when combined with clomiphene citrate, especially in obese women.

Antiandrogens: Effective in treating hirsutism when combined with hormonal contraceptives to minimize side effects and teratogenic risks.

Laser Treatment and Eflornithine HCl Cream: Recommended for hair removal in hirsutism, with combined therapies showing improved outcomes.

Cardiovascular and Diabetes Risk Management: Lifestyle changes are emphasized, with metformin for delaying diabetes onset and consideration of statins for potential cardiovascular benefits. Low-dose hormonal contraceptives are recommended to minimize impact on cardiovascular and diabetes risk.

Polycystic Ovary Syndrome.pdf

106

Pediatric gynecology

Open

Ensure Confidentiality: Establish routines to protect adolescents’ privacy in reproductive health care and be informed about state-specific consent regulations.

Address Contraceptive Needs Early: Discuss contraceptive options, prioritizing the most effective methods and including emergency contraception in the discussion, irrespective of age or sexual history.

Counsel on LARC Methods: Educate on the high efficacy, continuation, and satisfaction rates of long-acting reversible contraception for adolescents.

Counteract Misperceptions: Prepare to address common concerns and provide evidence-based information on contraceptive use without age-based restrictions.

Consider Special Needs: Offer tailored counseling strategies for adolescents with mental health issues, disabilities, or medical comorbidities.

Provide Thorough Follow-Up: Continually reassess the patient's satisfaction with contraception, sexual concerns, and risk of STIs, offering various follow-up communication methods.

Counseling Adolescents About Contraception.pdf

107

Pelvic inflammatory disease

Obstetrical Emergencies

Open

Early Diagnosis and Treatment: Healthcare providers should diagnose and treat PID promptly to avoid serious long-term consequences, even if the STI tests are negative.

Empiric Treatment: Begin treatment empirically to cover likely pathogens, including N. gonorrhoeae, C. trachomatis, and anaerobic bacteria.

Outpatient vs. Inpatient Treatment: Mild-to-moderate PID can be managed on an outpatient basis, while severe cases should be hospitalized.

Retesting: Women treated for chlamydial or gonococcal PID should be retested 3 months after treatment.

Management of Sex Partners: Evaluate, test, and treat all recent sex partners of the patient to prevent reinfection and spread of STIs.

Prevention Strategies: Encourage abstinence, condom use, and STI screenings to prevent PID and its sequelae.

Long-term Risks: Educate patients about the increased risk of tubal infertility, ectopic pregnancy, and chronic pelvic pain after PID episodes.

pdf.pdf

Pelvic Inflammatory Disease (PID) - STI Treatment Guidelines.pdf

pelvic_inflammatory_disease.25.pdf

pelvic-inflammatory-disease.pdf

108

Pelvic Organ Prolapse

Open

Pelvic Organ Prolapse Quantification (POP-Q) Before Treatment: It is recommended to perform a POP-Q examination before any treatment to objectively assess and document the extent of prolapse.

Non-Surgical Options for Symptomatic POP: Vaginal pessaries should be offered as a non-surgical alternative for symptomatic POP, especially for women planning future pregnancies.

Surgical Approach Selection: The surgical approach for POP should be based on the location and severity of prolapse, patient's health, preference, and the surgeon's expertise.

Avoiding Synthetic Mesh for Transvaginal Repair: Due to safety concerns, the use of transvaginal synthetic mesh is discouraged and should be limited to high-risk individuals with proper patient counseling.

Intraoperative Cystoscopy During High-Risk Surgeries: Recommended during surgeries with a higher risk of bladder or ureteral injury, such as apical suspensions or anterior colporrhaphy with mesh.

Addressing Stress Urinary Incontinence: Preoperative assessment for occult stress urinary incontinence is crucial, and concomitant treatment should be considered to prevent postoperative incontinence.

Counseling on Recurrence Risk: Women should be informed about the possibility of POP recurrence post-surgery, with management options ranging from non-surgical to repeat surgeries.

Referral to Specialists for Complex Cases: Referral to a specialist is advised if the primary surgeon is not comfortable with advanced procedures for managing recurrent POP.

Pelvic Organ Prolapse.pdf

109

Pelvic pain/Abdominal Pain

Open

Non-recommended Laparoscopic Adhesiolysis: The guideline advises against routine laparoscopic adhesiolysis for managing chronic pelvic pain, as it is supported by good and consistent scientific evidence (Level A).

Physical and Psychological Therapies: Referral for pelvic floor physical therapy, sex therapy, or cognitive behavioral therapy is recommended based on limited or inconsistent scientific evidence (Level B).

Pharmacologic Treatments: The use of serotonin–norepinephrine reuptake inhibitors (SNRIs) for neuropathic chronic pelvic pain, and gabapentin and pregabalin for the treatment of neuropathic chronic pelvic pain are recommended, while opioids are advised against for chronic pelvic pain management (Level B).

Trigger Point Injections: Recommended to improve pain and function in patients with myofascial chronic pelvic pain, based on limited or inconsistent scientific evidence (Level B).

Holistic Initial Evaluation: A comprehensive medical history and physical examination, focusing on the abdominal and pelvic neuromusculoskeletal systems, are recommended (Level C).

Screening for Non-Gynecologic Conditions: The guideline recommends screening and evaluation for conditions such as interstitial cystitis, irritable bowel syndrome, diverticulitis, and mood disorders (Level C).

Multidisciplinary Care Referral: Referral to pain medicine specialists for part of a multidisciplinary care approach may be appropriate (Level C).

Alternative Therapies: Acupuncture and yoga can be considered for chronic pelvic pain of musculoskeletal etiology (Level C).

Chronic Pelvic Pain.pdf

110

Perimenopausal and menopausal care

Open

Systemic Hormone Therapy (HT) Usage: Should be individualized and is effective for VMS, but consider risks like thromboembolism and breast cancer.

Nonhormonal Alternatives: SSRIs, SSNRIs, and gabapentin are effective for VMS for those avoiding hormone use.

Local Estrogen Therapy for Vaginal Symptoms: Preferable for women with exclusive vaginal symptoms to avoid systemic effects.

Transdermal Estrogen for Lower Thromboembolism Risk: May be safer regarding venous thromboembolism than oral HT.

HT Duration and Dosage: Use the lowest effective dose for the shortest duration, tailored to the individual's symptoms and risks.

Management of Menopausal Symptoms.pdf

111

Placenta accreta spectrum

Open

Antenatal Diagnosis and Coordination of Care: Early detection allows for strategic planning and coordination among a multidisciplinary team at a specialized facility, which is critical for the management of PAS.

Cesarean Hysterectomy as Preferred Delivery Approach: The standard recommendation is to perform a cesarean hysterectomy with the placenta left in place to minimize hemorrhage, typically between 34 and 35 weeks gestation.

Proactive Hemorrhage Management: Collaboration with a blood bank and adherence to massive transfusion protocols are essential, along with the use of tranexamic acid and other strategies to manage severe bleeding.

Conservative Uterine Preservation: In select cases, a conservative approach to preserve the uterus may be considered, but this requires careful evaluation due to the associated risks and variable success rates.

Expectant Management Risks: Though expectant management might preserve fertility, it is considered investigational and carries a high risk of complications; therefore, it is not generally recommended.

Awareness of Recurrence Risk: Patients should be informed of the high risk of PAS recurrence in future pregnancies, particularly if uterine preservation strategies are employed.

Placenta Accreta Spectrum.pdf

112

Placental Abruption

Open

None

113

PO visit

Open

Tailored Postpartum Care Process: Transition to an ongoing postpartum care process from a single visit, tailored to the individual needs of each woman, and including steps like initial assessment, ongoing care, and a comprehensive postpartum visit up to 12 weeks after birth.

Insurance Policy Revision: Advocate for the revision of insurance coverage policies to accommodate the new model of postpartum care, ensuring that the tailored, extended care is financially supported.

Postpartum Care Plan Development: Encourage the development of a detailed postpartum care plan during pregnancy, which should be reviewed after birth, involving a comprehensive care team, and addressing key areas such as infant feeding, emotional health, chronic health conditions, and reproductive life planning.

Shared Decision-Making for Contraception: Promote shared decision-making between healthcare providers and women regarding contraceptive options, informed by individual needs and preferences, and emphasize the importance of birth spacing.

