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Topic Overview
1
Abdominal Pain + Fever
Abdominal Pain + Fever
GYN Emergencies
1. History and Physical Examination
Detailed History: Obtain information on the onset, duration, location, character, and any radiation of pain; associated symptoms such as nausea, vomiting, diarrhea, dysuria, or abnormal vaginal discharge; menstrual and sexual history; contraceptive use; and any recent surgeries or medical conditions.
Physical Exam: Assess vital signs to identify signs of hemodynamic instability. Perform a comprehensive abdominal exam (inspect, auscultate, palpate, and percuss) and pelvic exam if needed to evaluate for tenderness, masses, or discharge.
2. Initial Laboratory Workup
Complete Blood Count (CBC): To assess for leukocytosis, anemia, or thrombocytopenia.
Serum Chemistries: Evaluate electrolytes, renal function, and glucose levels.
Amylase and Lipase: Check for signs of pancreatitis.
Liver Function Tests (LFTs): To assess for hepatic involvement or biliary tract disease.
Beta-HCG: To rule out or confirm pregnancy.
3. Cultures and Specialized Testing
Gonorrhea and Chlamydia Cultures: For sexually transmitted infection assessment, particularly in suspected pelvic inflammatory disease (PID).
Vaginal Cultures: If vaginitis is a concern.
Urinalysis and Urine Culture: To evaluate for urinary tract infection or pyelonephritis.
Blood Cultures: Especially if there are signs of sepsis or bacteremia.
4. Imaging Studies
Pelvic Ultrasound: First-line imaging for gynecological concerns such as PID, tubo-ovarian abscess, or ectopic pregnancy.
CT Abdomen and Pelvis: Helpful for non-gynecological causes like appendicitis, diverticulitis, or other intra-abdominal pathology.
Renal Ultrasound: If there is concern for pyelonephritis or obstruction.
Gallbladder Ultrasound: If biliary disease or cholecystitis is suspected.
Chest Radiograph: To rule out pneumonia, especially if diaphragmatic irritation or lower lobe pathology is suspected.
5. Assessment and Triage
Prioritize stabilizing measures for patients showing signs of systemic infection or sepsis.
Initiate empiric treatment based on the most likely diagnosis while awaiting confirmatory results.
Ensure consultation with relevant specialties as needed, such as gynecology, surgery, or infectious disease.
2
Abnormal uterine bleeding
Abnormal uterine bleeding
Obstetrics
Introduction
Definition: Abnormal Uterine Bleeding associated with Ovulatory Dysfunction (AUB-O) is a condition characterized by heavy, irregular uterine bleeding due to ovulatory dysfunction. It often occurs as a result of chronic unopposed estrogen effects on the endometrium.
Etiology:
Hypothalamic-Pituitary-Ovarian Axis Dysfunction: Disruptions in the normal functioning of this axis lead to anovulation.
PALM-COEIN Classification: Used to classify the causes of abnormal uterine bleeding. "PALM" refers to structural causes, while "COEIN" refers to non-structural causes such as coagulopathy and ovulatory dysfunction.
Causes of Anovulation (Box 1)
Physiologic Causes:
Adolescence: Immature hypothalamic-pituitary-gonadal axis.
Perimenopause: Decreased ovarian function.
Pregnancy: Typically anovulatory.
Pathologic Causes:
Hyperandrogenic Anovulation: Includes polycystic ovary syndrome (PCOS), congenital adrenal hyperplasia.
Thyroid Disease: Both hypothyroidism and hyperthyroidism can contribute to anovulation.
Hyperprolactinemia and Pituitary Disorders: Disrupt hormone regulation.
Diagnosis
Clinical Evaluation:
History and Physical Examination: To assess bleeding patterns and exclude structural abnormalities.
Laboratory Testing:
Pregnancy Testing: To exclude pregnancy.
Thyroid and Prolactin Levels: To assess for thyroid dysfunction and hyperprolactinemia.
Endometrial Biopsy: Recommended for women with risk factors for endometrial hyperplasia or malignancy.
Imaging Studies: Transvaginal ultrasound or saline infusion sonohysterography may be used to rule out structural causes.
Age-Based Evaluation:
Adolescents: Most often caused by anovulation due to immaturity of the hypothalamic-pituitary-gonadal axis.
Women Aged 19-39: PCOS is the most common cause; rule out premalignant endometrial pathology.
Women Aged 40 to Menopause: Evaluate for endometrial hyperplasia or cancer, especially if bleeding is irregular.
Treatment Options
Medical Therapy:
Hormonal Treatments:
Combined Hormonal Contraceptives (CHCs): Help regulate bleeding, treat hyperandrogenism, and prevent endometrial hyperplasia.
Progestin Therapy: Includes oral progestins, depot medroxyprogesterone acetate, and levonorgestrel-releasing intrauterine system (LNG-IUD).
Non-Hormonal Approaches:
Iron Supplementation: For patients with anemia due to chronic heavy bleeding.
Weight Loss: Recommended for women with obesity, particularly those with PCOS, as weight reduction can lead to improved ovulation.
Surgical Interventions:
Hysterectomy: Reserved for patients who have completed childbearing and failed medical management or for those with significant structural pathology.
Endometrial Ablation: Not recommended as a first-line treatment for AUB-O, as it makes future endometrial evaluation challenging and does not provide contraception.
Management Based on Age Groups
Adolescents (13-18 Years):
Combined Hormonal Contraceptives: Effective for managing anovulatory bleeding.
Acute Bleeding: May require hospitalization and high-dose estrogen therapy if hemodynamically unstable.
Women Aged 19-39 Years:
Hormonal Contraceptives: First-line treatment for anovulatory bleeding.
Lifestyle Modifications: Weight loss and exercise are beneficial, especially for PCOS patients.
Perimenopausal Women (40 to Menopause):
Hormonal Therapy: Low-dose oral contraceptives or LNG-IUD can provide relief from perimenopausal symptoms, regulate cycles, and prevent endometrial hyperplasia.
Clinical Recommendations
Diagnosis: A thorough evaluation to rule out structural causes and confirm anovulation is critical before treating AUB-O.
Hormonal Management: Combined hormonal contraceptives and progestin therapy are effective in managing bleeding and preventing endometrial hyperplasia.
Surgical Considerations: Hysterectomy should be considered only when medical management fails or is contraindicated.
Question: In a patient with abnormal uterine bleeding/heavy menstrual bleeding, what workup do you do before you take her for a hysterectomy?
There is likely a myomatous component to the patient's problem, but other conditions may also be present. These other conditions could include: [1]
Underlying endocrinopathy
Thyroid dyscrasias
Oligo-ovulation or anovulation
Coagulopathy
Adenomyosis
Endometrial lesions
Polyps
Hyperplasia
Cervical lesions, including malignancy
Evaluation begins with: [1]
A careful history of the problem, including its severity and progression.
A review of any prior evaluations.
A physical exam
A pap smear
Lab work, including:
CBC
TSH
hCG
Targeted screening for bleeding disorders (when indicated)
Chlamydia screening (when indicated)
An ultrasound evaluation of the uterus, endometrium, and adnexa.
Endometrial sampling (may be appropriate).
3
Abortion - 2nd trimester
Abortion - 2nd trimester
Gynecology
Second-Trimester Abortion - Summary
Introduction
Definition: Second-trimester abortion refers to pregnancy termination performed between 13 weeks and 26 weeks of gestation. In 2008, approximately 6.2% of abortions in the United States occurred between 13-15 weeks, and 4% occurred at 16 weeks or later.
Indications:
Medical and Social Reasons: Women seek second-trimester abortions for reasons such as delayed pregnancy recognition, issues with insurance or referrals, and difficulty accessing a provider.
Fetal Anomalies: Major anatomic or genetic anomalies are often detected in the second trimester, prompting decisions for termination.
Obstetric and Medical Conditions: Indications include preeclampsia, preterm premature rupture of membranes (PPROM), pregnancy failure before 20 weeks, and fetal demise.
Methods of Second-Trimester Abortion
Surgical Method - Dilation and Evacuation (D&E):
Technique: Involves cervical preparation followed by removal of the fetus using grasping forceps. Cervical preparation, often with osmotic dilators or misoprostol, reduces the risk of cervical trauma.
Intact D&E: A variation where the fetus is removed intact. It requires more advanced cervical dilation and may be preferred for autopsy purposes or to reduce the risks of uterine perforation and infection.
Medical Method - Medical Abortion:
Agents Used: Typically involves mifepristone followed by misoprostol, which is effective for second-trimester induction. Misoprostol alone can also be used where mifepristone is unavailable.
Effectiveness and Preference: Medical induction with misoprostol is less cost-effective and associated with a greater risk of incomplete abortion compared to D&E. However, it may be preferred for terminations involving fetal anomalies or maternal health issues.
Complications and Risks
Mortality and Morbidity:
The mortality rate associated with abortion is 0.6 per 100,000 abortions, with abortion-related mortality increasing with gestational age.
The risk of death from childbirth is approximately 14 times higher compared to that from legal induced abortion.
Common Complications:
Postabortion Hemorrhage: Can be managed with uterotonics like misoprostol or methylergonovine. Severe hemorrhage may require uterine tamponade with a Foley catheter or intrauterine balloon, and uterine artery embolization in refractory cases.
Uterine Perforation and Rupture: Uterine perforation can occur with D&E, while uterine rupture is a rare complication associated with medical abortion, particularly in women with prior cesarean delivery.
Infection: Prophylactic antibiotics are recommended for D&E but not routinely for medical abortion. Infection is a rare complication of second-trimester abortion.
Clinical Recommendations
D&E as Preferred Method: D&E is recommended for its safety, effectiveness, and predictability, with fewer complications compared to medical induction involving misoprostol alone.
Cervical Preparation: Cervical preparation before D&E is advised to minimize the risk of trauma.
Provider Training: Residency programs should include integrated abortion training, including D&E, to ensure access to skilled providers.
4
Abortion - Medication
Abortion - Medication
Gynecology
Medication Abortion Outline
Medication abortion, also known as medical abortion, is a safe and effective way to terminate a pregnancy using medication rather than a uterine aspiration procedure.
This method uses a combination of two medications: mifepristone and misoprostol.
Mifepristone is an antiprogestin that blocks the progesterone hormone needed to maintain pregnancy. It causes decidual necrosis, softens the cervix, and increases uterine contractility and sensitivity to prostaglandins.
Misoprostol, a prostaglandin E1 analogue, causes the cervix to soften further and the uterus to contract, expelling the pregnancy.
The FDA-approved regimen for medication abortion involves a 200 mg oral dose of mifepristone followed by 800 micrograms of misoprostol buccally 24-48 hours later.
The World Health Organization (WHO) recommends the same dosage of mifepristone and misoprostol, but allows for vaginal, sublingual, or buccal administration of misoprostol 24-48 hours later.
If mifepristone is not available, misoprostol-only regimens are an acceptable alternative.
Medication abortion is highly effective, especially in early pregnancy, with success rates over 90%.
The effectiveness of medication abortion decreases as gestational age increases.
Counseling patients about medication abortion should include a discussion of:
Eligibility and contraindications: Most women with pregnancies up to 70 days gestation are eligible. Contraindications include ectopic pregnancy, IUD in place, long-term systemic corticosteroid therapy, chronic adrenal failure, coagulopathy or anticoagulant therapy, inherited porphyria, or allergies to mifepristone or misoprostol.
What to expect: Bleeding and cramping are typical and necessary parts of the process. Bleeding will likely be much heavier than a normal period.
Possible side effects: Common side effects of misoprostol include nausea, vomiting, diarrhea, headache, dizziness, and fever or chills.
When to contact their clinician: Patients should be advised to contact their clinician if they experience heavy bleeding (soaking more than two maxi pads per hour for two consecutive hours).
Teratogenicity and ongoing pregnancy: In the rare case of an unsuccessful abortion, misoprostol can cause birth defects. Patients with ongoing pregnancies after medication abortion should be counseled on all pregnancy options.
Impact on future fertility: Medication abortion does not have an adverse effect on future fertility or pregnancy outcomes.
Before a medication abortion:
The clinician must confirm pregnancy and estimate gestational age.
An ultrasound is not necessary for patients with regular periods, a certain last menstrual period within the past 56 days, and no signs or risk factors for ectopic pregnancy.
Rh testing is recommended, and Rh D immunoglobulin should be administered if indicated.
Preoperative assessment of hemoglobin or hematocrit is only needed if anemia is suspected.
Qualified providers and settings:
Any clinician with the skills to screen patients for eligibility and provide appropriate follow-up can provide medication abortion.
This includes physicians, nurse-midwives, physician assistants, and nurse practitioners.
Medication abortion can be safely and effectively provided through telemedicine.
Patients can safely and effectively take mifepristone and misoprostol at home.
After a medication abortion:
Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for pain relief.
Follow-up: Routine in-person follow-up is not necessary after an uncomplicated medication abortion. Patients can choose self-assessment or clinical follow-up to assess success.
Follow-up options: Follow-up can be done by phone, urine pregnancy test, serum hCG testing, or ultrasound.
Incomplete abortion or ongoing pregnancy: Management options include a repeat dose of misoprostol, uterine aspiration, or expectant management, depending on clinical circumstances and patient preference.
Contraception after medication abortion:
Most contraceptive methods can be started immediately on the day mifepristone is taken (Day 1).
All methods can be started after a successful medication abortion.
Patients choosing depot medroxyprogesterone acetate (DMPA) should be counseled that starting it on Day 1 may slightly increase the risk of ongoing pregnancy.
The American College of Obstetricians and Gynecologists (ACOG) advocates for the removal of FDA REMS restrictions on mifepristone, which currently limit its access.
The sources provide evidence-based recommendations on various aspects of medication abortion, graded according to the strength of the evidence:
Level A: Recommendations based on good and consistent scientific evidence.
Level B: Recommendations based on limited or inconsistent scientific evidence.
Level C: Recommendations based primarily on consensus and expert opinion.
5
ACOG statements
ACOG statements
General
OB Videos Part 1: Oral Board Examination Preparation Outline
Here’s a detailed outline based on the lecture content for preparing for the oral board examination in obstetrics. This will serve as a comprehensive guide for your study sessions:
I. Introduction to Oral Board Examination Preparation
Purpose: To ensure candidates confidently manage case lists and effectively respond to examiners.
Primary Focus: Case list presentation, review, defense, and structured oral responses.
Key Tools: “Exam Pro Prep Manual,” case list review, and mock oral board sessions.
II. Case List Management and Presentation
A. Importance of Case List Familiarity
1. Know your case lists inside and out—be prepared to explain each case confidently.
2. Update, revise, or correct outdated or unclear wording.
3. Practice articulating concise, accurate responses to examiners’ questions.
B. Case List Format
1. Normal Obstetrics Cases:
Vaginal deliveries, spontaneous labor, and management of uncomplicated pregnancies.
2. High-Risk Obstetrics Cases:
Preterm labor, multiple gestations, hypertensive disorders, gestational diabetes, etc.
3. Structured Case Review:
Anticipate common complications (e.g., postpartum hemorrhage, shoulder dystocia).
Be ready to defend decisions and explain deviations from standard guidelines.
C. Common Pitfalls to Avoid
1. Inaccurate or inconsistent details within the case list.
2. Inability to clearly explain the rationale for clinical decisions.
3. Lack of familiarity with current guidelines or terminology changes.
D. Mock Case Presentations
1. Practice giving a brief synopsis of each case.
2. Emphasize key management decisions and outcomes.
3. Practice responding to potential examiner questions (e.g., “Why did you choose this course of treatment?”).
III. Structured Oral Responses
A. Key Examination Techniques
1. Be brief and to the point; avoid overcomplicating answers.
2. Use clinical reasoning and evidence-based practice in responses.
3. Break down complex cases into manageable steps for clear explanation.
B. Articulating Differential Diagnoses
1. Start with the most likely diagnosis based on the clinical presentation.
2. Always mention key differential diagnoses and why they were ruled out.
C. Anticipating Examiner Questions
1. Prepare for high-yield obstetrics questions (e.g., labor dystocia, shoulder dystocia, preeclampsia).
2. Be prepared to explain the rationale for certain treatments (e.g., induction of labor, cesarean delivery).
3. Learn to handle unexpected examiner questions with composure.
IV. Key Obstetrics Knowledge Areas
A. Labor Management
1. Normal Labor: Stages of labor, cervical dilation, and effacement.
2. Labor Abnormalities:
Prolonged latent phase, failure to progress, and arrest of labor.
Management of dysfunctional labor: augmentation, amniotomy, oxytocin use.
B. Operative Vaginal Delivery
1. Indications and contraindications for vacuum-assisted and forceps delivery.
2. Criteria for safe use: fetal station, maternal conditions, fetal lie, and presentation.
3. Risks and complications: maternal lacerations, fetal injury.
C. Cesarean Delivery
1. Indications for primary and repeat cesarean sections (e.g., non-reassuring fetal heart tones, cephalopelvic disproportion, placenta previa).
2. Common complications: hemorrhage, infection, injury to adjacent organs.
3. VBAC (Vaginal Birth After Cesarean) criteria and management.
D. Preterm Labor and Preterm Premature Rupture of Membranes (PPROM)
1. Risk factors and early recognition of preterm labor.
2. Management with tocolytics, steroids (betamethasone), and magnesium sulfate for neuroprotection.
3. Monitoring and management of PPROM: antibiotics, steroids, and timing of delivery.
E. Postpartum Hemorrhage (PPH)
1. Identification of uterine atony, retained placental fragments, and genital tract lacerations.
2. Medical management: uterotonics (oxytocin, misoprostol), tranexamic acid.
3. Surgical options: uterine balloon tamponade, B-lynch sutures, hysterectomy in severe cases.
F. Hypertensive Disorders in Pregnancy
1. Preeclampsia: diagnostic criteria (proteinuria, blood pressure thresholds), management based on gestational age.
2. Eclampsia: seizure management, magnesium sulfate.
3. HELLP syndrome: hematological and liver dysfunction, rapid delivery considerations.
G. Diabetes in Pregnancy
1. Gestational Diabetes Mellitus (GDM): diagnosis via glucose tolerance test, diet vs. insulin management.
2. Complications: fetal macrosomia, neonatal hypoglycemia, increased cesarean rates.
H. Multiple Gestation
1. Management of twin pregnancies: chorionicity determination (dichorionic vs. monochorionic).
2. Increased risks of preterm labor, discordant growth, twin-twin transfusion syndrome (TTTS).
3. Mode of delivery based on presentation (e.g., both cephalic, one breech).
V. Statistics and Clinical Terms
A. Statistical Terms
1. Sensitivity: the ability of a test to correctly identify those with the disease.
2. Specificity: the ability of a test to correctly identify those without the disease.
3. Positive Predictive Value (PPV) and Negative Predictive Value (NPV).
B. Obstetrics Terminology
1. Fetal lie (longitudinal, transverse, oblique).
2. Fetal presentation (cephalic, breech, shoulder).
3. Fetal station: how far the fetus has descended into the birth canal (-3 to +3).
C. Interpretation of Test Results
1. Fetal heart rate tracings: variability, accelerations, decelerations, sinusoidal patterns.
2. Amniotic fluid index (AFI): oligohydramnios vs. polyhydramnios.
3. Biophysical profile (BPP) scoring: assessing fetal well-being (movement, tone, breathing, AFI, non-stress test).
VI. Updates on Guidelines and Terminology
A. Current Guidelines
1. Review of ACOG guidelines and committee opinions on key obstetric issues (e.g., VBAC, labor induction).
2. Importance of staying up-to-date with the latest clinical practices.
B. Terminology Changes
1. Replacement of outdated terms like “cephalopelvic disproportion (CPD)” with more accurate descriptors.
2. Updated definitions of labor stages and clinical conditions.
VII. Mock Oral Board Sessions
A. Simulation of Oral Exam Conditions
1. Practice presenting cases concisely and clearly.
2. Verbalizing management plans, including rationale for treatment decisions.
B. Mock Examiner Questions
1. High-yield clinical questions based on the candidates’ case lists.
2. Practice defending your case management decisions and anticipating examiner challenges.
C. Self-Evaluation and Feedback
1. Identify weak areas in case presentation and clinical reasoning.
2. Continuous practice to improve clarity, confidence, and accuracy of responses.
This outline provides a structured approach for reviewing the key elements covered in the lecture, focusing on case list management, technical knowledge, and mock oral exam preparation to ensure success in the oral board examination.
6
Adnexal Masses
Adnexal Masses
Gynecology
Introduction
• Adnexal masses refer to growths in the ovary, fallopian tube, or surrounding tissues.
• Commonly encountered by OB-GYNs, adnexal masses can be benign or malignant.
• Key challenge: differentiating between benign and malignant masses.
• Goal: to provide evaluation and management guidelines
Differential Diagnosis
• Gynecologic origins:
• Benign: functional cysts, endometriomas, tubo-ovarian abscesses, leiomyomas, etc.
• Malignant: epithelial carcinoma, germ cell tumors, sex-cord stromal tumors, etc.
• Nongynecologic origins:
• Benign: diverticular or appendiceal abscess, ureteral diverticulum, etc.
• Malignant: gastrointestinal cancers, retroperitoneal sarcomas, metastatic cancers.
Risk Factors for Malignancy
• Age:
• Incidence of ovarian cancer increases sharply post-menopause.
• Median age at diagnosis: 63 years.
• Postmenopausal women at higher risk for malignancy.
• Family history:
• BRCA1/BRCA2 mutations increase lifetime risk of ovarian, fallopian tube, or peritoneal cancers.
• Other risk factors include nulliparity, early menarche, late menopause, and endometriosis.
General Evaluation
• Patient history:
• Gynecologic and family history, detailed review of symptoms.
• Pregnancy testing in reproductive-age women to rule out ectopic pregnancy.
• Physical exam:
• Comprehensive examination including pelvic, abdominal, and lymph node evaluation.
• Features concerning for malignancy: irregular, fixed, nodular masses, or ascites.
Imaging
• Transvaginal ultrasonography:
• Primary imaging technique to assess mass size, composition, and features (e.g., septations, solid components).
• Color Doppler ultrasonography: evaluates blood flow, improving specificity for malignancy.
• Other imaging (limited use initially):
• CT and MRI may be employed for further evaluation, especially if metastasis is suspected.
Laboratory Testing
• Serum markers:
• CA-125: elevated in 80% of epithelial ovarian cancers but has limited sensitivity in stage I disease.
• Other markers for specific tumors: beta-hCG, alpha-fetoprotein, LDH.
Management Guidelines
1. Observation:
• Simple cysts <10 cm in diameter with benign features can be monitored with serial ultrasounds.
• Larger or complex masses may require further evaluation.
2. Surgical Intervention:
• Minimally invasive surgery is preferred for presumed benign masses.
• Laparoscopy reduces operative time, hospital stay, and postoperative pain compared to laparotomy.
3. Referral to a gynecologic oncologist:
• Referral is indicated for postmenopausal women with elevated CA-125, suspicious ultrasound findings, or metastatic evidence.
• Referral also recommended for premenopausal women with elevated CA-125 and suspicious imaging.
Special Considerations
• Adolescents:
• Prioritize ovarian conservation to preserve fertility.
• Germ cell tumors are the most common ovarian malignancies in adolescents.
• Pregnancy:
• Most adnexal masses resolve spontaneously during pregnancy.
• If intervention is necessary, laparoscopy in the second trimester is generally safe.
Conclusion
• The primary aim in evaluating adnexal masses is to exclude malignancy while considering age, symptoms, and imaging.
• Management is tailored based on individual patient factors, balancing the risks of malignancy against the benefits of conservative versus surgical management.
• Transvaginal ultrasonography is the first-line imaging tool.
• Produces high-resolution images of adnexal masses.
• It is widely available, cost-effective, and well-tolerated by patients.
• Color Doppler can assess vascularity to increase specificity for malignancy.
• CT and MRI are reserved for cases with suspicion of metastasis or unclear findings on ultrasound.
7
Adnexal Torsion
Adnexal Torsion
Gynecology
Detailed Outline of Adnexal Torsion in Adolescents
Adnexal torsion is the fifth most common gynecologic emergency.
Thirty percent of all cases occur in females younger than 20 years old.
The most common symptom is sudden, intermittent, nonradiating abdominal pain, frequently accompanied by nausea and vomiting.
Adnexal torsion is a surgical diagnosis.
Timely intervention with diagnostic laparoscopy is indicated if ovarian torsion is suspected. This is done to preserve ovarian function and fertility.
There are no reliable clinical or imaging criteria to confirm the preoperative diagnosis.
Doppler flow alone should not guide clinical decision making.
A minimally invasive surgical approach is recommended with detorsion and preservation of the adnexal structures regardless of the appearance of the ovary.
Surgeons should not remove a torsed ovary unless oophorectomy is unavoidable.
An example of this is when a severely necrotic ovary falls apart.
The appearance of the ovary during surgery is not a reliable indicator of ovarian viability.
Future ovarian function has been reported in cases where the ovary appeared ischemic at the time of surgery.
The majority of adnexal masses in adolescents are benign.
Cancer rarely presents as adnexal torsion in this age group.
It is reasonable to perform a cystectomy if a cyst is present at the time of adnexal torsion, but not always necessary.
A cystectomy does not need to be performed at the time of detorsion as it may cause additional trauma to the area.
Incision and drainage for large cysts may be an option.
Follow up ultrasonography to reevaluate the cyst in 6-12 weeks is recommended.
Oophoropexy (a procedure to fix the ovary in place) is a controversial procedure and current data is insufficient to support it being performed to decrease the risk of recurrent ovarian torsion.
There are two possible indications to perform this procedure: recurrent torsion or an absent contralateral ovary.
Postoperative pain should be treated with a combination of scheduled nonsteroidal anti-inflammatory medications and a short course of opiates.
The postoperative visit is crucial for patient and parent/guardian education and counseling. The discussion should include details of the diagnosis, procedure, prevention and likelihood of recurrence, potential effect on future fertility, and the need for additional imaging.
Continued education of medical professionals about current treatment recommendations for adnexal torsion in young patients is needed, along with encouragement for collaborative care pathways.
Adolescents are a unique population with specific needs, requiring special care, such as specific port placement and lower insufflation pressure. Multispecialty collaboration is crucial to optimize care and ensure that minimally invasive detorsion with ovarian preservation is the standard treatment.
Recommended Surgical Approach
The recommended surgical approach for adnexal torsion in adolescents is a minimally invasive approach with laparoscopy. This approach is preferred in order to detorse the adnexa and preserve the ovary, regardless of the ovary's appearance or time of presentation.
Laparoscopy is a surgical procedure that uses small incisions and specialized tools to view and operate on the inside of the abdomen and pelvis.
A minimally invasive approach helps minimize pain, scarring, and recovery time.
When performing a laparoscopy on adolescents, there are unique characteristics to consider:
Abdominal wall tissue integrity: This varies throughout adolescence as the fascial wall tension and strength increases with age. Abdominal wall puncture pressure needs to be considered to avoid injury to the underlying structures.
Higher risk of vascular injury: This risk is elevated because the distance from the umbilical entry site to major vessels such as the aorta, inferior vena cava, or the left common iliac vein is short. This must be taken into consideration when planning and performing the laparoscopic entry.
Placement of secondary trocars: Placement of the trocars (and laparotomy incisions if required) requires an understanding of the smaller cranial to caudal distance and lateral abdominal and pelvic distances in adolescents.
The smallest possible trocars should be used.
Fascial closure should be considered due to the increased risk of fascial herniation in adolescents compared to adults.
Insufflation process: Adolescents have a lower tolerable maximum distention pressure, so the insufflation process must be modified.
For those weighing 20 kg or greater, a starting insufflation pressure of 12 mm Hg and flow rates of 3–6 L/min is usually well-tolerated.
For adolescents weighing less than 20 kg, lower pressure and flow rates are recommended.
Surgeons should avoid removing a torsed ovary (oophorectomy) unless it is unavoidable, such as when the ovary is severely necrotic and falls apart during the procedure. This is because the ovary has a dual blood supply, making it more resilient to vascular injury. While the viability of the ovary does decrease as the time between the onset of pain and surgical detorsion increases, the exact duration of vascular interruption required to cause irreversible damage to the ovary is unknown.
It is a misconception that a black or blue ovary implies necrosis and needs to be removed.
The appearance of the ovary during surgery is not a reliable predictor of ovarian viability.
There have been multiple reports of preserved future ovarian function even when the ovary appeared ischemic during surgery.
While the ovary might not show improvements in color during surgery, a second-look laparoscopy 36 hours later can show near-normal appearing ovaries (See Fig. 3 and Fig. 4).
Another unfounded myth is that detorsion will cause embolic phenomena. There is no evidence to support this and there have been no reported cases of venous thromboembolism after detorsion.
8
Age-based health assessment
Age-based health assessment
Gynecology
Well Women Care Presentation Outline
I. Introduction
Well-woman visits are recommended to promote health over a woman's lifetime through disease prevention and preventive health care.
Goals of a Well-Woman Visit:
Maintain physical, mental, and social wellness.
Disease prevention.
Identify and reduce risk factors for disease.
Detect diseases or conditions early for effective treatment.
Promote healthy behaviors for better health outcomes.
The Affordable Care Act mandates coverage for well-woman visits without cost-sharing in most private insurance plans and Medicaid plans, making these services more accessible.
II. Age-Specific Recommendations
A. Adolescents (13–18 years)
1. History:
Menstrual history.
Sexual history.
Mental health screening.
Family history of medical conditions.
2. Physical Examination:
Blood pressure.
Body mass index (BMI).
3. Counseling:
Nutrition and exercise.
Substance use (tobacco, alcohol, drugs).
Sexual health and contraception.
Mental health.
4. Screening:
Sexually transmitted infections (STIs).
Cervical cancer screening (starting at age 21).
Immunizations (as recommended by the CDC).
B. Reproductive-Aged Women (19–45 years)
1. History:
Update medical, surgical, family, and social history.
Focus on gynecologic history, including menstrual and sexual health.
Assess for mental health concerns.
Utilize screening tools as needed.
2. Physical Examination:
Breast exam (as indicated by medical history or symptoms).
Pelvic exam (as indicated by medical history or symptoms).
Blood pressure.
BMI.
3. Counseling:
Reproductive life plan: includes family planning discussions, infertility assessment, and the full range of contraceptive options.
Healthy lifestyle: address smoking, diet, physical activity, and their impact on health conditions like cardiovascular disease, type 2 diabetes, and cancer.
Substance use.
Mental health.
Intimate partner violence.
Folic acid supplementation.
Bone health.
Vulvovaginal symptoms.
Sexual health.
4. Screening:
STIs.
Cervical cancer.
Breast cancer (recommendations may vary).
HIV.
Gestational diabetes (during pregnancy).
Immunizations (as recommended by the CDC).
C. Mature Women (46–64 years)
1. History:
Continue updating comprehensive history as with reproductive-aged women.
Pay particular attention to the onset and progression of menopausal symptoms.
2. Physical Examination:
Follow the same guidelines for breast and pelvic exams as reproductive-aged women.
Continue monitoring blood pressure and BMI.
3. Counseling:
Menopause management.
Hormone therapy (as needed and with informed consent).
Continued focus on a healthy lifestyle, including smoking cessation, a balanced diet, and regular physical activity.
Substance use.
Mental health, considering the increased risk of depression during menopause.
Bone health, especially considering the increased risk of osteoporosis after menopause.
Cardiovascular health, taking into account age-related risk factors.
4. Screening:
Continue STI screening as needed, based on risk factors and sexual activity.
Cervical cancer screening (may change based on age and individual risk factors).
Breast cancer.
Colorectal cancer.
Osteoporosis.
Immunizations, including those recommended by the CDC for this age group (e.g., shingles vaccine).
D. Women Older than 64 years
1. History:
Detailed medical, surgical, family, and social history with particular attention to age-related health concerns.
2. Physical Examination:
Breast exam (as indicated).
Pelvic exam (as indicated).
Blood pressure.
BMI.
3. Counseling:
Healthy aging strategies.
Fall prevention.
Cognitive health.
Continued emphasis on a healthy lifestyle, adapting to age-related changes and needs.
Substance use.
Mental health, addressing potential for isolation and other age-related concerns.
Management of chronic conditions common in this age group (e.g., hypertension, arthritis).
4. Screening:
STIs (based on individual risk factors and sexual activity).
Cervical cancer (may cease depending on individual guidelines and risk).
Breast cancer (continue as per recommended guidelines).
Colorectal cancer.
Osteoporosis (continue monitoring and managing as needed).
Immunizations (e.g., pneumonia vaccine).
III. Role of the Obstetrician-Gynecologist
Traditionally provide preventive care for women.
May manage both reproductive health and preventive health services.
Should counsel on healthy lifestyle choices and their impact on reproductive health.
Can play a crucial role in educating, screening, monitoring, and treating women to reduce risks of morbidity and mortality.
Should work within their healthcare systems to promote their role in primary and preventive care.
IV. The Well-Woman Visit as a Tool for Holistic Care
Offers an opportunity for a comprehensive health assessment, going beyond just reproductive health.
Facilitates early detection and management of health conditions.
Allows for patient education and empowerment, promoting healthy lifestyle choices and disease prevention.
V. Importance of Patient-Centered Care
Shared decision-making between the provider and the patient.
Consider individual needs, preferences, and risk factors when developing a care plan.
Effective communication and counseling to ensure patient understanding and adherence to recommendations.
VI. Conclusion
The Well-Woman visit is a valuable tool for preventive healthcare and promoting women's health throughout their lifespan.
Following age-specific recommendations and employing a patient-centered approach ensures comprehensive care.
The role of healthcare providers, including obstetrician-gynecologists, is essential in providing guidance, education, and support to women.
Note: The specific recommendations for screening and preventive services may vary based on individual risk factors and the latest guidelines from organizations such as the U.S. Preventive Services Task Force, the CDC, and ACOG. It's crucial to consult these guidelines and tailor care plans accordingly.
Well-Woman Visit Checklist
Based on the information in the sources, here's a checklist that attempts to capture the breadth of the Well-Woman Chart:
I. Essential Components of Every Visit (for All Ages):
Comprehensive History:
Symptoms (current and past)
Medications (including supplements and over-the-counter products)
Allergies
Medical History (personal and family)
Pay close attention to family history for risk assessment of conditions like cancer.
Surgical History
Social History (lifestyle factors, living situation, support systems)
Be sure to screen for tobacco use, alcohol use, and diet and exercise habits.
Gynecologic History (menstrual cycles, sexual history, reproductive health)
Mental Health Screening (using age-appropriate tools)
Vital Signs:
Blood pressure
Heart rate
Respiratory rate
Temperature
Height
Weight
Calculate BMI to assess for overweight and obesity.
Counseling and Education:
Tailor counseling to the patient's age and individual needs.
Promote healthy lifestyle choices (diet, exercise, stress management, sleep hygiene)
Discuss reproductive life plan and family planning goals (contraceptive options, pre-pregnancy counseling, infertility assessment)
Address any concerns or questions the patient has.
Educate about age-appropriate preventive services.
Provide resources and referrals as needed.
Shared Decision-Making:
Engage the patient in discussions about her health and care plan.
Respect patient preferences and values.
Note: Pelvic and breast examinations are no longer routinely recommended for asymptomatic patients but should be performed if indicated by medical history or symptoms.
II. Age-Specific Screening and Services:
Adolescents (13-18 years):
Focus on building a foundation for healthy habits and addressing unique needs of this age group.
Mental health screening (depression, anxiety, eating disorders)
Sexual health counseling (safe sex practices, STIs, contraception)
Vaccinations (as per CDC guidelines)
Address substance use (tobacco, alcohol, drugs)
Reproductive-Aged Women (19-45 years):
Cervical cancer screening (Pap smear)
Chlamydia and gonorrhea screening (if sexually active)
Contraception counseling and services
Preconception counseling (if planning pregnancy)
Mature Women (46-64 years):
Breast cancer screening (mammography)
Colorectal cancer screening
Bone density screening (to assess osteoporosis risk)
Menopause management (if experiencing symptoms)
Women Older than 64 years:
Continue age-appropriate cancer screenings.
Focus on maintaining functional health and independence.
Assess fall risk and cognitive function.
Address any chronic health conditions.
III. Selective Screening (Based on Risk Factors):
Diabetes: Screening for type 2 diabetes in women with risk factors (overweight/obesity, family history, certain ethnicities)
HIV: Screening for HIV based on individual risk factors (sexual history, injection drug use)
Sexually Transmitted Infections: Screening for STIs other than chlamydia and gonorrhea based on risk factors (multiple partners, history of STIs).
Mental Health: Further evaluation and treatment for depression, anxiety, or other mental health concerns based on screening results or individual needs.
Domestic Violence: Screening for intimate partner violence in all women.
Genetic Testing: Refer for genetic testing and counseling if there's a family history of certain cancers (breast, ovarian) or other genetic conditions.
Lipid Panel (Cholesterol): Screening for high cholesterol in women with risk factors.
IV. Key Considerations for Clinicians:
Stay Current: Review and update knowledge of preventive health guidelines regularly, as recommendations can change over time.
Tailor Care: Individualize the care plan based on each patient's unique needs and circumstances.
Patient Education: Provide clear explanations and resources to empower patients to make informed decisions about their health.
Referrals: Establish relationships with specialists for referrals, ensuring access to comprehensive care.
V. Important Notes:
This checklist is a summary based on information available in the provided sources. It is not an exhaustive list of all possible screenings and services.
It is essential to consult with individual patients and consider their specific medical history, risk factors, and preferences when determining the appropriate components of a well-woman visit.
Clinicians should refer to the full guidelines and recommendations from the organizations cited in the sources for detailed information and the most up-to-date advice.
This information is solely from the provided sources. Always consult with qualified healthcare professionals for personalized medical advice and treatment plans.
9
AMA
AMA
Obstetrics
Pregnancy at Age 35 Years or Older - Presentation Outline
Introduction
The mean age of pregnant individuals in the United States is increasing. [1, 2]
Nearly 19% of all pregnancies and 11% of all first pregnancies in the United States were in women aged 35 years and older in 2020. [2]
Globally, there is a trend toward later pregnancies, with most countries noting an increasing age at first pregnancy. [2]
Pregnancy at an older age is associated with an increased risk of adverse pregnancy outcomes for both the patient and the fetus. [1, 2]
This presentation will focus on pregnancy with anticipated delivery at age 35 years or older. [3]
The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals is important. [1, 3]
Background
Historically, advanced maternal age has been defined as 35 years or older at the estimated date of delivery. [4]
This age cutoff was based on evidence of declining fertility and increasing risks for genetic abnormalities in the offspring. [4]
Recent studies suggest that risks associated with older age may not influence outcomes until later ages (i.e., 40 years and older). [3]
Studies evaluating chronic medical conditions, such as diabetes, hypertension, and obesity, show an increasing risk with increasing age at the time of pregnancy. [4]
Advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. [5]
Methods
This Obstetric Care Consensus document was developed using an a priori protocol. [6]
A literature search was performed from 2000 to November 2021 for clinical questions. [6]
The search included considerations for the prepregnancy, antepartum, intrapartum, and postpartum periods. [6]
The literature search included terms for racial and ethnic disparities in maternal and fetal outcomes. [6]
The recommendations were drafted with the intent to promote health equity and reduce disparities. [6]
Antepartum Care
Pregnancy with anticipated delivery at age 35 years or older should be recognized as a risk factor for adverse outcomes. [7]
Counseling and management plans should be tailored to the individual's specific age and comorbidities. [7]
Women aged 35 years and older are at higher risk for complications such as gestational diabetes, preeclampsia, labor dystocia, and cesarean delivery. [7]
They are also at risk of delivering a neonate who is born preterm, requires NICU admission, and has low birth weight. [7]
Genetic Counseling for AMA Patients
The sources provide information about prenatal genetic screening and testing for patients of advanced maternal age (AMA), defined as 35 years or older at the estimated date of delivery. Here's how genetic counseling can be provided to an AMA patient:
Explain the age-related risks: Begin by explaining that the risk of chromosomal abnormalities, such as trisomies 21, 18, and 13, increases with maternal age. While this doesn't mean that every AMA patient will have a child with a chromosomal abnormality, it's important to understand the increased risk.
Discuss screening options: Prenatal genetic screening tests, such as serum screening with or without nuchal translucency ultrasonography or cell-free DNA screening, can help estimate the risk of a fetus having a chromosomal abnormality. These are not diagnostic tests, meaning they can't definitively say whether or not a fetus has a chromosomal abnormality, but they can help guide further decision-making.
Explain diagnostic testing: If screening tests indicate an increased risk, or if the patient desires a definitive diagnosis, diagnostic tests such as chorionic villus sampling or amniocentesis can be offered. These tests involve obtaining a sample of fetal cells to analyze the chromosomes directly, providing a definitive diagnosis.
Address patient concerns and values: It's crucial to create a safe and open environment for the patient to ask questions and express their concerns. The decision to undergo prenatal genetic screening or testing is a personal one. The counselor should respect the patient's choices and provide non-directive counseling, supporting them in making decisions that align with their values and preferences.
Offer additional resources: If available, referral to a genetic counselor can be beneficial. Genetic counselors are healthcare professionals with specialized training in genetics and counseling. They can provide more in-depth information about chromosomal abnormalities, inheritance patterns, and the implications for the patient and their family.
Consider health disparities: The sources emphasize the importance of health equity in providing care to AMA patients. Obstetrician-gynecologists should be aware of the disproportionate rates of adverse maternal and perinatal outcomes in Black and American Indian and Alaska Native pregnant individuals aged 35 years and older and understand how racism contributes to these disparities. This awareness should be integrated into the counseling process to ensure equitable care and address potential barriers to access and understanding.
Remember that the sources focus on providing medical information. The emotional and psychological aspects of genetic counseling are equally important but are not discussed in detail. Providing empathetic and supportive care throughout the process is crucial.
Risks for adverse outcomes increase progressively with advancing age, particularly over 40 years. [7]
Daily low-dose aspirin is recommended for preeclampsia reduction for pregnant individuals aged 35 or older with at least one other moderate risk factor. [8, 9]
Pregnant individuals aged 35 years and older have an increased risk for preeclampsia. [9]
The risk appears linear, with increasing age leading to increased risk for hypertensive disorders of pregnancy. [9]
A first-trimester ultrasonogram is suggested due to the increased rate of multiple gestations for pregnant individuals with anticipated delivery at age 35 years or older. [10, 11]
The incidence of multifetal gestation increases with advancing age. [11]
Women aged 30–39 years have double the rate of twinning compared to individuals younger than age 20 years, and those older than 40 years have triple the rate. [11]
Prenatal genetic screening and diagnostic testing options should be discussed and offered to all pregnant individuals regardless of age or risk. [10, 12]
Patients have the right to pursue or decline prenatal genetic screening and diagnostic testing after review and discussion. [10, 12]
Fertility rate declines with increasing age, and there is an increasing risk of aneuploidy and spontaneous abortion. [12]
A detailed fetal anatomic ultrasonogram is suggested for pregnant individuals with anticipated delivery at age 35 years or older. [13, 14]
This is due to the increased risk of aneuploidy and the potential increased risk of congenital anomalies. [14, 15]
Early studies suggested an increased risk of major congenital anomalies with pregnancy at age older than 35 years; however, more recent studies have conflicting results. [15]
An ultrasonogram for growth assessment is suggested in the third trimester for pregnant individuals with anticipated delivery at age 40 years or older. [13, 16]
This is due to the increased risk of both large-for-gestational-age and small-for-gestational-age neonates. [16]
Rates of macrosomia and small-for-gestational-age increase progressively with maternal age. [16]
Antenatal fetal surveillance should be offered for pregnant individuals with anticipated delivery at age 40 years or older. [17, 18]
There is an increased stillbirth risk associated with advancing age. [18]
The risk of stillbirth at 37 to 41 weeks of gestation is higher for women aged 35–39 years and even higher for women 40 years and older. [19]
Delivery should proceed in well-dated pregnancies at 39 0/7–39 6/7 weeks of gestation for individuals with anticipated delivery at age 40 years or older. [17, 20]
This is due to increasing rates of neonatal morbidity and stillbirth beyond this gestational age. [20]
There is a distinct increased risk of stillbirth associated with age at the time of pregnancy beyond 37 weeks of gestation. [19]
Counseling should be provided that vaginal delivery is safe and appropriate if there are no other indications for cesarean delivery. [21, 22]
Counseling should include a discussion of the risks of cesarean delivery, the patient's comorbidities, and preferences. [21, 22]
Advancing patient age alone is not an indication for cesarean delivery. [21, 22]
There is a significant difference in the overall cesarean delivery rate related to age at the time of pregnancy. [22]
Observational studies show an association between older age at the time of pregnancy and cesarean delivery, but the etiology of the higher rate remains unknown. [23]
Health Equity
Obstetrician–gynecologists should be aware of the disproportionate rates of adverse outcomes in Black and American Indian and Alaska Native pregnant individuals aged 35 years and older. [21, 24]
They should understand how racism contributes to perpetuating these outcomes. [21, 24]
Maternal mortality rates for individuals who identify as American Indian and Alaska Native and non-Hispanic Black are significantly higher than for non-Hispanic White individuals. [25]
Fetal outcomes, including preterm birth, small for gestational age, and stillbirth, occur more frequently in some racial and ethnic groups that are disproportionately affected by social and structural barriers to care. [26]
Obstetrician–gynecologists should consider systems-based and individual strategies to reduce racial and ethnic disparities in care and outcomes. [27]
Further Research
Future research should clearly delineate risk by age category to allow for tailored recommendations. [28]
More research is needed on the benefits of antenatal fetal surveillance in reducing stillbirth risk and the optimal timing and frequency of testing. [29]
There is limited data on disparities and whether the risks associated with older age are increased in different populations, including racial and ethnic groups. [29]
More granular data regarding race and ethnicity is needed in future analyses. [29]
10
Ambiguous Genitalia
Ambiguous Genitalia
General
11
Amenorrhea
Amenorrhea
Gynecology
Amenorrhea
Amenorrhea is defined as the absence of menstruation. It can be classified as:
Primary amenorrhea: the absence of menarche by the age of 15 years in girls who have never menstruated.
Secondary amenorrhea: the absence of menstruation for 3 or more months in women with past menses.
Oligomenorrhea: women who menstruate fewer than 9 times in any 12-month period.
Causes of Amenorrhea can be categorized as follows:
Anatomic causes
These causes can almost always be identified by physical examination alone.
Pregnancy is the most common cause of secondary amenorrhea.
Other examples include:
Müllerian agenesis or dysgenesis (uterine, cervical, or vaginal)
Cervical stenosis
Disorders of sexual differentiation
Intrauterine adhesions (Asherman syndrome)
Imperforate hymen
Transverse vaginal septum
Ovarian failure
Premature ovarian failure (POF) or primary ovarian insufficiency is characterized by the triad of amenorrhea, hypergonadotropinism, and hypoestrogenism in women under the age of 40 years.
Causes of POF include:
Genetic abnormalities such as Turner syndrome and mutations in various genes.
Immune dysfunction
Physical insults such as chemotherapy, radiation, and viral agents.
Gonadotropin-secreting pituitary tumors (extremely rare)
Idiopathic
Chronic anovulation
Chronic anovulation is the most common pathological cause of oligomenorrhea or amenorrhea in women of reproductive age.
It may be classified into three groups:
Group I: hypothalamic-pituitary forms of amenorrhea
Group II: polycystic ovary syndrome (PCOS)
Group III: gonadal failure
Causes of chronic anovulation include:
Hypothalamic
Psychogenic, including pseudocyesis
Exercise-associated
Eating disorders, nutritional
Systemic illness
Hypothalamic neoplasms
Functional hypothalamic amenorrhea (FHA) is a common cause of oligomenorrhea and amenorrhea that is suggested by the abrupt cessation of menses in women younger than 30 years of age who have no clinically evident anatomic abnormalities of the hypothalamic-pituitary-ovarian axis or any other endocrine abnormalities. One common feature of women with FHA is that all have a relative "energy deficit".
Some forms of isolated (idiopathic) hypogonadotropic hypogonadism (including Kallmann syndrome)
Pituitary
Some forms of isolated (idiopathic) hypogonadotropic hypogonadism (including Kallmann syndrome)
Hypopituitarism
Pituitary neoplasms, including microadenomas
Inappropriate steroid feedback
Functional androgen excess (PCOS)
Adrenal hyperplasia
Neoplasms producing androgens or estrogens
Neoplasms producing hCG (including trophoblastic disease)
Liver and renal disease
Obesity
Other endocrine disorders
PCOS
It is a heterogeneous disorder that is estimated to affect approximately 5% of women of reproductive age, making it the most common form of chronic anovulation.
It is characterized by:
Clinical evidence of hyperandrogenism and/or hyperandrogemia.
Oligoovulation.
Exclusion of related disorders.
PCOS may be viewed as a state of chronic anovulation associated with LH-dependent ovarian overproduction of androgens.
Evaluation of Amenorrhea
A detailed history, examination, and laboratory analysis will identify most causes.
In all cases, pregnancy should first be excluded.
Initial workup of primary and secondary amenorrhea includes:
Pregnancy test
Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid-stimulating hormone (TSH)
Pelvic ultrasonography or other laboratory testing if clinically indicated.
Treatment of Amenorrhea depends on the underlying cause.
Anatomic causes may require surgery.
Ovarian failure is typically treated with hormone replacement therapy.
Chronic anovulation may be treated with lifestyle modifications, medications to induce ovulation, or surgery.
Complications of Amenorrhea
Infertility
Osteoporosis
Cardiovascular disease
Mental health problems
Key Points
Amenorrhea is a symptom, not a disease.
It is important to determine the underlying cause of amenorrhea in order to provide appropriate treatment.
Amenorrhea can have serious long-term health consequences if left untreated.
12
Amniotic Fluid Embolism
Amniotic Fluid Embolism
Obstetrics
Comprehensive Outline of Amniotic Fluid Embolism
Amniotic fluid embolism (AFE) is a rare but potentially fatal syndrome affecting pregnant women. It is characterized by the sudden onset of cardiorespiratory collapse during labor or shortly after delivery.
Historically, AFE was attributed to amniotic fluid entering the maternal circulation. However, recent studies suggest it is not directly related to amniotic fluid or an embolism. Instead, the syndrome is believed to be triggered by the release of fetal material, such as trophoblasts, into the mother's bloodstream.
AFE is rare, occurring in 1.9 to 6.1 per 100,000 births. However, it has a high mortality rate, exceeding 50% in severe cases.
Clinical Features
The classic presentation of AFE involves:
Sudden hypoxia
Hypotension
Coagulopathy
These symptoms typically occur in relation to labor and delivery.
Other possible symptoms include:
Anxiety
Agitation
Seizures
Severe respiratory distress
Cardiac arrest
Diagnosis
AFE is primarily a clinical diagnosis, meaning it is based on the patient's symptoms and the exclusion of other possible causes.
No specific laboratory test can confirm or rule out AFE.
Differential diagnoses that need to be considered include:
Myocardial infarction
Pulmonary embolism
Air embolism
Anesthetic complications
Anaphylaxis
Eclampsia
Sepsis
Management
Immediate Management:
Support airway, breathing, and circulation (ABCs)
If cardiac arrest occurs:
Start cardiopulmonary resuscitation (CPR) immediately
Displace the uterus manually or tilt the patient laterally
Prepare for perimortem cesarean delivery (resuscitative hysterotomy) if no pulse after 4 minutes of CPR
Post-Resuscitation Management:
Hemodynamic stabilization
Management of coagulopathy:
Anticipate uterine atony, disseminated intravascular coagulation (DIC), and hemorrhage
Administer uterotonics to prevent and manage atony
Initiate massive transfusion protocol
Consider thromboelastography
Administer tranexamic acid if DIC or hemorrhage occurs
Management of pulmonary hypertension and right ventricular failure:
Consider echocardiography
Avoid fluid overload
Administer vasopressors and inotropes as needed
Consider pulmonary vasodilators
Wean inspired oxygen fraction to maintain oxygen saturation between 94-98%
Post-event debriefing:
Identify opportunities for improvement
Discuss family and staff support needs
Report the case to the Amniotic Fluid Embolism Registry
Prognosis and Recurrence
The recurrence rate of AFE is difficult to determine due to its rarity and high mortality rate.
Although multiple cases of subsequent uneventful pregnancies have been reported, no definitive conclusions can be drawn regarding the recurrence risk due to limited data.
Checklist for Initial Management
The Society for Maternal-Fetal Medicine (SMFM) has developed a checklist to guide the initial management of AFE. This checklist is designed to help providers, especially those with limited experience with AFE, deliver prompt and effective care during this critical situation.
The checklist covers various aspects of immediate management, including:
Circulatory collapse management
Anticipation and management of uterine atony, DIC, and hemorrhage
Management of pulmonary hypertension and right ventricular failure
Post-event debriefing
Implementation of Checklist
The SMFM recommends several steps for effective implementation of the AFE checklist:
Establish a multidisciplinary team to review and modify the checklist according to facility-specific requirements.
Determine the checklist's location, ensuring easy access for relevant staff.
Conduct pilot tests and simulations to identify and address potential issues.
Communicate the checklist's availability and content to all relevant staff through training, meetings, and discussions.
Conduct regular simulations and drills to familiarize staff with the checklist and its use in AFE scenarios.
Perform sentinel event analysis after each AFE case to identify areas for improvement and modify the checklist if needed.
Importance of the Checklist
Using a checklist can help ensure a coordinated and controlled response to AFE.
It can also improve patient outcomes by ensuring timely and optimal care during this rare and catastrophic event.
13
Anemia
Anemia
General
Anemia in Pregnancy Presentation Outline
I. Introduction
Anemia is the most common hematologic abnormality encountered during pregnancy. [1]
It is defined as a reduction in the concentration of erythrocytes or hemoglobin in the blood. [1]
Iron deficiency and acute blood loss are the two leading causes of anemia in pregnancy and the postpartum period. [1]
II. Understanding Anemia
ClassificationThe Centers for Disease Control and Prevention (CDC) defines anemia based on hemoglobin or hematocrit values falling below the fifth percentile for healthy individuals at a specific stage of pregnancy. [2]
Anemia can be classified by inheritance pattern (acquired or inherited), underlying mechanism, or red blood cell morphology. [3]
MechanismsDecreased Red Blood Cell Production: This can result from nutritional deficiencies (iron, vitamin B12, folate), dietary issues, malabsorption, bleeding, bone marrow disorders, hormone imbalances, and chronic diseases. [3]
Increased Red Blood Cell Destruction (Hemolytic Anemias): Examples include inherited conditions like sickle cell anemia and thalassemia, as well as acquired conditions. [3, 4]
Blood Loss: This is a major contributor to anemia. [3, 4]
Classification by Cell SizeMacrocytic Anemia: Mean corpuscular volume (MCV) greater than 100 fL, often caused by folate deficiency. [5]
Microcytic Anemia: MCV less than 80 fL, most commonly caused by iron deficiency or hemoglobinopathies. [5]
Physiologic Changes in PregnancyPregnancy leads to an expansion of plasma volume (40-50%) and erythrocyte mass (15-25%). [6]
Iron requirements increase significantly to support the growing red blood cell mass, fetus, placenta, and anticipated blood loss during delivery. [6]
III. Iron Deficiency Anemia in Pregnancy
DefinitionIron deficiency anemia represents a spectrum ranging from depletion of stored iron to insufficient iron for red blood cell production and ultimately a reduction in functional iron. [7]
DiagnosisHemoglobin and hematocrit measurements are initial screening tools, but they are not specific to iron deficiency. [8]
Serum ferritin level measurement is the most sensitive and specific test for diagnosing iron deficiency in anemic patients. [8]
The CDC recommends universal iron supplementation during pregnancy to meet increased iron demands. [8]
Prevalence, Etiology, and Risk FactorsPrevalence varies, with higher rates observed in non-Hispanic Black women and teenage mothers. [9, 10]
Risk factors include dietary factors (low intake of iron-rich foods, low intake of iron absorption enhancers, high intake of iron absorption inhibitors), pica, gastrointestinal diseases, heavy menstruation, short interpregnancy interval, and excessive blood loss during delivery. [11]
Consequences of Iron Deficiency AnemiaAssociated with increased risk of low birth weight, preterm delivery, and perinatal mortality. [12]
Possible links to postpartum depression and developmental issues in offspring. [12-15]
IV. Other Types of Anemia
Macrocytic AnemiaCan be megaloblastic (folate or vitamin B12 deficiency) or nonmegaloblastic. [12]
Folate deficiency is the most common cause during pregnancy in the United States. [12]
Other ClassificationsAnemia can be categorized by MCV into microcytic, normocytic, and macrocytic anemias. [13, 14]
V. Clinical Management of Anemia in Pregnancy
ScreeningAll pregnant women should undergo anemia screening with a complete blood count (CBC) during the first trimester and again at 24-28 weeks of gestation. [15]
Consistent criteria should be applied to all populations, regardless of race, to ensure appropriate identification and treatment. [16]
Evaluation of Asymptomatic AnemiaInitial evaluation includes medical history, physical examination, CBC, red blood cell indices, serum iron, and ferritin levels. [17]
Peripheral smear examination can help diagnose hemolytic or parasitic diseases. [17]
Hemoglobin analysis and genetic testing might be necessary based on history and red blood cell indices. [17]
Iron SupplementationThe recommended daily allowance of iron during pregnancy is 27 mg. [18]
Low-dose iron supplementation improves hematologic parameters and reduces the risk of iron deficiency at term. [18]
The CDC recommends low-dose iron supplementation starting in the first trimester for all pregnant patients. [18, 19]
VI. Treatment and Management of Anemia
TransfusionRarely indicated unless there is blood loss or an operative delivery is required in an anemic patient. [20]
May be considered for maternal or fetal indications in severe anemia (hemoglobin < 6 g/dL). [20, 21]
Parenteral IronIntravenous iron can be considered for those who cannot tolerate or do not respond to oral iron, or those with severe iron deficiency later in pregnancy. [22]
ErythropoietinLimited evidence supports its use in pregnant patients with anemia. [23]
Autologous TransfusionRarely performed and generally not considered cost-effective. [24, 25]
Intraoperative Cell SalvageCan be useful in situations with anticipated significant blood loss (e.g., placenta previa, placenta accreta). [26, 27]
Summary of RecommendationsThe presentation should conclude with a summary of recommendations from the ACOG Practice Bulletin, categorized by level of evidence. [25, 28-30]
VII. Conclusion
Anemia in pregnancy is a significant health concern that requires careful attention.
Early screening, diagnosis, and appropriate management are crucial for optimal maternal and fetal outcomes.
Further research is needed to address evidence gaps and improve clinical practices.
This outline provides a comprehensive framework for your presentation on anemia in pregnancy, incorporating key details and recommendations from the provided source. You can further elaborate on these points and include relevant visual aids to enhance your presentation.
14
Aneuploidy screening and prenatal diagnosis
Aneuploidy screening and prenatal diagnosis
Obstetrics
Screening For Fetal Chromosomal Abnormalities During Pregnancy
All pregnant women should be offered screening and diagnostic tests for fetal chromosomal abnormalities regardless of age or baseline risk. This includes the following options:
Screening tests: These tests assess the risk of a fetus having a chromosomal abnormality.
Serum screening with or without a nuchal translucency (NT) ultrasound.
Cell-free DNA (cfDNA) screening.
Diagnostic tests: These tests can definitively diagnose a chromosomal abnormality.
Chorionic villus sampling (CVS).
Amniocentesis.
Patients have the right to decline any or all of these tests.
Informed decision-making is crucial. Counseling should include:
Information about chromosomal disorders.
Risks of carrying a fetus with a chromosomal abnormality, based on age, genetic history, and family history.
A discussion of the risks, limitations, and benefits of each testing option.
Types of chromosomal abnormalities:
Aneuploidy: Having extra or missing whole chromosomes. Examples: Trisomy 21 (Down syndrome), Trisomy 18 (Edward syndrome), Trisomy 13 (Patau syndrome).
Microdeletions and duplications: Loss or gain of a small portion of a chromosome. These are also known as copy number variants.
Screening Tests
There are multiple approaches to screening, each with its own advantages and disadvantages:
Single Time Point Screening:
cfDNA Screening:
Can be performed from 9-10 weeks gestation until term.
Analyzes cfDNA fragments in the maternal circulation; the fetal component is derived from placental trophoblasts.
Is the most sensitive and specific screening test for common fetal aneuploidies (trisomies 21, 18, and 13).
Can identify fetal sex and sex chromosome aneuploidies.
Potential for false-positive and false-negative results, and is not equivalent to diagnostic testing.
Not recommended in patients who have undergone organ transplantation, as the test may reflect the sex of the organ donor.
Several laboratory methods exist, with the single nucleotide polymorphism (SNP) method able to identify triploidy.
First-Trimester Screening:
Typically performed between 10 and 14 weeks of gestation.
Includes an NT measurement and serum analytes (PAPP-A and free or total hCG, and possibly AFP).
Risk estimate is calculated using these test results along with maternal factors.
Allows for earlier diagnosis and can screen for other structural, genetic, or placental disorders.
Requires a specialized ultrasound for NT measurement.
Second-Trimester Screening:
Quad screen can be performed between approximately 15 and 22 weeks of gestation.
Measures four maternal serum analytes (hCG, AFP, DIA, and uE3).
Provides risk assessment for trisomies 21 and 18, and also for open fetal defects.
Does not require specialized ultrasonography.
Less sensitive than first-trimester screening and combined first- and second-trimester screening.
Combined First-Trimester and Second-Trimester Screening:
Integrated Screening:
Includes first-trimester NT measurement and serum analyte screening, followed by a second-trimester blood draw.
Provides a single test result in the second trimester.
Higher detection rate and lower false-positive rate than single time point testing.
No results available until the second trimester, and potential for no result if the second blood draw is not obtained.
Serum Integrated Screening:
Similar to integrated screening, but does not include the NT measurement.
Can be used when a reliable NT measurement is unavailable.
Lower detection rate than integrated screening but similar to first-trimester screening.
Sequential Screening:
Provides a risk estimate after the first trimester, allowing for earlier diagnostic testing if needed.
Final risk assessment is given after the second trimester.
High detection rate with a marginal increase in the false-positive rate.
Contingent Screening:
Classifies risk as high, intermediate, or low after the first trimester.
High-risk patients are offered additional testing.
Low-risk patients are reassured and no further screening is recommended.
Intermediate-risk patients receive a final risk assessment after the second trimester.
Aims to maintain high detection rates while reducing the number of second-trimester tests.
Ultrasound Screening:
Can be used to identify soft markers for aneuploidy, which are nonspecific findings that are more common in fetuses with certain chromosomal abnormalities.
Examples of soft markers: echogenic intracardiac focus, thickened nuchal fold, renal pelvis dilation, echogenic bowel, choroid plexus cysts.
Soft markers are not diagnostic and most commonly occur in euploid fetuses.
If a soft marker is identified, aneuploidy screening should be offered or reviewed if already performed.
All patients should be offered a second-trimester ultrasound to assess for structural abnormalities, regardless of screening or diagnostic testing results.
Diagnostic Tests
Diagnostic tests are recommended for patients with positive screening results, abnormal ultrasound findings, or other risk factors.
CVS and amniocentesis are the two main diagnostic tests:
Both tests carry a small risk of miscarriage.
Both can detect a wide range of chromosomal abnormalities, including those not screened for by serum or cfDNA tests.
CVS is performed earlier in pregnancy (typically between 10 and 13 weeks), while amniocentesis is performed later (typically between 15 and 20 weeks).
Chromosomal microarray analysis (CMA) can be performed on samples obtained through CVS or amniocentesis.
CMA can detect smaller chromosomal abnormalities than traditional karyotyping.
May be recommended for patients who prefer comprehensive prenatal detection of chromosomal aberrations.
Special Considerations
Twin Gestations:
Serum-based screening and cfDNA screening are less accurate in twin gestations.
NT measurements can be used in twin gestations, as the distribution does not differ significantly from singletons.
cfDNA screening is possible in twin gestations, but there is a higher rate of test failure.
Patients Who Have Undergone Preimplantation Genetic Testing:
Prenatal screening and diagnostic testing should still be offered to these patients.
While preimplantation genetic testing can reduce the risk of chromosomal abnormalities, it is not 100% accurate, and false-negative results can occur.
Incidental Findings:
Screening tests may reveal information about maternal or fetal health unrelated to chromosomal abnormalities.
Examples: Maternal malignancy, placental mosaicism, fetal growth restriction.
Interpretation and Communication of Results
Pretest and posttest counseling are essential.
Screen Positive Results:
Do not confirm the presence of a chromosomal abnormality but indicate an increased risk.
Diagnostic testing (CVS or amniocentesis) is recommended to confirm or rule out a chromosomal abnormality.
Patients should be counseled about the positive predictive value (PPV) of the screening test, which is the chance that a positive result is a true positive.
PPV is affected by the prevalence of the condition in the population being screened.
For example, the PPV for trisomy 21 is lower in younger women because the prevalence is lower in this group.
Screen Negative Results:
Substantially decrease the risk of the targeted aneuploidy but do not guarantee an unaffected fetus.
Patients should be counseled about the concept of residual risk, which is the chance that a fetus may still be affected even with a negative screening result.
Patients may still choose to pursue diagnostic testing, especially if other concerns arise during the pregnancy.
Cell-free DNA Test Failures:
Test failures are associated with an increased risk of aneuploidy.
Patients with a failed cfDNA test should be offered genetic counseling, comprehensive ultrasound evaluation, and diagnostic testing.
It is important to note that this outline is for informational purposes only and should not be considered medical advice. Please consult with a healthcare professional for any questions or concerns.
15
Anterpartum fetal surveillance
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16
Antibiotic prophylaxis in obstetrics
Antibiotic prophylaxis in obstetrics
Obstetrics
Antibiotic Prophylaxis in Obstetrics
Cesarean delivery is the most important risk factor for postpartum infection.
Antibiotic prophylaxis is recommended for all cesarean deliveries unless the patient is already receiving an antibiotic regimen with equivalent broad-spectrum coverage (e.g. for chorioamnionitis).
Prophylactic antibiotics should be administered within 60 minutes before the start of the cesarean delivery.
If this is not possible (e.g. emergent delivery), prophylaxis should be administered as soon as possible after the incision is made.
A single dose of a targeted antibiotic, such as a first-generation cephalosporin, is the first-line antibiotic of choice, unless significant drug allergies are present.
Cefazolin is a commonly used first-generation cephalosporin.
For patients with penicillin or cephalosporin allergies, clindamycin plus an aminoglycoside is recommended.
The addition of azithromycin to a standard antibiotic prophylaxis regimen may be considered for women undergoing a nonelective cesarean delivery.
Weight-based dosing of antibiotics is recommended for obese patients undergoing cesarean delivery.
A 2-g dose of cefazolin is recommended for patients weighing 80 kg or more.
The benefit of administering 3 g in obstetric patients weighing 120 kg or more has not been established.
Patients with lengthy surgical procedures (greater than 4 hours for cefazolin) or those who experience excessive blood loss (greater than 1,500 mL) should receive an additional intraoperative dose of the same antibiotic given for preincision prophylaxis.
Preoperative skin cleansing before cesarean delivery with an alcohol-based solution (e.g., a chlorhexidine–alcohol skin preparation) should be performed unless contraindicated.
Vaginal cleansing before cesarean delivery in laboring patients and those with ruptured membranes using either povidone–iodine or chlorhexidine gluconate may be considered.
Chlorhexidine gluconate solutions with high concentrations of alcohol are contraindicated for surgical preparation of the vagina.
Routine screening of obstetric patients for MRSA colonization is not recommended.
In obstetric patients known to be MRSA colonized, consideration may be given to adding a single dose of vancomycin to the recommended antibiotic prophylaxis regimen for women undergoing cesarean delivery.
Vancomycin alone does not provide sufficient coverage for cesarean delivery surgical prophylaxis.
A single dose of antibiotic at the time of repair is reasonable in the setting of obstetric anal sphincter injuries (OASIS).
Antibiotic prophylaxis is indicated for patients with preterm prelabor rupture of membranes (PROM) at less than 34 0/7 weeks of gestation to prolong the latency period between membrane rupture and delivery.
A 2-day course of therapy with a combination of intravenous ampicillin and erythromycin followed by a 5-day course of oral amoxicillin and erythromycin is recommended.
Amoxicillin–clavulanic acid is not recommended due to the possible increased risk of necrotizing enterocolitis.
Antibiotic prophylaxis should not be used for pregnancy prolongation in women with preterm labor and intact membranes.
Infective endocarditis prophylaxis is not recommended for women with acquired or congenital structural heart disease for either vaginal or cesarean delivery in the absence of infection, except possibly for the small subset of patients at highest potential risk of adverse cardiac outcomes.
Those at highest risk are women with cyanotic cardiac disease, or prosthetic valves, or both.
For these patients, antibiotic regimens for endocarditis prophylaxis can be administered as close to 30–60 minutes before the anticipated time of delivery as is feasible.
Evidence is insufficient to recommend antibiotic prophylaxis for history-, ultrasonography-, or examination-indicated cervical cerclage.
There are no data to recommend for or against prophylactic antibiotics for postpartum dilatation and curettage or placement of indwelling intrauterine balloon catheters in the clinical situation of retained placenta or postpartum hemorrhage.
The use of prophylactic antibiotics in the setting of severe perineal trauma or obstetric anal sphincter injuries (OASIS) has not been extensively studied.
The use of a single preoperative dose of doxycycline is recommended to prevent infection after surgical management of early pregnancy loss.
Important Note: This outline is based on the provided sources. Clinical practice guidelines and recommendations can change over time, so it's always best to consult the most up-to-date sources and clinical judgment when making treatment decisions.
Antibiotic Prophylaxis in Gynecology
Hysterectomy
Vaginal, abdominal, laparoscopic, or robotic hysterectomy: Single-dose antimicrobial prophylaxis with cefazolin is recommended.
For patients weighing more than 120 kg, a 3-g intravenous dose of cefazolin is recommended. For those weighing 80 kg or less, a 1-g dose can be considered.
In surgical cases with excessive blood loss (exceeding 1,500 mL), a second dose of prophylactic antibiotics may be appropriate.
Other Laparoscopic and Laparotomy Procedures
Antibiotic prophylaxis is not recommended for diagnostic or operative laparoscopy if entry into the bowel or vagina is not anticipated.
Single-dose antibiotic prophylaxis may be considered for laparotomy.
Consider antibiotic prophylaxis for patients at very high risk of conversion from laparoscopy to laparotomy.
Hysterosalpingography and Chromotubation
In patients with no history of pelvic infection, hysterosalpingography (HSG) can be performed without prophylactic antibiotics.
If HSG shows dilated fallopian tubes, doxycycline (100 mg twice daily for 5 days) is recommended to reduce the incidence of post-HSG pelvic inflammatory disease (PID).
In patients with a history of pelvic infection, doxycycline can be administered before the procedure and continued if dilated fallopian tubes are found.
Neither HSG nor chromotubation should be performed in patients thought to have an active pelvic infection.
Because chromotubation at the time of diagnostic laparoscopy is similar to HSG, the same prophylaxis regimen is reasonable for chromotubation.
Sonohysterography
Routine antibiotic prophylaxis is not recommended for patients undergoing sonohysterography.
Hysteroscopy
Antibiotic prophylaxis is not recommended for routine hysteroscopic procedures.
Endometrial Ablation
The role of antibiotic prophylaxis for endometrial ablation is unclear.
One randomized trial found no difference in infection rates between women who received antibiotic prophylaxis and those who received a placebo.
Intrauterine Device (IUD) Insertion
Routine antibiotic prophylaxis is not recommended before IUD insertion.
Endometrial Biopsy
Routine antimicrobial prophylaxis is not recommended before endometrial biopsy.
Uterine Evacuation
Induced abortion: Antimicrobial prophylaxis should be administered.
Early pregnancy loss: Antimicrobial prophylaxis should be administered.
A single preoperative dose of doxycycline is recommended to prevent infection after surgical management.
Colporrhaphy and Vaginal Slings
Antibiotic prophylaxis is reasonable for patients undergoing anterior or posterior colporrhaphy or transvaginally placed slings.
Postoperative Indwelling Catheters
The sources do not provide a clear recommendation on antibiotic prophylaxis for postoperative indwelling catheters.
Cystoscopy
Antibiotic prophylaxis is not recommended for cystoscopy in women with negative urine cultures.
Cervical Tissue Excision Procedures
Antibiotic prophylaxis is not necessary for cervical excision procedures, including loop electrosurgical excision procedure, biopsy, or endocervical curettage.
Vulvectomy
The role of antibiotic prophylaxis for vulvectomy is not clear.
Oocyte Donation
The role of antibiotic prophylaxis for oocyte donation is not clear.
Embryo Transfer
Routine antibiotic prophylaxis is not recommended before embryo transfer.
Note: The sources do not discuss the role of antibiotic prophylaxis in the management of conditions such as mastitis. However, information on the treatment of mastitis is provided in source.
This outline is based on the provided sources. Clinical practice guidelines and recommendations can change over time, so it's always best to consult the most up-to-date sources and clinical judgment when making treatment decisions.
17
Antipartum Fetal Surveillance
Antipartum Fetal Surveillance
Obstetrics
Antepartum Fetal Surveillance - Summary
Introduction
Definition and Purpose: Antepartum fetal surveillance aims to assess fetal well-being to reduce the risk of stillbirth. Techniques include fetal heart rate (FHR) monitoring, ultrasound, and Doppler velocimetry. Surveillance is used in pregnancies complicated by conditions like diabetes and fetal growth restriction.
Fetal Physiology: FHR patterns, fetal activity, and muscle tone are sensitive to hypoxemia and acidemia. Reduced renal perfusion due to hypoxemia may lead to oligohydramnios. Acute events like placental abruption or umbilical cord accidents are not always predictable by fetal surveillance techniques.
Surveillance Techniques
Maternal Perception of Fetal Movement: Decreased fetal movement may indicate fetal distress, but studies show that fetal movement counting alone does not significantly reduce perinatal mortality. Multiple counting protocols exist, with no optimal approach defined.
Contraction Stress Test (CST): The CST assesses FHR response to uterine contractions, identifying late decelerations that indicate poor fetal oxygenation. Contractions can be induced by nipple stimulation or intravenous oxytocin.
Nonstress Test (NST): Measures FHR response to fetal movement; a reactive test indicates normal autonomic function. Vibroacoustic stimulation can help reduce nonreactive results by eliciting FHR accelerations.
Biophysical Profile (BPP): Combines an NST with ultrasound evaluations of fetal breathing, movement, tone, and amniotic fluid volume. Scores range from 0-10, with lower scores indicating potential fetal compromise.
Modified BPP: Combines NST with amniotic fluid volume assessment to assess both short-term and long-term fetal well-being.
Umbilical Artery Doppler Velocimetry: Assesses vascular resistance in pregnancies with fetal growth restriction. Abnormal findings include reduced or reversed diastolic flow, which correlates with hypoxemia and increased perinatal risk.
Management Recommendations
Indications for Testing: Surveillance should be initiated for pregnancies at increased risk of fetal demise. Testing is usually started at 32 weeks gestation for most high-risk pregnancies, but may start earlier in severe cases.
Frequency of Testing: For persistent high-risk conditions, weekly testing with NST, BPP, or CST is typical. More frequent testing may be indicated for severe high-risk conditions, but the optimal frequency remains unknown.
Response to Abnormal Results: Abnormal surveillance results should be followed by additional testing or delivery, depending on gestational age and overall maternal and fetal health. The management approach is individualized.
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Antiphospholipid syndrome
Antiphospholipid syndrome
General
Introduction
Definition and Characteristics: Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPL) that increase the risk of thrombosis and pregnancy-related complications. It can lead to both arterial and venous thrombosis, as well as recurrent pregnancy loss (unexplained, consecutive), 1 or more loss of 10wks of gestation with normal morphology, 1 or more premature birth before 34 weeks preeclampsia, and fetal growth restriction. APS primarily affects women of reproductive age, making up around 70% of diagnosed cases.
Antibodies Involved: APS is diagnosed by the presence of specific antibodies including lupus anticoagulant (LA), anticardiolipin antibodies (aCL), and anti-β2 glycoprotein I antibodies. These antibodies must be present on two separate occasions, at least 12 weeks apart, to confirm diagnosis. LA is detected via coagulation assays, while aCL and anti-β2 glycoprotein I antibodies are detected using enzyme-linked immunosorbent assays (ELISA).
Clinical and Laboratory Criteria: To confirm APS, patients must meet at least one clinical criterion and one laboratory criterion. Clinical criteria include vascular thrombosis or specific pregnancy complications. Laboratory criteria involve the persistence of antiphospholipid antibodies over time, confirmed by multiple tests.
Complications of APS
Thrombosis:
Venous Thrombosis: The most common complication, occurring in about 65-70% of APS patients. It frequently affects the lower extremities and can lead to deep vein thrombosis (DVT) or pulmonary embolism.
Arterial Thrombosis: Occurs in atypical sites such as the retinal, subclavian, or cerebral arteries, which can lead to serious complications such as stroke or transient ischemic attacks (TIAs).
Obstetric Complications:
Recurrent Pregnancy Loss: A significant complication, affecting up to 50% of pregnancies in APS patients. Most losses occur after 10 weeks of gestation.
Preeclampsia and Intrauterine Growth Restriction (IUGR): Women with APS are at increased risk for severe preeclampsia and poor fetal growth, with about 15-30% of pregnancies affected by these complications.
Placental Insufficiency: Due to impaired blood flow, placental insufficiency can lead to poor fetal growth, premature birth, and other complications.
Management of APS During Pregnancy
Thromboprophylaxis for Pregnancy:
Women with Prior Thrombotic Events: Prophylactic heparin is administered throughout pregnancy and continued for 6 weeks postpartum. Low-dose aspirin is also often used to reduce the risk of clot formation.
Women Without Prior Thrombotic Events: Prophylactic treatment with low-dose aspirin and heparin during pregnancy may be considered, particularly for patients with a history of recurrent pregnancy loss. Management is individualized based on patient history and risk factors.
Other Treatments:
Corticosteroids and IVIG: Corticosteroids are not routinely recommended due to potential adverse effects, and intravenous immunoglobulin (IVIG) has not shown consistent evidence of efficacy for APS management.
Postpartum Management: Continuation of anticoagulation for 6 weeks postpartum is recommended to reduce the risk of postpartum thrombosis. Options include heparin or a transition to coumarin (warfarin).
Contraceptive Considerations:
Avoidance of Estrogen: Estrogen-containing contraceptives increase the risk of thrombosis and are contraindicated in women with APS. Progesterone-only options, such as pills or intrauterine devices (IUDs), are considered safer alternatives for these patients.
Key Recommendations
Accurate Diagnosis: Diagnosis requires meeting both clinical and laboratory criteria, with a persistent presence of antiphospholipid antibodies on at least two occasions separated by at least 12 weeks.
Management of Pregnancy: Prophylactic anticoagulation with heparin and low-dose aspirin is recommended for pregnant women with APS, particularly those with a history of thrombotic events or pregnancy loss.
Contraception Guidance: Estrogen-containing contraceptives should be avoided in women with APS due to increased thrombosis risk, with progesterone-only methods being the preferred alternative.
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Asthma
Asthma
Obstetrics
Asthma in Pregnancy - Summary
Introduction
Prevalence and Impact: Asthma affects approximately 4-8% of pregnancies and poses significant risks if not well controlled. Poorly managed asthma during pregnancy can increase the likelihood of complications such as prematurity, low birth weight, cesarean delivery, preeclampsia, and fetal growth restriction. Mild and well-controlled asthma, however, is associated with favorable pregnancy outcomes.
Management Goal: The primary goal of asthma management during pregnancy is to maintain adequate maternal oxygenation to prevent fetal hypoxia. Optimal management involves regular monitoring of lung function, controlling triggers, educating patients, and using pharmacologic therapy tailored to the severity of asthma.
Effects of Pregnancy on Asthma
Asthma Course During Pregnancy: The course of asthma during pregnancy varies—symptoms may worsen, improve, or remain unchanged. Pregnant women with asthma, even if well-controlled, require regular monitoring through peak expiratory flow rate (PEFR) and forced expiratory volume (FEV1) testing to assess changes in pulmonary function.
Asthma Severity and Classification
Severity Levels: Asthma in pregnancy is classified into mild intermittent, mild persistent, moderate persistent, and severe persistent based on symptom frequency and pulmonary function tests (PEFR and FEV1). Regular assessment is crucial as asthma severity may change during pregnancy, affecting treatment requirements.
Management Strategies
Pharmacologic Therapy:
Rescue Therapy: Inhaled short-acting β2-agonists (e.g., albuterol) are the first-line rescue medications for pregnant women with asthma.
Controller Therapy: For persistent asthma, inhaled corticosteroids are the preferred first-line therapy. Budesonide is considered the safest corticosteroid for use during pregnancy. For moderate to severe asthma, long-acting β2-agonists or oral corticosteroids may be added.
Add-On Therapy: Long-acting β2-agonists are the preferred add-on therapy when asthma is not controlled with medium-dose corticosteroids.
Nonpharmacologic Management:
Avoiding Triggers: Identifying and controlling asthma triggers, including allergens and irritants like tobacco smoke, is important for reducing symptom severity.
Patient Education: Emphasizing self-management skills, including proper inhaler use, self-monitoring, and handling exacerbations promptly, can improve asthma outcomes.
Management During Labor and Postpartum
Intrapartum Management: Asthma medications should be continued during labor and delivery. Adequate analgesia and hydration are important to reduce the risk of bronchospasm. Systemic corticosteroids may be needed during labor for patients on long-term corticosteroids to prevent adrenal insufficiency.
Postpartum Considerations: Asthma medications, including inhaled corticosteroids, β2-agonists, theophylline, and antihistamines, are generally safe during breastfeeding. Breastfeeding is encouraged, as the benefits outweigh the potential risks of medication transfer through breast milk.
Clinical Recommendations
Asthma Control During Pregnancy: It is safer to use asthma medications to maintain good control rather than allow symptoms or exacerbations to persist, which may compromise maternal and fetal oxygenation.
Regular Monitoring: Pulmonary function should be routinely assessed using PEFR or FEV1, and therapy should be adjusted based on changes in asthma severity.
Step-Up/Step-Down Therapy: Adjust therapy using a step-wise approach to achieve and maintain asthma control, and cautiously reduce treatment only after prolonged stability.
Avoiding New Immunotherapy: Starting allergen immunotherapy during pregnancy is generally not recommended due to the risk of anaphylaxis, but maintenance therapy can be continued if well tolerated.
20
Bariatric Surgery
Bariatric Surgery
Bariatric Surgery and Pregnancy - Summary
Introduction
Obesity and Pregnancy: Obesity is a growing epidemic, with over 66% of adults in the U.S. considered overweight or obese. Maternal obesity, defined as a body mass index (BMI) of 30 or greater, has significant effects on pregnancy outcomes, including reduced fertility due to oligo-ovulation and anovulation. Obese women are at higher risk of complications such as gestational diabetes, preeclampsia, cesarean delivery, and increased infectious morbidity.
Bariatric Surgery: Bariatric surgery is increasingly used for weight loss in individuals with a BMI of 40 or higher, or 35 or higher with comorbidities. The primary procedures include Roux-en-Y gastric bypass (combining restrictive and malabsorptive effects) and adjustable gastric banding (restrictive). Bariatric surgery can improve fertility outcomes in obese patients, although it is not primarily a treatment for infertility.
Maternal and Fetal Outcomes After Bariatric Surgery
Maternal Outcomes:
Bariatric surgery generally reduces obesity-related complications, including hypertension, gestational diabetes, and preeclampsia. Studies show a decreased prevalence of these conditions in women who had bariatric surgery compared to before surgery.
The average weight gain during pregnancy is typically lower post-surgery, with fewer occurrences of macrosomia and large-for-gestational-age infants. Despite the benefits, complications like bowel obstruction, gastrointestinal hemorrhage, and internal hernias may still arise, often necessitating surgical intervention during pregnancy.
Fetal Outcomes: Bariatric surgery is associated with a reduction in the number of large-for-gestational-age infants. No increased risk of congenital anomalies has been found compared to the general population. Maternal nutritional deficiencies after surgery can impact fetal growth; therefore, monitoring and supplementation are crucial.
Management During Pregnancy After Bariatric Surgery
Preconception Counseling: Women should receive preconception counseling after bariatric surgery, with special attention to contraception, as pregnancy rates double among post-surgery adolescents. Oral contraceptives may be less effective in patients with malabsorptive procedures, and alternative forms of contraception are recommended.
Nutritional Monitoring: Nutritional deficiencies, particularly in iron, vitamin B12, folate, vitamin D, and calcium, are common after bariatric surgery and should be monitored. Women are advised to take prenatal vitamins in addition to multivitamins, and supplementation with higher doses of folic acid may be required. Monitoring should continue postpartum, especially in breastfeeding women, as nutritional deficiencies can affect the infant.
Gestational Diabetes Screening: The use of the 50-g glucose load test may not be well tolerated due to "dumping syndrome" in women who underwent malabsorptive surgery. Instead, home glucose monitoring or alternative screening methods are recommended.
Labor and Delivery Considerations: Bariatric surgery itself does not necessitate cesarean delivery, although rates are higher in this population due to other factors such as previous cesarean delivery and obesity. Consultation with a bariatric surgeon may be beneficial if the patient has had extensive abdominal surgery.
Key Recommendations
Preconception and Contraception: Counseling should address the increased pregnancy risk post-surgery and consider nonoral contraception due to potential malabsorption of oral contraceptives.
Nutritional Surveillance: Micronutrient deficiencies should be evaluated at the start of pregnancy, with ongoing monitoring each trimester to ensure adequate nutrition.
Pregnancy Management: Consider alternative glucose screening methods for gestational diabetes. Consult with a bariatric surgeon if complications such as gastrointestinal symptoms arise.
21
Bartholin’s Abscess
Bartholin’s Abscess
22
Benign Breast Disorders
Benign Breast Disorders
Diagnosis and Management of Benign Breast Disorders - Summary
Introduction
Definition: Benign breast disorders include a wide range of conditions such as breast masses, cysts, abnormalities detected by imaging, nipple discharge, breast pain (mastalgia), inflammatory breast disease, and skin disorders.
Categories: Benign breast lesions are divided into three major categories:
Nonproliferative: Includes simple cysts and mild hyperplasia.
Proliferative Without Atypia: Fibroadenomas, intraductal papillomas, sclerosing adenosis, and moderate hyperplasia.
Atypical Hyperplasia: Atypical ductal hyperplasia and atypical lobular hyperplasia.
Purpose of Management: The aim of managing benign breast disorders is to alleviate symptoms, differentiate benign from malignant conditions, and identify women at higher risk of breast cancer to initiate surveillance or preventive measures.
Types of Benign Breast Lesions
Nonproliferative Lesions:
Simple Breast Cysts: The most common type of nonproliferative lesion, found in up to one-third of women aged 35-50. These cysts are benign and may only require aspiration if symptomatic.
Mild Hyperplasia: Focal thickening of duct epithelial cell layers, not associated with an increased risk of breast cancer.
Proliferative Lesions Without Atypia:
Fibroadenomas: Most common in young women, fibroadenomas are firm, well-circumscribed, and mobile masses. Giant fibroadenomas are a variant that can distort breast tissue.
Sclerosing Adenosis: Involves increased glandular components within lobular units, with a slight increase in future breast cancer risk.
Radial Scars: Pseudoproliferative lesions that are incidental findings but may facilitate the development of atypical proliferations.
Atypical Hyperplasia:
Atypical Ductal and Lobular Hyperplasia: Identified on histologic evaluation, associated with a substantially increased risk of future breast cancer development.
Common Symptoms and Clinical Evaluation
Breast Mass: The most common presentation of benign breast disorders. Evaluation involves patient history, physical examination, and age-appropriate imaging (e.g., ultrasonography for those younger than 30 years and mammography for those 30 years and older).
Nipple Discharge:
Benign Discharge: More likely bilateral, expressed (not spontaneous), and non-bloody.
Concerning Discharge: Unilateral, spontaneous, and bloody or serous, which warrants further investigation and imaging.
Mastalgia:
Cyclic and Noncyclic Mastalgia: Cyclic mastalgia is related to menstrual cycles, while noncyclic can result from trauma or other etiologies like mastitis.
Extramammary Pain: Conditions like costochondritis, chest trauma, and certain cardiac or gastrointestinal issues may mimic breast pain.
Evaluation and Management Strategies
Imaging:
BI-RADS System: Used to classify imaging findings and guide management decisions. BI-RADS categories help determine the likelihood of malignancy and the need for further testing or biopsy.
Histologic Evaluation:
Fine-Needle Aspiration (FNA): Used for cytologic evaluation, though core needle biopsy is preferred for more definitive diagnosis.
Core Needle Biopsy: Minimally invasive, provides histologic samples, and allows for marker placement for future reference.
Management of Common Benign Conditions:
Simple Cysts: Typically managed conservatively unless symptomatic.
Fibroadenomas: May be monitored if asymptomatic but excised if they cause significant symptoms or grow.
Radial Scars and Atypical Hyperplasia: Often require excisional biopsy to confirm the diagnosis and exclude malignancy.
Risk Reduction and Surveillance
Increased Risk Lesions:
Women with atypical hyperplasia or lobular carcinoma in situ (LCIS) are at an increased risk of breast cancer and should be offered enhanced screening and risk-reducing strategies such as chemoprophylaxis (e.g., tamoxifen, raloxifene).
LCIS Management: Surgical excision is often recommended to rule out associated carcinoma, and ongoing screening with mammography and clinical breast exams is essential.
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BRCA
BRCA
Gynecology
Hereditary Breast and Ovarian Cancer Syndromes
All patients diagnosed with ovarian, fallopian tube, or peritoneal carcinoma should undergo genetic risk evaluation, regardless of family history. This is because the presence of a familial cancer syndrome, such as BRCA1 or BRCA2 or Lynch syndrome, can affect treatment, post-treatment care, and testing of other family members.
Hereditary breast and ovarian cancer syndrome (HBOC) is an inherited cancer-susceptibility syndrome. It is characterized by multiple family members diagnosed with breast cancer, ovarian cancer, or both.
For simplicity, ovarian cancer is used in medical writing to refer to fallopian tube cancer and primary peritoneal cancer as well. This is due to the shared origins and management approaches for these cancers.
Germline mutations in the BRCA1 and BRCA2 genes are responsible for most HBOC cases.
These mutations are present in 9–24% of epithelial ovarian cancer cases and approximately 4.5% of breast cancer cases.
Both genes are tumor suppressor genes, which encode proteins that are part of the DNA repair process.
Individuals with HBOC inherit one defective allele in BRCA1 or BRCA2 from either parent. They are born with one normal and one defective copy of the gene.
Other genes are implicated in HBOC, accounting for up to 25% of hereditary ovarian cancer risk.
Table 1 in lists some of these genes and their associated cancer risks.
Patients with these mutations may benefit from risk-reduction strategies for breast and/or ovarian cancer.
Risk of Breast Cancer:
Individuals with a BRCA1 or BRCA2 mutation have a 45–85% risk of developing breast cancer by age 70.
A meta-analysis of 10 studies involving 1,641 BRCA mutation carriers found a mean cumulative risk of breast cancer of 57% for BRCA1 and 49% for BRCA2 carriers.
For BRCA mutation carriers already diagnosed with breast cancer, the 10-year risk of developing ovarian cancer is 12.7% for BRCA1 and 6.8% for BRCA2.
Risk of Ovarian Cancer:
Familial genetic syndromes are the strongest known risk factors for ovarian cancer, accounting for 10–12% of cases.
BRCA gene mutations are involved in about 10% of cases, while Lynch syndrome is involved in 2–3% of cases.
The estimated lifetime risk of ovarian cancer is 40% in BRCA1 mutation carriers and 18% in BRCA2 mutation carriers.
However, due to incomplete penetrance, 35–85% of BRCA carriers do not develop ovarian cancer, and 20–30% never develop breast cancer.
BRCA mutations account for about 90% of ovarian cancer cases in families with a history of ovarian or breast cancer.
The majority of BRCA-associated ovarian cancers are high-grade serous or endometrioid carcinomas.
Mucinous cancer and borderline ovarian tumors do not appear to be associated with BRCA mutations.
There is growing evidence that the fallopian tube is the origin for many BRCA-associated high-grade serous cancers.
Studies have found early microscopic high-grade cancer and serous tubal intraepithelial carcinoma, predominantly in the fallopian tubes of women with BRCA1 and BRCA2 mutations who underwent risk-reducing salpingo-oophorectomy.
These occult lesions are more frequent when salpingo-oophorectomy is delayed, and women with these findings have a higher risk of subsequent peritoneal carcinoma.
Genetic Counseling:
Genetic counseling is recommended for all women with ovarian epithelial cancer (including fallopian tube cancer and primary peritoneal cancer) and individuals with a personal or family history of breast or ovarian cancer.
It should be a routine part of obstetric and gynecologic practice.
It is also recommended for women who meet certain criteria, including those with a family history of certain cancers, early-onset breast cancer, or Ashkenazi Jewish ancestry.
Ideally, genetic testing should begin with the cancer-affected individual in the family. If that is not possible, testing the closest cancer-affected relative may be appropriate, but a negative result may be uninformative.
Genetic Testing:
Genetic testing is recommended when risk assessment during genetic counseling suggests an inherited cancer syndrome for which specific genes have been identified and when the results will likely influence medical management.
The two main options for HBOC are BRCA mutation testing and multigene panel testing, which includes BRCA and other genetic mutations.
Multigene panel testing is helpful when multiple genes may be involved or when single-gene testing has not found a pathogenic variant.
It should be offered by a healthcare provider specializing in cancer genetics and after thorough genetic counseling and informed consent.
Risk-Reducing Strategies:
Women with BRCA mutations or other actionable deleterious mutations predisposing to breast cancer should be offered risk-reducing bilateral mastectomy.
Women with similar mutations predisposing to ovarian cancer should be offered risk-reducing bilateral salpingo-oophorectomy.
The timing of this procedure can be individualized based on the specific mutation, the patient's desire for future childbearing, and family history.
Typically, it is recommended at age 35–40 for BRCA1 carriers and age 40–45 for BRCA2 carriers.
Note: This outline focuses on information directly from the sources provided. For a complete understanding of hereditary breast and ovarian cancer syndromes, it's recommended to consult with a healthcare professional and refer to updated medical guidelines.
24
Breast disease and breast cancer screening
Breast disease and breast cancer screening
Breast Cancer Risk Assessment and Screening in Average-Risk Women - Summary
Introduction
Prevalence: Breast cancer is the most commonly diagnosed cancer in women in the United States, accounting for 30% of all new cancer cases. It is also the second leading cause of cancer death.
Screening Benefits: Mammography screening starting at age 40 has been shown to reduce breast cancer mortality. However, screening has associated risks, including false positives, overdiagnosis, and overtreatment.
Guideline Variations: Recommendations on when to start, stop, and the frequency of mammography vary between major organizations due to the need to balance benefits and harms. Guidelines emphasize shared decision-making based on individual patient preferences and values.
Background
Risk Factors:
Demographic Factors: Female gender and advancing age are the two strongest risk factors for breast cancer.
Familial Risk: Family history of breast cancer, ovarian cancer, or other germline mutation-associated cancers (e.g., prostate, pancreatic) increases risk. Women with germline mutations, such as BRCA1 or BRCA2, have a significantly increased risk.
Reproductive Risk Factors: Early menarche, late menopause, nulliparity, and long intervals between menarche and first birth are linked with increased risk of hormone receptor-positive breast cancer.
Hormone Therapy: Combined hormone therapy (estrogen and progestin) for menopause increases breast cancer risk, whereas estrogen alone does not have the same effect.
Lifestyle Factors: High BMI, alcohol use, smoking, and lack of breastfeeding also increase the risk.
Breast Density: Dense breast tissue increases both the risk of breast cancer and reduces the sensitivity of mammography screening.
Screening Recommendations
Mammography Initiation:
Offer at 40 years: Women at average risk should be offered mammography from age 40.
Mandatory by 50 years: Screening should start by age 50 at the latest.
Frequency:
Annual or Biennial: Screening can be conducted annually or biennially, depending on patient preferences and risk factors.
Stopping Age:
Until at Least 75: Screening should continue until at least age 75, beyond which it depends on overall health status and longevity.
Potential Harms of Screening
False Positives: False-positive results can lead to unnecessary anxiety, additional tests, and biopsies. The cumulative false-positive rate is higher with annual screening compared to biennial screening.
Overdiagnosis: Overdiagnosis refers to the identification of cancers that would not progress to symptomatic disease, leading to overtreatment.
Radiation Exposure: There is a very low risk of developing radiation-induced breast cancer due to mammography, but the benefits of early detection typically outweigh this risk.
Shared Decision-Making
Importance: Screening decisions should reflect patients' personal values, weighing the potential benefits against the harms such as false positives, overdiagnosis, and treatment side effects.
Patient Preferences: Patients should be informed about the different screening options, including starting age, screening intervals, and stopping age, to help guide their decisions.
Clinical Breast Examination (CBE) and Breast Self-Awareness
CBE:
May Be Offered: Screening CBE may be offered every 1-3 years for women aged 25-39 and annually from age 40. It continues to be recommended for women at high risk.
Breast Self-Awareness: Women should be encouraged to know the normal appearance and feel of their breasts and report changes to their healthcare provider. Routine breast self-examination is no longer recommended for average-risk women due to lack of evidence on reducing mortality.
25
Breastfeeding
Breastfeeding
Obstetrics
Comprehensive Outline of Breastfeeding Challenges
The sources outline several challenges associated with breastfeeding, exploring their causes, signs and symptoms, and management strategies.
Engorgement
Definition: Engorgement refers to the physiological breast fullness that typically occurs between days 3 and 5 postpartum. It signals the transition to mature milk production.
Causes: The distention of the alveolar ducts with milk leads to vascular and lymphatic compression, resulting in breast fullness and tenderness.
Risk Factors: Primiparity, high intravenous fluid intake during labor, history of premenstrual breast tenderness, and breast surgery are associated with increased risk and severity. Cesarean deliveries can delay the onset of peak engorgement compared to vaginal births.
Symptoms:
Bilateral breast firmness
Pain and tenderness
Difficulty with infant latch due to flattening of the nipple-areolar complex
Management:
Expectant management for mild symptoms and adequate infant latch.
Minimal milk expression to relieve symptoms, as excessive emptying can exacerbate engorgement and related issues like plugged ducts.
Early and frequent breastfeeding to stimulate milk flow and prevent milk stasis.
Reverse pressure softening techniques to address breast edema, improving latch by reducing tension on the nipple-areolar complex.
Limited evidence supports specific treatment recommendations, but acupuncture, hot and cold packs, herbal remedies, and cabbage leaves have been explored.
Persistent Pain with Breastfeeding
Significance: Persistent pain is a significant contributor to early and undesired weaning.
Causes:
Infant factors: Latch issues, ankyloglossia (tongue-tie).
Maternal factors: Breast pump trauma or misuse, dermatoses, infection (bacterial, fungal), vasospasm, allodynia (pain from stimuli that are not normally painful), oversupply, plugged ducts.
Diagnosis: A thorough history and physical examination are crucial to identifying the underlying cause and guiding treatment. Postpartum depression screening is essential, as pain during breastfeeding has been linked to increased risk.
Management:
Addressing the specific cause of pain, such as improving latch technique, resolving infections, or treating vasospasm.
Nipple care and pain relief measures.
Lactation support and referral to specialists like lactation consultants, ear, nose, and throat specialists, or breastfeeding medicine providers if necessary.
Low Milk Supply
Context: Perceived or actual low milk supply is another major reason for undesired weaning.
Causes:
Maternal factors: Medical history (e.g., endocrine disorders, obesity, autoimmune diseases), anatomical issues (e.g., breast surgery, nipple variations), antepartum, intrapartum, or postpartum conditions (e.g., preeclampsia, medications, postpartum hemorrhage).
Infant factors: Ineffective latch, suboptimal suckling, early pacifier use, dehydration, jaundice.
Diagnosis:
Assess feeding frequency (8-12 times per day is considered normal).
Monitor infant weight gain (steady weight gain by day 4 or 5, exceeding birth weight by 10-14 days).
Observe for signs of adequate milk transfer (6-8 wet diapers per day).
Be aware of signs of low milk supply or dehydration in the infant (jaundice, insufficient wet or soiled diapers, lethargy, inconsolability, unchanged stool color, lack of weight gain).
Management:
Reassure patients with adequate feeding patterns, weight gain, and wet diaper output that their milk supply is sufficient.
Encourage more frequent feeding or expression to stimulate milk production.
Address underlying medical conditions or anatomical issues if present.
Consider supplementation with donor milk or formula if necessary for infants with excessive weight loss, poor growth, dehydration, or hyperbilirubinemia.
Use of Galactagogues
Definition: Galactagogues are substances thought to promote milk production. They can be pharmaceutical (e.g., domperidone, metoclopramide) or herbal (e.g., fenugreek, fennel, milk thistle).
Role:
Galactagogues are not considered first-line therapy due to limited evidence supporting their effectiveness and potential side effects.
They may be considered in specific situations, such as inducing lactation for an adopted infant.
Approach:
Thorough assessment by a lactation expert to optimize latch, positioning, and address any underlying medical causes of low milk supply before considering galactagogues.
Education on potential benefits and risks of specific galactagogues.
Mastitis
Definition: Mastitis is an inflammation of the breast tissue, often involving an infection.
Risk Factors: Oversupply, nipple injury, latch difficulties, and skipped feedings increase the risk.
Symptoms:
Fever, chills
Flu-like symptoms
Tender, hot, swollen, wedge-shaped area of the breast
Management:
Frequent and effective milk removal through breastfeeding or pumping is crucial to resolving milk stasis, the primary contributing factor.
Antibiotics (e.g., dicloxacillin, cephalexin, clindamycin) are used to treat the infection.
Pain relief measures and support for continued breastfeeding.
Investigate methicillin-resistant Staphylococcus aureus or abscess formation if no improvement with antibiotics.
Special Concerns with Late Preterm and Early Term Infants
Challenges: Mothers of late preterm (34-36 6/7 weeks gestation) and early term (37-38 6/7 weeks gestation) infants often experience greater difficulty establishing breastfeeding.
Contributing Factors:
Infant factors: Decreased alertness and stamina, challenges with latch, suck, and swallow compared to full-term infants.
Maternal factors: Increased likelihood of medical conditions or cesarean delivery, which can impact lactation.
Management:
Proactive lactation support, including education on hand expression and potential feeding difficulties.
Focus on developing and maintaining milk supply while infants develop their feeding skills.
Frequent hand expression, with or without a pump, in the immediate postpartum period.
Medication Use During Lactation
Concerns: Many women discontinue breastfeeding prematurely due to concerns about medication safety during lactation.
Realities:
Most medications are safe during breastfeeding.
Healthcare professionals should base their counseling on reliable sources like LactMed.
Guidance:
Open communication about medication use and any potential concerns.
Accurate information and reassurance based on evidence.
Continued breastfeeding unless a medication is contraindicated.
Substance Use Disorder and Breastfeeding
Recommendations:
Women using cocaine, phencyclidine, or illicit drugs should not breastfeed.
Marijuana use should be discouraged due to limited safety data and potential impact on child care.
Women stable on medication-assisted treatment for opioid use disorders can breastfeed if they are not using other drugs and have no contraindications.
Tobacco smoking should be discouraged, but it is not a strict contraindication to breastfeeding.
Considerations:
Assess for additional risk factors, such as mental health conditions, use of psychotropic medications, and other medical conditions.
Educate on the potential benefits of breastfeeding for infants exposed to opioids prenatally, as it may reduce the severity and duration of neonatal abstinence syndrome.
Palpable Breast Mass While Breastfeeding
Importance: Any persistent breast mass during lactation requires prompt evaluation to rule out pregnancy-associated breast cancer, which can have a worse prognosis if diagnosed postpartum.
Evaluation:
Ultrasound is typically the first-line imaging modality for pregnant and lactating women.
Mammography or digital breast tomosynthesis may be considered if ultrasound is inconclusive or suspicious.
Biopsy may be indicated if imaging reveals abnormal findings.
Management: Lactation support should be provided throughout the evaluation and treatment process.
This outline provides a comprehensive overview of common breastfeeding challenges, incorporating information from the provided sources. It highlights the importance of accurate assessment, appropriate management strategies, and ongoing support to address these challenges and help women achieve their breastfeeding goals.
26
Breech
Breech
Obstetrics
Term Breech Delivery Outline
The sources focus on the management of term singleton breech deliveries, emphasizing the shift towards planned cesarean deliveries and the role of external cephalic version (ECV). They also discuss the possibility of planned vaginal breech deliveries under specific circumstances.
Trends in Term Breech Delivery Management
Shift Towards Cesarean Deliveries: There is a growing trend in the United States to perform cesarean deliveries for term singleton breech presentations.
Decline in Vaginal Breech Delivery Expertise: The number of practitioners skilled and experienced in performing vaginal breech deliveries has decreased, affecting training opportunities even in academic settings.
Factors Influencing Delivery Mode Decision
Patient Preferences: The patient's wishes regarding the mode of delivery are crucial in the decision-making process.
Healthcare Provider Experience: The experience and comfort level of the healthcare provider in performing vaginal breech deliveries is a significant factor.
External Cephalic Version (ECV)
Definition: ECV is a procedure to turn a breech fetus to a cephalic (head-down) presentation.
Recommendation: ECV should be offered as an alternative to planned cesarean delivery for women with term singleton breech fetuses who desire a vaginal birth and have no contraindications.
Benefits: ECV significantly reduces the likelihood of cesarean delivery without increasing maternal or fetal complications.
Analgesia: Regional anesthesia (epidural or spinal) significantly increases the success rate of ECV.
Availability of Cesarean Delivery: ECV should only be performed in settings where cesarean delivery services are readily available if needed.
Planned Vaginal Breech Delivery
Considerations: While generally not recommended, planned vaginal breech delivery might be considered under specific hospital-specific protocol guidelines.
Eligibility and Labor Management: Strict criteria for patient selection and labor management are essential to ensure the safety of a planned vaginal breech delivery.
Informed Consent: Detailed informed consent, including the potential for higher perinatal/neonatal mortality and morbidity compared to cesarean delivery, is crucial.
Term Breech Trial Findings
Study Design: The Term Breech Trial, a large international randomized controlled trial, compared planned cesarean delivery with planned vaginal delivery for term breech presentations.
Results: The trial demonstrated lower perinatal mortality, neonatal mortality, and serious neonatal morbidity in the planned cesarean group compared to the planned vaginal group.
Impact on Practice: These findings led to the recommendation that planned vaginal breech delivery was no longer appropriate.
Subsequent Research and Observations
Long-Term Outcomes: Subsequent research, including 2-year follow-up of the Term Breech Trial participants, found no difference in long-term neurodevelopmental outcomes between children born via planned cesarean and those born via planned vaginal breech delivery.
Netherlands Study: A retrospective study in the Netherlands observed a decrease in neonatal mortality and birth trauma rates after the Term Breech Trial, possibly due to improved selection criteria for vaginal breech delivery candidates.
Current ACOG Recommendations
Shared Decision-Making: The decision regarding delivery mode should involve shared decision-making between the patient and the healthcare provider, considering the provider's experience and the patient's preferences.
ECV: ECV is recommended as a way to potentially reduce cesarean deliveries for term breech presentations.
Planned Vaginal Breech Delivery: Planned vaginal breech delivery may be considered under strict hospital-specific protocols, but detailed informed consent emphasizing the potential risks is mandatory.
Conclusion
The sources emphasize the importance of individualized care in managing term breech deliveries. While planned cesarean delivery remains the preferred option for many providers, ECV and carefully planned vaginal breech delivery under strict protocols are alternative options that should be considered based on patient preferences and provider experience. The sources highlight the ongoing debate regarding the long-term implications of different delivery modes and the need for shared decision-making in this context.
27
BSO
BSO
Gynecology
The study in Green Journal focuses on determining the optimal age for performing bilateral salpingo-oophorectomy (BSO) concurrently with hysterectomy for benign indications using an updated Markov model. The key findings are as follows:
1. Age Recommendation for BSO: The revised model suggests that BSO can be safely performed at age 50 or older without increasing overall mortality. Performing BSO before age 50, however, can increase mortality risks if estrogen therapy is not provided.
2. Estrogen Therapy Impact: For patients under 50 who undergo BSO, the study found that postoperative estrogen therapy significantly mitigates mortality risk, especially concerning cardiovascular disease (CVD) and stroke.
3. Cancer Risks: While BSO reduces ovarian cancer risk across all ages, the updated model indicates that for women over 50, it also lowers the risk for breast cancer and does not adversely affect colorectal or lung cancer mortality.
4. Cardiovascular Findings: The study challenges earlier models, particularly one from 2005, by showing that the cardiovascular risk associated with BSO was previously overestimated. The updated model reveals no increased CVD risk when BSO is performed after age 50.
5. Mortality Reduction through Hormone Therapy: For women undergoing BSO under 50, hormone therapy is beneficial in reducing risks associated with premature estrogen loss, such as increased CVD mortality.
The findings support BSO at the time of hysterectomy at age 50 or later, with hormone therapy as a viable option for younger patients requiring the procedure.
“A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited” on the Green Journal (Obstetrics & Gynecology) website
28
Cardiac disease in pregnancy
Cardiac disease in pregnancy
Obstetrics
Cardiac Disease in Pregnancy
Introduction
Maternal heart disease is a major threat to safe motherhood and women's long-term cardiovascular health.
Cardiovascular disease is the leading cause of death in pregnant women and women in the postpartum period in the United States.
Cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths.
There are disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women.
Background
Cardiovascular disease affects approximately 1–4% of the nearly 4 million pregnancies in the United States each year.
The incidence of pregnancy in women with congenital heart disease and acquired heart disease is on the rise.
The most common presentations of maternal acquired heart disease during pregnancy and the postpartum periods are heart failure, myocardial infarction, arrhythmia, or aortic dissection.
Diagnosis can be challenging because the overlap of cardiovascular symptoms with those of normal pregnancy may lead to delays in diagnosis and subsequent care.
Risk Factors
There are four key risk factors linked to cardiovascular disease-related maternal mortality:
Race/Ethnicity: Non-Hispanic black women have a 3.4 times higher risk of dying from cardiovascular disease-related pregnancy complications compared with non-Hispanic white women.
Age: Age older than 40 years increases the risk of heart disease-related maternal death 30 times the risk for women younger than 20 years.
Hypertension: Hypertensive disorders affect up to 10% of pregnancies and can lead to maternal morbidity and mortality.
Obesity: Prepregnancy obesity increases maternal death risk due to a cardiac cause.
Social determinants of disparities in cardiovascular disease in health and healthcare:
Increased rates of cardiovascular disease-related complications among women of color are explained, in part, by racial and ethnic bias in the provision of healthcare and health system processes.
Patient, physician, and health system-level factors can affect outcomes.
Physician implicit and explicit bias and overt racism can result in missed diagnoses or inappropriate treatment.
Health system barriers to efficient triage based on symptom severity, language barriers, and differences in cultural humility are important factors.
Non-Hispanic black women are more likely to develop gestational diabetes mellitus, pre-eclampsia, and have a preterm delivery or low-birth-weight infant compared with non-Hispanic white women.
Physiologic Changes in Pregnancy That Affect Cardiovascular Stress
Pregnancy is a natural stress test because the cardiovascular system undergoes structural and hemodynamic adaptations to sustain a high-volume load.
Hemodynamic Changes:
Pregnancy causes a continuous increase in cardiac output and plasma volume and a decrease in maternal systemic vascular resistance.
Blood pressure initially decreases but increases in the third trimester.
Uterine mechanical compression of the inferior vena cava can occur during the second and third trimesters.
Structural Changes:
The heart ventricles adapt to the plasma volume increase during pregnancy.
Left ventricular end diastolic volume increases by approximately 10%.
Left and right ventricular mass increase by approximately 50% and 40%, respectively.
Approximately 20% of women have diastolic dysfunction at term.
Structural changes of the maternal heart return to baseline before 1 year postpartum.
Hematologic, Coagulation, and Metabolic Changes:
Although intensified erythropoiesis in pregnancy increases red blood cell mass by 20–30%, this increase is proportionally lower than the increase in plasma volume, resulting in physiologic anemia from hemodilution.
Pregnancy is associated with physiologic and anatomic changes that increase the risk of thromboembolism.
Pregnancy also alters the levels of coagulation factors normally responsible for hemostasis.
From a metabolic standpoint, pregnancy is a catabolic state that leads to insulin resistance and an atherogenic lipid profile with elevated serum fatty acids.
Signs and Symptoms of Heart Disease
Normal pregnancy and postpartum symptoms and signs can overlap with findings reflective of underlying heart disease.
Health care providers should become familiar with the signs and symptoms of cardiovascular disease.
Clinical Considerations and Recommendations
Prepregnancy Counseling
Optimization of maternal health status should be attempted and achieved before pregnancy.
Women with known cardiovascular disease should be evaluated by a cardiologist ideally before pregnancy.
A detailed history, including family history and any current cardiovascular symptoms, physical examination, and review of medical records, should be obtained.
A comprehensive cardiovascular family history should include an inquiry about structural, vascular, or rhythm disorders and sudden unexpected death.
A known gene mutation, such as MYH7 for cardiomyopathy, may have implications for a patient's individual risk.
Pregnancy Heart Team
Patients with moderate and high-risk cardiovascular disease should be managed during pregnancy, delivery, and the postpartum period in medical centers with a multidisciplinary Pregnancy Heart Team.
The Pregnancy Heart Team should include obstetric providers, maternal–fetal medicine subspecialists, cardiologists, and an anesthesiologist at a minimum.
The Pregnancy Heart Team should work together to assess and counsel the patient regarding the individualized risks of her underlying cardiac condition.
Risk Assessment
A key area of competence and expertise for obstetric care providers is the ability to differentiate between common symptoms of pregnancy and those suggestive of cardiovascular disease.
All women should be assessed for cardiovascular disease in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm.
Risk assessment can be accomplished using one of the several available risk stratification models.
The Canadian Cardiac Disease in Pregnancy risk index (CARPREG II)
The Zwanger-schap bij Aangeboren HARtAfwijkingen (ZAHARA)
The modified World Health Organization (WHO) classification of maternal cardiovascular risk
Testing
Testing of maternal cardiac status is warranted during pregnancy or postpartum in women who present with symptoms such as shortness of breath, chest pain, or palpitations and known cardiovascular disease whether symptomatic or asymptomatic.
The type of testing and urgency of evaluation depends on the underlying cardiac condition and symptoms at the time of presentation.
Natriuretic peptides: should be measured in the presence of new clinical symptoms or suggestive signs of heart failure.
Electrocardiogram: should be performed in pregnant women presenting with chest pain, shortness of breath, or palpitations.
Chest Radiograph: should be considered as an important early test in pregnant or postpartum women presenting with shortness of breath.
Echocardiogram: should be performed in pregnant or postpartum women with known or suspected congenital heart disease.
Exercise Stress Test: is an important predictor of a woman’s ability to tolerate pregnancy.
Magnetic Resonance Imaging: is the preferred imaging modality in pregnant women to assess aortic dimension and for assessment of ventricular function and wall motion when echocardiography is non-diagnostic.
Holter Monitor or Prolonged Cardiac Monitoring Device: is helpful for assessing symptoms of palpitations, lightheadedness, and syncope during pregnancy.
Types of Preexisting Maternal Cardiac Disease With the Greatest Effect on Pregnancy and the Postpartum Period
Women with any high-risk cardiovascular disease, such as pulmonary hypertension, congenital heart disease, noncongenital valvular disease, dilated hypertrophic or peripartum cardiomyopathy, aortic disorders, or coronary artery disease should be monitored during pregnancy and the postpartum period.
Pulmonary Arterial Hypertension
Pulmonary arterial hypertension is defined as a mean pulmonary arterial pressure more than 25 mm Hg at rest.
Pulmonary arterial hypertension carries an increased risk of maternal mortality, reported to range from 9% to 28%.
All women with severe pulmonary arterial hypertension should be advised against pregnancy.
Congenital Heart Disease
Many patients with congenital heart disease require additional specialized care while pregnant.
Patients with high-risk lesions are counseled to avoid pregnancy or to proceed with surgical correction before pregnancy.
Noncongenital Valvular Disease
Noncongenital valvular disease requires specialized evaluation.
A transthoracic echocardiogram and an exercise stress test are generally recommended for patients with moderate-to-severe valve disease.
Ideally, symptomatic severe valve disease should be treated before pregnancy.
Mechanical Valve Prostheses
During pregnancy, mechanical valve prostheses and some cardiac lesions require therapeutic anticoagulation.
A detailed discussion about anticoagulation options and risks should be performed before pregnancy.
All pregnant patients with mechanical and bioprosthetic valves should be maintained on daily low-dose (81 mg) aspirin during pregnancy.
Preexisting Dilated Cardiomyopathy
Prepregnancy assessment will include a baseline BNP level, transthoracic echocardiogram, and an exercise stress test.
The cause of the cardiomyopathy should be evaluated.
Women with preexisting dilated cardiomyopathy have a high rate (25–40%) of major adverse cardiovascular events during pregnancy.
Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy is the most common genetic cardiac disease, with a prevalence of 2%.
Prepregnancy cardiovascular and genetic consultations are recommended for patients with hypertrophic cardiomyopathy.
Aortic Aneurysmal Disease and Dissection
Aortic aneurysmal disease and dissection in women of childbearing age are generally triggered genetically.
Before pregnancy, a thorough cardiovascular specialty consultation is recommended.
The risk of aortic dissection associated with these conditions is increased during pregnancy and postpartum.
Atrial Arrhythmias
Atrial arrhythmias that cause palpitations are a common indication for cardiac evaluation during pregnancy.
Any pregnant woman who presents with an arrhythmia should undergo an evaluation.
Ventricular Arrhythmias
Ventricular arrhythmias are rarely encountered during pregnancy.
If detected, a search for a cause and underlying structural heart disease is appropriate.
Peripartum Cardiomyopathy
Peripartum cardiomyopathy occurs in 25–100 per 100,000 live births in the United States.
It is characterized as a nonischemic cardiomyopathy presenting late in pregnancy or the first few months postpartum.
Most women eventually recover myocardial function.
The overall rate of death or cardiac transplantation for women presenting with peripartum cardiomyopathy is 5–10% by 1 year postpartum.
Peripartum cardiomyopathy disproportionately affects non-Hispanic black women.
Other risk factors include increased maternal age, multifetal pregnancies, gestational hypertension, and preeclampsia.
Women with a history of peripartum cardiomyopathy have a risk as high as 20% of experiencing a recurrence during subsequent pregnancies.
Management
Pregnant or postpartum women who present with shortness of breath, chest discomfort, palpitations, arrhythmias, or fluid retention should be evaluated for peripartum cardiomyopathy.
An echocardiogram is generally the most important diagnostic test.
Consultation with a cardiologist is recommended.
Medical management follows the same general principles as management of heart failure with a reduced ejection fraction.
For women who are pregnant at the time of diagnosis, timing and mode of delivery should be individualized.
Acute Coronary Events
Acute Myocardial Infarction and Acute Coronary Syndrome
Ischemic heart disease complicates 8 per 100,000 hospitalizations for pregnancy and postpartum care.
Maternal death occurs in 5–11% of affected patients with the highest risk in the peripartum period.
Risk factors include traditional and pregnancy-specific features.
Management
Every pregnant or postpartum patient with chest pain or cardiac symptoms should have consideration of acute coronary syndrome.
Management of the maternal condition should receive priority.
Initial medical management usually includes oxygen supplementation, nitrates, aspirin, intravenous unfractionated heparin, and beta-blocker therapy.
Maternal Cardiac Arrest
Maternal cardiac arrest occurs infrequently.
Etiologies include pregnancy-related and nonpregnancy-related conditions.
Management
An obstetric care provider is among the members of a multidisciplinary team that should be assembled immediately.
Management requires familiarity with the physiologic adaptations of pregnancy that affect the execution of interventions dictated by basic and advanced cardiac life support.
Aortocaval compression by a uterus larger than 20 weeks of gestation should be reduced with manual left uterine displacement.
Simultaneous concurrent interventions are recommended.
Preparations for fetal delivery should be initiated in parallel with maternal resuscitative efforts.
Perimortem Cesarean Delivery/Resuscitative Hysterotomy
When initial interventions are unsuccessful, timely consideration of perimortem cesarean delivery or resuscitative hysterotomy is recommended.
General Approaches to Pregnancy Management
Antepartum Management Principles
Pregnant women with cardiac disease should give birth at a hospital with the appropriate maternal level of care.
Women with complex congenital or noncongenital heart disease should be treated by a Pregnancy Heart Team.
In women with congenital heart disease, screening fetal echocardiogram is indicated at 18–22 weeks of gestation.
Daily low-dose aspirin prophylaxis is recommended in women at high risk of preeclampsia.
Prompt treatment of severe hypertension (systolic blood pressure more than 160 mm Hg and diastolic blood pressure more than 110 mm Hg) is recommended.
Intrapartum Management Principles
A detailed delivery plan should be determined between 20–30 weeks of gestation.
Women with stable cardiac disease can undergo a vaginal delivery at 39 weeks of gestation.
Anticoagulation must be carefully reviewed and managed during pregnancy and adjusted appropriately at the time of neuraxial anesthesia and delivery.
The most common intrapartum cardiac complications include pulmonary edema or arrhythmias.
Obstetric Anesthesia Principles
Cardiac disease patients may require an elevated level of monitoring and anesthetic care.
Consultation with an anesthesiologist should be performed antepartum.
Under the direction of an anesthesiologist, cardiac disease patients undergoing vaginal delivery should be offered epidural labor analgesia.
Exceptions for neuraxial anesthesia include the usual anesthetic contraindications and patients receiving pharmacologic anticoagulation.
Immediate Postpartum Management Principles
The postpartum period is a time of heightened risk of cardiovascular disease-related maternal morbidity and mortality.
Women with cardiac disease are at high risk of immediate complications during the early puerperium (first 7 days after delivery) and as long as 6 months postpartum.
Postpartum Considerations After Delivery Hospitalization
Complications are frequently encountered in the days, weeks, and months after delivery.
A postpartum follow-up visit with either the primary care provider or cardiologist is recommended within 7–10 days of delivery for women with hypertensive disorders or 7–14 days of delivery for women with heart disease/cardiovascular disorders.
Optimal care requires a team-based approach and a cardiovascular disease risk assessment.
Long-Term Considerations and Implications After Pregnancy
There are immediate and long-term continuity of care considerations for women with congenital or acquired heart and cardiovascular disease.
Specific and immediate considerations include:
Ensure proper cardiology follow-up is initiated during pregnancy or postpartum.
Acknowledge the effect of a chronic diagnosis and possible need for long-term medication use.
Refer patients with cardiovascular disease to lactation services when breastfeeding presents challenges.
Be mindful of the mental health implications of cardiovascular disease during the postpartum period and beyond.
Continuity of Care Considerations for Women With Cardiovascular Disease Risk Factors
Acute (gestational hypertension, preeclampsia) and chronic hypertensive disorders of pregnancy are important identifiers of patients at risk of cardiovascular disease.
Cardiovascular assessment and follow-up at 3 months postpartum is recommended for women with the following conditions:
Hypertension
Gestational diabetes mellitus
Intrauterine fetal growth restriction
Idiopathic preterm birth
Placental abruption
Obesity
Sleep disorders/moderate-to-severe obstructive sleep apnea
Maternal age older than 40 years
Cardiovascular risk screening within 3 months postpartum includes a detailed medical history, postpartum medication monitoring, a physical examination, and basic biochemical testing.
Ongoing Postpartum Care After the 3-Month Cardiovascular Assessment Visit
Continuing follow-up provides the opportunity for counseling, planning, and intervention to optimize underlying medical conditions.
Contraceptive needs can be considered, managed, or modified.
In addition to the usual prepregnancy topics such as folic acid usage, restoration to prepregnancy weight should be emphasized.
Women with pregnancy complications should be counseled regarding the risks of future cardiovascular disease and overt diabetes.
Breastfeeding should be recommended.
The patient must be educated about her individualized cardiovascular risk, and a recommended plan of care for future pregnancies should be developed.
Conclusion
Maternal heart disease is a significant public health concern.
Early identification and management of cardiovascular disease in pregnancy are essential to improve maternal and fetal outcomes.
A multidisciplinary approach to care is critical.
Please note: The sources primarily address cardiac disease in pregnancy in the United States. Information about prevalence, trends, and practices in other countries may vary and should be researched independently.
29
Cerclage
Cerclage
Obstetrics
Cervical Insufficiency: A Comprehensive Overview
I. Introduction and Background
Definition: Cervical insufficiency is defined as the inability of the cervix to retain a pregnancy in the second trimester without signs and symptoms of labor or contractions [1-3].
Cervix Function: The cervix, the lower part of the uterus connecting to the vagina, remains closed during pregnancy, providing support for the developing fetus.
Pathophysiology: The exact cause of cervical insufficiency is not fully understood [1]. Factors that may increase risk include:
Surgical trauma to the cervix from conization, LEEP procedures, dilation during pregnancy termination, or obstetric lacerations (data is inconsistent) [1, 4].
Congenital Müllerian anomalies, cervical collagen/elastin deficiencies, and in utero diethylstilbestrol exposure have been proposed, but not specifically linked to cervical insufficiency [4].
Challenges: Diagnosis is challenging due to a lack of clear criteria and objective findings [3, 4].
Scope: This presentation will discuss pathophysiology, screening, diagnosis, and management of cervical insufficiency, including the use of cerclage [2]. Other cervical issues like short cervical length are discussed in other ACOG publications [2].
II. Risk Factors
Prior Preterm Birth: The most significant risk factor [5-10].
The number of prior preterm births and gestational age at delivery are important considerations [11].
Recurrent Cervical Dilation [5].
History of Cervical Procedures:Cone biopsy, LEEP procedures [5, 12].
Data on association with preterm birth is inconsistent [11].
Risk may increase with excision depth >15 mm and a short interval between surgery and pregnancy [12].
Cervical Laceration [5].
Urogenital Abnormalities [5].
Low Maternal Pre-pregnancy Weight (BMI < 18.5) [11].
Smoking, Substance Abuse [11].
Short Interpregnancy Interval (< 18 months) [11].
III. Diagnosis
Historical Findings:Painless cervical dilation after the first trimester [4].
Subsequent pregnancy loss in the second trimester, usually before 24 weeks gestation [4].
Absence of contractions, labor, or other pathologies (bleeding, infection, ruptured membranes) [4].
Physical Examination: Painless cervical dilation in the second trimester [13, 14].
Ultrasonography:A short cervical length in the second trimester is associated with increased preterm birth risk, but not sufficient for diagnosing cervical insufficiency [1, 15].
Serial transvaginal ultrasound can help avoid unnecessary history-indicated cerclage procedures [16-18].
Dynamic cervical shortening during the exam may also be assessed [19].
IV. Non-Surgical Management
Activity Restriction, Bed Rest, Pelvic Rest: Not proven effective and discouraged [20-22].
Vaginal Pessary: Limited evidence suggests potential benefit in select high-risk patients [20]. However, it is generally not indicated in various clinical scenarios, including:
Women with a previous spontaneous preterm birth and a short cervix [23].
Women with no previous history of preterm birth but with a short cervix [24].
Multiple gestations with or without a history of preterm birth [25].
Progesterone Supplementation:Vaginal Progesterone:Recommended for women with no history of preterm birth but with a short cervix [26-29].
May be considered for patients with a history of preterm birth, singleton gestation, and a shortened cervix [29].
Not effective if the cervix is not shortened [28].
Not recommended as an alternative to 17-OHPC in the setting of a previous spontaneous preterm birth [29].
Dosing: Most studies used 200 mg daily from identification of a short cervix (<25 mm) at 18 0/7–25 6/7 weeks until 36–37 weeks, but no definitive data on optimal dose or formulation exists [24].
Intramuscular 17-OHPC:Not recommended for primary prevention of preterm birth in patients with a history of spontaneous preterm birth [30].
FDA has withdrawn approval of Makena and its generics due to insufficient data supporting effectiveness [31-33]. This decision impacts access to and availability of 17-OHPC [29].
Not indicated for primary prevention in women with a previous spontaneous preterm birth (singleton) [23].
Not indicated in women with no previous history of preterm birth and a short cervix [24].
Not indicated in multiple gestations [25].
V. Surgical Management: Cervical Cerclage
Description: A surgical procedure involving a stitch placed around the cervix to keep it closed [34].
Indications:History-Indicated Cerclage:History of one or more second-trimester pregnancy losses related to painless cervical dilation without labor or placental abruption [13, 35].
Prior cerclage due to painless cervical dilation in the second trimester [13, 14].
Placement typically occurs around 13–14 weeks gestation [36].
Randomized controlled trials show inconsistent results on efficacy [36].
Physical Examination-Indicated Cerclage (Emergency/Rescue Cerclage):Women presenting with advanced cervical dilation in the absence of labor or placental abruption [14, 37, 38].
Limited data suggest possible benefit [37, 39].
Placement may be beneficial after ruling out uterine activity and/or intraamniotic infection [40].
Ultrasound-Indicated Cerclage:Women with a current singleton pregnancy, prior spontaneous preterm birth before 34 weeks gestation, and a short cervical length (<25 mm) before 24 weeks gestation [14, 41, 42].
May be effective in this specific setting, but does not meet diagnostic criteria for cervical insufficiency [41, 42].
Associated with significant decreases in preterm birth outcomes and improvements in neonatal morbidity and mortality [41, 42].
Contraindications:Incidentally detected short cervical length in the second trimester without prior singleton preterm birth [43].
Twin pregnancies with cervical length <25 mm on ultrasound [44-46].
Cerclage solely based on prior LEEP, cone biopsy, or Müllerian anomaly [44].
Types of Cerclage:Transvaginal Cerclage:McDonald Technique: A purse-string suture of nonresorbable material is inserted at the cervicovaginal junction [34, 36].
Shirodkar Technique: Involves dissecting the vesicocervical mucosa to place the suture closer to the internal os [18, 34, 47]. Nonresorbable sutures are recommended [34].
No evidence supports the superiority of one suture type or technique over the other [21, 34, 38, 41].
Transabdominal Cerclage:Reserved for patients where transvaginal cerclage is not feasible due to anatomical limitations (e.g., after trachelectomy) or failed transvaginal cerclage [13, 35, 48].
Can be performed via laparotomy or laparoscopy [35]. No evidence favors one surgical approach over another [44].
Usually performed in the late first or early second trimester (10–14 weeks gestation) or in a nonpregnant state [35, 49].
The stitch can remain between pregnancies, with subsequent cesarean delivery [35].
Perioperative and Postoperative Management:Antibiotics and prophylactic tocolytics do not improve efficacy [22, 50].
Serial ultrasound surveillance of cervical length after cerclage is unnecessary [50, 51].
Cerclage Removal:Timing:Transvaginal McDonald cerclage removal is recommended at 36–37 weeks gestation in uncomplicated cases [40, 50, 52].
For planned cesarean delivery at or beyond 39 weeks, cerclage removal can occur at delivery, but the possibility of spontaneous labor between 37 and 39 weeks should be considered [50, 52, 53].
Setting: McDonald cerclage removal can typically be performed in an office setting [40, 52].
Management of Complications:Preterm Premature Rupture of Membranes (PPROM):No prospective studies to guide management [47].
Retrospective studies show inconsistent results, but cerclage retention for >24 hours after PPROM may prolong pregnancy [47].
Cerclage retention with PPROM has been associated with increased neonatal mortality from sepsis and maternal chorioamnionitis in some studies [47, 54].
No firm recommendation on removal or retention, both are reasonable [47, 52].
Prolonged antibiotic prophylaxis beyond 7 days is not recommended if the cerclage remains [47, 52].
Preterm Labor:Diagnosis may be more difficult with cerclage [55, 56].
Clinical judgment is advised regarding cerclage removal [55].
Routine preterm labor management should be followed [55-58].
Cerclage removal is recommended if cervical change, painful contractions, or bleeding progress [55, 56].
Complications of Cerclage:Rupture of membranes, chorioamnionitis, cervical lacerations, and suture displacement [49].
Incidence varies depending on timing and indication for cerclage [49].
Increased risk of complications when placed with membrane rupture or dilation [49].
Rare but life-threatening complications: uterine rupture and maternal septicemia [49].
Transabdominal cerclage carries a higher risk of hemorrhage, along with other abdominal surgery complications [59]. It generally precludes uterine evacuation or vaginal delivery [59].
VI. Evidence and Guidelines
ACOG Practice Bulletin No. 142: This document, published in 2014 and reaffirmed in 2016, provides a comprehensive review of evidence on cervical insufficiency and guidelines for managing it using cerclage [35, 60].
ACOG Updated Clinical Guidance (April 2023): This update addresses the FDA's withdrawal of Makena (17-OHPC) approval and provides revised recommendations on the use of progesterone for preventing recurrent preterm birth [31].
Society for Maternal-Fetal Medicine (SMFM): Provides guidance on routine cervical length screening in high- and low-risk women for preterm birth prevention [56].
Other Organizations: Guidance on cervical length screening is also available from:
Society of Obstetricians and Gynaecologists of Canada (SOGC) [61].
International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) [62, 63].
Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) [62].
International Federation of Gynecology and Obstetrics (FIGO) [62, 64].
Levels of Evidence: Sources use the U.S. Preventive Services Task Force method to evaluate the quality of evidence, ranging from Level I (randomized controlled trials) to Level III (expert opinion) [54, 58]. Recommendations are graded as Level A (good and consistent evidence), Level B (limited or inconsistent evidence), or Level C (consensus and expert opinion) [58].
VII. ObG Project Resources
The ObG Project provides educational materials and clinical recommendations on cervical cerclage, including:
Indications for cerclage placement based on SMFM guidelines [65].
Ideal candidates for cerclage [65].
Timing of cerclage placement [66].
Management considerations for cerclage removal [52].
Discussion of emergency/rescue cerclage [38].
Information on the use of progesterone and pessaries in preterm birth prevention [67-69].
ObGFirst Platform: Offers guideline notifications, daily research summaries, and CME credits [70, 71].
VIII. Conclusion
Cervical insufficiency is a complex condition that can lead to preterm birth.
Understanding the risk factors, diagnostic approaches, and various management options is essential for healthcare providers.
Shared decision-making with patients is crucial, considering individual risk factors, clinical presentation, and preferences.
Ongoing research is needed to improve our understanding of cervical insufficiency and develop more effective preventive and treatment strategies.
IX. Additional Notes
Sources include details about the learning objectives, faculty disclosures, and methods of participation for the ObG Project educational activities [65, 72, 73].
Sources present related ObG topics and information about the ObGFirst platform, computer system requirements, disclosures, and disclaimers [70, 71, 74, 75].
Sources provide copyright information for "Cerclage for the Management of Cervical Insufficiency.pdf" [76-78].
Sources describe the literature search methodology and evidence grading system used for the ACOG Practice Bulletin [54, 58, 60].
30
Cervical Cancer Screening
Cervical Cancer Screening
Gynecology
Pap Smear Screening Guidelines Outline
The sources provide updated cervical cancer screening guidelines, emphasizing a shift towards primary human papillomavirus (HPV) testing for individuals aged 30 years and older. The guidelines also stress the importance of consistent adherence to routine screening, regardless of the specific strategy chosen.
Key Updates and Recommendations
Endorsement of USPSTF Guidelines: The American College of Obstetricians and Gynecologists (ACOG) endorses the U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations, replacing previous ACOG and ASCCP guidelines.
Primary HPV Testing for Ages 30 and Older: The guidelines recommend screening every 5 years with primary high-risk HPV testing as an option for average-risk individuals aged 30 years and older. This means HPV testing alone, without cytology, using an FDA-approved test for this purpose.
Screening Initiation Age: Screening should begin at age 21 years.
Screening for Ages 21-29 Years: Screening recommendations for average-risk individuals aged 21-29 years remain unchanged, using cytology alone every 3 years.
Screening After Age 65: Recommendations for screening after age 65 also remain unchanged.
Management of Abnormal Results: Management of abnormal cervical cancer screening results should follow current ASCCP guidelines.
Consideration for Ages 25-29 Years: While cytology alone is the recommended method for ages 21-29, primary HPV testing every 5 years can be considered for average-risk patients aged 25–29 years, based on FDA approval and demonstrated efficacy.
Future Directions
Primary HPV Testing as the Preferred Method: The American Cancer Society (ACS) updated its guidelines in 2020 to recommend primary HPV testing as the preferred screening method due to its higher sensitivity in detecting precancerous lesions.
Phasing Out Cytology-Based Screening: ACS advocates phasing out cytology-based screening in the future, but acknowledges barriers to widespread access and implementation of primary HPV testing.
HPV Self-Sampling: While still investigational in the United States, HPV self-sampling has the potential to improve access to screening.
Impact of HPV Vaccination: Increasing HPV vaccination coverage is expected to lead to a decline in HPV prevalence, potentially prompting future changes to screening guidelines, such as raising the age to initiate screening.
Importance of Consistent Screening
The sources highlight that inadequate cervical cancer screening remains a significant problem in the United States. They emphasize that the specific screening strategy chosen is less important than consistent adherence to routine screening guidelines.
Other Important Points
Health Inequities: There are persistent health inequities across the entire spectrum of cervical cancer care in the United States.
HPV Vaccination: Obstetrician-gynecologists should strongly recommend HPV vaccination to eligible patients, emphasizing its benefits and safety in preventing cervical cancer.
The sources underscore a shift in cervical cancer screening practices towards primary HPV testing for individuals aged 30 years and older. They stress the importance of routine and consistent screening, along with HPV vaccination, as crucial components of comprehensive reproductive healthcare.
31
Cesarean complications
[ ]
32
Cesarean hysterectomy
Cesarean hysterectomy
Cesarean Hysterectomy
Cesarean Hysterectomy: A Detailed Outline
The sources provide a comprehensive overview of cesarean hysterectomy, covering its history, indications, surgical technique, potential complications, and management strategies.
Historical Context
Early attempts at cesarean hysterectomy date back to the mid-1700s with animal experiments.
The first successful cesarean hysterectomy on a human, saving both mother and infant, was performed by Porro in 1876. The procedure, known as the Porro operation, aimed to control uterine hemorrhage and prevent peritonitis.
The introduction of sutural closure of the uterus in cesarean deliveries by Max Sanger in the late 19th century marked a significant advancement, leading to a reduction in hemorrhage and infection and a decline in maternal mortality.
Despite these advances, cesarean hysterectomy remains a necessary procedure in specific situations.
Incidence and Indications
Cesarean hysterectomy can be categorized as:
Emergent: Performed as an emergency, most commonly for life-threatening hemorrhage.
Indicated Non-Emergent: Planned in advance, usually for conditions like uterine rupture or malignancy.
Elective Sterilization: This indication is controversial and generally not recommended.
Historical Trends
Data from 1975-1985 showed abnormal placentation and abruption as the most common indications for cesarean hysterectomy.
More recent data (2005-2006) from the UK revealed a shift towards recalcitrant hemorrhage as the primary reason, likely due to the increasing incidence of placenta accreta.
Current Indications
Hemorrhage: The most frequent indication, accounting for the majority of cases. Common causes include:
Uterine atony
Morbidly adherent placenta (placenta accreta, increta, and percreta)
Uterine rupture
Extension of uterine incision at delivery
Malignancy: Performed in non-emergent cases, usually concurrently with cesarean section.
Infection: A less common indication, accounting for only 1% of cases in a recent review.
Risk Factors
Previous Cesarean Deliveries: The risk of cesarean hysterectomy increases significantly with each subsequent cesarean delivery.
Maternal Age Over 35: Older mothers are at higher risk.
Abnormal Placentation: Conditions like placenta accreta are major risk factors.
Previous Uterine Surgery: History of cesarean section or myomectomy increases the risk.
Surgical Technique
Preparation: Ideally, cesarean hysterectomy is planned in advance, allowing for preoperative evaluation of the patient's hematologic and coagulation status, selection of experienced assistants, and preparation of necessary instruments and sutures. However, many cases are emergencies.
Incision: A vertical abdominal incision provides optimal exposure, but a transverse incision may be sufficient.
Delivery of Infant and Placenta: The infant is delivered, and if possible, the placenta is removed.
Hysterectomy Procedure:
The uterus is brought through the incision.
Round ligaments are clamped and divided.
The bladder is reflected from the lower uterine segment.
The broad ligament is incised, and the ureter is visualized.
The fallopian tubes and ovarian ligaments are clamped and ligated.
The uterine arteries are carefully isolated and ligated.
Subtotal vs. Total Hysterectomy: The surgeon decides whether to remove the entire uterus (total hysterectomy) or leave the cervix (subtotal hysterectomy) based on factors like patient stability and blood loss.
The cervix is amputated (if performing a total hysterectomy) and the vaginal cuff is closed.
Hemostasis is meticulously ensured throughout the procedure.
Intraoperative Complications
Hemorrhage: A significant risk, occurring in over 40% of cases.
Sources of bleeding can include the adnexal pedicles, uterine vascular pedicles, cardinal ligaments, or angles of the vagina.
Management involves meticulous surgical technique, including proper clamping, ligation, and suturing.
Urinary Tract Injury: Can occur during bladder dissection or due to distorted anatomy from previous surgery or hematomas.
Incidence is reported as high as 16%.
Direct visualization of the ureters is crucial to prevent injury.
Other Complications:
Infection
Thromboembolism
Bowel injury
Postoperative Complications
Fever: A common occurrence, often associated with cuff cellulitis or pelvic hematoma/abscess formation.
Wound Complications: Infection, dehiscence, seroma, hematoma.
Urinary Tract Infection:
Vaginal Cuff Hematoma/Infection:
Other Complications:
Ileus
Deep vein thrombosis
Pulmonary embolism
Breast engorgement mastitis
Mortality
Maternal mortality associated with cesarean hysterectomy is rare but serious.
Reported rates vary, ranging from 0.6% to 19% depending on the study and patient population.
Factors contributing to mortality include:
Underlying medical conditions
Severe hemorrhage
Sepsis
Advanced malignancy
Delay in seeking medical care
Management of Complications
Hemorrhage: Prompt surgical intervention, blood transfusions, and potentially interventional radiology procedures like embolization.
Urinary Tract Injuries: Immediate repair, if recognized. Postoperative management may involve urinary catheterization and antibiotics.
Infections: Broad-spectrum antibiotics, drainage of abscesses if necessary.
Thromboembolism: Anticoagulation therapy.
Conclusion
Cesarean hysterectomy is a complex and potentially life-saving procedure that requires careful consideration and meticulous surgical technique. Understanding the indications, risk factors, surgical steps, and potential complications is essential for healthcare providers involved in the care of pregnant women. Early recognition and management of complications are crucial to minimize morbidity and mortality.
33
Chorioamnionitis
Chorioamnionitis
Obstetrics
Intra-amniotic Infection Management: A Detailed Outline
The sources provide limited direct information on the management of intra-amniotic infection. However, they do offer insights into the management of related conditions and general principles of infection management in pregnancy.
Key Concepts from the Sources
Infection Prevention and Prophylaxis: Several sources emphasize the importance of preventing and treating infections during pregnancy:
Source highlights the significance of prophylactic antibiotics to reduce the risk of surgical site infections, particularly in gynecologic procedures.
Source underscores the importance of prophylactic antibiotics in labor and delivery, particularly for preventing Group B streptococcal infection in newborns.
Source discusses the need for heightened awareness and management of infection risk in obese pregnant patients.
Multidisciplinary Care:
Source advocates for the formation of a Pregnancy Heart Team to manage pregnant women with heart disease. This model emphasizes collaboration among specialists, including obstetricians, cardiologists, and anesthesiologists. While not directly addressing intra-amniotic infection, this approach highlights the value of coordinated care for high-risk pregnancies with potential complications, which can include infection.
Individualized Management:
Source emphasizes that the management of thrombocytopenia in pregnancy should be tailored to the specific cause, highlighting the need for a detailed workup and individualized treatment strategies.
Fetal and Neonatal Considerations:
Source states that women with hepatitis B can breastfeed safely, as long as their newborns receive appropriate immunoprophylaxis at birth. This emphasizes the importance of considering both maternal and neonatal well-being in managing infections during pregnancy.
Source details the appropriate neonatal care for infants born to mothers with immune thrombocytopenia, highlighting the need for careful monitoring, avoidance of procedures that increase bleeding risk, and effective communication between obstetric and pediatric care providers.
Extrapolating to Intra-amniotic Infection
While not explicitly discussed, the sources provide a foundation for understanding key aspects of managing intra-amniotic infection.
Prompt Diagnosis and Treatment: Drawing on the principles outlined in the sources, prompt recognition and treatment of intra-amniotic infection is crucial to prevent maternal and neonatal complications.
Antibiotic Therapy: Antibiotics are a cornerstone of treatment. Broad-spectrum antibiotics are typically initiated, with adjustments based on culture and sensitivity results if available.
Delivery: In many cases, expedited delivery is necessary to control the infection. The mode of delivery is determined based on factors such as gestational age, fetal well-being, and maternal clinical status.
Supportive Care: Managing fever, pain, and maintaining fluid and electrolyte balance are essential components of supportive care.
Monitoring: Close monitoring of both the mother and fetus is vital to assess response to treatment and detect any complications.
Seeking Further Information
To gain a comprehensive understanding of intra-amniotic infection management, you should consult sources specifically addressing this topic, including:
UpToDate
ACOG Practice Bulletins or Committee Opinions
Medical textbooks dedicated to obstetrics and infectious diseases
Note: It is always prudent to verify information obtained from sources outside of those provided.
34
CHTN (non-pregnant)
CHTN (non-pregnant)
Gynecology
35
CHTN (Pregnancy)
CHTN (Pregnancy)
Obstetrics
Chronic Hypertension in Pregnancy: ACOG Practice Bulletin 203
Chronic hypertension is present in 0.9–1.5% of pregnant women. This rate has been increasing, likely due to the obesity epidemic and increasing maternal age.
Chronic hypertension may result in significant maternal, fetal, and neonatal morbidity and mortality.
Definition and diagnosis of chronic hypertension:
Chronic hypertension in pregnancy is defined as hypertension diagnosed or present before pregnancy or before 20 weeks of gestation.
Hypertension that is diagnosed for the first time during pregnancy and that does not resolve in the typical postpartum period is also classified as chronic hypertension.
Traditionally, the criteria for hypertension in pregnancy have been a systolic blood pressure of 140 mm Hg or more, a diastolic blood pressure of 90 mm Hg or more, or both.
Recent recommendations from the American College of Cardiology (ACC) and the American Heart Association (AHA) have changed the criteria for diagnosing hypertension in adults, including lower thresholds for diagnosis.
Obstetric care providers may see an increase in patients classified as hypertensive based on these ACC/AHA definitions.
Using the ACC/AHA definition to determine chronic hypertension for pregnant women presents a lower threshold for diagnosis than traditionally used.
To establish a diagnosis of chronic hypertension, it is ideal to have knowledge of prepregnancy blood pressure values.
For many women, prepregnancy blood pressures are not known.
Types of chronic hypertension:
It is estimated that chronic hypertension antedating pregnancy is essential (ie, of unknown cause) in more than 86–89% of cases and secondary (ie, related to underlying renal, endocrine, or vascular conditions) in 11–14% of cases.
A thorough history and physical examination are crucial to detect the rarer secondary forms of hypertension.
Hypertension in pregnancy is classified as severe if at or above cutoff points of 160 mm Hg for systolic blood pressure or 110 mm Hg for diastolic blood pressure, or both.
Measuring blood pressure:
Blood pressure levels that meet the definition criteria should be documented on repeat readings only after the patient has rested (preferably for 10 minutes or more) and is seated with legs uncrossed and back supported.
No caffeine or tobacco should have been used for at least 30 minutes before measurement.
An appropriate-sized cuff should be used and positioned at the level of the heart to ensure accurate readings.
Chronic hypertension with superimposed preeclampsia:
Preeclampsia is considered superimposed when it complicates preexisting chronic hypertension.
Up to 20–50% of women with chronic hypertension may develop superimposed preeclampsia.
Superimposed preeclampsia is not always easy to diagnose and is often a diagnosis of exclusion.
White coat hypertension:
White coat hypertension is defined as elevated blood pressure primarily in the presence of health care providers.
It may account for up to 15% of individuals with office hypertension, although the exact prevalence in pregnancy is not known.
For women with suspected white coat hypertension, the use of ambulatory blood pressure monitoring may be beneficial to confirm the diagnosis and to assist with decisions for initiation of antihypertensive therapy.
Monitoring blood pressure:
Good clinical practice dictates increased monitoring for women with elevated blood pressure especially in the second half of pregnancy.
Out-of-office and self-monitoring of blood pressure may be beneficial for women with hypertension.
Effects of chronic hypertension on pregnancy:
Maternal risks:
A population study of nearly 30,000 pregnant women with chronic hypertension demonstrated that maternal mortality and the risk of cerebrovascular accidents, pulmonary edema, or renal failure were about fivefold to sixfold higher than in normotensive pregnant women.
Chronic hypertension is associated with an increased risk of gestational diabetes.
Compared with normotensive women, those with uncomplicated chronic hypertension have a 1.8-fold increased risk of planned cesarean delivery before labor and twice the risk of postpartum hemorrhage.
Fetal risks:
Chronic hypertension in pregnancy is associated with poorer perinatal outcomes.
A systematic review of 55 studies demonstrated that the pooled incidence for low birth weight was approximately 17%, and the pooled incidence for preterm delivery was 28%.
The perinatal mortality rate reported with maternal chronic hypertension is 2–4 times higher than that of the general population.
The incidence of these adverse perinatal effects appears to be related to the duration and severity of chronic hypertension as possible surrogates for end-organ damage.
Limited evidence is emerging that patients with chronic hypertension may be at higher risk of fetal congenital malformations.
Prepregnancy counseling:
A woman with chronic hypertension should be evaluated prepregnancy to identify possible end-organ involvement, to consider evaluation for secondary hypertension, and for the optimization of maternal comorbidities (eg, obesity, diabetes) before pregnancy.
Women with chronic hypertension should have their blood pressure optimized before pregnancy and should avoid excessive sodium and caffeine intake as well as smoking.
Prepregnancy counseling should include an explanation of the risks associated with chronic hypertension in pregnancy.
The medication review should place special emphasis on agents to be avoided, in particular angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.
Initial evaluation of a pregnant woman with chronic hypertension:
Specific testing before or at the time of presenting for pregnancy care is used to detect possible end-organ involvement.
This baseline evaluation may be influenced by the physiologic changes of pregnancy seen as early as the early first trimester and underscores the importance of prepregnancy testing.
Because the kidneys are usually the first end-organ to be affected by chronic hypertension, baseline renal function assessment commonly includes serum creatinine, a spot urine protein-to-creatinine ratio, and, if needed, a 24-hour urinary collection for total protein and creatinine clearance.
Women who have had poorly controlled hypertension for more than 4 years or those suspected of having long-standing hypertension based on age (older than 30 years) are more likely to have cardiac hypertrophic changes, cardiomegaly, and ischemic heart disease and are candidates for additional diagnostic testing.
Evaluation for secondary hypertension:
Hypertension resistant to treatment or diagnosed at a young age (younger than 30 years) warrants consideration and diagnostic workup for secondary (and potentially curable) hypertension unless such evaluations were previously performed.
Treatments for pregnant women with chronic hypertension:
Controversy exists over the potential benefits and harms of treatment with antihypertensive drugs during pregnancy.
The precise blood pressure level at which antihypertensive therapy is indicated during pregnancy in women with chronic hypertension continues to be debated.
In the absence of clear evidence supporting the use of antihypertensive therapy for lower blood pressures, initiation of antihypertensive therapy is recommended for persistent chronic hypertension when systolic pressure is 160 mm Hg or more, diastolic pressure is 110 mm Hg or more, or both.
For chronic maintenance treatment, labetalol or nifedipine are reasonable options and are recommended above all other antihypertensive drugs.
For acute blood pressure treatment, labetalol, hydralazine, and immediate-release oral nifedipine can be considered.
Low-dose aspirin:
For women with chronic hypertension, it is recommended to initiate daily low-dose aspirin (81 mg) between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and to continue this therapy until delivery.
Fetal surveillance:
Antenatal fetal testing is recommended for women with chronic hypertension complicated by issues such as the need for medication, other underlying medical conditions that affect fetal outcome, any evidence of fetal growth restriction, or superimposed preeclampsia.
The risks of fetal growth restriction in patients with chronic hypertension warrant third-trimester ultrasound assessment of fetal growth, with subsequent evaluation as appropriate.
Intrapartum concerns:
Women with chronic hypertension who are admitted for delivery should continue their medications.
Blood pressure should be monitored at regular intervals and acute elevations should be addressed accounting for transient elevations that may occur in the setting of labor.
Whenever possible, unless contraindicated by maternal thrombocytopenia, neuraxial anesthesia should be employed because general anesthesia may pose a higher risk for pregnant women with severe hypertension.
Distinguishing chronic hypertension from superimposed preeclampsia:
It often is difficult to distinguish chronic hypertension from superimposed preeclampsia when a patient with chronic hypertension presents with elevated blood pressure later in pregnancy.
In cases of diagnostic uncertainty in discriminating transient blood pressure increases in chronic hypertension from superimposed preeclampsia, particularly with severe-range blood pressures, initial surveillance in the hospital setting is recommended.
Timing of delivery:
For women with chronic hypertension and with no additional maternal or fetal complications supporting earlier delivery, if not prescribed maintenance antihypertensive medications, delivery before 38 0/7 weeks of gestation is not recommended.
For women with chronic hypertension and with no additional maternal or fetal complications supporting earlier delivery, if prescribed maintenance antihypertensive medications, delivery before 37 0/7 weeks of gestation is not recommended.
Women with severe acute hypertension that is not controlled with traditional chronic antihypertensive regimens or women who develop superimposed preeclampsia with severe features should be delivered upon diagnosis at 34 0/7 weeks of gestation or more.
Postpartum considerations:
Blood pressure control usually continues to be an issue postpartum, and even women who were not treated during pregnancy may require treatment with antihypertensive medication in the postpartum period.
Women with chronic hypertension should be closely monitored for blood pressure changes and symptoms of severe-range hypertension or superimposed preeclampsia.
Antihypertensive medications may be used more liberally in the postpartum period than during pregnancy.
Antihypertensives, in general, can be used in breastfeeding women.
Please note that this outline is a summary of the information provided in the source document and does not include all of the details and nuances discussed. You should refer to the full text of the Practice Bulletin for complete information.
36
Clomid
Clomid
37
CMV, parvovirus, VZV, toxo in pregnancy
CMV, parvovirus, VZV, toxo in pregnancy
Obstetrics
Cytomegalovirus, Parvovirus B19, Varicella Zoster, and Toxoplasmosis in Pregnancy - Summary
Introduction
Definition: Cytomegalovirus (CMV), Parvovirus B19, Varicella Zoster Virus (VZV), and Toxoplasmosis are common infections that can cause moderate-to-severe complications when transmitted congenitally.
Immunological Changes in Pregnancy: The maternal immune system undergoes alterations to reduce inflammatory responses and promote fetal tolerance, increasing susceptibility to some infections.
Risk of Congenital Infections: These infections pose risks for both mother and fetus, including maternal morbidity and fetal developmental issues or death. The guideline provides updated clinical understanding and management strategies for these infections.
Cytomegalovirus (CMV)
Transmission and Symptoms:
CMV is transmitted by contact with infected blood, urine, saliva, or sexual fluids.
After a 28-60 day incubation, adults can experience a mononucleosis-like illness.
CMV remains latent in host cells and can reactivate.
Prevalence and Transmission:
Primary CMV infection occurs in 0.7-4% of pregnant women in the U.S.
Transmission risk is higher during the third trimester, but fetal sequelae are most severe with infection in the first trimester.
Of infants infected in utero, 12-18% present with symptoms at birth; 65-80% of symptomatic infants have neurologic sequelae.
Clinical Manifestations:
Congenital CMV presents with symptoms like jaundice, petechiae, growth restriction, and neurologic deficits.
The risk of severe infection is lower with maternal reactivation of CMV compared to primary infection.
Management:
Routine serologic screening for CMV is not recommended in pregnancy.
No proven treatments are currently available; antiviral medications like ganciclovir are used only under research protocols.
CMV-specific hyperimmune globulin is under investigation for prevention but is not yet proven effective.
Parvovirus B19
Transmission and Symptoms:
Causes erythema infectiosum (fifth disease) in children, presenting with a "slapped cheek" rash.
In adults, it may cause arthropathy or be asymptomatic.
Parvovirus B19 is transmitted via respiratory secretions and hand-to-mouth contact.
Fetal Complications:
Fetal transmission occurs in 17-33% of maternal infections, often leading to nonimmune hydrops fetalis, stillbirth, or aplastic anemia.
Severe outcomes are more frequent if the infection occurs before 20 weeks' gestation.
Management:
Pregnant women with parvovirus infection should be monitored for fetal anemia and hydrops fetalis using ultrasound and Doppler.
Intrauterine transfusion may be required for severe fetal anemia.
Varicella Zoster Virus (VZV)
Transmission and Symptoms:
VZV, a herpesvirus, is transmitted by respiratory droplets or contact with lesions.
Primary infection causes chickenpox, while reactivation results in herpes zoster (shingles).
Maternal and Fetal Complications:
Maternal varicella during pregnancy is rare, but it can lead to pneumonia and significant morbidity.
Congenital varicella syndrome (skin scarring, limb hypoplasia, microcephaly) occurs in 0.4-2% of infections, primarily with exposure in the first and second trimesters.
Management:
Oral acyclovir may reduce the severity of maternal varicella.
Varicella-Zoster Immune Globulin (VZIG) should be given to pregnant women exposed to VZV if they lack immunity.
Toxoplasmosis
Transmission:
Caused by the parasite Toxoplasma gondii, transmitted via undercooked meat, contaminated produce, and contact with cat feces.
Fetal Complications:
The risk of transmission increases with advancing gestation, while severity is greater when transmitted earlier.
Congenital toxoplasmosis can cause severe neurologic impairment, visual impairment, seizures, and other symptoms.
Diagnosis and Management:
Diagnosis is made by serologic testing, though standardization of these tests is lacking.
If acute infection is suspected, repeat testing and confirmatory tests are recommended.
Treatment with spiramycin is used to reduce vertical transmission, while pyrimethamine, sulfadiazine, and folinic acid are used for confirmed fetal infection.
Routine serologic screening for toxoplasmosis is not recommended during pregnancy.
38
Condyloma Acuminata (CHPV)
Condyloma Acuminata (CHPV)
39
Congenital abnormalities of the reproductive tract
Congenital abnormalities of the reproductive tract
40
Contraception (general overview)
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41
Contraceptive Counseling
Contraceptive Counseling
Gynecology
Comprehensive Outline On Contraception
I. Introduction
Contraception encompasses various methods and techniques to prevent pregnancy.
Effective contraception is essential for reproductive health and family planning.
The selection of a contraceptive method should be based on individual preferences, medical history, and lifestyle factors.
II. Hormonal Contraception
A. Combined Hormonal Contraceptives (CHCs):
Contain both estrogen and progestin.
Available in various forms, including pills, patches, and vaginal rings.
Mechanism of action:
Primarily prevent ovulation by suppressing the release of hormones from the pituitary gland.
Also thicken cervical mucus, hindering sperm transport.
Alter the endometrial lining, making implantation less likely.
Considerations:
US MEC provides guidance on the use of CHCs in women with underlying medical conditions.
Risks include venous thromboembolism (VTE), particularly in certain populations.
Benefits include highly effective pregnancy prevention, cycle regulation, and reduced menstrual bleeding.
Counseling should include a discussion of the risks and benefits and address any concerns or misperceptions.
B. Progestin-Only Contraceptives:
Contain only progestin, without estrogen.
Available in forms such as pills, injections (DMPA), implants, and LNG-IUDs.
Mechanism of action:
Primarily thicken cervical mucus.
May also suppress ovulation or inhibit implantation.
Considerations:
Safer for women with contraindications to estrogen, such as those with a history of VTE or certain medical conditions.
Potential side effects may include irregular bleeding, weight gain, and mood changes.
C. Emergency Contraception (EC):
Used to prevent pregnancy after unprotected or inadequately protected sexual intercourse.
Available in oral and intrauterine forms.
Mechanism of action:
Primarily delay or inhibit ovulation.
The copper IUD, the most effective EC method, also interferes with fertilization and implantation.
Types:
Ulipristal acetate (prescription-only, effective up to 5 days after intercourse)
Levonorgestrel (available over-the-counter)
Copper IUD (most effective, inserted by a healthcare provider)
Considerations:
Should be offered to all women who have had unprotected intercourse and do not desire pregnancy.
Counseling should include information on access, effectiveness, and side effects.
III. Long-Acting Reversible Contraception (LARC)
A. Intrauterine Devices (IUDs):
Small, T-shaped devices inserted into the uterus.
Types:
Copper IUD: Releases copper ions, creating a spermicidal environment.
LNG-IUDs: Release levonorgestrel, thickening cervical mucus and suppressing ovulation.
Advantages:
Highly effective, with typical-use pregnancy rates lower than other reversible methods.
Long-lasting, providing years of protection.
Reversible, with rapid return of fertility upon removal.
Convenient, requiring no user action after insertion.
LNG-IUDs can reduce menstrual bleeding and pain.
Considerations:
Potential side effects include irregular bleeding, cramping, and expulsion.
Insertion can be uncomfortable, but pain management options are available.
B. Contraceptive Implants:
Small, flexible rods inserted under the skin of the arm.
Release etonogestrel, a progestin, suppressing ovulation and thickening cervical mucus.
Advantages:
Highly effective and long-lasting, providing up to 3 years of protection.
Reversible and convenient.
Considerations:
Potential side effects include irregular bleeding, weight gain, and mood changes.
Removal requires a minor procedure.
IV. Sterilization
A. Female Sterilization:
Permanent procedure to block the fallopian tubes, preventing eggs from reaching sperm.
Types:
Tubal ligation: Surgical procedure performed laparoscopically or through a mini-laparotomy.
Hysteroscopic sterilization: Essure device was removed from the market.
Advantages:
Highly effective, with low failure rates.
Permanent contraception, eliminating the need for ongoing methods.
Considerations:
Permanent, with reversal procedures being expensive and not always successful.
Surgical procedure, carrying risks associated with anesthesia and surgery.
Potential for regret, especially in younger women.
B. Male Sterilization (Vasectomy):
Permanent procedure to sever or block the vas deferens, preventing sperm from being released.
Advantages:
Highly effective and relatively simple procedure.
Outpatient procedure with local anesthesia.
Considerations:
Permanent, although reversal is possible but not always successful.
Requires follow-up testing to confirm sterility.
V. Patient Counseling and Education
A. Comprehensive Counseling:
Essential for informed decision-making and patient satisfaction.
Should include a discussion of:
All available contraceptive options
Benefits and risks of each method
Correct use and potential side effects
Emergency contraception
Protection against STIs
B. Addressing Misperceptions and Concerns:
Patients may have inaccurate information or concerns about contraception.
Counselors should be prepared to provide accurate information and dispel myths.
C. Shared Decision-Making:
Respect patient preferences and values.
Encourage patient participation in the decision-making process.
D. Adolescents:
Create a safe and confidential environment.
Address concerns and misperceptions in an age-appropriate manner.
Ensure confidentiality and respect their autonomy.
E. Special Considerations:
Mental health, intellectual or physical disabilities: Additional counseling strategies and awareness of specific barriers.
Medical comorbidities: Consult the US MEC and discuss potential impacts of pregnancy.
Patients on anticoagulant therapy: Consult the sources and discuss safety of methods.
Breastfeeding women: Provide information on suitable methods.
VI. Follow-Up and Ongoing Care
A. Follow-Up Visits:
Important to assess adherence, satisfaction, and address any concerns.
Frequency depends on the chosen method and individual needs.
B. Ongoing Education:
Reinforce correct use and provide updates on new developments.
C. STI Prevention:
Integrate STI prevention counseling into contraceptive care.
Encourage condom use to reduce STI risk.
VII. Conclusion
Effective contraception is crucial for reproductive health and well-being.
A wide range of contraceptive options are available, each with its own benefits and considerations.
Comprehensive counseling and shared decision-making are essential to help individuals choose the most appropriate method for their needs and circumstances.
Ongoing follow-up and education are essential to ensure continued satisfaction and effectiveness.
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Contraindicated drugs
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43
Criteria for dating
Criteria for dating
This article summarizes methods for estimating the due date (EDD) during pregnancy.
The most accurate way to determine gestational age and estimated due date is through ultrasound measurement of the embryo or fetus in the first trimester, ideally before or at 13 6/7 weeks of gestation.
Ultrasound measurements in the first trimester have an accuracy of plus or minus 5–7 days.
Crown–rump length (CRL) measurements are the most accurate in early pregnancy, and using the mean of three separate CRL measurements taken in the midsagittal plane is recommended.
Mean sac diameter is not recommended for estimating the due date.
If the pregnancy resulted from assisted reproductive technology (ART), the EDD should be determined using the age of the embryo and date of transfer.
If ultrasound dating before 14 0/7 weeks of gestation differs from LMP dating by more than 7 days, the EDD should be changed to the ultrasound date.
If a first-trimester ultrasound has been performed, especially one consistent with LMP dating, gestational age should not be adjusted based on a second-trimester ultrasound examination.
Ultrasound dating in the second trimester (between 14 0/7 weeks and 21 6/7 weeks) has an accuracy of ± 7–10 days.
The EDD should be changed to the ultrasound date if the ultrasound between 14 0/7 weeks and 15 6/7 weeks varies from LMP dating by more than 7 days, or if the ultrasound between 16 0/7 weeks and 21 6/7 weeks varies by more than 10 days.
Ultrasound dating between 22 0/7 weeks and 27 6/7 weeks has an accuracy of ±10–14 days.
The EDD should be changed to the ultrasound date if the ultrasound dating between 22 0/7 weeks and 27 6/7 weeks differs from LMP dating by more than 14 days.
A pregnancy without an ultrasound that confirms or revises the EDD before 22 0/7 weeks is considered suboptimally dated.
Ultrasound dating in the third trimester (28 0/7 weeks and beyond) is the least accurate method, with an accuracy of ± 21–30 days.
Because of the possibility of misdating a small fetus that may have growth restrictions, management decisions based only on third-trimester ultrasonography need to be guided by careful consideration of the entire clinical picture and may require close monitoring, including repeat ultrasounds, to ensure appropriate interval growth.
If the first ultrasound of the pregnancy is performed during the third trimester and suggests a discrepancy in gestational dating of more than 21 days, the EDD should be adjusted.
Table 1 of the article provides guidelines for estimating the due date based on ultrasonography and the LMP in pregnancy, and provides single-point cutoffs and ranges based on available evidence and expert opinion.
Accurate dating of pregnancy is important for improving outcomes and is important for both research and public health. As soon as information from the LMP and the first accurate ultrasound are obtained, the gestational age and EDD should be determined, discussed with the patient, and documented in the medical record. For research and monitoring, the best obstetric estimate should be used as the measure for gestational age, rather than relying only on estimates based on the LMP.
The best obstetric estimate, as determined by the methods in the article, represents gestational age at delivery for the purpose of clinical care and should be recorded on the birth certificate.
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Critical Care in Pregnancy
Critical Care in Pregnancy
This article focuses on critical care in pregnancy, noting the lack of obstetric-specific critical care research.
Common Causes of Maternal Intensive Care Unit (ICU) Admission
Hypertensive disorders and obstetric hemorrhage are the leading causes of ICU admission during pregnancy and the postpartum period.
Additional diagnoses that result in ICU admission include sepsis, trauma, respiratory conditions, cardiovascular disorders, diabetic ketoacidosis, gastrointestinal disorders (pancreatitis, appendicitis, bowel obstruction), overdose or poisoning, and neurologic disorders.
Most pregnant and postpartum patients in the ICU require more intensive monitoring rather than major life-saving interventions.
Admission to Intensive Care
The demand for ICU admission may be driven by factors other than medical need, such as bed availability, staffing, or local practice.
Therefore, ICU admission alone is not an adequate quality or epidemiologic marker of maternal morbidity.
ICU admission should be considered for patients who are clinically unstable, have a high risk of deterioration, or need specialized ICU care, like mechanical ventilation.
Laboratory work, like arterial blood gas and serum lactate measurements, may also be useful in identifying women with progressive clinical deterioration who could benefit from ICU admission.
Most obstetric admissions to the ICU occur postpartum, due to hypertension and major obstetric hemorrhage.
The thresholds for ICU admission appear to vary by facility, with hospitals with lower delivery volumes transferring patients to the ICU at lower acuity levels than hospitals with busier obstetric services.
Transfer Considerations
Ideally, the care of any pregnant woman who requires ICU services should be managed in a facility that has obstetrics, adult ICU, and neonatal ICU capability.
In cases requiring a higher level maternal care facility for critically ill women, transport should be considered as soon as the need is identified and the patient is stable for transport.
Decisions about fetal monitoring during transport should be individualized based on the gestational age, maternal hemodynamic status, and the feasibility of intervention.
Transport should not be delayed by the inability to provide fetal monitoring in a critically ill pregnant woman.
Optimizing maternal status will optimize fetal status.
Role of the Obstetrician-Gynecologist
When an obstetric patient is in the ICU, the obstetrician-gynecologist’s role may be that of the primary physician or a consultant to the intensivist team, depending on the ICU model.
Regardless of the type of ICU, obstetricians can provide expertise when considering the risks and benefits of interventions, like medication administration and diagnostic imaging. They can also work with the intensive care team to interpret vital signs and laboratory parameters that may be affected by pregnancy.
When obstetric patients are transferred to the ICU, patient care decisions, including mode, location, and timing of delivery, should be made collaboratively between the intensivist, obstetrician–gynecologist, and neonatologist. Decisions should involve the patient and her family, when possible.
Care of a Pregnant Woman in a Critical Care Setting
Maternal stabilization is the first priority when caring for critically ill pregnant women.
If the woman is stable, determining the fetal gestational age is important as it will affect the plan of care.
Necessary medications and diagnostic imaging should not be withheld from a pregnant woman due to fetal concerns, though attempts should be made to limit fetal exposure to ionizing radiation and teratogenic medications, when feasible.
Decisions regarding fetal monitoring should be made proactively and will depend on the specific clinical scenario, staff availability for interpretation of the fetal heart rate tracing, and stability of the patient for intervention, if indicated.
Organization of Care for a Laboring Patient in Need of Critical Care
A multidisciplinary group should be convened to make decisions regarding the appropriate location for critically ill laboring patients. The team should consider the patient's physical location, specific clinical circumstances, and available hospital resources.
Cesarean delivery in the ICU should be restricted to cases where transport to the operating room cannot be achieved quickly and safely, or for a perimortem procedure.
If cesarean delivery in the ICU is anticipated, obstetrician-gynecologists should ensure that necessary equipment is available, including operative instruments, a cord clamp, and neonatal resuscitation equipment and a warmer.
Critical Care Tools and Techniques
Mechanical Ventilation:
Intubation and mechanical ventilation are performed when hypoxemia is profound and cannot be corrected by noninvasive means, or when ventilation is failing.
Airway management in pregnancy can be challenging due to changes in respiratory physiology and anatomy, including increased airway edema and breast size.
The risk of failed intubation in obstetrics is higher than in the general population.
Hemodynamic Monitoring:
Central venous catheters may be used to administer fluids or medications, or to monitor central venous pressure.
Arterial cannulation is indicated for continuous blood pressure monitoring or when frequent arterial blood gas sampling is needed.
The pulmonary artery catheter has largely been replaced by minimally invasive monitoring techniques.
Point-of-Care Ultrasonography:
Point-of-care ultrasonography is increasingly important in critical care medicine.
It is used to guide procedures, confirm or rule out diagnoses, and direct therapies.
Further research is needed on the use of point-of-care ultrasonography in critically ill pregnant patients.
Resuscitative Hysterotomy in Maternal Cardiopulmonary Arrest
Cardiac arrest in pregnancy is treated the same way as for any adult in cardiac arrest, with manual left uterine displacement recommended to alleviate aortocaval compression.
If resuscitation efforts are unsuccessful, resuscitative hysterotomy is recommended for maternal benefit in women with a uterine size at or above the umbilicus (20 weeks of gestation or more).
Resuscitative hysterotomy should be considered as soon as initial resuscitative measures are unsuccessful.
Although survival curves for women and neonates show a 50% injury-free survival rate with perimortem cesarean delivery as late as 25 minutes after maternal cardiac arrest, more rapid resuscitative hysterotomy is associated with improved survival.
Tele-intensive Care Units
Tele-ICUs allow for intensivist consultation, collaboration, and supervision of care in facilities that do not have high-intensity intensivist staffing.
While data are still limited, tele-ICU use may be beneficial in obstetrics, allowing smaller facilities to consult with larger centers with full-time intensivists and maternal-fetal medicine specialists.
Recommendations and Conclusions
Early antibiotic therapy for sepsis is recommended to reduce mortality.
Resuscitative hysterotomy is recommended for maternal benefit in women with a uterine size at or above the umbilicus (20 weeks of gestation or more) if efforts to resuscitate a pregnant woman in cardiac arrest are unsuccessful.
Consideration of resuscitative hysterotomy should occur as soon as there is a maternal cardiac arrest, and preparations should begin in the event that return to spontaneous circulation does not occur within the first few minutes of maternal resuscitation.
Survival curves for women and neonates have shown 50% injury-free survival rates with perimortem cesarean delivery as late as 25 minutes after maternal cardiac arrest. Even if delivery does not occur within 4–5 minutes, there still may be benefit, and resuscitative hysterotomy should be considered. However, more rapid resuscitative hysterotomy has been associated with improved survival, and the procedure should be considered as soon as initial resuscitative measures are unsuccessful.
Levels of Evidence
The recommendations and conclusions in this article are based on varying levels of evidence:
Level A: Good and consistent scientific evidence.
Level B: Limited or inconsistent scientific evidence.
Level C: Primarily consensus and expert opinion.
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Decreased FM
Decreased FM
Obstetrics
Purpose of Antenatal Fetal Surveillance
The purpose of antenatal fetal surveillance is to reduce the risk of stillbirth. While it is routinely used in pregnancies with an increased risk of fetal demise, antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth.
Challenges in Determining Indications for Surveillance
It is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered.
The pathway that results in an increased risk of stillbirth for a given condition may not be known.
There is limited evidence for the efficacy of antenatal fetal surveillance.
There is limited evidence for evidence-based recommendations on the timing and frequency of antenatal fetal surveillance.
Recommendations for antenatal fetal surveillance are largely based on expert consensus and relevant observational studies.
ACOG Recommendations for Antenatal Fetal Surveillance
This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition.
Table 1 (pages e179-e180 of the source document) presents suggestions for the timing and frequency of testing for specific conditions.
Shared decision-making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance.
Timing of Surveillance
Initiating antenatal fetal surveillance at 32 0/7 weeks of gestation or later is appropriate for most at-risk patients.
For pregnant individuals with multiple or particularly worrisome high-risk conditions (e.g., chronic hypertension with suspected fetal growth restriction), antenatal fetal surveillance might begin at a gestational age when delivery would be considered for perinatal benefit.
When data on gestational age-adjusted risk of occurrence of stillbirth were not available, the Committee’s suggestions regarding when to begin antenatal fetal surveillance are based on the reported risk of stillbirth, generally falling into one of three major categories:
At or by 32 0/7 weeks
At or by 36 0/7 weeks
At or beyond 39 0/7 weeks of gestation (if undelivered).
Individualization about when to begin antenatal fetal surveillance is advised.
Frequency of Surveillance
There are no large clinical trials to guide the recommended frequency of antenatal fetal surveillance and, thus, the optimal frequency remains unknown.
If the maternal medical condition is stable and test results are reassuring, tests of fetal well-being (nonstress test, biophysical profile, modified biophysical profile, or contraction stress test) have often, in practice, been repeated at weekly intervals.
In the presence of certain high-risk conditions, some investigators have performed more frequent antenatal fetal surveillance.
The Committee’s suggestions regarding the frequency of antenatal fetal surveillance for each condition are based on the approach of testing at least weekly, unless additional information is available that supports more frequent testing (e.g., abnormal Doppler results), multiple conditions are present that each warrant antenatal fetal surveillance, or a patient’s status is deteriorating.
Importance of Shared Decision-Making
Shared decision-making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth.
This can be particularly important in situations that involve fetal structural or genetic anomalies or when initiating antenatal fetal surveillance around the threshold of viability, where the pregnant individual’s goals for pregnancy care are critical in decision-making.
When counseling individuals regarding the risks, benefits, and efficacy of antenatal fetal surveillance, it should be acknowledged that unaccounted-for costs of antenatal fetal surveillance include the potential for additional visits that may require transportation, taking time off from work, and additional copays. Acknowledging these costs and reviewing them with patients are important aspects of providing this additional surveillance.
The Guidance Should Not Be Construed As Mandates
It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions and should not be construed as mandates or as all-encompassing.
Paucity of Evidence and the Need for Individualization
There is a paucity of evidence for the efficacy of antenatal fetal surveillance and for evidence-based recommendations on the timing and frequency of antenatal fetal surveillance; consequently, for most conditions, recommendations for antenatal fetal surveillance are largely based on expert consensus and relevant observational studies. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.
Future Research
Further research is needed to:
Identify individualized risks of stillbirth
Develop evidence-based recommendations regarding the initiation and frequency of testing
Address the potential for false-positive tests and resultant unnecessary interventions
Gain a better understanding of specific causes of stillbirth (e.g., underlying placental dysfunction)
Develop better surveillance methodology to detect suspected dysfunction
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Differential diagnosis of fetal hydrops
Differential diagnosis of fetal hydrops
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Drug Interactions
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48
Dysmenorrhea
Dysmenorrhea
Gynecology
Dysmenorrhea in Adolescents
Dysmenorrhea, or menstrual pain, is the most common menstrual symptom in adolescent girls and young women.
Obstetrician-gynecologists should be prepared to diagnose and treat this condition.
Types of Dysmenorrhea
Primary Dysmenorrhea:
Defined as painful menstruation without pelvic pathology.
Typically begins when adolescents develop ovulatory cycles, usually within 6-12 months of menarche.
The pain is related to prostaglandins and leukotrienes, which are mediators of inflammation.
Higher levels of prostaglandin F2a and urinary leukotrienes have been found in dysmenorrheic women compared to women without pain.
Secondary Dysmenorrhea:
Defined as painful menses due to pelvic pathology or a recognized medical condition.
Endometriosis is the most common cause.
Other causes: adenomyosis, infection, myomas, müllerian anomalies, obstructive reproductive tract anomalies, or ovarian cysts.