Comprehensive Postpartum Visit Components: Include thorough assessments and counseling during the comprehensive postpartum visit on mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance.

Special Care for Adverse Pregnancy Outcomes: Provide specialized postpartum care and counseling for women with adverse pregnancy outcomes, focusing on cardiovascular risks and emotional support for those experiencing pregnancy loss.

Supportive Policy Recommendations: Recommend supportive policies such as reimbursement for ongoing postpartum care and minimum 6 weeks of fully paid parental leave to enhance maternal and infant health post-delivery.

Optimizing Postpartum Care.pdf

114

Post-term pregnancy

Open

Early Ultrasound Dating: Emphasizes the importance of early ultrasound to accurately determine gestational age, which is critical for appropriate management of late-term and postterm pregnancies.

Selective Membrane Sweeping: Recommends selective use of membrane sweeping to decrease the chances of progressing to late-term or postterm pregnancy, considering the potential discomfort and contraindications.

Induction of Labor: Advises induction of labor to be reasonable between 41 and 42 weeks, and recommended after 42 weeks, with the aim to reduce perinatal morbidity and mortality.

Antepartum Fetal Surveillance: Suggests initiating surveillance at 41 weeks to monitor fetal well-being and to detect oligohydramnios, with the decision to deliver if abnormalities are found.

Management of Late-Term and Postterm Pregnancies.pdf

115

Postpartum Hemorrhage

Obstetrical Emergencies

Open

Identification of PPH: Recognize postpartum hemorrhage by blood loss exceeding 500 mL for vaginal delivery or 1000 mL for cesarean, or by symptoms like tachycardia and hypotension.

Immediate Action and Team Coordination: Summon the obstetric and anesthesia teams, assign a nurse to monitor vitals and document, and another to manage IVs and medication.

Patient and Family Communication: Briefly inform the patient and family about the situation and the steps being taken to manage the bleeding.

Primary Survey and Uterine Assessment: Check vital signs, assess blood loss, perform fundal massage if the uterus is atonic, and consider the Four Ts (Tone, Trauma, Tissue, Thrombin) as potential causes of PPH.

Initial Medical and Supportive Management: Administer uterotonics like Oxytocin and Methylergonovine, ensure two large-bore IV lines are in place, and order a CBC and coagulation panel.

Escalation to the Operating Room: If bleeding persists, move the patient to the OR for better resources and possible surgical interventions like uterine tamponade or D&C.

Advanced Surgical Options: Employ compression sutures (B-Lynch or CHO), uterine artery ligation, or as a last resort, hysterectomy if the bleeding is uncontrolled.

Post-Procedure Monitoring and Support: Provide continuous monitoring, debrief the patient and family post-stabilization, and ensure follow-up care for potential delayed hemorrhage and thromboembolic complications.

Postpartum Hemorrhage.pdf

116

PPROM

Open

Management Options for PPROM: Patients with previable and periviable PPROM have two primary management options: expectant management and abortion care, with counseling provided to discuss risks and benefits.

Expectant Management Risks: Expectant management poses significant maternal risks with potential emotional benefits; however, a study showed only 16% avoided morbidity with neonatal survival.

Factors Affecting Expectant Management Outcomes: Gestational age at PPROM and amniotic fluid volume are key in expectant management outcomes, with later gestation and more fluid indicating better survival chances.

Antibiotics and Expectant Management: Antibiotics are recommended post 24 weeks gestation in expectant management, but the optimal type and dosage are not well-defined, especially before 20 weeks.

Interventions Post-PPROM: Antenatal corticosteroids and magnesium sulfate are advised only if neonatal intensive care is appropriate; experimental treatments like serial amnioinfusions are not recommended.

Subsequent Pregnancy Management: For those with a history of PPROM, following guidelines for spontaneous preterm birth is suggested, with history-indicated cerclage considered in specific cases only.

Informed Decision-Making: Informed consent and shared decision-making are essential, respecting patient autonomy and employing the best data available. Further research is needed for optimal PPROM management.

Prelabor Rupture of Membranes.pdf

117

Preconception counseling

Open

Minimize Risks and Optimize Outcomes: Emphasize the importance of a patient-centered approach to improve reproductive and obstetric outcomes by optimizing health, modifying risk factors, and providing education.

Universal Prepregnancy Counseling: Advocate that all individuals planning a pregnancy receive counseling to ensure informed decision-making and optimized health regardless of their sexual orientation or gender identity.

Routine and Repetitive Counseling: Recommend that counseling be a standard part of healthcare and occur at multiple intervals to adapt to changing health statuses and risk factors.

Early Engagement in Medical Care: Encourage seeking medical care before conception or early in pregnancy for proper management of medical conditions and pregnancy monitoring.

Pregnancy Spacing: Educate about the risks of unintended pregnancies and advise on optimal pregnancy spacing, recommending intervals of at least 6 months but considering intervals shorter than 18 months.

Chronic Conditions Management: Stress the importance of managing chronic conditions before pregnancy and the potential need for referral to specialists.

Medication Safety: Review all medications for pregnancy safety and discuss alternatives for those with potential teratogenic effects.

Genetic Risk Assessment: Obtain detailed family and genetic history from both partners and offer genetic screening as done during pregnancy.

Immunization Status: Perform annual immunization assessments and administer necessary vaccines, considering specific timing for some before conception.

Infectious Disease Screening: Implement routine STI screening and provide counseling on risk reduction, with additional screenings for high-risk individuals.

Substance Use Screening: Conduct routine substance use assessments and educate on the negative impacts on reproductive health and pregnancy outcomes.

Violence and Coercion Screening: Integrate screening for various forms of violence and coercion into counseling, ensuring patient safety and providing resources.

Nutritional Assessment and Supplementation: Encourage a healthy diet and supplement with folic acid and other essential nutrients as necessary based on dietary assessments.

Achieve Healthy Body Weight: Guide patients to reach a normal BMI before pregnancy to reduce the risk of complications related to abnormal BMI.

Exercise Promotion: Advocate for regular physical activity before, during, and after pregnancy, with tailored adjustments for competitive athletes.

Environmental and Occupational Risk Evaluation: Assess and educate on environmental and occupational exposures to minimize contact with potential teratogens.

Prepregnancy Counseling.pdf

118

Pregestational diabetes

Open

Prepregnancy Counseling: Essential for women with pregestational diabetes to improve pregnancy outcomes, covering euglycemic control, risks associated with poor diabetes management, and the need for stricter blood glucose targets during pregnancy.

Folic Acid Supplementation: At least 400 mcg daily is critical to reduce the risk of fetal neural tube defects.

Low-Dose Aspirin Prophylaxis: Recommended from 12-28 weeks gestation to lower the risk of preeclampsia.

Stringent Glucose Control: Maintaining near-physiologic glucose levels throughout pregnancy, with specific targets for fasting, premeal, and postprandial glucose levels to reduce the risk of congenital anomalies and perinatal complications.

Medical Nutrition Therapy: A carbohydrate-controlled diet devised in collaboration with a dietitian to meet the caloric and nutritional needs of pregnancy, with a focus on complex carbohydrates, proteins, and healthy fats.

Insulin Therapy: The preferred treatment for managing pregestational diabetes during pregnancy, with adjustments in dosing as pregnancy progresses and monitoring to prevent hypoglycemia.

Frequent Blood Glucose Monitoring: Necessary for managing glucose levels effectively, with options for continuous glucose monitoring as a consideration.

Fetal Assessment: Includes early ultrasound for dating and viability, detailed anatomical survey at 18-20 weeks, third-trimester growth scans, and antepartum fetal surveillance starting around 32 weeks gestation.

Pregestational Diabetes Mellitus.pdf

acog_clinical_practice_update__screening_for.34 (1).pdf

119

Pregnancy visit

Open

None

120

Premenstrual syndrome or PMDD

Open

SSRIs as First-Line Treatment: SSRIs are recommended for managing mood-related symptoms in PMS and PMDD, making them a first-line pharmacologic treatment option.

Combined Oral Contraceptives: COCs are suggested to improve general premenstrual symptoms, although their effect on mood symptoms requires further clarification.

Cognitive Behavioral Therapy: CBT is highlighted as an effective non-pharmacologic intervention for affective premenstrual symptoms, focusing on cognitive restructuring and coping skills.

GnRH Agonists for Severe Cases: For severe, treatment-resistant premenstrual disorders, GnRH agonists with add-back therapy are conditionally recommended despite potential side effects.