Symptoms and Comorbidities of Dysmenorrhea
Symptoms:
Nausea
Vomiting
Diarrhea
Headaches
Muscle cramps
Poor sleep quality
Dysmenorrhea is the leading cause of recurrent short-term school absenteeism for girls.
12% of adolescent girls and young women aged 14–20 years missed school or work each month due to dysmenorrhea.
Nearly two-thirds of adolescents with chronic acyclic pain undergoing laparoscopy are found to have endometriosis.
A significant number of adolescents with laparoscopically diagnosed endometriosis present with acyclic nonmenstrual pain and gastrointestinal or genitourinary symptoms.
Comorbidities:
Premenstrual syndrome and premenstrual dysphoric disorder
Increased risk of depression and anxiety
Negative impact on physical and psychosocial functioning
Evaluating Primary Dysmenorrhea
Adolescents may experience delays in accessing medical care and receiving a diagnosis of pelvic pain.
Barriers to care: difficulty with insurance coverage and a perceived lack of physician knowledge, time, or interest in chronic pain.
Initial Evaluation: medical, gynecologic, menstrual, family, and psychosocial history.
Pelvic Exam: Not necessary for primary dysmenorrhea unless symptoms of a sexually transmitted infection are present.
Suspecting Secondary Dysmenorrhea:
Severe dysmenorrhea immediately after menarche or progressively worsening dysmenorrhea
Abnormal uterine bleeding (heavy or irregular)
Mid-cycle or acyclic pain
Infertility
Lack of response to empiric medical treatment
Family history of endometriosis
Renal anomaly
Other congenital anomalies (spine, cardiac, or gastrointestinal)
Dyspareunia
Managing Primary Dysmenorrhea
Empiric treatment should be initiated when the patient’s history suggests primary dysmenorrhea.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs):
Considered first-line treatment.
Interrupt cyclooxygenase-mediated prostaglandin production.
More effective than placebo in providing pain relief.
No superiority of any individual NSAID has been demonstrated regarding safety or efficacy.
Dosage should be individualized.
Most effective when started 1–2 days before menses onset and continued through the first 2–3 days of bleeding.
Taking medication with food and increasing fluid intake can help reduce gastrointestinal and renal side effects.
Opioids should not be used for dysmenorrhea due to the risks of dependence, hyperalgesia, and addiction.
Patient education is crucial as self-medication is prevalent, and sub-therapeutic treatment due to incorrect dosage and timing is a concern.
Education can improve medication knowledge and reduce pain.
Hormonal Agents:
Considered when NSAIDs do not provide adequate relief or as a first-line option.
NSAIDs may be continued or added to hormonal therapy as needed.
Options include combined oral contraceptives, contraceptive patch or vaginal ring, progestin implant, depot medroxyprogesterone acetate, and LNG-IUS.
Decision-making should be patient-driven, considering the benefits and potential side effects of each method.
Mechanism of action: prevention of endometrial proliferation and/or ovulation, reducing prostaglandin and leukotriene production.
Continuous regimens may provide faster pain reduction compared to cyclic use of combined oral contraceptives.
GnRH agonists are not recommended for empiric use due to concerns about bone mineral density.
Complementary and Alternative Therapies:
Exercise and heat treatment show promise and should be encouraged due to their low risk, low cost, and general health benefits.
Dietary supplements with limited evidence of benefit: fenugreek, ginger, valerian, zataria, zinc sulfate, fish oil, and vitamin B1.
High-dose vitamin D supplementation showed a decrease in dysmenorrhea prevalence in one study, but other studies show limited effects.
Limited evidence for transcutaneous electrical nerve stimulation, acupuncture, herbal preparations, and yoga as first-line complementary therapies.
Safety and efficacy data on herbal treatments are unclear.
Surgical Approaches:
Not recommended for primary dysmenorrhea.
Insufficient evidence to support the use of uterine nerve ablation or presacral neurectomy.
Definitive and irreversible procedures like ablation and hysterectomy should not be considered in adolescents.
Follow-Up for Primary Dysmenorrhea
Monitor patients for response to treatment, which supports the diagnosis of primary dysmenorrhea.
Assessment tools: visual analog scales and numerical rating scales.
Investigate for secondary causes if no clinical improvement within 3–6 months of treatment initiation.
Assess treatment adherence.
Adolescents may be less adherent due to medication schedules, conflicts with parents, forgetfulness, disorganization, financial costs, and pharmacy access.
Social support and peer relations are key factors influencing medication adherence.
Adolescents may worry about stigma, embarrassment, and social deviance related to taking medications.
Nonadherence may stem from conflicts with parents regarding decision-making, self-management, and treatment responsibilities.
Addressing these issues and discussing strategies to overcome challenges can be helpful.
Consider trying another hormonal method for 3 months after confirming adherence if initial treatment fails.
Evaluating Suspected Secondary Dysmenorrhea
Most adolescents presenting with dysmenorrhea have primary dysmenorrhea and respond well to empiric treatment.
Further evaluation is necessary if:
Initial presentation suggests secondary dysmenorrhea.
Empiric treatment for primary dysmenorrhea fails.
Pain persists for 3–6 months.
Comprehensive evaluation for chronic pelvic pain: history and focused physical exam to assess potential gastrointestinal, urologic, musculoskeletal, and psychosocial etiologies.
Pelvic Exam:
Considered to evaluate potential causes of secondary dysmenorrhea.
Many adolescents can tolerate it with education and support.
Findings may indicate other etiologies: endometriosis, obstructed reproductive tract anomaly, enlarged or irregularly shaped uterus, cervical friability or discharge, pelvic masses, vaginismus, or pelvic floor disorders.
Pelvic Imaging:
Ultrasonography is the most appropriate initial imaging modality.
Can identify potential causes: obstructive anomalies, uterine myomas, and adnexal masses.
Helpful in diagnosing ovarian endometriomas but not useful for nonovarian lesions.
Magnetic resonance imaging (MRI) may be needed to further evaluate müllerian anomalies but is not cost-effective as an initial screening tool.
MRI is not superior to ultrasonography in diagnosing endometriomas and does not effectively identify peritoneal lesions or determine disease extent.
Normal pelvic imaging or physical exam does not rule out endometriosis.
Reproductive Tract Anomalies
Any obstructive anomaly, whether hymenal, vaginal, or müllerian, can cause secondary dysmenorrhea.
True incidence is unknown, estimated to occur in 0.1–3.8% of young women.
Associated with endometriosis.
Patients with urogenital sinus abnormalities or anorectal malformations are at increased risk and should be monitored for outflow tract obstructions during puberty and menarche.
Treatment Goal:
Establish a patent outflow tract.
Relieve symptoms.
Decrease endometriosis and adhesions caused by retrograde menses.
Endometriosis associated with obstructive anomalies may improve after surgical correction.
Persistent endometriosis after surgical correction has been reported.
Suspected Endometriosis
Endometriosis is the leading cause of secondary dysmenorrhea in adolescents.
Consider endometriosis in patients with:
Persistent, clinically significant dysmenorrhea despite treatment with hormonal agents and NSAIDs.
No other identified cause for chronic pelvic pain or secondary dysmenorrhea based on history, physical examination, and pelvic ultrasonography.
Family history of endometriosis (7- to 10-fold increased risk).
Assessment: Ask if symptoms are causing missed school or participation in extracurricular activities.
Endometriosis is a common finding in young women undergoing laparoscopy for chronic pelvic pain.
At least two-thirds of adolescents with chronic pelvic pain or dysmenorrhea unresponsive to hormonal therapies and NSAIDs will be diagnosed with endometriosis at laparoscopy.
Diagnosis:
Remains a surgical and pathologic diagnosis in adolescents.
Requires the presence of endometrial glands and stroma in a biopsy specimen from outside the endometrial cavity.
Counseling:
Patients with persistent dysmenorrhea despite treatment and no other identified cause should be informed about:
The high likelihood of endometriosis.
Risks and benefits of diagnostic laparoscopy.
Benefits of laparoscopy:
Confirms or rules out endometriosis and other causes of chronic pain.
Provides an opportunity to treat endometriosis and adhesive disease.
Risks of laparoscopy:
Adverse effects from anesthesia.
Venous thromboembolism.
Bleeding, infection, wound infection.
Adhesion formation.
Injury to surrounding structures.
Shared Decision-Making: Some patients and their families may opt for medical treatment without a confirmed pathologic diagnosis to avoid laparoscopy.
Laparoscopy for Endometriosis
Appearance of endometriosis may differ in adolescents compared to adults:
Lesions are typically clear or red in adolescents.
Can be difficult to identify for gynecologists unfamiliar with adolescent endometriosis.
Visualization techniques:
Magnification technique.
Filling the pelvis with saline and "diving in" with the laparoscope.
Suspicious lesions should be biopsied.
Visible lesions should be destroyed, ablated, or excised during the initial laparoscopy.
Visual diagnosis may suffice in some cases when biopsy does not confirm endometriosis, allowing treatment initiation.
Peritoneal stripping is not recommended in adolescents due to:
Theoretical concerns (e.g., adhesion formation, bowel obstruction, infertility, persistent pain).
Lack of short-term and long-term outcome data.
Staging:
Most adolescents are diagnosed with early-stage endometriosis (stage 1 or 2).
Recent reports indicate some young women present with more advanced disease.
Counseling:
It is essential to communicate that the stage and location of endometriosis do not directly correlate with symptom frequency or severity.
Adolescents may experience significant pain even with early-stage disease because:
Clear and red lesions are more metabolically active.
They are associated with greater prostaglandin production, pain, and inflammation compared to "powder burn" lesions seen in adults.
LNG-IUS Placement:
Consider placing an LNG-IUS during laparoscopy for dysmenorrhea or chronic pain to minimize insertion pain.
LNG-IUS has been shown to reduce pain associated with:
Dysmenorrhea unresponsive to oral contraceptives.
Dysmenorrhea and pain associated with endometriosis.
LNG-IUS is not FDA-approved for treating endometriosis-associated pain.
Oophorectomy and hysterectomy should not be used to treat adolescents with endometriosis.
Managing Endometriosis in Adolescents
Endometriosis is a chronic disease with the potential for progression if left untreated.
Treatment Goals:
Symptom relief.
Suppression of disease progression.
Protection of future fertility.
Treatment Considerations:
No cure for endometriosis.
No single best treatment option.
Therapy must be individualized.
Consider patient choice, contraceptive needs, contraindications to hormone use, and potential side effects.
Counsel the adolescent and her family about treatment options.
Endometriosis is an inflammatory-mediated, estrogen-dependent disorder.
Estrogen from the ovaries and local production by endometriotic implants (due to aromatase activity) promotes increased prostaglandin production, leading to pain.
Recommended treatment:
Conservative surgical therapy (for diagnosis and treatment).
Ongoing suppressive medical therapy to prevent endometrial proliferation.
First-line therapy:
Suppressive hormonal therapy using:
Continuous combined hormonal contraceptives.
Progestin-only agents.
LNG-IUS (52 mg).
All of these methods have demonstrated effectiveness.
Patients may need to try different types of hormonal suppression to find the best fit.
Hormonal suppression should be continued unless the patient is actively trying to conceive.
GnRH Agonist Therapy:
Considered for patients with pain refractory to conservative surgical and suppressive hormonal therapy.
At least 6 months of therapy with add-back medicine is often beneficial.
Limited data on long-term effects on bone mineralization in adolescents.
Leuprolide has been used in younger adolescents for precocious puberty, obstructive anomalies, and transgender care, and during cancer therapies.
Discuss potential risks and benefits based on individual needs.
Add-back hormone therapy should be initiated with GnRH agonist treatment to:
Prevent bone loss.
Avoid menopausal symptoms.
A combination of conjugated equine estrogen (0.625 mg) and norethindrone acetate (5 mg) daily was superior to norethindrone acetate alone for quality of life and bone density preservation in one study.
Dual-energy X-ray absorptiometry scanning is not needed:
Before starting therapy.
During GnRH agonist treatment lasting less than 12 months.
After treatment.
Counsel patients about adequate calcium and vitamin D intake and the benefits of weight-bearing exercise during GnRH agonist therapy.
Continuous hormone suppression therapy should be started after discontinuing leuprolide.
Pain Relief:
NSAIDs should be the mainstay for pain relief.
Long-term narcotic prescriptions are not recommended outside a specialized pain management team.
Monitoring:
CA 125 levels may be elevated, but ACOG does not recommend using it to monitor treatment or screen for endometriosis.
Long-term Patient and Family Education and Support
Adolescents with endometriosis benefit from:
Ongoing education and support.
Integration of multidisciplinary services (e.g., biofeedback, pain management teams, acupuncture, herbal therapy).
Fertility:
No longitudinal data exists on fertility rates in adolescents with endometriosis.
Early diagnosis and treatment may protect future fertility.
Resources:
Endometriosis Foundation of America (www.endofound.org)
The Endometriosis Association (www.endometriosisassn.org)
49
Dyspareunia
Dyspareunia
50
Dysplasia
Dysplasia
51
Early Pregnancy Loss
Early Pregnancy Loss
Obstetrics
Early Pregnancy Loss: An Outline
The sources provide a detailed overview of early pregnancy loss, covering its definition, incidence, etiology, diagnosis, and various management options.
I. Definition and Background
Early pregnancy loss refers to the loss of a pregnancy within the first trimester, specifically a nonviable intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without cardiac activity before 12 6/7 weeks of gestation.
The terms miscarriage, spontaneous abortion, and early pregnancy loss are often used interchangeably.
II. Incidence and Etiology
Early pregnancy loss is common, affecting 10% of clinically recognized pregnancies, with 80% of losses occurring within the first trimester.
The primary cause is fetal chromosomal abnormalities (50% of cases).
Risk factors include advanced maternal age and a history of previous early pregnancy loss.
III. Diagnosis
Symptoms like vaginal bleeding and uterine cramping are common in both normal and nonviable pregnancies, necessitating careful differentiation from other conditions such as ectopic or molar pregnancy.
Ultrasonography is the preferred method for confirming a viable intrauterine pregnancy.
Serum β-hCG testing can also be helpful.
Table 1 in Source outlines specific ultrasound criteria for diagnosing pregnancy failure, including:
Crown-rump length (CRL) of 7 mm or greater with no heartbeat
Mean sac diameter of 25 mm or greater with no embryo
Absence of an embryo with a heartbeat for specified durations after previous scans showing a gestational sac, yolk sac, or embryo
IV. Management Options
Expectant Management: Allowing the pregnancy to pass naturally. Successful in about 80% of cases with adequate time (up to 8 weeks).
Medical Management: Using medications like misoprostol to induce expulsion. Can shorten the time to complete expulsion and increase the success rate compared to expectant management.
Surgical Evacuation: Involves procedures like suction curettage to remove pregnancy tissue. Offers the fastest and most predictable complete evacuation.
V. Comparing Management Options
Effectiveness: Surgical evacuation has the highest success rate, followed by medical management and then expectant management.
Complications: Serious complications are rare for all approaches.
Potential risks include hemorrhage, infection, and intrauterine adhesions (though rare).
Medical management may carry a slightly higher risk of significant blood loss.
Antibiotic prophylaxis is recommended for surgical management to prevent infection.
Cost: Surgical management in an operating room is the most expensive, but office-based surgical procedures can be more cost-effective in certain situations. Medical management is generally less expensive than surgical management.
VI. Other Considerations
Interpregnancy Interval: No need to delay conception after early pregnancy loss.
Contraception: Hormonal contraception or an IUD can be started immediately after treatment.
Rh D Immune Globulin: Should be considered for Rh D-negative women, especially in later first-trimester losses, to prevent Rh alloimmunization.
Workup After Loss: Generally not recommended after one loss. Evaluation is considered after two consecutive losses.
Prevention: No proven interventions to prevent early pregnancy loss.
VII. Key Recommendations
Misoprostol (800 mcg vaginally) is the recommended initial treatment for medical management. A repeat dose can be given as needed. The addition of mifepristone (200 mg orally) 24 hours before misoprostol may improve efficacy.
Anticoagulants and aspirin are not recommended for preventing early pregnancy loss, except in women with antiphospholipid syndrome.
Ultrasonography is the preferred method for confirming a viable intrauterine pregnancy.
Asymptomatic women with a thickened endometrial stripe after treatment do not require surgical intervention.
Expectant, medical, and surgical management are all acceptable options. Patient preferences should be considered in decision-making.
Doxycycline prophylaxis is recommended to prevent infection after surgical management.
Rh D immune globulin should be considered for Rh D-negative women, especially in later first-trimester losses.
VIII. Counseling and Support
While the sources focus on medical management, it is important to remember that early pregnancy loss is a significant emotional event for women and their families. Counseling and support should be an integral part of care, addressing grief, emotional well-being, and future family planning.
52
Eclampsia
Eclampsia
Obstetrical Emergencies
Management of Eclampsia
Case Description:
21-year-old G1 at 37 weeks, presents with severe preeclampsia (BP 162/112, pulse 130, RR 32, O2 Sat 88%, FHR 144).
Initial Steps:
Confirm elevated BP by repeating in 15 minutes.
Diagnose severe preeclampsia and initiate treatment.
Treatment Plan:
Start antihypertensives and magnesium sulfate.
Inform the patient and reassure them.
Alert nursing staff and anesthesiology.
Ensure equipment and medications are ready.
Place patient in left lateral position if fetal deceleration is noted.
Draw labs (CBC, CMP, LFTs) and perform a physical exam (check reflexes, abdomen, cervical exam if contractions).
During Convulsion:
Place patient in lateral recumbent position.
Assess airway, perform a jaw thrust, insert oral airway if needed.
Provide 10L/min oxygen via rebreather mask.
Shout for help, ensure anesthesiology and neonatology/pediatrics are at bedside.
Administer IV or IM magnesium sulfate (preferably IV).
Implement seizure precautions: pad side rails, prevent injury.
Monitor and document seizure duration, body parts involved, and consciousness.
Post-Seizure Management:
Monitor patient and fetus continuously (vital signs, FHR, BP every 5 minutes).
Continue administering IV antihypertensives.
Insert Foley catheter, ensure stat labs are sent.
Repeat magnesium and pre-eclampsia labs as needed.
Continue magnesium sulfate for 24 hours post-seizure or delivery.
Magnesium Sulfate Administration:
IV loading dose: 4-6 grams over 20-30 minutes.
IM dose (if no IV access): 10 grams (5 grams in each buttock).
Maintenance: 1-2 grams/hour IV or 5 grams IM every 4 hours.
Managing Recurrent Seizures:
Continue magnesium sulfate.
Administer benzodiazepines (Lorazepam 4 mg IV, Diazepam 5-10 mg IV, or Midazolam 10 mg IM).
If seizures persist: administer fosphenytoin, consider intubation.
Monitor serum magnesium every 4 hours, therapeutic range 4.9-8.5 mg/dL.
Magnesium Toxicity:
Signs: Loss of reflexes (>8.5 mg/dL), respiratory paralysis (>12.2 mg/dL), cardiac arrest (>30 mg/dL).
Treatment: Stop magnesium infusion, administer calcium gluconate 1 gram IV over 3 minutes.
53
Ectopic pregnancy
Ectopic pregnancy
Gynecology
Tubal Ectopic Pregnancy Outline
Definition: An ectopic pregnancy occurs outside the uterine cavity, most commonly in the fallopian tube. [1]
Significance:
Ectopic pregnancy is a significant cause of pregnancy-related mortality and morbidity. [2]
Early detection allows for minimally invasive surgery or medical management using methotrexate. [1]
A ruptured ectopic pregnancy in an unstable patient requires prompt surgical intervention. [1]
Epidemiology:
Accounts for approximately 2% of all reported pregnancies. [2]
True incidence is difficult to estimate due to outpatient treatment and outdated national data. [2]
Ruptured ectopic pregnancy was a leading cause of hemorrhage-related mortality from 2011–2013. [2]
Prevalence can be as high as 18% among women presenting to the emergency department with first-trimester vaginal bleeding or abdominal pain. [2]
Etiology:
The fallopian tube is the most common location (over 90% of cases). [3]
Other locations: abdomen (1%), cervix (1%), ovary (1-3%), and cesarean scar (1-3%). [3]
Heterotopic pregnancy (co-occurring ectopic and intrauterine pregnancy) is rare. [3]
Risk Factors:
Half of all women diagnosed with an ectopic pregnancy have no known risk factors. [4]
Significant risk factors:History of ectopic pregnancy (10% chance of recurrence with one previous, over 25% with two or more). [4]
Previous fallopian tube damage. [4]
Ascending pelvic infection. [4]
Prior pelvic or fallopian tube surgery. [4, 5]
History of infertility. [5]
Risk factors among women using assisted reproductive technology:Tubal factor infertility. [4]
Multiple embryo transfer. [4]
Less significant risk factors:Cigarette smoking history. [5]
Age over 35 years. [5]
IUD users have a lower risk overall, but up to 53% of pregnancies with an IUD are ectopic. [5]
Factors not associated with increased risk:Oral contraceptive use. [5]
Emergency contraception failure. [5]
Previous elective pregnancy termination. [5]
Pregnancy loss. [5]
Cesarean delivery. [5]
Diagnosis:
Minimum evaluation:Transvaginal ultrasound. [6]
Pregnancy confirmation. [6]
Serial evaluation often needed:Transvaginal ultrasonography. [6]
Serum hCG level measurement. [6]
Urgent evaluation and treatment required for:Hemodynamic instability. [6]
Acute abdomen. [6]
Screening for pregnancy recommended for all sexually active, reproductive-aged women with abdominal pain or vaginal bleeding. [6]
Women with known risk factors should be evaluated for possible ectopic pregnancy even without symptoms. [6]
Diagnostic Tools:
Transvaginal Ultrasonography:Definitive diagnosis if a gestational sac with yolk sac or embryo is seen in the adnexa. [7]
Suspicion raised by a mass or mass with hypoechoic area separate from the ovary. [7]
Definitive intrauterine pregnancy signs: visualization of a gestational sac with yolk sac or embryo. [7]
Pseudogestational sac can be mistaken for an intrauterine gestation. [7]
Serum Human Chorionic Gonadotropin (hCG) Measurement:Aids in diagnosis but should not be used alone. [8]
Correlate with history, symptoms, and ultrasound findings. [8]
Accurate gestational age calculation is the best determinant of when a normal pregnancy should be seen on ultrasound. [8]
"Discriminatory level" concept suggests a nonviable gestation if hCG is above a certain value and no gestational sac is seen on ultrasound. [9]
Discriminatory level should be conservatively high (e.g., 3,500 mIU/mL) to avoid misdiagnosis. [9]
Multiple gestations have higher hCG levels. [9]
Trends of Serial Serum hCG: Single measurement cannot diagnose viability or location. [10]
Serial measurements differentiate normal from abnormal pregnancies. [10]
Second measurement recommended 2 days after the initial to assess increase or decrease. [10]
Subsequent assessments 2-7 days apart. [10]
hCG increases curvilinearly until a plateau at 100,000 mIU/mL by 10 weeks. [11]
An increase of less than the minimal threshold in 48 hours is suspicious of an abnormal pregnancy. [11]
Decreasing values suggest a failing pregnancy but should not be considered diagnostic. [12]
Pregnancy of Unknown Location:
A transient state where no intrauterine or ectopic pregnancy is definitively found on ultrasound. [13]
Efforts should be made to establish a definitive diagnosis. [13]
For stable patients desiring to continue a potential intrauterine pregnancy: repeat transvaginal ultrasound and/or serial hCG measurements. [14]
Uterine aspiration can distinguish early intrauterine pregnancy loss from ectopic pregnancy. [15]
Perform through shared decision-making, considering maternal risk and the possibility of interrupting a desired pregnancy. [15]
If chorionic villi are found, it confirms a failed intrauterine pregnancy. [15]
If chorionic villi are not found, monitor hCG levels. [15]
Plateau or increase suggests incomplete evacuation or an ectopic pregnancy. [15]
Large decreases are more consistent with a failed intrauterine pregnancy. [15]
A decrease of 50% or greater within 12-24 hours likely indicates a failed intrauterine pregnancy. [15]
Debate exists on the need for uterine aspiration before methotrexate. [16]
Proponents: confirm diagnosis, avoid unnecessary methotrexate exposure, guide future management. [16]
Opponents: increased rupture risk due to treatment delay, increased healthcare costs. [16]
Rupture risk during surveillance is low. [16]
Presumptive methotrexate treatment does not significantly save costs or reduce complications. [16]
Candidates for Medical Management:
Confirmed or high clinical suspicion of ectopic pregnancy. [17]
Hemodynamically stable. [17]
Unruptured mass. [17]
No absolute contraindications to methotrexate. [17]
Decision should be patient-informed, considering the benefits and risks of both medical and surgical management. [17]
Methotrexate:
Folate antagonist that inhibits DNA synthesis and cell replication. [18]
Affects actively proliferating tissues. [18]
Used for ectopic pregnancy treatment since 1982. [18]
No recommended alternative medical treatments. [18]
Intramuscular administration is preferred over oral. [18]
Contraindications: (See Box 1 in source material) [19-21]
Absolute: intrauterine pregnancy, immunodeficiency, blood dyscrasias, active pulmonary or peptic ulcer disease, hepatic or renal dysfunction, breastfeeding. [19, 21]
Relative: embryonic cardiac activity, high initial hCG, ectopic pregnancy larger than 4cm, refusal of blood transfusion. [20, 21]
Relative contraindications indicate potentially reduced effectiveness, not absolute restrictions. [20]
High initial hCG is a relative contraindication: failure rates increase above 5,000 mIU/mL. [20]
Other predictors of treatment failure: advanced/rapidly growing gestation, rapidly increasing hCG. [20]
Treatment Protocols: (See Box 2 in source material) [22-28]
Single-dose: 50 mg/m2 intramuscularly on day 1. [23-25]
Two-dose: 50 mg/m2 intramuscularly on days 1 and 4. [23, 26]
Fixed multiple-dose: 1 mg/kg intramuscularly on days 1, 3, 5, and 7, alternating with folinic acid (0.1 mg/kg) on days 2, 4, 6, and 8. [23, 27, 29]
Treatment Success:Ranges from 70% to 95% in observational studies. [30]
Depends on the regimen and initial hCG level. [30]
No clear consensus on the optimal regimen. [30]
Regimen Selection:Guided by initial hCG level and patient discussion of benefits and risks. [30]
Single-dose may be appropriate for low initial hCG or plateauing values. [30]
Two-dose may be an alternative for high initial hCG. [30]
Single-dose vs. Multiple-dose:Observational studies: multiple-dose statistically more effective but with increased adverse effects. [24]
Randomized controlled trials: similar success rates, multiple-dose with higher adverse effect risk. [31]
Single-dose vs. Two-dose:Systematic review and meta-analysis: similar success rates and adverse effect risks. [31]
Two trials suggest greater two-dose success in women with high initial hCG. [31]
Surveillance After Methotrexate:
Monitor hCG levels serially until a non-pregnant level is reached. [32]
hCG may increase initially before progressively decreasing. [32]
Failure to decrease by at least 15% from day 4 to day 7 indicates high treatment failure risk. [32]
Requires additional methotrexate or surgery. [32]
If pretreatment uterine aspiration was not done:Treatment failure raises concern for an abnormal intrauterine gestation. [32]
Consider uterine aspiration before repeat methotrexate or surgery. [32]
Ultrasound surveillance of resolution is not routinely indicated. [33]
Complete hCG resolution usually takes 2-4 weeks (up to 8 weeks). [33]
Two-dose regimen has faster hCG resolution than single-dose. [33]
Adverse Effects of Methotrexate:
Usually dose- and duration-dependent. [34]
Most common: gastrointestinal problems (nausea, vomiting, stomatitis). [34]
Vaginal spotting is expected. [34]
Abdominal pain 2-3 days after administration is common. [34]
Less common: elevated liver enzymes (usually resolves after discontinuing methotrexate). [35]
Rare: alopecia, pneumonitis. [35]
Patient Counseling After Methotrexate:
Risks: ectopic pregnancy rupture, decreased efficacy due to certain foods/supplements/drugs, importance of avoiding pregnancy until resolution. [35]
Symptoms of tubal rupture: emphasize the need for immediate medical attention. [35]
Avoid: vigorous activity, sexual intercourse, pelvic/ultrasound exams (unless necessary). [35]
Foods/supplements/drugs to avoid: folic acid, NSAIDs, narcotic analgesics, alcohol, gas-producing foods, sunlight exposure. [35, 36]
Potential for fetal death or teratogenic effects: counsel on pregnancy avoidance during and after treatment. [37]
FDA labeling recommends avoiding pregnancy for at least one ovulatory cycle after treatment. [37]
Some experts recommend delaying pregnancy for at least 3 months. [37]
Methotrexate and Subsequent Fertility:
Limited evidence suggests no adverse effect on fertility or ovarian reserve. [38]
One study found no difference in anti-Müllerian hormone levels or reproductive outcomes after methotrexate. [38]
A systematic review found no significant difference in the number of oocytes retrieved before and after methotrexate. [38]
Candidates for Surgical Management:
Required for:Hemodynamic instability. [39]
Symptoms of ongoing ruptured ectopic mass (e.g., pelvic pain). [39]
Signs of intraperitoneal bleeding. [39]
Necessary for:Patients meeting absolute contraindications to medical management. [39]
Failed medical management. [39]
Can be considered for:Clinically stable patients with a nonruptured ectopic pregnancy. [39]
Concurrent surgical procedures (e.g., tubal sterilization, hydrosalpinx removal). [39]
Surgical Procedures:
Laparoscopic salpingectomy: removal of part or all of the affected fallopian tube. [40]
Laparoscopic salpingostomy: removal of the ectopic pregnancy while preserving the fallopian tube. [40]
Laparotomy: reserved for unstable patients, significant bleeding, or compromised laparoscopic visualization. [40]
Medical vs. Surgical Management:
Medical management: avoids surgical/anesthesia risks. [41]
Surgical management: higher success rate, shorter surveillance, fewer office visits/phlebotomy. [41]
Randomized trials:Single-dose methotrexate: lower success rate than laparoscopic salpingostomy. [41]
Multidose methotrexate: no difference in success rate compared to laparoscopic salpingostomy. [41]
No difference in overall tubal preservation, patency, repeat ectopic pregnancy, or future pregnancies between methotrexate and laparoscopic surgery. [41]
Medical management is cost-effective when:Laparoscopy is not needed for diagnosis. [36]
hCG is less than 1,500 mIU/mL. [36]
Surgical management is more cost-effective when:Prolonged resolution is expected. [36]
Higher chance of medical management failure (e.g., high/increasing hCG, embryonic cardiac activity). [36]
Salpingostomy vs. Salpingectomy:
Decision based on: clinical status, fertility desires, extent of tubal damage. [42]
Randomized controlled trials: no significant difference in subsequent intrauterine or repeat ectopic pregnancy rates. [42]
Cohort studies: salpingostomy associated with higher subsequent intrauterine pregnancy but also higher repeat ectopic pregnancy rates. [42]
Salpingectomy preferred when: severe tubal damage, significant bleeding from the surgical site. [43]
Salpingectomy can be considered for future fertility if: the contralateral tube is healthy. [43]
Salpingostomy considered if: future fertility desired, contralateral tube damaged, removal would necessitate assisted reproduction. [43]
Monitor hCG after salpingostomy to ensure resolution. [43]
Consider prophylactic methotrexate for incomplete resection concerns. [43]
Expectant Management:
Potential role in specific circumstances. [44]
Candidates: asymptomatic, objective evidence of resolution, understand and accept potential risks. [44]
Spontaneous resolution is likely when hCG is less than 200 mIU/mL (lower rates with higher hCG). [45]
One trial: no significant difference in success between expectant management and single-dose methotrexate for hCG less than 2,000 mIU/mL. [45]
Reasons to abandon: intractable/increasing pain, insufficient hCG decrease, tubal rupture with hemoperitoneum. [45]
Summary of Recommendations: (See source material for complete list) [46-53]
Level A (good and consistent evidence):Laparoscopic surgery or intramuscular methotrexate are safe and effective treatments for stable women with nonruptured ectopic pregnancies. [46]
Surgical management is required for hemodynamic instability, ruptured ectopic mass symptoms, or intraperitoneal bleeding signs. [47]
Level B (limited or inconsistent evidence):Do not use hCG levels alone to diagnose an ectopic pregnancy. [47]
Use a conservatively high hCG discriminatory level (e.g., 3,500 mIU/mL). [48]
Base the decision for salpingostomy vs. salpingectomy on clinical status, fertility desires, and tubal damage. [49]
Guide methotrexate protocol selection by initial hCG level and patient discussion. [50]
Treatment failure is likely if hCG doesn't decrease by at least 15% from day 4 to day 7 after methotrexate. [51]
Methotrexate does not appear to adversely affect subsequent fertility or ovarian reserve. [51]
Expectant management may be appropriate in specific circumstances. [52]
Level C (consensus and expert opinion):Minimum diagnostic evaluation: transvaginal ultrasound and pregnancy confirmation. [52]
Stable patients desiring to continue a potential intrauterine pregnancy should have repeat transvaginal ultrasound and/or serial hCG measurements. [52]
Consider medical management with methotrexate for stable patients with confirmed/suspected ectopic pregnancy, an unruptured mass, and no absolute contraindications. [53]
Monitor hCG serially after methotrexate until a non-pregnant level is reached. [53]
Counsel patients on the risk of ectopic pregnancy rupture, avoidance of certain substances, and the importance of delaying pregnancy until resolution. [53]
54
Emergency Contraception
Emergency Contraception
Gynecology
Emergency Contraception - Summary
Introduction
Definition: Emergency contraception (EC) is a postcoital method used to prevent pregnancy after unprotected or inadequately protected sexual intercourse. Common indications include contraceptive failure (e.g., condom breakage or missed doses of oral contraceptives) or failure to use contraception.
History: Research on emergency contraceptive steroids began in the 1960s, with the first oral regimen published in 1974. The FDA approved the first dedicated EC product in 1998.
Purpose: EC aims to prevent pregnancy before a fertilized egg implants, and it is distinct from medical abortion. It is effective only if used before a pregnancy is established.
Methods of Emergency Contraception:
Oral Emergency Contraceptives: Combined estrogen-progestin, progestin-only pills, and selective progesterone receptor modulators.
Copper Intrauterine Device (IUD): Also effective as an EC method if inserted within 5 days of unprotected intercourse.
Types of Emergency Contraception
Progestin-Only Pills:
Levonorgestrel (1.5 mg): Most commonly used, available over the counter without age restriction. It is labeled for use up to 72 hours after unprotected intercourse but works best when used as soon as possible.
Levonorgestrel (Two doses of 0.75 mg): This regimen has fallen out of favor in favor of the single-dose version, which is just as effective.
Selective Progesterone Receptor Modulator (Ulipristal Acetate):
Ulipristal Acetate (30 mg): Requires a prescription and can be effective up to 120 hours (5 days) after unprotected intercourse. It maintains its effectiveness throughout this time.
Copper IUD:
Highly effective for EC when placed within 5 days of unprotected intercourse. It also serves as an ongoing contraceptive method.
Mechanism of Action
Levonorgestrel and Ulipristal Acetate: These agents inhibit or delay ovulation. Levonorgestrel delays follicular development, while ulipristal acetate inhibits follicular rupture, even after luteinizing hormone levels rise.
Copper IUD: Works primarily by affecting sperm viability and function and possibly altering the endometrium to prevent implantation.
Adverse Effects
Short-Term Adverse Effects:
Nausea and Headache: Occurs in about 12-19% of users.
Irregular Bleeding: Some women experience non-menstrual bleeding shortly after taking EC, especially if taken early in the menstrual cycle.
Other Effects: Abdominal pain, dizziness, breast tenderness, and fatigue are also reported.
Copper IUD: Risks include uterine perforation (1/1,000), cramping, and increased menstrual flow or dysmenorrhea.
Effectiveness and Body Weight Considerations
Levonorgestrel vs. Ulipristal Acetate: Ulipristal acetate is more effective than levonorgestrel, particularly for those with a BMI >25. Studies show that the efficacy of levonorgestrel may decrease in overweight or obese women, while the copper IUD is effective regardless of weight.
Preventive Efficacy: The levonorgestrel regimen prevents 60-94% of pregnancies when taken as directed, and ulipristal acetate has a slightly lower failure rate.
Barriers to Use
Awareness: Many women are unaware of EC or have misconceptions about its availability and safety. Adolescents and women who are poor or foreign-born are particularly likely to lack knowledge.
Access: Despite being available over the counter, access to EC may still be restricted by pharmacy policies or other barriers, especially for young women.
Clinical Recommendations
Candidates for EC: All women who have had unprotected or inadequately protected intercourse and do not wish to become pregnant are candidates. There are no medical conditions for which EC use outweighs the benefits.
Screening Before EC: No clinical examination or pregnancy testing is required before providing EC, and it should not be withheld based on the timing of intercourse within the menstrual cycle.
Repeat Use: EC can be used more than once in a cycle, but it should not be considered a replacement for regular contraception.
Follow-Up: No specific follow-up is required, but women should seek evaluation if their menses are delayed by a week or if they experience persistent abdominal pain.
55
Endometrial ablation
Endometrial ablation
Gynecology
Managing Endometrial Intraepithelial Neoplasia (EIN)
This Clinical Consensus from the American College of Obstetricians and Gynecologists (ACOG) provides guidance on the management of EIN, also known as atypical endometrial hyperplasia (AEH). This condition is often a precursor to endometrial cancer. The consensus emphasizes the importance of ruling out concurrent carcinoma and offers recommendations for surgical and non-surgical management, follow-up, and patient counseling on lifestyle modifications.
Detecting Concurrent Carcinoma
Gynecologists should attempt to exclude the presence of concurrent carcinoma in individuals diagnosed with EIN-AEH. This is important because EIN-AEH is a precursor to endometrial cancer, and studies have shown that a significant percentage of patients diagnosed with EIN-AEH who undergo hysterectomy are found to have endometrial cancer in the hysterectomy specimen.
Hysteroscopic examination with endometrial sampling is considered the most accurate method for detecting concurrent carcinoma. While in-office suction endometrial sampling has been used in the past, recent data suggest that it may miss endometrial pathology, particularly in cases of "mass lesions". Hysteroscopic-guided uterine sampling allows for direct visualization and targeted biopsy.
Surgical Management
Hysterectomy is the definitive treatment for EIN–AEH. This is because it allows for both the removal of the precancerous lesion and the definitive assessment of the presence or absence of concurrent carcinoma.
Supracervical hysterectomy should not be performed for EIN-AEH. This is because the lesion may extend into the lower uterine segment or upper endocervix, which would not be removed during a supracervical hysterectomy.
Endometrial ablation should not be performed for EIN-AEH. The high persistence and recurrence rates after ablation, along with the potential difficulty in evaluating future bleeding episodes, make this an inappropriate treatment option.
Non-Surgical Management
Progestational agents are recommended for patients in whom hysterectomy is not an option. This is particularly relevant for patients who desire to preserve fertility. Progestin therapy helps to prevent or delay the progression of EIN-AEH to endometrial cancer.
While there is no clear evidence supporting the superiority of oral or intrauterine progestational agents, limited data suggest that intrauterine administration (e.g., LNG-IUD) may be associated with a higher rate of disease regression.
Continuous oral progestin therapy appears to be more effective than cyclic therapy.
No specific formulation of oral progestational agent is recommended over another. Megestrol acetate or medroxyprogesterone acetate are often used, as they have been utilized in the majority of studies on the management of EIN-AEH with progestins.
Follow-Up
Patients treated with progestational agents should undergo repeat histologic assessment within 3-6 months to evaluate treatment response. This helps to determine if the EIN-AEH has resolved, regressed, persisted, or progressed to cancer.
Long-term maintenance therapy with progestational agents may be considered for patients with persistent risk factors for endometrial cancer. This includes factors like obesity, type 2 diabetes, and family history of endometrial cancer.
Surveillance after total hysterectomy for EIN-AEH is not recommended if there is no evidence of concurrent endometrial carcinoma in the pathology specimen.
Counseling Patients on Lifestyle Modifications
Gynecologists should counsel patients that lifestyle modifications resulting in weight loss and glycemic control can improve overall health and may decrease the risk of EIN-AEH and endometrial cancer. Obesity is a significant risk factor for endometrial cancer, and weight loss has been shown to have positive effects on health outcomes.
Future Research
The sources highlight several areas where further research is needed, including:
The comparative effectiveness of different progestational agents
The utility of repeat sampling for excluding concurrent malignancy
Long-term outcomes for patients managed non-surgically
The impact of lifestyle modifications on EIN-AEH and endometrial cancer risk
The role of molecular classification in guiding treatment decisions
Addressing disparities in EIN-AEH treatment and mortality, particularly in historically excluded populations
1. What are the contraindications for endometrial ablation?
• Answer: Contraindications for endometrial ablation include uterine anomalies, active genital or pelvic infections, endometrial hyperplasia or cancer, a history of endometrial ablation with incomplete results, and the desire for future fertility. Patients with large fibroids that distort the uterine cavity are also not ideal candidates.
2. How do you counsel patients post-endometrial ablation?
• Answer: Patients should be informed that while endometrial ablation may reduce or stop menstrual bleeding, it is not a guarantee, and some may require additional treatment. They should be advised that future pregnancies are not recommended due to the high risk of complications, including abnormal placentation and miscarriage. Regular follow-up is essential to monitor for recurrence of symptoms or complications.
3. What are the expected outcomes and success rates of endometrial ablation?
• Answer: Endometrial ablation is generally effective, with about 75-85% of patients experiencing a significant reduction in menstrual bleeding and around 40-50% achieving amenorrhea. Success is higher in women with smaller uteri and those without significant intracavitary lesions.
4. What alternatives to endometrial ablation should be considered?
• Answer: Alternatives include medical therapy (e.g., hormonal treatments), uterine artery embolization, myomectomy (for fibroids), or hysterectomy. The choice of treatment depends on the patient’s symptoms, underlying pathology, and reproductive goals.
56
Endometrial Cancer
Endometrial Cancer
Gynecology
Endometrial Cancer - Summary
Introduction
Prevalence: Endometrial cancer is the most commonly diagnosed gynecologic malignancy, predominantly affecting women in their postmenopausal years. The estimated number of new cases in 2015 was 54,870, with around 10,170 deaths.
Age and Racial Factors: The average age at diagnosis is 63 years. Caucasian women have a lifetime risk of 2.81% of developing endometrial cancer, while African American women have a slightly lower lifetime risk of 2.48% but are more likely to have aggressive, high-grade tumors (type II).
Prognosis: More than 70% of cases are diagnosed at stage I, where the five-year survival rate is approximately 90%.
Types and Classification
Type I (Endometrioid Adenocarcinoma):
Characteristics: The most common form, accounting for over three-quarters of all cases.
Risk Factors: Linked to prolonged exposure to estrogen, obesity, polycystic ovary syndrome (PCOS), and diabetes.
Prognosis: Typically low grade and confined to the uterus at diagnosis.
Type II (Non-Endometrioid Cancer):
Characteristics: Includes clear cell and papillary serous histologies, and carcinosarcoma.
Prognosis: Considered high grade, often associated with a more advanced stage and poorer prognosis.
Risk Factors
Estrogen Exposure:
Prolonged exposure to unopposed estrogen (without progesterone) significantly increases the risk, especially in cases of chronic anovulation (PCOS), estrogen-producing tumors, or obesity.
Obesity and Lifestyle:
Women with BMI greater than 25 have a substantially increased risk, especially those who have never used hormone therapy. Diabetes and hypertension also contribute to increased risk, independent of obesity.
Age and Genetics:
Risk increases with age, especially after 50 years. Genetic syndromes like Lynch syndrome and Cowden disease are linked to higher risks of endometrial cancer.
Diagnosis
Symptoms: The most common presentation is abnormal uterine bleeding, particularly postmenopausal bleeding.
Screening and Biopsy:
Routine screening is not recommended for asymptomatic women. For symptomatic women, transvaginal ultrasound and endometrial biopsy are utilized. In cases of postmenopausal bleeding, an endometrial thickness of 4 mm or less generally excludes malignancy.
Management and Staging
Surgical Staging:
Standard management includes a total hysterectomy with bilateral salpingo-oophorectomy (BSO), pelvic, and para-aortic lymphadenectomy. Comprehensive staging is essential to assess disease spread.
Role of Radiation and Chemotherapy:
Radiation is used for reducing local recurrence in intermediate and high-risk patients. Chemotherapy, particularly with carboplatin and paclitaxel, is used for advanced or recurrent disease.
Adjuvant Therapy
Radiation:
Recommended for certain patients with high-intermediate risk factors. Vaginal brachytherapy is preferred over whole pelvic irradiation for better quality of life.
Chemotherapy:
A combination of doxorubicin, cisplatin, and paclitaxel is used for advanced-stage disease, showing improved survival.
Fertility-Sparing Treatment
Eligibility: Young women with well-differentiated, grade 1 endometrioid carcinoma confined to the endometrium may be considered for fertility-sparing treatment using high-dose progestins.
Outcome: Treatment response rates are variable, with high recurrence rates. Definitive surgery is advised after childbearing.
Follow-Up
Post-Treatment Surveillance:
Follow-up includes regular clinical examinations every 3-6 months for the first 2 years, then every 6 months for the next 3 years, and annually thereafter. Imaging is reserved for patients with suspected recurrence.
57
Endometriosis
Endometriosis
Gynecology
Introduction
Definition and Incidence: Endometriosis is a gynecologic condition characterized by the presence of endometrial-like tissue outside the uterus, leading to chronic pain and infertility. It affects approximately 6-10% of women of reproductive age and up to 38% of infertile women. There is no evidence suggesting an increase in incidence; however, better recognition and diagnostic methods have led to an increased rate of detection.
Risk Factors: Factors associated with an increased risk of developing endometriosis include early menarche (before age 11), shorter menstrual cycles (less than 27 days), and prolonged heavy menstrual flow. A familial association is also suggested, with first-degree relatives having a 7-10 times higher risk.
Etiology and Pathogenesis: The principal mechanism is thought to be retrograde menstruation, leading to the attachment and implantation of endometrial cells on the peritoneum. Genetic polymorphisms and an abnormal peritoneal environment contribute to lesion formation. Elevated levels of inflammatory cytokines (such as TNF-alpha, IL-1, IL-6, and IL-8) and overproduction of prostaglandins and estrogen also play a role in disease progression.
Clinical Manifestations
Symptoms: Endometriosis presents with variable symptoms, including dysmenorrhea (painful menstruation), chronic pelvic pain, dyspareunia (pain during intercourse), and, in some cases, bowel and bladder symptoms. Pain often does not correlate with the stage of the disease but may be associated with the depth of lesion infiltration.
Infertility: Endometriosis is a major contributor to infertility, although the mechanisms are complex. Inflammation, oxidative stress, and anatomical abnormalities due to adhesions can negatively affect fertility by impairing oocyte quality and sperm function.
Diagnosis
Definitive Diagnosis: The gold standard for diagnosing endometriosis is histology of lesions obtained during surgery. Laparoscopy is typically used to confirm diagnosis, as imaging and serum markers alone are insufficient.
Imaging: Transvaginal ultrasound is the imaging modality of choice, particularly for detecting ovarian endometriomas. Magnetic resonance imaging (MRI) may be used when ultrasound results are equivocal or for assessing deeply infiltrating endometriosis involving the rectum or bladder.
Treatment and Management
Medical Management:
Hormonal Therapies: Oral contraceptives (OCs), gonadotropin-releasing hormone (GnRH) agonists, and progestins are commonly used to manage pain. Progestins, such as medroxyprogesterone acetate (DMPA), can reduce pain effectively with fewer bone-related side effects compared to GnRH agonists. Recurrence of symptoms is common after discontinuation of treatment.
Add-Back Therapy: Used with GnRH agonists to reduce bone mineral loss and mitigate menopausal symptoms. Norethindrone or transdermal estradiol is used as add-back therapy.
Surgical Management:
Laparoscopic Excision: Removal of lesions is the standard surgical treatment, providing symptom relief and improved fertility rates. Excision of ovarian endometriomas is superior to drainage and ablation, with reduced recurrence of pain and higher pregnancy rates.
Definitive Surgery: Hysterectomy with or without oophorectomy is considered for patients with intractable pain who do not desire future fertility. Recurrence of symptoms may occur even after hysterectomy, particularly if ovaries are preserved.
Alternative Medical Options:
Aromatase Inhibitors: Drugs such as anastrozole and letrozole have been used in patients unresponsive to other therapies. These are typically combined with OCs or progestins to reduce ovarian stimulation.
Clinical Recommendations
Diagnosis and Imaging: Transvaginal ultrasound should be used initially to evaluate suspected endometriosis. Laparoscopy is necessary for a definitive diagnosis.
Hormonal Therapy: Medical treatment with OCs, GnRH agonists, or progestins is effective in reducing pain but is associated with high recurrence after discontinuation.
Surgical Treatment: Laparoscopic excision of lesions should be offered, especially for those with infertility. Definitive surgery, such as hysterectomy, may be considered in cases of failed conservative treatment and when fertility is no longer desired.
Individualized Approach: Management should be individualized based on symptom severity, fertility goals, and patient preferences, with both medical and surgical options considered.
58
Endometritis - Postprocedural
Endometritis - Postprocedural
Gynecology
59
External cephalic version
External cephalic version
Obstetrics
A Detailed Outline of External Cephalic Version (ECV)
External cephalic version (ECV) is a procedure used to turn a fetus from a breech presentation to a vertex presentation.
The goal of ECV is to increase the chances of a vaginal delivery.
ECV is performed by applying pressure to the woman's abdomen to turn the fetus.
Patient Selection for ECV
Pregnant women at or after 37 weeks of gestation are the preferred candidates for ECV.
By 37 weeks, spontaneous version is likely to have occurred.
The risk of reversion after ECV is lower at or after 37 weeks.
If there are any complications, emergency cesarean delivery can be performed safely at term.
There is limited information about ECV in women with prior cesarean sections or during early labor.
Studies on ECV after a cesarean section have shown mixed results, with success rates between 50% and 84%.
ECV during early labor has a success rate of 65%.
ECV is contraindicated when vaginal delivery is not an option.
Absolute and relative contraindications may need to be individualized.
Benefits and Risks of ECV
Benefits:
Increased likelihood of a vertex presentation for delivery.
Lower cesarean birth rates.
Reduced hospital charges and length of stay.
Lower risk of endometritis and sepsis.
Risks:
Adverse events occur in less than 1% of cases and include:
Placental abruption.
Umbilical cord prolapse.
Premature rupture of membranes.
Stillbirth.
Fetomaternal hemorrhage.
Fetal heart rate changes are common but usually resolve when the procedure is stopped.
Success Rates and Predictive Factors
Success rates for ECV range from 16% to 100%, with a pooled success rate of 58%.
Factors associated with higher success rates:
Parity (number of previous births)
Transverse or oblique fetal presentation
Lower hospital cesarean birth rates
Other factors, such as amniotic fluid volume, placental location, and maternal weight, have varying levels of association with ECV success.
Scoring systems to predict ECV success have not been validated.
Tocolysis and Anesthesia
Tocolysis (use of medication to relax the uterus) is commonly used during ECV and has been shown to increase success rates.
Specifically, parenteral β-stimulant tocolysis is more effective than other types.
Neuraxial analgesia (epidural or spinal anesthesia) in combination with tocolysis has been shown to increase success rates.
Data is insufficient to recommend neuraxial analgesia without tocolysis or to favor either spinal or epidural anesthesia.
ECV and Cesarean Birth Rates
Successful ECV leads to lower cesarean birth rates compared to unsuccessful ECV or no ECV.
Cesarean birth rates after successful ECV may still be higher than in women with spontaneous cephalic presentations.
Several factors influence the overall impact of ECV on cesarean birth rates, including spontaneous version and provider willingness to perform vaginal breech deliveries.
Standard Protocol for ECV
Before ECV:
Ultrasound: Confirm fetal malpresentation and rule out anomalies.
Informed Consent: Discuss risks and benefits of the procedure, including tocolysis and neuraxial analgesia.
Fetal Monitoring: Nonstress test or biophysical profile to assess fetal well-being and contraction patterns.
During ECV:
Setting: Must have cesarean delivery services readily available.
Technique: Manual manipulation of the fetus, often with the assistance of ultrasound guidance.
Tocolysis and Anesthesia: May be used to facilitate the procedure.
Monitoring: Continuous fetal heart rate monitoring.
Termination: Procedure stopped if fetal distress occurs, the patient experiences significant discomfort, or if the fetus cannot be easily turned.
After ECV:
Fetal Monitoring: Repeat nonstress test or biophysical profile.
Observation: Monitor the patient for at least 30 minutes.
Rh Immune Globulin: Administer to Rh-negative patients if delivery is not anticipated within 72 hours.
Cost Implications
ECV is generally considered cost-effective compared to scheduled cesarean delivery or a trial of labor without ECV.
Cost-effectiveness is influenced by the success rate of ECV and the cost of neuraxial analgesia.
ACOG Recommendations
Level A (Good and Consistent Evidence):
ECV should be offered to all eligible women with breech presentations near term.
Level B (Limited or Inconsistent Evidence):
Fetal presentation should be assessed and documented beginning at 36 weeks.
Parenteral tocolysis is recommended to improve ECV success.
Neuraxial analgesia in combination with tocolysis can be considered to increase the ECV success rate.
Level C (Consensus and Expert Opinion):
Fetal well-being and contraction pattern should be assessed before and after the procedure.
ECV should only be performed in settings with cesarean delivery capabilities.
This detailed outline provides a comprehensive overview of ECV, including patient selection, benefits, risks, success rates, techniques, and associated costs. Please remember to consult with a healthcare professional for specific medical advice.
60
Fecal incontinence
Fecal incontinence
Gynecology
Overview of Fecal Incontinence
This Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG) provides evidence-based guidelines on the screening, evaluation, and management of fecal incontinence, with a focus on women. The bulletin aims to aid obstetrician-gynecologists in diagnosing the condition, providing conservative treatment, and making appropriate referrals for further evaluation and surgical management when necessary.
What is Fecal Incontinence?
Fecal incontinence, also known as accidental bowel leakage, is defined as the recurrent, involuntary loss of solid or liquid stool, or mucus from the rectum. A more encompassing term, "anal incontinence", also includes the loss of flatus. The condition is estimated to affect 7-15% of community-dwelling women and is associated with a significant reduction in quality of life, negative psychological effects, and social stigma.
Prevalence and Impact
The prevalence of fecal incontinence varies depending on several factors, including the specific definition used, the frequency of episodes, and the characteristics of the population being studied, such as age and living situation (community-dwelling vs. institutionalized).
Data from the National Health and Nutrition Examination Survey (NHANES) indicates a prevalence of 8.3% in community-dwelling adults based on experiencing at least one episode of solid or liquid stool, or mucus loss in the previous 30 days. .
The most common type of incontinence is liquid stool loss (6.2%), followed by mucus (3.1%) and solid stool (1.6%).
Prevalence increases with age and is highest among nursing home populations, where it ranges from 40% to 70%.
It's important to note that these figures likely underestimate the true prevalence as many individuals with fecal incontinence do not seek help or disclose their symptoms to healthcare providers.
Causes and Contributing Factors
Fecal incontinence can stem from a wide range of causes, typically categorized as neurological or non-neurological.
Non-neurological causes are more prevalent in women, particularly fecal incontinence following Obstetric Anal Sphincter Injuries (OASIS), which can occur even long after childbirth.
Table 1 in the source document (page e260) provides a detailed list of common non-neurological causes of fecal incontinence along with their characteristic symptoms and physical examination findings.
Various medications, especially those known to cause loose stools, can also contribute to fecal incontinence, with metformin being a notable example.
Table 2 (page e261) lists various drug classes associated with loose stools or fecal incontinence, along with examples and their mechanism of action.
Neurological causes include conditions such as spinal cord injury, spina bifida, and cerebral vascular accidents, but these are not the focus of this Practice Bulletin.
A number of risk factors have been linked to fecal incontinence:
Independent risk factors in women: loose or watery stool, frequent bowel movements (more than 21 per week), and having two or more chronic illnesses.
Other risk factors: urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS or pelvic irradiation, and other medical comorbidities like diabetes mellitus and inflammatory bowel disease.
Nursing home residents face an elevated risk due to factors like constipation leading to fecal impaction and overflow incontinence.
Treatment Approaches
The management of fecal incontinence typically involves a combination of approaches, starting with conservative measures and progressing to more intensive interventions if necessary.
Initial Management: Non-Surgical Interventions
Non-surgical treatments, such as the use of pads and protective devices, dietary modifications, fiber supplementation, and stool-modifying medications, are the recommended first-line approach for managing fecal incontinence.
These interventions aim to reduce the frequency and severity of episodes, and while they often provide some short-term relief, they rarely offer a long-term solution or cure.
Further Interventions
For cases that do not respond to conservative management, more intensive interventions, such as pelvic floor muscle training with or without biofeedback and anal sphincter tissue bulking injections, may be considered.
Surgical Options
Surgical treatment is typically reserved for specific situations, such as fistulae or rectal prolapse, or when other treatments have failed to provide sufficient relief.
Table 3 (pages e262-e263) provides a comprehensive overview of the available treatments for fecal incontinence, categorized by type and the specific conditions they address.
Clinical Considerations and Recommendations
The Practice Bulletin emphasizes several key considerations and provides specific recommendations for managing fecal incontinence in women. These include:
Screening: Proactive screening is recommended for women with risk factors for fecal incontinence, especially those with other pelvic floor disorders. These risk factors include age 50 and older, residence in a long-term care facility, history of OASIS, pelvic irradiation, anal intercourse, urinary incontinence, chronic diarrhea, diabetes, obesity, and rectal urgency.
Initial Evaluation: For women reporting fecal incontinence symptoms, a thorough evaluation is crucial. This includes a complete medical history, a symptom assessment, and a physical examination of the rectal, vaginal, and perineal areas. Routine laboratory tests are not required unless there's suspicion of infectious diarrhea.
Ancillary Testing: The routine use of ancillary diagnostic tests, such as anal sphincter imaging, defecography, anorectal mammography, and pudendal nerve terminal motor latency testing, is not recommended. Referral for these tests is considered if an anatomical defect or dysfunction is suspected, or if clinical examination findings are inconclusive.
Role of Obstetrician-Gynecologists: While the management of fecal incontinence may require a multidisciplinary approach, involving referrals to specialists like gastroenterologists, urogynecologists, and pelvic floor physical therapists, obstetrician-gynecologists can play a significant role in initiating conservative interventions. These interventions include dietary modifications, bowel scheduling, fiber supplementation, and the use of stool-modifying agents. However, cases requiring surgical intervention or those not responding to conservative treatment should be referred to healthcare providers with expertise in pelvic surgery.
Effectiveness of Non-Surgical Interventions: Non-surgical treatments demonstrate modest short-term effectiveness with a low risk of adverse events, making them the preferred initial management strategy (except for cases of fistulae or rectal prolapse). Many women with fecal incontinence experience some benefit from these interventions, including dietary fiber supplementation, stool-modifying agents, and pelvic floor muscle exercises, with or without biofeedback. Other conservative therapies are listed in Table 3. While short-term efficacy data exists, evidence supporting the long-term effectiveness (beyond 6 months) of any treatment, whether surgical or non-surgical, is lacking.
Effectiveness of Anal Sphincter Bulking Agents: Injectable bulking agents are an invasive, non-surgical option for treating fecal incontinence, administered by trained healthcare providers. While they may effectively reduce fecal incontinence episodes for up to 6 months, data on their long-term effects are limited. The procedure involves injecting biocompatible agents into the anal canal walls to increase bulk. A variety of agents have been used, including collagen materials, silicone, carbon-coated beads, and dextranomer in hyaluronic acid (NASHA-Dx). Studies have shown mixed results, with some demonstrating significant reductions in episodes but also high rates of retreatment requests. The most common adverse events include proctalgia, rectal hemorrhage, bleeding at the injection site, diarrhea, and rectal discharge.
Surgical Treatment Candidacy, Benefits, and Risks: Surgical interventions are generally not recommended as the initial approach, except for cases involving fistulae or rectal prolapse. This is because surgical treatments offer only short-term improvement and carry a higher risk of complications compared to non-surgical options. Women who haven't responded to conservative treatments may be considered for surgery. However, the current evidence doesn't provide sufficient support for the effectiveness of surgical interventions beyond 3-6 months post-operation. Potential candidates should be referred to a urogynecologist or a qualified surgical specialist for further evaluation and treatment. The choice of surgical intervention often depends on surgeon and patient preferences due to limited evidence guiding therapy selection.
Summary of Recommendations
The Practice Bulletin provides specific recommendations graded according to the level of evidence supporting them:
Level B Recommendations (Based on Limited or Inconsistent Evidence):
Non-surgical treatments are recommended as the initial management approach for fecal incontinence, with the exception of fistulae or rectal prolapse cases, due to their modest short-term efficacy and low risk of adverse events.
Fiber, antimotility agents, and laxatives are considered useful treatments for fecal incontinence.
Pelvic floor muscle exercises, with or without biofeedback, are recommended for strengthening the anal sphincter and levator ani muscles, although data on the most effective protocol is insufficient.
Anal sphincter bulking agents may be considered as a short-term treatment option for women who have not responded to more conservative approaches, as they may reduce fecal incontinence episodes for up to 6 months.
Surgical treatments should not be considered as the initial management strategy (except for fistulae or rectal prolapse) due to their short-term benefits and higher risk of complications compared to non-surgical interventions.
Sacral nerve stimulation may be considered for women who haven't responded to conservative treatment, with or without anal sphincter disruption.
Sphincteroplasty may be considered for women with anal sphincter disruption and persistent fecal incontinence symptoms after trying conservative treatments.
Level C Recommendations (Based Primarily on Consensus and Expert Opinion):
Women with risk factors for fecal incontinence should be screened.
A comprehensive evaluation, including a detailed medical history, symptom assessment, and physical examination of the rectal, vaginal, and perineal areas, is recommended for women reporting fecal incontinence symptoms. Routine laboratory tests are only necessary if there's a suspicion of infectious diarrhea.
Ancillary diagnostic testing is not recommended for routine evaluation.
A colonoscopy should be considered for women presenting with fecal incontinence and changes in bowel habits, especially if accompanied by "red flag" symptoms like unexplained weight loss, abdominal pain, rectal bleeding, melena, or anemia.
Obstetrician-gynecologists can initiate conservative interventions, but referrals to specialists are warranted for surgical candidates or those not responding to conservative treatment.
Dietary manipulation (food diaries and changes) and bowel schedules (regular toileting) should be offered in conjunction with other treatments as they may improve symptoms with minimal adverse events.
This overview provides a comprehensive summary of the key points and recommendations presented in the ACOG Practice Bulletin on fecal incontinence.
61
Female Sexual Dysfunction
Female Sexual Dysfunction
Gynecology
Overview of Female Sexual Dysfunction
This article, "Female Sexual Dysfunction," is an ACOG Practice Bulletin that provides guidelines for the clinical management of female sexual dysfunction (FSD).
Introduction
FSD is a prevalent condition affecting a significant percentage of American women, with about 43% reporting sexual problems and 12% experiencing distress due to these problems.
Prevalence increases through middle age, peaking between 45-64 years, and then declines in older age.
Many women are hesitant to discuss FSD with healthcare providers, and providers may also be uncomfortable addressing the issue due to various factors such as lack of knowledge and time constraints.
The bulletin aims to offer a comprehensive overview of FSD, including updated diagnostic criteria and recommended management strategies based on current evidence.
Normal Sexual Response and Types of Dysfunction
Contemporary models of female sexual response are non-linear and encompass various sequences of the traditional four stages: desire, arousal, orgasm, and pain.
Estrogen plays a crucial role in female sexual physiology, impacting genital tissue sensitivity, elasticity, secretions, and pelvic muscle tone.
While testosterone is thought to modulate female sexual desire, its role is not fully understood, and no specific serum level is diagnostic of FSD.
The DSM-5 identifies four main types of FSD:
Female sexual interest/arousal disorder
Female orgasmic disorder
Genito-pelvic pain/penetration disorder
Substance/medication-induced sexual dysfunction
It is important to note that women may experience more than one type of FSD concurrently.
FSD Related to Life Stages
Pregnancy: Pre-existing sexual dysfunction is a risk factor for postpartum difficulties. Trauma from childbirth increases the risk of genito-pelvic pain/penetration disorder and associated arousal difficulties. Breastfeeding may cause vaginal dryness, contributing to pain. Postpartum depression can also decrease desire and frequency of sexual activity.
Menopause: Genitourinary syndrome of menopause (GSM) encompasses a range of symptoms associated with declining estrogen, including vaginal dryness, pain with intercourse, and urinary issues.
Evaluation and Diagnosis
Obstetrician-gynecologists are encouraged to initiate conversations about sexual function during routine visits to identify concerns and destigmatize the topic.
The use of a brief sexual function self-report checklist can facilitate these discussions.
For patients with potential FSD, an initial evaluation should include a comprehensive history and physical examination to assess potential gynecologic causes.
A thorough sexual history should cover various aspects of the patient's sexual experiences, relationships, and overall health, including past and current abuse or violence.
The physical examination should focus on areas of concern identified in the history, with attention to potential gynecologic pathologies.
Diagnosis relies on the DSM-5 criteria, which require symptoms to persist for at least six months and cause significant distress.
Treatment Approaches
The article discusses various treatment options for FSD, including:
Psychologic Interventions:
Recommended for all types of FSD
Include sexual skills training, cognitive-behavioral therapy, mindfulness-based therapy, and couples therapy
Referral to mental health specialists with expertise in FSD is advised based on the patient's needs and the provider's expertise
Hormonal Therapy:
Low-dose vaginal estrogen is the preferred treatment for FSD related to GSM.
Low-dose systemic hormone therapy (estrogen with or without progestin) is an alternative for women with dyspareunia and vasomotor symptoms.
Ospemifene is another alternative to vaginal estrogen for dyspareunia caused by GSM.
Hormonal therapy (estrogen or SERMs) is not recommended for FSD not caused by a hypoestrogenic state.
Androgen Therapy:
Short-term transdermal testosterone can be considered for postmenopausal women with sexual interest/arousal disorders after proper counseling about risks and unknown long-term effects.
Evidence is insufficient to recommend testosterone for premenopausal women with sexual interest/arousal disorders.
Systemic DHEA is not recommended for women with these disorders as it is ineffective.
Non-hormonal Medications:
Flibanserin may be considered for premenopausal women with hypoactive sexual desire disorder who do not have depression and are counseled about the risks of alcohol use during treatment.
Sildenafil should not be used outside clinical trials for female interest/arousal disorders.
Bupropion may improve symptoms in women experiencing antidepressant-induced sexual dysfunction.
Treatment for Genito-Pelvic Pain and Penetration Disorders:
Pelvic floor physical therapy is recommended to restore muscle function and reduce pain.
Intravaginal prasterone, low-dose vaginal estrogen, and ospemifene can be used in postmenopausal women with moderate to severe dyspareunia due to GSM.
Lubricants, topical anesthesia, and moisturizers may help alleviate dyspareunia.
Vaginal CO2 fractional laser treatment should not be used outside research settings for dyspareunia due to GSM.
Conclusion
The article concludes with a summary of recommendations based on the level of evidence supporting them. Level A recommendations are supported by good and consistent evidence, Level B by limited or inconsistent evidence, and Level C by consensus and expert opinion. The article also provides details on the literature search process and evidence grading methodology used to formulate the recommendations.
62
Fetal Bradycardia
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63
Fetal growth restriction
Fetal growth restriction
Obstetrics
Fetal Growth Restriction: A Detailed Outline
The sources provide an in-depth discussion of Fetal Growth Restriction (FGR), also known as Intrauterine Growth Restriction (IUGR), a common pregnancy complication associated with adverse outcomes.
I. Definition and Terminology
Fetal Growth Restriction (FGR): The term used to describe a fetus with an estimated fetal weight or abdominal circumference less than the 10th percentile for gestational age.
Small for Gestational Age (SGA): Used exclusively to describe newborns whose birth weight is less than the 10th percentile for gestational age.
Challenges with Definitions: These definitions don't consider individual fetal growth potential, leading to potential misdiagnosis – missing larger fetuses not reaching their potential and mislabeling constitutionally small fetuses.
II. Prevalence
The prevalence of FGR varies depending on the definition used.
Using the 10th percentile definition, it's estimated that FGR occurs in approximately 5% of pregnancies.
III. Etiology
FGR can result from various factors categorized as maternal, fetal, and placental:
Maternal Disorders:
Vascular Diseases: Chronic conditions affecting blood vessels, such as chronic hypertension and preeclampsia, are associated with FGR.
Antiphospholipid Syndrome: An autoimmune disorder affecting blood clotting, linked to FGR.
Substance Use: Tobacco, alcohol, cocaine, and narcotics can contribute to FGR.
Malnutrition: Severe caloric restriction, especially inadequate protein intake before 26 weeks, can lead to FGR. However, simply increasing nutrient intake without true malnutrition does not improve outcomes.
Fetal Disorders:
Genetic and Structural Abnormalities: Chromosomal abnormalities, such as Trisomy 13 and 18, and structural defects like congenital heart disease and gastroschisis, are often associated with FGR.
Placental Disorders:
Placental Insufficiency: Abnormal placentation leading to poor placental perfusion is the most common pathology associated with FGR.
Placental Abnormalities: Conditions like placental abruption, infarction, and abnormal cord insertion can contribute to FGR.
Infections: Intrauterine infections, including cytomegalovirus, rubella, toxoplasmosis, varicella, and syphilis, can cause FGR.
Multiple Gestation: The increased demands of multiple pregnancies can lead to FGR, particularly in monochorionic twins.
Teratogen Exposure: Certain medications, such as some antineoplastic, antiepileptic, and antithrombotic drugs, are associated with increased FGR risk.
Common Pathway: Many of these factors, while diverse in origin, often share a final common pathway: suboptimal uterine-placental perfusion and fetal nutrition.
IV. Perinatal Morbidity and Mortality
Increased Risks: FGR significantly increases the risk of intrauterine demise, neonatal morbidity (complications like hypoglycemia, respiratory distress, and seizures), and neonatal death.
Long-term Consequences: Studies suggest that FGR can predispose individuals to cognitive delays in childhood and chronic diseases (obesity, diabetes, cardiovascular disease) in adulthood.
Stillbirth: The risk of stillbirth is significantly higher in FGR, particularly in severely affected fetuses.
V. Screening and Diagnosis
Risk Factor Assessment: Reviewing medical and obstetric history for FGR risk factors is the initial step in screening.
Fundal Height Measurement: At each prenatal visit after 24 weeks, measuring fundal height helps screen for FGR.
Limitations of Fundal Height: Maternal obesity, multiple pregnancies, and uterine fibroids can affect the accuracy of fundal height measurements.
Ultrasonography: Ultrasound is crucial for both screening and diagnosis, providing biometric measurements (biparietal diameter, head and abdominal circumference, femur length) to estimate fetal weight.
VI. Management
Serial Ultrasonography: Regular ultrasound monitoring of fetal growth and amniotic fluid volume is essential in managing FGR.
Doppler Velocimetry: Umbilical artery Doppler assessment plays a critical role in FGR management. It helps assess placental function and identify fetuses at increased risk of adverse outcomes.
Antenatal Surveillance: Nonstress tests and biophysical profiles are used to monitor fetal well-being but should not begin before a gestational age where delivery would be considered beneficial.
Timing of Delivery: Determining the optimal delivery time for FGR is complex, considering factors like the underlying cause, gestational age, and fetal surveillance results.
General Recommendations: The sources suggest delivering at 38-39 weeks for isolated FGR with normal umbilical artery Doppler, and 34-37 weeks for FGR with additional risk factors or abnormal Doppler findings. Earlier delivery is indicated for absent or reversed umbilical artery flow.
Preterm Delivery Considerations:
Deliveries before 34 weeks should ideally occur in a tertiary care center with a neonatal intensive care unit and may involve consultation with a maternal-fetal medicine specialist.
Antenatal corticosteroids are recommended for deliveries anticipated before 37 weeks to improve neonatal outcomes.
Magnesium sulfate may be considered for fetal neuroprotection before 32 weeks.
Mode of Delivery: FGR alone is not an indication for cesarean delivery. The decision regarding the mode of delivery should be based on other clinical factors.
VII. Prevention
Limited Options: Currently, no consistently effective strategies exist to prevent FGR.
Ineffective Strategies: The sources specifically note that various nutritional and dietary supplement strategies, as well as bed rest, have not been proven effective in preventing FGR.
Aspirin for Recurrence Prevention: While some experts suggest low-dose aspirin for women with a prior SGA birth to prevent placental insufficiency, evidence is insufficient for routine use.
VIII. Genetic Counseling and Testing
When to Offer: Genetic counseling and prenatal diagnostic testing should be offered when FGR is diagnosed before 32 weeks, in combination with polyhydramnios, or when structural abnormalities are also present. This helps assess for potential underlying genetic causes.
The sources focus primarily on the medical aspects of FGR. It's important to note that the emotional and psychological impact of this diagnosis on expecting parents should be acknowledged and addressed through supportive counseling and care.
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Fetal heart rate abnormalities
Fetal heart rate abnormalities
Obstetrics
Introduction
Purpose and Utilization: Intrapartum electronic fetal monitoring (EFM) is widely used in the United States to evaluate fetal heart rate (FHR) during labor. The purpose of monitoring is to identify fetal hypoxia or acidemia and guide obstetric management to prevent fetal complications. The American College of Obstetricians and Gynecologists (ACOG) developed the current framework to aid in interpreting FHR tracings and making clinical decisions based on those findings.
Three-Tiered Categorization System: A three-tiered system is recommended for interpreting FHR patterns during labor. The categories help assess the condition of the fetus and determine appropriate interventions. The system categorizes FHR tracings into Category I (Normal), Category II (Indeterminate), and Category III (Abnormal).
Categories of FHR Tracings
Category I: These tracings are considered normal and are not associated with fetal acidemia. A Category I tracing includes a baseline FHR of 110-160 beats per minute, moderate baseline variability, and the absence of late or variable decelerations. Management includes routine monitoring during labor, with a review of the FHR every 30 minutes in the first stage and every 15 minutes in the second stage.
Category II: This is an indeterminate category and includes all FHR patterns that do not meet the criteria for Category I or III. Category II patterns require close evaluation and continued surveillance. It may be associated with minimal variability, tachycardia, or prolonged decelerations. Corrective actions, such as maternal repositioning or oxygen administration, may be used to address these tracings, and interventions are necessary if the patterns do not revert to Category I.
Category III: Category III tracings are abnormal and indicate a high risk of fetal acidemia. This category includes absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern. Immediate interventions, including intrauterine resuscitative measures, and consideration for expedited delivery are warranted for Category III tracings.
Management of Specific FHR Patterns
Variable Decelerations:
Intermittent: These are common and generally benign, occurring with less than 50% of contractions. They do not require treatment if they are not persistent.
Recurrent: When variable decelerations occur with 50% or more of contractions, they are more concerning and may indicate umbilical cord compression. Maternal repositioning is often the first step, followed by other measures like amnioinfusion if necessary to alleviate cord compression.
Late Decelerations: These are associated with uteroplacental insufficiency, commonly due to maternal hypotension or uterine tachysystole. Management includes promoting uteroplacental perfusion through interventions like maternal lateral positioning, administering intravenous fluids, and discontinuing uterotonics.
Tachycardia: Fetal tachycardia is defined as an FHR baseline greater than 160 beats per minute for at least 10 minutes. It may be associated with maternal fever, medications, or fetal infection. Management includes identifying the cause and treating accordingly.
Bradycardia and Prolonged Decelerations: Bradycardia is defined as an FHR less than 110 beats per minute, and prolonged decelerations last between 2 and 10 minutes. These are often indicative of umbilical cord prolapse, placental abruption, or uterine rupture and require prompt assessment and intervention.
Intrauterine Resuscitative Measures
Maternal Repositioning: Changing maternal position can help alleviate cord compression and improve uteroplacental blood flow. This is a first-line intervention for variable or late decelerations.
Oxygen Administration: Supplemental oxygen may be provided to improve fetal oxygenation during labor, particularly when late or prolonged decelerations are noted.
Intravenous Fluids: Administering a fluid bolus can improve maternal blood pressure and increase placental perfusion.
Amnioinfusion: For recurrent variable decelerations due to cord compression, amnioinfusion can be used to provide additional fluid in the uterine cavity and reduce pressure on the umbilical cord.
Key Recommendations
Routine Management for Category I: Category I tracings, which indicate no fetal compromise, should be managed with routine monitoring throughout labor.
Corrective Measures for Category II: Category II tracings necessitate increased surveillance and implementation of corrective measures such as maternal repositioning, oxygen supplementation, or fluid bolus. The goal is to assess whether the fetal condition improves or deteriorates to Category III.
Immediate Action for Category III: Category III tracings indicate increased risk for fetal acidemia, necessitating intrauterine resuscitation and preparation for prompt delivery if the FHR pattern does not improve.
Tachysystole Management: Tachysystole (more than five contractions in 10 minutes) requires evaluation and reduction of uterine activity if associated with Category II or III FHR patterns. Discontinuing uterotonics or administering a tocolytic agent may be necessary.
65
GBS +
GBS +
Obstetrics
Preventing Group B Strep in Newborns: ACOG Committee Opinion 797
This committee opinion, published by the American College of Obstetricians and Gynecologists (ACOG), provides updated guidelines on preventing Group B Streptococcus (GBS) infections in newborns. Here are the key points:
Background
GBS is the leading cause of newborn infections. The bacteria colonizes the mother's genitourinary and gastrointestinal tracts and can be transmitted to the newborn during labor or after rupture of membranes.
While most colonized women do not experience symptoms, GBS can cause urinary tract infections, intraamniotic infection, and endometritis. GBS is also associated with preterm labor and stillbirth.
Neonatal GBS infection presents in two forms:
Early-onset disease (EOD), occurring within 7 days after birth, is characterized by sepsis, pneumonia, and meningitis.
Late-onset disease occurs between 7 days and 2-3 months of age and is characterized by bacteremia, meningitis, or less commonly, organ or soft tissue infection.
Intrapartum antibiotic prophylaxis has significantly reduced the incidence of GBS EOD.
Key Recommendations and Updates
Universal GBS screening for all pregnant women should be performed between 36 0/7 and 37 6/7 weeks of gestation, unless intrapartum antibiotic prophylaxis is already indicated due to GBS bacteriuria or a history of a previous GBS-infected newborn. This change in timing from previous guidelines allows for a 5-week window of valid culture results, covering births up to at least 41 0/7 weeks gestation.
Vaginal-rectal culture remains the standard screening method. A single swab should be used to collect samples from both the lower vagina and rectum.
Nucleic Acid Amplification Testing (NAAT) is a reasonable alternative to culture-based screening. However, NAAT does not allow for antibiotic susceptibility testing, which is essential for women with penicillin allergies. While NAAT can be used for rapid intrapartum testing, it does not replace routine prenatal screening.
Intravenous penicillin remains the first-line treatment for intrapartum antibiotic prophylaxis, with intravenous ampicillin as an acceptable alternative.
The guidelines provide detailed recommendations on managing penicillin allergies.
The severity of the allergy should be assessed to determine the risk of anaphylaxis.
First-generation cephalosporins (e.g., cefazolin) are recommended for women with low-risk penicillin allergies.
For women with high-risk penicillin allergies, clindamycin is recommended if the GBS isolate is susceptible.
Penicillin allergy testing is safe during pregnancy and can be beneficial, especially for those with possible IgE-mediated allergies or allergies of unknown severity.
Intravenous vancomycin remains the only option for women with high-risk penicillin allergies whose GBS isolate is resistant to clindamycin. The dosage should be weight-based (20 mg/kg intravenously every 8 hours, with a maximum of 2 g per single dose).
Obstetric interventions should not be delayed solely to achieve 4 hours of antibiotic administration before birth. However, efforts should be made to maximize intrapartum antibiotic exposure.
The opinion addresses common questions about obstetric procedures in GBS-colonized women, including membrane sweeping, mechanical cervical ripening, immersion in water during labor, vaginal examinations, artificial rupture of membranes, and intrauterine monitoring.
Future Directions
The opinion highlights the need for ongoing research on GBS prevention strategies, including:
The impact of intrapartum antibiotic prophylaxis on the newborn gut microbiome.
The development of vaccines to prevent GBS colonization.
Conclusion
The ACOG Committee Opinion 797 offers comprehensive and updated guidance on preventing GBS EOD in newborns. The opinion emphasizes universal screening, appropriate antibiotic prophylaxis, and careful management of penicillin allergies. It also stresses the importance of ongoing research to further improve prevention strategies and minimize potential risks.
66
Geriatric care
[ ]
67
Gestational Diabetes
Gestational Diabetes
Obstetrics
Gestational Diabetes Mellitus (GDM)
Definition: Carbohydrate intolerance that develops during pregnancy.
Types:
Diet-controlled GDM (Class A1GDM): Adequately controlled without medication.
Medication-requiring GDM (Class A2GDM): Needs medication to achieve euglycemia.
Prevalence:
A common complication of pregnancy, affecting an estimated 7% of pregnancies in 2009 (86% of those being GDM).
Prevalence varies directly with type 2 diabetes prevalence in the population.
Higher rates in Hispanic, African American, Native American, and Asian or Pacific Islander women.
Lower rates in Caucasian women.
Risk increases with factors like obesity and advanced maternal age.
Maternal and Fetal Risks:
Offspring of women with GDM have increased risks of:
Macrosomia
Neonatal hypoglycemia
Hyperbilirubinemia
Shoulder dystocia
Birth trauma
Stillbirth (though the impact of glycemic control on this is debated)
HAPO Study: Demonstrated a continuous link between maternal glucose levels (from the 75-g, 2-hour OGTT) and:
Cesarean delivery
Birth weight above the 90th percentile
Clinical neonatal hypoglycemia
Fetal hyperinsulinemia
Maternal diabetes exposure contributes to offspring's risk of childhood and adult obesity and diabetes, independent of genetic factors and obesity risks.
Management of Gestational Diabetes Mellitus
Diagnosis:
Universal screening for GDM is recommended using laboratory-based blood glucose tests.
Screening is generally performed at 24–28 weeks gestation.
ACOG does not recommend routine GDM screening before 24 weeks gestation due to lack of consistent evidence for maternal/neonatal benefit from early diagnosis/treatment.
Early screening for pregestational diabetes (preferably at prenatal care initiation) is recommended for women with risk factors.
Diagnostic criteria may use either plasma or serum glucose levels.
Carpenter and Coustan criteria
National Diabetes Data Group criteria
Practices/institutions should select a single set of criteria for consistency.
Treatment:
Women diagnosed with GDM should receive nutrition and exercise counseling.
If lifestyle interventions fail to control glucose, medication is used for both maternal and fetal benefit.
Blood Glucose Monitoring:
Once nutrition therapy (dietary counseling) begins, blood glucose monitoring is needed to confirm glycemic control.
Fasting and postprandial values should be used.
Postprandial glucose can be assessed either 1 or 2 hours after meals.
Monitoring frequency is individualized based on glucose control and treatment.
Lifestyle Interventions:
Nutrition Therapy:
Carbohydrate intake should be limited to 33–40% of total calories to prevent excessive weight gain and postprandial hyperglycemia.
The remaining calories are divided between protein (20%) and fat (40%).
Complex carbohydrates are recommended over simple carbohydrates as they are digested more slowly and less likely to cause spikes in blood sugar.
Eating three meals and two to three snacks helps distribute carbohydrate intake and reduce postprandial glucose fluctuations.
Exercise:
Regular exercise can help improve insulin sensitivity and glucose control.
Specific exercise recommendations for GDM are not well-studied, but moderate-intensity aerobic activity is generally advised.
Pharmacological Treatment:
Insulin is the traditional first-line medication when lifestyle modifications are insufficient.
Does not cross the placenta, allowing for tight metabolic control.
Oral Antidiabetic Agents:
Metformin is a reasonable alternative to insulin in specific situations.
For women who decline insulin
For women who cannot safely administer insulin
For women who cannot afford insulin
While current data show no adverse short-term effects on maternal or neonatal health, long-term outcomes are not yet available.
Health care providers should discuss the limitations in safety data when prescribing oral agents for GDM.
Postpartum Management:
While GDM often resolves after delivery, a significant proportion of women will develop diabetes or impaired glucose metabolism later.
Screening at 4–12 weeks postpartum is recommended using a fasting plasma glucose test and the 75-g, 2-hour OGTT.
Ongoing monitoring and lifestyle interventions are crucial to prevent or delay the progression to type 2 diabetes.
Please note that this outline is based solely on the provided sources. For the most up-to-date and personalized medical advice, it is crucial to consult with a healthcare professional.
68
Gestational Hypertension and Preeclampsia
Gestational Hypertension and Preeclampsia
Obstetrics
Severe Hypertension Management (Pregnancy/Postpartum)
Assess Patient Condition:
Check vital signs, especially blood pressure (systolic >140, diastolic >90).
Assess fetal status using fetal heart rate (FHR) monitoring.
Obtain Relevant Labs:
LFTs (liver function tests)
CBC (platelets)
CMP (renal function)
Assess Signs and Symptoms:
Headache, visual disturbances, epigastric pain, shortness of breath, pulmonary edema, oliguria.
Inform Patient of the Situation:
Explain the need for possible delivery if condition worsens.
Obtain consent for treatment if magnesium sulfate or antihypertensives are needed.
Alert Nursing Staff and Anesthesiology:
Ensure all necessary medications are available (e.g., magnesium sulfate, hydralazine, labetalol, nifedipine).
Prepare checklist for severe preeclampsia and have it printed and ready at the bedside.
Consider Imaging if:
Severe headache unresponsive to medication.
Neurological symptoms indicating possible stroke.
Distinguish Between Gestational Hypertension and Preeclampsia:
Gestational hypertension: No proteinuria, normal labs, and mild or no elevated blood pressures.
Preeclampsia: Proteinuria (>0.3 P-to-C ratio or 2+ dipstick), and/or severe features (e.g., BP >160/110, low platelets, elevated LFTs, elevated creatinine, pulmonary edema, severe headaches).
Initiate Treatment:
Confirm persistent severe range blood pressure after 15 minutes.
Administer antihypertensives and start magnesium sulfate.
Antihypertensive Regimen:
Nifedipine (if no IV access): Start with 10 mg oral nifedipine, repeat BP in 20 minutes.
Hydralazine (if asthma/bradycardia): 5-10 mg IV over 2 minutes, repeat BP in 20 minutes.
Labetalol: 20 mg IV over 2 minutes, repeat BP every 10 minutes, increase dose to 40 mg, then 80 mg IV as needed to target BP <140/90.
Continuous Monitoring:
Monitor fetal heart rate and vital signs every 5-15 minutes.
Continue for 4 hours with decreasing intervals: Q10 min first hour, Q15 min second hour, Q30 min third hour, Q1 hour thereafter.
Delivery Decision:
If gestational age >34 weeks and stable: Proceed with delivery.
Consider betamethasone if preterm (<34 weeks) and stable; deliver once steroids are complete.
Magnesium Sulfate Protocol:
Loading dose: 4-6 grams IV over 20-30 minutes.
Maintenance dose: 1-2 grams per hour.
Pathophysiology Basics
Understanding the Disease Process
Root Causes:
- Abnormal placentation
- Maternal systemic vascular dysfunction
Early Changes:
- Improper remodeling of spiral arteries
- Leads to placental ischemia
- Release of antiangiogenic factors into maternal circulation
Systemic Effects:
- Disruption of normal endothelial function
- Systemic vasoconstriction
- Increased capillary permeability
- Development of clinical manifestations
Overview of Preeclampsia:
Preeclampsia is defined as a multisystem progressive disorder typically occurring after 20 weeks of gestation or in the postpartum period. It is characterized by new-onset hypertension (≥140/90 mmHg) and proteinuria (≥0.3 grams in a 24-hour urine collection), or by hypertension accompanied by signs of end-organ dysfunction even in the absence of proteinuria.
The condition represents a spectrum of severity, ranging from mild cases to those involving significant end-organ damage such as renal failure, liver involvement, pulmonary edema, or neurologic complications (e.g., eclampsia).
Timing and Classification:
Preeclampsia can present at different gestational periods, including:
Late preterm (≥34 to <37 weeks),
Term (≥37 weeks),
Postpartum (typically within 48 hours but up to six weeks postpartum).
Approximately 90% of cases present in the late preterm or term period and are generally associated with favorable maternal and fetal outcomes. However, 10% of cases occur before 34 weeks (early-onset preeclampsia), which is associated with higher risks of severe maternal and fetal complications, such as very preterm birth, intrauterine growth restriction (IUGR), and increased perinatal morbidity and mortality.
Pathophysiology:
Preeclampsia is rooted in abnormal placentation and maternal systemic vascular dysfunction. The disorder is believed to start with improper remodeling of spiral arteries in early pregnancy, leading to placental ischemia and release of antiangiogenic factors into the maternal circulation.
These factors disrupt normal endothelial function, causing systemic vasoconstriction, increased capillary permeability, and the subsequent clinical manifestations observed in preeclampsi
Outcomes and Prognosis:
Although the disorder typically resolves after delivery, individuals with a history of preeclampsia have an elevated lifetime risk of cardiovascular-related morbidity and mortality, including chronic hypertension, ischemic heart disease, and stroke.
Long-term management of patients who have had preeclampsia includes monitoring for cardiovascular health, lifestyle modifications, and counseling on risks for future pregnancies.
Risk Factors
Who is at Risk?
Reproductive and Obstetric Factor
Nulliparity (first pregnancy)
Previous preeclampsia
Multiple gestation
Medical History:
Chronic hypertension
Pre-gestational diabetes (Type 1 or 2)
Kidney disease
Systemic lupus erythematosus
Antiphospholipid syndrome
Thrombophilia
Obstructive sleep apnea
Maternal Characteristic
Age ≥35 years
BMI >30
Assisted reproductive technology u
Important Note: Most cases occur in healthy nulliparous women without obvious risk factors
Clinical Significance
Why Is This Important?
Leading Cause of maternal and perinatal mortality worldwide
Long-term Impact:
- Increased lifetime cardiovascular risk
- Higher risk of chronic hypertension
- Greater chance of ischemic heart disease and stroke
Fetal Implications:
- Major cause of preterm birth
- Leading cause of fetal growth restriction
- Significant impact on neonatal outcomes
Initial Assessment
Clinical Assessment:
Blood pressure measurements
Maternal symptoms evaluation
Physical examination
Laboratory Testing:
Complete blood count
Liver function tests
Renal function assessment
Urinary protein quantification
Fetal Assessment:
Growth monitoring
Well-being evaluation
Amniotic fluid assessment
Global Prevalence:
Systematic reviews estimate the global prevalence of preeclampsia at approximately 4.6% of pregnancies, but rates can vary from 2.7% to 8.2% depending on regional factors and healthcare access.
Incidence in the United States:
Approximately 5% of pregnancies are affected by preeclampsia, with rates increasing due to factors like advanced maternal age, rising obesity rates, and the prevalence of pre-existing conditions such as diabetes and hypertension.
Trends in Incidence:
The increasing incidence of hypertensive disorders in pregnancy is partially attributed to population-level changes such as rising obesity rates, older maternal age, and a higher proportion of nulliparous pregnancies.
4. Risk Factors
Maternal Demographics and History:
Significant risk factors include advanced maternal age, obesity, nulliparity, and history of preeclampsia or other hypertensive disorders in previous pregnancies.
Medical Conditions:
Chronic hypertension, pre-existing diabetes, kidney disease, and autoimmune disorders (e.g., systemic lupus erythematosus, antiphospholipid syndrome) significantly elevate the risk of developing preeclampsia.
Pregnancy-Specific Risk Factors:
Multifetal gestation, fetal genetic abnormalities (e.g., trisomy 13), and assisted reproductive technology (ART) pregnancies are associated with a higher risk.
Genetic and Familial Factors:
A family history of preeclampsia, particularly in first-degree relatives, significantly increases risk, suggesting heritable mechanisms.
5. Pathogenesis
Abnormal Placentation:
The failure of normal spiral artery remodeling results in placental hypoxia and ischemia, which are central to the development of preeclampsia. The release of antiangiogenic factors, such as soluble fms-like tyrosine kinase-1 (sFlt-1), interferes with endothelial function.
Systemic Vascular Dysfunction:
Preeclampsia involves widespread endothelial cell activation, increased vascular permeability, and vasoconstriction, leading to the clinical manifestations of hypertension, proteinuria, and end-organ damage.
Inflammatory and Immune Factors:
The interplay of placental and maternal immune responses, including aberrant activation of inflammatory pathways, further contributes to the endothelial dysfunction seen in preeclampsia.
Gestational Hypertension
Definition:
Systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg on two occasions at least 4 hours apart.
Occurs after 20 weeks of gestation in women with previously normal blood pressure.
Criteria for Preeclampsia with Severe Features:
Women with gestational hypertension with severe-range blood pressures (systolic ≥160 mm Hg, diastolic ≥110 mm Hg) are diagnosed with preeclampsia with severe features.
Criteria for Severe Features (Box 2 & Box 3)
Hypertension:
Systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg after 20 weeks.
Severe hypertension is considered at systolic ≥160 mm Hg or diastolic ≥110 mm Hg.
Proteinuria:
24-Hour Urine Collection:
≥300 mg protein in a 24-hour urine collection.
Protein/Creatinine Ratio:
Ratio of ≥0.3 mg/dL.
Dipstick:
2+ reading (if other quantitative methods are unavailable).
In Absence of Proteinuria - Criteria for Preeclampsia Diagnosis:
Thrombocytopenia: Platelet count < 100,000 x 10^9/L.
Renal insufficiency: Serum creatinine > 1.1 mg/dL or doubling of serum creatinine without other renal disease.
Impaired liver function: Elevated liver transaminases to twice the normal concentration.
Pulmonary edema.
New-onset headache unresponsive to acetaminophen or visual disturbances.
Differentiating Similar Presentations
Consider Alternative Diagnoses:
For presentations resembling preeclampsia but occurring before 20 weeks, consider:
Thrombotic thrombocytopenic purpura.
Hemolytic–uremic syndrome.
Molar pregnancy.
Renal disease.
Autoimmune diseases.
Additional Considerations
Severe Features of Preeclampsia (Box 3):
Severe-range blood pressures and specific clinical features (e.g., liver impairment, renal dysfunction).
High risk for maternal morbidity and mortality.
Blood Pressure Definition for Gestational Hypertension:
Defined as either systolic ≥140 mm Hg or diastolic ≥90 mm Hg.
Severe range: Systolic ≥160 mm Hg, diastolic ≥110 mm Hg.
Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome (HELLP Syndrome)
Introduction to HELLP Syndrome
Definition and Classification:
HELLP stands for Hemolysis, Elevated Liver Enzymes, and Low Platelet Count.
Recognized as one of the more severe forms of preeclampsia.
Clinical Relevance:
Associated with increased maternal morbidity and mortality.
Represents a potentially life-threatening condition that requires prompt intervention.
Incidence:
Although HELLP syndrome primarily occurs in the third trimester, approximately 30% of cases present postpartum, contributing to the variability of the clinical presentation.
Diagnostic Criteria for HELLP Syndrome
Laboratory Evaluation:
Hemolysis:
Lactate Dehydrogenase (LDH) levels of ≥ 600 IU/L.
Indicates red blood cell destruction and tissue injury.
Elevated Liver Enzymes:
Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) levels are elevated to more than twice the upper limit of normal.
Reflects liver cell damage and periportal necrosis.
Low Platelet Count:
Platelet count of < 100,000 x 10^9/L.
Represents a coagulopathy component linked to platelet consumption and activation.
Clinical Presentation of HELLP Syndrome
Symptoms and Signs:
Right Upper Quadrant Pain:
Pain often described as right upper quadrant or epigastric.
Associated with liver involvement and capsular distension.
Generalized Malaise:
Experienced by up to 90% of patients.
Nonspecific symptom but often signals systemic involvement.
Nausea and Vomiting:
Affects 50% of cases and can be misinterpreted as gastrointestinal disturbances.
Hypertension and Proteinuria:
Not always present; 15% of patients with HELLP lack these classical features, complicating diagnosis.
Atypical Presentation:
HELLP syndrome may progress insidiously without classic signs of preeclampsia.
Differentiation from other conditions like acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, or hemolytic uremic syndrome can be challenging.
Disease Course and Progression
Rapid Progression:
HELLP syndrome can worsen rapidly, and the peak severity is often observed within 48 hours postpartum.
Early recognition and treatment are critical for improving outcomes.
Indicators of Severity:
Elevated Liver Enzymes and declining platelet count are key markers for assessing the severity and progression of HELLP syndrome.
The lowest platelet count is usually observed at an average of 23 hours after delivery.
Natural History:
With supportive care, 90% of patients see a return of platelet counts >100,000 x 10^9/L within 7 days postpartum.
A rebound in platelet count (sometimes reaching up to 400,000–871,000 x 10^9/L) can occur.
Management of HELLP Syndrome
Delivery as Definitive Treatment:
Due to the severity of HELLP syndrome, delivery is the primary treatment, regardless of gestational age.
The timing of delivery is often dictated by maternal and fetal stability.
Setting for Management:
Tertiary care centers are ideal for the management of patients with HELLP syndrome due to the need for specialized maternal and neonatal care.
Use of Corticosteroids:
Rationale:
Corticosteroids are used due to their anti-inflammatory and immunosuppressive properties, which may mitigate some features of HELLP.
Evidence:
A Cochrane review found no conclusive evidence of a reduction in maternal mortality or severe morbidity with corticosteroids.
Improved Platelet Count:
Corticosteroids may help to improve platelet counts, but this effect does not directly translate to better clinical outcomes.
Monitoring and Stabilization:
Frequent monitoring of platelet count and liver enzymes every 12 hours.
Patients with extremely high AST (>2000 IU/L) or LDH (>3000 IU/L) are at increased risk of complications and may require more intensive interventions.
Postpartum Considerations for HELLP Syndrome
Postpartum Monitoring:
Intensive monitoring for at least 48 hours postpartum is crucial.
HELLP syndrome may continue to worsen postpartum, and the peak severity is often reached during this period.
Complications:
Patients are at increased risk for complications such as:
Pulmonary Edema:
May occur due to fluid shifts, decreased oncotic pressure, or compromised cardiac function.
Acute Respiratory Distress Syndrome (ARDS):
A severe, potentially life-threatening complication that requires intensive respiratory support.
Renal Failure:
Acute renal dysfunction may result from intrarenal vasospasm or reduced glomerular filtration rate.
Recovery:
The improvement in platelet count and reduction in liver enzyme levels are typically observed within 7 days postpartum.
The condition should be reassessed if laboratory abnormalities persist beyond 4 days postpartum.
HELLP Syndrome and Maternal-Fetal Outcomes
Maternal Morbidity and Mortality:
HELLP syndrome is associated with a higher risk of:
Disseminated Intravascular Coagulation (DIC).
Placental Abruption.
Acute Liver Failure.
Careful monitoring and immediate intervention are essential to prevent severe complications.
Fetal Outcomes:
Prematurity:
Delivery often occurs preterm, and prematurity is a major factor affecting neonatal outcomes.
Fetal Growth Restriction:
Fetal growth may be restricted due to uteroplacental insufficiency.
Key Management Recommendations
Prompt Delivery:
Delivery is indicated once the maternal or fetal condition deteriorates.
Corticosteroid Use:
Use of corticosteroids for fetal lung maturity is recommended if preterm delivery is anticipated.
Maternal Stabilization Before Delivery:
Ensure maternal stabilization prior to delivery, including:
Blood Pressure Control.
Seizure Prophylaxis.
Fluid Management.
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Gestational trophoblastic disease
[ ]
70
Headache in pregnancy
Headache in pregnancy
Obstetrics
Headaches in Pregnancy and Postpartum: A Comprehensive Outline
The sources, specifically a clinical practice guideline from the American College of Obstetricians and Gynecologists (ACOG) on headaches in pregnancy and postpartum, provide extensive information regarding the classification, evaluation, and management of headaches during this period.
I. Types of Headaches
Primary Headaches: These are not caused by an underlying medical condition and include:
Migraine: Characterized by unilateral, pulsating pain, often accompanied by nausea, vomiting, and sensitivity to light and sound.
Tension-type: Bilateral, with a feeling of pressure or tightness.
Cluster: Severe, unilateral pain around the eye, occurring in clusters (multiple headaches over a period of days or weeks).
Secondary Headaches: These are caused by an underlying medical condition and can be a sign of a serious problem. Examples in pregnancy and postpartum include:
Preeclampsia: A serious pregnancy complication characterized by high blood pressure and protein in the urine. Headache can be a symptom, often severe and frontal.
Postdural Puncture Headache (PDPH): Occurs after a spinal tap or epidural anesthesia. It is typically worse when upright and improves when lying down.
Reversible Cerebral Vasoconstriction Syndrome (RCVS): Characterized by sudden, severe headaches and temporary narrowing of blood vessels in the brain.
Posterior Reversible Encephalopathy Syndrome (PRES): Involves headache, visual changes, confusion, and seizures, often associated with high blood pressure.
Cerebral Venous Sinus Thrombosis (CVST): A blood clot in a vein that drains blood from the brain. Can cause headache, visual problems, and seizures.
Idiopathic Intracranial Hypertension (IIH): Increased pressure in the fluid surrounding the brain and spinal cord, causing headache, vision changes, and ringing in the ears.
Pituitary Apoplexy: Bleeding or lack of blood flow to the pituitary gland, causing sudden, severe headache, visual problems, and hormonal changes.
Infections: Various infections, such as meningitis, encephalitis, and sinusitis, can cause headaches.
II. Evaluation
History: A thorough medical history, including the nature of the headache, onset, frequency, associated symptoms, and prior headache history, is crucial.
Physical Examination: A complete neurological exam is essential to assess for any focal deficits or signs of an underlying medical condition.
Imaging Studies:
MRI: The preferred imaging modality during pregnancy when evaluating secondary headache causes, particularly when brain or vascular imaging is necessary.
CT Scan: May be performed if MRI is not available or in cases of suspected stroke.
Lumbar Puncture: May be needed to assess cerebrospinal fluid for infection or other conditions.
III. Management
A. Prevention of Primary Headaches
Medication Review: Obstetricians should review a patient’s headache prevention medications and consider adjusting them due to the potential for symptom reduction during pregnancy.
Nonpharmacologic Interventions: These are often preferred during pregnancy and include:
Trigger Avoidance: Identifying and avoiding headache triggers (such as certain foods, stress, or lack of sleep).
Lifestyle Modifications: Getting adequate sleep, managing stress, staying hydrated, and engaging in regular physical activity.
Cognitive Behavioral Therapy: May be helpful for managing headache frequency and severity.
Acupuncture and Biofeedback: Limited data on efficacy for headache prevention during pregnancy, but considered safe for other indications.
Pharmacologic Interventions: Used when nonpharmacologic approaches are insufficient.
First-Line Medications: Calcium channel blockers (like amlodipine and nifedipine) and antihistamines (like cyproheptadine and diphenhydramine) are generally considered safe and effective.
Beta-blockers: May be considered, but potential risks (such as cardiovascular anomalies in the fetus) need to be weighed against the benefits.
Medications to Avoid: ACE inhibitors (like lisinopril), topiramate, and valproic acid are associated with significant fetal risks and should not be used during pregnancy.
B. Treatment of Acute Headaches
Home Management of Primary Headaches:
First-Line Treatment: Acetaminophen (1000 mg orally) is recommended as initial therapy.
Combination Therapy: Acetaminophen with caffeine can be used, but caution is advised with caffeine doses exceeding 200 mg per day due to potential fetal effects.
NSAIDs: Use should be limited to the second trimester for intractable migraine due to potential fetal risks.
Medications to Avoid:
Butalbital-containing products are not recommended due to the risk of habituation, medication overuse headache, and potential fetal cardiac defects.
Opioids (like codeine, fentanyl, and hydrocodone) are not recommended due to the risk of medication overuse headache, maternal addiction, and neonatal abstinence syndrome.
Ergot alkaloids should not be used during pregnancy due to the risk of uterine contractions.
Management in Obstetric Triage or Emergency Department:
Metoclopramide: 10 mg intravenously or enterally, alone or with diphenhydramine (25 mg), is recommended for persistent headaches.
NSAIDs: Single doses may be considered for resistant headaches in the second trimester.
Other Options: Prednisolone, intravenous magnesium, or sumatriptan may be considered cautiously for secondary treatment.
Medications to Avoid: Opioids, ergot alkaloids, and butalbital-containing medications should not be used.
Management in Lactating Patients:
Recommended Medications: Acetaminophen, NSAIDs (except standard-dose aspirin), caffeine, and metoclopramide are generally considered safe.
Opioids: Use with caution as they can cause sedation in infants and may lead to life-threatening neonatal central nervous system depression in women who are cytochrome P450 2D6 ultrametabolizers.
Ergot Alkaloids: Not recommended due to potential adverse effects in infants and suppression of lactation.
Oral CGRP Antagonists and Ditans: No data on safety during lactation, so alternative medications are preferred.
C. Treatment of Secondary Headaches
Preeclampsia: Management includes magnesium sulfate, blood pressure control, and often delivery.
Postdural Puncture Headache: An epidural blood patch is the recommended treatment.
Other Secondary Headaches: Treatment depends on the underlying cause and often involves a multidisciplinary approach.
IV. Additional Points
Migraine and Pregnancy Outcomes: The sources note that migraine during pregnancy may be associated with an increased risk of preeclampsia, low birth weight, and preterm birth. However, more research is needed to confirm these associations.
Headache Red Flags: Certain headache characteristics warrant prompt attention, especially in women with no prior headache history:
Sudden onset or “thunderclap” headache
Severe pain
High blood pressure
Fever
Focal neurological deficits
Altered consciousness
Patient Counseling and Support: It is important to address the emotional impact of headaches, particularly when they are severe or persistent, and provide appropriate counseling and support.
Note: The sources focus primarily on the medical aspects of headache management. However, the psychological and emotional well-being of women experiencing headaches during pregnancy and postpartum should not be overlooked.
71
HELLP Syndrome
HELLP Syndrome
Obstetrical Emergencies
72
Hemoglobinopathies
Hemoglobinopathies
Hemoglobinopathies in Pregnancy - Summary
Introduction
Definition: Hemoglobinopathies are a heterogeneous group of single-gene disorders, including structural variants like sickle cell disease (SCD) and thalassemias. More than 270 million people worldwide are heterozygous carriers of hereditary hemoglobin disorders, and about 300,000 affected homozygotes are born annually.
Hemoglobin Structure: Hemoglobin consists of four polypeptide chains (α, β, γ, δ, ε, ζ), with adult hemoglobins mainly consisting of α-chains paired with either β (Hb A), γ (Hb F), or δ (Hb A2). In fetuses, Hb F predominates until the third trimester.
Sickle Cell Disease (SCD): Sickle cell disease involves an abnormal hemoglobin (Hb S) due to a mutation in the β-globin gene, leading to the substitution of valine for glutamic acid. Patients with homozygous Hb S (SS) suffer from sickle cell anemia, while compound heterozygotes (e.g., Hb SC, Hb S/β-thalassemia) also present with clinical symptoms. Under low oxygen tension, sickled red cells lead to vasoocclusion, hemolysis, and anemia, affecting organs like the spleen, lungs, kidneys, heart, and brain.
Thalassemias in Pregnancy
Alpha-Thalassemia: This condition results from gene deletions affecting the α-globin genes. Alpha-thalassemia trait causes mild microcytic anemia, while more severe forms (e.g., Hb Bart’s disease) lead to hydrops fetalis and intrauterine death. Alpha-thalassemia is common among individuals of Southeast Asian, African, and Mediterranean descent.
Beta-Thalassemia: Beta-thalassemia involves mutations in the β-globin gene, leading to decreased or absent β-chain production. Patients may present with β-thalassemia minor (mild anemia) or β-thalassemia major (Cooley’s anemia), characterized by severe anemia requiring lifelong transfusions.
Screening and Diagnosis
Who Should Be Screened: Individuals of African, Southeast Asian, and Mediterranean descent are at higher risk for hemoglobinopathies and should be offered carrier screening and genetic counseling if both parents are carriers.
Screening Methods:
Complete Blood Count (CBC) and Hemoglobin Electrophoresis: These are used to identify hemoglobinopathies. Solubility tests (e.g., Sickledex) alone are inadequate, as they cannot distinguish between heterozygous and homozygous conditions or identify variants like Hb C or β-thalassemia.
Genetic Testing: DNA-based testing can identify specific mutations in α- or β-globin genes, especially for prenatal diagnosis.
Pregnancy Management in Hemoglobinopathies
Sickle Cell Disease:
Risks: Pregnancy in women with SCD is associated with increased risks of preterm labor, preeclampsia, IUGR, low birth weight, and fetal demise. Complications such as acute chest syndrome can be life-threatening and require urgent intervention.
Folic Acid Supplementation: Pregnant women with SCD require higher doses of folic acid (4 mg daily) due to increased red cell turnover.
Pain Management: Painful crises are managed with prompt analgesia and hydration. Hydroxyurea, used to reduce pain crises in non-pregnant individuals, is contraindicated in pregnancy due to its teratogenicity.
Transfusion Therapy: Prophylactic transfusions are controversial and are typically reserved for severe complications, with the goal of reducing Hb S levels to 40% and maintaining total hemoglobin at approximately 10 g/dL.
Thalassemias:
Alpha-Thalassemia: Pregnancy outcomes are generally favorable in individuals with α-thalassemia trait, though severe forms (Hb Bart’s) are lethal in utero.
Beta-Thalassemia: Pregnancy is feasible in women with β-thalassemia major if they have undergone adequate transfusion and iron chelation therapy. Hemoglobin levels should be maintained at 10 g/dL, and fetal growth should be monitored with serial ultrasounds.
Clinical Recommendations
Screening: Offer carrier screening to individuals at high risk for hemoglobinopathies, such as those of African, Southeast Asian, or Mediterranean descent. Couples at risk for having an affected child should receive genetic counseling.
Monitoring and Testing: Use CBC and hemoglobin electrophoresis for initial screening. DNA analysis should be used for prenatal diagnosis of specific mutations when needed.
Pregnancy Management: Pregnant women with hemoglobinopathies should be managed by a multidisciplinary team, including obstetricians experienced in high-risk pregnancies and hematologists.
73
Hepatitis Vaccination
Hepatitis Vaccination
Obstetrics
Detailed Outline for the Management of Hepatitis in Pregnancy
This outline focuses on the management of hepatitis B and C in pregnancy, as this is where the sources provide the most detail. The sources also mention hepatitis A and E but primarily to distinguish them from hepatitis B and C.
Hepatitis B
Screening and Diagnosis
All pregnant individuals should be screened for hepatitis B at the first prenatal visit in each pregnancy, regardless of vaccination or testing history.
The screening test is for Hepatitis B surface antigen (HBsAg).
A triple panel test (HBsAg, anti-HBs, and total anti-HBc) is also recommended at least once in adulthood and during pregnancy if certain criteria are met.
The triple panel helps determine if a person is susceptible to infection, has an active infection, or is immune due to past infection or vaccination.
For those who test positive for HBsAg, a quantitative hepatitis B virus DNA test is recommended. This information helps guide decisions regarding antiviral therapy.
Additional testing may be done for HBsAg-positive patients to distinguish between acute and chronic infection and determine viral load.
Counseling
Individuals with chronic hepatitis B should receive prepregnancy counseling addressing the impact of pregnancy on their disease and the risks to the fetus and neonate.
Counseling should involve a multidisciplinary team, including a hepatitis specialist.
Counseling should include information about:
The stability of maternal disease
Maternal viral burden, genotype, and the presence of cirrhosis
Increased risk of fetal growth restriction, preterm birth, and intrahepatic cholestasis of pregnancy for those with hepatitis C
The importance of abstaining from alcohol
Recommended vaccinations
Patients should be informed about the risk of a postpartum hepatitis flare, which can occur due to immunologic changes during pregnancy.
Patients with high viral loads (greater than 200,000 IU/mL) should be counseled about the benefits of antiviral therapy to reduce the risk of perinatal transmission.
Management
Pregnant individuals with hepatitis B without evidence of advanced liver disease generally tolerate pregnancy well but should be closely monitored during pregnancy and postpartum.
There is no specific treatment for acute hepatitis B infection, so supportive care is recommended.
Treatment decisions for chronic hepatitis B are made based on various factors, including:
Presence or absence of cirrhosis
HBV DNA levels
ALT levels
Presence or absence of HBeAg
For patients who need treatment, tenofovir (tenofovir disoproxil fumarate or tenofovir alafenamide) is the first-line antiviral therapy. Tenofovir alafenamide is associated with lower risks of bone density and renal function problems with long-term use.
Treatment may be indicated to protect maternal health or prevent perinatal transmission.
For those with high viral loads (greater than 200,000 IU/mL), antivirals are recommended to reduce vertical transmission risk. Treatment is usually started at the beginning of the third trimester.
A hepatitis specialist should be involved in the management of these patients.
Neonatal prophylaxis is critical to prevent perinatal transmission. All newborns of HBsAg-positive mothers should receive hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth, regardless of whether the mother received antiviral therapy. This reduces the risk of perinatal transmission to less than 5%. Without prophylaxis, the transmission rate can be as high as 90%.
Intrapartum and Postpartum Considerations
Routine intrapartum care does not need to be altered for individuals with chronic hepatitis B.
Cesarean delivery is not recommended solely to reduce perinatal transmission.
Individuals with hepatitis B can safely breastfeed if their infant has received prophylaxis at birth.
The risk of vertical transmission associated with amniocentesis is considered low. Shared decision-making should be used when counseling patients about this procedure.
Hepatitis C
Screening and Diagnosis
Pregnant individuals should be screened for hepatitis C at the first prenatal visit of each pregnancy.
The screening test is for hepatitis C virus antibody. If this test is positive, a hepatitis C virus RNA polymerase chain reaction test is done to confirm the diagnosis.
Counseling
Prepregnancy counseling for individuals with hepatitis C should include information about the potential impact of pregnancy on the disease and the risks to the fetus.
Patients should be informed about the increased risks of fetal growth restriction, preterm birth, and intrahepatic cholestasis of pregnancy.
Abstinence from alcohol and recommended vaccinations should be discussed.
Management
Currently, no treatment options are available for hepatitis C during pregnancy.
There are also no recommended interventions to decrease the risk of perinatal transmission.
Pregnant individuals diagnosed with hepatitis C should be referred to a hepatitis specialist for postpartum care and treatment after breastfeeding.
Shared decision-making should be used when counseling patients about the generally low risk of vertical transmission associated with amniocentesis and chorionic villus sampling.
Breastfeeding is not discouraged for individuals with hepatitis C.
Intrapartum Considerations
There is no evidence to suggest that routine intrapartum care needs to be modified for individuals with hepatitis C.
Accidental or Occupational Exposure to Hepatitis B or C in Pregnant Healthcare Workers
Pregnant healthcare workers exposed to hepatitis B or C should be managed similarly to non-pregnant individuals.
Evaluate the healthcare worker's vaccination status.
Determine the source patient's hepatitis B infection status.
Administer postexposure prophylaxis according to CDC criteria if needed.
Hepatitis A and Hepatitis E
Hepatitis A is usually a benign, self-limited disease. The risk of vertical transmission is low. Pregnant women with acute hepatitis A infection may have a higher risk of gestational complications and preterm labor.
Hepatitis E can have serious consequences for pregnant women in endemic areas, but it is rare in the United States.
Vaccination for hepatitis A and B is recommended during pregnancy for those who are susceptible.
General Management of Acute Hepatitis
Pregnant individuals with severe acute hepatitis (encephalopathy, coagulopathy, or severe debilitation) should be hospitalized.
Management includes:
Nutritional support
Correction of fluid and electrolyte abnormalities
Administration of blood products (erythrocytes, platelets, clotting factors) as needed
Pregnant individuals with less severe acute hepatitis may be managed as outpatients.
All individuals with hepatitis should:
Use condoms during intercourse
Avoid sharing household items that could be contaminated with blood
Key Changes in Hepatitis B Management
The sources highlight several key changes in hepatitis B management, particularly in the context of pregnancy:
Universal Adult Hepatitis B Screening: The CDC updated its recommendations in March 2023 to include universal triple-panel screening (HBsAg, anti-HBs, and total anti-HBc) for all adults at least once in their lifetime. This approach aims to provide a complete understanding of an individual's hepatitis B status: whether they are immune due to infection or vaccination, have an active infection, or are susceptible. This differs from previous guidelines that focused on risk-based screening.
Screening During Pregnancy: The recommendation for universal hepatitis B surface antigen (HBsAg) screening during each pregnancy remains. For individuals with a previously documented negative triple-panel test, universal HBsAg screening alone at the first prenatal care visit is recommended.
Expanded Indications for Antiviral Therapy: The sources emphasize the importance of maternal HBV DNA levels in guiding decisions about antiviral therapy during pregnancy. For individuals with viral loads >200,000 IU/mL (>5.3 log10 IU/mL), antiviral therapy with tenofovir (tenofovir alafenamide or tenofovir disoproxil fumarate) is recommended in the third trimester (initiated at 28-32 weeks of gestation) as an adjunctive strategy to immunoprophylaxis to reduce perinatal transmission. This change stems from research demonstrating a strong correlation between high maternal viral loads and the risk of perinatal transmission.
Tenofovir as First-Line Therapy: The guidelines now strongly recommend tenofovir as the first-line antiviral therapy for chronic hepatitis B in pregnancy. Previously, lamivudine was considered a first-line agent, but concerns about resistance have led to its replacement by tenofovir.
Availability of Tenofovir Alafenamide: Tenofovir alafenamide (TAF) has emerged as a safe and effective alternative to tenofovir disoproxil fumarate (TDF) for treating chronic hepatitis B in pregnancy. TAF offers the advantage of a lower risk of long-term bone density and renal function problems. While data on TAF use in pregnancy is primarily based on observational studies in pregnant women with HIV and chronic hepatitis B, no safety signals have been identified, and its efficacy in preventing perinatal transmission has been noted.
Emphasis on Neonatal Immunoprophylaxis: The sources reinforce the importance of neonatal immunoprophylaxis with hepatitis B vaccine and HBIG within 12 hours of birth for all newborns of HBsAg-positive mothers or those with unknown or undocumented HBsAg status, regardless of maternal viral load or antiviral therapy. This combined approach significantly reduces the risk of chronic infection.
Safety of Breastfeeding: The guidelines continue to support the safety of breastfeeding for individuals with chronic hepatitis B, as long as the infant has received appropriate immunoprophylaxis at birth.
Vaccination During Pregnancy: Hepatitis B vaccination is recommended during pregnancy for all individuals without serologic evidence of immunity or a documented history of vaccination. Data supports the safety and efficacy of vaccination during pregnancy, with no vaccine-specific adverse outcomes reported. Prenatal care presents a valuable opportunity for vaccination due to frequent visits and high compliance rates.
These changes in hepatitis B management reflect evolving research and a greater understanding of the virus and its impact on maternal and neonatal health.
74
Herpes and HIV in pregnancy
[ ]
75
Hirsutism/Congenital adrenal hyperplasia
Hirsutism/Congenital adrenal hyperplasia
Screening and Managing Hyperandrogenism in Adolescents
This article, "Screening and Management of the Hyperandrogenic Adolescent," is an ACOG Committee Opinion that offers guidance to healthcare providers on evaluating and treating androgen excess in adolescent girls.
Understanding Androgen Excess
Androgen excess, primarily manifesting as hirsutism and acne, is a common issue in adolescent girls. While these conditions are prevalent, it's crucial to address them seriously due to their potential impact on self-esteem, quality of life, and possible links to underlying medical conditions.
Diagnosing hyperandrogenism involves a combination of clinical evaluation and measurement of serum androgens.
The primary sources of androgens in females are the ovaries, adrenal glands, and peripheral conversion within tissues. The most potent androgens, testosterone and dihydrotestosterone, bind to androgen receptors and exert their effects.
While total testosterone levels provide valuable information, it's important to consider that most testosterone is bound to proteins, leaving a small fraction as "free testosterone," which is the biologically active form.
Challenges of PCOS Diagnosis in Adolescents
Polycystic ovary syndrome (PCOS) is a common cause of persistent hyperandrogenism in adolescents, but diagnosing it during this stage can be challenging due to the overlap of symptoms with normal puberty.
Symptoms like irregular periods, acne, and the appearance of polycystic ovaries on ultrasound can be present in both normal puberty and PCOS, making it difficult to differentiate.
The article emphasizes the need for a cautious approach to PCOS diagnosis in adolescents, particularly within the first two years after menarche. A longitudinal evaluation over 1-2 years is recommended to monitor symptom evolution before confirming PCOS.
Despite the diagnostic challenges, treatment for acne and hirsutism should not be delayed while evaluating for PCOS.
Evaluating the Hyperandrogenic Adolescent
The initial evaluation focuses on identifying signs and symptoms of androgen excess through a detailed medical history and physical examination.
The medical history should cover the timing of puberty milestones, menstrual patterns, history of hair removal methods, use of anabolic steroids or testosterone, and family history of related conditions.
Assessing the patient's distress level due to the symptoms is essential, as treatment is recommended only when symptoms are bothersome.
The physical examination should include evaluating body mass index, blood pressure, signs of hyperandrogenism (acne, hirsutism), and potential indicators of insulin resistance.
A pelvic exam is rarely necessary, while pelvic ultrasonography is indicated only if serum androgen levels or signs of virilization raise concerns about an ovarian tumor.
Laboratory testing typically involves measuring total testosterone, free testosterone, and a 17-hydroxyprogesterone test to screen for nonclassic congenital adrenal hyperplasia.
Additional tests, such as an ACTH stimulation test and DHEAS measurement, may be considered in cases of rapid virilization.
Treatment Strategies for Hirsutism
A multimodal approach, combining lifestyle modifications, physical hair removal, and medication to suppress or block androgen action, is the most effective way to manage hirsutism.
Weight loss in obese patients can help reduce androgen levels and improve hirsutism by decreasing androgen production and increasing sex hormone-binding globulin.
Combined hormonal contraceptives (CHCs) are commonly used to suppress ovarian androgen production. CHCs containing third-generation progestins or drospirenone (with antiandrogenic properties) are often preferred.
Antiandrogens, like spironolactone, work by blocking androgen receptors and 5α-reductase, an enzyme that converts testosterone to the more potent dihydrotestosterone.
Physical hair removal methods, such as shaving, waxing, electrolysis, and laser therapy, offer temporary or permanent solutions depending on the method.
Managing Acne in Adolescents
Similar to hirsutism, treating acne often involves a multimodal approach.
Topical therapies, including benzoyl peroxide and retinoids, are frequently used as first-line treatments.
Hormonal therapy with CHCs can be an effective first-line option for postmenarchal adolescents, particularly those seeking menstrual cycle regulation or contraception.
Oral antibiotics are considered for moderate to severe acne, especially cases with inflammatory lesions not responding to topical treatments.
Oral isotretinoin is reserved for severe acne, but requires strict monitoring and adherence to the iPLEDGE program due to its teratogenic effects.
Follow-Up and Long-Term Considerations
Before starting any treatment, patients should be counseled about realistic expectations and the potential for a long-term management approach.
Regular follow-up is crucial to assess treatment effectiveness, manage side effects, and adjust treatment plans as needed.
Monitoring serum androgen levels is generally not recommended.
Conclusion
Managing androgen excess in adolescents requires a comprehensive approach involving a thorough evaluation, individualized treatment plans, and ongoing communication with the patient. Recognizing the psychological impact of these conditions and addressing patients' concerns is essential for successful management.
76
HIV in Pregnancy
HIV in Pregnancy
Obstetrics
HIV in Pregnancy Management
Identifying HIV-infected women is vital because treatment with combination antiretroviral therapy (cART) can reduce the risk of mother-to-child transmission to below 1–2% when the viral load is 1,000 copies/mL or less near the time of delivery.
HIV RNA levels should be checked at the first prenatal visit, 2–4 weeks after starting or changing cART, followed by monthly testing until levels are undetectable, and every three months thereafter.
Rapid HIV screening should be done during labor and delivery or immediately postpartum using the opt-out method for all women not tested earlier in pregnancy or with unknown status. The results should be available within one hour, 24 hours a day. Viral load should be checked between 34 and 36 weeks of gestation to inform decisions about the mode of delivery.
Management of HIV in pregnancy is largely dependent on the mother's viral load at the time of delivery.
Management Based on Viral Load
Low Viral Load (≤ 1,000 copies/mL)
Vaginal delivery is appropriate.
Delivery at 39 weeks gestation or later is recommended.
Vaginal delivery before 40 weeks gestation does not reduce the risk of transmission.
The duration of ruptured membranes is not independently associated with an increased risk of transmission.
High Viral Load (> 1,000 copies/mL) or Unknown Viral Load Near Delivery
A scheduled pre-labor cesarean delivery at 38 weeks gestation is recommended.
Pre-delivery prophylaxis with IV zidovudine is recommended, ideally beginning three hours before delivery. The dosing for zidovudine is a 2 mg/kg load over the first hour, followed by a 1 mg/kg/hour maintenance infusion.
Studies have shown significantly higher ratios of cord blood-to-maternal zidovudine levels in women who received an IV infusion for three to six hours versus less than three hours.
If a woman with a high viral load elects to have a vaginal delivery, IV zidovudine should be administered from the onset of in-house labor monitoring until delivery, along with other cART drugs.
The patient’s autonomy and informed decision regarding the mode of delivery should be respected, irrespective of viral load.
Note: Although IV zidovudine is not recommended for women with a viral load ≤ 1,000 copies/mL, some data suggest a higher transmission risk (1–2%) in women with a viral load above 50 copies/mL compared with those with a viral load less than 50 copies/mL; therefore, many experts continue to advocate for IV zidovudine even in this group.
Prelabor Rupture of Membranes (PROM)
Low viral load: (≤1,000 copies/mL) HIV transmission does not increase with the duration of PROM.
High viral load: (> 1,000 copies/mL) some studies suggest a 2% increased transmission rate with every additional hour of PROM. It is unclear how many hours must pass before the benefit of a cesarean is lost. Care should be individualized, and expert consultation may help when managing high-risk patients with HIV and PROM, especially if decisions need to be made urgently.
Note: Consultation with the National Perinatal HIV/AIDS Clinical Consultation Center is available 24/7 at 888-448-8765.
Special Circumstances
Postoperative morbidity is higher in HIV-infected women with CD4 counts < 200.
Even in the setting of an undetectable viral load, fetal scalp electrodes and operative vaginal deliveries should be avoided.
Prostaglandin F2-alpha, misoprostol, and oxytocin are preferred over methergine for the treatment of postpartum hemorrhage because methergine and other ergotamines interact with protease inhibitors or cobicistat and may lead to an exaggerated vasoconstriction response.
The sources provided do not contain information about the potential impact of other sexually transmitted infections like herpes or syphilis on HIV in pregnancy.
77
Hypercholesterolemia and dyslipidemias
Hypercholesterolemia and dyslipidemias
General
Goals and General Recommendations
• Primary Goal: Reduction of atherosclerotic cardiovascular disease.
• Universal Recommendation: Heart-healthy diet, appropriate exercise, and nutrition.
Cholesterol Screening and Statin Use
• Screening Based on 10-Year Cardiovascular Event Risk:
• Patients with clinical cardiovascular disease.
• LDL > 190 mg/dL.
• Diabetes, ages 40-75, LDL 70-189 mg/dL, and no clinical cardiovascular disease.
• LDL 70-189 mg/dL and a 10-year cardiovascular disease risk > 7.5%.
• Based on pooled risk calculators from the American Heart Association.
• Risk Calculator Factors:
• Demographics: Age, race, gender.
• Lab Values: Total cholesterol, HDL.
• Physical Exam: Systolic blood pressure.
• Medical History: Hypertension, diabetes, smoking history.
Statin Therapy Goals
• LDL Reduction: Main goal of statin therapy.
• Moderate-intensity statins: Reduce LDL by 30-50%.
• High-intensity statins: Reduce LDL by >50%.
Lipid Panel Reference Ranges
• Total Cholesterol:
• Desirable: < 200 mg/dL.
• Borderline: 200-240 mg/dL.
• High risk: > 240 mg/dL.
• LDL (Low-Density Lipoprotein):
• Desirable: < 100 mg/dL.
• Moderate risk: 100-160 mg/dL.
• High risk: > 160 mg/dL.
• HDL (High-Density Lipoprotein):
• Desirable: > 60 mg/dL.
• Moderate risk: 40-60 mg/dL.
• High risk: < 40 mg/dL.
• Triglycerides:
• Desirable: < 150 mg/dL.
• Moderate risk: 150-885 mg/dL.
• High risk: > 885 mg/dL.
Cardiovascular Disease in Women
• Leading Cause of Death for Women: Cardiovascular disease.
• Risk Factors Unique to Women:
• Premature menopause.
• Primary ovarian insufficiency.
• Adverse pregnancy outcomes: preterm delivery, preeclampsia, abruption.
• History of metabolic syndrome and PCOS (Polycystic Ovary Syndrome).
• General Risk Factors (Both Men and Women):
• Age, family history of premature cardiac disease.
• Hypertension, diabetes, current smoking, and alcohol use.
• Obesity, sedentary lifestyle, low HDL.
Presentation Differences in Wome
• Risk Perception: Women are often erroneously thought to be at lower risk than men.
• Age of Onset: Women present about 10 years later than men.
• Symptoms:
• Atypical symptoms are more common in women, but chest pain remains the most common symptom for both sexes.
• Women have a higher likelihood of presenting without chest pain.
• Stress Testing:
• Less accurate in women due to difficulty reaching target heart rate.
• Higher likelihood of microvascular angina, which is not easily detected by stress testing.
• Additional Symptomatology in Women:
• Symptoms may occur with mental stress, at rest, or during sleep.
I. Significance of Cholesterol Screening
ASCVD Prevention: Cholesterol screening plays a crucial role in primary and secondary prevention of ASCVD.
Early Detection: It helps identify asymptomatic individuals at high risk due to genetic predispositions or underlying health conditions like diabetes, chronic kidney disease, and HIV.
Detection of Other Conditions: Cholesterol screening can reveal abnormally high cholesterol levels potentially indicating familial hypercholesterolemia or low levels suggestive of hypobetalipoproteinemia or abetalipoproteinemia.
II. Specimen Collection
Fasting vs. Non-Fasting: Traditionally, fasting for 8+ hours before the test was mandatory, but recent guidelines indicate fasting is not always necessary.
Factors Determining Fasting: The decision to fast depends on the physician’s clinical question and the patient’s specific situation.
Conditions Necessitating Fasting: Fasting is preferred or mandatory for patients with a family history of genetic hyperlipidemia, premature ASCVD, suspected hypertriglyceridemia, for residual risk estimation in treated patients, and in cases of potential pancreatitis.
Non-Fasting Acceptability: Non-fasting blood lipid profiles are acceptable for initial risk estimation in untreated patients and for diagnosing metabolic syndrome.
Blood Sample Collection: Typically involves drawing 0.5 to 1 mL of venous blood, usually from the antecubital vein.
Specimen Handling: The blood is collected in specific tubes (gel-barrier transport, green-top heparin, or lavender-top EDTA), and serum is separated within 45 minutes.
IV. Cholesterol Screening Guidelines
Multiple Guidelines Exist: Various clinical practice guidelines from different medical organizations offer recommendations for cholesterol screening.
Shared Goals: Despite minor variations, these guidelines aim to prevent coronary artery disease (CAD) in healthy individuals (primary prevention) and enable early detection to slow disease progression (secondary prevention).
Patient Categories for Screening: Guidelines suggest screening individuals with:
Family history of premature death from myocardial infarction in first-degree relatives
Family history of hypercholesterolemia or exhibiting symptoms of this condition
Comorbidities that could benefit from statins (e.g., diabetes, chronic kidney disease, HIV)
The need for risk stratification to determine potential benefits from cholesterol-lowering treatment.
1.
In all individuals, emphasize a heart-healthy lifestyle across the life course. A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion (see No. 6) and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.
2.
In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy. The more LDL-C is reduced on statin therapy, the greater will be subsequent risk reduction. Use a maximally tolerated statin to lower LDL-C levels by ≥50%.
3.
In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L). In patients at very high risk whose LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.
4.
In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), without calculating 10-year ASCVD risk, begin high-intensity statin therapy. If the LDL-C level remains ≥100 mg/dL (≥2.6 mmol/L), adding ezetimibe is reasonable. If the LDL-C level on statin plus ezetimibe remains ≥100 mg/dL (≥2.6 mmol/L) and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered, although the long-term safety (>3 years) is uncertain and economic value is uncertain at mid-2018 list prices.
5.
In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk. In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by ≥50%.
6.
In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy. Risk discussion should include a review of major risk factors (eg, cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors (see No. 8); the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making.
7.
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy. Risk-enhancing factors favor statin therapy (see No. 8). If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity (see No. 9). If statins are indicated, reduce LDL-C levels by ≥30%, and if 10-year risk is ≥20%, reduce LDL-C levels by ≥50%.
8.
In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy (see No. 7). Risk-enhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels ≥160 mg/dL (≥4.1 mmol/L); metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (age <40 years); chronic inflammatory disorders (eg, rheumatoid arthritis, psoriasis, or chronic HIV); high-risk ethnic groups (eg, South Asian); persistent elevations of triglycerides ≥175 mg/dL (≥1.97 mmol/L); and, if measured in selected individuals, apolipoprotein B ≥130 mg/dL, high-sensitivity C-reactive protein ≥2.0 mg/L, ankle-brachial index <0.9 and lipoprotein (a) ≥50 mg/dL or 125 nmol/L, especially at higher values of lipoprotein (a). Risk-enhancing factors may favor statin therapy in patients at 10-year risk of 5-7.5% (borderline risk).
9.
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL to 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC. If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD. A CAC score of 1 to 99 favors statin therapy, especially in those ≥55 years of age. For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion.
10.
Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed. Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. In ASCVD patients at very high-risk, triggers for adding nonstatin drug therapy are defined by threshold LDL-C levels ≥70 mg/dL (≥1.8 mmol/L) on maximal statin therapy (see No. 3).
78
Hysterectomy
Hysterectomy
Overview of Choosing the Route of Hysterectomy for Benign Disease
This Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) provides guidance on selecting the optimal approach for hysterectomy in cases of benign disease. The opinion emphasizes minimally invasive techniques and shared decision-making between the patient and physician.
Preferred Approaches to Hysterectomy
Vaginal hysterectomy is the recommended approach whenever feasible. This method has demonstrated superior outcomes compared to other hysterectomy techniques.
Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy when vaginal hysterectomy is not possible.
Minimally invasive approaches (vaginal or laparoscopic) are generally preferred over abdominal hysterectomy. These techniques result in shorter hospital stays, faster recovery times, and fewer complications.
Factors Influencing Route Selection
Multiple factors can influence the choice of hysterectomy route, including:
Patient factors:
Size and shape of the vagina and uterus
Accessibility to the uterus (e.g., uterine prolapse, pelvic adhesions)
Patient preference
Disease factors:
Extent of extrauterine disease
Need for concurrent procedures
Surgical factors:
Surgeon training and experience
Average case volume
Availability of hospital technology, devices, and support
Whether the case is emergent or scheduled
Role of Opportunistic Salpingectomy
Opportunistic salpingectomy (removal of the fallopian tubes to reduce cancer risk) can often be performed safely during vaginal hysterectomy.
The decision to perform opportunistic salpingectomy should not change the planned route of hysterectomy.
Prophylactic salpingectomy in patients with genetic mutations necessitates a laparoscopic or abdominal approach to ensure adequate tissue margins.
Considerations for Morcellation
Power morcellation, used to remove the uterus in smaller pieces during laparoscopic hysterectomy, has been linked to the risk of spreading malignant tissue, especially uterine sarcoma.
Minimally invasive techniques, including morcellation, offer reduced surgical morbidity compared to open abdominal hysterectomy. The risk of cancer dissemination with morcellation must be balanced against the increased risks associated with open surgery.
Alternatives to power morcellation, like scalpel morcellation and contained power morcellation (using a bag device), are being developed to minimize tissue dissemination.
Patients should be fully informed about the risks and benefits of morcellation before consenting to the procedure.
Robot-Assisted Laparoscopic Hysterectomy
Robot-assisted laparoscopic hysterectomy should be considered based on available data and surgeon expertise. Surgeons should be proficient in abdominal and laparoscopic hysterectomy before performing robot-assisted procedures.
The role of robotic assistance in laparoscopic hysterectomy is still being evaluated. Further research is needed to determine the most appropriate applications for this technology and its benefits compared to other hysterectomy approaches.
Importance of Shared Decision-Making
The choice of hysterectomy route should be made collaboratively by the patient and the obstetrician-gynecologist.
A thorough discussion of the risks and benefits of each approach, tailored to the patient's specific clinical situation and preferences, is crucial.
Referral to another surgeon may be appropriate if the patient desires a particular hysterectomy route that the initial surgeon cannot provide.
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Immunizations
Immunizations
Obstetrics
Vaccination in Pregnancy Outline
Importance of Immunization: Vaccination is a crucial aspect of healthcare for adults, especially pregnant women.
Benefits for Mother and Fetus:
Influenza vaccination is particularly important for pregnant women as they are at a higher risk of complications from the flu, including increased morbidity and mortality. Additionally, influenza can negatively impact fetal health, potentially leading to congenital anomalies, miscarriage, premature birth, and low birth weight.
The Tdap vaccine offers protection to both the fetus and newborn through the transfer of antibodies across the placenta.
Vaccines against pathogens like pneumococcus, meningococcus, and hepatitis safeguard at-risk pregnant women from severe health complications.
Safety of Vaccines During Pregnancy:
There is no scientific evidence suggesting that vaccinating pregnant women with inactivated virus, bacterial, or toxoid vaccines has adverse effects on the fetus.
A growing body of research supports the safety of these vaccines for pregnant women.
The only RSV vaccine currently approved for use during pregnancy is Pfizer's bivalent RSVpreF vaccine, Abrysvo.
GSK's RSV vaccine, Arexvy, and Moderna's RSV vaccine, MRESVIA, are not approved for use during pregnancy.
Recommended Vaccines During Pregnancy:
Influenza Vaccine: All pregnant women should receive the annual influenza vaccine, regardless of the trimester.
Tdap Vaccine: It is recommended during every pregnancy, preferably between 27 and 36 weeks of gestation, to maximize antibody transfer to the newborn.
RSV Vaccine: A single dose of Pfizer's Abrysvo vaccine is recommended between 32 0/7 and 36 6/7 weeks of gestation for eligible pregnant individuals. Eligibility criteria include not having a planned delivery within 2 weeks and not having received the maternal RSV vaccine during the 2023–2024 season.
Other Vaccines: Additional vaccines may be recommended based on individual risk factors such as age, previous immunizations, comorbidities, and exposure risks.
Obstetrician's Role in Vaccination:
Obstetricians and other healthcare providers caring for pregnant women play a vital role in ensuring they receive recommended vaccines.
Routine assessment of vaccination status during pregnancy is crucial.
They should recommend and administer necessary vaccines whenever possible.
Studies indicate that when vaccination recommendations come directly from the obstetrician, acceptance and uptake rates increase significantly.
Obstetricians should counsel their patients about the safety and efficacy of both maternal vaccination and the monoclonal antibody nirsevimab for the prevention of severe RSV in infants.
Patient preference should be a factor in choosing between maternal vaccination and nirsevimab administration to the infant.
Coadministration with Other Vaccines:
It is safe and important for pregnant women to receive all recommended vaccines, including the maternal RSV vaccine, concurrently with other routinely recommended vaccines.
Early discussion about recommended vaccines (COVID-19, influenza, Tdap, RSV) at the first prenatal visit can help plan the timing of administration and reduce the burden of multiple appointments.
Documentation:
Accurate documentation of vaccine administration or refusal is vital for any immunization program.
This information should be recorded in the patient's medical records and the state immunization information system.
Documentation is particularly crucial for RSV vaccination due to its connection with the administration of monoclonal antibodies to infants.
Additional Information:
Table 1 in the source "Maternal Immunization.pdf" provides a detailed summary of recommended immunizations during pregnancy based on CDC guidelines.
The ACOG website offers further resources on maternal immunization.
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Induction of labor
Induction of labor
Induction of Labor - Summary
Introduction
Definition and Prevalence: Induction of labor is a procedure used to stimulate uterine contractions before the spontaneous onset of labor to achieve vaginal delivery. It is employed when the benefits of early delivery outweigh the risks of continuing the pregnancy. The rate of induction has increased significantly, now accounting for more than 22% of births in the United States. The purpose of this bulletin is to review current induction methods and their effectiveness.
Historical Background: Oxytocin was first used for induction in 1948, and in 1953, it became the first polypeptide hormone synthesized for medical use. Methods for induction include the use of oxytocin, prostaglandins, membrane stripping, amniotomy, nipple stimulation, and mechanical dilation.
Indications and Contraindications
Indications for Induction:
Maternal or Fetal Conditions: Abruptio placentae, chorioamnionitis, fetal demise, gestational hypertension, preeclampsia/eclampsia, premature rupture of membranes (PROM), postterm pregnancy, maternal medical conditions (e.g., diabetes, chronic hypertension), and fetal compromise (e.g., growth restriction, oligohydramnios).
Logistical Reasons: Includes the risk of rapid labor, distance from the hospital, and psychosocial reasons.
Contraindications:
Absolute Contraindications: Vasa previa, complete placenta previa, transverse fetal lie, umbilical cord prolapse, prior classical cesarean delivery, active genital herpes infection, and previous myomectomy involving the endometrial cavity.
Methods of Induction
Cervical Ripening:
Mechanical Methods: Mechanical dilation involves devices like hygroscopic dilators, osmotic dilators (e.g., Laminaria japonicum), Foley catheters, and double balloon devices. Mechanical methods are effective for cervical ripening and are associated with a lower risk of uterine tachysystole.
Pharmacologic Agents:
Prostaglandin E1 (Misoprostol): Can be used intravaginally, orally, or sublingually. It is effective in inducing labor, but higher doses are associated with uterine tachysystole.
Prostaglandin E2 (Dinoprostone): Available as a gel or vaginal insert, both approved for cervical ripening. Dinoprostone increases the likelihood of delivery within 24 hours.
Labor Induction:
Oxytocin: One of the most commonly used drugs for labor induction. It is typically administered intravenously, and its dosage is adjusted according to uterine response.
Membrane Stripping: Involves separating the membranes from the lower uterine segment, which increases the likelihood of spontaneous labor and reduces the need for other induction methods.
Amniotomy: Artificial rupture of membranes may be used for induction, often in combination with oxytocin to shorten labor duration.
Complications and Risks
Tachysystole: Defined as more than five contractions in 10 minutes, tachysystole is a common side effect associated with oxytocin and prostaglandins. It may lead to fetal heart rate abnormalities, which require prompt intervention.
Uterine Rupture: More likely with the use of misoprostol in women with a prior uterine scar; therefore, misoprostol should be avoided in women with previous cesarean sections during the third trimester.
Other Complications: Include fetal heart rate changes, uterine rupture, cord prolapse (after amniotomy), and increased risk of infections with mechanical dilation methods.
Clinical Recommendations
Indications for Induction: Induction should be performed based on maternal and fetal indications, considering gestational age and cervical status.
Cervical Ripening: Prostaglandins or mechanical methods should be used to ripen the cervix in women with an unfavorable cervix before labor induction.
Tachysystole Management: Tachysystole should be managed by adjusting or stopping oxytocin, providing maternal repositioning, administering intravenous fluids, or using tocolytic agents if needed.
Appropriate Use of Misoprostol: Misoprostol should be administered cautiously, with an initial dose of 25 mcg and no more than every 3-6 hours. It should not be used in patients with previous cesarean delivery or uterine surgery.
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Infertility
Infertility
Overview of Primary Ovarian Insufficiency
This committee opinion from the American College of Obstetricians and Gynecologists (ACOG) provides guidance on the diagnosis and management of primary ovarian insufficiency (POI) in adolescents and young women. POI is the depletion or dysfunction of ovarian follicles before the age of 40, resulting in the cessation of menses. The opinion stresses the sensitive nature of this condition and the importance of patient counseling and support.
Understanding Primary Ovarian Insufficiency
Primary ovarian insufficiency, formerly known as premature menopause or primary ovarian failure, is characterized by the depletion or dysfunction of ovarian follicles and the cessation of menses before the age of 40. The preferred term "primary ovarian insufficiency" acknowledges the intermittent or unpredictable nature of ovarian function in many cases.
A key distinction between POI and natural menopause is the potential for spontaneous conception in 5-10% of women with POI.
The variability in the number of reproductive years among women is influenced by steroid production in the ovaries.
Decreased ovarian reserve is another term used to describe POI, reflecting the reduced number of functional ovarian follicles.
Etiology and Contributing Factors
The causes of follicle depletion or dysfunction in adolescents are diverse, ranging from chromosomal abnormalities to iatrogenic factors.
Chromosomal abnormalities, particularly gonadal dysgenesis with or without Turner syndrome, are common causes of POI in adolescents. Around 50% of adolescents with primary amenorrhea without other health issues have abnormal karyotypes. Additionally, 13% of younger women (30 years or younger) with secondary amenorrhea also exhibit abnormal karyotypes. While growth and pubertal delays are common, menstrual abnormalities may be the first noticeable sign.
Chemotherapy and radiation therapy can damage ovarian follicles, leading to acute ovarian failure, which may be temporary or permanent. Factors influencing the likelihood of gonadotoxicity include the patient's age at the time of treatment, the type of medication, and the dosage. Alkylating agents and procarbazine carry the highest risk of acute ovarian failure. Younger patients have a higher chance of follicle survival. Whole-body, whole-brain, pelvic, and spinal irradiation, particularly pelvic irradiation exceeding 10 Gy, significantly increase the risk of acute ovarian failure. Combined chemotherapy and radiation therapy further elevates the risk. Importantly, even women who resume menstruation after chemotherapy face an increased lifetime risk of POI.
A premutation in the FMR1 gene for fragile X syndrome, the most prevalent inheritable form of mental retardation, is associated with POI. Approximately 6% of women with POI and normal karyotypes have this premutation. While menstruation usually begins normally in carriers, about 1% experience their final menses before age 18. Testing for fragile X premutation is recommended for women with a personal or family history of ovarian failure or elevated follicle-stimulating hormone (FSH) levels before age 40 without a known cause.
POI can be associated with various endocrinopathies, including hypoparathyroidism and hypoadrenalism.
Other factors, such as infiltrative or infectious processes, pelvic surgery, and autoimmune mechanisms (indicated by adrenal or ovarian antibodies in 4% of women with POI), can also contribute to POI. In many cases, the cause remains unknown.
Diagnosis: Recognizing the Signs and Confirming POI
Diagnosing POI in adolescents is challenging due to the lack of consensus on diagnostic criteria and frequent delays in diagnosis.
Amenorrhea, either primary or secondary, is the most common presenting symptom, although some experience hot flashes or vaginal symptoms like dryness or dyspareunia. The incidence of POI among patients with amenorrhea is 2-10%.
Other menstrual irregularities, such as oligomenorrhea (bleeding less frequently than every 35 days), nonstructural causes of abnormal uterine bleeding (e.g., ovulatory dysfunction), or polymenorrhea (bleeding more frequently than every 21 days) can also signal POI.
The overlap between irregular menstrual cycles in early adolescence and initial symptoms of POI complicates diagnosis in this age group.
Despite the fact that less than 10% of women with abnormal menses have POI, early diagnosis is crucial due to the condition's impact on bone health.
A reasonable approach to diagnosis and initial evaluation of POI involves:
Assessing menstrual irregularity: Look for a pattern of irregularity lasting at least 3 consecutive months.
Measuring follicle-stimulating hormone (FSH) and estradiol levels: Two random tests should be conducted at least 1 month apart. Elevated gonadotropin levels (basal FSH typically greater than 30-40 mIU/mL) and low estradiol levels (less than 50 pg/mL) suggest POI.
Excluding other conditions: Perform tests for pregnancy, thyroid disease, and hyperprolactinemia.
Further investigation: If POI is confirmed, karyotype analysis, FMR1 premutation testing, adrenal antibody testing, and pelvic ultrasonography may be indicated.
The use of hormonal medications, including oral contraceptives, can affect gonadotropin and estradiol values, so these tests should only be done in patients not taking these medications.
Antimüllerian hormone and inhibin B are being investigated as potential diagnostic markers for POI, but more research is needed. Inhibin B levels fluctuate significantly between cycles and are not reliable predictors of ovarian stimulation response.
Surrogate markers like regular menses, serial serum estradiol levels, and antral follicle count (via transvaginal ultrasonography) are variable and not predictive of future fertility or hormonal production in young women treated for cancer. Research on these markers is ongoing.
Treatment and Management: Addressing Hormonal Needs and Fertility Concerns
Treatment for adolescents with POI requires sensitivity to their physical and emotional needs, as the diagnosis can be difficult to process during this developmental stage.
The primary objective of treatment is to replace hormones that would normally be produced by the ovaries before menopause. This approach differs from menopausal hormone therapy, which focuses on symptom management.
Hormonal therapy aims to support bone, cardiovascular, and sexual health, going beyond mere symptom relief.
Young women with POI may require higher doses of estrogen than menopausal women to ensure adequate replacement and optimal bone health.
Estrogen therapy should be started gradually and increased slowly before introducing progesterone in girls with absent or incomplete breast development to prevent tubular breast formation.
Consultation with a specialist in growth, development, and hormonal therapy in children is recommended for those who have not started or completed puberty.
Once puberty is complete, ongoing hormonal therapy is necessary for long-term health.
Transdermal, oral, or occasionally transvaginal estradiol (100 micrograms daily) is recommended to mimic physiological levels.
Oral estradiol, while an option, carries a higher risk of thromboembolism than transdermal estradiol due to the first-pass effect on the liver.
Oral contraceptives are not recommended as first-line therapy because they contain higher estrogen doses than needed for hormonal therapy.
Cyclic progesterone (10-12 days per month) protects against endometrial hyperplasia and endometrial cancer, risks associated with unopposed estrogen.
Despite the diagnosis, fertility can persist, with a 5-10% chance of spontaneous pregnancy due to the occasional resumption of ovarian function.
Contraception discussions are essential unless pregnancy is desired.
Barrier methods or intrauterine devices are preferred over oral contraceptives.
Estrogen should be administered if non-estrogen contraception is chosen to maintain bone mineral density and prevent adverse effects of hypoestrogenemia.
A missed period necessitates a pregnancy test.
Associated Comorbidities: Understanding the Broader Health Implications
POI elevates the risk of various health issues, including bone loss, cardiovascular disease, and endocrine disorders.
Bone Loss:
Early loss of ovarian function impacts bone architecture during peak bone accrual.
Specific recommendations for dual-energy X-ray absorptiometry scanning in adolescents with estrogen deficiency are lacking. Some experts suggest annual monitoring during early to mid-puberty, followed by biennial monitoring in late adolescence. Others advise against routine scanning due to the low fracture risk and the potential for long-term treatment.
Long-term bisphosphonate use is not recommended in adolescents due to safety concerns and uncertain adverse effects. Further research is needed.
Cardiovascular Disease:
Early loss of endogenous estrogen increases the risk of cardiovascular mortality.
While specific screening regimens for adolescents are lacking, vigilant monitoring is crucial.
Routine visits should include counseling on tobacco avoidance, healthy diet, and exercise to promote cardiovascular health.
Blood pressure should be measured at least annually, and lipid levels should be checked every 5 years.
Patients with Turner syndrome face additional risks, including aortic aneurysm. Those without apparent cardiovascular pathology should undergo routine cardiac imaging every 5-10 years or focused imaging during transitions in care, before pregnancy, or with the onset of hypertension.
Despite the association between early ovarian function loss and cardiovascular mortality, there is no evidence of increased cardiovascular risks from hormone therapy in these patients.
Endocrine Disorders:
Approximately 20% of adults with idiopathic POI develop hypothyroidism, most commonly Hashimoto thyroiditis.
Thyrotropin levels and thyroid peroxidase antibodies should be checked after POI diagnosis.
While routine thyroid screening is not specifically recommended, testing every 1-2 years is reasonable given the high prevalence.
Patients with POI and adrenal autoimmunity have a 50% risk of adrenal insufficiency. Corticotropin stimulation testing is recommended annually for those with positive adrenal antibody results. Data on follow-up for those with negative results is limited.
Other associated conditions include diabetes mellitus, pernicious anemia, myasthenia gravis, rheumatoid arthritis, systemic lupus erythematosus, and dry eye syndrome. Testing should be guided by symptoms.
Antiovarian antibodies may be present but their specificity and usefulness for diagnosis have not been validated.
Patient Counseling and Support: Navigating the Emotional and Psychological Impact
Delivering a POI diagnosis to an adolescent and her family requires careful consideration of the potential emotional impact.
An in-person conversation in the office is the best way to convey the diagnosis and its implications for fertility, self-image, and the need for long-term hormonal therapy.
Adolescents may exhibit a range of emotions, from apathy and denial to remorse and sadness, which may differ from their parents' or guardians' reactions.
Informing parents separately can allow them time to process the information and offer their daughter the best support.
Healthcare providers must be sensitive to the diagnosis's nature and its cultural significance within the family unit.
The term "premature ovarian failure" can be distressing and should be avoided. "Insufficiency" is more appropriate and accurately reflects the potential for intermittent ovarian function.
Counseling should address the impact on future fertility and the risk of associated comorbidities.
Referral to a reproductive endocrinology and infertility specialist can provide more detailed information about reproductive treatments, such as in vitro fertilization with donor oocytes. This option offers hope for those with severely compromised fertility. However, it is not recommended for patients with Turner syndrome due to the risk of aortic rupture during pregnancy.
Psychological counseling should be offered to address potential emotional distress and impaired self-esteem.
Guidance on accessing reliable online resources can enhance patient care and provide support. The sources list the International Premature Ovarian Failure Association, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Fragile X Foundation as helpful resources.
Conclusion: A Comprehensive Approach to Care
A deep understanding of POI's physiological and psychological effects empowers healthcare providers to offer comprehensive care and support to young women facing this diagnosis. Regular evaluations, open communication, and appropriate referrals are crucial for addressing their unique needs and ensuring their long-term health and well-being.
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Infertility w/ PCOS (management)
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83
Influenza and pregnancy
Influenza and pregnancy
Obstetrics
Overview of Influenza in Pregnancy: Prevention and Treatment
This article, published by the American College of Obstetricians and Gynecologists (ACOG), outlines recommendations for preventing and treating influenza in pregnant individuals.
Recommendations for Influenza Vaccination in Pregnancy
The CDC and ACOG recommend an annual influenza vaccine for all adults and an inactivated or recombinant influenza vaccine as soon as it is available for those who are or will be pregnant during influenza season. The vaccine can be administered during any trimester.
Vaccination is encouraged by the end of October, but vaccination at any time during influenza season is beneficial.
Annual vaccination is recommended because circulating influenza strains change from season to season and immunity from a single dose wanes over the influenza season.
It is safe and effective to administer the influenza vaccine during the same visit as other inactivated or non-virus containing vaccines, such as Tdap, RSV, or COVID-19 vaccines.
Individuals should be vaccinated even if they were vaccinated during a previous pregnancy.
Vaccination during pregnancy protects both the pregnant individual and their newborn from influenza infection.
Postpartum vaccination is less optimal because it does not provide protection during pregnancy, which is a time of highest risk for severe illness, and the newborn will not receive the full benefit of passive protection from maternal antibodies.
Lactating individuals can safely receive the influenza vaccine if they did not receive it during pregnancy.
Safety and Effectiveness of the Influenza Vaccine During Pregnancy
Numerous studies, including clinical trials and observational studies, as well as data from safety-reporting systems, have consistently demonstrated the safety of influenza vaccination during pregnancy.
The efficacy of seasonal influenza vaccination in pregnant individuals is similar to its efficacy among the general adult population.
Although the influenza vaccine may be less effective than other adult vaccines, vaccination still offers the most significant protection against severe illness from influenza infection.
Four large-scale randomized controlled trials and numerous observational studies have demonstrated neonatal protection from maternal influenza vaccination.
Studies have also shown a reduction in influenza-related hospitalization among infants born to vaccinated women.
Importance of Clinician Recommendations for Vaccination
Studies consistently demonstrate that when recommendations for influenza vaccination during pregnancy come from the patient's obstetrician–gynecologist or other obstetric health care professional and the vaccine is available in the clinician’s office, the odds of vaccine acceptance and receipt are 5-fold to 50-fold higher.
Obstetrician–gynecologists and other obstetric health care professionals should confidently recommend influenza vaccination and counsel pregnant individuals about the benefits of influenza vaccination for themselves as well as the benefits of passive immunity for their newborns conferred by maternal immunization.
Mask Use During Pregnancy
Wearing a well-fitting respiratory mask is safe during pregnancy and may help prevent transmission of respiratory infections, particularly when community levels of circulating viruses are elevated.
Considerations for mask use include local public health guidance and recommendations, an individual's vulnerability to infection complications, and clinical and health care professional recommendations.
Pregnant individuals with suspected or confirmed respiratory illness should isolate or wear a mask to reduce exposure to others.
Respiratory Infection Assessment and Treatment During Pregnancy
Obstetrician–gynecologists and other obstetric health care professionals should consider both influenza and SARS-CoV-2 infection for pregnant individuals presenting with respiratory illness symptoms.
Symptoms of respiratory illness can include fever, cough, fatigue, headache, and body aches.
Initial triage and treatment by telemedicine are acceptable to reduce disease spread.
Pregnant individuals presenting with respiratory illness symptoms should be tested for both influenza and SARS-CoV-2 infection when testing is available.
Assessment should include questions to determine illness severity.
Pregnant individuals who cannot maintain oral fluid intake, show signs of dehydration, experience difficulty breathing or chest pain, or exhibit signs of obstetric complications are considered moderate or high risk and should be immediately referred to an emergency department.
Pregnant individuals without high-risk symptoms but with comorbidities, obstetric issues, or who are unable to care for themselves are considered moderate risk and should be seen as soon as possible in an ambulatory or triage setting.
Empiric antiviral treatment should be initiated as soon as possible, ideally within 48 hours of symptom onset, for all pregnant individuals with suspected influenza.
Oseltamivir is the preferred treatment, assuming sufficient supply and low prevalence of resistant viruses. Other options include zanamivir or peramivir. Baloxavir is not recommended for pregnant individuals due to a lack of safety and efficacy data.
Antiviral treatment should not be delayed while awaiting respiratory infection test results, and a patient’s vaccination status should not affect the decision to treat.
Paxlovid (nirmatrelvir and ritonavir) should be prescribed for pregnant patients who test positive for SARS-CoV-2 infection.
If co-infection with influenza and SARS-CoV-2 is suspected or confirmed, both oseltamivir and Paxlovid should be prescribed and can be taken together.
Postexposure Chemoprophylaxis for Influenza
Postexposure antiviral chemoprophylaxis can be considered for pregnant individuals and those up to 2 weeks postpartum (including after pregnancy loss) who have had close contact with infectious individuals.
The recommended chemoprophylaxis is oseltamivir 75 mg once daily for 7 days after the last known exposure.
Chemoprophylaxis should ideally be started within 48 hours of the most recent exposure.
Individuals receiving chemoprophylaxis should seek medical evaluation if they develop a febrile respiratory illness.
Early treatment may be considered for individuals with frequent exposures.
At-risk family members of patients with influenza should be referred to their health care professionals to consider antiviral chemoprophylaxis.
Addressing Disparities in Influenza Vaccination and Outcomes
Racial and ethnic minoritized groups experience higher rates of hospitalization and death from influenza and lower influenza vaccination rates compared with White adults.
These disparities are due to systemic racism, barriers to affordable health care, concerns about vaccine safety and side effects, and a higher prevalence of chronic medical conditions among individuals in racial and ethnic minoritized groups.
Obstetrician–gynecologists and other obstetric care professionals can help reduce disparities by strongly recommending influenza vaccination to all patients.
Other key strategies include using culturally responsive language and messages and partnering with community groups and trusted messengers.
**When discussing vaccines with an individual who expresses concerns, it is critical to: **
be aware of historical and current injustices perpetuated on communities of color
actively listen to and validate fears and concerns
address misinformation about the vaccine
be knowledgeable about vaccine access in underserved communities
For patients who decline vaccination, the discussion should be documented, and vaccination should be offered again at subsequent visits.
Conclusion
Influenza vaccination is a key component of obstetric care and is recommended for all pregnant individuals to prevent severe illness.
A conversation with and recommendation from a trusted health care professional plays a critical role in a patient’s decision to receive a vaccine.
Obstetrician–gynecologists should confidently counsel pregnant patients about the benefits and safety of influenza vaccination.
Timely assessment and treatment of respiratory virus infections is essential to improving outcomes for pregnant patients.
Obstetrician–gynecologists and other obstetric health care professionals can help reduce disparities in influenza vaccination rates and severe outcomes by strongly recommending influenza vaccination to all patients.
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Inherited Thrombophilias in Pregnancy
Inherited Thrombophilias in Pregnancy
Obstetrics
Thrombophilia Overview (2:27 - 4:50)
• Thrombophilia types: Antithrombin deficiency, Factor V Leiden mutation, prothrombin 20210A, Protein C and Protein S deficiencies.
• Evaluation: Know mutations, prevalence, and tests for diagnosing thrombophilias.
Detailed Thrombophilia Explanations (4:50 - 6:45)
• Risk multipliers for heterozygotes and homozygotes.
• In-depth look at Protein C, Protein S, antithrombin deficiency.
• Testing approaches: Qualitative/quantitative assays.
Antiphospholipid Antibody Syndrome (6:45 - 8:01)
• Prevalence and association with lupus.
• Diagnostic criteria and testing: lupus anticoagulant, beta-2 glycoprotein, anticardiolipin antibodies.
Thrombophilia Evaluation Indications (8:01 - 9:54)
• Scenarios where workup is necessary: family history, recurrent thrombosis, arterial thrombosis.
• Cases where evaluation is not needed: malignancy-related VTEs, HIT, etc.
85
Intraoperative complications
Intraoperative complications
Gynecology
86
Iso-immunization
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87
IUFD (intrauterine fetal demise)
IUFD (intrauterine fetal demise)
88
IUGR
IUGR
89
Labor management
Labor management
Obstetrics
Presentation Outline: First and Second Stage Labor Management
Introduction
This presentation will define labor and labor arrest.
It will provide recommendations for managing dystocia in the first and second stages of labor.
The most common indication for a primary cesarean delivery is labor dystocia.
The goal is to optimize labor management, minimize risks, and assist in assessing the need for cesarean delivery.
Labor and Labor Arrest Definitions
Normal Labor: The onset of labor is marked by regular, painful uterine contractions leading to cervical dilation and/or effacement.
The first stage is from labor onset to full cervical dilation (10 cm).
Latent Phase: Gradual cervical dilation beginning with regular contractions and ending when rapid change starts.
Active Phase: Rapid cervical change continuing until full dilation.
The second stage starts at full dilation and ends with the neonate's delivery.
The third stage encompasses the time between neonate and placenta delivery.
Friedman Compared With Zhang Labor Curves
Dr. Friedman's work in the 1950s provided an early graphical representation of labor progression, outlining latent, active, and deceleration phases.
The Consortium on Safe Labor research in 2010 (Zhang et al) refined this understanding.
Key differences include:
The latent phase is highly variable, and the transition to the active phase is now considered to be around 6 cm dilation (vs. 4 cm in the Friedman model).
The 95th percentile rate of active phase dilation is slower in contemporary data.
The Zhang data do not indicate a deceleration phase.
Labor curves can be influenced by factors like maternal obesity, hypertension, age, labor induction, gestational age, multiple gestations, fetal anomalies, fetal size, and sex.
Latent Labor
Duration varies greatly among individuals.
Progression can be slow (e.g., >6 hours from 4 cm to 5 cm dilation).
The 95th percentile for latent phase duration in nulliparous patients is estimated at 16 hours; anything longer may be considered prolonged.
There's no established definition of latent phase arrest.
Cesarean delivery is not advised for prolonged latent phase when maternal and fetal conditions are stable.
In induced labor cases with no latent phase progression, the term "failed induction of labor” is preferable.
Active Labor
6 cm dilation is recommended as the active phase start.
This is an average point, and the transition from latent to active labor can occur within a range of 4 cm to 6 cm.
Management protocols for active phase and arrest should not be applied before reaching at least 6 cm dilation.
Active Phase Protraction and Arrest Disorder
Protraction = slower than normal labor progress.
Arrest = labor stops progressing despite augmentation efforts.
Risk factors include:
Nulliparity, large for gestational age fetus
Maternal obesity, advanced maternal age
Fetal position (occiput posterior), cephalopelvic disproportion.
Both protraction and arrest elevate risks for adverse outcomes, including:
Cesarean delivery, chorioamnionitis
Postpartum hemorrhage, fetal acidemia
Neonatal intensive care unit (NICU) admission.
Active phase dilation is slower than in the past, with the 95th percentile ranging from 0.5 cm/hour to 1.3 cm/hour.
A protracted active phase can be defined as less than 1 cm dilation in 2 hours, though maternal cervical examination findings and parity need to be considered.
Oxytocin Augmentation
Studies support extending oxytocin augmentation duration for protraction/arrest.
A slow but progressive active phase with cervical change every 4 hours (and stable maternal/fetal status) is not a reason for cesarean delivery.
Extending the minimum oxytocin augmentation period from 2 to at least 4 hours can enable many women to deliver vaginally.
ACOG Recommendations for Active Phase Arrest
Based on prior research, ACOG suggests defining active phase arrest as no cervical dilation despite:
4 hours of adequate uterine activity (over 200 MVUs)
6 hours of inadequate uterine activity with oxytocin augmentation
This definition applies to patients at or beyond 6 cm dilation with ruptured membranes.
Impact of ACOG Guidelines
Mixed evidence on whether revised guidelines reduced cesarean rates.
Studies in Norway and Canada found no difference, while U.S. observational studies show varied results.
More research is needed to clarify the effects, especially on maternal/neonatal morbidity.
The guidelines provide a framework, but individualization is key.
Second Stage
Prolonged second stage is recommended to be defined as:
Over 3 hours of pushing for nulliparous individuals
Over 2 hours of pushing for multiparous individuals.
An individualized approach to diagnosing second-stage arrest is advised, considering progress, factors influencing vaginal delivery likelihood, risks/benefits of interventions, and patient preference.
Second-stage arrest may be identified earlier if there's no fetal rotation or descent despite sufficient contractions, pushing efforts, and time.
Factors affecting second stage length include:
Parity, delayed pushing, epidural use
Maternal BMI, birth weight, occiput posterior position
Fetal station at full dilation.
Second Stage Duration and Outcomes
Studies show a link between prolonged second stage and adverse maternal outcomes, but findings for neonatal outcomes are mixed.
As second stage length increases, the chance of vaginal delivery decreases, but remains fairly high even after exceeding typical time limits.
Longer pushing is associated with higher risks of:
Postpartum hemorrhage, cesarean/operative vaginal delivery
Third-/fourth-degree lacerations.
While there's a statistical association with increased neonatal morbidity, the absolute difference in risk is small.
ACOG Recommendations for Second Stage
To balance the chance of vaginal delivery with the relatively low risk of complications, the 2014 guidelines recommend extending the traditional second stage limits by 1 hour (to at least 3 hours for nulliparous, 2 hours for multiparous).
Individualized extensions are possible as long as fetal descent progress is observed and documented.
Considerations for Extending the Second Stage
A randomized trial showed a decreased cesarean rate with a 1-hour extension in nulliparous women with prolonged second stage.
However, a retrospective study found that this extension was linked to higher rates of:
Neonatal acidemia, NICU admission, third-/fourth-degree lacerations.
Shared decision-making is essential, discussing both the risks of prolonged second stage and the potential benefits of achieving a vaginal delivery.
Fetal Descent in Second Stage
Ongoing second stage management assumes fetal descent is occurring.
Most women are at station 0 or lower at full dilation; a station remaining at 0 despite pushing is uncommon.
Induced Labor
The latent phase is considerably longer in induced labor compared to spontaneous labor.
Many patients who are in latent phase for 12-18 hours with oxytocin and ruptured membranes will eventually deliver vaginally if induction continues.
If maternal and fetal status are good, cesareans for failed induction in the latent phase can often be avoided by extending oxytocin administration for at least 12-18 hours post-membrane rupture.
Individualized decisions to continue beyond 18 hours can be made based on clinical factors, patient wishes, and risk/benefit discussions.
Management of Dystocia in the First Stage of Labor
Epidural Analgesia
ACOG recommends neuraxial anesthesia be offered for pain relief in any labor stage.
It is a highly effective pain relief method.
A systematic review found that neither the type (epidural vs. combined spinal-epidural) nor timing of neuraxial analgesia influenced cesarean risk.
Active Management of Labor
Developed to reduce labor duration, this approach involves:
Standardized labor diagnosis criteria
Early amniotomy, oxytocin for protracted labor
One-to-one nursing care.
Research suggests that active management leads to shorter labor and lower maternal fever incidence, but does not significantly reduce cesareans.
Given the risks of prolonged labor, active management is generally preferred, but can be adjusted based on patient preference after discussing risks.
Amniotomy
ACOG recommends amniotomy for patients undergoing labor augmentation or induction to shorten labor duration.
Studies show it reduces labor time for nulliparous women without raising the risk of:
Cesarean delivery, maternal infection
Hemorrhage, pelvic floor trauma.
Neonatal outcomes are not consistently assessed, but no significant differences are found.
Cord prolapse risk does not appear to increase with amniotomy.
Early vs. Late Amniotomy
Research supports early amniotomy in induced labor, showing shorter delivery times.
A systematic review found a roughly 5-hour reduction in the induction-to-delivery interval with early amniotomy, without impacting cesarean risk.
High-quality evidence supports early amniotomy as an adjunct to reduce delivery time without increasing cesarean or other complication rates.
Oxytocin
ACOG recommends either low- or high-dose oxytocin strategies as reasonable ways to manage labor and reduce operative deliveries.
Early augmentation (when dystocia is identified) is linked to:
A slight increase in spontaneous vaginal delivery
Lower antibiotic use, but higher risk of tachysystole (without adverse neonatal effects).
Pain and discomfort levels may be higher with early oxytocin.
Discontinuing Oxytocin in Active Phase
Studies suggest that stopping oxytocin after active phase is reached could lower cesarean and tachysystole risks, but may slightly lengthen the active phase.
More research is needed due to study limitations.
High-Dose vs. Low-Dose Oxytocin
Research indicates no major maternal or neonatal outcome differences between regimens.
The AHRQ systematic review found that high-dose oxytocin may reduce cesareans in nulliparous women, but no impact on hemorrhage.
A maximum oxytocin dose has not been established.
Adjunctive Considerations for Labor Dystocia
Several non-pharmacological measures may help labor progress.
Research on these is often challenging due to variability in intervention type and timing.
Continuous Support in Labor
Having continuous support personnel or a one-on-one support person is highly effective for improving outcomes.
Benefits include increased likelihood of spontaneous vaginal birth, shorter labor, lower rates of:
Cesarean birth, instrumental vaginal birth
Intrapartum analgesia use, negative birth experiences
Neonatal low 5-minute Apgar scores.
Developing programs to integrate trained support personnel into labor care is recommended.
Peanut Ball
A birthing ball placed between the legs to encourage pelvic widening and fetal descent.
Research does not show significant differences in maternal outcomes, including labor duration, vaginal delivery, or cesarean rates.
Hydration
Routine continuous intravenous fluids may not be necessary in spontaneous labor.
Oral hydration is generally sufficient for meeting needs.
Increased intravenous fluid rates may lower cesarean incidence and shorten labor duration, but more research is needed on risks and benefits.
Position Changes and Ambulation
Upright positions (sitting, standing, kneeling) and/or ambulation may shorten the first stage of labor and reduce cesarean likelihood.
Frequent position changes for comfort and optimal fetal positioning are encouraged.
Ambulation is linked to shorter labor duration, but evidence is limited.
Other Interventions
Limited evidence for perineal massage, water immersion, or acupuncture/acupressure in affecting cesarean rates or labor duration.
Patient satisfaction with these interventions needs further study.
Propranolol
A beta-blocker studied for its potential to enhance uterine contractility.
Mixed research findings; some studies suggest it might reduce cesareans for labor induction, but others find no effect.
More data are needed; routine use is not recommended.
Cervical Examinations
Frequency of cervical exams is not well-established.
Perform as clinically needed to assess progress.
The number of cervical exams is not strongly linked to intrapartum fever.
Intrauterine Pressure Catheters
ACOG recommends using intrauterine pressure catheters in patients with ruptured membranes to assess contraction adequacy.
This applies to those with protracted active labor or when external monitoring is unreliable.
While research hasn't shown clear benefits in labor dystocia, catheters can be helpful when external monitoring is inadequate, enabling potential oxytocin augmentation.
200 MVUs has been the traditional cutoff for adequate contraction strength, but further research is needed on the impact of various pressure levels on outcomes.
Management of Dystocia in the Second Stage of Labor
Delayed or Immediate Pushing
ACOG recommends starting pushing when full cervical dilation is reached.
Delayed pushing in nulliparous women with regional anesthesia has been studied, with mixed results.
While some studies showed an increased spontaneous vaginal delivery rate, this was not consistent across high-quality research.
Delayed pushing is linked to longer second stage duration and may increase risks of postpartum hemorrhage, chorioamnionitis, and neonatal acidemia.
Immediate pushing is recommended based on current evidence.
Manual Rotation
Used to adjust fetal head position to a more favorable presentation (e.g., from occiput posterior/transverse to occiput anterior).
Studies suggest it might reduce cesarean and operative vaginal delivery rates, along with related morbidities, without raising maternal/neonatal risks.
Knowing fetal spine position may improve success rates.
The timing of rotation is debated; early, prophylactic rotation hasn't shown a change in vaginal delivery rates, but may shorten the second stage.
Management of Labor Arrest
Active Phase Arrest of Labor
ACOG recommends cesarean delivery for active phase arrest.
While vaginal delivery is possible in some cases, there's an elevated risk of maternal and neonatal complications associated with prolonged first stage labor, regardless of delivery method.
These include chorioamnionitis, postpartum hemorrhage, and neonatal sepsis.
If no other maternal/fetal indications for delivery exist, counseling should address intervention options and potential outcomes, incorporating patient preferences in the decision to continue labor or proceed to cesarean.
Second-Stage Arrest of Labor
ACOG suggests assessing for operative vaginal delivery before cesarean for second-stage arrest.
This should be a shared decision, factoring in:
Clinician skill and experience, hospital resources
Patient preferences and suitability for operative delivery.
Operative Vaginal Delivery
Can be a safe alternative to cesarean when performed by experienced clinicians.
Success rates are high, with less than 3% of attempted cases needing cesarean.
Outcomes data indicate lower maternal morbidity after successful operative vaginal delivery compared to unplanned cesarean, with no difference in serious neonatal morbidity.
Ultrasound guidance hasn't been proven to reduce morbidity.
Forceps and vacuum deliveries from mid-pelvic stations or with rotation require more skill and are less common.
Training in these techniques, especially forceps, is crucial.
Cesarean Delivery
Also a viable option for second-stage arrest, but carries higher maternal morbidity compared to cesarean in the first stage.
Endometritis and hysterotomy extensions are more frequent.
This information is important for surgical planning and resource allocation.
Conclusion
Labor dystocia is a significant contributor to cesarean deliveries.
Understanding the definitions of labor stages and arrest is fundamental for appropriate management.
Evidence-based recommendations provide a framework, but individualized care, shared decision-making, and considering patient preferences are vital for optimizing outcomes.
References:
The presentation should conclude by properly citing all sources used.].
90
Laparoscopy
Laparoscopy
91
Lichen Sclerosis
Lichen Sclerosis
look up management
92
Liver diseases
Liver diseases
93
Long-Acting Reversible Contraception Implants and Intrauterine Devices
Long-Acting Reversible Contraception Implants and Intrauterine Devices
Comprehensive Outline on LARC
I. Introduction
LARC refers to Long-Acting Reversible Contraception, encompassing intrauterine devices (IUDs) and contraceptive implants.
These methods are the most effective reversible contraceptive options available.
The primary advantage of LARC is the lack of ongoing patient effort required for long-term efficacy.
Fertility rapidly returns after LARC removal.
II. Types of LARC Available in the United States
A. Intrauterine Devices (IUDs)
1. Copper IUD:
Prevents fertilization by impacting sperm viability and function.
May also affect the oocyte and endometrium.
2. Levonorgestrel-Releasing Intrauterine Devices (LNG-IUDs):
Several types are available, all T-shaped with a levonorgestrel-containing sleeve on the stem.
Primary mechanism of action: Create a thick cervical mucus barrier, impeding sperm penetration.
Do not disrupt established pregnancies and are not abortifacients.
Four LNG-IUDs are currently marketed in the U.S.:
Mirena (LNG-20 IUD): 52 mg levonorgestrel, releasing 20 mcg/day, FDA-approved for up to 5 years.
Liletta (LNG-18.6 IUD): 52 mg levonorgestrel, releasing 18.6 mcg/day, FDA-approved for up to 4 years.
Kyleena (LNG-19.5 IUD): 19.5 mg levonorgestrel, releasing 17.5 mcg/day.
Skyla (LNG-13.5 IUD): 13.5 mg levonorgestrel, releasing 14 mcg/day.
B. Etonogestrel Single-Rod Contraceptive Implant:
Inserted subdermally in the non-dominant arm.
Releases etonogestrel, a progestin, to suppress ovulation and thicken cervical mucus.
Two types are available: Implanon and Nexplanon (contains barium for radiographic localization).
Both are FDA-approved for 3 years of use.
III. Advantages of LARC
A. Highly Effective:
Typical-use pregnancy rates for LARC are lower than for oral contraceptives.
The CHOICE Project demonstrated that women using oral contraceptives, the patch, or ring were 20 times more likely to experience an unintended pregnancy than LARC users in the first year.
B. Long-Term, Reversible Contraception:
Provide years of continuous protection without daily action.
Rapid return to fertility upon removal.
C. High Continuation and Satisfaction Rates:
LARC methods have higher continuation rates compared with short-acting methods.
Higher satisfaction rates than other contraceptive methods.
D. Cost-Effective:
A cost-effectiveness analysis found that LARC use becomes cost-neutral within 3 years when compared to short-acting methods from a public payer perspective.
E. Additional Benefits of LNG-IUDs:
Can reduce menstrual bleeding and pain.
May be used to treat heavy menstrual bleeding.
IV. Considerations for LARC Use
A. Bleeding Changes:
LARC methods can alter menstrual bleeding patterns.