Exercise and Calcium Supplementation: Routine exercise and calcium supplementation are advised to potentially alleviate physical and mood symptoms, with specific guidance for adult and adolescent calcium intake.

Acupuncture and NSAIDs: Acupuncture may help manage symptoms, and NSAIDs are acknowledged for their efficacy in pain management related to premenstrual disorders.

Patient Education: Educating patients on premenstrual disorders and self-help strategies is encouraged as part of comprehensive care.

Bilateral Oophorectomy as Last Resort: This irreversible surgical option should be considered only after all other treatments have failed and following a trial of GnRH agonist therapy.

Screening for Suicidal Thoughts: Clinicians should screen for suicidal thoughts in patients with moderate-to-severe premenstrual symptoms, especially when prescribing SSRIs.

Treatment Resistance and Long-term SSRI Use: Addressing treatment resistance to SSRIs and the need for long-term treatment is essential, with a focus on medication adherence and the potential need for dosage adjustments or specialist consultation.

Challenges with Access to CBT: The guideline notes that access to CBT may be limited and suggests online-based CBT as a possible alternative.

Diversity in Research: There is a call for more inclusive research to better understand premenstrual disorders across diverse populations.

Management of Premenstrual Disorders.pdf

121

Prenatal Diagnostic Testing for Genetic Disorders

Open

Consideration of Maternal Age: Given the increased risk of aneuploidies with advanced maternal age, recommending prenatal diagnostic testing should be a standard part of prenatal care for older expectant mothers.

Assessment of Parental Carrier Status: If either parent is a known carrier of genetic mutations or chromosomal rearrangements, prenatal diagnostic testing is crucial to assess the fetus's condition.

Family History Review: A detailed family history can indicate a higher risk of genetic disorders, suggesting the need for prenatal diagnostic tests.

Interpreting Ultrasound Findings: Structural abnormalities detected via ultrasound should prompt consideration of invasive prenatal testing to rule out or confirm associated genetic conditions.

Approach to Mosaicism: Encountering chromosomal mosaicism in prenatal tests necessitates a nuanced approach, often involving follow-up testing and genetic counseling.

Importance of Genetic Counseling: Offering genetic counseling before and after prenatal diagnostic testing helps parents understand potential outcomes, benefits, and risks associated with the results.

Managing Procedure-Related Risks: Emphasizing the selection of experienced providers for invasive procedures can minimize the risk of miscarriage.

Monitoring Infectious Disease Risks: For pregnant women with infections like HIV or hepatitis, careful monitoring and management are essential to reduce the risk of viral transmission during invasive testing.

Planning for Non-Termination Scenarios: Prenatal diagnosis can inform perinatal management and parental decision-making, even when termination of pregnancy is not being considered.

Prenatal Diagnostic Testing for Genetic Disorders.pdf

122

Preoperative care

Gynecology

Open

Preoperative Counseling: Advise patients on the benefits of avoiding prolonged fasting and the importance of nutritional strategies, including carbohydrate loading for nondiabetic patients.

Perioperative Considerations: Emphasize the use of regional anesthesia and nonopioid analgesics to manage pain, maintain fluid balance, and ensure normothermia during surgery.

Postoperative Recovery: Encourage early mobilization, appropriate thromboprophylaxis, and early feeding to promote recovery and reduce complications.

ERAS Program Components: Implement key interventions from Table 1 across all phases of care: patient education, multimodal pain management, minimizing fluid overload, and judicious use of tubes and drains.

Implementation Strategy: Ensure active patient engagement, strong leadership, effective teamwork, and a culture focused on safety and quality improvement for successful ERAS program adoption.

Perioperative Pathways Enhanced Recovery After Surgery.pdf

123

Preterm Labor

Obstetrics

Open

Patient History Importance: Understanding a patient's specific history, including gestational age, previous preterm births, and current symptoms, is crucial in assessing the risk and management of preterm labor.

Physical Examination Procedures: Conducting thorough physical and pelvic examinations helps in identifying signs of preterm labor, such as uterine contractions and cervical changes.

Laboratory Tests for Infection: Utilizing urinalysis, CBC, and cervicovaginal cultures are essential for identifying infections that could contribute to preterm labor.

Transvaginal Ultrasound Significance: Measuring cervical length via transvaginal ultrasound is a key indicator of preterm birth risk, guiding further intervention.

Antenatal Corticosteroids: Administering corticosteroids between 24-34 weeks of gestation can significantly improve neonatal outcomes by enhancing fetal lung maturity.

Magnesium Sulfate for Neuroprotection: Considering magnesium sulfate before 32 weeks of gestation for neuroprotection is recommended to reduce the risk of cerebral palsy.

Consultation with Specialists: Involving MFM specialists and neonatologists is vital for high-risk cases and imminent preterm delivery discussions.

First-Trimester Ultrasound Accuracy: Emphasize the use of first-trimester ultrasound for accurate pregnancy dating, critical for preterm labor assessments.

Viability and Resuscitation Policies: Be familiar with the institution's viability thresholds and resuscitation policies for extremely preterm births.

Selective Tocolysis: Tocolysis should be used selectively for short-term benefits, including fetal condition optimization, treating underlying maternal conditions, and allowing transfer to a higher-level care facility.

Cervical Insufficiency Management: For women with a history of spontaneous preterm birth and a shortened cervix, intervene with vaginal progesterone or cerclage to prevent preterm labor.

Prediction and Prevention of Spontaneous Preterm Birth.pdf

Management of Preterm Labor.pdf

124

Prevention of Infection After Gynecologic Procedures

Gynecology

Open

Hysterectomy Management: A single-dose of cefazolin is recommended for prophylaxis in various hysterectomy procedures. Dosage adjustments are suggested based on patient weight and additional doses for excessive blood loss.

Laparoscopic and Laparotomy Procedures: Prophylactic antibiotics are generally not required for laparoscopic procedures unless bowel or vaginal entry is expected, but may be considered for laparotomy, particularly in high-risk patients.

Hysterosalpingography (HSG) and Chromotubation: Prophylactic antibiotics are not necessary for HSG in patients without a history of pelvic infection, but doxycycline is recommended if dilated fallopian tubes are observed.

Sonohysterography and Hysteroscopy: Routine antibiotic prophylaxis is not necessary for these procedures.

Endometrial Ablation: There is no clear evidence supporting the use of antibiotic prophylaxis for endometrial ablation.

Intrauterine Device (IUD) Placement and Endometrial Biopsy: Antibiotic prophylaxis is not recommended before these procedures.

Uterine Evacuation: Prophylactic antibiotics should be given for induced abortions and surgical management of early pregnancy loss.

Colporrhaphy and Vaginal Slings: Antibiotic prophylaxis is considered reasonable for these surgical interventions.

Cystoscopy: Antibiotic prophylaxis is not recommended for women with negative urine cultures undergoing cystoscopy.

Cervical Tissue Excision Procedures: These procedures, including loop electrosurgical excision, do not require antibiotic prophylaxis.

Vulvectomy and Oocyte Donation: The necessity of antibiotic prophylaxis for these procedures is not clearly defined.

Embryo Transfer: Routine antibiotic prophylaxis is not recommended prior to embryo transfer.

Prevention of Infection After Gynecologic Procedures.pdf

125

PROM (premature rupture of membranes)

Obstetrics

Open

Expectant Management for Preterm PROM: Before 34 weeks of gestation without complications, expectant management is recommended, involving hospital admission for surveillance and periodic assessments for maternal and fetal well-being.

Corticosteroid Use: A single course of corticosteroids is advised between 24 and 34 weeks of gestation to reduce neonatal morbidity and mortality, with consideration for administration as early as 23 weeks if preterm birth is imminent.

Magnesium Sulfate for Neuroprotection: Recommended before 32 weeks of gestation for fetal neuroprotection when the risk of imminent delivery is present.

Latency Antibiotics: A 7-day course of antibiotics is suggested for women with preterm PROM before 34 weeks to decrease the risk of maternal and neonatal infections and associated morbidities.

GBS Prophylaxis: Should be administered to women with preterm PROM and a viable fetus who are candidates for this intervention, regardless of prior antibiotic treatment.

Induction of Labor at Term PROM: If spontaneous labor does not occur near the time of presentation at or after 37 weeks, induction of labor is recommended unless contraindicated.