Counseling should include information on expected changes and reassurance that these are typically not harmful.
Abnormal bleeding should be evaluated similarly to non-LARC users, considering pregnancy complications, infection, and malignancy.
B. Potential for Expulsion:
IUDs can be expelled, particularly in the first few months after insertion.
Higher expulsion rates have been reported in adolescents and nulliparous women.
C. Risk of Ectopic Pregnancy:
Although the overall risk of pregnancy with LARC is low, ectopic pregnancies can still occur.
The rate of ectopic pregnancy after sterilization is low but higher than in women using no contraception.
D. Regret and Counseling:
While uncommon, regret can occur, particularly with sterilization, especially in women under 30.
Thorough pre-procedure counseling is essential, emphasizing the permanence of sterilization and discussing all contraceptive options.
V. Eligibility and Insertion Timing
A. US MEC (U.S. Medical Eligibility Criteria for Contraceptive Use):
Provides evidence-based guidance for contraceptive use in various medical conditions.
Includes recommendations for LARC initiation and continuation.
LARC methods are safe and effective for most women, with few contraindications.
B. US SPR (U.S. Selected Practice Recommendations for Contraceptive Use):
Offers guidance on contraceptive practices, including initiation, timing, and follow-up.
C. Specific Insertion Scenarios:
Postabortion: Immediate insertion after induced or spontaneous abortion is safe and effective.
High continuation rates and lower repeat abortion rates compared to interval insertion.
Postpartum: Immediate postpartum insertion is a best practice to prevent rapid repeat and unintended pregnancy.
Prenatal counseling is recommended to discuss options and facilitate informed decision-making.
Emergency Contraception: The copper IUD is the most effective method of emergency contraception.
VI. Patient Counseling and Shared Decision-Making
A. Comprehensive Counseling:
Discuss all contraceptive options, including LARC methods, and their benefits and risks.
Emphasize the long-acting, reversible nature of LARC and the rapid return of fertility upon removal.
Address expected bleeding changes and potential side effects.
B. Shared Decision-Making:
Respect the patient's individual needs, preferences, and values.
Facilitate an informed and autonomous decision without coercion.
C. Adolescents:
Establish a trusting and confidential environment.
Address common misperceptions and concerns with sensitivity.
Consider potential barriers and special considerations for adolescents with disabilities or medical conditions.
VII. Conclusion
LARC methods are highly effective, safe, convenient, and cost-effective options for most women.
Comprehensive counseling and shared decision-making are crucial to ensure patient satisfaction and successful LARC use.
94
Lupus
Lupus
Obstetrics
Management of Lupus Patients During Pregnancy
The sources provide a comprehensive overview of managing systemic lupus erythematosus (SLE) in pregnant patients, focusing on pre-pregnancy counseling, antenatal care, and postpartum management. Here is a detailed summary of the recommendations:
Pre-pregnancy Counseling
Risk Stratification and Counseling:
It is crucial to stratify patients based on disease activity and potential risks. [1-3]
Women with SLE in remission or stable low disease activity can safely plan a pregnancy. [2]
Those with recently diagnosed or active SLE should postpone pregnancy until their condition improves, ideally achieving remission. [2]
Pregnancy is discouraged for women with severe organ impairment or damage, and alternatives like adoption or surrogacy should be explored. [2]
Counseling should address the potential impact of pregnancy on SLE (flares, organ damage) and the effects of SLE on pregnancy. [4]
Risks for the mother include preeclampsia and VTE, while risks for the fetus include miscarriage, IUGR, preterm birth, stillbirth, and NLS. [4]
Medication Review and Adjustment:
A thorough review of medications is essential, aiming to discontinue or adjust those potentially harmful during pregnancy. [5, 6]
The pre-pregnancy consultation should include gathering detailed information about the patient's medical history, disease activity, organ damage, medications, and serological profile. [7]
It is important to distinguish between antiphospholipid antibodies (aPL) and antiphospholipid syndrome (APS) as they have different implications for management. [8]
A diagnosis of APS requires specific laboratory and clinical criteria, and not all patients with aPL will develop APS. [8]
Patients should be advised to take low-dose aspirin (75 mg) from 12 weeks gestation throughout pregnancy to reduce preeclampsia risk. [5, 9]
European League Against Rheumatism (EULAR) and British Society for Rheumatology (BSR) guidelines provide evidence-based recommendations for medication use during pregnancy and lactation. [10]
Switching to pregnancy-compatible medications is crucial. [11]
Patients with moderate or severe disease activity should delay pregnancy until disease is controlled on pregnancy-compatible medications. [11]
Contraception:
Reliable contraception methods should be discussed with women advised to delay pregnancy. [6]
A study showed a significant proportion of women with SLE faced risks of unintended pregnancy, highlighting the importance of contraceptive counseling. [6]
When pregnancy is not desired, effective birth control options should be discussed. [12]
Antenatal Care
Multidisciplinary Care:
All pregnant women with SLE should receive care coordinated by an obstetrician and see a rheumatologist familiar with SLE in pregnancy. [13-15]
Those with active disease or high complication risk need regular input from both specialists and may benefit from management in a multidisciplinary clinic. [14]
A multidisciplinary team, including a maternal-fetal medicine specialist and, if necessary, a nephrologist and pediatric cardiologist, is recommended. [15]
Regular assessments during pregnancy are crucial to identify potential complications and allow for early intervention. [15]
Monitoring and Management:
Routine prenatal care should be provided, including blood pressure checks, SLE clinical assessments, and laboratory tests. [12]
Home blood pressure monitoring is also recommended. [16]
Disease activity should be monitored closely using validated tools (e.g., SLEDAI, BILAG) to assess disease activity. [16]
Laboratory assessments are necessary at least once per trimester to monitor medication toxicity and disease activity. [16]
Low-dose aspirin (81 mg/day) is recommended early in pregnancy to reduce preeclampsia risk. [16]
Anticoagulation with heparin is indicated for patients with OB-APS, and therapeutic doses are needed for those with T-APS. [16]
Fetal echocardiograms are necessary starting at week 16 through week 25 for mothers with positive anti-Ro/SSA or anti-La/SSB antibodies. [12]
Ultrasound evaluations are important to assess fetal growth and anatomy, placental insufficiency, and amniotic fluid levels. [12]
Managing Flares:
Pregnancy is considered a high-risk period for SLE flares, although research on flare frequency during pregnancy shows mixed results. [17]
Mild flares can be managed with acetaminophen, topical pain creams, or short-term NSAIDs (before 20 weeks gestation). [18]
For moderate to severe flares or when NSAIDs are contraindicated, pregnancy-compatible DMARDs should be added to hydroxychloroquine. [18]
Prednisone should be kept at the lowest effective dose due to its potential adverse effects on the mother and fetus. [18]
Distinguishing preeclampsia from a lupus flare is crucial, and certain laboratory tests can aid in differentiation, although none are 100% accurate. [19, 20]
Renal biopsy may be considered in uncertain clinical situations when a diagnosis of lupus nephritis would impact management decisions. [20]
Medications:
Hydroxychloroquine is generally safe and recommended during pregnancy, unless contraindicated. [21-24]
Studies suggest that hydroxychloroquine reduces flares, preeclampsia risk, and adverse pregnancy outcomes. [22, 25, 26]
Azathioprine, tacrolimus, and cyclosporine are considered compatible with pregnancy and lactation. [21, 27, 28]
Mycophenolate mofetil (MMF) and mycophenolic acid are contraindicated due to teratogenicity and pregnancy loss risks. [21, 29, 30]
Methotrexate, leflunomide, and cyclophosphamide are also contraindicated in pregnancy and lactation. [21, 30]
Biologics like rituximab, belimumab, and abatacept can be continued until conception and resumed during lactation. [21]
Glucocorticoids should be used at the lowest possible dose to manage flares due to potential adverse effects. [18, 21]
The safety of voclosporin during pregnancy and lactation is currently unknown, and avoidance is recommended. [27]
Postpartum Management
Monitoring and Follow-up:
The postpartum period carries an increased risk of flares and thrombosis. [31, 32]
Women with APS should continue anticoagulation for at least 6-12 weeks postpartum. [32, 33]
A multidisciplinary team member should review the woman before discharge, with a follow-up appointment scheduled for 4-6 weeks postpartum. [34]
Close monitoring for disease activity, blood pressure, and urine analysis is necessary. [34]
Postpartum depression should be considered as it can mimic neuropsychiatric lupus. [32]
Ongoing rheumatology follow-up and appropriate contraception are essential. [35, 36]
Medications and Breastfeeding:
Most medications used during pregnancy can be continued during lactation. [31]
Women taking long-term oral steroids might need dose adjustments in the postpartum period. [34]
NSAIDS, hydroxychloroquine, and corticosteroids are considered compatible with breastfeeding. [36]
Decisions about breastfeeding while on other medications should be made in consultation with healthcare providers, as data on safety during lactation may be limited. [36]
The sources emphasize the importance of individualized care plans, close monitoring, and a multidisciplinary approach for managing SLE in pregnancy. By adhering to these recommendations, healthcare professionals can help optimize maternal and fetal outcomes.
Laboratory Tests for Prenatal Visits in Women with SLE
The sources provide specific recommendations for laboratory tests to be performed at prenatal visits for women with SLE:
Baseline Tests (Ideally Pre-pregnancy and in Early Pregnancy)
Full Blood Count (FBC): This provides information on red blood cell count, white blood cell count, and platelet count, which can help assess for anemia, infection, or thrombocytopenia. [1, 2]
Urea and Electrolytes (U&E): This assesses kidney function and electrolyte balance. [1, 2]
Creatinine: A more specific marker of kidney function. Elevated creatinine levels could indicate impaired kidney function. [1, 2]
Liver Function Tests (LFTs): Evaluates liver function. Abnormal LFTs could suggest liver involvement or complications like preeclampsia. [1, 2]
Serological Profile: Includes tests for:
Anti-dsDNA antibodies: A specific marker for SLE and its activity. [1]
Anti-Ro/La antibodies: Associated with neonatal lupus. [1]
Antiphospholipid antibodies (aPL): To identify those at risk for thrombosis and pregnancy complications. [1]
Complement Levels (C3 and C4): Can be helpful in monitoring disease activity, but levels may be unreliable during pregnancy. [2-4]
Urinalysis: To detect proteinuria, hematuria, or other abnormalities that could suggest kidney involvement. [1, 2]
Proteinuria Quantification: If protein is detected on a dipstick urinalysis, a 24-hour urine collection or a protein-to-creatinine ratio (PCR) is recommended to quantify the amount of protein in the urine. [1, 5]
Additional Tests Based on Risk Factors and Symptoms
Organ-specific investigations: Additional tests, such as echocardiograms or lung function tests, might be necessary for women with a history of cardiac or lung involvement. [1]
Urinary Protein Quantification: Women with a history of lupus nephritis or those with proteinuria on a dipstick urinalysis should have a 24-hour urine collection or PCR to quantify proteinuria. [5-7]
Gestational Diabetes Screening: Women with a history of gestational diabetes or those taking steroids should be screened for gestational diabetes, ideally at 16 weeks and again at 26-28 weeks. [4, 6-8]
Disease Activity Markers: For women with severe or active SLE, repeating baseline blood tests (FBC, U&E, creatinine, LFTs, serological profile) every 4-8 weeks during pregnancy is recommended, with more frequent testing if symptoms suggest a flare or preeclampsia. [6, 9]
Angiogenic Factors: New biomarkers, such as placental growth factor, may be considered to help differentiate preeclampsia from lupus nephritis in challenging cases. [10]
Notes on Interpretation
Erythrocyte Sedimentation Rate (ESR) is not a reliable marker of disease activity during pregnancy. It is typically elevated due to increased fibrinogen production. [2-4]
C3 and C4 levels can rise in pregnancy due to increased liver production, making them less reliable indicators of lupus activity. It is important to assess relative changes in C3 and C4 levels rather than absolute values. A fall of ≥25% during pregnancy might suggest a flare. [2-4, 11]
These laboratory tests help monitor disease activity, identify potential complications, and guide management decisions during pregnancy for women with SLE. The frequency and specific tests ordered should be individualized based on the patient's medical history, disease activity, and risk factors. Close collaboration between the obstetrician and rheumatologist is crucial for optimal care.
95
Lynch Syndrome
Lynch Syndrome
Lynch Syndrome - Summary
Introduction
Definition: Lynch syndrome, formerly known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant cancer susceptibility syndrome caused by mutations in the DNA mismatch repair (MMR) genes. It predisposes individuals to several cancers, most notably colorectal, endometrial, and ovarian cancers.
Prevalence: Lynch syndrome accounts for 3-5% of uterine cancers and 8-13% of ovarian cancers. It is the most common hereditary cause of endometrial and colorectal cancer and the second most common hereditary cause of ovarian cancer.
Common Cancers:
Gastrointestinal Cancers: Colorectal, gastric, and small bowel cancers.
Gynecologic Cancers: Endometrial and ovarian cancers.
Other Cancers: Hepatobiliary, renal pelvis, ureter, and certain brain tumors, as well as sebaceous skin tumors.
Pathogenesis and Genetic Basis
Mismatch Repair System: Lynch syndrome is caused by mutations in the MMR genes (e.g., MLH1, MSH2, MSH6, and PMS2). These genes correct errors during DNA replication, and mutations lead to genomic instability, resulting in microsatellite instability (MSI).
Microsatellite Instability (MSI): A hallmark of Lynch syndrome, MSI occurs due to the inability to repair replication errors at microsatellite regions. MSI is detected in nearly all Lynch syndrome-associated tumors.
Risk Assessment and Diagnosis
Family History and Genetic Testing:
Genetic testing should be considered for individuals with a family history of Lynch-associated cancers, especially with diagnoses at younger ages.
Amsterdam Criteria and Bethesda Guidelines are used to identify candidates for genetic testing. These criteria include family history of colorectal or extracolonic cancers.
Tumor Testing:
Immunohistochemistry (IHC): Evaluates MMR protein expression in tumors. If a protein is missing, it indicates a potential gene mutation.
Microsatellite Instability Testing: Evaluates genomic instability by comparing tumor and normal tissue.
Cancer Risks for Lynch Syndrome Carriers
Colorectal Cancer: Lifetime risk of 18-61% by age 70, compared to 1.7% in the general population.
Endometrial Cancer: Lifetime risk of 16-61%, which can be as high as or exceed the risk of colorectal cancer in female carriers.
Ovarian Cancer: Risk of 5-10% by age 70. Other cancers (e.g., stomach, hepatobiliary, urinary tract) also have elevated risks.
Screening and Surveillance Recommendations
Colonoscopy: Every 1-2 years starting at age 20-25, or 2-5 years before the youngest cancer diagnosis in the family.
Endometrial Cancer:
Endometrial Biopsy: Every 1-2 years starting at age 30-35.
Menstrual Tracking: Any changes in bleeding patterns should be evaluated promptly.
Ovarian Cancer: There is no consensus on surveillance. Ovarian cancer screening is not effective in detecting early-stage disease.
Management and Risk Reduction Strategies
Prophylactic Surgery:
Hysterectomy and Bilateral Salpingo-Oophorectomy: A risk-reducing option for women with Lynch syndrome after childbearing is complete. This significantly reduces the risks of endometrial and ovarian cancers.
Chemoprevention:
Oral Contraceptives: May reduce the risk of endometrial cancer by up to 50%.
Aspirin: May reduce colorectal cancer risk if taken at a high dose for at least 2 years.
Genetic Counseling
Genetic Risk Assessment: Genetic testing and counseling are crucial for at-risk individuals and their family members. Counseling should include discussion of the potential outcomes of testing, options for surveillance, and the implications for family members.
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mAB
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97
Macrosomia
Macrosomia
Obstetrics
Macrosomia Outline
Definition: Macrosomia is a term that refers to excessive fetal growth beyond a certain birth weight, typically 4,000 g or 4,500 g, irrespective of gestational age. Establishing a universally accepted definition of macrosomia is challenging.
Alternative terminology: Large for gestational age (LGA) generally means a birth weight at or above the 90th percentile for a given gestational age.
Risk Factors:
Maternal factors:
Constitutional factors
Preexisting diabetes and gestational diabetes mellitus (GDM)
Maternal prepregnancy obesity
Excessive gestational weight gain
Abnormal fasting and postprandial glucose levels
Dyslipidemia
Prior macrosomic newborn (weight more than 4,000 g)
Postterm pregnancy
Maternal birth weight exceeding 8 lbs (approximately 3,600 g)
Multiparity and grand multiparity
Height in the 80th percentile or more
Fetal factors:
Male fetal sex
The interplay of these risk factors is complex and varies by prepregnancy body mass index (BMI), race, and ethnicity.
Maternal hyperglycemia:
Increases the risk of macrosomia.
Maternal glucose can cross the placenta and lead to fetal hyperglycemia.
Fetal hyperglycemia causes the release of insulin, insulin-like growth factors, and growth hormone in the fetus.
These hormones lead to increased fetal fat deposition and larger fetal size.
Relationship between maternal obesity and macrosomia:
Obese women are more likely than normal-weight women to have large newborns. [8–11, 17, 27]
Several issues confound this observation:
Obese women are more likely to have diabetes.
Excess weight gain during pregnancy is a risk factor for excessive fetal growth.
The risk of newborn macrosomia (more than 4,000 g) associated with excessive maternal weight gain is higher for obese women than for nonobese women. [9–12, 17]
Diagnosis:
An accurate diagnosis of macrosomia can only be made by weighing the newborn after birth.
Prenatal prediction of newborn birth weight is imprecise.
Ultrasonography:
Enables the direct measurement of various fetal body parts.
Accuracy in predicting macrosomia is poor.
A meta-analysis of 29 studies found a sensitivity of 56% and specificity of 92% for predicting birth weight more than 4,000 g.
Accuracy decreases with increasing fetal weight beyond 4,000 g.
An ultrasound-estimated fetal weight of more than 4,500 g accurately predicts birth weight more than 4,500 g in only 33–44% of cases. [35–40]
Physical examination:
Studies comparing the accuracy of ultrasonography with that of physical examination for the detection of macrosomia have had inconsistent findings, and none have shown that ultrasonography is superior to physical examination in a clinically meaningful way.
Maternal estimation:
Parous women appear to be able to predict the weight of their newborns as well as clinicians who use ultrasonography or clinical palpation maneuvers.
Risks Associated With Macrosomia:
Maternal morbidity:
Increased risk of cesarean birth.
Studies show that with birth weights more than 4,500 g, the risk of cesarean birth for women attempting a vaginal delivery is at least double that of controls. [2–4, 52, 53]
Labor protraction and arrest disorders are more frequent with macrosomia.
Almost all of the increased risk of cesarean birth is attributed to labor abnormalities.
Increased risks of postpartum hemorrhage, chorioamnionitis, and significant vaginal lacerations.
Fetal morbidity and mortality:
Increased risk of shoulder dystocia.
Increased risk of brachial plexus palsy.
Increased risk of clavicle fracture.
Increased risks of depressed 5-minute Apgar scores, hypoglycemia, respiratory problems, polycythemia, meconium aspiration, and increased rates of admission and prolonged admission (more than 3 days) to a neonatal intensive care unit.
Increased risk of becoming overweight and obese later in life.
Interventions:
Exercise during pregnancy
Low glycemic diet in women with GDM
Prepregnancy bariatric surgery in women with class 2 or class 3 obesity [44, 45, 114–117]
The sources do not contain information on the neuroprotective effects of magnesium sulfate on newborns with meconium-stained amniotic fluid.
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Magnesium sulfate for fetal neuroprotection
Magnesium sulfate for fetal neuroprotection
Magnesium Sulfate for Fetal Neuroprotection
Magnesium sulfate is given to pregnant women who are at risk of delivering before 32 weeks of gestation to protect the fetus's brain.
Magnesium sulfate for fetal neuroprotection is administered when delivery is anticipated before 32 weeks of gestation.
While no individual studies showed that magnesium sulfate improved primary outcomes, a meta-analysis of several studies concluded that prenatal magnesium sulfate reduces the risk of cerebral palsy.
Magnesium sulfate administered for neuroprotection does not appear to prolong pregnancy.
Although minor maternal complications were more common when women received magnesium sulfate, there were no increases in serious complications like cardiac arrest, respiratory failure, or death.
If magnesium sulfate is administered for fetal neuroprotection, specific guidelines should be developed regarding inclusion criteria, treatment regimens, concurrent tocolysis, and monitoring. These guidelines should be in accordance with one of the larger trials.
Examples of dosage regimens from larger trials:
6g load, up to 12 hours of treatment; 2g/hour treatment resumed when delivery is imminent
4g intravenous bolus over 30 minutes, then 1g/hour until delivery
6g load, then 2g/hour for 12 hours
Magnesium sulfate may be considered for secondary treatment of persistent headache in pregnancy. In nonpregnant adults, intravenous magnesium sulfate (1-2 g infused over 15–20 minutes) may be effective for migraine with aura.
Intravenous magnesium sulfate for headache in pregnancy is associated with:
Hot flashes
Maternal and fetal hypotonia
Respiratory depression
Cardiac depression
Increased perinatal mortality with infusion rates over 2g/hour
Intravenous magnesium sulfate is contraindicated with:
Myasthenia gravis
Hypocalcemia
Moderate to severe renal failure
Cardiac ischemia
Heart block
Myocarditis
Oral magnesium may be a reasonable option for the prevention of headaches in pregnancy. However, a Cochrane Review noted that oral magnesium increased the risk of neonatal death (RR 2.21; 95% CI 1.02–4.75). This finding should be interpreted with caution because it was primarily driven by one study in which the supplemented group had more pregnancies affected by congenital anomalies.
The sources do not mention the neuroprotective effects of magnesium sulfate on newborns with meconium-stained amniotic fluid.
99
Management of Alloimmunization During Pregnancy
Management of Alloimmunization During Pregnancy
Obstetrics
Comprehensive Outline Regarding Alloimmunization in Pregnancy
I. Introduction
Alloimmunization occurs when a pregnant woman develops antibodies against fetal blood group antigens inherited from the father but not possessed by the mother.
This immune reaction can occur due to antepartum or intrapartum fetal-maternal bleeding or blood product transfusion.
Maternal antibodies can cross the placenta and lead to varying degrees of hemolytic disease in the fetus and neonate.
Rh D alloimmunization, specifically incompatibility regarding the D antigen, is the most common cause of significant hemolytic disease in the fetus and newborn.
II. Causes of Alloimmunization
Alloimmunization is triggered by the entry of a sufficient volume of fetal red blood cells carrying the incompatible antigen into the mother's circulation.
The minimum volume required for alloimmunization varies among individuals and depends on factors like the antigenicity of the fetal red blood cells and the mother's immune responsiveness.
Potential sensitizing events include:
Delivery (the most common cause, occurring in 15-50% of births)
Cesarean delivery, multifetal gestation, placenta previa, abruptio placentae, manual removal of the placenta, and intrauterine manipulation
Miscarriage, both spontaneous and induced
Ectopic pregnancy
Threatened abortion
Invasive procedures: chorionic villus sampling, amniocentesis, external cephalic version
III. Rh D Alloimmunization
A. Background
Nomenclature: Rh D refers to a specific red blood cell antigen.
Individuals carrying the Rh D antigen are Rh D positive, while those lacking it are Rh D negative.
The frequency of Rh D negativity varies among ethnicities, being most common in individuals of European descent (15-17%).
Rh D alloimmunization has historically been a significant cause of perinatal morbidity and mortality, especially in regions without effective prophylaxis programs.
B. Prevention
Anti-D immune globulin (RhIG) is a highly effective measure for preventing Rh D alloimmunization.
It is extracted from plasma donated by individuals with high titers of anti-D antibodies.
RhIG works by binding to and clearing fetal Rh D-positive red blood cells that have entered the maternal circulation, thus preventing maternal antibody formation.
Routine antenatal administration of RhIG at 28 weeks of gestation, followed by a postpartum dose if the infant is Rh D positive, has dramatically reduced the incidence of Rh D alloimmunization in developed countries.
The current standard dose is 300 micrograms, which is effective for exposures up to 30 mL of fetal whole blood or 15 mL of fetal red blood cells.
RhIG is also recommended for Rh D-negative women after any potential sensitizing event (see Section II).
The dosage may vary depending on the event and the gestational age.
Potential shortages of RhIG have been a concern in the past due to the limited donor pool.
However, national guidelines still recommend routine RhIG administration in indicated situations.
Research into alternative sources, such as recombinant RhIG, is ongoing.
Cost-effectiveness analysis generally supports the routine use of RhIG prophylaxis programs.
C. Management of Rh D Alloimmunization
If a woman is found to be Rh D sensitized, RhIG is not beneficial.
Management focuses on monitoring the fetus for signs of hemolytic disease and intervening when necessary.
IV. Other Blood Group Incompatibilities
While Rh D incompatibility is the most common and serious, alloimmunization can also occur due to other blood group antigens.
Kell alloimmunization is of particular concern as it can lead to severe fetal anemia and may not be reliably predicted by maternal antibody titers or amniotic fluid bilirubin levels.
Management of non-Rh D alloimmunization generally follows a similar approach to Rh D alloimmunization, with adjustments made for specific antigen characteristics and the availability of diagnostic tools.
V. Conclusion
Advances in prevention strategies, particularly the use of RhIG, have significantly reduced the incidence of Rh D alloimmunization and associated hemolytic disease of the newborn.
Continued adherence to recommended guidelines and appropriate management of alloimmunized pregnancies are crucial for ensuring optimal perinatal outcomes.
Ongoing research and development of novel therapies, such as recombinant RhIG and noninvasive fetal Rh D typing, hold promise for further improving the care of women at risk of alloimmunization.
Managing Alloimmunization During Pregnancy
I. Paternal Testing
When a pregnant woman is alloimmunized, the first step is to determine the paternal erythrocyte antigen status.
If the father is negative for the antigen in question, and it is certain that he is the biological father, then further assessment and intervention are unnecessary.
If the father is Rh positive, it is important to determine if he is homozygous for the D antigen (meaning all of his children will be Rh positive) or heterozygous (meaning there is a 50% chance each pregnancy will result in a Rh-negative fetus not at risk of anemia).
There is a DNA-based test commercially available that can be used to make this determination, and can also be used to identify a number of minor antigens (C, c, E, and e).
II. Fetal Genotype and Anemia Assessment
If the father is heterozygous, or if the paternal genotype is unknown, the fetal antigen type should be assessed using polymerase chain reaction (PCR) on uncultured amniocytes in 2 mL of amniotic fluid obtained via amniocentesis.
Chorionic villus biopsy is not recommended as a method to determine fetal blood type, because it may increase the risk of fetomaternal hemorrhage, which could worsen the alloimmunization.
If the fetus tests negative for the erythrocyte antigen in question, further testing may not be warranted. However, because the false-negative rate for PCR typing is 1-3%, periodic noninvasive assessment may be warranted.
Fetal D can also be detected with greater than 99% accuracy in the second trimester using molecular analysis of maternal plasma or serum. This is possible because of high concentrations of fetal DNA found in maternal plasma.
It is important to note, however, that this is not a widely used clinical tool.
Middle cerebral artery Doppler testing can be used to noninvasively assess the degree of fetal anemia, and recent advances in Doppler technology have made it possible to assess the degree of fetal anemia noninvasively.
Doppler measurements of the peak systolic velocity in the fetal middle cerebral artery can predict moderate or severe anemia with 100% sensitivity when values are above 1.5 times the median for gestational age.
Correct technique is critical when using Doppler to determine peak systolic velocity in the fetal middle cerebral artery, and should only be used by those with adequate training and clinical experience.
This test does have some limitations, including a higher false-positive rate after 34-35 weeks of gestation.
III. Non-D Antigen Alloimmunization
Management of a pregnant patient who has antibodies to clinically significant minor antigens is generally similar to the care of Rh D-alloimmunized pregnant women.
One notable exception is Kell alloimmunization, which is less predictable than Rh D alloimmunization and often results in more severe fetal anemia.
Experience suggests that maternal Kell antibody titers and amniotic fluid bilirubin measurements are not as predictive of the degree of fetal anemia as they are in Rh D sensitization.
While amniotic fluid bilirubin measurements may be misleading in cases of Kell alloimmunization, Doppler measurements appear to be accurate in predicting severe fetal anemia.
IV. Delivery
Delivery timing for infants of alloimmunized patients is controversial.
Standard treatment is to prolong the pregnancy until the fetus reaches a gestational age necessary for survival.
If the history and antenatal studies indicate only mild fetal hemolysis, delivery by induction of labor at 37-38 weeks of gestation is reasonable.
Induction may be considered earlier if fetal pulmonary maturity is documented by amniocentesis.
With severely sensitized pregnancies that require multiple invasive procedures, the risks of continued cord blood sampling and transfusions must be weighed against the neonatal risks associated with early delivery.
Given that the overall neonatal survival rate after 32 weeks of gestation in most neonatal intensive care nurseries is greater than 95%, it is prudent to time procedures so that the last transfusion is performed at 30–32 weeks of gestation, with delivery at 32–34 weeks of gestation after maternal steroid administration to enhance fetal pulmonary maturity.
Some authors recommend intrauterine transfusion up to 36 weeks of gestation, when intravascular transfusion is feasible, in order to limit neonatal morbidity. Delivery can then be accomplished between 37 and 38 weeks of gestation.
Middle Cerebral Artery Doppler Testing and Fetal Anemia
Middle cerebral artery (MCA) Doppler testing is a noninvasive method of assessing the degree of fetal anemia, which can be caused by red cell alloimmunization. Advances in Doppler technology have allowed for the development of this technique. Doppler ultrasound is used to measure the peak systolic velocity in the fetal MCA. In a study of 111 fetuses at risk for fetal anemia due to red cell alloimmunization, MCA Doppler was able to predict moderate or severe anemia when peak systolic velocity values were above 1.5 times the median for gestational age. This study found MCA Doppler had a sensitivity of 100% and a false-positive rate of 12%.
According to the sources, MCA Doppler is an appropriate, non-invasive means to monitor pregnancies complicated by red cell alloimmunization. However, for accurate results, correct technique is critical. Only practitioners with adequate training and clinical experience in using Doppler to measure peak systolic velocity in the fetal MCA should perform this procedure.
There are some limitations to MCA Doppler testing.
Studies have suggested that the false-positive rate is higher after 34–35 weeks of gestation.
It is important to use correct technique, and practitioners should be specifically trained to perform Doppler for measurement of peak systolic velocity in the fetal MCA.
MCA Doppler testing may be particularly useful in cases of Kell alloimmunization, where maternal Kell antibody titers and amniotic fluid bilirubin measurements are not as predictive of the degree of fetal anemia. Studies have shown that Doppler measurements appear to be accurate in predicting severe fetal anemia in these pregnancies.
Studies have also shown a good correlation between MCA peak systolic velocity and hemoglobin in fetuses who have had two prior transfusions. This finding has broadened the clinical applicability of MCA Doppler.
100
Management of Genital Herpes in Pregnancy
Management of Genital Herpes in Pregnancy
Obstetrics
Genital Herpes in Pregnancy: A Comprehensive Outline
Introduction
Genital herpes simplex virus (HSV) infection is a common sexually transmitted infection that poses risks to both the pregnant individual and the newborn.
The prevalence of HSV-2 infection in females aged 14-49 is 15.9%, with an even higher prevalence of genital herpes due to the increasing role of HSV-1 in genital infections.
This outline examines the diagnosis, management, and implications of genital herpes during pregnancy.
Etiology and Transmission
HSV is a double-stranded DNA virus, classified into HSV-1 and HSV-2 based on their glycoproteins.
Traditionally, HSV-1 was associated with oral infections (cold sores) and HSV-2 with genital infections, but HSV-1 is increasingly causing genital infections.
HSV is transmitted through direct contact with infected mucosa or abraded skin.
The incubation period ranges from 2 to 12 days, with viral replication in the skin causing characteristic lesions.
After initial infection, HSV establishes latency in sensory ganglia, with the potential for reactivation and recurrent outbreaks.
Diagnosis
Suspected genital herpes infections in pregnancy should be confirmed using type-specific laboratory tests, but repeat testing is not necessary for those with a known history of genital HSV.
There are two main types of tests for HSV infection:
Viral Detection Techniques:
Viral culture: While considered the gold standard, it has low sensitivity, especially for recurrent lesions.
Polymerase chain reaction (PCR): Detects viral DNA and is more sensitive than viral culture.
Antibody Detection Techniques:
Serologic tests: These tests detect antibodies to HSV-1 and HSV-2, which develop within weeks after infection and persist indefinitely.
Type-specific serologic assays: Distinguish between HSV-1 and HSV-2 antibodies and can be helpful in patients without active lesions or with negative viral detection tests.
Distinguishing Primary from Non-Primary Infection
Clinically distinguishing between primary and non-primary first-episode HSV infection is not possible.
Laboratory confirmation is crucial:
Primary infection: Characterized by positive viral detection and negative serologic test results, or evidence of seroconversion.
Non-primary first-episode infection: Diagnosed when one viral type is detected in lesions, but the individual has antibodies to the other viral type, indicating prior infection with the other type.
Screening During Pregnancy
Routine screening for genital herpes in pregnancy is not currently recommended due to the lack of evidence demonstrating cost-effectiveness.
Factors influencing this recommendation include:
The high cost of screening and counseling.
Variable effectiveness of antiviral therapy.
The uncertainty of asymptomatic shedding at delivery in women diagnosed only through screening.
The low likelihood of neonatal herpes with vaginal delivery.
Antiviral Treatment in Pregnancy
Three oral antiviral medications are commonly used for HSV infections:
Acyclovir: The most studied antiviral in pregnancy, with a good safety profile.
Valacyclovir: A prodrug of acyclovir with increased bioavailability and potentially better patient adherence.
Famciclovir: No published data on its use in pregnancy.
Topical antiviral therapy is not beneficial for genital herpes.
Antiviral treatment during pregnancy aims to:
Reduce the duration and severity of symptoms.
Decrease the duration of viral shedding.
Treatment Regimens
Primary or Non-primary First-Episode Outbreak:
Oral antiviral therapy is administered to alleviate symptoms and reduce shedding.
Suppressive therapy, starting at 36 weeks of gestation, is offered to reduce the risk of recurrence at delivery.
Recurrent Outbreak:
Oral antiviral therapy is administered to manage symptoms and shedding.
Suppressive therapy is offered starting at or beyond 36 weeks of gestation to reduce the risk of recurrence at delivery.
Dosage:
Dosages for suppressive therapy in pregnancy are higher than those for non-pregnant individuals due to enhanced renal clearance.
Management of Labor and Delivery
Cesarean Delivery:
Indicated for women with active genital lesions or prodromal symptoms at the time of labor, regardless of whether the infection is a primary or recurrent episode.
May be offered to women with a primary or non-primary first-episode genital HSV infection during the third trimester, even without active lesions, due to the potential for prolonged viral shedding.
Not routinely recommended for women with a history of HSV but without active lesions or prodromal symptoms.
Nongenital Lesions:
Cesarean delivery is not recommended for women with HSV lesions on areas like the back, thigh, or buttock.
These lesions can be covered with occlusive dressings, and vaginal delivery is appropriate.
Ruptured Membranes:
Cesarean delivery should be performed as soon as possible for women with active lesions or prodromal symptoms and ruptured membranes at term.
Preterm Prelabor Rupture of Membranes (PPROM):
In cases of PPROM and active genital HSV lesions, the decision between expectant management and delivery should weigh the risks of prematurity against the risk of neonatal HSV.
No consensus exists on the gestational age at which prematurity risks outweigh those of HSV.
Antiviral treatment is recommended if expectant management is chosen.
Other Considerations
Invasive Procedures:
Transabdominal procedures (chorionic villus sampling, amniocentesis) can be performed even with active genital HSV lesions.
Transcervical procedures should be delayed until lesions have resolved.
Breastfeeding:
Breastfeeding is not contraindicated unless there is an active lesion on the breast.
Women with active HSV lesions should practice meticulous hand hygiene to prevent postnatal transmission.
Valacyclovir and Acyclovir in Breastfeeding:
Valacyclovir appears to be safe during breastfeeding.
While acyclovir is present in breast milk, the amount is significantly lower than therapeutic doses for neonates.
Conclusion
Managing genital herpes in pregnancy requires a careful assessment of the individual's infection history, clinical presentation, and gestational age to minimize risks to both the mother and the newborn.
Antiviral therapy plays a crucial role in managing outbreaks and suppressing viral shedding, and cesarean delivery is recommended in specific situations to prevent neonatal transmission.
Open communication and patient education are essential to ensure informed decision-making and optimal outcomes.
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Mastitis
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102
Meconium Stained Fluids
Meconium Stained Fluids
Obstetrics
Meconium-Stained Amniotic Fluid: An Outline
The sources primarily focus on guidelines for neonatal resuscitation in the presence of meconium-stained amniotic fluid. They emphasize a shift in practice, moving away from routine intrapartum suctioning.
Understanding Meconium-Stained Amniotic Fluid
Meconium is the first stool of a newborn infant.
Meconium-stained amniotic fluid occurs when meconium is released into the amniotic fluid before birth.
Historical Management and 2005 Guidelines
Before 2005, routine suctioning of the oropharynx and nasopharynx was performed on newborns with meconium-stained amniotic fluid after head delivery but before shoulder delivery (intrapartum suctioning).
The 2005 guidelines from the American Academy of Pediatrics and the American Heart Association challenged this practice.
Routine intrapartum suctioning was deemed unnecessary for vigorous newborns as it didn't prevent or change the course of meconium aspiration syndrome.
However, intubation and tracheal suctioning were recommended for nonvigorous newborns to remove meconium below the glottis.
Updated 2015 Guidelines and Rationale
The 2015 guidelines further revised the approach to meconium-stained amniotic fluid.
Routine intubation and tracheal suctioning are no longer recommended, even for nonvigorous newborns.
This change stems from a focus on minimizing potential harm from interventions (like delays in ventilation or unnecessary procedures) rather than the uncertain benefits of routine tracheal suctioning.
For vigorous infants with good respiratory effort and muscle tone, initial newborn care can be provided with the mother.
Gentle clearing of the mouth and nose with a bulb syringe may be used if needed.
Nonvigorous newborns should receive initial resuscitation steps under a radiant warmer, with interventions tailored to their specific needs.
Intubation and suctioning may be necessary if the airway is obstructed.
Current Recommendations
The American College of Obstetricians and Gynecologists advises against routine intrapartum suctioning for infants with meconium-stained amniotic fluid, regardless of their vigor.
However, the presence of meconium-stained amniotic fluid necessitates:
Notification and availability of a qualified team skilled in neonatal resuscitation, including endotracheal intubation.
Resuscitation protocols for infants with meconium-stained amniotic fluid should mirror those for infants with clear fluid.
Key Takeaways
The management of newborns with meconium-stained amniotic fluid has evolved significantly, moving away from routine intervention towards a more individualized approach.
Emphasis is placed on minimizing harm from unnecessary procedures while ensuring prompt intervention for airway obstruction or respiratory distress.
The presence of meconium-stained amniotic fluid calls for preparedness, with a skilled resuscitation team readily available.
103
Medical management of fibroids
Uterine leiomyoma, Medical management of fibroids
Gynecology
Management of Symptomatic Uterine Leiomyomas (Fibroids)
This outline draws heavily on the ACOG Practice Bulletin No. 228, which offers comprehensive guidance on managing symptomatic uterine leiomyomas.
Background
Definition: Uterine leiomyomas, commonly known as fibroids, are benign tumors arising from the smooth muscle cells and fibroblasts of the uterus. Their size and location within the uterus are variable.
Epidemiology: Fibroids are incredibly common, with an estimated occurrence in up to 70% of women by menopause. However, the majority are asymptomatic and remain undiagnosed.
Symptoms: The most common symptoms include:
Abnormal Uterine Bleeding (AUB-L): Prolonged or heavy menstrual bleeding, potentially leading to anemia.
Bulk Symptoms: Pelvic pressure, urinary frequency, and constipation resulting from the size of the fibroids.
Diagnosis
Clinical Evaluation: Begins with a detailed medical history and a pelvic and abdominal examination.
Imaging Studies:
Transvaginal Ultrasound: An initial screening tool to identify fibroids.
Sonohysterography: Helps to differentiate between different types of fibroids based on their submucosal component.
Hysteroscopy: Visualizes the uterine cavity and helps distinguish between fibroid types with varying degrees of endometrial contact.
Magnetic Resonance Imaging (MRI): Useful for surgical planning, assessing fibroid vascularity and degeneration, and distinguishing between fibroid types with intramural components.
Differential Diagnosis: It's crucial to rule out other conditions that can cause similar symptoms, including other causes of AUB and pelvic masses. The possibility of a uterine sarcoma must also be considered.
Treatment Options
The ACOG Practice Bulletin emphasizes that the ideal treatment for symptomatic fibroids is individualized and takes into account factors like symptom severity, desire for future fertility, patient preferences, and the availability of resources.
Expectant Management
Appropriate for: Asymptomatic patients or those who choose to avoid intervention.
Considerations: Studies suggest that bleeding patterns, hemoglobin levels, and fibroid size generally remain stable in the short term (up to a year).
Counseling: Patients should be informed about the potential for symptom progression and the need for follow-up if symptoms worsen or if pregnancy is desired.
Medical Management
Focus: Primarily targets bleeding symptoms but some medications can also shrink fibroids.
Options:
GnRH Antagonists with Hormonal Add-Back Therapy: Can be considered for AUB-L for up to 2 years. Elagolix is an example.
Levonorgestrel-Releasing Intrauterine Device (LNG-IUD): Effective for reducing bleeding.
Contraceptive Steroids: May improve bleeding patterns.
Tranexamic Acid: Reduces menstrual blood loss.
GnRH Agonists: Induce temporary menopause, reducing bleeding and shrinking fibroids. Used as a short-term bridge to other treatments.
Selective Progesterone Receptor Modulators: Reduce bleeding and fibroid size.
Procedural Interventions
Uterine Artery Embolization (UAE):
Recommended for: Patients who want to preserve their uterus but are informed about the limited data on reproductive outcomes.
Procedure: Embolic agents are injected into the uterine arteries to cut off blood supply to the fibroids, causing them to shrink.
Benefits: Significant reduction in fibroid and uterine volume, improvement in bleeding symptoms, high patient satisfaction.
Risks: Major complications are uncommon but can include infection, postembolization syndrome, and potential impact on ovarian reserve.
Radiofrequency Ablation (RFA):
Considered for: Patients desiring uterine preservation who are informed about limited reproductive outcome data.
Procedure: Uses radiofrequency energy to destroy targeted fibroids.
Benefits: Effective in reducing fibroid volume and improving quality of life.
Risks: Limited data on long-term complications and effects on fertility.
Endometrial Ablation:
Limited Evidence: Some data suggests improvement in AUB-L but not enough to make a strong recommendation.
Surgical Management
Myomectomy:
Recommended for: Patients who wish to retain their uterus, particularly if they desire future fertility.
Approaches: Minimally invasive techniques (laparoscopic or robot-assisted) are preferred when feasible.
Considerations: The choice of surgical approach depends on several factors, including fibroid size, location, and number, surgeon experience, and patient preference.
Hysterectomy:
Recommended for: Definitive treatment for patients who do not desire future childbearing or wish to keep their uterus. Patients should be informed about long-term health risks.
Approaches: Minimally invasive approaches, particularly vaginal hysterectomy, are preferred when feasible.
Benefits: Resolution of AUB-L and bulk symptoms, high patient satisfaction.
Risks: Surgical risks associated with any major surgery, including bleeding, infection, and potential long-term effects of removing the uterus and ovaries.
Shared Decision-Making
Crucial Aspect of Care: Treatment decisions for fibroids should be made collaboratively between the patient and healthcare provider.
Factors to Consider: Patient preferences, symptom severity, desire for future fertility, risks and benefits of each treatment option, and the individual patient's medical history.
Conclusion
Management of symptomatic fibroids requires a thoughtful and individualized approach. The ACOG Practice Bulletin provides evidence-based guidance to help clinicians navigate the available options and make informed treatment decisions in partnership with their patients.
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Migraine
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105
Multiple gestations
Multiple gestations
Obstetrics
Approach to Twins
Talk about what is common to all twin pregnancies vs the unique type of twin we are discussing
Overview of Twin Pregnancies
The incidence of twin pregnancies in the United States has increased dramatically in recent decades, likely due to the trend toward older maternal age at conception and the increased use of assisted reproductive technology (ART).
However, the rate of twin births has declined slightly since 2014.
Twin pregnancies carry an elevated risk of various complications for both the mother and infants.
Understanding the unique characteristics of twin pregnancies, such as chorionicity and amnionicity, is crucial for effective management and improved outcomes.
Types of Twin Pregnancies
Chorionicity: This refers to the number of placentas the twins share.
Dichorionic: Each twin has its own placenta.
Monochorionic: The twins share one placenta.
Amnionicity: This refers to the number of amniotic sacs the twins share.
Diamniotic: Each twin has its own amniotic sac.
Monoamniotic: The twins share one amniotic sac.
Risks and Complications
Fetal and Infant Morbidity and Mortality
Twin pregnancies have an approximately fivefold increased risk of stillbirth and a sevenfold increased risk of neonatal death, primarily due to complications of prematurity.
Preterm birth is a major concern, with women carrying twins being six times more likely to give birth preterm and 13 times more likely to deliver before 32 weeks compared to singleton pregnancies.
Short-term and long-term neonatal and infant morbidity is also increased. Preterm twins are at twice the risk of high-grade intraventricular hemorrhage and periventricular leukomalacia compared to singletons of the same gestational age.
The prevalence of cerebral palsy is higher in twin pregnancies.
Medical costs associated with twin pregnancies are significantly higher, mainly due to prematurity.
Specific Risks Associated with Monochorionicity
Monochorionic twins have a higher frequency of fetal and neonatal mortality compared to dichorionic twins.
They also have a higher risk of:
Fetal and congenital anomalies
Prematurity
Fetal growth restriction
Twin-to-twin transfusion syndrome
Single fetal death
Stillbirth
Maternal Morbidity and Mortality
Medical complications are more common in women with twin pregnancies than in those with singleton pregnancies. These include:
Hyperemesis gravidarum
Gestational diabetes mellitus
Hypertensive disorders of pregnancy, such as preeclampsia
Anemia
Hemorrhage
Cesarean delivery
Postpartum depression
Management of Twin Pregnancies
Determination of Chorionicity
Early determination of chorionicity is essential for appropriate counseling and management.
Ultrasonography is the primary tool for assessing chorionicity, and it is most accurate in the first trimester or early second trimester.
Key ultrasonographic features for determining chorionicity:
Two placentas or differing fetal sex definitively indicate a dichorionic pregnancy.
If only one placenta is seen, the "twin peak sign" (also known as the lambda or delta sign) is the most reliable indicator of dichorionicity.
Prophylactic Interventions
Routine prophylactic interventions such as cerclage, hospitalization, bed rest, tocolytics, and pessaries have not been proven to decrease neonatal morbidity or mortality.
These interventions should not be used solely based on the presence of a twin pregnancy.
Management of Preterm Labor
Tocolytic therapy may be used for short-term prolongation of pregnancy to allow for:
Administration of antenatal corticosteroids
Transport to a tertiary care facility, if needed
Calcium channel blockers or nonsteroidal anti-inflammatory drugs are considered first-line tocolytic treatments.
Maternal risks of tocolytic use should be considered, including pulmonary edema.
Antenatal Corticosteroids
Antenatal corticosteroids are recommended for women at risk of preterm delivery between 24 and 34 weeks of gestation, regardless of fetal number.
They have been shown to reduce the incidence of neonatal death and various complications of prematurity.
A single repeat course may be considered in certain situations, but regularly scheduled or serial courses are not recommended.
Magnesium Sulfate for Fetal Neuroprotection
Intravenous magnesium sulfate is recommended for women expecting delivery before 32 weeks of gestation to reduce the risk and severity of cerebral palsy in surviving infants.
Prenatal Screening and Diagnosis of Fetal Chromosomal Abnormalities
All women with twin pregnancies, regardless of age, are candidates for routine screening for fetal chromosomal abnormalities.
Serum-based screening methods are less accurate in twin pregnancies than in singleton pregnancies.
First-trimester, quad, sequential, or integrated screening options are available, but data on test performance are limited.
Nuchal translucency (NT) measurement can be used in twin pregnancies, with standard cutoffs from singleton pregnancies being applicable.
Cell-free DNA screening can be performed in twin pregnancies, with promising results for trisomy 21 detection, but a higher rate of test failure compared to singleton pregnancies.
Amniocentesis and chorionic villus sampling (CVS) can be performed in twin pregnancies for definitive diagnosis, but they carry a slightly increased risk of pregnancy loss.
Management of Discordant Fetal Growth
Discordant fetal growth is typically defined as a 20% difference in estimated fetal weight between the larger and smaller twin.
Twin pregnancies with discordant but appropriate-for-gestational-age growth are generally not at increased risk of adverse outcomes.
However, discordant growth with at least one growth-restricted fetus is associated with a higher risk of neonatal morbidity.
Management of Single Fetal Death
Spontaneous reduction of one fetus, known as "vanishing twin," is relatively common in the first trimester, with the probability increasing with the number of fetuses.
Later in pregnancy, the death of one twin can have significant implications, especially in monochorionic gestations.
In monochorionic pregnancies, fetal demise after 14 weeks carries a 15% risk of death for the surviving twin, compared to 3% in dichorionic pregnancies.
The surviving twin in a monochorionic pregnancy also faces a greater risk of neurological abnormalities.
Management after single fetal death in monochorionic pregnancies before 34 weeks should be individualized, considering the mother's and surviving fetus's condition.
Delivery before 34 weeks is not routinely recommended unless there are other indications.
Antenatal Fetal Surveillance
In dichorionic pregnancies:
An ultrasound examination between 18 and 22 weeks is recommended for fetal anatomy, amniotic fluid, placentation, and growth assessment.
Serial ultrasonographic surveillance every 4 weeks is reasonable in the absence of complications.
Weekly antenatal fetal surveillance may be considered at 36 0/7 weeks in uncomplicated cases.
Surveillance should be individualized for pregnancies complicated by maternal or fetal disorders.
In monochorionic pregnancies:
Closer monitoring is needed due to the increased risk of complications.
Serial ultrasonographic evaluation is recommended approximately every 2 weeks starting at 16 weeks to monitor for twin-to-twin transfusion syndrome (TTTS).
Antenatal fetal surveillance is typically initiated at 32 0/7 weeks due to higher stillbirth risks.
Management of Monochorionic Placentation Complications
Twin-to-twin transfusion syndrome (TTTS):
Occurs in 10-15% of monochorionic-diamniotic pregnancies
Caused by arteriovenous anastomoses in the shared placenta leading to imbalanced blood flow between twins
Diagnosed via ultrasound: oligohydramnios in one sac and polyhydramnios in the other
Prognosis depends on gestational age and severity (staged using the Quintero system)
Interventions include laser coagulation, amnioreduction, or selective reduction
Monoamniotic twins:
Increased perinatal mortality risk (12-23%)
Management often involves early inpatient care (24-28 weeks), daily fetal surveillance, and delivery between 32 and 34 weeks
Rare complications:
Acardiac twin pregnancy
Conjoined twinning
Management of these conditions should involve collaboration with a specialist in complicated twin gestations.
Timing and Route of Delivery
Timing of delivery in uncomplicated twin pregnancies:
Dichorionic-diamniotic: 38 0/7–38 6/7 weeks
Monochorionic-diamniotic: 34 0/7–37 6/7 weeks
Monochorionic-monoamniotic: 32 0/7–34 0/7 weeks
Route of delivery:
Cesarean birth is recommended for monoamniotic twins to prevent umbilical cord complications.
Vaginal birth is an option for diamniotic twins with a vertex presenting fetus, even if the second twin is not in a vertex position.
Higher-order multifetal gestations:
The optimal route of delivery is unknown.
Planned vaginal delivery can be considered for uncomplicated triplet pregnancies with a vertex presenting fetus if experienced obstetricians are available.
Postpartum Considerations
Women with twin pregnancies are at increased risk of:
Uterine atony
Postpartum hemorrhage
Emergent hysterectomy
Neuraxial analgesia can facilitate:
Operative vaginal delivery
External or internal cephalic version
Total breech extraction
106
Nausea and Vomiting of Pregnancy
Nausea and Vomiting of Pregnancy
Nausea and Vomiting in Pregnancy: A Comprehensive Overview
This article, published in the Obstetrics & Gynecology journal, provides a clinical management guideline for obstetrician-gynecologists regarding nausea and vomiting of pregnancy (NVP).
Defining and Distinguishing Nausea and Vomiting of Pregnancy
Nausea and vomiting of pregnancy (NVP) is a common condition, with nausea affecting 50-80% of pregnant individuals and vomiting affecting 50%. While it is common in early pregnancy, NVP may be minimized and undertreated by healthcare providers and pregnant individuals.
NVP is distinct from hyperemesis gravidarum (HG), a clinical diagnosis of exclusion that represents the extreme end of the NVP spectrum. HG is typically characterized by:
Persistent vomiting unrelated to other causes
Ketonuria (a sign of acute starvation)
Weight loss (often at least 5% of pre-pregnancy weight)
Understanding the Potential Causes and Risk Factors
The exact cause of NVP remains unknown, but theories include hormonal changes, evolutionary adaptation, and psychological predisposition.
Hormones
Human Chorionic Gonadotropin (hCG): The close relationship between peak hCG concentrations and peak NVP symptoms suggests a potential link. The association of NVP with higher hCG levels has been observed, but standardization for pregnancy duration makes comparisons difficult.
Estrogen: NVP is more common when estradiol levels are elevated and less common when they are decreased.
Evolutionary Adaptation: Some posit that NVP evolved to protect the woman and fetus from potentially harmful foods, explaining temporary aversions to certain tastes and smells.
Psychological Predisposition: While the idea of NVP as a psychological disorder has been debated, recent studies have found no association between NVP or HG and underlying psychiatric conditions.
Risk factors for HG include:
Increased placental mass (e.g., multiple gestation or molar pregnancy)
History of motion sickness or migraines
Family history of HG
Previous HG pregnancy
Recognizing Maternal and Fetal Effects
Maternal Effects:
Although death from NVP is rare today, significant morbidity has been reported, including:
Wernicke encephalopathy (vitamin B1 deficiency)
Esophageal rupture
Pneumothorax
Acute tubular necrosis
Fetal Effects:
Mild to moderate NVP has little apparent effect on pregnancy outcomes.
Studies have shown a lower rate of miscarriage among women with NVP and HG compared to controls.
No significant association between HG and congenital anomalies has been found.
The incidence of low birth weight varies among studies; some show no increase with NVP, while others show an increased risk of low birth weight and preterm birth with HG.
No association between HG and perinatal or neonatal mortality has been demonstrated.
Diagnosing and Managing NVP
Differential Diagnosis
When NVP symptoms begin after 9 weeks of gestation, other conditions should be considered, as listed in Box 1 of the source article.
Clinical Considerations
The PUQE index (Table 1) assesses NVP severity during the first trimester and is associated with quality-of-life measurements.
Early treatment is recommended to prevent progression to HG.
Nonpharmacologic therapies:
Taking prenatal vitamins before conception may reduce NVP incidence and severity.
Frequent, small meals and dietary modifications may be helpful.
Ginger has shown some benefit in reducing nausea.
Acupressure has shown limited benefit, but not acupuncture or nerve stimulation.
Pharmacologic therapies: Figure 1 outlines a hierarchy of treatment interventions.
Vitamin B6 (pyridoxine) alone or with doxylamine is considered first-line pharmacotherapy.
Dopamine antagonists (e.g., metoclopramide, promethazine) can provide relief.
Antihistamines (e.g., dimenhydrinate, diphenhydramine) are effective in controlling symptoms.
Serotonin 5-HT3 receptor antagonists (e.g., ondansetron) may be used, but there are limited safety data, and the FDA recommends against intravenous doses greater than 16 mg.
Corticosteroids (e.g., methylprednisolone) may be efficacious in refractory cases but should be a last resort due to the risk profile.
Laboratory and Radiologic Assessment for Hyperemesis Gravidarum
Ultrasound can identify predisposing factors like multiple gestation or molar pregnancy.
Laboratory assessment can help establish a diagnosis and assess severity.
Enteral and Parenteral Nutrition
Intravenous hydration is recommended for individuals who cannot tolerate oral liquids or show signs of dehydration.
Enteral tube feeding is the first-line treatment for nutritional support for individuals with HG who are not responsive to medical therapy and cannot maintain their weight.
Total parenteral nutrition is a last resort due to the potential for life-threatening complications.
Peripherally inserted central catheters (PICCs) should be used only as a last resort due to significant associated morbidity.
Hospitalization
Hospitalization is recommended for individuals who cannot tolerate liquids and haven't responded to outpatient management.
The option for hospitalization should be preserved for individuals who experience changes in vital signs or mental status, continue to lose weight, or are refractory to treatment.
Behavioral Interventions
Evidence for traditional behavioral interventions is limited.
Mindfulness-based cognitive therapy has shown promise in improving symptoms.
This overview provides a comprehensive summary of the key points and recommendations from the source article.
Please note that this information is intended for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional for diagnosis and treatment.
107
Neural Tube Defects
Neural Tube Defects
Obstetrics
Neural Tube Defects: A Comprehensive Outline
The sources provide a detailed overview of neural tube defects (NTDs), covering their embryology, epidemiology, etiology, clinical consequences, and management. Here's a comprehensive outline based on the information provided:
I. Definition and Significance
Congenital Abnormalities: NTDs are a group of congenital structural abnormalities affecting the central nervous system (brain and spinal cord) and vertebral column.
Common Birth Defect: They are the second most common major congenital anomaly, following cardiac malformations.
Variable Prevalence: The prevalence of NTDs varies geographically, racially, and by environmental factors.
Range of Severity: Outcomes and disabilities associated with NTDs depend on the lesion's level and extent, ranging from life-incompatible conditions like anencephaly to manageable conditions like spina bifida requiring surgical repair.
Preventable with Folic Acid: Notably, primary prevention of NTDs is achievable through folic acid supplementation.
II. Embryology
Neural Tube Formation: The neural tube, the precursor to the brain and spinal cord, forms from a flat sheet of neuroepithelial cells (neural plate) that folds and fuses in the midline during the third to fourth week after fertilization.
Cranial and Caudal Closure: Neural tube closure begins in the cervical region and progresses both cranially (towards the head) and caudally (towards the tail).
Discontinuous Process: The closure process is complex and occurs in a discontinuous manner, with multiple points of closure.
Common NTDs: Anencephaly results from cranial closure failure, while myelomeningocele (spina bifida) arises from caudal closure failure.
Genetic and Cellular Mechanisms: The closure process is intricate, involving numerous genes and cellular processes. Mutations in these genes can disrupt closure, leading to NTDs.
III. Epidemiology
Global Burden: Around 300,000 infants are born with NTDs annually worldwide.
Significant Neonatal Mortality: NTDs contribute to a substantial proportion of neonatal deaths attributed to congenital abnormalities, especially in low-income countries.
Variable Prevalence by Region: A recent systematic review encompassing 75 countries revealed a wide prevalence range, from 6.9 per 10,000 births in the Western Pacific to 21.9 per 10,000 births in the Middle East.
US Statistics: Between 2004 and 2006, the prevalence of anencephaly was 0.55 per 10,000 live births and 2.54 per 10,000 live births, stillbirths, or terminations combined. For spina bifida, the corresponding figures were 3.40 and 4.41 per 10,000, respectively.
Declining Prevalence: The widespread adoption of folic acid supplementation has led to a decline in NTD prevalence.
IV. Etiology
Multifactorial Origin: Isolated or nonsyndromic NTDs usually result from a complex interplay of genetic and environmental factors.
Environmental Exposures:
Medications: Certain medications, especially antiepileptics like carbamazepine and valproic acid, that interfere with folic acid metabolism increase NTD risk.
Toxins: Exposure to environmental toxins, such as the fungal toxin fumonisin, has been linked to increased NTD risk.
Maternal Hyperthermia: Maternal hyperthermia, including fever and heat exposure (e.g., hot tubs, saunas), during early pregnancy can elevate NTD risk.
Maternal Medical Conditions:
Pregestational Diabetes: Women with pregestational diabetes have a substantially higher risk of NTDs.
Maternal Obesity: Obesity is associated with an increased risk of NTDs, with a positive correlation between body mass index (BMI) and risk. Obese women have a 1.7-fold higher risk, and severely obese women (BMI ≥ 38) have a 3.1-fold higher risk compared to women with normal BMI.
Geographic and Ethnic Associations: Variations in NTD prevalence exist based on geographic location and ethnicity.
Genetic Factors:
Chromosomal Abnormalities: NTDs are associated with certain chromosomal abnormalities, including trisomy 13, trisomy 18, and triploidy.
Single Gene Disorders: Some genetic syndromes caused by single gene disorders or chromosomal microdeletions, like 22q11.2 deletion syndrome and Waardenburg syndrome, increase the risk of NTDs.
Genes Involved in Neural Tube Closure: Hundreds of genes are implicated in neural tube closure in mice, suggesting a similar complexity in humans. These genes are involved in folate metabolism, planar cell polarity, and cilia development, all crucial for proper closure.
Methylenetetrahydrofolate Reductase (MTHFR) Gene: Polymorphisms in the MTHFR gene, particularly C677T, have been linked to a higher NTD frequency in some populations, although not consistently.
Family History: A family history of NTDs significantly increases the risk of recurrence. Parents with one affected child have a 3.2% risk of having another child with an NTD, while the risk with two affected siblings rises to 10%.
V. Pathophysiology
Location-Specific Defects: Table 1 in source provides a detailed description of the malformations associated with different NTDs based on their location along the neural tube.
Anencephaly: Failure of the cephalic (head) portion of the neural tube to close results in anencephaly, characterized by the absence or partial development of the brain, skull, and skin. Anencephalic infants typically do not survive beyond a few hours or days after birth.
Iniencephaly: Closure defects in the cervical and upper thoracic regions lead to iniencephaly, involving malformations of the vertebrae, retroflexion of the spine, and abnormalities in the development of the thoracic cage, diaphragm, lungs, and heart.
Spina Bifida: Failure of caudal (tail) neural tube closure, commonly in the lumbosacral region, causes spina bifida. This can manifest as:
Meningocele: Exposure of the meninges (protective membranes surrounding the spinal cord)
Myelomeningocele: Exposure of both the meninges and neural tissue
Associated Anatomic Changes in Spina Bifida: Spina bifida is often accompanied by hydrocephalus (fluid accumulation in the brain), abnormal head shape, decreased head size, and Arnold-Chiari malformation (herniation of the hindbrain). Other associated conditions include clubfoot and scoliosis.
VI. Clinical Consequences
Specialized Care: Pregnancies with spina bifida require specialized management involving a multidisciplinary team, including maternal-fetal medicine specialists, neonatologists, pediatric neurosurgeons, and geneticists.
Pregnancy Complications: Polyhydramnios (excessive amniotic fluid) can occur due to impaired fetal swallowing, particularly with anencephaly and high-level spinal lesions, leading to uterine overdistention and increased risk of preterm labor, umbilical cord prolapse, and placental abruption. Breech presentation is common at term.
Neonatal Challenges:
Prognostic Factors: Lesion size and location, and the presence of hydrocephalus, significantly influence the prognosis for infants with NTDs.
Survival Rate: With appropriate surgical and medical intervention, at least 75% of infants with myelomeningocele survive to early adulthood.
Hydrocephalus Management: Most infants with spina bifida and ventriculomegaly (enlarged brain ventricles) require ventriculoperitoneal shunt placement (a surgical procedure to drain excess fluid) in their first year of life, and many require multiple shunt revisions throughout their lives.
Neurological Dysfunction: Arnold-Chiari malformation can worsen, leading to severe or even fatal neurological problems.
Cognitive Impairment: Cognitive deficits are frequent and are related to the level of spinal disruption, hydrocephalus, and associated brain malformations.
Long-Term Health Issues:
Mobility Impairment: Individuals with spina bifida often experience mobility limitations.
Bowel and Bladder Dysfunction: Neurogenic bladder (impaired bladder control) and bowel dysfunction are common, leading to urinary tract infections, chronic kidney disease, and fecal incontinence.
Latex Allergy: A significant proportion of individuals with NTDs develop a severe latex allergy, requiring careful attention to latex avoidance.
Economic Burden: The lifelong medical care required for individuals with spina bifida results in a considerable economic burden, including direct medical costs and indirect costs related to morbidity and caregiver support.
VII. The Role of Folic Acid
Historical Context: Research in the 1970s revealed lower B vitamin levels, including folate, in mothers of infants with NTDs compared to unaffected pregnancies.
Landmark Studies: Multicenter randomized trials demonstrated that folic acid supplementation significantly reduced both the recurrence and first occurrence of isolated, nonsyndromic NTDs.
Folic Acid Fortification: Mandatory folic acid fortification of wheat flour in the US and other countries has been successful in reducing NTD prevalence.
Mechanism of Action: While the exact mechanism remains incompletely understood, folic acid plays a crucial role in one-carbon metabolism, essential for DNA replication and cell growth and proliferation, particularly during neural tube formation.
Supplementation Recommendations:
Universal Supplementation: All women planning or capable of becoming pregnant are advised to take 400 micrograms of folic acid daily, starting at least one month before conception and continuing through the first trimester. This is due to the early occurrence of neural tube closure and the high rate of unplanned pregnancies.
High-Risk Women: Women at high risk of having a child with an NTD (e.g., those with a previous affected pregnancy) may require higher doses of folic acid.
Limitations: Despite the effectiveness of folic acid supplementation, it does not prevent all NTDs, highlighting the multifactorial nature of these conditions.
VIII. Prenatal Screening and Diagnosis
Maternal Serum Alpha-Fetoprotein (MSAFP) Screening: MSAFP screening, typically performed between 15 and 18 weeks of gestation as part of aneuploidy screening, can detect elevated levels of alpha-fetoprotein, a fetal protein that leaks into the maternal circulation in cases of open NTDs.
Ultrasonography: Second-trimester ultrasonography, recommended for all pregnant women between 18 and 22 weeks, is effective in visualizing fetal anatomy and detecting NTDs.
First-Trimester Ultrasound: While some NTDs can be detected in the first trimester, the detection rate is lower than with second-trimester ultrasonography.
Three-Dimensional Ultrasonography: Three-dimensional ultrasonography has not been shown to be superior to two-dimensional ultrasonography for NTD diagnosis.
Additional Diagnostic Tools:
Amniocentesis: Amniocentesis, a procedure that involves analyzing amniotic fluid, can be used for chromosomal microarray analysis to identify genetic abnormalities in a fetus with an NTD.
Acetylcholinesterase Measurement: Measuring acetylcholinesterase levels in amniotic fluid helps distinguish between open and closed NTDs.
Fetal MRI: Fetal MRI may be considered for further evaluation if ultrasound findings are unclear.
IX. Pregnancy Management
Referral to Specialists: Upon suspicion or detection of an NTD, referral to a maternal-fetal medicine unit is essential for comprehensive evaluation, diagnosis confirmation, lesion assessment, and identification of associated anomalies.
Fetal Echocardiography: Considering the increased risk of other abnormalities in fetuses with NTDs, fetal echocardiography should be considered.
Counseling and Options: Patients require thorough counseling regarding the nature of the NTD, anticipated outcomes, and available management options. These options typically include:
Pregnancy Termination:
Expectant Management with Neonatal Repair:
In Utero Fetal Repair: For eligible candidates
Antenatal Fetal Surveillance: The role of routine fetal surveillance is unclear, but serial ultrasound examinations may be considered to monitor fetal growth, head size, and hydrocephalus progression.
Delivery Planning:
Tertiary Care Center: Delivery should be planned at a hospital equipped to provide tertiary neonatal care and specialized management of NTDs and potential complications.
Optimal Timing:
Term Delivery: In most cases, delivery at term is preferred.
Late Preterm to Early Term Delivery: For pregnancies that have undergone in utero fetal surgery, delivery is usually planned between 37 and 39 weeks of gestation due to the increased risk of uterine rupture.
Individualized Decisions: The optimal timing of delivery should be individualized based on factors such as rapidly progressing hydrocephalus.
Mode of Delivery:
Breech Presentation: Planned cesarean delivery is the standard for breech fetuses with NTDs.
Cephalic Presentation: The optimal delivery route for cephalic fetuses remains controversial, with the majority of evidence suggesting that vaginal delivery does not negatively impact neonatal outcomes in cases of meningomyelocele. However, decisions should be made on a case-by-case basis, considering factors such as fetal head size and available expertise.
Latex Precautions: Due to the high risk of latex allergy in infants with NTDs, the use of latex-free gloves during delivery and subsequent care is crucial.
X. Fetal Surgery
Rationale: The "two-hit hypothesis" posits that neurologic damage in myelomeningocele results from the initial developmental defect (first hit) and subsequent inflammation and trauma to the exposed spinal cord from amniotic fluid exposure (second hit). Fetal surgery aims to minimize the second hit by repairing the lesion in utero.
Management of Myelomeningocele Study (MOMS): This landmark randomized trial demonstrated that in utero spina bifida closure performed in the second trimester reduced the need for shunt placement, the incidence of hindbrain herniation, and improved motor function at 12 months compared to postnatal repair.
Candidate Selection: Fetal surgery is not suitable for all cases of spina bifida and requires careful patient selection based on specific criteria.
XI. Ongoing Research and Future Directions
Understanding Folic Acid's Mechanisms: Further research is needed to fully elucidate the mechanisms by which folic acid prevents NTDs and to identify other potential preventative strategies.
Exploring New Pathways: Current research is focusing on various pathways involved in neural tube development, including neuronal migration, cell signaling, mitochondrial folate metabolism, and inositol pathways.
Improving Fetal Surgery Techniques: Ongoing efforts aim to refine fetal surgical techniques and expand their applicability to a wider range of NTDs.
The sources highlight the complex and multifactorial nature of neural tube defects. They emphasize the importance of folic acid supplementation for primary prevention, comprehensive prenatal screening and diagnosis, individualized pregnancy management, and specialized care for affected infants. Continued research is crucial to enhance our understanding of NTDs and develop more effective preventative and treatment strategies.
108
No/Late prenatal care
No/Late prenatal care
Management of Suboptimally Dated Pregnancies: A Comprehensive Overview
This Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) provides guidance on managing pregnancies where the gestational age is uncertain, termed "suboptimally dated pregnancies."
Defining a Suboptimally Dated Pregnancy
ACOG defines a suboptimally dated pregnancy as one without an ultrasound examination to confirm or revise the estimated due date before 22 0/7 weeks of gestation. First-trimester ultrasonography is considered the most accurate method for establishing gestational age. The 22-week cutoff replaced the previous 20-week threshold because the same discrepancy (more than 10 days) between ultrasound and menstrual dating, which justifies revising the due date, applies to pregnancies between 16 0/7 and 21 6/7 weeks. This cutoff also aligns with ACOG's recommendation for a single ultrasound examination between 18-22 weeks for fetal anatomical assessment and accurate gestational age estimation.
Key Considerations for Management
Timing of Delivery:
The timing of indicated delivery should be based on the best clinical estimate of gestational age. This means that if there is a medical reason to deliver the baby, the decision should be made using the best available information about the gestational age, even if it is not confirmed by early ultrasound.
There is no role for elective delivery in a woman with a suboptimally dated pregnancy. Elective delivery could unnecessarily risk neonatal morbidity if the pregnancy is less advanced than estimated.
For indicated preterm deliveries, follow the same guidelines as accurately dated pregnancies, using the best clinical estimate. This is because there is no better alternative.
Antenatal Corticosteroid Exposure:
Base decisions about antenatal corticosteroid exposure on the best clinical estimate of gestational age for women at risk of preterm delivery.
While corticosteroids are generally recommended between 24 and 34 weeks and may be considered between 34 0/7 and 36 6/7 weeks for those at imminent risk of preterm birth within seven days, there isn't enough data to guide corticosteroid use in suboptimally dated pregnancies undergoing presumed term delivery.
Amniocentesis for Fetal Lung Maturity:
Amniocentesis for fetal lung maturity is not routinely recommended. While historically used to assess fetal lung maturity before planned delivery in pregnancies lacking accurate gestational age, it is not reliable for predicting newborn pulmonary outcomes or nonrespiratory outcomes. Moreover, late-preterm and early-term newborns with mature lung profiles still face an increased risk of adverse respiratory and nonrespiratory morbidities compared to those born at or beyond 39 weeks.
Late-Term Pregnancies:
Late-term delivery is indicated at 41 weeks using the best clinical estimate when gestational age is uncertain. This is due to the increased risk of unrecognized advanced postmaturity and associated perinatal morbidity and mortality in ongoing, suboptimally dated pregnancies.
Initiating antepartum fetal surveillance at 39-40 weeks may be considered for similar reasons.
Prior Cesarean Delivery:
For women with prior cesarean deliveries who are candidates for a trial of labor after cesarean (TOLAC), delivery decisions should be based on the best clinical estimate.
For women with prior low-transverse cesarean deliveries who request a repeat cesarean, delivery is advised at 39 weeks using the best clinical estimate.
Interval Ultrasonographic Assessment:
It is reasonable to consider an interval ultrasound 3-4 weeks after the initial one to assess fetal weight and gestational age. This can help support the estimated gestational age and potentially detect fetal growth restriction.
If fetal growth restriction is suspected on follow-up ultrasound, fetal surveillance with umbilical artery Doppler velocimetry is indicated, and delivery timing should be reconsidered.
Patient Counseling:
Inform the patient that limitations in determining accurate gestational age introduce a higher risk of neonatal morbidity if the pregnancy is misdated.
Explain that the rationale for delivery is that the risks of continuing the pregnancy, given the specific indication, outweigh the risks associated with inaccurate gestational age assignment.
109
Non-Rh alloimmunization
[ ]
110
NSGA (non-small gestational age)
[ ]
111
OB anesthesia complications
[ ]
112
OB Emergency
OB Emergency
Obstetrical Emergencies
Preparing for Clinical Emergencies in Obstetrics and Gynecology
I. Introduction
Importance of Emergency Preparedness: Patient care emergencies are possible in any setting, making preparedness crucial for obstetrician-gynecologists.
Severity of Maternal Morbidity: The United States has seen a dramatic increase in severe maternal morbidity, emphasizing the need for effective emergency response systems.
Key Elements of Preparation: Planning and interdisciplinary collaboration are essential for successful emergency preparedness.
II. Planning for Emergencies
Risk Assessment: Identify potential risks in the practice setting and patient population. Consider factors like medications, procedures, and historical emergency data.
Collaboration and Culture Shift:
Involve all staff members in audit programs and multidisciplinary collaboration.
Empower frontline team members, such as nurses and intake clerks, to play an active role in emergency response.
Encourage a shift in patient care culture that embraces coordinated interventions.
III. Advance Provision of Resources
Centralized Emergency Supplies: Ensure essential items are readily available in a central location, saving valuable time during emergencies.
Crash Cart (Resuscitation Cart):
Maintain a well-stocked crash cart with up-to-date supplies and equipment.
Adhere to Advanced Cardiac Life Support protocol changes and replenish perishable supplies.
Specialized Emergency Kits: Consider creating kits tailored to specific emergencies, such as allergic reactions or hemorrhage.
Designated Team Leader: A designated team leader, capable of managing the initial stages of an emergency and activating a response team, must be available.
Patient Transportation Plan: Establish a clear plan for transporting unstable patients or transferring care.
IV. Early Warning Systems
Recognizing Warning Signs: Many emergencies are preceded by a period of instability, providing an opportunity for timely intervention.
Triggers for Intervention: Establish protocols that define "triggers," such as agitation or new-onset movement difficulties, that necessitate immediate action, including notifying the attending physician.
Empowering Bedside Personnel: Empower nurses and caregivers to request immediate assistance without fear of recrimination when they observe triggers.
Modified Early Obstetric Warning System (MEOWS): Consider implementing a system like MEOWS, which utilizes specific physiological parameters to identify potential emergencies.
V. Rapid Response Team
Composition: Rapid response teams are composed of skilled clinicians, including advanced practice nurses, respiratory therapists, and first responders, who provide critical care expertise at the patient's bedside.
Authority to Activate: All regular clinical team members should have the authority to activate the rapid response team when critical events or criteria are met.
Benefits: Early activation of a rapid response team is associated with positive outcomes, including a reduction in cardiac arrest, improved survival rates, and decreased ICU admissions.
Establishing a Rapid Response Team: The process involves:
Identifying clinicians, support staff, and stakeholders
Defining activation criteria
Implementing a protocol with designated roles
Conducting drills and ongoing training
Establishing debriefing procedures for feedback and process improvement
Regularly evaluating the effectiveness of the rapid response team
Four Components of a Rapid Response Team:
Activators: individuals authorized to activate the team
Responders: clinicians who stabilize the patient and determine their disposition
Quality Improvement: team responsible for reviewing activations, implementation, and outcomes
Administration: provides support and oversight for the rapid response team
VI. Emergency Drills and Simulation
Standardized Care for Emergencies: Periodic drills, following designated protocols, can improve a unit's ability to respond to common emergencies like fetal bradycardia or postpartum hemorrhage.
Benefits of Simulation Training: Simulations can identify and correct clinical errors, enhance communication, and reinforce protocols.
Experiential Learning: Drills provide valuable experiential learning opportunities, addressing communication challenges in a hierarchical and stressful environment.
Teamwork and Communication: Effective communication is crucial during emergencies, and drills can help overcome barriers and improve teamwork.
Outcomes of Effective Drills: Improved standardization of response, increased provider satisfaction, and enhanced patient outcomes.
VII. Conclusion
Emergency Preparedness is Essential: Obstetrician-gynecologists must be prepared for emergencies.
Key Elements: Resource allocation, planning, collaboration, and a well-trained rapid response team are essential.
Rapid Response Team: Defined roles, streamlined communication, access to emergency supplies, and ongoing training are vital for an effective rapid response team.
Importance of Teamwork and Training: Prompt recognition of critical scenarios, teamwork, and training enhance patient safety and mitigate adverse outcomes.
Please note that this outline is based solely on the information provided in the source document. For additional insights or resources, you may want to explore the references cited within the document, particularly those highlighted with an asterisk (*) in the References section.
General Guidance
Bullet Point List of the Notes
Start the case with a straightforward explanation.
Limit how much is said; only say what’s necessary.
Begin by assessing the situation:
Look at the fetal status.
Obtain labs and check vitals.
Ensure the patient has adequate IV access.
Inform the patient.
Consent the patient if it’s a procedure.
Ensure all necessary personnel are in place (nursing, anesthesia).
Ensure the needed equipment is available.
Make sure the patient has necessary analgesia or anesthesia if applicable.
Memorize the steps of the checklist for each obstetrical emergency.
Provide contextual advice for specific situations (e.g., severe range blood pressures).
Use a consistent approach to each emergency situation, focusing on assessment, informing the patient and team, and preparing for interventions.
Template for Discussing Obstetrical Emergencies
Introduction:
Begin with a brief and clear summary of the emergency situation.
Limit details to only what is necessary for understanding.
Assessment:
Vitals: Check maternal vital signs.
Fetal status: Assess fetal heart rate (FHR) and patterns.
Labs: Obtain or review relevant labs (e.g., CBC, CMP, LFTs, etc.).
Access: Ensure the patient has IV access.
Inform the Patient:
Explain the situation and potential interventions to the patient.
Obtain consent if a procedure is required.
Inform the Team:
Alert the nursing staff and any necessary personnel (anesthesia, additional OB providers).
Make sure the required support team is in place.
Equipment and Medications:
Ensure all necessary equipment and medications are available.
Double-check that all resources are ready for immediate intervention.
Pain Control/Anesthesia:
Ensure that adequate analgesia or anesthesia is available and provided if necessary.
Checklist Completion:
Run through the checklist specific to the emergency, ensuring each step is completed in a timely manner.
113
Obesity - non-pregnant
Obesity - non-pregnant
Obesity - non-pregnant
Obstetrics
Obesity in Adolescents: A Comprehensive Overview
This Committee Opinion, published by the American College of Obstetricians and Gynecologists (ACOG), addresses the increasing prevalence of obesity in adolescents and its implications for their overall health, particularly focusing on gynecologic and obstetric aspects.
Defining Obesity in Adolescents
The article defines Body Mass Index (BMI) as a measure of body fat based on height and weight. To account for the changes during puberty, BMI in adolescents is interpreted using growth charts to determine BMI-for-age and BMI-for-sex percentile.
Weight categories are defined as follows:
Overweight: BMI at or above the 85th percentile but less than the 95th percentile
Obesity: BMI at or above the 95th percentile
Class I: BMI at or above the 95th percentile but less than 120% of the 95th percentile
Class II: BMI at or above 120% but less than 140% of the 95th percentile, or a BMI of 35 or greater, whichever is lower
Class III: BMI at or above 140% of the 95th percentile, or a BMI of 40 or greater, whichever is lower
Severe Obesity: BMI greater than or equal to the 99th percentile for age
Extreme Obesity: BMI at or above 120% of the sex-specific 95th percentile for age
It's important to note that BMI doesn't directly measure adiposity and might not accurately predict health risks in athletic adolescents with increased muscle mass or sedentary adolescents with reduced muscle mass.
Prevalence and Trends of Obesity in Adolescents
The prevalence of obesity among adolescent females in the United States increased from approximately 10% in the 1980s to 21% in 2014. While the increase has slowed in children aged 2-11 years, it continues to rise in adolescents aged 12-19 years.
Several factors contribute to the prevalence of obesity:
Genetic predisposition
Race: Black adolescents have the highest prevalence (24.4%), followed by Hispanic (22.8%), White (20.4%), and Asian (5.7%).
Socioeconomic status
Built environment (e.g., presence of sidewalks)
Accessibility of healthy and affordable foods
Sleep habits
Geographic region
Changes in lifestyle: including consuming high glycemic index foods and beverages, increased food portions, decreased physical activity, and increased screen time.
Intrauterine environment: Large-for-gestational-age infants have a higher risk of developing obesity in adolescence.
Health Risks Associated with Obesity
Obese adolescents face various medical, psychological, and reproductive health challenges. The sources highlight the following risks:
Medical Risks:
Impaired glucose tolerance and Type 2 diabetes: Risk increases with increasing weight.
Cardiovascular disease: Increased risk due to hypertension and dyslipidemia.
Metabolic syndrome: Coexistence of risk factors for Type 2 diabetes and cardiovascular disease, including abdominal obesity, hyperglycemia, dyslipidemia, and hypertension.
Nonalcoholic fatty liver disease: Prevalence estimated to be 38% in obese children and adolescents.
Disordered breathing: Including obesity hypoventilation syndrome and obstructive sleep apnea.
Orthopedic conditions: Increased risk of slipped capital femoral epiphysis, tibia vara, genu valgum, musculoskeletal pain, and fractures.
Gynecologic Risks:
Abnormal uterine bleeding: May be due to anovulation or elevated estrogen levels.
Endometrial cancer: Rare in adolescents but may occur after prolonged abnormal bleeding.
Polycystic ovary syndrome (PCOS): Characterized by ovulatory dysfunction and hyperandrogenism, leading to menstrual irregularities and hirsutism.
Obstetric Risks:
Increased risk of cesarean delivery, labor induction, preeclampsia, and gestational diabetes.
Protective effect on preterm birth in some cases.
Psychosocial Risks:
Low self-esteem and distorted body image
Depression and anxiety
Discrimination and strained peer relationships
Bullying and peer victimization
Managing Adolescent Obesity
Lifestyle Interventions:
The American Academy of Pediatrics recommends a four-stage approach to obesity in adolescents:
Prevention Plus: Focuses on healthy eating, physical activity, and minimizing screen time.
Structured Weight Management: Involves a balanced diet, increased physical activity, and monitoring progress.
Comprehensive Multidisciplinary Intervention: More frequent contact with healthcare providers, active use of behavioral strategies, and a multidisciplinary team approach.
Tertiary Care Intervention: May include meal replacement, very-low-energy diet, medication, or surgery.
Medical Therapies:
Tetrahydrolipstatin: FDA-approved for adolescents 12 years and older with a BMI at least two units above the 95th percentile. It inhibits digestive lipases to block dietary fat absorption.
Metformin: Not recommended for weight loss alone but may be considered for adolescents with PCOS and insulin resistance.
The article cautions against the use of weight loss supplements due to a lack of evidence for safety and efficacy.
Surgical Interventions:
Bariatric surgery may be considered for adolescents meeting specific criteria, including a BMI of 35 or greater with severe comorbidities or a BMI of 40 or greater with minor comorbidities.
Types of surgical procedures include:
Adjustable gastric banding: A restrictive procedure where a band is placed around the stomach entrance.
Sleeve gastrectomy: A restrictive procedure where a portion of the stomach is removed.
Roux-en-Y gastric bypass: A restrictive and malabsorptive procedure that creates a small gastric pouch and bypasses a portion of the small intestine.
A multidisciplinary team should be involved in selecting appropriate candidates and providing postoperative support.
Preventing Obesity
The article emphasizes the role of obstetrician-gynecologists in educating adolescents and their families about the importance of a healthy lifestyle. They can advocate for programs that promote physical activity and healthy nutrition.
Behavioral modification strategies include:
Self-monitoring
Stimulus control
Goal setting
Positive reinforcement
Parents play a crucial role as role models and in creating a supportive environment for healthy habits. They should focus on healthy behaviors rather than dieting.
The article encourages obstetrician-gynecologists to address the psychosocial aspects of obesity, screening for depression, bullying, and peer victimization. They can also provide referrals to appropriate resources., GYN Surgery in the Obese Patient: A Comprehensive Outline
The sources highlight the unique challenges and considerations related to performing GYN surgery in obese patients. They provide guidance on preoperative assessment, intraoperative management, and postoperative care, emphasizing the importance of individualized care and a minimally invasive approach whenever possible.
Understanding Obesity and its Implications
Obesity as a Serious Health Problem: Obesity, defined as a BMI of 30 or greater, is a significant health issue, particularly in the United States. It is associated with increased risks of death, various medical conditions (hypertension, diabetes mellitus, obstructive sleep apnea, hypercholesterolemia), and malignancies like endometrial and postmenopausal breast cancer.
Challenges and Discrimination: Managing weight effectively remains a challenge for both patients and physicians. Obese individuals often face discrimination based solely on their weight and appearance.
Risks and Considerations in GYN Surgery
The "Obesity Paradox": While obesity generally increases surgical risks, some studies have noted a lower overall mortality and composite morbidity in obese patients without metabolic complications undergoing general surgery. This phenomenon is known as the "obesity paradox" and might be attributed to the distinction between metabolically healthy and unhealthy obese individuals.
Metabolic Syndrome and Increased Risks: Obese patients with metabolic syndrome, particularly those with hypertension and diabetes, face a heightened risk of perioperative morbidity and mortality compared to normal-weight individuals, especially in general, vascular, and orthopedic surgeries.
Elevated Post-Surgical Complications: Obese women undergoing GYN surgery experience a higher prevalence of adverse effects, including:
Surgical site infections: The risk significantly increases with a BMI greater than 35.
Venous thromboembolism: The risk is higher for those with a BMI of 35 or greater, particularly after surgery.
Wound complications: The likelihood of wound complications is considerably greater in obese women, particularly those with a BMI of 40-49, compared to normal-weight patients.
Preoperative Management
Individualized Counseling: Counseling should be tailored to each patient's specific risk factors, the indication for surgery, and the surgeon's experience, including a discussion about the possibility of conversion to an open procedure.
Considering Less Invasive Options: Due to the increased risk of complications, a less invasive approach should always be considered, including alternatives to surgery or a less invasive procedure.
Evaluation of Comorbid Conditions: A comprehensive assessment of underlying comorbid conditions like coronary artery disease, hypertension, diabetes mellitus, obstructive sleep apnea, and venous thromboembolism is crucial before surgery.
Anesthesiologist Consultation: Consultation with an anesthesiologist is recommended for obese patients with suspected obstructive sleep apnea, risk of coronary artery disease, a difficult airway, or poorly controlled hypertension.
Preoperative Imaging: Imaging studies like magnetic resonance imaging (MRI) can be helpful in determining the optimal surgical approach for obese patients, especially when the physical examination is challenging.
Intraoperative Management
Venous Thromboembolism Prophylaxis: Obese patients undergoing GYN surgery exceeding 45 minutes and not at high risk of bleeding should receive prophylaxis for venous thromboembolism. This can include low molecular weight heparin, low-dose unfractionated heparin, or mechanical prophylaxis with intermittent pneumatic compression.
Antibiotic Prophylaxis: The sources suggest considering an increased dose of prophylactic antibiotics in obese patients to achieve adequate tissue concentration. For instance, some advocate for a 2-g prophylactic cefazolin dose for patients weighing more than 80 kg and 3 g for those exceeding 120 kg. However, the specific dosage recommendations for antibiotic prophylaxis in obese patients remain a subject of ongoing research and debate.
Surgical Positioning and Equipment: Proper positioning on the operating table is critical for maximizing exposure and minimizing the risk of injury. The table should accommodate the patient's weight and allow for secure positioning with belts and gel pads. Stirrups should be chosen carefully to avoid nerve injury and ensure patient comfort.
Surgical Challenges in Abdominal and Laparoscopic Surgery:
Abdominal Surgery: Increased subcutaneous tissue can make retraction and exposure difficult, often leading to longer operative times for abdominal hysterectomies in obese women compared to normal-weight women.
Laparoscopic Surgery: Laparoscopy can be technically challenging in obese patients. Considerations include the use of longer Veress needles and ancillary trocars, potential difficulties in trocar placement due to suboptimal visualization of the inferior epigastric vessels, challenges with exposure and manipulation in the pelvis, and difficulties in port closure.
Postoperative Management
Focus on Comorbid Conditions: Postoperative care should be individualized and tailored to the specific needs of the patient, considering any comorbid conditions.
Extended Venous Thromboembolism Prophylaxis: Patients who are not fully ambulatory before surgery might benefit from extended venous thromboembolism prophylaxis.
Respiratory Morbidity Management: Increased respiratory morbidity is common in obese patients. Postoperative hypoxemia can be addressed with incentive spirometry or continuous positive airway pressure. Conservative use of opioids is recommended to maintain respiratory drive.
Pain Management: A multimodal approach to pain management helps reduce opioid use. Nonsteroidal anti-inflammatory drugs (NSAIDs) administered preoperatively or intraoperatively may be more effective than acetaminophen in reducing nausea, vomiting, and overall postoperative opioid requirements. Regional anesthesia can be used to minimize opioid use or even avoid intubation for minor procedures.
Wound Management: Wound complications and surgical site infections are common postoperative issues in obese patients who undergo abdominal hysterectomies. Subcutaneous suture placement, talc application, or wound vacuums may help reduce postoperative wound complications, although data are limited.
Glycemic Control in Diabetic Patients: Maintaining good glycemic control in patients with diabetes is important for optimal postoperative wound healing.
Preference for Minimally Invasive Approaches
Vaginal Hysterectomy: Evidence consistently demonstrates that vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy, and this holds true for patients of all weights.
Laparoscopic Hysterectomy: For patients who are not suitable candidates for vaginal surgery, laparoscopy offers a less invasive alternative to open abdominal hysterectomy, potentially reducing blood loss and length of hospital stay. However, laparoscopy can be more challenging in obese patients, and the conversion rate to laparotomy is higher.
Conclusion
The sources offer comprehensive guidance for managing GYN surgery in obese patients, emphasizing the importance of:
Recognizing the unique challenges and risks associated with obesity.
Individualized patient counseling and shared decision-making.
Thorough preoperative assessment and management of comorbid conditions.
Careful intraoperative considerations, including positioning, prophylaxis, and potential surgical challenges.
Comprehensive postoperative care tailored to individual patient needs.
Prioritizing a minimally invasive approach whenever feasible.
These recommendations underscore the need for a multidisciplinary and patient-centered approach to GYN surgery in obese patients, striving to optimize outcomes and minimize complications.
114
Obesity - pregnant
Obesity - pregnant
Obstetrics
Management of Obesity in Pregnancy: A Comprehensive Outline
The sources provide an in-depth look at the multifaceted issue of obesity in pregnancy, emphasizing its prevalence, associated complications, and evidence-based management strategies to optimize both maternal and fetal outcomes.
Understanding the Scope of the Problem
Obesity as a Prevalent Health Condition: Obesity, defined by a BMI of 30 or greater, has reached epidemic proportions globally and particularly in the United States. For women of reproductive age (20-39 years) in the U.S., the prevalence of obesity is a staggering 39.7%.
Trends and Disparities: While the overall prevalence of obesity and severe obesity (BMI ≥ 40) in the U.S. has been increasing, recent data (2017-2018) suggest a plateau in this trend. Notably, there are significant racial and ethnic disparities in obesity prevalence.
Categorizing Obesity: The World Health Organization classifies obesity into three classes based on BMI ranges: Class I (BMI 30.0-34.9), Class II (BMI 35.0-39.9), and Class III (BMI ≥ 40).
Risks and Complications Associated with Obesity in Pregnancy
Obesity during pregnancy is linked to a wide range of complications for both the mother and the developing fetus.
Maternal Complications
Pregnancy Loss: Obese women face a higher risk of spontaneous abortion and recurrent miscarriage compared to women with a normal BMI.
Congenital Anomalies: There is an increased risk of certain congenital anomalies in infants born to obese mothers. However, the risk of gastroschisis appears to be significantly reduced.
Antepartum Complications: Obesity increases the risk of various antepartum complications, including:
Cardiac dysfunction
Proteinuria
Sleep apnea
Nonalcoholic fatty liver disease
Gestational diabetes mellitus
Preeclampsia
Stillbirth
Intrapartum Complications:
Increased Risk of Cesarean Delivery: Numerous studies report a significantly elevated risk of cesarean delivery among overweight and obese women compared to their normal-weight counterparts. This is likely due to factors such as prolonged labor, increased risk of labor arrest, and concerns about fetal macrosomia.
Trial of Labor After Cesarean: Obese women attempting a trial of labor after cesarean delivery have a higher likelihood of maternal morbidity and neonatal injury.
Other Complications: Obesity is also associated with an increased risk of:
Failed trial of labor
Endometritis
Wound rupture or dehiscence
Venous thrombosis
Postpartum Complications:
Venous Thromboembolism: The risk of venous thromboembolism is significantly higher in obese women postpartum.
Excess Gestational Weight Gain and Postpartum Weight Retention: A large proportion of obese pregnant women gain weight beyond the Institute of Medicine (IOM) guidelines, increasing the risk of postpartum weight retention. This can lead to a cycle of metabolic dysfunction and pregravid obesity in subsequent pregnancies.
Other Issues: Obese women are also more likely to experience:
Early termination of breastfeeding
Postpartum anemia
Depression
Fetal Complications and Long-Term Health Impacts
Fetal Macrosomia and Impaired Growth: Obese mothers are at increased risk of having infants with macrosomia (excessive birth weight), while paradoxically also being at risk for impaired fetal growth.
Childhood Obesity and Metabolic Syndrome: Offspring of obese mothers are more likely to develop childhood obesity and metabolic syndrome later in life. This risk persists even after adjusting for complications like gestational diabetes mellitus.
Other Childhood Morbidities: Studies have linked maternal obesity to an increased risk of childhood asthma and altered behavior in children.
Preconception Counseling and Management
The optimal management of obesity in pregnancy starts before conception.
Weight Loss Before Pregnancy: Weight loss prior to conception, achieved through surgical or nonsurgical interventions, is the most effective strategy to improve obesity-related comorbidities and enhance pregnancy outcomes. Even modest weight reduction can have a positive impact.
Motivational Interviewing: This patient-centered counseling technique can help women with obesity set realistic goals, explore ambivalence towards behavior change, and make sustainable lifestyle modifications.
Weight Loss Medications: Medications for weight management are generally not recommended during the prepregnancy period or pregnancy due to safety concerns.
Management During Pregnancy
Prenatal care for obese pregnant women requires careful attention to several key aspects.
Assessment of BMI and Gestational Weight Gain: BMI should be calculated at the first prenatal visit and used to guide counseling on weight gain goals based on the IOM recommendations.
IOM Weight Gain Guidelines: The IOM recommends:
15-25 lb of weight gain for overweight pregnant women (BMI 25-29.9).
11-20 lb of weight gain for all obese women (BMI ≥ 30).
It is important to note that weight loss or inadequate weight gain during pregnancy is not recommended for obese women, as it can have adverse effects on fetal growth and increase the risk of a small-for-gestational-age (SGA) infant.
Dietary and Lifestyle Modifications:
Dietary Counseling: Nutrition counseling is crucial for all overweight and obese pregnant women. This should focus on healthy eating habits, portion control, and limiting processed foods and sugary drinks.
Exercise: Regular, moderate-intensity exercise is recommended, unless contraindicated.
Behavioral Interventions: Programs that combine dietary and exercise modifications with behavioral counseling have shown promise in preventing excessive gestational weight gain.
Screening and Management of Complications:
Congenital Anomalies: Obese women should be counseled about the limitations of ultrasound in detecting fetal anomalies due to technical challenges.
Metabolic Disorders: Early screening for gestational diabetes and overt diabetes is essential, especially for women with a BMI of 30 or greater. Screening for obstructive sleep apnea (OSA) is also recommended due to its increased prevalence in obese pregnant women.
Stillbirth: For women with a prepregnancy BMI of 35-39.9, weekly antenatal fetal surveillance may be considered starting at 37 weeks. For those with a BMI of 40 or greater, surveillance may be considered starting at 34 weeks.
Intrapartum Care:
Anesthesia Consultation: Early consultation with an anesthesiologist is advisable to plan for potential challenges related to airway management, positioning, and pain control.
Venous Thromboembolism Prophylaxis: Mechanical prophylaxis with pneumatic compression devices is recommended before and after cesarean delivery. Weight-based dosing of low molecular weight heparin (LMWH) may be preferable to BMI-stratified dosing in women with class III obesity.
Labor Management: Consider allowing a longer first stage of labor in obese women before resorting to cesarean delivery for labor arrest.
Trial of Labor After Cesarean: Obesity itself is not a contraindication for a trial of labor after cesarean. However, the decision should be made on a case-by-case basis after careful discussion of risks and benefits with the patient.
Postpartum Care:
Weight Management: Behavioral interventions that address both diet and exercise should be encouraged to help women achieve a healthier weight before a subsequent pregnancy.
Contraceptive Counseling: Discuss and provide appropriate contraceptive options to prevent unintended pregnancy and allow for healthy interpregnancy weight management.
Conclusion
Managing obesity in pregnancy is a complex endeavor that necessitates a multidisciplinary and individualized approach. The sources highlight the importance of:
Early Intervention: Preconception counseling and weight management are key to improving outcomes.
Comprehensive Prenatal Care: This includes careful monitoring of weight gain, addressing comorbid conditions, and anticipating potential complications.
Intrapartum and Postpartum Strategies: Specific considerations for anesthesia, labor management, thromboembolism prophylaxis, and postpartum weight loss are essential.
Long-Term Perspective: Addressing the intergenerational cycle of obesity and its related health risks is crucial for the well-being of both mothers and their children.
By implementing these evidence-based recommendations, healthcare providers can help obese pregnant women navigate the challenges of pregnancy and optimize outcomes for themselves and their infants.
115
Obstetric Analgesia and Anesthesia
Obstetric Analgesia and Anesthesia
Overview of Obstetric Analgesia and Anesthesia
This article, an ACOG Practice Bulletin, offers a comprehensive review of pain management options during labor and delivery, focusing on various methods of analgesia and anesthesia. It explores the physiological basis of labor pain, available pain relief methods, associated risks and benefits for both mother and fetus, and specific clinical considerations.
Understanding Labor Pain
The pain experienced during labor stems from two primary sources:
Visceral Pain: Originating from the uterus and cervix during the first stage of labor, this pain is typically diffuse and poorly localized, often felt in the lower abdomen and sometimes radiating to the lower back, buttocks, or thighs.
Somatic Pain: As labor progresses and the fetus descends, this pain arises from the stretching and pressure on the vagina, pelvic floor, and perineum. Transmitted through the pudendal nerve and sacral nerves, somatic pain is more localized.
Measuring pain intensity during labor poses a challenge due to the subjective nature of pain perception and the potential cognitive impairment caused by analgesic medications. Self-reported instruments like the visual analogue scale are commonly used, but their reliability is limited by individual variations in pain tolerance, expectations, and the influence of medication.
Analgesia and Anesthesia Options
The article emphasizes the importance of providing pain relief during labor and outlines various methods available, each with its own advantages and disadvantages. The choice of method depends on factors such as patient preference, medical status, and contraindications. Decisions should be made collaboratively between the patient, obstetrician-gynecologist, anesthesiologist, and support personnel.
Parenteral or Systemic Analgesia
Opioids: While commonly used due to their low cost and ease of administration, parenteral opioids have limited effectiveness in reducing pain scores, often leading to inconsistent analgesia and side effects like nausea and vomiting.
Common opioids used in the US include fentanyl, morphine, nalbuphine, butorphanol, and remifentanil, administered intramuscularly or intravenously.
Fentanyl can also be given intranasally.
Remifentanil, an ultra-short-acting opioid, is administered only as a patient-controlled intravenous infusion, offering better pain relief than other opioids but requiring close monitoring due to the risk of maternal apnea.
All opioids cross the placenta, potentially causing fetal heart rate changes, neonatal respiratory depression, and neurobehavioral effects.
Meperidine is generally not recommended because its active metabolite, normeperidine, has a long half-life in newborns, leading to prolonged effects that cannot be reversed by naloxone.
Nalbuphine and Butorphanol: These mixed agonist-antagonists are associated with less respiratory depression but should be avoided in patients on full opioid agonist treatment to prevent reduced analgesic effect or withdrawal symptoms.
Non-opioid Agents: These agents, including NSAIDs and antihistamines, are generally less effective than opioids in providing labor pain relief, although they might be more effective than placebo.
Regional (Neuraxial) Analgesia and Anesthesia
Regional techniques, administered by qualified healthcare providers, are considered highly effective for both labor analgesia and operative anesthesia with minimal adverse effects for mother and neonate.
Types of Regional Techniques:
Epidural Analgesia and Anesthesia: Involves placing a catheter into the epidural space for repeated or continuous administration of medications, typically a mixture of local anesthetic and opioid. This allows for lower doses of each agent, minimizing potential side effects.
Commonly used local anesthetics include bupivacaine and ropivacaine, which have similar outcomes and adverse effects.
Fentanyl and sufentanil are the commonly used opioids.
Epidural analgesia can be maintained through intermittent boluses, continuous infusion, or patient-controlled analgesia.
Single-Injection Spinal Anesthesia: Involves injecting a single dose of an opioid, local anesthetic, or both into the subarachnoid space. While not typically used for labor, it is common for cesarean delivery, providing rapid onset and dense sensory block.
Continuous Spinal Analgesia: Rarely used due to the risk of postdural puncture headache and past concerns about cauda equina syndrome.
Combined Spinal-Epidural Analgesia: This technique combines the rapid onset of spinal anesthesia with the flexibility of epidural analgesia. A subarachnoid injection of local anesthetic, opioid, or both is followed by continuous analgesia through the epidural catheter.
Comparison of Epidural and Combined Spinal-Epidural:
Combined spinal-epidural offers faster pain relief, but it is associated with a higher incidence of fetal bradycardia, attributed to the intrathecal opioids.
Fetal bradycardia in this context is independent of maternal hypotension and may be caused by the rapid onset of pain relief, which can lead to uterine hypertonus and reduced uteroplacental blood flow.
General Considerations for Regional Techniques:
More than 60% of women giving birth in the US opt for epidural or spinal analgesia.
Regional analgesia does not increase the cesarean delivery rate and should not be withheld based on this concern.
Early placement of a neuraxial catheter is recommended for women undergoing a trial of labor after cesarean.
Local Anesthesia
Local anesthetics are used for pudendal nerve blocks (providing pain relief in the second stage of labor or for perineal laceration repair) and for local infiltration of tissue during laceration repair.
Common local anesthetics: Bupivacaine, lidocaine, ropivacaine, chloroprocaine, and tetracaine.
Risks of local anesthetics: Allergic reactions, toxicity from excessive absorption or accidental intravascular injection. Toxicity can manifest as neurological or cardiac symptoms.
Treatment of toxicity: Cardiovascular collapse or seizure should be treated in a standard evidence-based manner. Hypoxemia and acidosis, which can worsen toxicity, should be addressed promptly with intravenous lipid emulsion administration by an anesthesiologist.
Inhaled Agents
Nitrous oxide, an anesthetic gas, offers self-administered analgesia during labor and postpartum repair.
Administered as a 50% mix with oxygen through a demand valve and mask.
Provides less effective pain relief compared to epidural analgesia, but allows for mobility, doesn't require extra monitoring, and has a rapid offset of effect once the mask is removed.
Transmitted to the placenta but quickly eliminated by the neonate.
Maternal side effects: Nausea, vomiting, dizziness, and drowsiness.
Can be safely used with other forms of analgesia.
General Anesthesia
General anesthesia is rarely used for vaginal or cesarean deliveries unless in emergencies or when regional anesthesia is not feasible or has failed.
Risks and considerations: Pregnant women are at increased risk of aspiration of gastric contents due to physiological changes during pregnancy and labor.
Airway management is more challenging in pregnant patients, and the risk of failed intubation is significantly higher compared to non-pregnant surgical patients.
Maternal and Fetal Risks and Considerations
Maternal Morbidity and Mortality
Obstetric analgesia and anesthesia are associated with a low risk of maternal morbidity and mortality, with anesthesia-related maternal deaths being rare in high-income countries.
The Society for Obstetric Anesthesia and Perinatology's Serious Complication Repository Project tracks severe adverse outcomes associated with obstetric anesthesia. Data from 30 US institutions over a 5-year period revealed a low incidence of serious complications.
Common Maternal Side Effects:
Hypotension: Caused by sympathetic blockade associated with neuraxial techniques. It can be prevented with fluid preloading or coloading, or treated with intravenous vasopressors like ephedrine or phenylephrine.
Pruritus: Commonly associated with neuraxial opioid use, particularly intrathecal administration. It can be managed with low doses of naloxone or nalbuphine, although this may reduce the analgesic effect. Antihistamines have also been used, but their effectiveness in centrally-induced pruritus is limited.
Other side effects: Nausea, vomiting, fever, shivering, urinary retention, and reactivation of oral herpes.
Fetal Risks
Fetal risks primarily stem from maternal effects like hypotension or the placental transfer of analgesic and anesthetic drugs.
Opioids: Can cause neonatal depression, manifested by low Apgar scores, respiratory depression, reduced muscle tone, and poor suckling. These effects are more pronounced with intravenous opioid administration compared to neuraxial administration.
Fetal Heart Rate Abnormalities: Commonly observed after parenteral opioid administration.
Combined Spinal-Epidural Analgesia: Compared to epidural analgesia alone, combined spinal-epidural is associated with a higher incidence of elevated uterine tone and fetal heart rate abnormalities, such as bradycardia and prolonged decelerations. These effects are independent of maternal hypotension and may be linked to the rapid pain relief and its impact on uteroplacental blood flow.
Clinical Considerations and Recommendations
The article provides specific recommendations and addresses common clinical questions regarding the use of analgesia and anesthesia in various scenarios. These recommendations are graded based on the level of scientific evidence supporting them.
Key Recommendations Based on Strong Evidence (Level A):
Neuraxial analgesia does not increase the cesarean delivery rate.
Opioids carry a risk of respiratory depression for both the mother and neonate, requiring careful monitoring of respiratory status.
Recommendations Based on Limited or Inconsistent Evidence (Level B):
Spinal anesthesia, combined spinal-epidural, or general anesthesia are appropriate for emergency cesarean deliveries when an epidural is not in place.
A safe lower limit for platelet count in women with thrombocytopenia who are considering neuraxial blockade has not been established.
Recommendations Based Primarily on Expert Opinion (Level C):
In the absence of medical contraindications, maternal request is sufficient justification for pain relief during labor.
Epidural and spinal analgesia are generally considered safe for patients with platelet counts greater than or equal to 70 x 109/L, provided certain conditions are met.
Conclusion
This article presents a comprehensive overview of pain management during labor and delivery, highlighting the importance of individualized care based on patient preferences, medical conditions, and a thorough understanding of the risks and benefits associated with different analgesia and anesthesia techniques. It emphasizes collaboration between the patient, obstetrician-gynecologist, anesthesiologist, and support personnel to ensure the safest and most effective pain management strategy.
116
Obstetrical vaginal lacerations
Obstetrical vaginal lacerations
Obstetric Lacerations at Vaginal Delivery: A Comprehensive Overview
This article, an ACOG Practice Bulletin, provides evidence-based guidelines on the prevention, identification, and repair of obstetric lacerations that can occur during vaginal delivery. It discusses the anatomy of the perineum, the incidence and classification of lacerations, the use and impact of episiotomy, and various management strategies.
Perineal Anatomy and Lacerations
The female external genitalia, including the mons pubis, labia majora and minora, clitoris, vaginal vestibule, and perineal body, are susceptible to trauma during childbirth.
The perineal body, composed of dense connective tissue and muscles, is the most common site of lacerations.
Lacerations are classified based on severity:
First-degree: Involves only the perineal skin.
Second-degree: Extends into the perineal muscles but not the anal sphincter.
Third-degree: Involves the anal sphincter complex, with varying degrees of sphincter involvement (3a, 3b, 3c).
Fourth-degree: Involves the anal sphincter complex and the anal epithelium.
Severe perineal lacerations, also known as obstetric anal sphincter injuries (OASIS), include third- and fourth-degree lacerations.
OASIS are associated with increased risk of long-term complications such as:
Pelvic floor injury
Fecal and urinary incontinence
Pain
Sexual dysfunction
The incidence of lacerations varies, but studies suggest:
53-79% of women sustain some type of laceration during vaginal delivery.
Most lacerations are first- or second-degree.
The true incidence of OASIS is estimated to be around 11%.
Episiotomy: Use, Types, and Impact
Episiotomy is a surgical incision made to the perineum during the second stage of labor to enlarge the vaginal opening.
Types of episiotomy:
Midline (median): The most common type in the US, extending downward from the posterior fourchette.
Mediolateral: More common in Europe, extending laterally from the posterior fourchette towards the ischial tuberosity.
National episiotomy rates have declined since 2006, with approximately 12% of vaginal births in the US involving episiotomy in 2012.
Current evidence does not support routine use of episiotomy.
The impact of episiotomy on pelvic floor function and long-term outcomes is debated:
Some studies associate episiotomy with an increased risk of anal incontinence, particularly midline episiotomy.
Others find no significant association between episiotomy and pelvic organ prolapse, stress urinary incontinence, or sexual dysfunction.
More research is needed to clarify the effects of episiotomy and determine specific indications for its use.
Risk Factors for Obstetric Anal Sphincter Injuries
Several factors increase the risk of OASIS:
Operative vaginal delivery (forceps or vacuum)
Midline episiotomy
Increased fetal birth weight
Primiparity (first vaginal delivery)
Asian ethnicity
Labor induction or augmentation
Epidural anesthesia
Persistent occiput posterior fetal position
Family history of OASIS
Maternal age, pregnancy duration, body mass index, and duration of the second stage of labor are not significantly associated with OASIS risk.
Prevention Strategies for Perineal Trauma
Various interventions have been studied to reduce the risk of perineal trauma during delivery, including:
Antepartum or intrapartum perineal massage: May reduce perineal trauma requiring sutures and episiotomy rates in women without prior vaginal birth. Perineal massage during the second stage of labor may reduce OASIS.
Manual perineal support: Evidence regarding effectiveness is inconclusive, and further research is needed to recommend a specific technique.
Warm compresses: Applying warm compresses to the perineum during pushing is recommended to reduce the risk of third- and fourth-degree lacerations.
Birthing position: Evidence is mixed, with some studies suggesting upright or lateral positions may reduce episiotomies and operative deliveries, while others find no clear benefit.
Delayed pushing: Studies have not shown a significant difference in perineal laceration or episiotomy rates between delayed and immediate pushing.
Repair and Management of Obstetric Lacerations
Diagnosis and Repair:
Adequate lighting, exposure, and analgesia are crucial for diagnosing lacerations.
A digital rectal examination can help identify OASIS.
The apex of the laceration must be identified for proper closure and hemostasis.
Specific Repair Techniques:
Periclitoral, periurethral, and labial lacerations: Repair is recommended if bleeding or anatomical distortion is present.
First- and second-degree lacerations: Evidence supporting surgical versus nonsurgical repair is limited, and clinical judgment should guide the decision.
Episiotomy and second-degree lacerations: Continuous suturing is preferred over interrupted suturing due to reduced pain, analgesia use, and suture removal needs.
Vulvar, vaginal, and cervical lacerations: Repair is typically not necessary unless bleeding or anatomical distortion is present. Specific techniques are described in the article.
OASIS (third- and fourth-degree lacerations): The article details specific techniques for repairing the anal mucosa, internal and external anal sphincters, including suture types and methods (end-to-end vs. overlap).
Antibiotics: A single dose of antibiotics at the time of repair is recommended for OASIS.
Postpartum Management:
Immediate care: Focuses on pain control, preventing constipation (stool softeners and laxatives are recommended), and monitoring for urinary retention.
Pain management: Various options are discussed, including topical anesthetics, ice packs, rectal suppositories, NSAIDs, and opiates.
Complications: Bleeding, infection, wound breakdown, and fistula formation are potential complications. The article provides guidance on managing these issues.
Long-term care: Pelvic floor exercises and biofeedback therapy may be considered, but evidence supporting their effectiveness in preventing anal incontinence is mixed. Women should be monitored for long-term complications like anal incontinence and referred for treatment if necessary.
Counseling for Subsequent Pregnancies:
Women with a history of OASIS should be counseled about the risks and benefits of vaginal versus cesarean delivery in subsequent pregnancies.
The absolute risk of OASIS recurrence with vaginal delivery is low (3%).
Cesarean delivery may be offered based on patient request after discussing the associated risks.
Asymptomatic women without sphincter compromise may choose vaginal delivery.
Conclusion
This article offers comprehensive guidelines for managing obstetric lacerations, emphasizing a patient-centered approach that considers individual preferences, medical history, and the latest evidence. While it outlines specific recommendations and techniques, it acknowledges the need for further research in some areas and emphasizes the importance of clinical judgment in making individualized decisions.
117
Oligohydramnios
Oligohydramnios
Late-Preterm and Early-Term Deliveries: When Are They Necessary?
This article, an ACOG Committee Opinion, focuses on medically indicated late-preterm (34 0/7–36 6/7 weeks of gestation) and early-term (37 0/7–38 6/7 weeks of gestation) deliveries. While elective deliveries before 39 weeks are discouraged due to associated neonatal risks, there are certain maternal, fetal, and placental conditions that warrant an earlier delivery.
Balancing Risks and Benefits
The key principle is to carefully weigh the risks and benefits for both the mother and the newborn when considering delivery timing. Delaying delivery to 39 weeks is not recommended if there's a medical reason for earlier intervention.
Decision-Making Factors
Individualized Care: Decisions about delivery timing should be made on a case-by-case basis, considering individual patient needs and preferences.
Accurate Gestational Age: Knowing the precise gestational age is crucial for making informed decisions about delivery timing.
Role of Fetal Lung Maturity Testing
Amniocentesis to determine fetal lung maturity should not be used to decide delivery timing. The reasons for this include:
Existing Indication: If a medical reason already exists for a late-preterm or early-term delivery, it should proceed regardless of lung maturity test results.
Imperfect Prediction: Mature amniotic fluid indicators don't guarantee the absence of neonatal respiratory problems and may not reflect the maturity of other organ systems.
Antenatal Corticosteroids
For anticipated late-preterm deliveries, a single dose of antenatal betamethasone is recommended within 7 days of delivery for women who haven't had a previous course.
However, a medically indicated late-preterm delivery should not be delayed to administer corticosteroids.
Specific Conditions and Delivery Timing
Table 1 in the source provides recommendations for the timing of delivery for various conditions, categorized as placental/uterine, fetal, and maternal. Examples include:
Placenta previa: Delivery between 36 0/7 and 37 6/7 weeks of gestation is suggested.
Growth restriction (singleton fetus): Delivery timing depends on estimated fetal weight and the presence of other complicating factors.
Multiple gestations: Timing varies depending on the type of multiples (dichorionic-diamniotic, monochorionic-diamniotic, etc.) and the presence of complications.
Hypertensive disorders of pregnancy: Timing recommendations vary based on the type and severity of the hypertensive disorder.
Diabetes: Control of diabetes influences the suggested delivery timing.
Preterm prelabor rupture of membranes (PROM): Delivery between 34 0/7 and 36 6/7 weeks of gestation is recommended, considering maternal and neonatal risks and patient preferences.
Note: This list is not exhaustive, and some conditions (like uterine dehiscence or chronic placental abruption) lack clear data to guide delivery timing. These situations require individualized decisions based on the clinical picture.
Addressing Competing Indications
The sources mention an ACOG applet designed to help clinicians navigate complex cases where multiple factors might influence the decision for a late-preterm or early-term delivery.
Conclusion
The article highlights the importance of a nuanced approach to delivery timing when medical indications exist for delivering before 39 weeks. The recommendations provided are not absolute and should be tailored to each patient's unique circumstances.
118
Operative vaginal delivery
Operative vaginal delivery
Obstetrical Emergencies
Introduction and Counseling
1. Counseling the Patient:
• “I would begin by explaining to the patient and her support team the need for operative assistance to help deliver the baby. I would inform her of the two options—vacuum or forceps—and discuss the potential risks, benefits, and what to expect during the procedure.”
• “I would explain that the goal is to expedite delivery due to reasons such as fetal distress or maternal exhaustion, ensuring her informed consent.”
• “I would discuss potential risks, such as bruising or minor injuries to the baby’s head with vacuum or forceps use, and the possibility of maternal perineal trauma. I would also explain that, if unsuccessful, a cesarean delivery might still be necessary.”
2. Obtaining Consent:
• “I would obtain informed consent, ensuring the patient understands and agrees to proceed with the operative vaginal delivery.”
Patient Evaluation
1. Indications and Examination:
• “I would confirm that operative vaginal delivery is indicated due to factors like prolonged second stage of labor, non-reassuring fetal status, or maternal exhaustion.”
• “I would perform a thorough assessment to ensure the fetal head is in a favorable position, at least at +2 station, and that the cervix is fully dilated, with ruptured membranes.”
• “I would evaluate the pelvis to confirm it is adequate for vaginal delivery, minimizing the risk of obstructed labor.”
2. Contraindications:
• “I would confirm there are no contraindications to operative vaginal delivery, such as:
• Incomplete cervical dilation
• High fetal station (above +2)
• Fetal position not clearly identifiable
• Suspected cephalopelvic disproportion
• Fetal bleeding disorders (for vacuum)
• Fetal demineralizing bone disease
• Gestation below 34 weeks for vacuum (due to soft skull).”
3. Assessing Conditions for Success:
• “I would ensure that the maternal bladder is emptied, adequate anesthesia is provided, and that the operating room is prepared as a backup in case a cesarean becomes necessary.”
Procedure: Vacuum-Assisted Delivery
1. Vacuum Setup:
• “I would choose the appropriate vacuum device and inspect it to ensure all parts are functional. I would use a flexible or rigid cup, depending on the fetal station and position.”
• “I would apply the vacuum cup to the fetal head at the flexion point (approximately 3 cm anterior to the posterior fontanelle), aiming to keep the head flexed during delivery.”
2. Applying Suction:
• “I would gradually apply suction in stages, starting with a low level and increasing to 500-600 mmHg once the cup is securely attached.”
3. Traction and Delivery:
• “With each contraction, I would apply gentle, steady traction along the pelvic curve. I would adjust my traction in coordination with maternal pushing efforts.”
• “I would limit the procedure to a maximum of three pulls or 15-20 minutes, and if the fetal head does not descend with these efforts, I would abandon the procedure and consider alternatives.”
4. Abandoning Vacuum:
• “I would abandon the procedure if the cup detaches three times, if there is no descent with each pull, or if there are signs of excessive maternal or fetal trauma.”
Procedure: Forceps-Assisted Delivery
1. Forceps Selection and Preparation:
• “I would select the appropriate forceps type based on fetal head position—Simpson forceps for an occiput anterior position or Kielland forceps for rotational assistance.”
• “I would inspect the forceps to ensure they are in proper working order.”
2. Applying Forceps:
• “I would insert the blades sequentially:
• I would hold the left blade in my left hand, gently guiding it along the maternal pelvis to rest against the fetal head without crossing the midline.
• Once the left blade is in place, I would insert the right blade in a similar manner, ensuring that both blades articulate smoothly without excessive force.”
• “I would lock the handles once both blades are appropriately positioned.”
3. Traction and Delivery:
• “I would apply gentle, controlled traction in line with the maternal pelvis and in synchrony with contractions and maternal pushing. I would direct the traction downward initially, following the natural curve of the pelvis.”
• “As the fetal head descends, I would adjust traction upward to guide the head out under the symphysis pubis, assisting rotation as needed.”
4. Abandoning Forceps:
• “I would abandon the procedure if there is no descent with each traction effort, if the fetal head does not advance with each pull, or if I encounter resistance or any signs of potential trauma to the fetus or mother.”
Post-Delivery Management
1. Assessing Maternal and Neonatal Outcomes:
• “After delivery, I would assess the baby for any signs of trauma, such as scalp bruising or lacerations from the vacuum or forceps, and ensure immediate neonatal care if needed.”
• “I would perform a careful examination of the mother for any perineal lacerations or other trauma related to the operative delivery, ensuring appropriate repair and postpartum management.”
2. Follow-Up and Counseling:
• “I would provide counseling on what to expect in terms of postpartum recovery and monitor both the mother and baby closely for any delayed complications. I would also offer reassurance and address any questions or concerns from the patient and family regarding the operative delivery.”
This script combines structured steps for both vacuum and forceps deliveries, emphasizing careful patient selection, counseling, procedure execution, and criteria for abandonment to ensure safe and effective management of operative vaginal delivery. Let me know if you’d like more detail on any part.
119
Osteoporosis
Osteoporosis
Gynecology
Osteoporosis Management Presentation Outline
I. Introduction
Osteoporosis is a common skeletal disorder characterized by low bone mineral density (BMD), microarchitectural deterioration, and decreased bone quality, leading to increased fracture risk. [1, 2]
It's a silent disease until a fracture occurs. [1, 2]
This presentation focuses on management, encompassing diagnosis and treatment of postmenopausal osteoporosis. [2, 3]
II. Diagnosis
Dual-energy X-ray absorptiometry (DXA) is the preferred test, measuring BMD at the hip and lumbar spine. [4, 5]
T-score compares an individual's BMD to a healthy young-adult reference population. [4, 5]
Osteoporosis is diagnosed with a T-score ≤ -2.5. [4, 6]
Osteopenia (low bone density) is indicated by a T-score between -1.0 and -2.5. [5, 6]
Fragility fracture (resulting from a fall from standing height or less) is diagnostic of osteoporosis, even with normal BMD. [4, 7]
Secondary causes of bone loss should be evaluated before starting treatment, especially in patients with very low BMD or multiple/recent fractures. [8]
III. Treatment
A. Candidates for Pharmacotherapy
Pharmacologic treatment is recommended for postmenopausal patients with: [9, 10]
T-score ≤ -2.5. [11]
History of fragility fracture. [11]
T-score between -1.0 and -2.5 and increased fracture risk as determined by a clinical risk assessment tool (e.g., FRAX). [11]
Secondary osteoporosis related to medications or medical conditions needs to be addressed. [8]
The need for bone-loss-inducing medications should be assessed with the prescribing physician. [8]
Referral to an endocrinologist or osteoporosis specialist may be necessary for unclear etiology or secondary causes. [8]
B. Pharmacotherapy Options
Antiresorptive agents: [12]
Bisphosphonates: first-line therapy for most patients, reducing vertebral, nonvertebral, and hip fractures. [13, 14]
Alendronate, risedronate, zoledronic acid are recommended. [13]
Consider "drug holidays" after 5 years of oral or 3 years of intravenous treatment for low-to-moderate risk patients. [15]
Longer treatment (up to 10 years for oral, 6 years for IV) suggested for high-risk patients. [15]
Denosumab: recommended for patients preferring subcutaneous administration every 6 months. [16]
Shows greater improvement in bone strength than bisphosphonates. [17]
Raloxifene: for patients with increased risk of vertebral fracture and breast cancer who are at low risk for venous thromboembolism and don't have significant vasomotor symptoms. [18]
Hormone therapy and calcitonin: generally reserved for patients intolerant of other therapies. [19]
Anabolic agents: [12]
Teriparatide and abaloparatide: recommended for patients at very high fracture risk or those who continue to have fractures or bone loss while on antiresorptive therapy. [20]
Treatment limited to 2 years due to the risk of osteosarcoma. [20]
Romosozumab: for patients at high risk of fracture. [21]
Followed by an antiresorptive agent to maintain benefits. [22]
C. Nonpharmacologic Interventions
Calcium and Vitamin D: recommended daily intake through diet or supplementation, especially for patients on pharmacotherapy or who can't tolerate it. [23, 24]
Lifestyle interventions: [25]
Fall prevention strategies (vision assessment, balance training, environmental modification). [26]
Regular aerobic and weight-bearing exercises. [27]
Smoking cessation and alcohol reduction. [28]
D. Treatment Monitoring
DXA testing every 1-3 years to monitor bone loss, depending on clinical circumstances. [29]
Evaluate and address reasons for suboptimal response to therapy (poor adherence, secondary causes, bone-loss-inducing medications). [29]
Renal function, serum calcium, and vitamin D levels should be checked every 1-2 years. [29]
Vertebral fracture assessment may be necessary for patients with height loss, prior vertebral fracture, or those on glucocorticoid therapy. [23]
E. Referral
Consider referral to an endocrinologist or osteoporosis specialist for patients with: [30]
T-score < -3.0. [31]
New fragility fracture. [31]
Normal BMD with fragility fracture. [31]
Recurrent fractures or bone loss despite treatment. [31]
Unusual or unresponsive osteoporosis. [31]
Endocrine or metabolic causes of secondary osteoporosis. [31]
Comorbidities complicating treatment. [31]
Patients hospitalized with a fragility fracture should consult a fracture liaison team or bone specialist. [30]
This outline provides a comprehensive overview of postmenopausal osteoporosis management, drawing upon the provided sources. You may want to adapt it based on your specific presentation needs and audience. Please note that this outline is based solely on the provided sources.
120
Ovarian cyst
Ovarian cyst
121
Pap Smear Guidelines
Pap Smear Guidelines
Gynecology
Cervical Cancer Screening Guidelines
This article provides guidelines for cervical cancer screening using Pap tests, HPV tests, or a combination of both. It outlines recommendations based on age and other factors, emphasizing regular screening to detect and address cervical changes early.
Understanding Cervical Cancer Screening
Cervical cancer screening aims to detect abnormal cells or HPV infections linked to cervical cancer. This involves collecting cells from the cervix for laboratory analysis.
Pap Test: Identifies abnormal cells in the cervix.
HPV Test: Detects infection with high-risk HPV types associated with cervical cancer.
Age-Based Screening Recommendations
The guidelines recommend different screening approaches depending on a woman's age:
Younger than 21: No screening is necessary.
21 to 29: A Pap test every 3 years is recommended. HPV testing alone is also an option for women aged 25 to 29, but Pap tests are preferred.
30 to 65: Women have three options:
Co-testing: A Pap test and an HPV test every 5 years.
Pap Test: Every 3 years.
HPV Test: Every 5 years.
65 or Older: Screening is not necessary if a woman has no history of cervical changes and meets any of the following criteria within the past 10 years:
Three consecutive negative Pap test results.
Two consecutive negative HPV test results.
Two consecutive negative co-test results.
Important Note: The most recent test should have been performed within the past 3 to 5 years, depending on the test type.
Continued Screening After Vaccination and Hysterectomy
HPV Vaccination: Even women who have received the HPV vaccine should still undergo regular cervical cancer screening as recommended.
Hysterectomy: Screening may still be necessary after a hysterectomy if the cervix was not removed.
Continued screening for 20 years after surgery is recommended for women with a history of cervical cancer or moderate to severe cervical changes.
Screening is not needed for women with no history of cervical cancer or cervical changes after a hysterectomy where the cervix was removed.
Exceptions to Standard Guidelines
More frequent screening may be necessary for women with:
HIV infection.
Weakened immune systems.
A history of cervical cancer.
Exposure to diethylstilbestrol before birth.
Importance of Regular OB-GYN Visits
Even if a woman is not due for cervical cancer screening, regular visits to an OB-GYN are essential for other aspects of reproductive health, including:
Birth control counseling.
Vaccinations.
Health screenings.
Prepregnancy care.
Staying updated on reproductive health information.
Disclaimer
The source emphasizes that the information provided is intended as an educational aid and not a substitute for professional medical advice. It does not encompass all possible treatments or represent the standard of care. Women should consult with their healthcare provider for personalized guidance and care.
Age, prior pap smear history, current, HPV
4% repeat of pap smear
10%
60%
CIN III risk
122
PCOS
PCOS
Gynecology
PCOS: A Comprehensive Outline
I. Definition and Diagnostic Criteria
Polycystic Ovary Syndrome (PCOS) is a hormonal disorder affecting women of reproductive age. [1]
It is characterized by:
Hyperandrogenism: excessive levels of androgens (male hormones). [1, 2]
Ovulatory Dysfunction: infrequent or absent ovulation. [1, 2]
Polycystic Ovaries: the presence of multiple small follicles in the ovaries. [1, 2]
No universally accepted definition exists, and different expert groups have proposed varying criteria. [2]
Three main diagnostic schemes:National Institutes of Health (NIH) Criteria: requires both hyperandrogenism and oligo-amenorrhea or amenorrhea. [2, 3]
Rotterdam Criteria: requires two out of three features: hyperandrogenism, oligo-amenorrhea or amenorrhea, and polycystic ovaries by ultrasound. [2, 3]
Androgen Excess Society (AES) Criteria: requires hyperandrogenism plus either oligo-amenorrhea or amenorrhea, or polycystic ovaries by ultrasound. [2, 3]
It is important to exclude secondary causes of these symptoms before diagnosing PCOS. [2]
II. Prevalence
The prevalence of PCOS varies depending on the diagnostic criteria used. [4]
Using the NIH criteria, approximately 7% of reproductive-aged women have PCOS. [4]
The broader Rotterdam criteria estimate a prevalence of 9-11%. [4]
III. Etiology
The exact cause of PCOS is unknown. [1, 5]
Several factors likely contribute, including:
Genetics: though no specific gene has been identified and genetic screening is not currently recommended. [5]
Insulin Resistance: may be central to the development of PCOS. [5]
This can lead to decreased levels of sex hormone-binding globulin (SHBG), making more androgen bioavailable. [5]
It may also stimulate androgen production in the adrenal glands and ovaries. [5]
Obesity: is a common comorbidity that can worsen PCOS symptoms. [5]
However, not all women with PCOS are obese. [5]
IV. Clinical Manifestations
Women with PCOS often present with a variety of symptoms: [6, 7]
Menstrual Irregularities: ranging from amenorrhea to menorrhagia. [6]
Infertility: due to ovulatory dysfunction. [6]
Increased risk of complications during pregnancy, including gestational diabetes and hypertensive disorders. [6]
Skin disorders: such as hirsutism (excess hair growth), acne, and androgenic alopecia (hair loss). [7]
Metabolic abnormalities: including insulin resistance, metabolic syndrome, nonalcoholic fatty liver disease, and obesity-related disorders like sleep apnea. [7]
Increased risk factors for endometrial cancer, though the direct link with PCOS is debated. [7]
Mood disturbances and depression. [7]
V. Differential Diagnosis
Other conditions can cause similar symptoms to PCOS, and it's crucial to rule them out through a thorough history, physical exam, and laboratory tests. [8]
Conditions to consider in the differential diagnosis: [8, 9]
Androgen-secreting tumors (ovarian or adrenal)
Exogenous androgen use
Cushing syndrome
Nonclassical congenital adrenal hyperplasia (CAH)
Acromegaly
Genetic defects in insulin action
Primary hypothalamic amenorrhea
Primary ovarian failure
Thyroid disease
Prolactin disorders
VI. Treatment
PCOS treatment focuses on managing individual symptoms and reducing long-term health risks. [1]
Menstrual Irregularities:Combination Hormonal Contraceptives: recommended as the primary treatment for menstrual disorders. [10, 11]
Progestin-only contraceptives or progestin-containing intrauterine devices: an alternative for endometrial protection but can cause abnormal bleeding. [12]
Infertility:Lifestyle modifications: weight loss and exercise are recommended before other interventions. [13, 14]
Letrozole (aromatase inhibitor): considered first-line therapy for ovulation induction due to higher live birth rates compared to clomiphene citrate. [15-17]
Clomiphene Citrate (antiestrogen): traditionally the first-line treatment but recent evidence suggests letrozole is more effective. [15, 18]
Gonadotropins or Laparoscopic Ovarian Surgery: recommended as second-line treatments if letrozole or clomiphene citrate are unsuccessful. [15, 19-21]
Metformin (insulin-sensitizing agent): alone is not as effective as clomiphene citrate for live birth, but may be beneficial when combined with clomiphene citrate, especially in obese women. [21, 22]
Hirsutism:Combination Therapies: generally more effective than single-agent approaches. [23]
Combined Hormonal Contraceptives: may improve hirsutism, but evidence is limited. [24]
Antiandrogens (spironolactone, flutamide, finasteride): can be effective but have potential side effects and teratogenic risks. [25-28]
These should be used in combination with oral contraceptives. [25]
Metformin: limited evidence for its efficacy in treating hirsutism. [29]
Eflornithine HCl cream: FDA-approved for treating facial hirsutism, with moderate effectiveness. [30]
Laser Treatment: can be effective for hair removal, often used in conjunction with medical management to prevent regrowth. [31, 32]
Adding eflornithine to laser treatment is more effective than laser alone. [32, 33]
Cardiovascular Disease and Diabetes Risks:Lifestyle Modifications: increased exercise and dietary changes are crucial for reducing risks. [17, 34, 35]
Metformin: may help delay the development of diabetes in high-risk individuals. [36]
Statins: may offer cardiovascular and endocrine benefits but long-term effects in young women are unknown. [37]
Combined Hormonal Contraceptives and Progestins: may be considered, but their effects on diabetes and cardiovascular risk in PCOS are not fully understood. [38]
Low-dose hormonal contraceptives are recommended. [11, 38]
123
Pediatric gynecology
Pediatric gynecology
Counseling Adolescents on Contraception
Introduction
Counseling adolescents about contraception requires a sensitive and comprehensive approach that respects their autonomy while ensuring they have the information and resources to make informed decisions about their reproductive health. It is important to establish a trusting relationship, address their individual needs and concerns, and provide accurate and unbiased information about all available contraceptive options, including long-acting reversible contraception (LARC) and emergency contraception.
Confidentiality
Confidentiality is crucial for adolescents seeking reproductive health care services.
Lack of confidentiality can be a barrier to accessing care.
Obstetrician-gynecologists should establish procedures and routines that safeguard the privacy of adolescent patients.
Confidentiality should be discussed with the adolescent and, as appropriate, with their parent(s) or guardian(s) during the initial visit.
Statutes on minors' rights to consent to health care services vary by state.
Obstetrician-gynecologists should be familiar with the regulations in their practice.
When confidential services cannot be provided, referral to Title X Federal Family Planning program clinics should be considered.
Discussing Contraception
The obstetrician-gynecologist should routinely address the adolescent's contraceptive needs, expectations, and concerns, regardless of age or previous sexual activity.
Discussions about contraception should begin with information on the most effective methods first.
LARC methods have higher efficacy, continuation, and satisfaction rates compared with short-acting contraceptives and are safe and excellent contraceptive choices for adolescents.
The CDC suggests taking a sexual history that encompasses the 5 Ps: Partners, Practices, Protection from STDs, Past history of STIs, and Prevention of pregnancy.
Emergency contraception should routinely be included in discussions about contraception, including access issues.
Obstetrician-gynecologists should write advance prescriptions for oral emergency contraception for their patients.
A copper intrauterine device (IUD) should be considered as an alternative to oral emergency contraception.
Counseling may be better received in an adolescent-friendly environment.
Adolescents' right of refusal for initiating or discontinuing a method should be addressed. They should not be forced to use a method chosen by someone else.
Addressing Common Misperceptions
Adolescents may have misperceptions and concerns about contraceptive methods.
Obstetrician-gynecologists should be aware of and prepared to address these concerns and counsel appropriately.
Candidacy for the use of individual methods is detailed in the CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.
There are no restrictions on any method based on age alone.
The CDC's U.S. Selected Practice Recommendations for Contraceptive Use, 2016 provides evidence-based information regarding required testing and follow-up, initiation and timing, missed dosages, and adverse effect management.
Open-ended and direct questions can help adolescents express their concerns or beliefs.
Special Considerations
Contraceptive counseling for adolescents with mental health issues or intellectual or physical disabilities may require awareness of other barriers and issues, and the implementation of additional counseling strategies.
Young women with medical comorbidities should be counseled about the potential effect their condition could have on a pregnancy or that pregnancy could have on their condition.
Obstetrician-gynecologists should consult the CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 for information on contraceptive counseling for patients with medical comorbidities.
Adolescents with disabilities should receive the same information on contraception as other patients, including the option of private time with the obstetrician-gynecologist.
Obstetrician-gynecologists should be aware of state laws surrounding health care power of attorney documents and consent processes that may apply to patients living with disabilities.
Follow-Up
Assessing adherence to and satisfaction with the chosen method is important.
Follow-up can be done via in-person visits, telephone calls, or electronic communication.
The availability of follow-up should be explained to the patient and documented in the record, and they should be provided with contact information.
The initial encounter and follow-up visits should include continual reassessment of sexual concerns, behavior, relationships, prevention strategies, and testing and treatment for STIs per CDC guidelines.
Conclusion
Effective contraceptive counseling for adolescents involves establishing a trusting and confidential relationship, providing comprehensive and accurate information, addressing individual needs and concerns, respecting their autonomy, and ensuring access to appropriate resources and services. It is essential to empower adolescents to make informed decisions about their reproductive health and support them in their choices.
124
Pelvic inflammatory disease
Pelvic inflammatory disease
Obstetrical Emergencies
Clinical Elements of PID
PID Definition: Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
Prevalence: PID is difficult to diagnose, so the incidence and prevalence in the United States are difficult to estimate. One study utilizing data from 2013-2016 estimates that 2 million or more reproductive-aged women in the US have been diagnosed with PID. For women with a previously diagnosed STI, the lifetime prevalence of PID has been estimated to be even higher, at 10%.
Trends: Available data suggests that the incidence of PID in the US has been declining overall since the year 2000. This decline is likely due to increased screening and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae in young women.
Causes: PID is most often caused by sexually transmitted infections (STIs), primarily N. gonorrhoeae and C. trachomatis.
Historically, these two pathogens were implicated in up to 50% of PID cases. However, in recent years, the proportion of cases attributable to these organisms has decreased.
Other microorganisms that comprise the vaginal flora have been associated with PID. These include strict and facultative anaerobes, G. vaginalis, H. influenzae, enteric gram-negative rods, and Streptococcus agalactiae.
Other pathogens that may contribute to PID include:
M. genitalium
T. vaginalis
CMV
M. hominis
U. urealyticum
Risk Factors
Factors associated with an increased risk for developing PID include:
Age younger than 25 years
Multiple sex partners
History of PID
History of gonorrhea or chlamydia
Vaginal douching
Recent IUD insertion
Male partners with gonorrhea or chlamydia
Bacterial vaginosis
Oral contraceptive use
Early age of sexual debut
Inconsistent condom use
Screening sexually active women for chlamydia and gonorrhea reduces their risk for PID. However, it is unclear whether treating bacterial vaginosis reduces PID incidence. Additionally, the impact of screening for M. genitalium on PID incidence is unknown.
Pathogenesis
PID is typically caused by the ascending spread of microorganisms from the lower genital tract to the upper genital tract.
This ascent can occur as a normal physiological event, but whether the organisms trigger PID depends on several factors. These include the number and viability of the organisms, their pathogenicity, and the host's immune defenses.
The ascending organisms trigger an inflammatory response, which can lead to fallopian tube damage, including a loss of cilia and subsequent dysregulation of egg transport. This increases the risk of ectopic pregnancy.
Clinical Manifestations
Symptoms: Women with PID present with a range of clinical manifestations.
Some women are asymptomatic. Others have nonspecific symptoms, leading to delayed or missed diagnoses.
Common symptoms include:
Lower abdominal or pelvic pain, often accentuated by intercourse
Cramping
Dysuria
Urinary frequency
Vaginal discharge
Intermittent or postcoital cervical bleeding
Systemic signs like fever, chills, nausea, and vomiting are often absent in mild to moderate cases, but may be present in severe cases.
Diagnosis
Difficulties: Acute PID is challenging to diagnose due to the wide range of clinical presentations and the lack of a single definitive diagnostic test.
Importance of Early Diagnosis: Healthcare providers should maintain a low threshold for diagnosing PID due to the potential for severe, long-term consequences if it is left untreated.
Clinical Diagnosis: Because of the difficulty of diagnosis, PID is often diagnosed clinically, based on patient history, symptoms, and pelvic examination findings.
Minimum Criteria for Presumptive Treatment:
Sexually active women experiencing pelvic or lower abdominal pain
No other identifiable cause for the pain
At least one of the following on pelvic exam:
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Additional Criteria:
Oral temperature >38.3°C (>101°F)
Abnormal cervical mucopurulent discharge or cervical friability
Abundant white blood cells (WBCs) on saline microscopy of vaginal fluid
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis
Specific Diagnostic Criteria (using more invasive procedures):
Endometrial biopsy with histopathologic evidence of endometritis
Transvaginal sonography or MRI showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex
Doppler studies indicating pelvic infection (e.g., tubal hyperemia)
Laparoscopic findings consistent with PID
Testing:
NAAT for chlamydia and gonorrhea
Saline microscopy of vaginal fluid
Urinalysis
Pregnancy test
HIV and syphilis testing
Consider CBC, CRP, and ESR for increased specificity
Differential Diagnoses: Consider other conditions with similar presentations, such as:
Appendicitis
Ectopic pregnancy
Endometriosis
Ovarian cyst (with or without rupture)
Nephrolithiasis
Urinary tract infection
Role of Microscopy:
Microscopic examination of vaginal secretions can help identify:
Leukorrhea: >1 leukocyte per epithelial cell
Clue cells and trichomonads
Cervical examination should include assessing for mucopus and friability.
Microscopy, combined with other clinical findings and STI testing, can aid in PID diagnosis.
Treatment
General Principles:
Treatment should be initiated promptly to prevent long-term sequelae.
Empiric treatment is recommended, covering likely pathogens even if STI testing is negative.
Regimens should provide broad-spectrum coverage, including N. gonorrhoeae, C. trachomatis, and anaerobic organisms.
Consideration should be given to coverage for M. genitalium, with moxifloxacin as the preferred treatment.
Treatment Setting:
Outpatient Treatment: Appropriate for women with mild-to-moderate PID.
Inpatient Treatment: Consider for women with severe PID or any of the following criteria:
Pregnancy
Severe illness, nausea and vomiting, or temperature >38.5°C (101°F)
Inability to follow or tolerate an outpatient oral regimen
Suspected surgical emergencies (e.g., appendicitis)
Tubo-ovarian abscess
No clinical response to oral antimicrobial therapy
Parenteral Treatment:
Recommended Regimens:
Ceftriaxone + doxycycline + metronidazole
Cefotetan + doxycycline
Cefoxitin + doxycycline
Alternative Regimens:
Clindamycin + gentamicin (for severe cephalosporin allergy)
Cefoxitin + doxycycline
Cefotetan + doxycycline
Ampicillin-sulbactam + doxycycline
Intramuscular/Oral Treatment:
Recommended Regimens:
Ceftriaxone + doxycycline + metronidazole
Cefoxitin + probenecid + doxycycline + metronidazole
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) + doxycycline + metronidazole
Alternative Regimens (consider if the patient has a cephalosporin allergy, the risk for gonorrhea is low, and follow-up is likely):
Levofloxacin + metronidazole
Moxifloxacin
Azithromycin + metronidazole
Azithromycin
Treatment Duration: Typically 14 days.
Transitioning from IV to Oral:
Patients can often be switched from IV to oral antibiotics within 24-48 hours of clinical improvement.
The oral regimen should correspond with the initial IV regimen.
Outpatient Follow-up:
Women treated as outpatients should be reevaluated within 72 hours.
Clinical improvement, such as decreased fever and tenderness, should be observed.
Hospitalization is usually required if there is no improvement within 72 hours.
Retesting for Chlamydia and Gonorrhea:
Women diagnosed with chlamydial or gonococcal PID should be retested 3 months after treatment.
If retesting at 3 months is not possible, retesting should occur at the next medical visit within 12 months.
Management of Tubo-ovarian Abscess (TOA):
Hospitalization is generally recommended.
Imaging, such as pelvic ultrasonography or CT, is recommended.
While 75% of women with TOA respond to antibiotics alone, some require surgical drainage.
The size of the abscess is a key factor in determining the need for surgery.
Specific Considerations:
Adolescents and Young Adults:
No evidence suggests improved outcomes with hospitalization compared to outpatient management.
Treatment approach should be the same as for older women, taking into account adherence and follow-up capabilities.
Women with HIV:
Management is generally the same as for women without HIV.
Some women with HIV may have a reduced response to therapy and an increased risk of complications.
IUD Use:
Women who develop PID after recent IUD insertion can be treated without IUD removal if close follow-up is ensured.
Consider IUD removal if there is no clinical improvement within 48-72 hours of treatment initiation.
Management of Sex Partners
Partner Evaluation and Treatment:
All sex partners within 60 days preceding the woman's PID diagnosis should be evaluated, tested, and presumptively treated for chlamydia and gonorrhea.
If the last sexual encounter was >60 days before diagnosis, the most recent sex partner should be treated.
This is critical to prevent reinfection.
Expedited Partner Therapy (EPT):
EPT can be considered if partner treatment is unlikely to occur promptly.
Abstinence from Sexual Intercourse:
Partners should be instructed to abstain from sexual intercourse until they and their partners have completed treatment.
Prevention
Strategies:
Abstinence
Reducing the number of sex partners
Consistent and correct condom use
Screening for and treating STIs, especially chlamydia in young women
Treating other lower genital tract infections like N. gonorrhoeae, bacterial vaginosis, and trichomoniasis
Partner Management:
Examining and treating partners of women with PID for gonorrhea and chlamydia, regardless of whether the woman's PID was caused by these pathogens.
Long-term Sequelae
Even a single episode of PID, including subclinical PID, can increase the risk of:
Tubal Infertility:
The risk increases with multiple PID episodes or more severe cases.
Ectopic Pregnancy:
The risk increases with the number of PID episodes and disease severity.
Chronic Pelvic Pain:
The risk exists for women with mild to severe PID, regardless of treatment setting.
Summary:
PID is a serious condition with potential long-term consequences. Early diagnosis and treatment are essential to minimize these risks. Healthcare providers should maintain a high index of suspicion for PID in women presenting with pelvic or lower abdominal pain. Comprehensive management includes treating the patient and her partner(s) and providing education on prevention strategies.
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Pelvic Organ Prolapse
Pelvic Organ Prolapse
Understanding and Managing Pelvic Organ Prolapse
This article, a joint publication from the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society, offers guidelines for diagnosing and managing pelvic organ prolapse (POP). It provides essential information for clinicians, covering risk factors, evaluation methods, treatment options (both surgical and non-surgical), potential complications, and the management of recurrent prolapse.
What is Pelvic Organ Prolapse?
Pelvic organ prolapse occurs when one or more pelvic organs descend into the vagina. This can involve the anterior vaginal wall (cystocele), posterior vaginal wall (rectocele), the uterus, or the apex of the vagina after a hysterectomy.
Key Points:
Not all prolapse is problematic: Mild descent is common and only considered an issue if it causes symptoms like vaginal bulge and pressure, voiding or defecatory dysfunction, or sexual dysfunction.
Symptoms often emerge when the prolapse extends 0.5 cm beyond the hymenal ring.
Multiple compartment involvement is common: Most women have prolapse in multiple areas due to general pelvic floor dysfunction.
How Common is POP and Who is at Risk?
POP is a common condition, with estimates suggesting that around 3% of U.S. women experience symptoms of vaginal bulging. However, the prevalence based on physical examination findings is much higher (41-50%), indicating that many women with POP are asymptomatic.
Risk Factors:
Several factors can increase the risk of developing symptomatic POP, including:
Parity and vaginal delivery
Age
Obesity
Connective tissue disorders
Menopausal status
Chronic constipation
Modifiable Risk Factors:
Obesity and constipation are modifiable risk factors that clinicians should address during wellness visits to potentially reduce the risk of POP.
Diagnosing Pelvic Organ Prolapse
Initial Evaluation:
A woman with suspected POP requires a comprehensive evaluation that includes:
Detailed History: This should cover the patient's medical, surgical, obstetric, and gynecologic history, as well as the nature and severity of her symptoms. It's important to determine if the prolapse is affecting physical activities, sexual function, or if it's progressively worsening.
Symptom Assessment: This is crucial for guiding treatment decisions, as treatment is only indicated for bothersome symptoms. Assessment should include questions about:
Urinary function: Urine loss, type of incontinence (stress or urgency), and difficulty voiding.
Bowel function: Straining with bowel movements, laxative use, fecal incontinence, and incomplete rectal emptying.
Sexual function: Dyspareunia, coital incontinence, and other prolapse-related sexual dysfunction.
Physical Examination: This should include an abdominal and pelvic examination to rule out pelvic masses and assess the vaginal epithelium.
Examination with a split speculum is recommended to evaluate prolapse during maneuvers like the Valsalva maneuver or coughing.
Assessment of pelvic floor muscle tone is essential.
Standing examination: If the prolapse isn't apparent during a supine examination but the patient reports symptoms, repeating the examination while standing may reveal greater prolapse descent.
Additional Testing:
Postvoid Residual Urine Volume: This is recommended if the prolapse extends beyond the hymen or the patient has voiding symptoms. It can be measured via catheterization or ultrasonography.
Urinalysis: This is necessary if the patient has urinary urgency or other lower urinary tract symptoms. Culture and microscopy may be performed if indicated.
Urodynamic Testing: This can be helpful for patient counseling and may be considered in cases of bothersome incontinence with stage II or greater prolapse, or voiding dysfunction.
Specialized Imaging or Referral: May be needed if initial findings don't align with the patient's symptoms.
Pelvic Organ Prolapse Quantification (POP-Q):
The POP-Q examination is strongly recommended before treatment to objectively assess and document the extent of the prolapse.
Importance of POP-Q:
Objective and Validated: It provides a standardized and reproducible way to measure prolapse in all three pelvic compartments.
Preoperative Comparator: It serves as a baseline for comparing postoperative results and assessing anatomic success.
Communication Tool: Facilitates clear communication between healthcare providers, especially if the patient requires future care for recurrent prolapse.
Outcomes Evaluation: Accurate pretreatment POP-Q measurements are essential for evaluating treatment outcomes.
Non-Surgical Treatment Options for POP
Expectant Management:
Education and reassurance: Appropriate for asymptomatic prolapse.
Symptom explanation: Helps women understand how prolapse might be contributing to their urinary or defecatory dysfunction.
Lifestyle Modifications:
Fiber supplementation and osmotic laxatives: May improve defecatory dysfunction.
Elevating feet while sitting: May reduce bulge symptoms.
Pelvic Floor Muscle Exercises:
Can be performed independently or under professional guidance.
May improve symptoms or slow POP progression.
Vaginal Pessary:
Effective non-surgical treatment: Offers an alternative to surgery for women with symptomatic POP.
High success rate: Up to 92% of women can be successfully fitted with a pessary.
Suitable for women planning pregnancy: A pessary should be considered for women who desire future pregnancies.
Independent pessary management is ideal: If a woman can't manage her pessary independently, more frequent follow-up is necessary.
Estrogen Therapy:
Limited evidence for treatment or prevention of POP.
May be helpful for vaginal irritation associated with POP.
Surgical Management of Pelvic Organ Prolapse
Indications for Surgery:
Surgery is indicated for women who experience bothersome POP symptoms and have either:
Failed non-surgical treatments.
Declined non-surgical options.
Surgical Approaches:
There are various vaginal and abdominal approaches for POP surgery, each with its own considerations.
Factors Influencing Surgical Approach:
Location and severity of the prolapse
Nature of symptoms (urinary, bowel, or sexual dysfunction)
Patient's overall health
Patient preference
Surgeon's expertise
Specific Surgical Techniques:
The sources discuss several surgical techniques for addressing POP, including:
Vaginal Hysterectomy with Vaginal Apex Suspension: Effective for uterovaginal and anterior/posterior vaginal wall prolapse.
Uterosacral or Sacrospinous Ligament Suspension: Used for apical POP, either at the time of hysterectomy or in women with post-hysterectomy vault prolapse. These techniques have similar efficacy and outcomes.
Anterior Colporrhaphy: Effective for anterior vaginal wall prolapse, often performed in conjunction with apical support procedures for better outcomes.
Posterior Colporrhaphy and Perineorrhaphy: Used for posterior vaginal wall prolapse, addressing rectoceles and perineal defects.
Abdominal Sacrocolpopexy: Proven and effective procedure for POP, involving the use of synthetic mesh or a biologic graft.
Obliterative Procedures: Narrow, shorten, or close the vagina, offering an effective treatment option for women with significant medical comorbidities or those who do not desire future vaginal intercourse.
Hysteropexy: A uterine suspension procedure that serves as an alternative to hysterectomy for women with uterine prolapse. However, there's less evidence regarding its safety and efficacy compared to hysterectomy.
Minimally Invasive Approaches:
Laparoscopic and robotic-assisted techniques are available for sacrocolpopexy, offering benefits like less blood loss and shorter hospital stays compared to open surgery. However, robotic assistance hasn't been shown to improve patient outcomes and may increase costs.
Synthetic Mesh and Biologic Grafts:
Transvaginal Synthetic Mesh: Currently, no FDA-approved transvaginal mesh products are available for POP repair in the U.S.. Their use is generally discouraged due to safety concerns.
Limited use in high-risk cases: May be considered for recurrent prolapse or in patients with medical conditions that prevent more invasive procedures. Requires careful patient counseling and informed consent.
Biologic Grafts: Show mixed results and many used in previous studies are no longer available.
Special Training Required: Surgeons performing POP surgery with mesh or grafts need specific training to manage the unique risks and complications associated with these materials.
Mesh/Graft Complications: Can include mesh contracture, erosion into surrounding organs, dyspareunia, and the need for multiple procedures to address these issues.
Intraoperative Cystoscopy:
Recommended during POP surgeries with a higher risk of bladder or ureteral injury, such as apical suspensions, sacrocolpopexy, and anterior colporrhaphy with mesh. This allows for immediate identification and management of any urinary tract injuries.
Managing Stress Urinary Incontinence After POP Surgery:
Preoperative Evaluation: All women with significant apical or anterior prolapse should be assessed for occult stress urinary incontinence before surgery.
Concomitant Treatment: Women with both bothersome POP and stress urinary incontinence should consider having both conditions addressed surgically to minimize the risk of persistent or worsening incontinence.
Prophylactic Continence Procedures: In women without preoperative stress urinary incontinence, procedures like Burch colposuspension (during abdominal sacrocolpopexy) or retropubic midurethral slings (during vaginal surgery) can reduce the risk of postoperative incontinence.
Recurrent Pelvic Organ Prolapse:
Recurrence is Possible: Women should be informed about the risk of POP recurrence before undergoing surgery, with rates ranging from 6% to 30%.
Management Options: Non-surgical options like observation or pessary use may be appropriate, but repeat surgery may be necessary for some women.
Referral to a Specialist: Recommended if the surgeon isn't comfortable with procedures like abdominal sacrocolpopexy, vaginal colpopexy with mesh/graft augmentation, or colpocleisis.
Key Recommendations and Conclusions
The article provides evidence-based recommendations and conclusions, categorized by the strength of the supporting evidence:
Level A (Good and Consistent Evidence):
Uterosacral and sacrospinous ligament suspension with native tissue have similar effectiveness for apical POP.
Mesh or grafts don't improve outcomes for transvaginal posterior vaginal wall prolapse repair.
Polypropylene mesh augmentation for anterior vaginal wall prolapse repair improves anatomic outcomes but increases morbidity.
Level B (Limited or Inconsistent Evidence):
Many women with POP on physical examination don't report symptoms, so treatment is only indicated for bothersome symptoms.
Vaginal pessaries should be offered as an alternative to surgery.
Vaginal apex suspension should be performed during hysterectomy for uterine prolapse to reduce recurrence risk.
Abdominal sacrocolpopexy with mesh has a lower recurrence risk but more complications than native tissue vaginal apex repair.
Obliterative procedures are effective for POP and should be considered for women with significant comorbidities who don't desire future vaginal intercourse.
Mesh or graft use in POP surgery carries unique complications.
Hysteropexy is a viable alternative to hysterectomy for uterine prolapse, but with less evidence on safety and efficacy.
Level C (Consensus and Expert Opinion):
POP-Q examination is recommended before treatment.
Pessaries should be considered for women with symptomatic POP who desire future pregnancy.
Vaginal mesh repair should be limited to high-risk individuals and requires careful patient counseling and informed consent.
Surgeons performing mesh or graft procedures need specific training.
Intraoperative cystoscopy is recommended during POP surgeries with a higher risk of bladder or ureteral injury.
Preoperative evaluation for occult stress urinary incontinence is crucial for women with significant apical or anterior prolapse.
Women undergoing POP surgery should be counseled about the potential for postoperative stress urinary incontinence, even if they don't have it preoperatively, and the options for concomitant or staged continence procedures.
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Pelvic pain/Abdominal Pain
Pelvic pain/Abdominal Pain
Chronic Pelvic Pain Overview
This article, "ACOG PRACTICE BULLETIN Clinical Management Guidelines for Obstetrician–Gynecologists NUMBER 218," defines chronic pelvic pain and discusses its diagnosis and management.
Definition and Background
Chronic pelvic pain is defined as pain perceived to originate from pelvic organs or structures, typically lasting more than 6 months. It often presents with negative cognitive, behavioral, sexual, and emotional consequences, along with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecological dysfunction.
Chronic pelvic pain is distinct from acute pelvic pain because it persists beyond the typical resolution period of acute pain. Chronic pain can lead to a cycle of physical and psychological consequences, including physical deconditioning due to activity restriction, and long-term mood deterioration and social isolation due to fear, anxiety, and distress.
Epidemiology and Prevalence
A 2014 review found the prevalence of chronic pelvic pain (noncyclical pain lasting at least 6 months) to range from 5.7% to 26.6%. Common conditions contributing to chronic pelvic pain include:
Irritable bowel syndrome
Interstitial cystitis or painful bladder syndrome
Pelvic floor muscle tenderness
Depression
These conditions are estimated to affect 20% to 60% of women with chronic pelvic pain. Studies have shown a high prevalence of bladder pain syndrome and endometriosis in women with chronic pelvic pain.
Pathophysiology and Central Sensitization
Central sensitization is a key factor in chronic pelvic pain. It occurs when peripheral pain triggers an exaggerated response from interneurons, amplifying pain perception. This leads to changes in the central nervous system's response to stimuli, activation of specific brain regions, and alterations in the hypothalamic–pituitary–adrenal axis and autonomic nervous system. Central sensitization can explain why individuals with chronic pelvic pain experience pain in response to non-painful stimuli (allodynia) and have a heightened response to painful stimuli (hyperalgesia).
Differential Diagnosis
The differential diagnosis for chronic pelvic pain is extensive and can be categorized into visceral, neuromusculoskeletal, and psychosocial factors.
Visceral etiologies involve disorders of the gynecologic, gastrointestinal, and urologic organ systems. Visceral pain arises from stimulation of organ nociceptors, sensitive to distention, ischemia, and inflammation. This pain is typically diffuse and poorly localized, often accompanied by autonomic symptoms.
Neuromusculoskeletal disorders are frequently overlooked but can significantly contribute to chronic pelvic pain. These disorders can result from myofascial trigger points or neurovascular entrapment due to surgical injury or inflammation. Pain is often reproducible upon examination by palpating affected muscle groups.
Psychosocial factors play a crucial role in chronic pain by influencing symptom severity and prognosis. A history of abuse, mental illness, lack of support, social stressors, and relationship discord can contribute to pelvic pain and dyspareunia.
Clinical Considerations and Recommendations
Initial Evaluation
A detailed medical history, including psychosocial factors, is crucial, along with a thorough physical examination focusing on the abdominal and pelvic neuromusculoskeletal systems, including a visceral examination. The physical examination should include palpation of the:
lower back
sacroiliac joints
pubic symphysis
abdomen
genitalia
Findings suggestive of neuromusculoskeletal pain include:
pelvic floor muscle tenderness
a positive forced flexion, abduction, and external rotation (FABER) test.
A positive Carnett test result, where tenderness worsens during abdominal wall muscle contraction, is associated with chronic pelvic pain severity.
Laboratory and imaging tests should be tailored to individual symptoms and physical examination findings.
Evaluation for Nongynecologic Etiologies
Screening for interstitial cystitis, irritable bowel syndrome, diverticulitis, and mood disorders is recommended when nongynecologic etiologies are suspected. Symptom questionnaires and referral for further evaluation may be necessary.
Treatment Recommendations
The article provides several treatment recommendations, graded by the level of evidence supporting them:
Level A (good and consistent scientific evidence):
Routine laparoscopic adhesiolysis is not recommended for chronic pelvic pain management.
Level B (limited or inconsistent scientific evidence):
Referral for pelvic floor physical therapy, sex therapy, or cognitive behavioral therapy is recommended.
Serotonin–norepinephrine reuptake inhibitors (SNRIs) are recommended for neuropathic chronic pelvic pain.
Gabapentin and pregabalin are recommended for the treatment of neuropathic chronic pelvic pain.
Opioids are not recommended for chronic pelvic pain. Patients currently on opioids should be weaned off slowly.
Trigger point injections are recommended to improve pain and function in patients with myofascial chronic pelvic pain.
Level C (based primarily on consensus and expert opinion):
A detailed medical history and physical examination, focusing on the abdominal and pelvic neuromusculoskeletal examination, is recommended.
Evaluation for common nonreproductive conditions (interstitial cystitis, irritable bowel syndrome, diverticulitis, and mood disorders) is recommended.
Referral to pain medicine specialists as part of multidisciplinary care may be appropriate.
Acupuncture and yoga can be considered for chronic pelvic pain of musculoskeletal etiology.
It's important to note that this is a summary of the key points in the article. The article contains more detailed information and discussions on these topics. You should refer to the original article for a comprehensive understanding.
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Perimenopausal and menopausal care
Perimenopausal and menopausal care
Management of Menopausal Symptoms - Summary
Introduction
Definition: Menopause is the permanent cessation of menstruation due to the loss of ovarian activity, typically occurring at a median age of 51 years in North America. The menopausal transition, or perimenopause, is marked by fluctuating hormone levels and physiologic changes leading to various symptoms.
Cardinal Symptoms:
Vasomotor Symptoms (VMS): Characterized by sudden sensations of heat, sweating, flushing, chills, and heart palpitations. Commonly referred to as hot flushes, these episodes typically last 1-5 minutes and occur frequently.
Vaginal Symptoms: Vaginal atrophy due to reduced estrogen levels can lead to dryness, itching, dyspareunia (painful intercourse), and increased risk of infections.
Vasomotor Symptoms (VMS)
Prevalence:
Affects 50-82% of U.S. women undergoing natural menopause, with 87% reporting daily episodes.
VMS may persist for 4-10 years after menopause.
Risk Factors:
Obesity: Adipose tissue may act as an insulator, affecting thermoregulation.
Psychosocial Factors: Depression, anxiety, low socioeconomic status, and smoking are linked with increased VMS.
Pathophysiology:
VMS is linked to decreased estrogen levels, leading to changes in thermoregulatory mechanisms, with increased sensitivity to body temperature changes.
Hormonal Treatment Options:
Hormone Therapy (HT): Systemic estrogen, alone or combined with progestin, is the most effective treatment. Various doses of conjugated estrogen, estradiol, or transdermal estrogen are used.
Risks: Systemic HT is associated with increased risks of thromboembolic disease and breast cancer, with differences based on age and timing of initiation. HT is typically used at the lowest effective dose for the shortest duration.
Nonhormonal Treatment Options:
Paroxetine (7.5 mg/d) is the only FDA-approved nonhormonal therapy for VMS.
Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin-Norepinephrine Reuptake Inhibitors (SSNRIs), Clonidine, and Gabapentin have shown benefit.
Alternative Therapies: Phytoestrogens, herbal supplements, and acupuncture have no consistent evidence of efficacy for VMS.
Vaginal Symptoms
Pathophysiology:
Vaginal atrophy, also termed genitourinary syndrome of menopause (GSM), is characterized by thinning of the vaginal epithelium, leading to dryness, decreased elasticity, and altered vaginal flora.
Hormonal Treatment:
Local Estrogen Therapy: Vaginal tablets, creams, and rings are effective for alleviating vaginal symptoms. Local therapy is recommended for women experiencing only vaginal symptoms, and systemic estrogen is generally not required.
Ospemifene: An estrogen agonist/antagonist approved by the FDA for the treatment of dyspareunia.
Nonhormonal Treatment:
Vaginal Lubricants and Moisturizers: Recommended for immediate relief of vaginal dryness and discomfort during intercourse.
No Strong Evidence: There is insufficient evidence to support the use of soy products, herbal remedies, or complementary botanicals for vaginal symptoms.
Clinical Recommendations and Considerations
Hormone Therapy (HT): Systemic HT is effective for VMS but has associated risks, such as thromboembolism and breast cancer. It should be individualized based on a woman’s risk–benefit ratio.
Nonhormonal Therapies: Nonhormonal treatments, such as SSRIs, SSNRIs, and gabapentin, are effective alternatives for those who cannot or do not wish to use hormones.
Local Estrogen Therapy: Recommended for women with only vaginal symptoms to minimize systemic hormone exposure.
Risk of Thromboembolism: Transdermal estrogen may have a lower risk of venous thromboembolism compared to oral regimens.
Duration of HT: Short-term use at the lowest effective dose is recommended to minimize risks, with individualization based on symptoms and personal risk factors.
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Perinatal infections
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PID
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Placenta abruption
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Placenta accreta spectrum
Placenta accreta spectrum
Comprehensive Overview of Placenta Accreta Spectrum
This article, "Placenta Accreta Spectrum" from the American College of Obstetricians and Gynecologists, provides a detailed overview of placenta accreta spectrum (PAS), a serious pregnancy complication involving abnormal placental attachment.
What is Placenta Accreta Spectrum?
PAS encompasses a range of abnormal placental adherence, including:
Placenta accreta: Placental attachment into the myometrium.
Placenta increta: Deeper penetration of the placenta into the myometrium.
Placenta percreta: Placental invasion through the myometrium and potentially into adjacent organs.
Significance of PAS
PAS presents serious risks due to potential hemorrhage:
Severe, life-threatening hemorrhage during or after delivery.
Increased need for blood transfusion.
Higher risk of maternal death.
Increased likelihood of hysterectomy.
Prolonged hospital stays.
Rising Incidence and Contributing Factors
The incidence of PAS has risen dramatically in recent decades, likely due to:
Increased cesarean delivery rates.
A 2016 study found a rate of 1 in 272 births in the US, the highest reported rate.
Risk Factors for Developing PAS
Several risk factors increase the likelihood of developing PAS:
Previous cesarean delivery (risk increases with each subsequent cesarean).
Placenta previa (especially in conjunction with previous cesareans).
Advanced maternal age.
Multiparity (having given birth multiple times).
Prior uterine surgeries or curettage.
Asherman syndrome (scarring of the uterine lining).
Elevated maternal serum alpha-fetoprotein levels (though not a reliable predictor).
Understanding the Cause of PAS
The leading theory suggests a defect at the endometrial-myometrial interface:
Disruptions in the uterine cavity, often from cesarean scars, may damage this interface.
This damage can hinder normal placental development, leading to abnormal attachment.
However, this theory doesn't fully explain PAS cases in women with no prior uterine surgery.
Diagnosing PAS
Early detection is crucial for optimal management:
Ultrasound is the primary diagnostic tool:
Can detect features as early as the first trimester, though diagnosis is often made in the second or third trimester.
Important ultrasound findings include:
Placenta previa.
Multiple vascular lacunae within the placenta.
Thinning of the retroplacental myometrium.
Abnormal blood flow patterns on color Doppler imaging.
Clinical risk factors are as important as ultrasound findings in predicting PAS, especially where ultrasound expertise is limited.
MRI can be helpful in complex cases, but it's not the preferred initial diagnostic tool.
Early referral to centers specializing in PAS is recommended for women with risk factors.
Managing PAS
Optimal management involves a multidisciplinary approach:
Antenatal diagnosis allows for planning and coordination of care:
Delivery at a Level III or IV maternal care facility (specialized for high-risk pregnancies).
Collaboration with a team including:
Obstetricians and maternal-fetal medicine specialists.
Pelvic surgeons (often gynecologic oncologists).
Urologists, interventional radiologists, anesthesiologists, and neonatologists.
Nursing staff experienced in managing postpartum hemorrhage.
Blood bank with massive transfusion protocols.
The recommended delivery approach is cesarean hysterectomy with the placenta left in situ:
Attempts to remove the placenta can lead to significant hemorrhage.
Delivery between 34 0/7 and 35 6/7 weeks gestation is suggested to balance maternal and fetal risks, unless extenuating circumstances require earlier delivery.
Managing Hemorrhage
Hemorrhage is a major concern in PAS, requiring proactive measures:
Blood bank collaboration is essential, given the high likelihood of transfusion.
Intraoperative monitoring of blood loss and vital signs is critical.
Transfusion with packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio is recommended in cases of hemorrhage.
Tranexamic acid (an antifibrinolytic agent) may reduce hemorrhage and is recommended in cases of postpartum hemorrhage.
Other clotting factors and procedures, such as hypogastric artery ligation or embolization, can be considered in refractory bleeding.
Uterine Preservation and Expectant Management
Conservative management (removing placental tissue without hysterectomy) can be considered in cases of focal placental adherence.
Expectant management (leaving the placenta in situ) is considered investigational and carries significant risks:
Success rates vary and appear to depend on the extent of placental invasion.
High risk of complications, including hemorrhage and infection.
Methotrexate use to hasten placental resorption is not recommended due to unproven benefits and potential toxicity.
Routine hysteroscopic resection of placental remnants is also not recommended.
Long-Term Considerations
Expectant management may preserve future fertility but has a high risk of PAS recurrence in subsequent pregnancies.
Delayed interval hysterectomy (performing hysterectomy weeks after delivery) is an investigational approach for women with placenta percreta who don't desire future fertility.
Conclusion
PAS is a complex condition with potentially severe consequences. Early diagnosis, multidisciplinary management, and proactive measures to control hemorrhage are crucial for optimizing outcomes for both mother and baby. While uterine preservation is a desirable goal, conservative and expectant management approaches should be considered carefully, recognizing their limitations and potential risks.
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Placenta previa
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Placental Abruption
Placental Abruption
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PO visit
PO visit
Optimizing Postpartum Care: A New Paradigm
This article, "Optimizing Postpartum Care," presents a new model for postpartum care, advocating for a shift from a single encounter to an ongoing process tailored to individual needs. This Committee Opinion, developed by the American College of Obstetricians and Gynecologists, emphasizes the importance of the “fourth trimester” and the need for comprehensive care beyond the traditional 6-week postpartum visit.
Redefining Postpartum Care
The weeks following birth, the "fourth trimester," represent a critical transition period where women experience numerous physical, social, and psychological changes.
Postpartum care should transition from a single encounter to an ongoing process that provides services and support tailored to each woman's needs.
A New Model for Postpartum Visits
The traditional 6-week postpartum visit is insufficient to address the complexities of the fourth trimester.
The American College of Obstetricians and Gynecologists recommends a new paradigm for postpartum care:
Initial Assessment: Contact within the first 3 weeks postpartum, either in person or by phone, to address acute issues.
Ongoing Care: Continued care as needed based on individual needs.
Comprehensive Postpartum Visit: A well-woman visit no later than 12 weeks after birth.
The timing of this visit should be individualized and woman-centered.
This visit should not be considered an "all-clear" signal, and continued recovery and support may be needed.
Insurance coverage policies should be revised to support this new, tailored approach to postpartum care.
The Postpartum Care Plan
A postpartum care plan should be developed during pregnancy and reviewed after birth.
This plan should include a care team with contact information, including:
Family and friends for social and material support.
The primary maternal care provider for postpartum needs.
The infant's health care provider.
The primary care provider for ongoing care.
Lactation support professionals.
A care coordinator or case manager.
A home visitor, if applicable.
Specialty consultants, if needed.
Prenatal discussions should address:
Infant feeding plans.
Postpartum emotional health, including “baby blues” and the challenges of parenting.
Plans for managing chronic health conditions.
The purpose and value of postpartum care and available resources.
Reproductive life planning, including desire for future pregnancies and birth spacing.
Women should be advised to avoid inter-pregnancy intervals shorter than 6 months.
The risks and benefits of repeat pregnancy sooner than 18 months should be discussed.
Shared decision-making regarding contraceptive options is essential and should be based on a woman's individual needs and preferences.
Components of the Comprehensive Postpartum Visit
Mood and Emotional Well-being:
Screening for postpartum depression and anxiety.
Guidance on local support resources.
Screening for tobacco and substance use disorders.
Follow-up on pre-existing mental health disorders.
Infant Care and Feeding:
Assessment of comfort and confidence with newborn care, including feeding, childcare, and ensuring the infant has a pediatric medical home.
Assessment of breastfeeding comfort and confidence, including pain management and logistical guidance.
Assessment of material needs, like housing, food, and diapers, with referrals to resources as needed.
Sexuality, Contraception, and Birth Spacing:
Guidance on sexuality, managing dyspareunia, and resuming intercourse.
Assessment of desire for future pregnancies and reproductive life plan.
Explanation of the importance of birth spacing.
Review of recommendations for preventing recurrent pregnancy complications.
Contraceptive counseling and same-day placement of long-acting reversible contraception (LARC), if desired.
Sleep and Fatigue:
Discussion on coping strategies for fatigue and sleep disruptions.
Engagement of family and friends to help with caregiving responsibilities.
Physical Recovery From Birth:
Assessment of perineal or cesarean incision pain.
Assessment of urinary and fecal continence, with referrals to physical therapy or urogynecology as needed.
Guidance on resuming physical activity and achieving a healthy weight.
Chronic Disease Management:
Discussion of any pregnancy complications and their implications for future childbearing and long-term health, including cardiovascular risks.
Glucose screening for women with gestational diabetes.
Review of medication selection and dosage, considering breastfeeding compatibility.
Referrals to primary care or specialists as needed.
Health Maintenance:
Review of vaccination history and administration of necessary immunizations.
Well-woman screening, including Pap tests and pelvic examinations, as indicated.
Special Considerations
Adverse Pregnancy Outcomes and Cardiovascular Risk: Women with pregnancy complications like preterm birth, gestational diabetes, or hypertensive disorders should be counseled about their increased risk of cardiovascular disease.
Pregnancy Loss: Women experiencing miscarriage, stillbirth, or neonatal death require specialized care, including emotional support, bereavement counseling, and review of laboratory and pathology reports.
Policy Recommendations
Reimbursement policies need to support postpartum care as an ongoing process, not a single visit.
Paid parental leave, including full benefits and 100% pay for at least 6 weeks, is essential to support maternal and infant health.
Conclusion
Optimizing postpartum care requires a shift in perspective, recognizing the fourth trimester as a crucial period requiring comprehensive and individualized support. By implementing the recommendations outlined in this article, healthcare providers can significantly improve the health and well-being of women and their families.
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Polyhydramnios
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Post-term pregnancy
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Post-term pregnancy
Post-term pregnancy
Management of Late-Term and Postterm Pregnancies - Summary
Introduction
Definition: Late-term pregnancies refer to those between 41 0/7 weeks and 41 6/7 weeks of gestation, while postterm pregnancies are those extending beyond 42 0/7 weeks. Accurate determination of gestational age is crucial to differentiate between these stages.
Incidence: In 2011, the overall incidence of postterm pregnancies in the United States was 5.5%. The variation in incidence can be due to differences in regional management practices and methods for determining gestational age.
Risks Associated:
Maternal Risks: Higher rates of perineal lacerations, infections, postpartum hemorrhage, and cesarean delivery as pregnancies approach the postterm period.
Fetal and Neonatal Risks: Late-term and postterm pregnancies increase the risk of macrosomia, neonatal convulsions, meconium aspiration syndrome, low Apgar scores, and NICU admissions.
Etiologic Factors
Risk Factors:
Nulliparity: First-time mothers are at higher risk of postterm pregnancies.
Previous Postterm Pregnancy: Women who have had postterm pregnancies in the past are at an increased risk of recurrence.
Genetic Factors: A genetic predisposition is suggested to account for 23-30% of the risk of late-term or postterm pregnancies.
Carrying a Male Fetus and Maternal Obesity: Both factors have been associated with an increased risk of postterm pregnancy.
Certain Fetal Disorders: Conditions such as anencephaly and placental sulfatase deficiency are linked with prolonged pregnancies.
Management Strategies
Accurate Gestational Age Determination:
Ultrasound Dating: Early ultrasonography to confirm gestational age significantly reduces the misclassification of pregnancies as late-term or postterm, which helps in proper management and prevents unnecessary interventions.
Membrane Sweeping: Membrane sweeping can reduce the risk of progressing to late-term or postterm pregnancy. It involves separating the fetal membranes from the lower uterine segment during a pelvic examination. However, it can cause discomfort and vaginal bleeding and is contraindicated in cases like placenta previa.
Induction of Labor:
Late-Term Induction: Induction of labor between 41 0/7 weeks and 42 0/7 weeks can be considered.
Postterm Induction: Induction is recommended after 42 0/7 weeks due to the increasing risk of perinatal morbidity and mortality.
Antepartum Fetal Surveillance
When to Initiate: Antepartum fetal surveillance is generally recommended to start at or beyond 41 0/7 weeks of gestation due to the increasing risk of stillbirth as gestational age advances.
Types of Surveillance:
Nonstress Test (NST), Contraction Stress Test, Biophysical Profile (BPP), or Modified BPP can be used. However, the optimal type and frequency of surveillance are not well defined by randomized trials.
Oligohydramnios Monitoring: Monitoring amniotic fluid volume is recommended to detect oligohydramnios. If detected at or beyond 41 weeks, delivery is often indicated.