Expectant Management vs. Immediate Delivery for PROM Between 34-37 Weeks: Both options are reasonable; the choice should be made through shared decision-making and should not extend beyond 37 weeks.

Tocolytics: May be considered for neonatal benefit or maternal transport in preterm PROM, particularly at earlier gestational ages. Not recommended between 34 and 37 weeks.

Progesterone Supplementation: Women with a history of preterm PROM may be offered progesterone to reduce the risk of recurrence in subsequent pregnancies.

Outpatient Management of Periviable PROM: After hospital assessment, outpatient management and surveillance may be considered for periviable PROM, with precautions for signs of chorioamnionitis and miscarriage.

Cerclage in Subsequent Pregnancies: May be considered for women with a history of spontaneous preterm birth before 34 weeks and a short cervical length detected before 24 weeks.

Prelabor Rupture of Membranes (1).pdf

126

Psychiatric disease

Obstetrics

Open

Prevalence of Mental Health Conditions: Mental health conditions affect about one in five women during the perinatal period, making vigilant screening and management by ob-gyns essential for maternal and child well-being.

Screening and Diagnosis: Regular use of validated screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9), is recommended for early detection and treatment initiation.

Treatment Approaches:

Psychotherapy: Recommended as first-line treatment for mild-to-moderate depression and anxiety disorders, with specific programs like CBT (Mothers and Babies program) and IPT (ROSE program) highlighted.

Pharmacotherapy: SSRIs, particularly sertraline and escitalopram, are preferred first-line pharmacological treatments for depression and anxiety disorders during pregnancy, while mood stabilizers (excluding valproate) are critical for managing bipolar disorder.

Monitoring and Adjustment: Monitoring treatment response with validated tools is crucial, with a note on the potential need for up-titration during pregnancy and avoidance of down-titration in the third trimester or postpartum.

Equitable Access to Care: It is important to ensure that all pregnant and postpartum individuals have equitable access to mental health care.

Medication Use During Pregnancy and Lactation: Medications for mental health conditions should not be withheld or discontinued solely due to pregnancy or lactation, with informed decisions made based on a careful risk-benefit analysis.

Postpartum Psychosis Management: This condition is a psychiatric emergency requiring immediate hospitalization and continuous observation, with sedating antipsychotics and potentially benzodiazepines used for acute management.

Shared Decision-Making: Emphasize the importance of shared decision-making in developing an individualized treatment plan that considers the patient's needs, preferences, and medical history.

Lactation Considerations: Stability on medication during pregnancy is usually maintained postpartum, with careful consideration of medication effects on breast milk and relative infant dose.

Multidisciplinary and Supportive Care: A collaborative approach involving ob-gyns, mental health professionals, and pediatricians is essential, as is the reduction of stigma and the provision of supportive care environments.

Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum.pdf

127

PUL

Gynecology

Open

None

128

Pulmonary Embolism

Open

None

129

Radiation exposure to fetus

Obstetrics

Open

Ultrasonography and MRI as Preferred Modalities: Use ultrasound and MRI as first-line imaging techniques during pregnancy due to their safety profile. Employ these methods only when they provide a clear medical benefit and can answer a specific clinical question.

Ionizing Radiation Safety: Employ radiography, CT scans, and nuclear medicine imaging when necessary, as the radiation dose is typically much lower than the threshold for fetal harm. Do not avoid these modalities due to unfounded safety concerns.

Gadolinium Contrast Use: Restrict the use of gadolinium contrast in MRI to cases where the diagnostic improvement justifies potential risks, and continue breastfeeding post-administration due to minimal transfer to breast milk.

Continuation of Breastfeeding: Maintain breastfeeding after the use of contrast agents, such as gadolinium and iodinated contrast, because of negligible secretion in breast milk.

Radiation Exposure Counseling: Provide pregnant patients with counseling on the risks and benefits of diagnostic imaging involving radiation and consult with radiologists to minimize exposure.

Caution with Radioactive Iodine: Avoid the use of radioactive iodine (iodine 131) during pregnancy to prevent adverse effects on the fetal thyroid and consult experts regarding the use of radionuclides during lactation due to possible excretion into breast milk.

Guidelines for Diagnostic Imaging During Pregnancy and Lactation.pdf

130

Recurrent pregnancy loss

Open

None

131

Retained Placenta

Obstetrics

Open

None

132

Risks of IVF

Obstetrics

Open

Singleton Pregnancy Focus: Physicians should aim for singleton pregnancies by using low-dose protocols, monitoring hormone levels and follicle numbers, and limiting the number of embryos transferred.

eSET Utilization: Elective single-embryo transfer (eSET) should be used when appropriate to reduce the incidence of multifetal pregnancies without affecting overall success rates.

Comprehensive Patient Counseling: Patients must be thoroughly counseled on the risks of multifetal gestations and the strategies to minimize such risks, including the potential financial implications.

ART Pregnancy Monitoring: Increased surveillance for complications such as preterm birth, low birth weight, and maternal morbidity should be implemented in singleton ART pregnancies.

Investigating Birth Defects: Patients should be informed about the slightly higher risk of birth defects with ART, and ultrasonographic surveillance for structural abnormalities should be considered.

Long-term Pediatric Research: Clinicians should stay informed about ongoing research related to long-term pediatric outcomes of ART to guide patients accurately.

Pre-ART Health Optimization: A thorough medical evaluation should be conducted before ART to optimize the patient's health and manage any pre-existing conditions.

Lifestyle Modification Counseling: Patients should receive counseling on lifestyle modifications that could reduce the risks associated with ART.

Continuous Risk-Benefit Analysis: Ongoing counseling is crucial to address concerns and provide updated information, ensuring decisions regarding ART are based on a careful analysis of the benefits and risks.

Perinatal Risks Associated With Assisted Reproductive Technology.pdf

133

RSV

Obstetrics

Open

FDA Approval and CDC Recommendation: The FDA has approved Pfizer's Abrysvo (RSVpreF) vaccine for pregnant individuals to protect newborns from RSV, with the CDC recommending vaccination during 32 0/7 to 36 6/7 weeks of gestation.

Vaccine Eligibility and Seasonal Considerations: Pregnant individuals are eligible for the RSV vaccine in the 2024-2025 season if not received in the 2023-2024 season and if their infants are not planned to receive nirsevimab.

Clinical Efficacy of Maternal RSV Vaccination: Abrysvo has shown to significantly reduce the risk of severe LRTI in infants post-birth, with efficacy rates of 81.8% within 90 days and 69.4% within 180 days.

Safety and Coadministration: Abrysvo is safe for pregnant individuals and can be concurrently administered with influenza and Tdap vaccines.

Monoclonal Antibody as an Alternative: Nirsevimab is recommended for infants under eight months during their first RSV season, even if born to vaccinated mothers in the prior season.

Role of Obstetricians in Patient Education: Obstetricians should counsel patients about RSV risks, vaccine and nirsevimab benefits, and address concerns and preferences.

Shared Decision Making: Patients should collaboratively decide with healthcare providers on receiving the RSV vaccine or nirsevimab for their infant, considering individual circumstances.

Importance of Documentation: Documenting RSV vaccination or declination in medical records and immunization systems is vital for informing subsequent infant care decisions.

Implementation Strategies for Practices: Obstetrician-gynecologists need to prepare their practice for effective RSV vaccination delivery, which includes staff training and patient education.

Maternal Respiratory Syncytial Virus Vaccination _ ACOG.pdf

134

Seizures

Obstetrics

Open

Contraception and AED Interactions: Women using antiepileptic drugs (AEDs) should be counseled on potential interactions with hormonal contraceptives, which may affect the effectiveness of either medication. Adjustments to contraception methods might be necessary to prevent unintended pregnancies and maintain seizure control.

Management of Catamenial Epilepsy: Hormonal fluctuations during the menstrual cycle can increase seizure frequency. Management may include adjusting AED dosages or considering adjunctive hormonal therapies such as progesterone supplementation during specific cycle phases.

Reproductive Challenges in Women with Epilepsy: Address reproductive dysfunctions like menstrual disorders and infertility through potential AED adjustments and monitoring of reproductive health, recognizing that women with epilepsy generally have similar fertility rates as those without epilepsy.

Prepregnancy Counseling: Preconception care should focus on optimizing AED regimens to balance seizure control with minimizing fetal risks, including considerations for AED adjustments or discontinuation based on individual seizure history and teratogenic risks.