Indications for Delivery and Interventions
Delivery Indications: If there are findings such as oligohydramnios, meconium-stained amniotic fluid, or fetal heart rate abnormalities, early delivery may be required.
Trial of Labor After Cesarean Delivery (TOLAC):
Consideration for TOLAC: TOLAC is a reasonable option for uncomplicated postterm pregnancies, although the failure rate increases as gestation advances beyond 41 weeks.
Counseling: Women opting for TOLAC should be counseled about the increased risks, including uterine rupture and TOLAC failure as gestation advances.
Key Recommendations
Accurate Dating: Early ultrasound dating is essential to minimize inaccurate gestational age assessments.
Membrane Sweeping: Can reduce the progression to late-term or postterm pregnancy but should be performed selectively.
Induction Recommendations: Induction between 41-42 weeks is reasonable, and induction after 42 weeks is recommended to reduce perinatal morbidity.
Antepartum Surveillance: Surveillance starting at 41 weeks is recommended, focusing on detecting oligohydramnios and assessing fetal well-being.
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Postmenopausal, stenotic cervix
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Postpartum depression
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Postpartum Hemorrhage
Postpartum Hemorrhage
Obstetrical Emergencies
Script for Management of Postpartum Hemorrhage
Introduction and Preparation
1. Identify PPH:
• “I would recognize postpartum hemorrhage as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean delivery, or if the patient becomes symptomatic (e.g., tachycardia, hypotension).”
2. Immediate Actions:
• “I would call for help, ensuring the obstetric and anesthesia teams, and additional nursing staff are present. I would assign one nurse to monitor vitals and document interventions while another administers medications and manages IV access.”
3. Communicate with Patient and Family:
• “I would explain the situation briefly to the patient, acknowledging her and her family’s concerns and assuring them that we’re taking immediate steps to manage the bleeding.”
Step 1: Assessment
1. Primary Survey:
• “I would evaluate vital signs, focusing on heart rate, blood pressure, respiratory rate, and mental status.”
• “Next, I would quickly assess the amount of blood loss, noting any active bleeding or clots.”
2. Uterine Tone:
• “My first assessment would be uterine tone. If the uterus is atonic, I would perform fundal massage to stimulate contraction.”
3. Consider Four Ts (Tone, Trauma, Tissue, Thrombin):
• “I would systematically consider the causes of PPH: Tone (uterine atony), Trauma (lacerations or uterine rupture), Tissue (retained products), and Thrombin (coagulopathy).”
Step 2: Initial Management
1. Medication Administration:
• “If uterine atony is present, I would initiate uterotonics as follows:
• Oxytocin: 10-40 units in 1 L of IV fluid.
• If no response, I would administer Methylergonovine 0.2 mg IM, understanding we can repeat this dose, but we should be preparing to escalate further management and likely head to the operating room.
• Additional options include Carboprost 250 mcg IM (if no contraindications such as asthma) or Misoprostol 800-1000 mcg per rectum if initial agents are ineffective.”
2. IV Access and Fluid Resuscitation:
• “I would ensure two large-bore IV lines are in place, starting crystalloid infusion and preparing for blood products if the patient is hemodynamically unstable. I would order type and crossmatch for at least 2 units of packed RBCs.”
3. Monitor Labs:
• “I would order a CBC, coagulation panel, and fibrinogen level to monitor for coagulopathy, which may necessitate transfusion of plasma, platelets, or cryoprecipitate if indicated.”
Step 3: Escalation of Interventions and Moving to the Operating Room
1. Rationale for Moving to the OR:
• “If bleeding persists despite initial measures, I would take the patient to the operating room to access better resources, improved lighting, and the ability to escalate to more advanced surgical interventions if needed. This setting also allows us to ensure adequate analgesia for further procedures.”
2. Mechanical and Surgical Interventions:
• “For uterine tamponade, I would first consider a Bakri balloon to apply intrauterine pressure. Additionally, I would consider using a Jada system for active suction-based tamponade if available and appropriate.”
3. Dilation and Curettage (D&C):
• “If the Bakri or Jada system fails, my first surgical step in the OR would be a Dilation and Curettage (D&C) to remove any retained products of conception that may contribute to bleeding.”
• “During this procedure, I would also take the opportunity to re-evaluate the vaginal and cervical anatomy carefully, looking for any missed cervical lacerations or deep sulcal tears that may be sources of hidden bleeding.”
Step 4: Advanced Surgical Options (If D&C and Tamponade Fail)
1. Compression Sutures:
• “If bleeding continues, I would proceed with uterine compression sutures to achieve hemostasis:
• B-Lynch suture: A suture is placed around the uterus to compress it, which can help control bleeding by reducing uterine volume and enhancing uterine contraction.
• CHO stitch: An alternative to the B-Lynch, this suture also compresses the uterus by passing through the uterine wall to achieve similar hemostatic effects.”
2. Uterine Artery Ligation:
• “If the compression sutures are ineffective, I would consider uterine artery ligation, where the uterine arteries are tied off to reduce blood flow to the uterus, helping to reduce bleeding.”
3. Hysterectomy:
• “As a last resort, if all other measures fail, I would perform a hysterectomy to control the hemorrhage. I would explain this decision as a life-saving measure when other interventions have not been successful in stopping the bleeding.”
Step 5: Monitoring and Follow-Up
1. Continuous Monitoring:
• “Throughout and following these interventions, I would closely monitor the patient’s vital signs, uterine tone, and ongoing blood loss, documenting all interventions and responses.”
2. Patient Support and Debrief:
• “Once stabilized, I would provide support to the patient and her family, explaining what happened and ensuring they understand the interventions provided. I would discuss her follow-up care, signs to watch for, and any further support needed.”
3. Post-Hemorrhage Care:
• “I would ensure continued monitoring for delayed hemorrhage and thromboembolic complications and arrange follow-up for counseling and support.”
Here’s a step-by-step description of each surgical procedure for managing postpartum hemorrhage. This includes the technical details of how each intervention is performed to achieve hemostasis effectively.
Detailed Steps for Surgical Procedures in Postpartum Hemorrhage Management
1. Dilation and Curettage (D&C)
• Preparation:
• Place the patient in the dorsal lithotomy position.
• Ensure adequate analgesia, either with regional anesthesia or sedation, as appropriate.
• Cleanse and prepare the vaginal area with antiseptic solution.
• Procedure:
• Insert a speculum to visualize the cervix, and use tenaculum forceps to stabilize it.
• Gradually dilate the cervix using a series of graduated dilators to a sufficient width to allow entry of a curette.
• Insert a curette into the uterine cavity and perform gentle scraping or suction to remove retained placental fragments or other products of conception.
• Carefully examine the removed tissue to confirm complete evacuation.
• Re-assessment:
• After D&C, re-evaluate the vagina and cervix for any lacerations or tears that might have been missed initially.
2. Uterine Compression Sutures
a. B-Lynch Suture
• Preparation:
• The uterus is exteriorized (brought outside the abdomen) if the patient has had a cesarean, or exposed through the abdomen if already in the OR.
• Confirm adequate uterine contraction and position for optimal suture placement.
• Procedure:
• Using a long, absorbable suture (e.g., #1 chromic or Vicryl), place the needle just below the cesarean incision at the level of the lower uterine segment.
• The needle is brought over the anterior uterine wall, across the fundus, and then down the posterior wall to create a compression loop.
• The suture is brought back around the opposite side of the uterus, creating a figure-eight pattern that compresses the uterine walls against each other.
• The suture is tied tightly enough to compress the uterine cavity, helping to control bleeding.
b. CHO Stitch
• Preparation:
• The uterus is exposed, as with the B-Lynch suture.
• Procedure:
• Similar to the B-Lynch, the CHO stitch is placed with a long, absorbable suture. It creates a compression effect by anchoring through the uterine muscle but typically involves fewer passes.
• The suture is placed vertically through the uterine walls in specific areas to achieve compression, helping to control persistent bleeding.
3. Uterine Artery Ligation
• Preparation:
• Position the uterus to expose the uterine arteries, typically achieved through abdominal access.
• Identify and isolate the uterine artery and the surrounding vascular structures.
• Procedure:
• Using absorbable suture material, identify the uterine artery at its course near the lower uterine segment, just as it ascends along the uterus.
• Tie off the uterine artery on each side, reducing blood flow to the uterus and decreasing hemorrhage.
• Ensure hemostasis by observing for reduced blood flow to the uterus, assessing for any persistent bleeding after ligation.
4. Hysterectomy
• Indication:
• A hysterectomy is the last-resort procedure for uncontrolled postpartum hemorrhage, performed only if all other measures fail.
• Procedure:
• After adequate analgesia and patient preparation, access the uterus through a midline or low transverse abdominal incision.
• Mobilize the bladder away from the lower uterine segment to prevent injury.
• Begin by clamping, cutting, and tying off the uterine arteries and surrounding ligaments, taking care to control vascular structures and prevent excessive bleeding.
• Proceed with removal of the uterus by sequentially ligating and dividing the ovarian vessels, broad ligament, and other attachments.
• Ensure meticulous hemostasis by tying off all major vessels and ligaments before the uterine stump is closed.
• Completion:
• Inspect the pelvis and abdomen to ensure there is no ongoing bleeding.
• Close the abdominal incision in layers, after ensuring the patient is hemodynamically stable.
These detailed steps outline each procedure, helping you communicate a precise and systematic approach to postpartum hemorrhage management during your board exam. Let me know if any further details are needed for any of the steps.
Certainly. Here’s a detailed breakdown of the abdominal wall incision, focusing on the Pfannenstiel incision, commonly used for obstetric and gynecologic surgeries.
Steps for a Pfannenstiel Incision
1. Skin Incision
• Location: A horizontal incision is made approximately 2-3 cm above the pubic symphysis, spanning 10-15 cm, depending on the surgeon’s preference and the patient’s anatomy.
• Technique: Using a scalpel, the surgeon makes a gentle, curved incision through the skin, following the natural Langer’s lines to improve cosmetic results and minimize scarring.
2. Subcutaneous Tissue (Fat)
• Layer: The subcutaneous layer, primarily composed of adipose tissue, is incised with cautery to reduce bleeding.
• Dissection: The surgeon carefully dissects through this fatty layer to expose the anterior rectus sheath while maintaining hemostasis.
• Hemostasis: Any bleeding vessels are cauterized or ligated to control blood loss.
3. Anterior Rectus Sheath
• Layer: The fibrous anterior rectus sheath, covering the rectus abdominis muscles, is the next layer encountered.
• Incision: A small incision is made in the center of the rectus sheath with the scalpel, and the sheath is then extended laterally on both sides with scissors or cautery.
• Elevation and Separation: The surgeon may use tissue forceps or a retractor to elevate the sheath, separating it from the underlying rectus muscles.
4. Rectus Abdominis Muscles
• Separation: The rectus abdominis muscles are separated along the midline (linea alba) rather than incised, reducing muscle damage and postoperative pain.
• Blunt Dissection: Blunt dissection with fingers or a blunt instrument is used to separate the muscles, creating space to reach the underlying peritoneum.
5. Transversalis Fascia and Preperitoneal Fat
• Identification: Beneath the rectus muscles lies the transversalis fascia, which may be thin or more developed depending on the patient.
• Dissection: The transversalis fascia and any preperitoneal fat are gently dissected and retracted to expose the peritoneum.
6. Peritoneum
• Incision: The peritoneum is tented up with forceps, creating a small initial incision with the scalpel or scissors.
• Extension: The incision is then extended using scissors to allow entry into the peritoneal cavity.
• Caution: Care is taken to avoid injury to underlying structures, particularly the bladder, which lies close to the peritoneum in the lower abdomen.
Closure of the Pfannenstiel Incision
The closure of each layer is done carefully to ensure hemostasis and reduce the risk of infection or hernia formation.
1. Peritoneum: Often not sutured, but if required, a continuous or interrupted absorbable suture can be used.
2. Rectus Sheath: The primary strength layer for abdominal wall closure. A continuous or interrupted suture of a long-lasting absorbable or non-absorbable suture is used.
3. Subcutaneous Layer: This layer is usually approximated with interrupted absorbable sutures if needed, especially in patients with significant subcutaneous tissue, to reduce dead space.
4. Skin: Closed with staples, non-absorbable sutures, or subcuticular sutures, depending on the surgeon’s preference and the patient’s condition.
This layered approach ensures a structured entry and closure, reducing the risk of complications and optimizing recovery. Let me know if you need further details on any specific step!
Steps for a Midline Vertical Incision
1. Skin Incision
• Location: The incision is typically made along the linea alba, starting from just below the xiphoid process (upper abdomen) or at the umbilicus and extending to just above the pubic symphysis (lower abdomen), depending on the surgical needs.
• Technique: A scalpel is used to make a straight, vertical incision through the skin along the midline, allowing access to deeper layers without significant muscle or nerve dissection.
2. Subcutaneous Tissue (Fat)
• Layer: The subcutaneous layer contains adipose tissue and is incised down to the fascia.
• Dissection: Using cautery or scissors, the surgeon carefully dissects through the adipose tissue, creating a straight pathway to the rectus sheath.
• Hemostasis: Any bleeding vessels in the subcutaneous tissue are cauterized or ligated to minimize blood loss.
3. Linea Alba and Anterior Rectus Sheath
• Layer: In the midline, the linea alba (the fibrous band joining the rectus sheaths of both sides) is incised, which provides direct access without cutting muscle tissue.
• Incision: The linea alba is incised with a scalpel in a straight, vertical line to maintain alignment, and the incision is extended using scissors or cautery.
• Elevation and Retraction: Retractors may be used to elevate and spread the rectus sheath, allowing the surgeon to reach the peritoneum beneath.
4. Rectus Abdominis Muscles
• Separation: In a midline vertical incision, the rectus abdominis muscles lie laterally to the incision and are generally not divided or separated directly. Instead, the incision goes through the avascular linea alba.
• Exposure: This approach avoids muscle disruption, reducing postoperative pain and minimizing muscle damage.
5. Transversalis Fascia and Preperitoneal Fat
• Identification: Beneath the rectus sheath, the thin transversalis fascia and any underlying preperitoneal fat are identified.
• Dissection: This layer is dissected gently and retracted to expose the underlying peritoneum.
6. Peritoneum
• Tenting and Incision: The peritoneum is gently tented upward with forceps to avoid underlying structures. A small initial incision is made with a scalpel.
• Extension: Using scissors, the peritoneal incision is extended vertically, allowing entry into the abdominal cavity.
• Caution: Special care is taken to avoid injury to underlying organs, particularly the bowel and bladder, which may adhere to the peritoneum.
Closure of the Midline Vertical Incision
Each layer is closed carefully to ensure structural integrity and reduce the risk of complications.
1. Peritoneum: Often left unsutured, but may be closed with a continuous absorbable suture if necessary.
2. Linea Alba and Rectus Sheath: This layer provides the main strength for the abdominal wall closure and is typically closed with a continuous or interrupted long-lasting absorbable or non-absorbable suture, taking bites that incorporate the fascia for a secure repair.
3. Subcutaneous Layer: Closed with interrupted absorbable sutures if needed, particularly in patients with significant subcutaneous tissue, to reduce dead space and risk of hematoma.
4. Skin: Closed with staples, interrupted non-absorbable sutures, or subcuticular sutures, depending on surgeon preference and patient factors.
The midline vertical incision offers rapid entry, minimal muscle dissection, and good exposure for exploration, making it ideal for emergencies or surgeries where broader access may be necessary. Let me know if you need any further details on specific steps or adjustments for certain clinical situations.
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PP visit
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PPROM
PPROM
PPROM: An Outline
PPROM, or preterm prelabor rupture of membranes, is a challenging obstetrical complication, especially in previable and periviable pregnancies, due to significant risks for both mother and fetus.
Previable refers to the stage when a fetus cannot survive outside the womb.
Periviable describes the stage when a fetus might survive with intensive care but faces a high risk of death or serious health issues.
The periviable period is generally considered to be between 20 0/7 and 25 6/7 weeks of gestation.
Survival rates at 23 weeks range from 23% to 27%, increase to 42% to 59% at 24 weeks, and reach 67% to 76% at 25 weeks.
Deliveries before 23 weeks have a 5% to 6% survival rate with a 98% to 100% chance of severe complications among survivors.
Viability is also influenced by factors like fetal weight, multiple pregnancies, genetic conditions, and anomalies.
Managing PPROM
The two primary management options for previable and periviable PPROM are expectant management and abortion care.
Patients should be evaluated for signs of infection, bleeding, and active labor.
Counseling should address the risks and benefits of both approaches.
Abortion care should be offered to all patients.
Expectant management is an option in the absence of contraindications.
Expectant Management:
Expectant management involves monitoring the pregnancy and intervening only when necessary.
It carries significant maternal risks without any direct benefit to the mother beyond the potential emotional benefit of trying to improve the fetal outcome.
A study revealed that only 16% of patients undergoing expectant management avoided maternal morbidity and had an infant survive to discharge.
The study, however, was limited to short-term outcomes and did not assess long-term health consequences for the mother or child.
37% of patients who opted for expectant management suffered complications without neonatal survival, while 23% experienced complications but had a surviving infant.
Latency, or the duration between PPROM and delivery, can be measured in various ways.
The proportion of patients who reach viability after expectant management might be a better indicator of latency than the time elapsed.
Neonates born after previable and periviable PPROM are vulnerable to short-term complications that can lead to chronic conditions and long-term health problems.
Factors Influencing Outcomes in Expectant Management:
Gestational age at PPROM and the volume of amniotic fluid remaining are crucial factors affecting outcomes.
Later gestational age at PPROM and a higher residual amniotic fluid volume generally correlate with better chances of perinatal survival.
Oligohydramnios, a condition of low amniotic fluid, and gestational age at PPROM were independently linked to severe breathing problems in newborns.
Maternal factors like age and multiple pregnancies can also impact outcomes.
Women over 35 years old and those carrying twins faced higher risks of maternal complications, including sepsis, ICU admission, and acute renal insufficiency.
Antibiotics in Expectant Management:
While antibiotics are recommended for expectant management at or after 24 0/7 weeks of gestation, the best type, dosage, and timing remain unclear.
Shared decision-making is advised when considering antibiotic use after previable PPROM at less than 20 weeks, weighing potential benefits against risks.
Limited data exists to guide decisions about antibiotic treatment following previable and periviable PPROM.
It is reasonable to follow recommendations similar to those for PPROM at later gestational ages, considering antibiotic type, regimen, and duration of treatment.
Other Interventions in Expectant Management:
Antenatal corticosteroids and magnesium sulfate are not recommended until neonatal resuscitation and intensive care are deemed appropriate and desired by the patient.
Serial amnioinfusions and amniopatch procedures, while investigated for improving outcomes, are considered experimental and are not advised for routine use.
Subsequent Pregnancies:
Individuals with a history of previable or periviable PPROM have an elevated risk of preterm birth in subsequent pregnancies.
Managing these pregnancies by following guidelines for those with a history of spontaneous preterm birth is recommended.
History-indicated cerclage, a procedure to reinforce the cervix, should be considered only in specific cases, like those with a history of cervical insufficiency or unexplained second-trimester loss without placental abruption.
Additional Notes:
Decisions regarding management should prioritize informed consent, respect for the patient's autonomy, and shared decision-making. This includes considering the patient's values and utilizing the best available data.
Further research is needed to optimize the management of PPROM, particularly in the periviable period.
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Pre-diabetes
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Preconception counseling
Preconception counseling
Prepregnancy Counseling: A Comprehensive Guide to Optimizing Reproductive Health
This article, "Prepregnancy Counseling," emphasizes the significance of prepregnancy counseling in reducing adverse health outcomes for women, fetuses, and neonates. Jointly developed by the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM), it outlines a comprehensive approach to prepregnancy care, covering a wide range of topics and recommendations.
The Goal of Prepregnancy Counseling
The primary goal of prepregnancy counseling is to minimize risks and enhance both reproductive and obstetric outcomes. This is achieved through a patient-centered approach that involves:
Optimizing health: Addressing existing health conditions and encouraging healthy habits.
Modifying risk factors: Identifying and mitigating modifiable risk factors that could negatively impact pregnancy.
Providing education: Empowering women with knowledge about healthy pregnancies.
Who Should Receive Prepregnancy Counseling?
All individuals planning to initiate a pregnancy should receive prepregnancy counseling, regardless of sexual orientation or gender identity. It is also relevant for both women currently using contraception and those actively planning a pregnancy.
When Should Prepregnancy Counseling Occur?
Prepregnancy counseling is recommended as a routine aspect of healthcare for individuals with reproductive potential. Due to the potential for changes in health status and risk factors, counseling should occur multiple times throughout a woman’s reproductive lifespan. This allows for ongoing education and may improve reproductive and pregnancy outcomes.
Ideally, medical care should be sought before conception or as soon as pregnancy is suspected. This helps with accurate pregnancy dating and allows for early monitoring and management of any medical conditions that may require treatment modification during pregnancy.
Key Components of Prepregnancy Counseling
1. Family Planning and Pregnancy Spacing:
Unintended pregnancies pose a higher risk of complications. Therefore, counseling should include:
Education about the impact of age on fertility.
Discussions on desired family size.
Guidance on optimal pregnancy spacing to reduce future complications.
The recommendation is to avoid intervals shorter than 6 months and to consider the risks and benefits of intervals shorter than 18 months.
2. Medical, Surgical, and Psychiatric History Review:
Optimal management of chronic conditions before pregnancy is crucial.
Conditions like diabetes, hypertension, psychiatric illnesses, and thyroid disease can significantly impact pregnancy outcomes.
Referral to a maternal-fetal medicine specialist might be necessary.
3. Medication Review:
All medications, including prescriptions, over-the-counter drugs, supplements, and herbal products, should be reviewed.
The pregnancy safety of each should be assessed and discussed.
Medications with potential teratogenicity warrant detailed discussion, emphasizing reliable contraception until safer alternatives are in place.
4. Family and Genetic History:
Obtaining a detailed genetic and family history of both partners is essential. This should include:
History of genetic disorders.
Birth defects.
Mental disorders.
Family history of cancers, particularly breast, ovarian, uterine, and colon.
Women should be offered the same genetic screening as recommended during pregnancy.
Early identification of potential genetic risks allows for informed family planning decisions.
5. Immunizations:
Annual assessment of immunization status is crucial for women of reproductive age. Vaccinations to be reviewed include:
Tetanus, diphtheria, and pertussis (Tdap).
Measles, mumps, and rubella.
Hepatitis B.
Varicella.
Annual influenza vaccination is recommended for all, especially for women who are or will be pregnant during flu season.
Specific timing considerations apply to certain vaccinations:
Rubella and varicella vaccines should be administered at least 28 days before conception.
Human papillomavirus (HPV) vaccination is not recommended during pregnancy, but it should not be delayed due to potential pregnancy.
6. Infectious Disease Screening:
Screening for sexually transmitted infections (STIs) is recommended based on age and risk factors.
This should include screening for gonorrhea, chlamydia, syphilis, and HIV.
Counseling on reducing STI risk is essential.
Screening and treatment for tuberculosis should be offered to those at high risk.
Individuals with potential exposure to infectious diseases like Zika virus require counseling about travel restrictions and appropriate waiting periods before conceiving.
7. Substance Use Assessment:
Routine screening for alcohol, nicotine, and drug use, including prescription opioids and other medications used non-medically, is crucial.
The harmful effects of these substances on reproductive health and pregnancy outcomes should be clearly explained.
8. Exposure to Violence and Coercion:
Screening for intimate partner violence, reproductive coercion, and sexual coercion should be integrated into prepregnancy counseling.
Ensuring privacy and confidentiality is paramount, while also informing patients about mandatory reporting requirements under state laws.
If abuse is identified, immediate safety assessments for the patient and her family are necessary, along with providing resources for victims.
9. Nutritional Status Assessment:
Encouraging a healthy diet rich in fruits, vegetables, and essential nutrients is key.
Folic acid supplementation is crucial for all women of reproductive age (15–45 years) to reduce the risk of neural tube defects (NTDs).
400 micrograms per day is recommended for average-risk women, while 4 mg per day is advised for those at increased risk.
Dietary assessments should ensure adequate intake of calcium, iron, vitamins A, B12, B6, D, and other essential nutrients.
Supplementation might be necessary for those with malabsorption, bariatric surgery, or vegan diets.
Patients should be advised to limit consumption of high-mercury fish and foods with a high risk of listeria contamination.
10. Healthy Body Weight:
Patients should be encouraged to achieve a normal BMI before pregnancy.
Both high and low BMI are associated with infertility and various maternal and fetal complications.
11. Exercise and Physical Activity:
Regular physical activity is beneficial for overall health and should be encouraged, aiming for at least 150 minutes of moderate exercise per week.
This recommendation applies to pre-pregnancy, pregnancy, and postpartum periods.
Competitive athletes might require closer monitoring and adjustments to their training regimens.
12. Environmental and Occupational Exposures:
Assessment of exposure to potential teratogens and environmental pollutants is important.
This includes exposures at home (e.g., certain plastics, pesticides, lead paint) and in the workplace (e.g., chemicals, radiation).
Patients should be educated on minimizing exposure to harmful agents and referred to occupational health services when necessary.
Conclusion
Prepregnancy counseling is a vital component of comprehensive women's healthcare. By addressing a wide array of factors that can impact pregnancy and reproductive health, healthcare providers can play a significant role in improving outcomes for women and their families.
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Preeclampsia
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Pregestational diabetes
Pregestational diabetes
Pregestational Diabetes Mellitus
Definition:
Pregestational diabetes mellitus is when a woman has diabetes before becoming pregnant.
Can be either type 1 or type 2 diabetes.
Diagnosed in the first trimester or early second trimester with standard diagnostic criteria.
Hemoglobin A1C (HbA1C) of 6.5% or greater
Fasting plasma glucose of 126 mg/dL or greater
2-hour glucose of 200 mg/dL or greater on a 75-g oral glucose tolerance test
Prevalence:
Observed in 1–2% of all pregnancies.
Higher rates in Black, Native American, and Hispanic women.
Lower rates in non-Hispanic white and Asian women.
Increasing incidence due in part to rising obesity rates in the United States.
Maternal Morbidity:
Pregnancy can worsen diabetes-related complications, especially retinopathy and nephropathy.
Diabetic ketoacidosis is a life-threatening emergency.
Occurs in 5–10% of pregnancies with pregestational diabetes.
More common in type 1 diabetes.
Can develop more rapidly during pregnancy, even with normal glucose levels.
Risk factors include new-onset diabetes, infections, poor patient compliance, insulin pump failure, and certain medications.
Chronic hypertension occurs in about 5–10% of pregnant patients with pregestational diabetes.
Increases the risk of preeclampsia, uteroplacental insufficiency, and stillbirth.
Acute myocardial infarction risk is higher during pregnancy.
Perinatal Morbidity and Mortality:
Perinatal outcomes are best when glucose control is achieved before pregnancy and in the absence of vascular or hypertensive disease.
Major congenital anomalies are the leading cause of perinatal mortality.
Occur in 6–12% of infants of women with diabetes.
Linked to poor prepregnancy glucose control, particularly hyperglycemia during organogenesis (5–8 weeks after the last menstrual period).
Cardiac defects, central nervous system anomalies (anencephaly, spina bifida), and skeletal malformations (sacral agenesis) are most common.
Stillbirths are more common and are associated with higher HbA1C values and inadequate prenatal care.
Fetal macrosomia (large birth weight) is a significant risk.
Caused by fetal hyperinsulinemia in response to maternal hyperglycemia.
Increases the risk of shoulder dystocia during vaginal delivery.
Strongly associated with HbA1C levels, particularly elevated postprandial values.
Neonatal complications include hypoglycemia, respiratory distress syndrome, polycythemia, organomegaly, electrolyte disturbances, and hyperbilirubinemia.
Long-term risks for offspring include obesity and carbohydrate intolerance, potentially leading to metabolic syndrome and cardiac disease in adulthood.
Management of Pregestational Diabetes During Pregnancy
Prepregnancy Counseling:
Strongly encouraged as it is beneficial and cost-effective.
Focuses on:
Achieving euglycemic control before pregnancy.
Risks of poorly controlled diabetes for both mother and baby.
Understanding the stricter glucose targets needed during pregnancy.
Contraception options if pregnancy is not desired.
Recommended evaluations:
Retinal exam by an ophthalmologist
24-hour urine collection for protein and creatinine clearance
Lipid assessment
Electrocardiogram
Thyroid function tests
Folic acid supplementation (at least 400 mcg daily) is crucial.
Low-dose aspirin (81 mg/day) prophylaxis is recommended from 12-28 weeks gestation (ideally before 16 weeks) to reduce preeclampsia risk.
Glucose Control:
Goal is to maintain near-physiologic glucose levels throughout pregnancy.
Fasting and premeal glucose: 95 mg/dL or less
1-hour postprandial: 140 mg/dL or less
2-hour postprandial: 120 mg/dL or less
Nighttime glucose: Not below 60 mg/dL
Average capillary glucose: Around 100 mg/dL
HbA1C in the second and third trimesters: Less than 6%
Strict control is especially critical in the first trimester to minimize congenital anomaly risks.
Management Strategies:
Medical nutrition therapy with a carbohydrate-controlled diet is essential.
Working with a registered dietitian or certified diabetes educator is beneficial.
Caloric needs increase by about 300 kcal/day during the second and third trimesters.
Focus on complex carbohydrates, protein, and healthy fats.
Carbohydrate counting helps tailor insulin doses to food intake.
Insulin is the preferred treatment for pregestational diabetes not controlled by diet and exercise alone.
Requirements increase throughout pregnancy, most significantly between 28 and 32 weeks.
Basal insulin (NPH, glargine, or detemir) maintains glucose between meals and overnight.
Rapid-acting insulin is used before meals.
Continuous subcutaneous insulin infusion (insulin pump) may be an option.
Oral hypoglycemic agents (glyburide, metformin) have limited data in pregestational diabetes and their use should be individualized.
Frequent blood glucose monitoring is essential, typically in the fasting state, 1 or 2 hours after meals, and at bedtime.
Continuous glucose monitoring may be considered.
Patient education on recognizing and managing hypoglycemia is vital.
Fetal Assessment:
Early ultrasound to confirm viability and accurately date the pregnancy.
Detailed anatomical ultrasound at 18–20 weeks to detect major anomalies, including fetal echocardiography if needed.
Third-trimester ultrasounds to monitor fetal growth, especially for macrosomia or growth restriction.
Antepartum fetal monitoring (nonstress test, biophysical profile) starting around 32 weeks gestation.
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Pregnancy visit
Pregnancy visit
148
Premenstrual syndrome or PMDD
Premenstrual syndrome or PMDD
Management of Premenstrual Disorders: A Clinical Practice Guideline Overview
This article presents the American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline for managing premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), collectively referred to as premenstrual disorders. The guideline aims to aid clinicians in providing care to reproductive-aged individuals and adolescents experiencing premenstrual symptoms.
Key Points and Recommendations:
Premenstrual disorders encompass a range of conditions, with PMS being more common, characterized by cyclical physical and mood-related symptoms during the luteal phase. PMDD is less prevalent but more severe, classified as a depressive disorder with significant impact on daily functioning.
The guideline development involved a rigorous methodology, including a comprehensive literature search and application of the GRADE (Grading of Recommendations Assessment, Development and Evaluations) framework.
Treatment recommendations prioritize evidence-based options, including pharmacologic agents (hormonal and nonhormonal), psychological counseling, complementary and alternative treatments, exercise, nutritional therapies, patient education, and, in rare cases, surgical management.
Multimodal approaches combining several interventions are often beneficial.
Shared decision-making, considering patient preferences, goals, and the benefits and risks of each option, is crucial for selecting the most appropriate treatment.
Specific Recommendations:
The guideline offers strong recommendations for:
SSRIs for affective premenstrual symptoms: SSRIs are considered first-line pharmacologic treatment, proven effective in managing mood-related symptoms in both PMS and PMDD.
Combined oral contraceptives (COCs) for overall premenstrual symptoms: COCs can improve overall premenstrual symptom severity and functional impairment, but their efficacy for mood symptoms, especially premenstrual depression, is less clear.
Cognitive behavioral therapy (CBT) for affective premenstrual symptoms: CBT, focusing on reframing negative thoughts and teaching coping mechanisms, shows promise in managing anxiety and depression related to premenstrual disorders.
Conditional recommendations are provided for:
GnRH agonists with add-back therapy for severe, refractory cases: GnRH agonists effectively suppress ovulation, alleviating symptoms, but carry risks like hypoestrogenic effects. Their use is limited to severe cases unresponsive to other treatments.
Routine exercise for managing physical and affective symptoms: Evidence suggests moderate exercise may improve premenstrual symptoms, though further research is needed.
Calcium supplementation (1,000-1,200 mg/day) in adults: Limited evidence suggests calcium may improve premenstrual symptoms, potentially due to its role in calcium metabolism.
Adequate calcium intake in adolescents: While data is limited, adequate calcium intake through diet may reduce physical premenstrual symptoms in adolescents.
Acupuncture: RCT evidence suggests acupuncture may help manage physical and affective symptoms, but further research is needed.
NSAIDs for pain management: NSAIDs are effective in reducing pain associated with premenstrual disorders, though evidence supporting their impact on mood is limited.
Patient education and self-help strategies: While studies show mixed results, providing information about premenstrual disorders and coping strategies is considered beneficial as part of a holistic approach.
Finally, the guideline includes a good practice point regarding:
Bilateral oophorectomy as a last resort: This procedure, inducing permanent anovulation, should only be considered in extreme cases where other treatments have failed and after thorough counseling about its risks and irreversibility. A trial of GnRH agonist therapy is advised beforehand to predict potential surgical response.
Additional Considerations:
The guideline emphasizes the importance of screening for suicidal thoughts and behavior in individuals with moderate-to-severe premenstrual symptoms.
Treatment resistance to SSRIs requires careful assessment, including medication adherence and potential adjustments to dosage or regimen. Switching to a different SSRI or seeking specialist consultation may be necessary.
The use of SSRIs in adolescents warrants careful consideration of the FDA warning regarding increased suicidal ideation and behavior risk, necessitating close monitoring.
Long-term SSRI treatment is often necessary for premenstrual disorders, with a high relapse rate upon discontinuation.
Hormonal add-back therapy after GnRH agonist treatment or bilateral oophorectomy requires consideration of potential symptom recurrence associated with progestin use.
Access to CBT can be a challenge due to cost, time commitment, and limited availability of qualified therapists. Online-based CBT interventions might offer an alternative but depend on internet access.
The guideline acknowledges the underrepresentation of diverse populations in premenstrual disorder research, advocating for future studies to understand prevalence, presentation, and treatment response in these groups.
This overview provides a comprehensive summary of the ACOG Clinical Practice Guideline on the management of premenstrual disorders. Clinicians are encouraged to review the full guideline for detailed information and supporting evidence.
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Prenatal Diagnostic Testing for Genetic Disorders
Prenatal Diagnostic Testing for Genetic Disorders
Introduction
Definition: Prenatal diagnostic testing aims to determine whether a specific genetic disorder or condition is present in the fetus with as much certainty as possible. It differs from screening, which assesses the risk of a fetus having a genetic disorder.
Purpose: The main goal is to detect health problems that could affect the mother, fetus, or newborn, allowing informed decisions regarding pregnancy management. Testing is often focused on specific conditions such as chromosomal abnormalities or single-gene disorders.
Common Genetic Conditions:
Chromosomal Abnormalities: Include aneuploidy (e.g., trisomies like Down syndrome), deletions, duplications, and translocations.
Single-Gene Disorders: Conditions like cystic fibrosis, sickle cell anemia, hemophilia, and Tay-Sachs disease.
Types of Prenatal Genetic Tests
Invasive Tests:
Chorionic Villus Sampling (CVS): Typically performed between 10-13 weeks; involves collecting placental villi through transcervical or transabdominal methods. Allows earlier diagnosis compared to amniocentesis but comes with a small risk of miscarriage.
Amniocentesis: Usually performed between 15-20 weeks, involves sampling amniotic fluid to detect chromosomal abnormalities or single-gene disorders. Miscarriage risk is estimated between 0.1-0.3%.
Laboratory Techniques:
Karyotype Analysis: Used for identifying chromosomal abnormalities larger than 5-10 megabases, such as aneuploidies and major structural changes.
Fluorescence In Situ Hybridization (FISH): Rapid screening for common aneuploidies (e.g., trisomies 13, 18, 21).
Chromosomal Microarray Analysis (CMA): Detects smaller chromosomal deletions/duplications not visible on karyotype. Preferred for cases with structural abnormalities detected on ultrasound.
Molecular DNA Testing: Targets known mutations within a family or suspected based on imaging findings.
Indications for Prenatal Diagnostic Testing
Increased Risk of Genetic Disorders:
Advanced Maternal Age: Increased risk of aneuploidy.
Parental Carrier Status: Carriers of chromosome rearrangements (e.g., translocations) or single-gene mutations.
Family History: History of genetic disorders or birth defects increases the risk of recurrence.
Ultrasound Abnormalities: Structural abnormalities suggestive of chromosomal or genetic conditions warrant invasive testing.
Screening vs. Diagnostic Testing: Diagnostic testing should be offered to all pregnant women, particularly those with an increased risk based on screening, family history, or other risk factors.
Management Considerations
Mosaicism: Chromosomal mosaicism, found in 0.25% of amniocentesis samples and 1% of CVS samples, requires careful interpretation and often a follow-up with amniocentesis to determine if it is confined to the placenta.
Counseling: Genetic counseling should be offered before and after testing to discuss the implications of results, including the benefits, risks, and potential outcomes.
Risks and Ethical Considerations
Procedure-Related Loss: The risk of miscarriage after amniocentesis or CVS is generally low (0.1-0.3%) but varies by procedure and provider experience.
Viral Transmission: For women with infections like HIV or hepatitis, the risk of transmission with invasive testing is generally low, especially with controlled viral load and antiretroviral therapy.
Non-Termination: Prenatal diagnosis is also valuable for planning perinatal management and making informed decisions even if pregnancy termination is not an option.
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Preoperative care
Preoperative care
Gynecology
Overview of Enhanced Recovery After Surgery (ERAS) Pathways in Gynecologic Surgery
This article from the American College of Obstetricians and Gynecologists (ACOG) focuses on Enhanced Recovery After Surgery (ERAS) pathways for gynecologic surgery. It highlights the benefits of these pathways and provides guidance for their implementation.
Background
Gynecologic surgeries are common, and the traditional perioperative care often includes practices that are not evidence-based and can delay healing and recovery.
Surgical stress induces a catabolic state that can lead to organ dysfunction, increased morbidity, and delayed recovery.
ERAS pathways were developed to address these issues by maintaining normal physiology in the perioperative period.
Principles of ERAS
ERAS focuses on optimizing patient outcomes by mitigating the negative consequences of surgical stress through a multi-pronged approach that includes:
Preoperative counseling and nutritional strategies: This includes avoiding prolonged fasting, allowing clear fluids up to 2 hours before induction of anesthesia, and solids up to 6 hours prior.
Perioperative considerations: This involves a focus on regional anesthetic and nonopioid analgesic approaches, maintaining fluid balance, and maintaining normothermia.
Promotion of postoperative recovery strategies: This includes early mobilization and appropriate thromboprophylaxis.
Benefits of ERAS
Implementing ERAS pathways has been shown to lead to:
Shorter length of stay
Decreased postoperative pain and need for analgesia
More rapid return of bowel function
Decreased complication and readmission rates
Increased patient satisfaction
Significant cost savings
Importantly, implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates.
Components of an ERAS Program
Table 1 in the source document provides a detailed list of interventions that can be considered when designing and implementing an ERAS program. These interventions cover the preoperative, intraoperative, and postoperative phases of care. Some key components include:
Preoperative
Patient education and engagement
Risk assessment and management of factors like smoking, alcohol use, obesity, anemia, and sleep apnea
Carbohydrate loading drinks for nondiabetic patients
Elimination of routine mechanical bowel preparation
Intraoperative
Multimodal pain management to minimize opioid use
Regional anesthesia when feasible
Minimizing fluid overload and maintaining normothermia
Judicious use of tubes and drains
Postoperative
Early mobilization
Thromboprophylaxis based on risk assessment
Early feeding and return to regular diet
Minimizing intravenous fluids
Blood glucose management
Criteria-based discharge planning
Implementation of ERAS
Implementing an ERAS program requires a shift away from traditional practices and the adoption of multiple ERAS principles.
It necessitates collaboration from all members of the surgical team and may require significant changes to clinical systems.
The article stresses the importance of active patient engagement and shared decision-making in the process.
Several factors are critical for the successful implementation of a sustainable ERAS program:
Measurement of outcomes and data-driven refinement of interventions
Strong leadership support
Effective teamwork and a patient-centered approach
A culture of safety and quality improvement
Conclusion
The article concludes by advocating for the widespread adoption of ERAS pathways in gynecologic surgery. It emphasizes that these pathways, grounded in evidence-based practices, have consistently demonstrated improved patient outcomes and healthcare delivery efficiency.
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Preterm Labor
Preterm Labor
Obstetrics
Clinical Assessment
• Patient History:
Gestational age
History of previous preterm births
Symptoms (e.g., contractions, pelvic pressure, vaginal discharge or bleeding)
Risk factors (e.g., multiple gestations, uterine anomalies, infections, history of cervical insufficiency)
• Physical Examination:
Vital signs, including blood pressure and temperature
Abdominal examination for uterine contractions and tenderness
Pelvic examination for cervical dilation, effacement, and fetal presentation
Sterile speculum examination to assess for cervical changes, vaginal bleeding, or ruptured membranes
Laboratory Tests
• Urinalysis and Urine Culture: To rule out urinary tract infection (UTI), a known trigger for preterm labor.
• Complete Blood Count (CBC): To assess for infection or anemia.
• Cervicovaginal Cultures: To check for bacterial vaginosis, Group B Streptococcus (GBS), and sexually transmitted infections (STIs) like Chlamydia and Gonorrhea.
• Fetal Fibronectin Test (fFN): A test of cervical secretions for fFN, a glycoprotein. A positive result may indicate an increased risk of preterm birth within the next 7-14 days.
• Amniocentesis: Considered in certain cases to assess for intra-amniotic infection or inflammation (chorioamnionitis), particularly if there is a concern for preterm premature rupture of membranes (PPROM).
Imaging Studies
• Transvaginal Ultrasound:
Measurement of cervical length is crucial. A short cervical length (<25 mm before 24 weeks of gestation) is associated with an increased risk of preterm birth.
Assessment of fetal position and amniotic fluid volume.
• Abdominal Ultrasound: To evaluate fetal growth, anatomy, and placental location.
Additional Considerations
• Assessment for Tocolysis: If preterm labor is diagnosed, determine if tocolytics are indicated to delay delivery and allow for antenatal corticosteroids to be administered for fetal lung maturity.
• Antenatal Corticosteroids: Administer betamethasone or dexamethasone if the gestational age is between 24 and 34 weeks, to enhance fetal lung maturity.
• Magnesium Sulfate: Consider for neuroprotection if delivery is imminent before 32 weeks of gestation.
• Infectious Disease Workup: If there are signs of infection (e.g., fever, leukocytosis), further testing and appropriate antibiotic therapy are indicated.
Consultation
• Consider consulting Maternal-Fetal Medicine (MFM) specialists for high-risk cases.
• Neonatology consultation may be necessary if preterm delivery is imminent to discuss neonatal care and outcomes with the parents.
Introduction
Definition: Preterm birth is defined as delivery between 20 0/7 and 36 6/7 weeks of gestation. Preterm labor involves regular uterine contractions accompanied by changes in cervical dilation or effacement.
Incidence: Approximately 12% of all live births in the U.S. are preterm, and preterm labor precedes about 50% of these preterm births. Preterm births are the leading cause of neonatal mortality and a significant reason for antenatal hospitalization.
Economic Impact: The annual cost of preterm birth in the U.S. is estimated at $26.2 billion, translating to over $51,000 per premature infant.
Risk Factors and Diagnosis
Diagnosis Criteria: Preterm labor is diagnosed based on clinical criteria, such as regular uterine contractions coupled with cervical changes or initial presentation with regular contractions and cervical dilation of at least 2 cm.
Risk Stratification Tools:
Fetal Fibronectin and Cervical Length: While both have been associated with preterm birth risk, their positive predictive value remains low, limiting their use in management decisions.
High-Risk Conditions: Risk factors include previous preterm births, multiple gestations, infections, uterine anomalies, and certain lifestyle factors (e.g., smoking, poor nutrition).
Interventions and Management Strategies
Pharmacologic Management:
Tocolytic Therapy: Used to delay labor by up to 48 hours, allowing time for the administration of antenatal corticosteroids or magnesium sulfate for neuroprotection. First-line agents include beta-adrenergic receptor agonists, calcium channel blockers, and NSAIDs.
Corticosteroids: A single course is recommended for women between 24-34 weeks gestation at risk of delivery within 7 days, improving neonatal outcomes by accelerating fetal lung maturity.
Magnesium Sulfate: Administered for fetal neuroprotection when delivery is expected before 32 weeks, reducing the risk of cerebral palsy.
Antibiotics: Not recommended for the prolongation of pregnancy in women with intact membranes, as their use has not demonstrated benefits for preventing preterm labor.
Nonpharmacologic Management:
Bed Rest and Hydration: Lack of efficacy has been shown for bed rest, hydration, and similar nonpharmacologic approaches in preventing preterm birth and should not be routinely recommended.
Special Considerations
Multiple Gestations: The use of tocolytics in multiple gestations poses higher risks of maternal complications, such as pulmonary edema. Nevertheless, corticosteroids are recommended for improving neonatal outcomes.
Contraindications for Tocolysis:
Conditions such as intrauterine fetal demise, lethal fetal anomaly, nonreassuring fetal status, and severe preeclampsia are contraindications for tocolysis.
Introduction and NICU Basics (0:05–0:31)
NICU Level Overview: Emphasis on knowing the level of NICU care available at the hospital where you practice or refer patients.
Gestational Limits: Be familiar with the gestational age limits for NICU care, which may differ by institution (e.g., 22 weeks vs. 23 weeks for viability).
Neonatal Statistics: Know basic statistics regarding neonatal outcomes based on gestational age and birth weight (e.g., at 20, 30, 36, and 40 weeks).
Survival Thresholds: Awareness of weight thresholds (in grams) for infant survival.
Ultrasound Assessment and Accuracy (0:32–1:05)
First Trimester Ultrasound: Most accurate, with a margin of error of ±5 days.
Second Trimester Ultrasound: Less accurate, with a margin of error of ±7–14 days.
Third Trimester Ultrasound: Even less accurate, with a margin of error of ±21 days.
Clinical Importance: Use first-trimester ultrasounds when available for dating pregnancies accurately, especially for induction or assessing premature labor.
Viability and Resuscitation (1:06–1:31)
Lower Limits of Viability: Current viability threshold is slightly below 23 weeks (some hospitals will go as low as 22 weeks with planned resuscitation).
Referral Considerations: For extremely preterm deliveries (before 23 weeks), many centers will refer to higher-level hospitals with NICUs capable of handling extreme preterm infants.
Institutional Variability: Gestational limits for resuscitation vary by institution; familiarize yourself with the policies of your referral centers.
Tocolysis in Preterm Labor (1:49–3:30)
Indicated Tocolysis: Use tocolysis only in specific cases for short-term use (typically 24–48 hours).
Purpose of Tocolysis:
1. Optimization of Fetal Status: Allows time for administration of antenatal steroids for lung maturity, GBS prophylaxis, or other medications to improve neonatal outcomes.
2. Treating Maternal Conditions: Conditions like pyelonephritis may induce preterm labor, and tocolysis can be used while treating the underlying cause (e.g., antibiotics for infection). Once the condition is treated, preterm labor may resolve.
3. Transfer of Care: Tocolysis can allow for safe transfer to a higher-level facility when needed for neonatal or maternal care.
Monitoring: Continuous maternal and fetal monitoring is essential during tocolysis to ensure both maternal stability and fetal well-being.
Cervical Insufficiency and Progesterone Use (4:02–8:17)
Cervical Insufficiency Overview: Discussion of the condition in patients with a history of spontaneous preterm birth (not iatrogenic, e.g., preeclampsia inductions).
Progesterone Use Guidelines:
17-hydroxyprogesterone injections are no longer available.
Vaginal progesterone is only indicated for patients with a history of spontaneous preterm birth if they develop a shortened cervix (<25mm) before 24 weeks.
High-Risk Patients:
Screen cervical length every 1–4 weeks from 16 to 24 weeks in those with a prior spontaneous preterm birth.
Intervene with vaginal progesterone or cerclage if the cervix measures ≤24mm.
Low-Risk Patients:
Cervical length screening is only performed at the 18-20 week anatomy ultrasound.
Intervene with vaginal progesterone if the cervix measures ≤25mm, and consider cerclage if the cervix is significantly shorter (<15mm).
Cerclage Types:
1. Elective Cerclage: Performed at 12–14 weeks in women with a diagnosis of cervical insufficiency based on history (e.g., prior preterm birth without other causes like infection or preterm labor).
2. Rescue Cerclage: For women with an acute diagnosis of cervical insufficiency (e.g., very short cervix <10–11mm).
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Preventing preterm delivery
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153
Prevention of Infection After Gynecologic Procedures
Prevention of Infection After Gynecologic Procedures
Gynecology
Antibiotic Prophylaxis in Gynecology
Hysterectomy
Vaginal, abdominal, laparoscopic, or robotic hysterectomy: Single-dose antimicrobial prophylaxis with cefazolin is recommended.
For patients weighing more than 120 kg, a 3-g intravenous dose of cefazolin is recommended. For those weighing 80 kg or less, a 1-g dose can be considered.
In surgical cases with excessive blood loss (exceeding 1,500 mL), a second dose of prophylactic antibiotics may be appropriate.
Other Laparoscopic and Laparotomy Procedures
Antibiotic prophylaxis is not recommended for diagnostic or operative laparoscopy if entry into the bowel or vagina is not anticipated.
Single-dose antibiotic prophylaxis may be considered for laparotomy.
Consider antibiotic prophylaxis for patients at very high risk of conversion from laparoscopy to laparotomy.
Hysterosalpingography and Chromotubation
In patients with no history of pelvic infection, hysterosalpingography (HSG) can be performed without prophylactic antibiotics.
If HSG shows dilated fallopian tubes, doxycycline (100 mg twice daily for 5 days) is recommended to reduce the incidence of post-HSG pelvic inflammatory disease (PID).
In patients with a history of pelvic infection, doxycycline can be administered before the procedure and continued if dilated fallopian tubes are found.
Neither HSG nor chromotubation should be performed in patients thought to have an active pelvic infection.
Because chromotubation at the time of diagnostic laparoscopy is similar to HSG, the same prophylaxis regimen is reasonable for chromotubation.
Sonohysterography
Routine antibiotic prophylaxis is not recommended for patients undergoing sonohysterography.
Hysteroscopy
Antibiotic prophylaxis is not recommended for routine hysteroscopic procedures.
Endometrial Ablation
The role of antibiotic prophylaxis for endometrial ablation is unclear.
One randomized trial found no difference in infection rates between women who received antibiotic prophylaxis and those who received a placebo.
Intrauterine Device (IUD) Insertion
Routine antibiotic prophylaxis is not recommended before IUD insertion.
Endometrial Biopsy
Routine antimicrobial prophylaxis is not recommended before endometrial biopsy.
Uterine Evacuation
Induced abortion: Antimicrobial prophylaxis should be administered.
Early pregnancy loss: Antimicrobial prophylaxis should be administered.
A single preoperative dose of doxycycline is recommended to prevent infection after surgical management.
Colporrhaphy and Vaginal Slings
Antibiotic prophylaxis is reasonable for patients undergoing anterior or posterior colporrhaphy or transvaginally placed slings.
Postoperative Indwelling Catheters
The sources do not provide a clear recommendation on antibiotic prophylaxis for postoperative indwelling catheters.
Cystoscopy
Antibiotic prophylaxis is not recommended for cystoscopy in women with negative urine cultures.
Cervical Tissue Excision Procedures
Antibiotic prophylaxis is not necessary for cervical excision procedures, including loop electrosurgical excision procedure, biopsy, or endocervical curettage.
Vulvectomy
The role of antibiotic prophylaxis for vulvectomy is not clear.
Oocyte Donation
The role of antibiotic prophylaxis for oocyte donation is not clear.
Embryo Transfer
Routine antibiotic prophylaxis is not recommended before embryo transfer.
Note: The sources do not discuss the role of antibiotic prophylaxis in the management of conditions such as mastitis. However, information on the treatment of mastitis is provided in source.
This outline is based on the provided sources. Clinical practice guidelines and recommendations can change over time, so it's always best to consult the most up-to-date sources and clinical judgment when making treatment decisions.
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Prolapse
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155
Prolonged or Arrested Labor
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156
PROM (premature rupture of membranes)
PROM (premature rupture of membranes)
Obstetrics
Overview of Prelabor Rupture of Membranes
This article, a Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG), provides clinical management guidelines for prelabor rupture of membranes (PROM). PROM is defined as the rupture of membranes before the onset of labor. It is further categorized as preterm PROM when it occurs before 37 weeks of gestation and term PROM when it happens at or after 37 weeks. The bulletin reviews the current understanding of this condition, discusses its diagnosis, and outlines management guidelines based on scientific evidence, consensus, and expert opinion.
Etiology of Prelabor Rupture of Membranes
At term, PROM is generally attributed to a physiological weakening of the membranes combined with the pressure from uterine contractions.
Preterm PROM, however, can be caused by various pathological mechanisms, including intra-amniotic infection which is frequently associated with preterm PROM, particularly at earlier gestational ages.
Other risk factors for preterm PROM are similar to those for spontaneous preterm birth and include:
Short cervical length
Bleeding during the second and third trimesters
Low body mass index
Low socioeconomic status
Cigarette smoking
Illicit drug use
A history of preterm PROM significantly increases the risk of preterm PROM or preterm labor in subsequent pregnancies.
It is important to note that preterm PROM can occur even in the absence of identifiable risk factors.
Diagnosis of Prelabor Rupture of Membranes
The diagnosis of PROM is usually based on the patient’s history and physical examination.
Digital cervical examinations should be avoided unless the patient is in active labor or delivery is imminent, as they increase the risk of infection.
Sterile speculum examination allows visualization of the cervix for signs of infection, prolapse of the umbilical cord or fetal parts, and assessment of cervical dilation and effacement.
Conventional clinical assessment usually confirms the diagnosis. This involves:
Visualizing amniotic fluid leaking from the cervical canal and pooling in the vagina
Testing the pH of vaginal fluid: Amniotic fluid has a pH of 7.1–7.3 while vaginal secretions usually have a pH of 3.8–4.5
Microscopic evaluation of dried vaginal fluid for arborization (ferning)
False-positive or false-negative results can occur with these tests.
Additional tests can aid in the diagnosis of PROM in equivocal cases:
Ultrasonography can assess amniotic fluid volume but is not a definitive diagnostic tool.
Fetal fibronectin testing has high sensitivity but low specificity.
Commercially available tests for amniotic proteins offer high sensitivity but have been associated with false-positive results and potential adverse events, including fetal death. The FDA advises against using these tests without other clinical assessments.
If the diagnosis remains uncertain, ultrasonographically guided transabdominal instillation of indigo carmine dye can be used. Blue-tinged amniotic fluid passing into the vagina confirms PROM. Fluorescein can be used as an alternative to indigo carmine dye.
Management of Prelabor Rupture of Membranes
Initial management of PROM involves:
Determining gestational age
Assessing fetal presentation and well-being
Evaluating for signs of intrauterine infection and abruptio placentae
Obtaining a group B streptococci (GBS) culture if results are not available and expectant management is being considered
For preterm PROM, electronic fetal heart rate and uterine activity monitoring is conducted to assess fetal status and identify contractions.
Management after PROM diagnosis depends primarily on gestational age. Abnormal fetal testing or evidence of intraamniotic infection are indications for delivery. Vaginal bleeding should raise concern for abruptio placentae, prompting consideration of delivery based on fetal status, bleeding severity, and gestational age.
Management of Term PROM
For patients with term PROM (37 weeks of gestation or more):
Confirm gestational age and fetal position.
Assess fetal status with fetal heart rate monitoring.
Administer GBS prophylaxis based on previous culture results or intrapartum risk factors.
Induction of labor is recommended if spontaneous labor doesn’t occur near the time of presentation and there are no contraindications to labor. Induction has been shown to:
Reduce the time from membrane rupture to birth
Lower the rates of chorioamnionitis and endometritis
Decrease neonatal intensive care unit admissions
Expectant management for a short duration (12–24 hours) is a reasonable option as long as the patient is adequately counseled about the risks of prolonged PROM and the limitations of available data. This option is appropriate if clinical and fetal conditions are reassuring.
If expectant management is chosen, GBS prophylaxis should not be delayed for GBS-positive women, and immediate induction is recommended.
During labor induction with oxytocin, allow a sufficient duration (at least 12–18 hours) for the latent phase of labor to progress before considering cesarean birth due to failed induction.
While prophylactic antibiotics may reduce infection morbidity, there is insufficient evidence to support their routine use with term PROM in the absence of an indication for GBS prophylaxis.
Management of Preterm PROM
Management of preterm PROM is guided by gestational age and the presence of complications:
Abnormal fetal testing, clinical intraamniotic infection, and significant abruptio placentae are indications for delivery.
For patients with preterm PROM before 34 weeks of gestation, expectant management is recommended if there are no maternal or fetal contraindications.
For patients with PROM between 34 and 37 weeks of gestation, both expectant management and immediate delivery are reasonable options.
This decision should be individualized through shared decision-making, considering the balance of benefits and risks for both the mother and neonate.
Expectant management should not extend beyond 37 weeks of gestation and should include careful monitoring for maternal infection, chorioamnionitis, and antepartum hemorrhage, preferably in a hospital setting.
Latency antibiotics are not appropriate in this setting.
General approaches for expectant management of preterm PROM:
Hospital admission for surveillance of the woman and fetus.
Periodic assessment for:
Infection
Abruptio placentae
Umbilical cord compression
Fetal well-being
Labor
Periodic ultrasonographic monitoring of fetal growth.
Periodic fetal heart rate monitoring.
Outpatient management may be considered for periviable PROM after an initial assessment period in the hospital, as long as the patient is carefully monitored.
Specific treatment considerations for preterm PROM:
Tocolytics can be considered in preterm PROM for steroid benefit to the neonate, especially at earlier gestational ages, or for maternal transport but should be avoided if there is evidence of infection or abruption. Tocolytic therapy is not recommended between 34 and 37 weeks of gestation.
Antenatal corticosteroids are recommended for women between 24 and 34 weeks of gestation to reduce neonatal morbidity and mortality. They can be considered as early as 23 weeks for women at risk of preterm birth within 7 days. A single course of corticosteroids is recommended for women between 34 and 37 weeks who are at risk of preterm birth within 7 days and haven't received a prior course. Late preterm administration of corticosteroids is not indicated in women with clinical chorioamnionitis, and delivery should not be delayed for steroid administration. A single repeat course of antenatal corticosteroids can be considered in women with preterm PROM before 34 weeks gestation who are at risk of preterm delivery within 7 days and whose prior course was administered more than 14 days previously. However, delivery should not be delayed to achieve a rescue course.
Magnesium sulfate for fetal neuroprotection is recommended for women before 32 weeks of gestation who are at risk of imminent delivery.
Latency antibiotics (a 7-day course of intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin) are recommended for women with preterm PROM before 34 weeks of gestation to reduce maternal and neonatal infections and gestational age-dependent morbidity. Some centers replace erythromycin with azithromycin, a suitable alternative in cases of erythromycin unavailability or intolerance. GBS prophylaxis should be administered to women with preterm PROM and a viable fetus who are candidates for intrapartum GBS prophylaxis, regardless of previous antibiotic treatment.
Management of preterm PROM in specific situations:
Home care is not recommended for preterm PROM with a viable fetus due to the risks of sudden infection and umbilical cord compression.
For patients with preterm PROM and a cervical cerclage, there is no definitive recommendation on whether the cerclage should be removed. Either removal or retention is reasonable, and the decision should be individualized. Prolonged antibiotic prophylaxis beyond 7 days is not recommended if the cerclage remains in place.
In cases of preterm PROM and herpes simplex virus (HSV) infection:
Expectant management is recommended before 34 weeks of gestation for recurrent active infection, with antiviral therapy, corticosteroids, antibiotics, and magnesium sulfate provided as needed.
Cesarean delivery is recommended if active lesions or prodromal symptoms are present at labor onset or when delivery is indicated.
Management of preterm PROM with primary HSV infection is less clear due to the higher risk of vertical transmission. Antiviral therapy is advised, and cesarean birth is recommended if lesions are present at delivery.
Generally, cesarean delivery is not recommended for women with a history of HSV infection but no active genital lesions or prodromal symptoms during labor. However, cesarean birth may be offered to women with primary or nonprimary first-episode genital HSV infection during the third trimester because of the possibility of prolonged viral shedding.
For patients with preterm PROM and human immunodeficiency virus (HIV) infection, management should be individualized, taking into account factors like gestational age, current antiretroviral regimen, and viral load.
Management of PROM Before Neonatal Viability
Women presenting with PROM before neonatal viability should be counseled about the risks and benefits of expectant management versus immediate delivery, including a realistic assessment of neonatal outcomes.
If the patient chooses expectant management and is clinically stable with no signs of infection, outpatient management and surveillance can be considered.
Precautions regarding symptoms of chorioamnionitis and miscarriage should be discussed, and the patient should be instructed to go to the hospital if she experiences signs of infection, labor, or abruptio placentae. Regular follow-up visits with ultrasonographic examinations to assess amniotic fluid volume are recommended.
Upon reaching viability, the administration of antenatal corticosteroids and latency antibiotics for fetal maturation is appropriate, as early delivery remains likely.
Management of PROM After Second-Trimester Amniocentesis
PROM following second-trimester amniocentesis is rare, occurring in less than 1% of cases .
Unlike spontaneous second-trimester PROM, reaccumulation of normal amniotic fluid and favorable outcomes are anticipated in these cases.
Following proper counseling, patients with periviable PROM after genetic amniocentesis can generally be managed expectantly as outpatients. Precautions regarding signs of chorioamnionitis and miscarriage should be provided, and regular follow-up with ultrasonography to assess amniotic fluid volume is recommended.
Management of Future Pregnancies in Women with a History of Preterm PROM
Women with a history of preterm PROM have a higher risk of recurrence and preterm birth, necessitating a thorough medical and obstetric history.
Interventions to prevent recurrent PROM are limited:
Progesterone supplementation may be offered to women with a singleton gestation and a prior spontaneous preterm birth (regardless of membrane status) to reduce the risk of recurrence.
Transvaginal cervical length screening can be considered.
Cerclage placement may be considered for women with a singleton gestation, a prior spontaneous preterm birth before 34 weeks, and a short cervical length (less than 25 mm) before 24 weeks of gestation.
Summary of Recommendations and Conclusions
The Practice Bulletin provides a detailed summary of recommendations and conclusions based on the level of evidence:
Level A (Good and consistent scientific evidence):
Expectant management for preterm PROM before 34 weeks of gestation in the absence of maternal or fetal contraindications.
A single course of corticosteroids for pregnant women between 24 and 34 weeks of gestation, and consideration of corticosteroids as early as 23 weeks for women at risk of preterm birth within 7 days.
A single course of corticosteroids for pregnant women between 34 and 37 weeks of gestation who are at risk of preterm birth within 7 days and haven't received a previous course.
Consideration of magnesium sulfate for fetal neuroprotection in women before 32 weeks of gestation who are at risk of imminent delivery.
A 7-day course of latency antibiotics with intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin for women with preterm PROM before 34 weeks of gestation. Azithromycin is a suitable alternative to erythromycin when necessary.
Intrapartum GBS prophylaxis for women with preterm PROM and a viable fetus who are candidates for this intervention, irrespective of previous antibiotic treatments.
Level B (Limited or inconsistent scientific evidence):
Induction of labor for women with PROM at or after 37 weeks of gestation if spontaneous labor does not occur near the time of presentation and there are no contraindications. Expectant management for a short period may be offered.
Both expectant management and immediate delivery are reasonable options for PROM between 34 and 37 weeks of gestation. The decision should be individualized, and expectant management should not extend beyond 37 weeks. Latency antibiotics are not appropriate in this setting.
Tocolytics can be considered in preterm PROM for steroid benefit to the neonate or maternal transport but should be used cautiously. They are not recommended between 34 and 37 weeks of gestation.
Progesterone supplementation may be offered to women with a single gestation and a prior spontaneous preterm birth to reduce the risk of recurrence.
Level C (Consensus and expert opinion):
Diagnosis of PROM is typically confirmed by conventional clinical assessment, including visualization of amniotic fluid, pH testing of vaginal fluid, and microscopic evaluation for ferning.
Outpatient management of preterm PROM with a viable fetus is not recommended. Periviable PROM may be considered for home care after assessment in the hospital.
The bulletin emphasizes the importance of shared decision-making, individualized care, and careful monitoring in the management of PROM. Clinicians are advised to refer to the full guideline for detailed information and supporting evidence.
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Psychiatric disease
Psychiatric disease
Obstetrics
Outline of Mental Health Disease in Pregnancy
This outline provides a comprehensive overview of managing, diagnosing, and approaching mental health diseases during pregnancy, as detailed in the source document.
I. Introduction
Mental health conditions are prevalent during the perinatal period, affecting approximately one in five women.
Untreated mental health conditions can have negative consequences for both the pregnant individual and the child.
Obstetrician-gynecologists (ob-gyns) play a crucial role in addressing perinatal mental health.
II. General Approach to Treatment
Screening: Use validated screening tools to identify mental health conditions during pregnancy and postpartum.
Counseling: Ob-gyns should be prepared to counsel patients on the benefits and risks of various treatment options, including psychopharmacotherapy.
Treatment Initiation: Ob-gyns should initiate psychotherapy and/or psychopharmacotherapy for perinatal depression and anxiety disorders or refer patients to appropriate mental health resources.
Treatment Goals: Aim for remission of symptoms and prevention of relapse.
Monitoring: Employ validated screening tools to monitor treatment response and remission and adjust treatment accordingly.
Equitable Access: Ensure all pregnant and postpartum individuals have equitable access to mental health care.
Medication Use: Medications for mental health conditions should not be withheld or discontinued solely due to pregnancy or lactation.
Resources: Utilize Perinatal Psychiatry Access Programs for management and treatment guidance.
III. Specific Mental Health Conditions
A. Depressive Disorders
Definition: Perinatal depression is major depressive disorder with onset during pregnancy or up to 12 months postpartum.
Treatment:
First-line treatment for mild-to-moderate perinatal depression is psychotherapy.
Examples: CBT (e.g., Mothers and Babies program), interpersonal therapy (e.g., ROSE program).
Pharmacotherapy is recommended as first-line treatment for perinatal depression.
Selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line pharmacotherapy, with sertraline or escitalopram being reasonable initial choices.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) are reasonable alternatives but individual patient risk factors must be considered.
Brexanolone is FDA-approved for moderate-to-severe postpartum depression with onset in the third trimester or within 4 weeks postpartum.
Benefits: Rapid onset of action.
Challenges: Limited access, high cost, lack of safety data for breastfeeding, inpatient monitoring required, limited efficacy data beyond 30 days.
Monitoring:
Use validated screening tools (e.g., PHQ-9, EPDS) to monitor symptoms and guide dosage adjustments.
Up-titration may be necessary throughout pregnancy due to physiological changes.
Down-titration in the third trimester or postpartum is not recommended.
B. Anxiety Disorders
Types: Generalized anxiety disorder, panic disorder, agoraphobia, separation anxiety disorder, social phobia, selective mutism, specific phobias.
OCD and PTSD are now separate categories but pharmacologic approaches are similar to other anxiety disorders.
Treatment:
SSRIs are recommended as first-line pharmacotherapy, with sertraline or escitalopram being reasonable initial choices.
SNRIs are reasonable alternatives.
Benzodiazepines should be avoided or used sparingly.
They can be considered for short-term use as a bridge until SSRIs or SNRIs take effect or for acute symptom management.
Tapering in the third trimester is often recommended to minimize neonatal risks.
Psychotherapy, specifically CBT, is generally considered first-line treatment for anxiety disorders.
C. Bipolar Disorder
Definition: Characterized by episodes of mania or hypomania and depressive episodes.
Types: Bipolar I disorder (mania) and bipolar II disorder (hypomania).
Clinical Significance: Childbirth significantly increases the risk of mood episodes, including postpartum psychosis.
Treatment:
Mood stabilizers (excluding valproate) should be continued during pregnancy to prevent relapse.
Lithium is often the first-line treatment for mania but requires careful monitoring.
Lamotrigine is an alternative, particularly for bipolar II disorder, but requires dosage adjustments during pregnancy.
Second-generation antipsychotics (SGA) (quetiapine, olanzapine, risperidone, aripiprazole) are often preferred over first-generation antipsychotics.
Quetiapine is often favored due to low placental passage but carries metabolic risks.
Lurasidone is a newer option with limited pregnancy data.
Valproate should be avoided due to its high teratogenicity risk.
Monitoring:
Closely monitor lithium levels throughout pregnancy and postpartum.
Screen for gestational diabetes when using antipsychotics.
Perform a detailed ultrasound in the second trimester for patients taking lithium in the first trimester.
D. Postpartum Psychosis
Definition: Acute onset of psychosis in the postpartum period, characterized by symptoms like agitation, delusions, hallucinations, and disorganized thoughts.
Clinical Significance:
Rare but serious condition with risk of infanticide and suicide.
Often associated with bipolar I disorder.
Treatment:
Postpartum psychosis is a psychiatric emergency requiring hospitalization and continuous observation.
Acute Management:
Sedating antipsychotics (olanzapine, haloperidol), potentially with benzodiazepines (lorazepam), are used.
Administer benztropine or diphenhydramine with haloperidol to prevent extrapyramidal symptoms.
Long-Term Management: Requires psychiatrist involvement for ongoing pharmacotherapy and potential electroconvulsive therapy.
High-dose lithium initiated immediately after delivery may be used for prevention.
IV. Key Considerations
Untreated Mental Illness is an Exposure: Consider the risks associated with untreated or inadequately treated mental health conditions.
Lowest Effective Dose and Minimal Medication Switches: Utilize the lowest effective dose of medication and avoid frequent medication changes to minimize exposure.
Psychotherapy as First-Line Treatment: Emphasize the importance of psychotherapy as a first-line treatment for mild-to-moderate conditions and a valuable adjunct to pharmacotherapy.
Shared Decision Making: Engage in shared decision-making with patients to determine the most appropriate treatment plan.
V. Lactation Considerations
In general, individuals with mental health conditions should not be discouraged from breastfeeding.
If a woman is stable on medication throughout pregnancy, it should not be changed postpartum as fetal exposure supersedes exposure through lactation.
When initiating medication during lactation, consider the passage of medication through breast milk, relative infant dose, prematurity, and infant age.
Consult resources like the Drugs and Lactation Database (LactMed) and MotherToBaby to guide decision-making.
Stress and sleep deprivation associated with breastfeeding should be considered, especially for individuals with bipolar disorder, as these factors can be destabilizing.
VI. Additional Points for Presentation
Highlight the importance of a multidisciplinary approach to perinatal mental health care, involving ob-gyns, mental health professionals, and pediatricians.
Emphasize the need for ongoing research to better understand the safety and efficacy of various treatments during pregnancy and lactation.
Discuss the impact of stigma surrounding mental health and the importance of creating a supportive and non-judgmental environment for pregnant and postpartum individuals.
This detailed outline, based solely on the provided source document, can be used as a foundation for creating a comprehensive presentation on managing mental health conditions during pregnancy. Please remember to consult updated guidelines and research. This outline should not be used as a substitute for professional medical advice.
Detailed Outline of Mental Health Disease in Pregnancy Management, Diagnosis, and Approach
This outline is organized around the specific conditions discussed in the source: depressive disorders, bipolar disorder, anxiety disorders, and postpartum psychosis.
Depressive Disorders
Definition: Perinatal depression is major depressive disorder with onset during pregnancy or up to 12 months postpartum.
Prevalence: Approximately one in five women will develop an incident mental health condition during pregnancy or postpartum.
Importance of Treatment:
Untreated perinatal depression is associated with negative health behaviors, strained relationships, difficulties with parenting, and physiological complications.
A quarter of women with perinatal depression experience symptoms for 3 years postpartum.
Treatment:
Psychotherapy:
First-line treatment for mild-to-moderate depression.
Examples: Cognitive Behavioral Therapy (CBT) (e.g., Mothers and Babies program), Interpersonal Therapy (e.g., ROSE program).
Pharmacotherapy:
SSRIs are the preferred first-line treatment.
Sertraline and escitalopram are reasonable first-line SSRI options due to their efficacy and tolerability.
SNRIs are reasonable alternatives, considering potential risks of preeclampsia and spontaneous abortion.
Brexanolone, an IV medication, is FDA-approved for moderate-to-severe postpartum depression.
Monitoring:
Use validated screening tools to monitor response and remission, such as the PHQ-9 or EPDS.
Up-titrate medication dosage if symptoms do not improve, considering physiological changes during pregnancy.
Down-titration in the third trimester is not recommended.
For SSRIs and SNRIs, down-titration postpartum is not recommended.
Bipolar Disorder
Definition: Bipolar disorder is characterized by episodes of mania or hypomania in addition to depressive episodes.
Types:
Bipolar I Disorder: At least one episode of mania, potentially with psychotic features.
Bipolar II Disorder: Characterized by hypomania, a less severe form of mania without psychotic symptoms.
Clinical Significance:
Childbirth is a significant trigger for hypomania or mania.
Risk of postpartum psychiatric hospitalization is significantly higher for women with bipolar disorder.
Women often present with more depressive symptoms, leading to misdiagnosis as unipolar depression.
Treatment:
Pharmacotherapy:
Mood stabilizers (except valproate) should be continued during pregnancy to minimize relapse risk.
Lithium is often the first-line treatment for mania, but requires careful monitoring due to its narrow therapeutic window.
Lamotrigine is a preferred option for bipolar II disorder, but dosage adjustments are needed during pregnancy.
Second-generation antipsychotics (quetiapine, olanzapine, risperidone, aripiprazole) are often preferred over first-generation antipsychotics.
Quetiapine is often favored due to low placental passage but carries metabolic risks.
Lurasidone is a newer option with limited pregnancy data.
Valproate Avoidance: Valproate should be avoided due to high teratogenicity risk (neural tube defects, craniofacial anomalies, limb abnormalities, cognitive impairment).
Monitoring:
Monitor lithium levels closely throughout pregnancy and postpartum due to fluctuating renal clearance.
Screen for gestational diabetes when using antipsychotics.
Detailed ultrasound in the second trimester is recommended for patients taking lithium in the first trimester.
Anxiety Disorders
Types: Generalized anxiety disorder, panic disorder, agoraphobia, separation anxiety disorder, social phobia, selective mutism, and specific phobias.
Comorbidity: Anxiety disorders are often comorbid with perinatal depression and can increase the risk of postpartum depression.
Impact: Anxiety disorders can cause functional impairment, suicidal ideation, and are associated with preterm birth and low birth weight.
Treatment:
Psychotherapy (CBT): Considered first-line treatment, similar efficacy to pharmacotherapy in the general adult population.
Pharmacotherapy:
SSRIs are the first-line pharmacotherapy.
Sertraline and escitalopram are reasonable first-line options.
SNRIs are reasonable alternatives.
Benzodiazepines:
Avoid or prescribe sparingly as a primary treatment due to side effects and addictive potential.
May be used for acute symptom management or when first-line treatments are ineffective.
Tapering in the third trimester is often recommended to minimize neonatal risks.
Postpartum Psychosis
Definition: Onset of psychosis in the postpartum period, often acute, characterized by agitation, delusions, hallucinations, disorganized thoughts, and bizarre behavior.
Clinical Significance:
Rare, occurring in 1-2 per 1,000 pregnancies.
Often associated with bipolar I disorder.
Risk of infanticide and suicide.
Treatment:
Acute Management:
Psychiatric emergency requiring hospitalization and continuous observation.
Sedating antipsychotics (olanzapine, haloperidol) are used, potentially with benzodiazepines (lorazepam).
Administer benztropine or diphenhydramine with haloperidol to prevent extrapyramidal symptoms.
Long-Term Management:
Requires psychiatrist involvement for pharmacotherapy and potential electroconvulsive therapy.
High-dose lithium initiated immediately after delivery is supported for prevention.
General Approach to Psychopharmacotherapy
Counseling: Obstetricians should counsel patients on the benefits and risks of psychopharmacotherapy.
Initiation and Referral: Obstetricians should initiate pharmacotherapy or refer patients to appropriate behavioral health resources when indicated.
Monitoring: Use validated screening tools to monitor treatment response and remission.
Equitable Access: Treatment should be equitably available and accessible.
Avoid Withholding or Discontinuation: Medications should not be withheld or discontinued solely due to pregnancy or lactation.
Utilization of Resources: Use Perinatal Psychiatry Access Programs for management and treatment guidance.
Key Points for Presentation
Emphasis on Screening: Highlight the importance of regular mental health screening during pregnancy and postpartum.
Shared Decision-Making: Discuss the importance of shared decision-making between the patient and clinician when choosing treatment options.
Balancing Risks and Benefits: Explain the risks of untreated mental illness and the potential risks and benefits of various treatments, including pharmacotherapy.
Individualized Treatment: Emphasize that treatment plans should be individualized based on the patient's specific needs, preferences, and medical history.
Importance of Support: Highlight the role of support systems (partners, family, friends) in managing mental health during pregnancy and postpartum.
Available Resources: Provide information on available resources, such as Perinatal Psychiatry Access Programs, support groups, and hotlines.
This outline draws solely from the information provided in the given source. Please remember that medical knowledge is constantly evolving, and it's essential to stay up-to-date with the latest guidelines and research. This outline is intended to assist in creating a presentation and should not be used as a substitute for professional medical advice.
Bullet Point Script for Oral Exam: Managing Mental Health in Pregnancy
I. Introduction
“Mental health conditions are common during the perinatal period, affecting approximately 1 in 5 women. Addressing these conditions is essential to support both maternal and fetal health. Without treatment, mental health disorders can lead to significant complications, including poor maternal-infant bonding, preterm birth, and low birth weight. Ob-gyns play a vital role in screening, diagnosing, and managing these mental health issues.”
II. General Approach to Treatment
Screening:
“We should routinely use validated screening tools like the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) during pregnancy and postpartum. Early detection allows for timely intervention.”
Counseling:
“Counseling is key. When discussing treatment, I make sure to outline the benefits and potential risks of treatment options, such as psychotherapy and pharmacotherapy, ensuring patients are informed and comfortable.”
Treatment Initiation:
“For patients with mild-to-moderate symptoms, I often start with psychotherapy, including cognitive behavioral therapy (CBT) or interpersonal therapy (IPT). For moderate-to-severe cases, SSRIs like sertraline or escitalopram are effective first-line pharmacologic treatments.”
“If needed, I refer patients to mental health specialists for more complex cases or when psychotherapy alone is insufficient.”
Goals:
“My goal is to achieve symptom remission and prevent relapse to improve quality of life and outcomes for both mother and baby.”
Monitoring:
“I use tools such as the EPDS and PHQ-9 for follow-up assessments to monitor treatment efficacy and make necessary adjustments.”
Equitable Access:
“Ensuring all pregnant and postpartum patients have access to mental health care is crucial. I advocate for resources and programs that support equitable care.”
Medication Use:
“It’s important to remember that medications should not be withheld or discontinued solely due to pregnancy or lactation. Decisions should be based on a thorough risk-benefit analysis.”
Resources:
“Perinatal Psychiatry Access Programs are invaluable for consulting on treatment strategies, especially when dealing with complex cases.”
III. Specific Mental Health Conditions
A. Depressive Disorders
Definition: “Perinatal depression is major depressive disorder that occurs during pregnancy or up to 12 months postpartum.”
Treatment:
Psychotherapy:
“First-line for mild-to-moderate depression. CBT and programs like the Mothers and Babies program are effective.”
Pharmacotherapy:
“SSRIs, such as sertraline and escitalopram, are my preferred first-line options due to their safety profile.”
“For severe cases, brexanolone (an IV treatment) can be considered, though it requires inpatient monitoring due to its potential side effects and cost.”
Monitoring:
“I use validated tools like the PHQ-9 to track symptom changes and adjust medication doses, understanding that up-titration may be necessary during pregnancy.”
B. Anxiety Disorders
Types: “This category includes generalized anxiety disorder, panic disorder, and social phobia.”
Treatment:
Pharmacotherapy:
“SSRIs like sertraline and escitalopram are effective first-line treatments. SNRIs, such as venlafaxine, are also reasonable options but require careful risk assessment.”
“Benzodiazepines can be considered for acute symptom management but should be used sparingly and tapered in the third trimester to minimize neonatal withdrawal risks.”
Psychotherapy:
“CBT is a highly effective, non-pharmacologic approach for anxiety disorders.”
C. Bipolar Disorder
Definition: “Bipolar disorder involves episodes of mania/hypomania and depression, with significant risks associated with childbirth.”
Treatment:
Mood Stabilizers:
“Continuing mood stabilizers, except valproate, during pregnancy is essential to reduce relapse risk.”
Lithium:
“Often a first-line treatment for mania but requires close monitoring due to its narrow therapeutic index. Monitoring includes checking lithium levels throughout pregnancy.”
Lamotrigine:
“A suitable option for bipolar II disorder; doses may need adjustment due to metabolic changes during pregnancy.”
Antipsychotics:
“Second-generation antipsychotics like quetiapine are favored due to lower placental transfer. However, metabolic risks must be monitored.”
Avoid Valproate:
“Due to its high risk of teratogenic effects such as neural tube defects, valproate is contraindicated.”
Monitoring:
“Regular lithium level checks and screening for gestational diabetes with antipsychotic use are essential. I also ensure detailed ultrasounds if lithium is used during the first trimester.”
D. Postpartum Psychosis
Definition: “A rare but severe psychiatric emergency often associated with bipolar I disorder, characterized by acute onset of psychosis within days to weeks postpartum.”
Treatment:
Emergency Management:
“Immediate hospitalization and continuous observation are necessary to ensure the safety of the mother and child.”
Pharmacotherapy:
“Sedating antipsychotics such as olanzapine or haloperidol can be used, and benzodiazepines like lorazepam may help manage acute agitation.”
Long-Term Management:
“Follow-up with a psychiatrist is crucial, with electroconvulsive therapy considered in severe cases.”
IV. Key Considerations
Untreated Mental Illness:
“Untreated mental illness poses significant risks, including impaired mother-infant bonding and adverse pregnancy outcomes.”
Minimal Medication Changes:
“Avoid frequent changes and use the lowest effective dose to minimize risks while ensuring treatment efficacy.”
Psychotherapy First-Line:
“For mild-to-moderate mental health conditions, psychotherapy should be prioritized.”
Shared Decision-Making:
“Engage in collaborative decision-making to tailor treatment to the patient’s needs, preferences, and medical history.”
V. Lactation Considerations
Stable Medications:
“If a patient is stable on a medication during pregnancy, it’s typically continued postpartum. Changes should be made only when necessary.”
New Medications:
“When initiating new medications during lactation, consider factors like passage into breast milk and relative infant dose. Consult LactMed and MotherToBaby for detailed information.”
Supportive Care:
“Sleep deprivation and stress are destabilizing for those with conditions like bipolar disorder, so addressing these factors is critical.”
VI. Additional Presentation Points
Multidisciplinary Approach:
“Collaborating with mental health professionals and pediatricians ensures comprehensive care.”
Stigma Reduction:
“Creating a supportive, non-judgmental environment helps patients feel safe and respected.”
Ongoing Research:
“Staying informed on the latest research and guidelines helps provide the best care, and it’s essential to emphasize support systems available for patients.”
“This structured approach ensures effective, evidence-based management of mental health conditions during pregnancy and beyond.”
158
PUL
PUL
Gynecology
159
Pulmonary Embolism
Pulmonary Embolism
160
Radiation exposure to fetus
Radiation exposure to fetus
Obstetrics
Diagnostic Imaging During Pregnancy and Lactation - A Summary
This article, published as Committee Opinion Number 723 by the American College of Obstetricians and Gynecologists (ACOG) in October 2017, provides guidelines for the use of diagnostic imaging during pregnancy and lactation. It is endorsed by the American College of Radiology and the American Institute of Ultrasound in Medicine.
Key recommendations from the article include:
Ultrasonography and magnetic resonance imaging (MRI) are the preferred imaging techniques for pregnant patients, as they are not associated with risk. These techniques should be used prudently and only when they are expected to answer a relevant clinical question or provide medical benefit.
With few exceptions, radiation exposure from radiography, computed tomography (CT) scans, or nuclear medicine imaging is at a dose much lower than the exposure associated with fetal harm. These techniques should not be withheld from a pregnant patient if necessary.
The use of gadolinium contrast with MRI should be limited and only used if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.
Breastfeeding should not be interrupted after gadolinium administration.
Concerns and Considerations
The article acknowledges that confusion about the safety of imaging modalities for pregnant and lactating women and their infants often leads to the avoidance of beneficial diagnostic tests or the unnecessary interruption of breastfeeding. To address these concerns, the article reviews the available literature on the safety and use of various imaging techniques during pregnancy and lactation.
Specific Imaging Modalities
The article discusses the following imaging modalities in detail:
Ultrasonography:
This technique uses sound waves and is not a form of ionizing radiation.
There are no reports of adverse fetal effects from diagnostic ultrasonography, including Doppler imaging.
Ultrasound should be used prudently and only when indicated to minimize fetal exposure risk using the ALARA (As Low As Reasonably Achievable) principle.
Magnetic Resonance Imaging (MRI):
MRI is advantageous as it can image deep soft tissue structures without using ionizing radiation and is not operator dependent.
There is no evidence of harm to the fetus from MRI, despite theoretical concerns.
The use of gadolinium-based contrast agents with MRI is controversial due to uncertainties about potential fetal effects.
Gadolinium crosses the placenta and can enter fetal circulation and amniotic fluid.
While animal studies have shown teratogenic effects at high doses, the only prospective human study found no adverse outcomes.
A recent large retrospective study raised concerns about potential long-term risks, but the study had limitations.
Given the uncertainties, gadolinium use should be limited to situations where benefits outweigh risks.
Breastfeeding should not be interrupted after gadolinium administration due to limited excretion into breast milk.
Ionizing Radiation (including X-rays):
X-ray procedures are commonly used and may be indicated during pregnancy.
Fetal risks from ionizing radiation depend on gestational age and dose.
Doses used in diagnostic imaging are much lower than those associated with fetal harm.
High-dose exposure can lead to adverse effects such as growth restriction, microcephaly, and intellectual disability.
The risk of anomalies, growth restriction, or abortion has not been reported with exposures below 50 mGy, a level higher than what is used in diagnostic procedures.
The risk of carcinogenesis is unclear but likely very small.
Pregnancy termination is not recommended solely based on exposure to diagnostic radiation.
There is no risk to lactation from external sources of ionizing radiation.
Computed Tomography (CT):
CT plays an important role in pregnancy but should be used judiciously.
MRI is a safer alternative when appropriate.
The use of intravenous iodinated contrast media is generally safe, but it should only be used when necessary.
Breastfeeding can be continued without interruption after the use of iodinated contrast.
Nuclear Medicine Imaging:
Fetal exposure depends on the radioisotope used.
Technetium 99m, commonly used in nuclear medicine, is considered safe during pregnancy.
Radioactive iodine (iodine 131) should not be used during pregnancy due to potential adverse effects on the fetal thyroid.
The use of radionuclides during lactation requires careful consideration and consultation with experts, as some can be excreted into breast milk.
Conclusion
The article emphasizes the importance of balancing the risks and benefits of diagnostic imaging during pregnancy and lactation. While ultrasonography and MRI are preferred, other imaging modalities utilizing ionizing radiation or contrast agents should not be withheld if clinically indicated. Healthcare providers should engage in a thorough discussion with patients about the risks and benefits of any imaging procedure and consider consulting with a radiologist to minimize radiation dose when necessary.
161
Recent changes to standard of care
[ ]
162
Recurrent pregnancy loss
Recurrent pregnancy loss
163
Retained Placenta
Retained Placenta
Obstetrics
164
Rh negative
[ ]
165
Risks of IVF
Risks of IVF
Obstetrics
Risks Associated with Assisted Reproductive Technologies (ART)
The sources provide information regarding various risks associated with ART, highlighting the importance of counseling and managing these potential complications.
I. Multifetal Gestation: The Most Significant Risk
Increased Occurrence: ART, particularly ovulation induction and IVF, significantly elevates the risk of multifetal gestations (twins, triplets, or more).
Multifetal Pregnancy Reduction: While multifetal pregnancy reduction is an option for higher-order pregnancies, it carries its own risks and ethical considerations.
Efforts to Limit Multiples:
Physicians should strive to achieve singleton pregnancies by using low-dose stimulation protocols, monitoring hormone levels and follicle numbers, and limiting the number of embryos transferred per cycle.
Elective single-embryo transfer (eSET) has proven effective in reducing multifetal gestations without compromising pregnancy rates.
Patient Counseling: It is essential to counsel patients about the risks of multifetal gestations and the importance of minimizing embryo transfers to reduce those risks.