Seizure Control During Pregnancy: Maintain seizure control during pregnancy to mitigate maternal and fetal risks. This may involve monitoring and adjusting AED levels due to pregnancy-related metabolic changes, especially for drugs like lamotrigine and levetiracetam.

Avoiding High-Risk AEDs During Pregnancy: Certain AEDs, particularly valproate, phenobarbital, and phenytoin, carry higher risks of congenital malformations and should be avoided during pregnancy if possible. Alternative AEDs with safer profiles should be considered.

Folic Acid Supplementation: Advise women with epilepsy to take 0.4 mg of folic acid daily before and throughout pregnancy to support fetal development, in line with ACOG guidelines for all women.

Postpartum Breastfeeding and Safety: Encourage breastfeeding while monitoring infants for possible adverse effects from AED exposure through breast milk. Implement safety precautions to reduce the risk of harm to the child due to potential seizure-related accidents during the postpartum period.

Menopause-Related Seizure Fluctuations: Recognize that women with epilepsy may experience changes in seizure frequency during menopause, especially those with a history of catamenial epilepsy, and that hormone therapy may affect seizure control.

Bone Health: Advocate for adequate calcium and vitamin D intake and consider bone density monitoring for women with epilepsy, especially those on enzyme-inducing AEDs, to mitigate the increased risk of bone disease and fractures.

Referral and Collaboration: Collaborate with neurologists for optimal management of women with epilepsy, particularly when adjusting AEDs, planning for pregnancy, or addressing reproductive and menopausal issues.

Seizures.pdf

135

Sepsis in Pregnancy

Obstetrical Emergencies

Open

None

136

Severe Pre-eclampsia

Open

None

Chronic Hypertension in Pregnancy.pdf

137

Sexual Assault

Gynecology

Open

Immediate Medical Care: Survivors of sexual assault should seek medical attention ideally within 72 hours to ensure timely evidence collection and address any immediate health concerns, with a focus on preserving evidence integrity.

Informed Consent: It is critical to obtain informed consent from survivors, thoroughly explaining medical and forensic examination procedures, and the release of evidence to law enforcement.

Thorough Documentation: Clinicians should document a detailed history of the assault, the survivor's medical background, and their emotional state, with additional protocols for minors and vulnerable adults.

Evidence Collection: A comprehensive physical examination is crucial, utilizing photographs or diagrams and a “rape kit” to document and preserve evidence while maintaining the chain of custody.

Medical Management: Address physical injuries, provide STI testing and prophylaxis, consider HIV PEP within 72 hours, offer emergency contraception, and recommend appropriate vaccinations.

Psychological Support: Be aware of rape-trauma syndrome, provide counseling and referrals, and adopt a trauma-informed approach to support the survivor's psychological recovery.

Follow-Up Care: Ensure clear post-care instructions and schedule follow-up visits to monitor health outcomes, test results, and offer continued support for any long-term health issues.

Advocacy and Support: Healthcare providers should advocate for the elimination of rape kit backlogs and support legislative efforts to improve sexual assault response and prevention.

Sexual Assault.pdf

138

Shoulder Dystocia

Open

McRoberts Maneuver Priority: The McRoberts Maneuver should be the first-line action due to its simplicity and effectiveness in relieving shoulder dystocia.

Suprapubic Pressure Application: Alongside the McRoberts Maneuver, suprapubic pressure is recommended to displace the anterior shoulder from the symphysis pubis.

Posterior Arm Delivery: If initial methods fail, delivering the posterior arm can help resolve shoulder dystocia.

Rotational Maneuvers Utilization: Employ Rubin or Woods Screw maneuvers to rotate the fetus and facilitate the release of the impacted shoulder.

All-Fours (Gaskin) Maneuver as an Option: As a non-standard approach, the Gaskin Maneuver can be effective when traditional methods are insufficient.

Zavanelli Maneuver as a Last Resort: In extreme cases, the Zavanelli Maneuver may be considered, but its use is rare due to associated risks.

Selective Cesarean Delivery: Cesarean delivery is an option for suspected cases of fetal macrosomia but should not be routinely elected due to the unpredictability of shoulder dystocia.

Emphasis on Simulation Training: Regular simulation training is advocated to enhance team readiness and performance during shoulder dystocia emergencies.

Importance of Accurate Documentation: Detailed recording of shoulder dystocia events is crucial for legal and clinical purposes.

Shoulder Dystocia.pdf

139

Sickel cell anemia

Open

None

140

Smoker - pregnant

Open

None

Drug Addiction

1. Medical, Social, and Obstetrical Consequences:

• Medical: Infectious diseases, organ damage.

• Social: Legal issues, family disruption.

• Obstetrical: Preterm birth, fetal growth restriction.

2. Methadone vs. Buprenorphine:

• Methadone: Effective but has a higher overdose risk.

• Buprenorphine: Partial agonist, lower overdose risk.

3. Effects of Marijuana:

• Cognitive impairment, respiratory issues, potential fetal growth restriction.

Tobacco and Nicotine Cessation During Pregnancy.pdf

141

Smoking - nonpregnant

Open

Significant Risks from Tobacco and Nicotine: Pregnant women should be informed of the serious risks posed by all tobacco and nicotine products to both maternal and fetal health, which can result in a wide range of pregnancy complications and negative health outcomes for the child.

Effective Counseling Techniques: Health professionals should employ motivational interviewing and cognitive behavioral therapy during prenatal and postpartum visits to support tobacco and nicotine cessation.

5A's Intervention Approach: The 5A's (Ask, Advise, Assess, Assist, and Arrange) provide a structured method for healthcare providers to address smoking cessation with pregnant women.

Referral to Tobacco Quit Lines: Clinicians are recommended to refer patients to tobacco quit lines for additional support in their cessation efforts.

Individualized Care for Heavy Addiction: For those with heavy addiction and psychosocial challenges, a personalized approach using a combination of psychosocial, behavioral, and pharmacotherapy interventions may be necessary.

Nicotine Replacement Therapy with Caution: Nicotine replacement therapy should be considered with caution and under close supervision after discussing the potential risks and benefits with the patient.

Limited Data on Pharmacotherapy during Pregnancy: The use of varenicline and bupropion for smoking cessation is less understood in pregnant populations; if used, clinicians should carefully weigh the risks and benefits.

Continued Postpartum Support: Ongoing interventions are crucial to address the high rate of smoking relapse postpartum, with a focus on psychosocial support and overall well-being.

Screening for Other Substance Use: Screening for alcohol and other drug use is important as tobacco use during pregnancy can be associated with other substance use.

Early Cessation is Most Beneficial: The greatest fetal benefit is seen when smoking cessation occurs before 15 weeks of gestation, although quitting at any stage of pregnancy is advantageous.

142

Sterilization

Gynecology

Open

Patient Selection and Counseling: Ensure thorough counseling about the permanence and alternatives to sterilization, including long-acting reversible contraception (LARC) and vasectomy, and discuss risks and benefits specific to the chosen technique.

Minimizing Regret in Sterilization: Offer extensive opportunities for decision-making, discuss factors that may increase the likelihood of regret such as young age and relationship status, and stress the permanence and limitations of reversal.

Shared Decision-Making: Uphold patient autonomy in the decision-making process, provide well-informed choices free from coercion, and avoid introducing personal biases regarding sterilization into the counseling session.

Benefits and Risks of Sterilization.pdf

143

STI Screening - non-pregnant

Open

None

STI Cover.jpg

144

Stillbirth and evaluation

Open

Definition and Reporting: The article defines stillbirth according to the U.S. National Center for Health Statistics and outlines reporting standards based on gestational age and fetal weight, highlighting the preference for the term "stillbirth" over "fetal death.”

Decreasing Stillbirth Rates: It notes a decline in the U.S. stillbirth rate between 2006 and 2013, attributing the decrease to reduced early stillbirths, while late stillbirth rates have remained stable.

Risk Factor Identification: The bulletin identifies various risk factors for stillbirth, including racial disparities, multiple pregnancies, previous obstetric history, fetal sex, maternal age, comorbid medical conditions, obesity, substance use, assisted reproductive technology, and gestational duration.

Causes of Stillbirth: The challenge in determining definitive causes of stillbirth is acknowledged, and potential causes are listed, such as fetal growth restriction, placental abruption, chromosomal abnormalities, infections, and umbilical cord events.

Evaluation Protocols: Recommendations for a comprehensive stillbirth evaluation are provided, stressing the importance of fetal autopsy, placental examination, and genetic evaluation.

Current Pregnancy Management: Guidance on delivery methods and timing after stillbirth is given, taking into account various factors like gestational age and maternal history.

Bereavement Support: Emphasizing the need for individualized emotional support and communication, the article outlines key principles of bereavement care and suggests referral to professionals for further support.

Subsequent Pregnancy Management: For pregnancies following an unexplained stillbirth, the article recommends minimizing risk factors, provides counsel on recurrence risk, suggests antepartum surveillance, addresses the utility of fetal kick counting, and carefully considers the timing of delivery.

Management of Stillbirth.pdf

145

Substance abuse disorder

Open

Routine Screening for All Patients: Obstetrician-gynecologists should conduct routine screenings for substance use disorder using validated tools, applicable to all patient demographics, to ensure timely and effective care.

Patient Interaction with Dignity and Respect: It is crucial for physicians to treat patients with substance use disorder with respect, focusing on building a therapeutic alliance and being familiar with local treatment resources.

Informed Consent for Mandatory Testing: When testing for substance use is required by law or medical necessity, obstetrician-gynecologists must inform patients and make reasonable efforts to obtain their consent.

Safe Prescribing Practices: Physicians should follow best practices for prescribing controlled medications to prevent abuse, considering non-opioid pain management strategies where appropriate.

Judicious Reporting in Medical Records: Accurate documentation that respects patient confidentiality is essential, with inclusion of only medically necessary information related to substance use.

Maternal Substance Use and Fetal Exposure: Open discussions with the patient about substance use history are important to evaluate fetal risk, with a consideration for alternative diagnoses for neonatal abnormalities.

Navigating Reporting Laws: Obstetrician-gynecologists should be aware of state reporting mandates, advocate for non-coercive, evidence-based interventions, and protect patient autonomy and confidentiality within legal limits.

Encouraging Treatment Over Punishment: Physicians should promote evidence-based treatment options and oppose punitive actions, such as incarceration, especially for pregnant women.

Supporting Breastfeeding Decisions: Breastfeeding should not be automatically contraindicated for women with substance use disorder, and recommendations should be informed by the risks associated with specific substances.

Preserving Family Integrity: Efforts should focus on treatment and maintaining family unity, rather than separating children from parents due to substance use concerns.

Substance Use in Infertility Treatment: Substance use disorder should be identified and treated prior to conception, with infertility treatment decisions based on clear evidence and multidisciplinary advice.

Confidentiality in Adolescent Care: Trust-building with adolescent patients is key, while navigating informed consent, parental involvement, and confidentiality laws for minors.

Addressing Physician Substance Use: Physicians have a responsibility to seek help for personal substance use issues or those of colleagues to ensure patient safety and maintain practice standards.

1. Screening Protocol for Suspected Alcoholism:

• CAGE Questionnaire: Quick assessment (Cut down, Annoyed, Guilty, Eye-opener).

• AUDIT (Alcohol Use Disorders Identification Test): Comprehensive screening tool.

• Detailed history of alcohol use, including quantity and frequency.

2. Fetal Alcohol Syndrome (Brief Overview):

• Growth retardation.

• Facial anomalies (e.g., smooth philtrum, thin upper lip).

• Neurodevelopmental issues (e.g., cognitive impairment).

Alcohol Abuse and Other Substance Use Disorders Ethical Issues in Obstetric and Gynecologic Practice.pdf

146

Syphilis

Obstetrics

Open

Universal Screening: Universal syphilis screening at the first prenatal visit, with follow-up screening in the third trimester and at birth, is crucial to identify and treat syphilis in pregnancy.

Testing Algorithms: Clinicians must be familiar with the traditional and reverse syphilis testing algorithms to accurately diagnose and manage syphilis.

Treatment with Benzathine Penicillin G: Benzathine penicillin G is the recommended treatment for syphilis during pregnancy, and alternative antibiotics should be avoided due to lack of evidence and higher congenital syphilis rates.

Monitoring Treatment Efficacy: Monitoring nontreponemal titers for a four-fold decline is necessary to determine the effectiveness of treatment for syphilis during pregnancy.

Partner Treatment: Improving sexual partner treatment rates to prevent reinfection and adverse pregnancy outcomes is essential.

Managing Jarisch-Herxheimer Reaction: The first dose of BPG during labor with continuous fetal monitoring is recommended to manage potential adverse outcomes from the Jarisch-Herxheimer reaction.

Ultrasound for Fetal Syphilis: A comprehensive ultrasound is recommended for women diagnosed with syphilis at >20 weeks gestation to assess for fetal infection and risk of complications.

Complexity in Congenital Syphilis Diagnosis: Congenital syphilis diagnosis relies on a combination of newborn nontreponemal titers, maternal treatment status, and clinical evaluation, necessitating long-term follow-up.

Overcoming Pandemic Impacts: Addressing the compounded effects of the COVID-19 pandemic on syphilis management, including healthcare access and increased opioid use, is critical.

Addressing Social Determinants and Access Barriers: Efforts to address social determinants of health and barriers to care are key to improving syphilis screening and treatment rates.

Advocacy, Awareness, and Education: Public advocacy, increased awareness, and enhanced provider knowledge are needed to reduce the spread of syphilis and improve management practices.

Development of Diagnostic Tools: Development of rapid and highly sensitive diagnostic tools will aid in the timely diagnosis and treatment of syphilis, especially for newborns.

Targeted Interventions: Implementing targeted interventions for high-risk populations can significantly improve access to care and reduce syphilis transmission rates.

Screening for Syphilis in Pregnancy _ ACOG.pdf

Syphilis.pdf

147

Teen pregnancy

Obstetrics

Open

Decrease in Adolescent Birth Rates: The historic low in adolescent birth rates is attributed to improved contraceptive use among teenagers.

Reproductive Justice Framework: Ensuring equitable health care requires a framework that supports contraceptive counseling, access, and coverage, while preventing coercion.

Confidential Counseling for Adolescents: Adolescents should have the chance to discuss reproductive goals and contraception without parental presence, where permissible.

Access to Contraceptives: Providing adolescents with a full range of contraceptive options, including the right to refuse any method, is crucial.

Endorsement of LARC by ACOG and AAP: The use of IUDs and implants is recommended for adolescents by leading health organizations.

Post-Pregnancy LARC Initiation: Pregnant adolescents should be offered LARC methods immediately following delivery, pregnancy loss, or abortion.

Immediate Post-Pregnancy LARC Counseling: The benefits and effectiveness of immediate post-pregnancy LARC and extended interpregnancy intervals should be communicated to patients.

Bias-Free Shared Decision Making: Health care providers must address personal biases and empower patients to achieve equitable outcomes across all demographics.

Addressing Barriers to Access: Adolescents' unique barriers like confidentiality and cost must be navigated, with Title-X-funded clinics as potential resources.

Parental Involvement and Sexuality Discussions: Encouraging discussions between adolescents and supportive parents or guardians can lead to more consistent use of contraception.

Pelvic Examination for Contraception: A pelvic exam is rarely needed, with the exception of IUD insertions.

Benefits of DMPA: The ease of its dosage schedule makes DMPA a favorable option for adolescents, with low pregnancy rates when access and cost barriers are removed.

Addressing DMPA Concerns: Providers should clarify the implications of the "black box" warning on DMPA, indicating it may be used indefinitely.

Combined Hormonal Contraceptives: These contraceptives, while having higher failure rates, can improve conditions affecting adolescents' quality of life.

Contraceptive Methods Initiation: All methods, including LARC, can be initiated the same day as the visit if pregnancy is unlikely.

Guidance on Menstrual Changes: Anticipatory guidance should be provided on expected bleeding effects and menstrual changes with various contraceptive methods.

Promoting Adherence: Strategies like electronic reminders can improve adherence to contraceptive methods like the pill, patch, ring, and DMPA.

Dual Method Use: Pairing condoms with other contraceptive methods is ideal for adolescents, offering protection against STIs and unwanted pregnancy.

Reinforcing Condom Use: The importance of condoms in preventing STIs should be reinforced when adolescents begin using highly effective contraceptive methods.

Support for Sexuality Education: ACOG and AAP advocate for evidence-based, age-appropriate sexuality education as part of health education.

School-Based Condom Availability: The impact of such programs on condom use is variable, with no evidence suggesting it increases sexual activity.

committee_opinion_no_699__adolescent_pregnancy,.49.pdf

148

Thrombocytopenia in pregnancy

Obstetrics

Open

Gestational Thrombocytopenia Management: As gestational thrombocytopenia is usually asymptomatic and poses no risks, it generally does not require treatment. Follow-up platelet counts should be monitored with frequency based on clinical judgment.

Preeclampsia Treatment: The primary treatment for severe preeclampsia or HELLP syndrome is delivery, irrespective of platelet count. Platelet transfusions may be necessary before significant surgery to raise platelet counts above 50 × 109/L.

Immune Thrombocytopenia Approach: Management includes corticosteroids or intravenous immunoglobulin to increase platelet count for safe regional anesthesia or delivery. Platelet transfusions are reserved for severe bleeding or urgent surgery preparation.

Fetal-Neonatal Alloimmune Thrombocytopenia: Preventative management to avoid intracranial hemorrhage may involve maternal treatment with IVIG and/or corticosteroids, or fetal platelet transfusions if necessary.

Regional Anesthesia Considerations: For platelet counts of 70 × 109/L or more, the risk of epidural hematoma is low, but below this count requires a tailored risk-benefit assessment. Normal platelet function and absence of antiplatelet or anticoagulant therapy are also key considerations.

Thrombocytopenia in Pregnancy.pdf

149

Thromboembolism

Open

VTE Risk Assessment: Utilize the Caprini score to stratify patients into low, moderate, or high-risk categories for VTE prior to gynecologic surgery.

Low-Risk Patient Prophylaxis: Recommend mechanical prophylaxis, primarily IPC devices, or graduated compression stockings if IPC is not available.

Moderate-Risk Patient Prophylaxis: Suggest either mechanical (IPC) or pharmacologic prophylaxis (LDUH or LMWH), unless there's an increased bleeding risk which would favor mechanical methods only.

High-Risk Patient Prophylaxis: Advise dual thromboprophylaxis with both mechanical and pharmacologic methods if bleeding risk is average; use mechanical until bleeding risk decreases, then add pharmacologic. Extended-duration LMWH for 28 days post-discharge is advised for cancer surgery patients.

Minimally Invasive Surgery: Mechanical prophylaxis generally suffices, with additional prophylaxis considered based on individual risk factors.

Obesity Considerations: Weight-adjusted pharmacologic prophylaxis is recommended, and ensure proper fit of mechanical devices.

Regional Anesthesia and Anticoagulation: Exercise caution with the timing of LMWH to prevent spinal hematoma; LDUH has a lower associated risk of spinal or epidural hematoma with neuraxial anesthesia.

Postoperative Hormone Use: Combined hormonal contraceptives are contraindicated with prolonged immobilization; menopausal hormone therapy decisions should be individualized.

Thrombophilia Testing: Routine testing is not recommended in the perioperative period for VTE events.

Prevention of Venous Thromboembolism in Gynecologic Surgery.pdf

150

Thyroid disease in pregnancy

Obstetrics

Open

Targeted Testing Over Universal Screening: Emphasize that targeted testing for thyroid disease is recommended over universal screening, focusing on women with a history of thyroid disease, Type 1 diabetes, or those clinically suspected of having thyroid issues.

First-Line Screening with TSH: Highlight that TSH is the preferred initial screening test for thyroid disease in pregnancy, supplemented by free T4 measurement if TSH levels are abnormal.

Antithyroid Drugs for Hyperthyroidism: Specify that antithyroid drugs like propylthiouracil and methimazole are the treatment of choice for overt hyperthyroidism, with careful dosing to maintain appropriate free T4 levels.

Levothyroxine for Hypothyroidism: Indicate that levothyroxine is used to treat overt hypothyroidism, with doses adjusted to achieve target TSH levels within a specific range.

No Routine Thyroid Antibody Screening: Mention that routine screening for thyroid antibodies in euthyroid women is not recommended, but may be considered in specific cases like Graves’ disease.

Thyroid Nodule Assessment: Point out the recommendation to assess thyroid nodules with TSH testing and ultrasonography, potentially followed by fine-needle aspiration for suspected malignancy.

Management of Postpartum Thyroiditis: Note that postpartum thyroiditis is treated supportively, and levothyroxine may be used for hypothyroid phases.

Thyroid Disease in Pregnancy.pdf

151

TOLAC

Open

None

152

Trauma in pregnancy

Open

None

153

Tubo-ovarian abscess, management

Open

None

154

Type 2 Diabetes

Open

None

155

Ultrasonography

Open

Guidance on Obstetric Ultrasound Use: Obstetric ultrasound is crucial for prenatal care, offering detailed information on fetal development, viability, and potential anomalies. Practitioners should follow the recommendations to ensure appropriate use.

Standard Ultrasound Examinations: A comprehensive evaluation should include checks for fetal presentation, amniotic fluid volume, cardiac activity, placental position, and fetal biometry. This is essential for routine prenatal assessments.

Ultrasound for Specific Concerns: Limited examinations should be performed to address particular clinical questions, such as confirming fetal heart activity or placental location, to tailor patient care.

High-Risk Pregnancy Assessments: Specialized examinations including Doppler ultrasonography and fetal echocardiography are critical for managing high-risk pregnancies, providing in-depth evaluations.

First Trimester Protocols: Confirm intrauterine pregnancies, accurately date pregnancies, and screen for aneuploidy with measurements such as nuchal translucency in the first trimester, aiding early intervention strategies.

Second and Third Trimester Monitoring: Conduct fetal anatomic surveys, evaluate fetal growth, and monitor amniotic fluid volume to manage the ongoing health of the fetus and adjust care as needed.

Maximizing Ultrasound Benefits: Utilize ultrasounds for accurate gestational age assessment and anomaly detection, and employ noninvasive monitoring techniques like Doppler ultrasonography to manage growth-restricted fetuses effectively.

Addressing Ultrasound Limitations: Recognize the varying sensitivity of anomaly detection and the impact of maternal obesity on imaging accuracy, adjusting surveillance and interpretation accordingly.

Management of Multiple Gestations: Assess chorionicity to identify monochorionic twins who require increased surveillance for complications such as twin-twin transfusion syndrome, ensuring vigilant prenatal care.

Upholding Ultrasound Safety: Adhere to the ALARA principle by using the lowest possible ultrasound settings to achieve quality imaging, and avoid nonmedical use, such as keepsake imaging, to minimize unnecessary exposure.

Ultrasound in Pregnancy.pdf

156

Umbilical Cord Prolapse

Open

None

157

Urinary incontinence

Open

Bladder Training: Encourages scheduled voiding to help increase bladder capacity and control.

Moderate Weight Loss: Advised for overweight women to improve symptoms of stress incontinence.

Fluid and Caffeine Intake: Recommends reduction to manage urinary incontinence symptoms.

Pelvic Floor Muscle Exercises (Kegels): Suggested to strengthen pelvic muscles, possibly enhanced with biofeedback.

Incontinence Pessary: Offered as a non-surgical support option for the urethra.

Antimuscarinic Agents: Prescribed to reduce urgency incontinence by controlling involuntary bladder contractions.

Beta-Agonists (Mirabegron): Used to relax bladder muscles and increase capacity.

OnabotulinumtoxinA: Injection treatment for overactive bladder with caution due to risk of urinary retention.

Local Estrogen Therapy: May be beneficial for urinary incontinence, avoiding systemic estrogen.

Midurethral Sling Procedures: Common surgical choice for stress incontinence, using a mesh sling for urethral support.

Urethral Bulking Agents: Injection therapy to enhance urethral resistance, suitable for older women or those who cannot undergo surgery.

Colposuspension: Performed alongside pelvic organ prolapse repair to address stress incontinence.

Urinary Incontinence in Women.pdf

158

Urinary tract infections and pregnancy

Open

None

159

Uterine Inversion

Open

None

160

Uterine leiomyoma

Medical management of fibroids

Gynecology

Open

Individualized Treatment: Management of symptomatic uterine leiomyomas should be personalized, considering symptom severity, fertility plans, and patient preferences.

Expectant Management: Suitable for asymptomatic individuals or those opting to avoid intervention, with the need for information on symptom progression and necessary follow-ups.

Medical Management: Targets bleeding symptoms and may shrink fibroids with options like GnRH antagonists, LNG-IUDs, contraceptive steroids, tranexamic acid, and selective progesterone receptor modulators.

Procedural Interventions: Include UAE and RFA for those wishing to preserve their uterus, offering significant symptom relief but with potential risks and limited data on reproductive outcomes.

Surgical Management: Myomectomy is advised for those desiring future fertility, while hysterectomy is a definitive treatment for those not concerned with childbearing; both require consideration of surgical risks and patient wellbeing.

Shared Decision-Making: Critical for aligning treatment with patient values and circumstances, requiring a collaborative approach between the patient and healthcare provider.

Management of Symptomatic Uterine Leiomyomas.pdf

161

Uterine Rupture

Open

None

162

Vaccination guidelines

General

Open

None

163

Vaginal birth after cesarean (VBAC)

Open

TOLAC Candidacy: Women with a single previous low-transverse cesarean are potential candidates for TOLAC, while those with high-risk factors for uterine rupture are not suitable candidates.

VBAC Success Factors: Success rates for VBAC are influenced by factors such as the reason for the initial cesarean, maternal characteristics, and history of vaginal delivery.

Labor Management: Induction of labor is permissible during TOLAC but may increase the risk of uterine rupture; mechanical cervical ripening may be considered for those with an unfavorable cervix.

Uterine Rupture Protocol: Continuous electronic fetal monitoring is essential for the diagnosis of uterine rupture, with cesarean delivery recommended for future pregnancies following rupture.

Patient Counseling: Discuss the risks and benefits of TOLAC versus elective repeat cesarean delivery, taking into account individual factors and the resources of the delivery facility.

Facility Resources: TOLAC should be conducted in facilities capable of performing immediate cesarean deliveries; home births are contraindicated for TOLAC.

Vaginal Birth After Cesarean Delivery.pdf

164

Vaginal discharge

Open

None

165

Vaginal or perineal hematoma

Open

None

166

Vaginitis in Nonpregnant Patients

Open

Diagnosing Bacterial Vaginosis: Utilize Amsel criteria or Gram stain with Nugent scoring for accurate diagnosis of bacterial vaginosis.

Treating Bacterial Vaginosis: Administer oral or intravaginal metronidazole or intravaginal clindamycin; consider alternatives like oral secnidazole, tinidazole, or clindamycin.

Diagnosing Trichomoniasis: Employ Nucleic acid amplification testing (NAAT) for the diagnosis of trichomoniasis due to its high sensitivity and specificity.

Treating Trichomoniasis: Use oral nitroimidazoles for effective treatment of trichomoniasis; retest within 3 months to manage high recurrence rates.

Detecting Vulvovaginal Candidiasis: Confirm diagnosis of symptomatic vulvovaginal candidiasis with microscopy visualization of fungal elements or positive culture/commercial test for Candida species.

Managing Recurrent Vulvovaginal Candidiasis: Prescribe extended antifungal treatment for recurrent cases and consider weekly suppressive therapy.

Initial Vaginitis Evaluation: Recommend complete history, physical examination, and specific vaginal discharge testing (pH, KOH whiff test, microscopy).

Treating Uncomplicated Vulvovaginal Candidiasis: Suggest intravaginal azole therapy or oral fluconazole for uncomplicated cases.

Avoiding Self-Diagnosis: Advise against self-diagnosis of vaginitis due to potential inaccuracy and nonspecific symptoms.

Treatment of Sexual Partners: Treat sexual partners of women with confirmed trichomoniasis presumptively; no partner treatment necessary for bacterial vaginosis or uncomplicated vulvovaginal candidiasis.

Probiotics and Nonmedical Therapies: Probiotics and nonmedical therapies are not recommended for the treatment or prevention of vaginitis.

Bacterial Vaginosis 1. Clue Cell:

• Vaginal epithelial cell covered with bacteria.

• Appears granular or stippled under a microscope.

Vaginitis in Nonpregnant Patients.pdf

167

Vasa Previa

Obstetrics

Open

Early Labor Recognition: Identification of labor signs and symptoms between 30-34 weeks and 34-37 weeks is crucial for timely management and intervention.

Vilamentous Cord Insertion Management: Special attention should be paid to pregnancies with vilamentous cord insertion due to associated risks.

Bilobed Placenta Monitoring: Continuous monitoring is recommended for pregnancies with a bilobed placenta to mitigate complications.

Cervical Canal Assessment: Regular assessment of the cervical canal, especially when it is 2cm, is important for predicting labor onset.

Fetal Demise Prevention: Proactive management strategies should be employed to minimize the risk of fetal demise associated with these conditions.

168

VAVD

Obstetrics

Open

None

vavad2.pdf

vavd.pdf

169

Von Willebrand’s disease

Gynecology

Open

None

170

VTE Prevention after GYN Surgery

Gynecology

Open

Preoperative VTE Assessment: Use the Caprini score to evaluate the risk of venous thromboembolism (VTE) before surgery.

Balancing Risks: Weigh the potential risk of VTE against the risk of bleeding when considering preventive strategies.

Preventive Strategies: Employ mechanical and/or pharmacological methods to prevent VTE.

Evaluating DVT & PE: Recognize clinical symptoms for deep vein thrombosis (DVT) and pulmonary embolism (PE), and use diagnostic tools while considering post-operative challenges.

PE Treatment Coordination: Involve generalists in co-management with specialists for the treatment of PE.

Medication Choices: Understand the specific indications for using various anticoagulants such as DOACs, unfractionated heparin, and low molecular weight heparin.

Monitoring Protocols: Follow established protocols for monitoring anticoagulant therapies including PTT, INR, and anti-factor Xa levels.

Pregnancy Considerations: Be aware of appropriate anticoagulant use and reversal agents during pregnancy.

Understanding HIT: Differentiate between benign thrombocytopenia and immune-mediated heparin-induced thrombocytopenia (HIT) and comprehend the mechanism of HIT.

Comparing Anticoagulants: Compare the mechanisms, indications, and special considerations of different anticoagulants, including those suitable in pregnancy and with reversible effects.

171

Vulvar Skin Disorders

Gynecology

Open

Avoidance of Irritants: Patients should be counseled to steer clear of known vulvar irritants and allergens, including certain hygiene products, clothing materials, topical agents, and more.

Gentle Vulvar Care: Recommending the use of water only for cleansing the vulva, patting the area dry gently, and applying preservative-free emollients can help in prevention and control.

Proper Menstrual Product Selection: Advice on using 100% cotton, unscented menstrual pads and adequate lubrication during intercourse can contribute to the prevention of vulvar skin disorders.

Use of Topical Corticosteroids: The application of topical corticosteroids with varying potency depending on the condition's severity is highlighted as a common treatment route.

Ointment Formulation Preference: For the treatment of vulvar skin disorders, ointments are preferred over creams, gels, or lotions to avoid additional irritation from alcohol or preservatives.

Diagnosis and Management of Vulvar Skin Disorders.pdf

172

Well woman exam

Gynecology

Open

None

Well Woman Visit.pdf

173

Wound Complications

Gynecology

Open

None

wc.pdf

174

Zika

Open

Pregnancy Risks: Zika virus infection can cause severe birth defects such as microcephaly and other brain abnormalities, which can result in seizures, hearing and vision problems, and cognitive difficulties, emphasizing the importance of prevention for pregnant women.

Transmission Methods: The virus is transmitted through mosquito bites, from mother to fetus, and through sexual contact, necessitating comprehensive strategies to mitigate each transmission route.

Symptoms: Infected individuals may experience mild symptoms like fever, rash, joint pain, and red eyes, but many do not show symptoms, which can complicate detection and increase the risk of unintentional transmission.

Pre-Pregnancy Counseling: Women planning to become pregnant should consult healthcare professionals about Zika risks and prevention, and take steps to avoid mosquito bites and sexual transmission from exposed partners.

Prevention During Pregnancy: Pregnant women should avoid travel to affected areas, consistently use protection during sex with partners who may be exposed to the virus, and consider testing for Zika if exposure or symptoms occur.

Mosquito Bite Prevention: Use EPA-registered insect repellents, wear protective clothing, treat gear with permethrin, and stay in well-screened or air-conditioned environments to reduce the risk of mosquito bites in Zika-endemic areas.

Zika Virus.pdf

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