Financial Considerations: Patient concerns about financial burdens associated with multiple IVF cycles and the desire for a higher chance of success can influence the decision to transfer multiple embryos. Increased insurance coverage and shared-risk programs can potentially mitigate these financial pressures.
II. Maternal and Perinatal Risks in Singleton ART Pregnancies
Even singleton pregnancies resulting from ART carry a higher risk of complications compared to naturally conceived pregnancies.
Preterm Birth and Low Birth Weight: Studies show an increased risk of preterm birth, low birth weight, very low birth weight, and small-for-gestational-age infants in singleton ART pregnancies.
Increased Pregnancy Complications: ART is associated with a higher risk of:
Cesarean delivery
Placenta previa
Abruptio placentae
Preeclampsia
Vasa previa
Stillbirth
Severe Maternal Morbidity: ART pregnancies, even singletons, have an elevated risk of severe maternal morbidity, with blood transfusion being the most common indicator.
III. Birth Defects
Slightly Elevated Risk: Some studies have observed a small increase in the risk of birth defects in infants conceived through ART compared to those conceived naturally.
Underlying Cause vs. ART Procedures: It's unclear whether the increased risk is due to the ART procedures themselves or factors associated with infertility. Some studies suggest that couples with infertility who conceive naturally also have a higher risk of birth defects.
ICSI and Birth Defects: The use of intracytoplasmic sperm injection (ICSI) appears to carry a higher risk of birth defects than IVF without ICSI.
No Specific Pattern: There is no identifiable pattern of specific birth defects linked to ART, making targeted screening challenging.
Epigenetic Alterations: Some studies suggest that ART may be associated with epigenetic alterations that could contribute to conditions like Beckwith-Wiedemann and Angelman syndromes.
Counseling and Surveillance: Given the potential risks, it's essential to counsel patients about the slightly elevated risk of birth defects associated with ART. Ultrasonographic surveillance for structural abnormalities during pregnancy may be offered.
IV. Long-term Pediatric Outcomes
Conflicting Data: Studies on long-term pediatric outcomes, excluding those related to multifetal gestations and prematurity, have yielded mixed results regarding neurodevelopmental outcomes.
Further Research Needed: More research is necessary to provide definitive recommendations about potential long-term effects on children conceived through ART.
V. Data Limitations and Confounding Factors
Observational Studies: The majority of research on ART risks relies on observational studies (cohort and case-control studies), which are prone to confounding factors.
Infertility as a Confounder: It's difficult to isolate the effects of ART procedures from the underlying causes of infertility, which themselves may contribute to adverse outcomes.
Other Confounders: Maternal age, health behaviors, and variations in obstetric practices can also influence outcomes and make it challenging to determine the precise impact of ART.
Data Collection Limitations: Lack of consistent and comprehensive data collection on ART outcomes, such as preterm birth and pregnancy complications, hinders risk assessment and counseling efforts.
VI. Pre-ART Evaluation and Counseling
Thorough Medical Evaluation: Before initiating ART, physicians should perform a comprehensive medical assessment to ensure that the patient is in optimal health and address any pre-existing medical conditions. This may involve optimizing weight, managing chronic conditions, and adjusting medications.
Preconception Counseling: Preconception counseling should include a detailed discussion of potential risks associated with ART and the importance of lifestyle modifications to minimize those risks.
Ongoing Counseling: Counseling should continue throughout the ART process, addressing concerns and providing updated information as needed.
The sources emphasize the importance of individualized patient care and counseling. Decisions regarding ART should be made after a thorough evaluation of the patient's medical history, a clear understanding of the potential risks, and a careful weighing of the benefits and risks of treatment.
166
RSV
RSV
Obstetrics
RSV Vaccination in Pregnancy: A Comprehensive Outline
Background:
Respiratory syncytial virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. However, it can lead to serious lower respiratory tract infections (LRTI), especially in infants and older adults.
RSV is a leading cause of hospitalization in children under five years old in the United States, with the highest hospitalization rates among infants aged 0-6 months.
Complications from RSV infection in infants can include secondary bacterial infections, inappropriate antibiotic use, and long-term respiratory problems like asthma.
Until recently, there was no vaccine available to prevent RSV infection.
Maternal RSV Vaccination:
FDA Approval and CDC Recommendation: In August 2023, the FDA approved Pfizer's Abrysvo (RSVpreF) vaccine for use in pregnant individuals to protect their infants from severe RSV disease. The CDC subsequently recommended a single dose of this vaccine for pregnant individuals between 32 0/7 and 36 6/7 weeks of gestation.
Eligibility Criteria: Pregnant individuals are eligible for the RSV vaccine during the 2024-2025 season if they did not receive it during the 2023-2024 season and are not planning to have their infant receive the monoclonal antibody nirsevimab.
Vaccine Efficacy: Clinical trials have shown that Abrysvo significantly reduces the risk of severe LRTI in infants. Within 90 days after birth, the vaccine's efficacy was 81.8%, and within 180 days, it was 69.4%.
Vaccine Safety: Abrysvo is considered safe for pregnant individuals and their infants. The most common side effects reported are similar to other vaccines, including pain at the injection site, headache, muscle pain, and nausea.
Coadministration: Abrysvo can be safely administered at the same time as other vaccines routinely recommended during pregnancy, such as the influenza and Tdap vaccines.
RSV Prevention: Monoclonal Antibody:
Nirsevimab: Nirsevimab is a long-acting monoclonal antibody that offers passive immunity to RSV. The CDC recommends a single dose for all infants younger than eight months born during or entering their first RSV season.
Infants of Vaccinated Mothers: Infants born to mothers who received the RSV vaccine during the 2023-2024 season should still receive nirsevimab during the 2024-2025 season.
Counseling and Shared Decision Making:
Obstetrician's Role: Obstetricians have a crucial role in educating their patients about RSV and the available prevention options.
Counseling Points:
Explain the risks of RSV infection for infants.
Discuss the benefits and safety of both the maternal RSV vaccine and the monoclonal antibody nirsevimab.
Address patient concerns and preferences.
Explain that infants may not need both interventions.
If nirsevimab supply is limited, emphasize the importance of maternal vaccination.
Shared Decision Making: The decision to receive the RSV vaccine or opt for nirsevimab for the infant should be made collaboratively between the patient and their healthcare provider, considering individual circumstances and preferences.
Documentation and Implementation:
Documentation is Essential: Both RSV vaccination and declination should be clearly documented in the patient's medical chart and the state immunization information system.
Importance for Infant Care: This documentation is crucial to inform healthcare providers about the need for nirsevimab administration to the infant.
Implementation Considerations: Obstetrician-gynecologists should develop strategies to ensure their practice can effectively provide the RSV vaccine to eligible patients. This may include staff training, patient education materials, and coordination with other healthcare providers.
This outline provides a thorough overview of RSV vaccination in pregnancy based on the provided sources. Remember, it's essential to consult with a healthcare professional for personalized medical advice.
167
Seizures
Seizures
Obstetrics
Overview of Seizures in Women
This article, published in the January 2021 issue of Clinical Updates in Women’s Health Care, focuses on the gynecological and obstetric management of women with seizure disorders. The authors, Amy Hessler and Katelyn Dolbec, are experts in neurology and epilepsy. They provide a comprehensive discussion of the diagnosis and management of seizure disorders across a woman's lifespan, including considerations for contraception, pregnancy, postpartum care, and menopause.
Basic Science and Diagnosis of Seizures
Epilepsy is defined as a disease of the brain characterized by at least one of the following:
Two unprovoked seizures occurring more than 24 hours apart
One unprovoked seizure with a high risk of recurrence (at least 60% over the next 10 years)
Diagnosis of an epilepsy syndrome based on electroencephalography, age at onset, course of epilepsy, associated neurologic and neuropsychologic findings, and underlying genetic or pathophysiologic mechanisms
It's crucial to distinguish epileptic seizures from other transient disorders that can mimic seizure symptoms. These nonepileptic episodic events can be caused by various factors, including:
Physiologic Causes:
Neurologic conditions like migraine, sleep disorders, cerebrovascular disorders, and movement disorders
Non-neurologic issues like metabolic abnormalities and cardiac arrhythmias
Psychogenic Causes: Particularly psychogenic nonepileptic seizures, often associated with a history of abuse
A thorough evaluation by a neurologist is essential for accurate diagnosis, involving a detailed history, physical examination, and additional tests like electroencephalography (EEG) and brain imaging (MRI).
Gynecologic Management
Contraception
Women with epilepsy who use antiepileptic drugs (AEDs) need to be aware of potential drug-drug interactions with combined hormonal contraception, which can reduce the effectiveness of either the contraceptive or the AED. AEDs are frequently prescribed for conditions beyond epilepsy, such as neuropathic pain, psychiatric disorders, and migraine, making interaction considerations important when discussing contraception. The article references ACOG guidelines for managing these interactions.
Menstrual Cycle and Seizures
Catamenial epilepsy is characterized by a twofold or greater increase in seizure frequency, often linked to hormonal fluctuations during the menstrual cycle. The most common periods of increased seizure activity are:
Perimenstrual period (3 days before and after menses)
Periovulatory period (mid-cycle)
Seizure frequency is typically lowest during the midluteal phase.
Fluctuations in estrogen and progesterone levels throughout the menstrual cycle are believed to influence seizure activity. Estrogen is generally considered pro-convulsant (increasing seizure likelihood), while progesterone is thought to have anti-convulsant properties. The varying estradiol-to-progesterone ratio throughout the cycle is thought to contribute to catamenial epilepsy, with higher ratios associated with increased seizure susceptibility.
Managing catamenial epilepsy can involve:
Non-hormonal approaches: Adjusting AED dosages if safe
Adjunctive hormonal therapies: Utilizing medications like acetazolamide, clomiphene (not routinely recommended), gonadotropin-releasing hormone analogues, benzodiazepines (clonazepam and clobazam), and progesterone supplementation
Seizures and Reproductive Function
Women with epilepsy often experience reproductive dysfunction, including:
Menstrual disorders
Hirsutism
Infertility
These issues may arise from:
Direct effects of seizures on the hypothalamic-pituitary-adrenal axis
Medications used to control seizures
Specific reproductive challenges associated with epilepsy include:
Increased rates of menstrual disorders and anovulatory cycles compared to the general population
Higher prevalence of polycystic ovary syndrome (PCOS)
Increased incidence of hypothalamic amenorrhea, functional hyperprolactinemia, and premature menopause
Potential negative effects of AEDs on endocrine function, fertility, sexual function, and bone health, especially with enzyme-inducing AEDs
Despite these challenges, recent research suggests that women with epilepsy, without known infertility, have a similar likelihood of achieving pregnancy and live birth rates compared to women without epilepsy.
Obstetric Management
Prepregnancy Counseling
Prepregnancy counseling is strongly recommended for women with epilepsy to address key issues, including:
Optimizing AED regimen to minimize fetal risk while maintaining seizure control
Considering AED adjustments or discontinuation based on seizure history and teratogenic risks
Continuing contraception and folic acid supplementation during medication changes
A collaborative approach involving the obstetrician-gynecologist and neurologist is essential for effective prepregnancy care.
Seizure Control During Pregnancy
Maintaining seizure control during pregnancy is crucial for both maternal and fetal well-being. Seizures during pregnancy can pose risks to the fetus, including:
Hypoxia
Acidosis
Decreased placental blood flow
Fetal heart rate decelerations
Maternal risks associated with seizures during pregnancy include:
Trauma from convulsions
Sudden unexpected death in epilepsy (SUDEP)
Women who experience seizures during pregnancy have an increased risk of adverse pregnancy outcomes, such as:
Low birth weight
Preterm delivery
Fetuses small for gestational age
Unplanned Pregnancy
A significant number of pregnancies in women with epilepsy are unplanned. The sources note that many women with epilepsy taking potentially teratogenic AEDs reported not using contraception. This underscores the need for consistent family planning discussions with women of reproductive age with epilepsy.
AED Use and Fetal Outcomes
Exposure to certain AEDs during pregnancy, particularly valproate, phenobarbital, and phenytoin, is associated with an increased risk of major congenital malformations in the fetus.
The article recommends that valproate be avoided during pregnancy due to its higher teratogenic risk.
The Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study revealed that prenatal exposure to valproate was linked to lower cognitive outcomes (specifically, intelligence quotient) in children.
The article highlights the importance of monitoring AED levels throughout pregnancy, as metabolic changes can lead to reduced drug concentrations and breakthrough seizures. Lamotrigine and levetiracetam, frequently used during pregnancy due to their relative safety profiles, often require dosage adjustments to maintain therapeutic levels.
Folic Acid Recommendations
The article recommends that women with epilepsy take 0.4 mg of folic acid daily before and during pregnancy, aligning with ACOG guidelines. This is consistent with recommendations for women without epilepsy.
Obstetric Complications
While there isn't conclusive evidence of increased obstetric complications for women with epilepsy overall, some studies suggest a potential for increased risk of:
Cesarean delivery
Late pregnancy bleeding
Premature labor and delivery
Maternal mortality
More research is needed to understand the specific factors contributing to these potential risks.
Postpartum Management
Breastfeeding
While breastfeeding is encouraged for its benefits, it's essential to consider the potential transfer of AEDs into breast milk. Infants should be monitored for possible adverse effects, especially sedation, from AED exposure through breast milk. The NEAD study found no significant difference in cognitive outcomes at age 3 in children exposed to a single AED (carbamazepine, lamotrigine, phenytoin, or valproate) in utero, regardless of whether they were breastfed or not.
Safety Precautions
The article suggests practical safety measures for women with epilepsy during the postpartum period, including:
Having someone else feed the baby at night to avoid sleep deprivation and potential seizures
Avoiding tub baths for the newborn when alone
Performing dressing and diaper changes on the floor to prevent falls
Avoiding carrying the newborn when alone if experiencing frequent seizures
Considerations for Aging Women
Timing of Menopause
Women with epilepsy are at increased risk for premature menopause, experiencing perimenopausal symptoms earlier than women without epilepsy. The frequency of seizures appears to be a risk factor, with women experiencing more seizures having an earlier average age of menopause.
Seizures and Menopause
Seizure frequency can fluctuate during the menopausal transition. Women with a history of catamenial epilepsy are particularly susceptible to worsening seizures during perimenopause due to hormonal fluctuations. However, once menopause is reached, seizure frequency often stabilizes.
Hormone Therapy (HT)
While hormone therapy can help manage menopausal symptoms, it may negatively affect seizure control in women with epilepsy. Research suggests that estrogen-progesterone combinations, like conjugated equine estrogen-medroxyprogesterone acetate (CEE/MPA), can increase seizure frequency. Alternative HT approaches, such as using a single estrogen compound with micronized progesterone, may be considered to minimize seizure exacerbation.
It's crucial to monitor AED levels in women on HT, as some medications, like lamotrigine, can have increased clearance while on HT.
Age-Related Changes
Physiological changes associated with aging can affect AED metabolism, leading to decreased clearance and potential dosage adjustments. Additionally, age-related decreases in renal function and drug metabolism are particularly important to consider for highly protein-bound AEDs, as serum albumin levels decline with age.
Bone Health
Women with epilepsy are at increased risk for bone disease and fractures due to various factors, including:
Increased risk of osteoporosis
Low bone density
Falls resulting from seizures
AED-induced incoordination
Potential negative effects of enzyme-inducing AEDs on bone health
The article stresses the importance of adequate calcium and vitamin D intake for women with epilepsy to mitigate bone health risks.
Referral and Collaboration
While obstetrician-gynecologists should be familiar with seizure disorders and AEDs, collaboration with a neurologist is often essential for optimal management of women with epilepsy. The article provides a referral guide outlining key questions to consider when consulting or referring a patient to a neurologist.
Key Takeaways
This article emphasizes the importance of a multidisciplinary approach to caring for women with epilepsy across their lifespan, involving both obstetrician-gynecologists and neurologists.
The most important points for ob-gyns to consider are:
Epilepsy is a common condition in women of childbearing age.
Accurate diagnosis and management of epilepsy are crucial for a woman's overall health and well-being.
AEDs can interact with hormonal contraceptives, necessitating careful contraceptive counseling.
Menstrual cycle fluctuations can affect seizure frequency, and specific management strategies exist for catamenial epilepsy.
Women with epilepsy may face reproductive challenges, but their fertility is generally comparable to women without epilepsy.
Preconception counseling is essential to optimize AED regimens and minimize fetal risks.
Seizure control during pregnancy is critical for both maternal and fetal health.
Certain AEDs carry a higher risk of congenital malformations, and alternatives should be considered.
Monitoring AED levels throughout pregnancy is crucial due to metabolic changes.
Breastfeeding is generally safe, but infants should be monitored for potential AED effects.
Women with epilepsy may experience premature menopause and seizure fluctuations during the menopausal transition.
HT can impact seizure control, and alternative approaches may be necessary.
Aging and menopause can affect AED metabolism, requiring dosage adjustments.
Women with epilepsy are at increased risk for bone disease, and preventive measures should be taken.
Collaboration with a neurologist is vital for comprehensive care.
This article provides valuable information for obstetrician-gynecologists to effectively manage the care of women with epilepsy.
168
Sepsis in Pregnancy
Sepsis in Pregnancy
Obstetrical Emergencies
169
Severe Pre-eclampsia
Severe Pre-eclampsia
170
Severe Pre-eclampsia/
[ ]
171
Sexual Assault
Sexual Assault
Gynecology
Management of Sexual Assault: A Multifaceted Approach
The sources provide a comprehensive overview of the management of sexual assault, emphasizing the crucial roles of healthcare providers in addressing both the immediate and long-term needs of survivors. Here’s a detailed outline based on the information provided:
I. Initial Response and Examination
Immediate Medical Attention: Survivors should be encouraged to seek medical care at a facility equipped to handle sexual assault cases, ideally within 72 hours of the assault, as many jurisdictions have time limits for evidence collection. They should be advised not to bathe, change clothes, or engage in any activities that could compromise evidence collection.
Specialized Examiners: Hospitals with designated sexual assault programs often have Sexual Assault Nurse Examiners (SANEs) or Sexual Assault Forensic Examiners (SAFEs) who are specially trained to provide comprehensive care and conduct forensic examinations.
National Protocol Guidance: If trained personnel are unavailable, clinicians can consult the U.S. Department of Justice’s “A National Protocol for Sexual Assault Medical Forensic Examinations of Adults/Adolescents” for detailed guidance.
Compliance with Regulations: Clinicians must strictly adhere to state and local regulations or national best practices for evidence gathering and chain of custody to ensure the integrity of evidence for potential legal proceedings.
II. Obtaining Informed Consent
Explanation of Procedures: Before initiating any examination or treatment, clinicians must obtain informed consent from the survivor, explaining the procedures involved in both the medical evaluation and evidence collection.
Release of Evidence: Consent must also be obtained for the release of any collected evidence to law enforcement agencies.
Respect for Autonomy: Ensuring informed consent empowers the survivor and allows them to make informed decisions about their care.
III. Comprehensive History and Documentation
Detailed Assault History: A thorough history of the assault should be obtained, including the time elapsed since the assault, the nature of the assault, and specific details about any injuries sustained.
Relevant Medical History: Documentation should include the survivor’s medical history, particularly any obstetric and gynecologic conditions, current pregnancy status, or risk of pregnancy.
Emotional State Documentation: The survivor’s emotional state should be carefully documented through direct observation and interaction.
Minors and Vulnerable Adults: Special considerations apply to minors and vulnerable adults. Clinicians are mandated to report the assault to the appropriate authorities as required by state law.
IV. Physical Examination and Evidence Collection
Full Body Examination: A detailed examination of the entire body should be performed to assess and document any injuries.
Photographic or Diagrammatic Documentation: Injuries should be carefully photographed or drawn to preserve evidence.
Pelvic Examination: A pelvic examination may be necessary to assess for internal injuries.
Evidence Collection Kit: A sexual assault evidence collection kit, commonly known as a "rape kit," should be used to collect and preserve evidence according to jurisdictional guidelines.
Chain of Custody Maintenance: Strict adherence to chain-of-custody protocols is essential to prevent evidence contamination or loss.
V. Medical Management
Treatment of Physical Injuries: Immediate medical care should be provided to address any physical injuries sustained during the assault.
Sexually Transmitted Infection (STI) Testing and Prophylaxis: The CDC recommends testing and empirical treatment for common STIs such as trichomoniasis, gonorrhea, and chlamydia, as well as testing for HIV, hepatitis B, and syphilis.
HIV Postexposure Prophylaxis (PEP): If the assailant’s HIV status is unknown, the risks and benefits of PEP should be carefully evaluated and discussed with the survivor. If indicated, PEP should be initiated as soon as possible, within 72 hours of potential exposure.
Emergency Contraception: Emergency contraception should be offered and provided to prevent pregnancy, considering the possibility of rape-related pregnancy.
Hepatitis B and HPV Vaccination: Vaccination for hepatitis B and human papillomavirus should be recommended as appropriate.
VI. Psychological and Emotional Support
Recognition of Rape-Trauma Syndrome: Clinicians should be aware of the psychological and emotional responses associated with rape-trauma syndrome, including the acute disorganization phase and the delayed organization phase.
Counseling and Referral: Survivors should be offered counseling and support services to help them cope with the trauma of the assault. Referrals to mental health professionals specializing in trauma-informed care are crucial.
Trauma-Informed Approach: Clinicians should adopt a trauma-informed approach that acknowledges the impact of trauma and prioritizes the survivor’s safety, autonomy, and empowerment.
VII. Follow-Up Care
Written Instructions: Providing clear written instructions and a follow-up plan is crucial, as survivors may have difficulty remembering information due to the emotional intensity of the experience.
Timely Follow-up Visits: Follow-up visits should be scheduled within 1-2 weeks to assess physical and psychological well-being, review test results, and provide ongoing support and referrals.
Addressing Long-Term Health Consequences: Long-term follow-up care should focus on managing any ongoing physical or mental health consequences, such as chronic pelvic pain, sexual dysfunction, or PTSD.
VIII. Advocacy and Support for Survivors
Addressing Rape Kit Backlog: Healthcare providers should advocate for policies and resources to address the significant backlog of untested rape kits, which hinders justice for survivors.
Support for Legislative Initiatives: Support for legislation aimed at improving the response to and prevention of sexual assault is vital.
The sources stress the importance of a compassionate, patient-centered, and trauma-informed approach to the management of sexual assault. Healthcare providers play a vital role in providing immediate medical care, collecting forensic evidence, offering emotional support, and facilitating access to long-term resources for survivors of sexual assault.
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Sexual dysfunction
[ ]
173
Shoulder Dystocia
Shoulder Dystocia
Introduction
Definition: Shoulder dystocia occurs when the descent of the fetal shoulders is obstructed during delivery. It typically involves impaction of the anterior shoulder against the maternal symphysis pubis, or the posterior shoulder against the maternal sacral promontory.
Incidence: The reported incidence of shoulder dystocia among vaginal deliveries ranges from 0.2% to 3%. The variation is due to differences in the definition of shoulder dystocia and reliance on the clinical judgment of the delivering healthcare provider.
Risk Factors: Shoulder dystocia is unpredictable and unpreventable, with poor predictive value from pre-pregnancy, antepartum, and intrapartum risk factors. It can occur in both diabetic and non-diabetic women, with the majority of cases happening in nondiabetic women with normal-sized infants.
Objective: This document provides evidence-based information regarding the management of shoulder dystocia, focusing on delivery maneuvers, risk management, and clinical strategies.
Maternal and Neonatal Complications
Maternal Complications:
Postpartum Hemorrhage: Incidence of 11% among cases of shoulder dystocia.
Perineal Lacerations: Higher rates of third- and fourth-degree lacerations.
Symphyseal Separation and Nerve Injury: Aggressive maneuvers can result in symphyseal separation and lateral femoral cutaneous neuropathy.
Catastrophic Injuries: Rare, but aggressive maneuvers such as the Zavanelli maneuver or symphysiotomy can cause serious injuries including uterine rupture and bladder damage.
Neonatal Complications:
Brachial Plexus Injury: Transient brachial plexus injuries occur in 10-20% of cases, with most resolving without permanent sequelae. Injuries may involve different levels of the brachial plexus (C5-T1).
Fractures: Clavicle or humeral fractures are relatively common but usually resolve without long-term effects.
Hypoxic-Ischemic Encephalopathy: Rare, but cases associated with prolonged delivery intervals have been reported.
Risk Factors and Predictability
Known Risk Factors:
Fetal Macrosomia: Associated with increased risk of shoulder dystocia.
Maternal Diabetes: Linked with larger fetal chest size relative to the biparietal diameter.
Labor Patterns: There is no specific pattern of labor abnormalities that accurately predicts shoulder dystocia.
Recurrence Risk: Women with a history of shoulder dystocia have a recurrence risk ranging from 1% to 16.7%.
Management Strategies
Initial Maneuvers:
McRoberts Maneuver: Should be attempted first as it is effective and simple. It involves sharp flexion of the maternal thighs to rotate the symphysis pubis and help release the impacted shoulder.
Suprapubic Pressure: Applied to dislodge the anterior shoulder from behind the symphysis pubis.
Further Maneuvers:
Delivery of Posterior Arm: If initial maneuvers are unsuccessful, delivery of the posterior arm may help to alleviate shoulder dystocia.
Rotational Maneuvers: The Rubin or Woods Screw maneuvers may be used to rotate the fetus and help release the shoulder.
All-Fours (Gaskin) Maneuver: Useful when other maneuvers fail, involves positioning the woman on her hands and knees to facilitate delivery.
Aggressive Maneuvers: Rarely, the Zavanelli maneuver (replacement of the fetal head followed by cesarean delivery) or clavicle fracture may be necessary.
Prevention and Role of Cesarean Delivery
Elective Cesarean Delivery: May be considered for women with suspected fetal macrosomia (estimated fetal weight ≥ 5000 g for non-diabetic women, ≥ 4500 g for diabetic women). Routine elective cesarean delivery is not recommended due to the low overall incidence of shoulder dystocia.
Documentation and Simulation Training
Documentation: Accurate documentation of the time of shoulder dystocia, maneuvers used, and delivery outcomes is essential.
Simulation Training: Recommended for healthcare teams to improve preparedness, team communication, and outcomes during shoulder dystocia events.
174
Sickel cell anemia
Sickel cell anemia
175
Smoker - pregnant
Smoker - pregnant
176
Smoking - nonpregnant
Smoking - nonpregnant
Overview of "Tobacco and Nicotine Cessation During Pregnancy"
This article, "Tobacco and Nicotine Cessation During Pregnancy", is a committee opinion from the American College of Obstetricians and Gynecologists published in Obstetrics & Gynecology in May 2020. The article focuses on the risks of tobacco and nicotine use during pregnancy, as well as interventions to help pregnant women quit.
Risks of Tobacco and Nicotine Use During Pregnancy
The article emphasizes that pregnant women should be advised of the significant risks associated with any form of tobacco or nicotine use, including cigarettes, e-cigarettes, hookahs, and smokeless tobacco.
These risks include pregnancy complications such as:
orofacial clefts
fetal growth restriction
placenta previa
abruptio placentae
preterm prelabor rupture of membranes
low birth weight
increased perinatal mortality
ectopic pregnancy
decreased maternal thyroid function
Risks also extend to the child's health after birth, including:
respiratory infections
asthma
infantile colic
bone fractures
childhood obesity
The article debunks the myth that alternative forms of nicotine, like e-cigarettes, are safer than cigarettes. It highlights that these products still contain nicotine, which crosses the placenta and poses significant health risks to the fetus, including adverse effects on brain and lung development. Additionally, they expose the user to harmful chemicals and combustion products.
Interventions for Cessation
The article stresses the importance of healthcare professionals inquiring about all forms of tobacco and nicotine use at every prenatal and postpartum visit. It recommends using motivational interviewing and cognitive behavioral therapy as effective counseling techniques to aid cessation.
The 5A's intervention is presented as a practical tool for healthcare professionals to guide their interactions with pregnant women who use tobacco or nicotine. This approach involves:
Asking about tobacco and nicotine use
Advising patients to quit
Assessing their willingness to quit
Assisting with cessation resources
Arranging follow-up visits to track progress
The article also recommends referring patients to tobacco quit lines, which provide counseling and support.
While counseling and pregnancy-specific resources are often effective, the article acknowledges that some women, particularly those with heavy addiction and psychosocial challenges, may need additional support. In such cases, clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions.
Pharmacotherapy
The article notes that nicotine replacement therapy should only be considered after a thorough discussion of the risks and benefits with the patient. It emphasizes the need for close supervision and the patient's strong commitment to quitting if nicotine replacement therapy is used.
Varenicline and bupropion are mentioned as pharmacotherapeutic options for smoking cessation in the nonpregnant population. However, data on their safety and efficacy during pregnancy are limited. The article advises that if these medications are prescribed, clinicians should stay informed about the potential risks and benefits.
Postpartum Support
The article highlights the high rate of smoking relapse postpartum (50-60% within one year) and underscores the need for continued support and interventions during this period. Addressing psychosocial stressors, promoting overall well-being, and identifying social support systems are crucial for preventing relapse.
Additional Points
The article acknowledges the limited evidence regarding the effectiveness of mindfulness, hypnosis, or acupuncture for smoking cessation.
It emphasizes the importance of screening for alcohol and other drug use in all pregnant women, as smoking continuation during pregnancy is linked to the likelihood of other substance use.
It stresses that the greatest benefit to the fetus is observed when smoking cessation occurs before 15 weeks of gestation, but quitting at any point during pregnancy is beneficial.
This committee opinion provides a comprehensive overview of the importance of addressing tobacco and nicotine cessation during pregnancy. It highlights the risks associated with tobacco and nicotine use, underscores the need for personalized interventions, and offers practical guidance for healthcare professionals to effectively support pregnant women in their journey towards quitting.
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Sterilization
Sterilization
Gynecology
Sterilization Outline
I. Introduction
Female and male sterilization are safe and effective methods of permanent contraception used by millions of couples globally.
Sterilization offers a long-term solution without the need for user-dependent contraception.
This outline will cover various aspects of sterilization, including benefits, risks, timing, techniques, efficacy, and clinical considerations.
II. Female Sterilization
A. Benefits
Eliminates the need for ongoing contraceptive management.
Provides an alternative for women with medical contraindications to reversible contraception.
Reduces the incidence of ovarian cancer.
Protects against pelvic inflammatory disease by reducing the spread of organisms from the lower genital tract to the peritoneal cavity.
B. Timing
Postpartum: Performed at the time of cesarean delivery or after vaginal delivery.
Advantages: Can be performed before significant uterine involution, typically using existing epidural anesthesia.
Considerations: Requires counseling and informed consent before labor, ideally during prenatal care.
Postabortion: Performed immediately after an uncomplicated spontaneous or induced abortion.
Considerations: Similar safety profile to interval procedures. Tubal occlusion can be achieved through laparoscopy or minilaparotomy.
Interval: Performed as a separate procedure unrelated to pregnancy.
Considerations: Requires a urine pregnancy test before the procedure. Performing the procedure during the follicular phase or using contraception reduces the likelihood of concurrent pregnancy.
C. Approaches and Techniques
Laparoscopy: Outpatient procedure using small incisions, allowing for inspection of abdominal and pelvic organs.
Advantages: Immediate effectiveness and rapid recovery.
Disadvantages: Risk of injury to bowel, bladder, or major vessels. Typically performed under general anesthesia, which slightly increases complication risk.
Tubal Occlusion Methods: Electrocoagulation, mechanical devices, or tubal excision.
Minilaparotomy: Typically reserved for postpartum procedures or patients at high risk of complications with laparoscopy.
Advantages: Requires basic surgical instruments and suitable for low-resource settings.
Considerations: Performed through a 2-3 cm incision, which may be larger for obese patients or failed laparoscopic procedures.
Tubal Ligation/Excision Techniques: Pomeroy, modified Pomeroy, and Parkland methods.
Hysteroscopy: Currently unavailable as the only hysteroscopic sterilization device (Essure) has been withdrawn from the market.
The manufacturer's decision followed increased reports of adverse events and FDA actions.
Postmarket surveillance of Essure is ongoing.
D. Risks
Regret: While most women do not regret sterilization, younger age (under 30) is a key indicator for potential regret.
Failure: Sterilization failure is uncommon but can occur, with varying rates depending on the technique used.
Ectopic Pregnancy: The risk of ectopic pregnancy after sterilization is low but higher than in women using no contraception.
Complications: Major complications from laparoscopic tubal ligation are uncommon (0.1-3.5%) and can include injury to the bowel, bladder, or major vessels.
III. Male Sterilization (Vasectomy)
A. Procedure: Involves severing and sealing the vas deferens to prevent sperm from entering the ejaculate.
B. Efficacy: Highly effective, with most men becoming azoospermic at 3 months and 98-99% at 6 months after the procedure.
C. Advantages Compared to Female Sterilization:
Safer
More effective
Less expensive
IV. Clinical Considerations and Recommendations
A. Patient Selection: Counseling should be thorough, addressing:
Permanence of the procedure
Alternative methods, including LARC and vasectomy
Risks and benefits of the chosen technique
Risk of failure and ectopic pregnancy
The need for continued condom use to prevent STIs
B. Counseling to Minimize Regret:
Provide ample opportunity for a considered decision.
Discuss potential risk factors for regret, including young age, relationship status, and parity.
Emphasize the permanence of the procedure and the limitations of reversal.
Thoroughly review all reversible contraceptive options, particularly LARC methods, highlighting their efficacy.
C. Shared Decision-Making:
Respect the patient's autonomy and avoid imposing personal biases regarding sterilization.
Ensure the patient's decision is well-informed and made without coercion.
V. Conclusion
Sterilization is a highly effective method of permanent contraception.
Understanding the benefits, risks, and considerations associated with both female and male sterilization is crucial for patient-centered counseling and informed decision-making.
Clinicians should provide comprehensive and unbiased information, emphasizing alternative options, particularly LARC methods, and supporting the patient's right to choose.
178
STI Screening - non-pregnant
STI Screening - non-pregnant
179
Stillbirth and evaluation
Stillbirth and evaluation
Comprehensive Overview of "Management of Stillbirth"
This article, "Management of Stillbirth," is a Practice Bulletin from the American College of Obstetricians and Gynecologists developed jointly with the Society for Maternal-Fetal Medicine. It was published in Obstetrics & Gynecology in March 2020. The article provides a comprehensive overview of stillbirth, encompassing its definition, frequency, risk factors, potential causes, evaluation, and management, including patient support.
Defining and Understanding Stillbirth
The U.S. National Center for Health Statistics defines fetal death (stillbirth) as the delivery of a fetus showing no signs of life. This is indicated by the absence of breathing, heartbeats, pulsation of the umbilical cord, or definite movements of voluntary muscles.
While there is some variation among states, fetal deaths are typically reported at 20 weeks or greater of gestation (if known), or a weight greater than or equal to 350 grams if the gestational age is unknown.
The term “stillbirth” is preferred over “fetal death” by parent groups and researchers.
Stillbirth Statistics
In the United States, stillbirth affects 1 in 160 deliveries, with approximately 23,600 stillbirths at or beyond 20 weeks of gestation reported annually.
The stillbirth rate in the United States has decreased from 6.61 per 1,000 live births in 2006 to 5.96 per 1,000 live births in 2013.
While rates of early stillbirth (20–27 weeks) have decreased, rates of late stillbirth (28 weeks or greater) have remained relatively stable.
Risk Factors Associated with Stillbirth
The article identifies several risk factors associated with stillbirth, categorized as:
Social Demographic Factors
Race: Non-Hispanic Black women experience a stillbirth rate more than twice that of other racial groups in the United States. The reasons for this disparity are complex and likely involve various factors, including higher rates of certain medical conditions (diabetes, hypertension, placental abruption, premature rupture of membranes) and potential healthcare disparities.
Multiple Gestations: The stillbirth rate for twin pregnancies is roughly 2.5 times higher than for singleton pregnancies, and the risk further increases with advancing gestational age. The rate is even higher for triplet and higher-order multiple pregnancies.
Past Obstetric History: Women with a previous stillbirth have an increased risk of recurrence in subsequent pregnancies. Previous adverse pregnancy outcomes (preterm delivery, growth restriction, preeclampsia) also increase the risk of stillbirth in later pregnancies.
Male Fetal Sex: Male fetuses have approximately a 10% higher risk for stillbirth than female fetuses. The reasons for this are not yet understood.
Maternal Age: Both younger (less than 15 years) and older (greater than 35 years) maternal age are independent risk factors for stillbirth.
Comorbid Medical Conditions
Maternal medical conditions, such as hypertension and diabetes, significantly increase the risk of stillbirth.
Obesity: Obesity (prepregnancy BMI of 30 or greater) is a major modifiable risk factor for stillbirth. The risk appears to increase with advancing gestational age and is likely linked to placental dysfunction.
Acquired Thrombophilias: Antiphospholipid syndrome (APS) is an acquired thrombophilia linked to stillbirth. Women with a history of stillbirth are typically tested for APS.
Substance Use: Maternal substance use, including cocaine, methamphetamine, other illicit drugs, and tobacco smoking, significantly contributes to placental abruption and stillbirth. Smoking during pregnancy, even secondhand smoke exposure, markedly elevates the risk.
Other Factors
Assisted Reproductive Technology (ART): Pregnancies achieved through in vitro fertilization (IVF) show an elevated risk of stillbirth, potentially related to the procedures themselves or underlying infertility causes.
Late-Term and Postterm Pregnancies: The risk of stillbirth increases in pregnancies extending beyond 41 weeks, and induction of labor is recommended at or after 42 weeks to mitigate this risk.
Potential Causes of Stillbirth
The article stresses that pinpointing a definitive cause of stillbirth can be challenging, with a significant proportion remaining unexplained even after thorough evaluation.
The lack of standardized protocols for evaluating and classifying stillbirths and declining autopsy rates have hindered research on specific causes.
Several potential causes are discussed, including:
Fetal Growth Restriction: Severely growth-restricted fetuses face a heightened risk of stillbirth.
Placental Abruption: Placental abruption contributes to 5–10% of stillbirth cases. Substance use is a major factor in abruption.
Chromosomal and Genetic Abnormalities: Abnormal karyotypes are present in 6–13% of stillbirths, with the rate increasing in fetuses with anatomical abnormalities or growth restriction.
Infection: Infection is linked to 10–20% of stillbirths in developed countries, and a greater percentage in developing countries.
Umbilical Cord Events: Umbilical cord abnormalities, such as vasa previa, cord entrapment, and cord prolapse, account for around 10% of stillbirths.
Essential Components of a Stillbirth Evaluation
A comprehensive stillbirth evaluation should include:
Fetal autopsy.
Gross and histologic examination of the placenta, umbilical cord, and membranes.
Genetic evaluation.
The article provides detailed guidance on each of these components, emphasizing the importance of a thorough and systematic approach.
The utility of various tests varies depending on the clinical presentation, suggesting a customized approach for each patient.
Management of the Current Pregnancy After Stillbirth
The method and timing of delivery following stillbirth depend on factors such as gestational age at fetal death, maternal obstetric history, and maternal preference.
Options for delivery typically include:
Dilation and evacuation.
Induction of labor.
The article provides detailed recommendations on the appropriate methods for labor induction based on gestational age, as well as considerations for women with previous cesarean deliveries.
Support and Counseling for Patients Experiencing Stillbirth
Providing emotional support and clear communication of test results is crucial.
Bereavement care should be individualized to address the parents' personal, cultural, and religious needs.
Key principles of bereavement care include:
Individualized care
Good communication
Shared decision-making
Recognition of parenthood
Acknowledging the grief of partners and families
Recognizing that grief is individual
Awareness of burial, cremation, and funeral options
Ongoing emotional and practical support
Access to healthcare professionals trained in bereavement care
Support and self-care for healthcare professionals
Referral to a bereavement counselor, peer support group, or mental health professional can be beneficial.
Management of Subsequent Pregnancies After Unexplained Stillbirth
Data on managing pregnancies after an unexplained stillbirth are limited.
Women should be encouraged to minimize modifiable risk factors (e.g., optimize glycemic control for diabetes).
Key aspects of managing subsequent pregnancies include:
Risk of Recurrence Counseling: Counseling should address the risk of stillbirth recurrence, which remains controversial and limited by information regarding the previous stillbirth's cause.
Antepartum Surveillance: While there's limited guidance on antepartum surveillance after unexplained stillbirth, the article recommends once or twice weekly monitoring starting at 32 weeks (or earlier based on the previous stillbirth) for stillbirths occurring at or after 32 weeks.
Fetal Kick Counting: Despite being a simple and inexpensive method, the evidence for fetal kick counting's effectiveness in preventing stillbirth is uncertain.
Timing of Delivery: The decision for early delivery to prevent stillbirth should carefully consider the increased risks of maternal and neonatal complications against potential benefits.
The article concludes with a comprehensive box summarizing recommendations for managing subsequent pregnancies after stillbirth, covering pre-pregnancy, first, second, and third trimesters, as well as delivery.
180
Substance abuse disorder
Substance abuse disorder
Substance Use Disorder: Ethical Issues and Recommendations for Obstetrician-Gynecologists
This Committee Opinion, published by the American College of Obstetricians and Gynecologists in June 2015, addresses the ethical considerations surrounding substance use disorder in obstetric and gynecologic practice. The opinion emphasizes the importance of routine screening, brief intervention, and referral to treatment for all patients, regardless of demographics. It also provides guidance on managing ethical dilemmas related to patient confidentiality, reporting mandates, and the care of pregnant and parenting patients with substance use disorder.
The Ethical Framework
The Committee Opinion is grounded in four fundamental principles of medical ethics:
Beneficence: Providing timely and effective care for substance use disorder is paramount. Routine screening, brief interventions, and appropriate referrals contribute to patient well-being.
Nonmaleficence: Avoiding harm includes recognizing that substance use disorder is a medical issue and not a moral failing. Physicians should approach patients with empathy and support, avoiding stigmatization and humiliation.
Justice: Equitable access to care and resources is essential. Routine screening should be applied universally, eliminating disparities in diagnosis and treatment based on sex, race, ethnicity, or socioeconomic status.
Respect for Autonomy: Patients have the right to make informed decisions about their healthcare. Physicians should foster a trusting relationship that promotes open communication and patient empowerment. When legally obligated to test for substance use, informed consent should be obtained.
Recommendations and Ethical Considerations
The Committee Opinion offers several key recommendations for obstetrician-gynecologists:
Routine Screening for All Patients: Using validated questionnaires or conversations, screening should be conducted regardless of patient demographics. Routine laboratory testing is not required.
Dignity and Respect in Patient Interactions: Physicians should strive to establish a therapeutic alliance with patients, treating them with respect and understanding. Familiarity with local resources for treatment referral is crucial.
Informed Consent for Mandatory Testing: When legal or medical obligations require substance use testing, patients must be informed and reasonable efforts made to obtain consent.
Safe Prescribing Practices: To prevent misuse and diversion of controlled medications, especially opioids, physicians should adhere to best prescribing practices. Alternative pain management approaches should be considered alongside appropriate treatment for acute pain.
Judicious Reporting in Medical Records: Balancing confidentiality with accurate documentation is essential. Including only medically necessary information related to substance use and informing the patient about its inclusion helps maintain trust while ensuring optimal collaborative care.
Addressing Specific Patient Care Issues
The Committee Opinion provides guidance on ethical approaches to several challenging scenarios:
Maternal Substance Use Disorder and Fetal Exposure: Open communication with the patient is critical to clarify substance use history and assess potential risks to the fetus. Alternate diagnoses for neonatal abnormalities should always be considered.
Navigating Reporting Laws: Physicians should be familiar with state reporting mandates, advocating for evidence-based interventions and opposing coercive measures. Patient autonomy and confidentiality should be protected to the extent legally permissible.
Encouraging Treatment and Opposing Punitive Measures: Physicians should advocate for evidence-based, consensual interventions and increased access to treatment, particularly for pregnant women. Incarceration is detrimental to both mother and child.
Supporting Breastfeeding: Women with a history of substance use disorder should not be automatically excluded from breastfeeding. Accurate information about potential risks associated with specific substances should guide recommendations.
Preserving Family Integrity: Physicians should discourage separating children from parents solely based on suspected or confirmed substance use disorder. Treatment is more effective and cost-efficient than restrictive policies, and family reunification should be prioritized.
Substance Use in Infertile Patients: Efforts should be made to identify and treat substance use disorder before conception. Decisions to deny infertility treatment based on child safety concerns require clear evidence and multidisciplinary input.
Confidentiality in Adolescent Care: Building trust with adolescent patients is vital for open discussions about substance use. Informed consent, parental permission, and state laws regarding minor confidentiality must be considered.
Physician Substance Use and Impairment: Physicians have an ethical duty to address substance use disorder in themselves or colleagues, seeking professional guidance and modifying practice to protect patient safety.
Commonly Misused or Abused Substances
The opinion provides a list of commonly misused or abused substances, including:
Alcohol (ethanol)
Cannabinoids (marijuana and hashish)
Club drugs
Dissociative drugs
Hallucinogens
Opioids (heroin and opium)
Other compounds
Prescription medications
Stimulants
Tobacco
This list, while comprehensive, is not exhaustive and may not include every substance that could be misused or abused.
Conclusion
This Committee Opinion emphasizes the ethical imperative for obstetrician-gynecologists to approach substance use disorder with compassion, understanding, and a commitment to evidence-based care. By adhering to the principles of beneficence, nonmaleficence, justice, and respect for autonomy, physicians can effectively address this challenging health issue while upholding the highest standards of ethical practice.
181
Syphilis
Syphilis
Obstetrics
Syphilis in Pregnancy: A Comprehensive Outline
Introduction
Syphilis is a treponemal infection that can be transmitted sexually, through blood, or from mother to fetus during pregnancy (vertical transmission).
Despite the availability of effective penicillin treatment, syphilis remains a public health concern, and congenital syphilis (CS) rates are increasing at an alarming rate.
Epidemiology of Congenital Syphilis in the United States
The number of CS cases in the U.S. rose dramatically between 2013 and 2018, increasing by 261%.
This upward trend has continued, with cases rising from 1870 in 2019 to 2022 in 2020.
The rise in syphilis infections is correlated with the increased use of opioids and methamphetamines among women of reproductive age.
Significant healthcare disparities exist, with higher syphilis incidence rates among Black, American Indian, and Pacific Islander populations, particularly in the Southern U.S.
Historical events like the unethical Tuskegee Syphilis Study, along with systemic racism and barriers to healthcare access, contribute to these disparities.
Syphilis: A Stealth Pathogen
The bacterium Treponema pallidum subspecies pallidum, a spirochete, is the causative agent of syphilis.
It's difficult to eradicate due to several characteristics:
It's narrow and difficult to stain, requiring dark-field microscopy for visualization.
Its outer membrane lacks easily recognizable protein targets for the immune system or diagnostic tests.
It depends entirely on a mammalian host for growth.
Recent breakthroughs in culturing T. pallidum in vitro offer hope for better understanding its growth, gene expression, and potential targets for diagnostics, treatment, and vaccine development.
Syphilis Testing in Pregnancy
Universal syphilis screening is recommended at the first prenatal visit, with rescreening in the third trimester and at birth.
This recommendation stems from the rising CS rates and the high percentage of missed opportunities for timely testing and treatment.
Gaps in Testing and Diagnostic Challenges
The complexity of syphilis testing algorithms often leads to misinterpretations and challenges in perinatal syphilis management.
A significant issue is distinguishing between new and past syphilis infections, complicated by the "serofast state," where low, persistent nontreponemal titers remain after successful treatment.
Currently available tests have limitations:
Ideal tests, like rabbit infectivity studies and PCR, are not readily available in clinical practice.
Serologic assays, relying on detection of antibodies, are the primary diagnostic tools.
Testing Algorithms
Two main algorithms are used to diagnose syphilis, both using nontreponemal (NTT) and treponemal (TT) tests:
Traditional Algorithm: Starts with an NTT (like RPR) and, if positive, proceeds with a TT to rule out false positives.
Reverse Algorithm: Starts with a TT (like CIA or EIA) and, if positive, proceeds with an NTT (RPR). Discrepant results may require a second TT (like TP-PA).
Understanding the strengths and limitations of each algorithm, and the interpretation of test results, is crucial for accurate diagnosis and staging of syphilis.
Newborn Testing
Testing newborns for syphilis presents unique challenges:
TTs can be positive due to passively transferred maternal antibodies, persisting for over 15 months, limiting their diagnostic utility.
IgM tests, while used to detect T. pallidum in neonates, can also be negative in early infection.
NTTs (VDRL and RPR), despite low sensitivity, are currently used to diagnose CS in newborns.
Clinical Course of Syphilis in Pregnancy
The progression of syphilis in pregnant individuals mirrors that of nonpregnant adults, encompassing primary, secondary, latent, and tertiary stages.
Each stage has distinct clinical manifestations, but the transient nature of early symptoms and the asymptomatic nature of latent syphilis can delay diagnosis.
Treatment of Syphilis During Pregnancy
Benzathine penicillin G (BPG) is the only recommended treatment for syphilis in pregnancy, effectively treating maternal infection and preventing CS.
Alternative antibiotics, although effective in nonpregnant individuals, lack sufficient evidence to support their use in pregnancy and are associated with higher CS rates.
Cefixime, a third-generation cephalosporin, shows promise as a potential alternative, but further research, including clinical trials in pregnancy, is needed.
Penicillin desensitization is recommended for pregnant individuals with a penicillin allergy to enable safe treatment with BPG.
Treatment Regimens Based on Stage
Specific BPG treatment regimens are tailored to the stage of syphilis.
Adequate treatment is typically determined by a four-fold decline in NTT titers, with the timeframe for decline varying depending on the initial stage of syphilis and HIV status.
Frequent monitoring of NTT titers can allow for early detection of treatment failure or reinfection, especially in high-risk populations.
Partner Treatment
Treating sexual partners is essential to prevent reinfection and adverse pregnancy outcomes, but partner treatment rates remain low.
Barriers to partner treatment include limited knowledge about STIs, fear of domestic violence, stigma, and the need for in-person BPG injections.
Strategies like rapid syphilis testing with same-day treatment and improved partner engagement interventions are needed to increase partner treatment rates.
Jarisch-Herxheimer Reaction
The Jarisch-Herxheimer (JH) reaction is an acute systemic inflammatory response triggered by the rapid killing of spirochetes during syphilis treatment.
While common in nonpregnant individuals, particularly in early syphilis, evidence on the JH reaction in pregnancy is limited.
Symptoms in pregnancy can include fever, chills, headache, and potentially preterm contractions, fetal heart rate changes, and decreased fetal movement.
Management of the JH reaction is supportive, and corticosteroids are not recommended for prevention.
Due to the potential for adverse pregnancy outcomes, it is recommended to administer the first dose of BPG during labor with continuous fetal monitoring.
Ultrasound Findings in Fetal Syphilis
Vertical transmission can occur in all stages of syphilis and trimesters.
Ultrasound evidence of fetal infection typically appears after 20 weeks of gestation when the fetal immune system mounts a response.
Common ultrasound abnormalities include:
Hepatomegaly
Fetal anemia
Placentomegaly
Polyhydramnios
Ascites and fetal hydrops
A comprehensive pretreatment ultrasound is recommended for women diagnosed with syphilis at >20 weeks gestation.
Fetal ultrasound abnormalities indicate severe infection and a higher risk for complications like the JH reaction, preterm labor, fetal demise, and treatment failure.
Congenital Syphilis
CS at birth primarily results from maternal infection during labor, although exposure to maternal genital lesions during delivery can also lead to infection.
CS can be asymptomatic at birth, making diagnosis challenging. It can lead to serious health issues, including stillbirth, preterm birth, low birthweight, and multi-organ dysfunction.
Diagnosis and Treatment
Diagnosing CS relies on a complex combination of factors, including changes in newborn NTT titers, maternal treatment status, presence of symptoms, and placental evaluation.
Current neonatal treatment algorithms are complex and can result in missed or delayed diagnoses, particularly in asymptomatic newborns.
Treatment strategies often require long-term follow-up of exposed newborns, which can lead to significant challenges with adherence and missed diagnoses.
Pandemic-Related Impacts on Syphilis in Pregnancy
The COVID-19 pandemic has exacerbated the challenges of syphilis management due to disruptions in healthcare access, strained public health resources, and increased opioid use.
Social Determinants of Health and Access to Care Barriers
Social determinants of health, such as poverty, lack of transportation, and unstable housing, create significant barriers to timely prenatal care and syphilis testing.
Addressing these social factors is crucial to improving syphilis screening and treatment rates.
Overcoming Challenges and Achieving Elimination
Several key areas require attention to effectively address the ongoing threat of CS:
Alignment of Syphilis Management: Implementing standardized national guidelines for screening, treatment, and partner management is crucial to eliminate inconsistencies between states.
Enhanced Provider Knowledge: Improving provider awareness of syphilis testing algorithms, treatment protocols, and the importance of partner treatment can reduce missed opportunities for intervention.
Public Advocacy and Awareness: Increasing public awareness about syphilis, reducing stigma, and promoting access to testing and treatment resources are essential for effective disease control.
Improved Diagnostic Tools: Developing rapid, highly sensitive, and readily available diagnostic tests would facilitate timely diagnosis and treatment, particularly for newborns.
Addressing Healthcare Disparities: Recognizing and addressing the impact of social determinants of health and systemic racism on syphilis rates is critical to ensure equitable access to care.
Targeted Interventions: Implementing targeted interventions that address the unique needs of high-risk populations, such as individuals experiencing homelessness, substance use disorders, or incarceration, can improve access to care and reduce transmission rates.
Conclusion
Syphilis remains a significant threat to maternal and child health, and the rising rates of CS underscore the urgent need for a multifaceted approach to address this preventable public health crisis. Efforts to eliminate syphilis must prioritize equitable access to care, comprehensive education and awareness campaigns, improved diagnostic tools, and targeted interventions for vulnerable populations.
182
Teen pregnancy
Teen pregnancy
Obstetrics
How Teens Are Managed In Pregnancy
The birth rate among U.S. adolescents and young adults (aged 15–19 years) reached a historic low at 22.3 per 1,000 women in 2015. This decrease is largely because adolescents are becoming more effective contraceptive users.
A reproductive justice framework for contraceptive counseling and access is essential to providing equitable health care, accessing and having coverage for contraceptive methods, and resisting potential coercion by health care providers.
Obstetrician–gynecologists should provide adolescents the opportunity to discuss their reproductive goals and contraceptive needs without a parent or guardian present for at least part of the visit, where allowed.
Adolescents should have access to the full range of contraceptives, including long-acting reversible contraceptive (LARC) methods. They should also be able to decline and discontinue any method on their own, without barriers.
The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) endorse the use of intrauterine devices (IUDs) and implants as contraceptive options for adolescents.
LARC methods should be discussed with pregnant adolescents and initiation should be offered immediately after delivery, pregnancy loss, or abortion.
Obstetrician–gynecologists should counsel women about the convenience and effectiveness of immediate post-pregnancy LARC, as well as the benefits of lengthening interpregnancy intervals.
When engaging in shared decision making regarding contraceptive use, obstetrician–gynecologists should be aware of and address their own biases, work to empower patients, and strive for equitable outcomes for all patients regardless of age, race or ethnicity, class, or socioeconomic status.
Adolescents face unique barriers in accessing contraceptive services, including concerns about confidentiality and cost. Obstetrician–gynecologists may refer patients to Title-X-funded clinics for confidential contraceptive services if they are unable to provide confidential care.
Adolescents who discuss sexuality and contraception with a parent or guardian are more likely to use contraception consistently and are less likely to become pregnant. Parental involvement should be encouraged when a supportive parent or guardian is available.
A pelvic examination is seldom necessary, except for IUD insertion.
Depot medroxyprogesterone acetate (DMPA) has a convenient dosage schedule, which makes it a good method for many adolescents. When cost and access barriers are eliminated, women who received repeat injections of DMPA within the recommended 3-month period had very low pregnancy rates, similar to those of LARC methods.
Obstetrician–gynecologists should address adolescents’ questions and concerns regarding the “black box” warning on DMPA, which cautions against use beyond 2 years unless no other contraceptive method was acceptable. Evidence suggests that DMPA may be used indefinitely by adolescents or older women.
Combined hormonal contraceptives include oral contraceptive pills (OCPs), the patch, and the ring.Although they have a higher failure rate than LARC methods or DMPA, combined hormonal contraceptives have a beneficial effect on a number of conditions that can affect an adolescent’s quality of life, including dysmenorrhea, benign breast disease, iron deficiency anemia, acne, and menstrual irregularity.
All contraceptive methods (including LARC methods) can be started anytime, including on the day of the visit, if there is reasonable certainty that the patient is not pregnant.
Obstetrician–gynecologists should be able to provide anticipatory guidance for adolescents and their parents or guardians regarding expected bleeding effects and possible menstrual changes with various methods.
Strategies to promote adherence to the pill, patch, ring, and DMPA include cell phone or electronic reminders and online programs that provide the user with daily, weekly, monthly, or quarterly text messages.
The ideal contraceptive practice for adolescents is dual method use—pairing condoms with more effective contraceptive methods—to protect against sexually transmitted infections (STIs) and unwanted pregnancy.
Obstetrician–gynecologists should reinforce the role of condoms in preventing STI acquisition when adolescents initiate highly effective methods.
ACOG and AAP support the use of evidence-based, medically accurate, age-appropriate sexuality education as an integral part of health education.
The effect of school-based condom availability programs on condom use is mixed. Some studies show increased use of condoms, but others report nonsignificant changes.
Concern that school-based condom availability programs will hasten initiation of sex and increase sexual activity are unfounded.
183
Thrombocytopenia in pregnancy
Thrombocytopenia in pregnancy
Obstetrics
Overview of Thrombocytopenia in Pregnancy
This article, "Thrombocytopenia in Pregnancy," is an ACOG Practice Bulletin that provides clinical management guidelines for obstetrician-gynecologists. It discusses the definition, diagnosis, and management of thrombocytopenia in pregnancy, covering various causes and their specific treatments.
Definition and Background
Thrombocytopenia is defined as a platelet count of less than 150 × 109/L. It is a common condition affecting 7–12% of pregnancies at delivery.
While other bleeding disorders often present with bruising after trauma, thrombocytopenia typically manifests as bleeding in mucous membranes, such as petechiae, ecchymosis, epistaxis, gingival bleeding, and abnormal uterine bleeding.
Causes of Thrombocytopenia in Pregnancy
Gestational thrombocytopenia is the most common cause (80% of cases), characterized by onset at any point in pregnancy (typically mid-second to third trimester), platelet counts above 75 × 109/L, asymptomatic presentation, no history of thrombocytopenia outside of pregnancy, and resolution within 1–2 months postpartum.
Other causes include:
Hypertension in pregnancy (preeclampsia and HELLP syndrome)
Immune thrombocytopenia (primary and secondary)
Disseminated intravascular coagulation
Thrombotic thrombocytopenia/hemolytic uremic syndrome
Splenic sequestration
Bone marrow disorders
Nutritional deficiencies
Congenital thrombocytopenia
Diagnosis and Workup
Thrombocytopenia is diagnosed by a platelet count less than 150 × 109/L. However, the normal range can vary by trimester, with a gradual decrease as pregnancy progresses.
The workup includes:
Detailed medical and family history
Physical examination focusing on medication use, blood pressure, splenomegaly, and signs of viral infection
Complete blood count (CBC)
Peripheral blood smear examination (to rule out pseudothrombocytopenia)
Viral serology and other laboratory studies as needed
Management of Specific Conditions
Gestational Thrombocytopenia
No treatment is generally needed as it poses no maternal or fetal risks.
Follow-up platelet counts are recommended, with the frequency determined by clinical reasoning.
Preeclampsia
Delivery is the primary treatment for preeclampsia with severe features or HELLP syndrome, regardless of platelet count.
Platelet transfusion is recommended before major surgery (including cesarean delivery) to increase the platelet count to more than 50 × 109/L.
Transfusions are generally reserved for patients with active bleeding or before cesarean delivery.
Immune Thrombocytopenia
Treatment aims to minimize bleeding risks during regional anesthesia and delivery.
Treatment is initiated for:
Symptomatic bleeding
Platelet counts below 30 × 109/L
To achieve a safe platelet count for procedures (70 × 109/L for epidural placement and 50 × 109/L for cesarean delivery)
First-line treatments include:
Corticosteroids (e.g., prednisone)
Intravenous immunoglobulin (IVIG)
Splenectomy is an option for patients who fail first-line treatment but is typically avoided during pregnancy.
Platelet transfusions are used only for life-threatening hemorrhage or to prepare for urgent surgery.
Vaginal delivery is not contraindicated for fetuses with platelet counts greater than 50 × 109/L. Cesarean delivery is recommended for those with counts below this level.
Mode of delivery should be based on obstetric considerations due to the low risk of serious neonatal hemorrhage.
Fetal-Neonatal Alloimmune Thrombocytopenia
Diagnosis is based on:
Unexplained fetal or neonatal thrombocytopenia or hemorrhage
Ultrasonographic findings suggestive of intracranial bleeding
Determination of HPA type and zygosity of both parents
Confirmation of maternal antiplatelet antibodies
Management aims to prevent intracranial hemorrhage and may include:
Maternal treatment with IVIG, with or without corticosteroids
Fetal platelet transfusions
Vaginal delivery is not contraindicated for fetuses with platelet counts greater than 50 × 109/L. Cesarean delivery is recommended for those with counts below this level.
Regional Anesthesia in Thrombocytopenia
The risk of epidural hematoma is exceptionally low (less than 0.2%) in patients with platelet counts of 70 × 109/L or more, provided that the platelet level is stable, there is no other coagulopathy, platelet function is normal, and the patient is not taking antiplatelet or anticoagulant therapy.
For patients with platelet counts less than 70 × 109/L, an individual risk-benefit assessment is necessary.
Conclusion
This Practice Bulletin provides comprehensive guidance on managing thrombocytopenia in pregnancy. Recognizing the different causes and understanding their specific management strategies is crucial for ensuring the best possible outcomes for both mother and fetus.
184
Thromboembolism
Thromboembolism
Prevention of Venous Thromboembolism (VTE) in Gynecologic Surgery
This article is an ACOG Practice Bulletin that provides clinical management guidelines for obstetrician-gynecologists on the prevention of VTE in patients undergoing gynecologic surgery. It discusses the risk factors, assessment, and various methods of VTE prophylaxis.
Background
Venous thromboembolic events (VTE) include deep vein thrombosis (DVT) and pulmonary embolism (PE).
VTE is a significant cause of morbidity and mortality in postoperative patients.
The risk of VTE after gynecologic surgery for benign indications ranges from 15% to 40% without thromboprophylaxis.
Most postoperative VTE cases begin within 24–72 hours after surgery, but symptoms may not appear for 6–15 days.
The risk of VTE can persist beyond 4 weeks after surgery in high-risk patients, such as those undergoing cytoreductive surgery for ovarian cancer.
Risk Assessment
The Caprini score is used to assess VTE risk before gynecologic surgery.
The Caprini score considers various risk factors, including age, BMI, surgery type, medical history, and the presence of thrombophilia.
Patients are classified into low, moderate, or high-risk categories based on their Caprini score.
Thromboprophylaxis Methods
Thromboprophylaxis methods can be categorized as mechanical or pharmacologic:
Mechanical methods reduce venous stasis and promote endogenous fibrinolysis. Examples include:
Intermittent pneumatic compression (IPC) devices, which compress the calf or leg with an inflatable sleeve.
Graduated compression stockings, which prevent blood pooling in the calves.
Pharmacologic methods prevent clot formation by targeting different points in the clotting cascade. Examples include:
Low-dose unfractionated heparin (LDUH)
Low-molecular-weight heparin (LMWH)
Fondaparinux (an indirect factor Xa inhibitor)
Recommended Thromboprophylaxis
The recommended thromboprophylaxis regimen depends on the patient's VTE risk and risk of bleeding complications:
Low-Risk Patients:
Mechanical prophylaxis (preferably IPC) is recommended.
Graduated compression stockings are an alternative if IPC is unavailable or not preferred by the patient.
Moderate-Risk Patients:
Mechanical prophylaxis (preferably IPC) or pharmacologic prophylaxis (LDUH or LMWH) is recommended if the patient is not at increased risk of bleeding complications.
If the patient has a high risk of bleeding complications, mechanical prophylaxis (preferably IPC) is recommended.
High-Risk Patients:
Dual thromboprophylaxis (mechanical and pharmacologic) is recommended if the patient has an average risk of bleeding complications.
If the patient has a high risk of bleeding complications, mechanical prophylaxis is recommended until the bleeding risk decreases, at which point pharmacologic prophylaxis can be added.
Extended-duration prophylaxis for 28 days with LMWH is recommended for patients undergoing cancer surgery after hospital discharge.
Fondaparinux is recommended for patients with contraindications to or unavailability of LMWH and LDUH, and who are not at high risk of major bleeding complications.
Minimally Invasive Surgery:
Mechanical prophylaxis (preferably IPC) is generally sufficient.
Individualized risk assessment is necessary to determine if additional prophylaxis is needed based on patient risk factors.
Obesity:
Weight-adjusted pharmacologic prophylaxis should be considered.
Devices should be inspected for proper fit in patients with obesity receiving mechanical prophylaxis.
Regional Anesthesia:
Caution is advised when timing spinal or epidural anesthesia in patients using LMWH to avoid spinal hematoma. Specific timing recommendations are provided.
LDUH is not associated with an increased risk of spinal or epidural hematoma when used with neuraxial anesthesia. Specific timing recommendations are provided.
Other Considerations
Routine thrombophilia testing is not recommended for patients experiencing VTE in the perioperative period.
Combined hormonal contraceptive use is contraindicated in patients undergoing major surgery with anticipated prolonged immobilization. If ambulation is expected postoperatively, there is no need to discontinue combined hormonal contraceptives.
Decisions regarding perioperative use of menopausal hormone therapy should be individualized based on clinical risk factors and shared decision-making.
Conclusion
This Practice Bulletin provides comprehensive guidance for preventing VTE in gynecologic surgery patients. It emphasizes the importance of:
Assessing VTE risk using the Caprini score.
Tailoring the thromboprophylaxis regimen to the individual patient's risk of VTE and bleeding complications.
Considering additional factors like obesity, minimally invasive surgery, and regional anesthesia when making prophylaxis decisions.
185
Thyroid disease in pregnancy
Thyroid disease in pregnancy
Obstetrics
Thyroid Disease in Pregnancy: An Overview
This article is an ACOG Practice Bulletin that offers clinical management guidelines for obstetrician-gynecologists regarding thyroid disease in pregnancy. It explores the physiological changes in thyroid function during pregnancy, the impact of thyroid disease on both the mother and the fetus, and recommendations for screening, diagnosis, and treatment.
Thyroid Function During Pregnancy
Pregnancy causes significant changes in thyroid function that can be mistaken for thyroid disorders.
Maternal thyroid volume increases by 10% to 30% during the third trimester due to increased extracellular fluid and blood volume.
Levels of total or bound thyroid hormone increase because of higher serum concentrations of thyroid-binding globulin.
Thyrotropin (TSH) levels decrease in early pregnancy due to stimulation of TSH receptors by human chorionic gonadotropin (hCG).
After the first trimester, TSH levels return to baseline and progressively increase in the third trimester.
The fetal thyroid gland begins functioning around 12 weeks of gestation.
Maternal T4 is transferred to the fetus throughout pregnancy, which is particularly important for fetal brain development before the fetal thyroid gland becomes active.
Hyperthyroidism in Pregnancy
Overt hyperthyroidism is characterized by decreased TSH and increased free T4 levels.
Graves' disease accounts for 95% of hyperthyroidism cases in pregnancy.
Untreated or inadequately treated maternal hyperthyroidism is associated with adverse pregnancy outcomes, including:
Preeclampsia with severe features
Maternal heart failure
Thyroid storm
Preterm delivery
Low birth weight
Miscarriage
Stillbirth
Fetal thyrotoxicosis can occur due to transplacental passage of maternal antibodies and may present as fetal tachycardia and poor fetal growth.
Neonatal Graves' disease can also occur in 1-5% of neonates born to mothers with Graves' disease.
Subclinical hyperthyroidism, characterized by low TSH and normal free T4 levels, is not associated with adverse pregnancy outcomes and treatment is not recommended.
Hypothyroidism in Pregnancy
Overt hypothyroidism is diagnosed when TSH levels are above the upper limit of normal and free T4 levels are below the lower limit of normal.
Hashimoto thyroiditis is the most common cause of hypothyroidism in pregnancy.
Untreated overt hypothyroidism is linked to:
Spontaneous abortion
Preeclampsia
Preterm birth
Abruptio placentae
Stillbirth
Low birth weight
Impaired neuropsychologic development in offspring
Subclinical hypothyroidism, with elevated TSH and normal free T4 levels, has not been definitively linked to adverse pregnancy or offspring outcomes.
Large randomized controlled trials have not shown improvement in neurocognitive development in offspring of mothers treated for subclinical hypothyroidism.
Recommendations for Thyroid Disease Management
Universal screening for thyroid disease in pregnancy is not recommended.
Targeted testing is recommended for women with:
Personal or family history of thyroid disease
Type 1 diabetes mellitus
Clinical suspicion of thyroid disease
TSH is the first-line screening test, followed by free T4 measurement if TSH is abnormal.
Treatment for overt hyperthyroidism involves antithyroid drugs (thioamides):
Propylthiouracil is generally preferred in the first trimester.
Methimazole or propylthiouracil can be used after the first trimester.
The lowest possible dose should be used to maintain free T4 levels slightly above or in the high-normal range.
Treatment for overt hypothyroidism involves levothyroxine (T4 replacement therapy):
Dosages are typically 1-2 micrograms/kg daily or approximately 100 micrograms daily.
TSH levels are monitored and levothyroxine dose is adjusted to achieve a TSH level between the lower limit of the reference range and 2.5 milliunits/L.
Routine screening for thyroid autoantibodies in euthyroid women is not recommended.
Testing for thyroid antibodies may be considered in women with Graves’ disease to assess the risk of fetal or neonatal hyperthyroidism.
Thyroid function tests are not routinely recommended for women with hyperemesis gravidarum unless other signs of overt hyperthyroidism are present.
Thyroid nodules should be assessed with TSH testing and neck ultrasonography. Fine-needle aspiration may be performed if malignancy is suspected.
Postpartum thyroiditis is diagnosed based on thyroid dysfunction within 12 months of delivery. Treatment is typically supportive, with levothyroxine used for hypothyroidism.
The article provides a comprehensive overview of thyroid disease management during pregnancy. The key takeaway is that while thyroid disease can significantly impact pregnancy outcomes, universal screening is not recommended. Instead, a targeted approach based on risk factors and clinical suspicion is advised. When thyroid disease is diagnosed, appropriate management with medication and monitoring is crucial for ensuring the well-being of both the mother and the fetus.
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TOLAC
TOLAC
187
Trauma in pregnancy
Trauma in pregnancy
188
Tubo-ovarian abscess, management
Tubo-ovarian abscess, management
189
Type 2 Diabetes
Type 2 Diabetes
190
ubal Ectopic Pregnancy
[ ]
191
Ultrasonography
Ultrasonography
Ultrasound in Pregnancy - Summary
Introduction
Prevalence: Obstetric ultrasound is an essential component of prenatal care, widely used in the United States and globally to monitor fetal health.
Purpose: The purpose of ultrasound in pregnancy is to provide vital information regarding fetal development, viability, gestational age, and potential anomalies. The recommendations outlined in this document are designed to guide practitioners in the appropriate use of obstetric ultrasound.
Types of Examinations:
Standard Examination: Comprehensive evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, and fetal biometry.
Limited Examination: Performed to address specific questions, such as confirming fetal heart activity or placental location.
Specialized Examination: Detailed assessment for high-risk pregnancies, often including Doppler ultrasonography and fetal echocardiography.
Indications for Ultrasound by Trimester
First Trimester:
Confirm Intrauterine Pregnancy: Assess presence of gestational sac and cardiac activity.
Dating Pregnancy: Accurate dating using crown–rump length.
Screening for Aneuploidy: Measurement of nuchal translucency to assess risk of chromosomal abnormalities.
Second and Third Trimester:
Fetal Anatomic Survey: Assessment of fetal organs, amniotic fluid volume, and placental location.
Evaluation of Fetal Growth: Monitoring for growth abnormalities such as intrauterine growth restriction (IUGR) or macrosomia.
Evaluation of Amniotic Fluid Volume: Estimation using amniotic fluid index (AFI) or single deepest pocket.
Benefits and Limitations of Ultrasound
Benefits:
Gestational Age Assessment: Most accurately determined in the first half of pregnancy.
Detection of Anomalies: Ultrasound can diagnose many major fetal anomalies, although detection rates vary by organ system and maternal characteristics.
Noninvasive Monitoring: Doppler ultrasonography can assess fetal anemia and umbilical artery blood flow, aiding in the management of growth-restricted fetuses.
Limitations:
Sensitivity: The sensitivity of ultrasound in detecting anomalies varies (40-80%), with higher detection rates at tertiary-level centers.
Obesity: Maternal obesity can reduce the accuracy of fetal imaging.
Limitations of Early Screening: First-trimester screening for fetal anomalies is less comprehensive compared to the second trimester.
Special Considerations
Multiple Gestations:
Chorionicity Assessment: Accurate determination of chorionicity is essential, as monochorionic pregnancies carry higher risks, such as twin-twin transfusion syndrome.
Increased Surveillance: Monochorionic twins require closer monitoring starting from the second trimester to detect complications.
Safety Considerations:
ALARA Principle: Ultrasound should be performed using the lowest possible settings that achieve adequate image quality to minimize potential risks.
Nonmedical Use: Casual use of ultrasound for keepsake images is not recommended due to the lack of anticipated medical benefit.
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Umbilical Cord Prolapse
Umbilical Cord Prolapse
193
Urinary incontinence
Urinary incontinence
Urinary Incontinence in Women - Summary
Introduction
Definition: Urinary incontinence is the involuntary leakage of urine, affecting physical, psychological, and social well-being. It can lead to significant lifestyle restrictions and has a considerable economic impact.
Prevalence:
25% of young women, 44-57% of middle-aged women, and 75% of older women experience some level of urinary incontinence.
The direct cost of urinary incontinence care in the U.S. is estimated at $19.5 billion.
Types:
Stress Urinary Incontinence: Leakage of urine with effort, physical exertion, sneezing, or coughing.
Urgency Urinary Incontinence: Involuntary loss of urine associated with a strong urge to void.
Mixed Urinary Incontinence: Combination of stress and urgency urinary incontinence.
Clinical Impact: Despite its prevalence, many women hesitate to seek medical help, resulting in reduced quality of life.
Evaluation
Basic Office Evaluation:
History: Assess symptoms, duration, precipitating factors, impact on daily life, and associated symptoms like frequency, urgency, or nocturia.
Physical Examination: Includes assessment of pelvic organ support, evaluation of muscle strength, and a rectal examination to rule out contributing factors like fecal impaction.
Urinalysis: Used to detect infections, which should be treated before further evaluation.
Cough Stress Test: Performed with a full bladder to demonstrate stress incontinence.
Assessment of Urethral Mobility: The cotton swab test or other imaging techniques are used to assess urethral movement.
Postvoid Residual Urine Volume: Assesses bladder emptying adequacy; residual volume should ideally be less than 150 mL.
Advanced Evaluation:
Urodynamic Testing: Used when diagnosis is unclear or treatment response is suboptimal, to assess bladder function.
Management Strategies
Behavioral and Lifestyle Modifications:
Bladder Training: Scheduled voiding to gradually increase bladder capacity.
Weight Loss: Even moderate weight loss improves stress incontinence, especially in overweight women.
Fluid Management: Reduce excessive fluid and caffeine intake to manage symptoms.
Non-Surgical Treatments:
Pelvic Floor Muscle Exercises (Kegels): Strengthen pelvic muscles, used alone or with adjunct therapies like biofeedback.
Incontinence Pessary: Provides support to the urethra, useful for women who prefer non-surgical management.
Pharmacotherapy:
Antimuscarinic Agents: Reduce urgency incontinence by inhibiting involuntary detrusor contractions.
Beta-Agonists (Mirabegron): Increase bladder capacity by relaxing the detrusor muscle.
OnabotulinumtoxinA: Injected into the bladder to treat overactive bladder symptoms; associated with a risk of urinary retention.
Estrogen Therapy: Local estrogen may be helpful, but systemic estrogen is not recommended.
Surgical Treatments:
Midurethral Sling Procedures: The most common surgical intervention for stress incontinence, involving a mesh sling to support the urethra.
Urethral Bulking Agents: Injection of materials to increase urethral resistance, often used in older women or those not suitable for surgery.
Colposuspension: Used with pelvic organ prolapse repair to reduce stress incontinence.
Special Considerations
Pelvic Organ Prolapse: Pelvic organ prolapse may mask stress incontinence. Concomitant incontinence procedures may be recommended during prolapse surgery to prevent postoperative incontinence.
Complicated Cases: Women with conditions like severe prolapse, failed previous surgeries, or multiple comorbidities may require individualized care, including advanced surgical interventions like autologous fascial slings.
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Urinary tract infections and pregnancy
Urinary tract infections and pregnancy
195
Uterine Inversion
Uterine Inversion
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Uterine leiomyoma
Uterine leiomyoma, Medical management of fibroids
Gynecology
Management of Symptomatic Uterine Leiomyomas (Fibroids)
This outline draws heavily on the ACOG Practice Bulletin No. 228, which offers comprehensive guidance on managing symptomatic uterine leiomyomas.
Background
Definition: Uterine leiomyomas, commonly known as fibroids, are benign tumors arising from the smooth muscle cells and fibroblasts of the uterus. Their size and location within the uterus are variable.
Epidemiology: Fibroids are incredibly common, with an estimated occurrence in up to 70% of women by menopause. However, the majority are asymptomatic and remain undiagnosed.
Symptoms: The most common symptoms include:
Abnormal Uterine Bleeding (AUB-L): Prolonged or heavy menstrual bleeding, potentially leading to anemia.
Bulk Symptoms: Pelvic pressure, urinary frequency, and constipation resulting from the size of the fibroids.
Diagnosis
Clinical Evaluation: Begins with a detailed medical history and a pelvic and abdominal examination.
Imaging Studies:
Transvaginal Ultrasound: An initial screening tool to identify fibroids.
Sonohysterography: Helps to differentiate between different types of fibroids based on their submucosal component.
Hysteroscopy: Visualizes the uterine cavity and helps distinguish between fibroid types with varying degrees of endometrial contact.
Magnetic Resonance Imaging (MRI): Useful for surgical planning, assessing fibroid vascularity and degeneration, and distinguishing between fibroid types with intramural components.
Differential Diagnosis: It's crucial to rule out other conditions that can cause similar symptoms, including other causes of AUB and pelvic masses. The possibility of a uterine sarcoma must also be considered.
Treatment Options
The ACOG Practice Bulletin emphasizes that the ideal treatment for symptomatic fibroids is individualized and takes into account factors like symptom severity, desire for future fertility, patient preferences, and the availability of resources.
Expectant Management
Appropriate for: Asymptomatic patients or those who choose to avoid intervention.
Considerations: Studies suggest that bleeding patterns, hemoglobin levels, and fibroid size generally remain stable in the short term (up to a year).
Counseling: Patients should be informed about the potential for symptom progression and the need for follow-up if symptoms worsen or if pregnancy is desired.
Medical Management
Focus: Primarily targets bleeding symptoms but some medications can also shrink fibroids.
Options:
GnRH Antagonists with Hormonal Add-Back Therapy: Can be considered for AUB-L for up to 2 years. Elagolix is an example.
Levonorgestrel-Releasing Intrauterine Device (LNG-IUD): Effective for reducing bleeding.
Contraceptive Steroids: May improve bleeding patterns.
Tranexamic Acid: Reduces menstrual blood loss.
GnRH Agonists: Induce temporary menopause, reducing bleeding and shrinking fibroids. Used as a short-term bridge to other treatments.
Selective Progesterone Receptor Modulators: Reduce bleeding and fibroid size.
Procedural Interventions
Uterine Artery Embolization (UAE):
Recommended for: Patients who want to preserve their uterus but are informed about the limited data on reproductive outcomes.
Procedure: Embolic agents are injected into the uterine arteries to cut off blood supply to the fibroids, causing them to shrink.
Benefits: Significant reduction in fibroid and uterine volume, improvement in bleeding symptoms, high patient satisfaction.
Risks: Major complications are uncommon but can include infection, postembolization syndrome, and potential impact on ovarian reserve.
Radiofrequency Ablation (RFA):
Considered for: Patients desiring uterine preservation who are informed about limited reproductive outcome data.
Procedure: Uses radiofrequency energy to destroy targeted fibroids.
Benefits: Effective in reducing fibroid volume and improving quality of life.
Risks: Limited data on long-term complications and effects on fertility.
Endometrial Ablation:
Limited Evidence: Some data suggests improvement in AUB-L but not enough to make a strong recommendation.
Surgical Management
Myomectomy:
Recommended for: Patients who wish to retain their uterus, particularly if they desire future fertility.
Approaches: Minimally invasive techniques (laparoscopic or robot-assisted) are preferred when feasible.
Considerations: The choice of surgical approach depends on several factors, including fibroid size, location, and number, surgeon experience, and patient preference.
Hysterectomy:
Recommended for: Definitive treatment for patients who do not desire future childbearing or wish to keep their uterus. Patients should be informed about long-term health risks.
Approaches: Minimally invasive approaches, particularly vaginal hysterectomy, are preferred when feasible.
Benefits: Resolution of AUB-L and bulk symptoms, high patient satisfaction.
Risks: Surgical risks associated with any major surgery, including bleeding, infection, and potential long-term effects of removing the uterus and ovaries.
Shared Decision-Making
Crucial Aspect of Care: Treatment decisions for fibroids should be made collaboratively between the patient and healthcare provider.
Factors to Consider: Patient preferences, symptom severity, desire for future fertility, risks and benefits of each treatment option, and the individual patient's medical history.
Conclusion
Management of symptomatic fibroids requires a thoughtful and individualized approach. The ACOG Practice Bulletin provides evidence-based guidance to help clinicians navigate the available options and make informed treatment decisions in partnership with their patients.
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Uterine Rupture
Uterine Rupture
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Vaccination guidelines
Vaccination guidelines
General
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Vaginal birth after cesarean (VBAC)
Vaginal birth after cesarean (VBAC)
Vaginal Birth After Cesarean Delivery (VBAC)
This article, "ACOG PRACTICE BULLETIN Clinical Management Guidelines for Obstetrician–Gynecologists," explores the risks and benefits of a trial of labor after cesarean delivery (TOLAC). The bulletin aims to provide guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.
Background
From 1970 to 2016, the cesarean delivery rate in the United States increased significantly, partly due to the belief that "once a cesarean always a cesarean".
However, data supports TOLAC as a reasonable approach in specific pregnancies.
Increased interest in VBAC led to its increased rates, but concerns arose regarding uterine rupture and other complications.
In 2010, the National Institutes of Health recognized TOLAC as a reasonable option for many women, encouraging organizations to facilitate access to it.
Evaluating the Evidence
No randomized trials exist comparing TOLAC to planned repeat cesarean delivery.
Recommendations are based on observational studies examining the probability of VBAC and its associated morbidities compared to repeat cesarean delivery.
The comparison should focus on the intention to deliver (TOLAC versus elective repeat cesarean delivery).
Benefits and Risks of TOLAC
Benefits:
VBAC avoids major abdominal surgery.
VBAC is associated with lower rates of hemorrhage, thromboembolism, infection, and shorter recovery times.
VBAC may reduce future pregnancy risks related to multiple cesarean deliveries.
Risks:
Both elective repeat cesarean delivery and TOLAC carry risks, including hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death.
Most TOLAC morbidity occurs when repeat cesarean becomes necessary.
Uterine rupture or dehiscence during TOLAC poses the most significant risk.
Vaginal Delivery Rate in TOLAC
The vaginal delivery rate for TOLAC is 60–80%, but individual success varies.
Factors influencing VBAC success include:
Indication for the first cesarean delivery.
Labor induction or augmentation.
Maternal age, BMI, birth weight, gestational age at delivery, and interdelivery interval.
History of prior vaginal delivery.
Prediction models can estimate the probability of VBAC based on individual factors.
Candidates for TOLAC
Most women with one previous low-transverse incision cesarean are candidates for TOLAC.
Women at high risk for uterine rupture, such as those with a previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery, are generally not candidates.
Women with placenta previa are also not typically candidates.
Good candidates are those with an acceptable balance of risks and chances of success.
Factors Affecting TOLAC Candidacy
More Than One Previous Cesarean Delivery: The risk of uterine rupture in women with multiple cesarean deliveries is unclear, but TOLAC can be considered with careful assessment.
Macrosomia: Women with larger fetuses may have a lower likelihood of VBAC but should not be excluded solely based on estimated fetal weight.
Gestation Beyond 40 Weeks: VBAC rates decrease beyond 40 weeks, but this alone should not preclude TOLAC.
Previous Low-Vertical Incision: TOLAC may be an option with careful consideration.
Unknown Type of Prior Uterine Incision: TOLAC may be considered unless a previous classical incision is suspected.
Twin Gestation: Outcomes for TOLAC in twin pregnancies are similar to singleton pregnancies.
Obesity: Higher BMI is associated with lower VBAC success rates, but individual assessment is crucial.
Labor Management in TOLAC
Induction and Augmentation of Labor: Induction is an option but may increase the risk of uterine rupture and decrease VBAC success.
Cervical Ripening: Data on specific cervical ripening agents is limited. Mechanical ripening may be an option for candidates with an unfavorable cervix.
External Cephalic Version: Not contraindicated in appropriate candidates with a prior low-transverse incision.
Analgesia: Epidural analgesia can be used but is not mandatory.
Anticipated Labor Curve: Women attempting TOLAC have similar labor patterns to those without a prior cesarean.
Diagnosis and Management of Uterine Rupture
Diagnosis: Continuous electronic fetal monitoring is recommended.
Signs and Symptoms: Fetal heart rate abnormality is the most common sign. Other signs include fetal bradycardia, increased uterine contractions, vaginal bleeding, loss of fetal station, and intense uterine pain.
Future Pregnancies After Uterine Rupture
Repeat cesarean delivery before the onset of labor is recommended.
Delivery timing between 36 0/7 weeks and 37 0/7 weeks of gestation may be considered.
Counseling for TOLAC
Discuss potential risks and benefits of TOLAC and elective repeat cesarean delivery.
Consider individual characteristics affecting complications and VBAC likelihood.
Address resources available at the intended delivery site.
The ultimate decision should be made by the patient in consultation with their healthcare provider.
Resources for TOLAC
TOLAC should be attempted at facilities equipped for emergency deliveries.
ACOG recommends TOLAC in facilities capable of immediate cesarean delivery.
If emergency resources are limited, patients should be informed of the risks and alternatives, including referral to a facility with appropriate resources.
Home birth is contraindicated for women undergoing TOLAC.
This Practice Bulletin provides comprehensive guidance on VBAC, highlighting the importance of individualized risk assessment, patient counseling, and access to appropriate resources for safe and successful TOLAC.
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Vaginal discharge
Vaginal discharge
201
Vaginal or perineal hematoma
Vaginal or perineal hematoma
202
Vaginitis in Nonpregnant Patients
Vaginitis in Nonpregnant Patients
Comprehensive Overview of Vaginitis in Nonpregnant Patients
This article, "ACOG PRACTICE BULLETIN Clinical Management Guidelines for Obstetrician–Gynecologists," offers guidance on diagnosing and treating various types of vaginitis in nonpregnant patients.
Background
Vaginitis, characterized by inflammation or infection of the vagina, presents with symptoms such as itching, burning, irritation, pain during intercourse, abnormal discharge, and a "fishy" odor.
These symptoms are frequent reasons for visits to obstetrician-gynecologists.
Accurately diagnosing the cause is crucial for successful treatment.
The most prevalent causes include:
Vulvovaginal candidiasis (17–39% of cases)
Bacterial vaginosis (22–50% of cases)
Trichomoniasis (4–35% of cases)
Other causes include vulvar skin diseases, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause.
Role of Estrogen in Vaginal Health
Estrogen significantly impacts the vaginal environment.
During reproductive years, estrogen elevates glycogen levels in vaginal epithelial cells, promoting lactobacilli colonization.
Lactobacilli produce lactic acid, lowering vaginal pH to below 4.5, which inhibits pathogenic organism growth.
The normal vaginal flora is diverse and may include organisms like Gardnerella vaginalis, Escherichia coli, group B streptococci, genital Mycoplasma species, and Candida albicans.
In prepubertal girls and postmenopausal women, estrogen deficiency hinders the normal growth of vaginal bacteria.
Microscopy often reveals few epithelial cells and bacteria in these populations.
The vaginal epithelium is thin, the pH is higher than 4.5 due to reduced lactobacilli, and the growth of bacteria associated with bacterial vaginosis and yeast forms is uncommon.
Bacterial Vaginosis
Bacterial vaginosis is not a true infection or inflammatory condition. It's a shift in the vaginal microbiome with an overgrowth of anaerobic organisms like G. vaginalis, Bacteroides species, Peptostreptococcus species, Fusobacterium species, Prevotella species, and Atopobium vaginae, along with a decrease in hydrogen peroxide-producing lactobacilli.
It is the most common cause of abnormal vaginal discharge in women of reproductive age.
Prevalence is higher in Black, Hispanic, and Mexican American women.
Risk factors include race/ethnicity, age, douching, and sexual activity.
While associated with sexual activity in heterosexual and lesbian couples, it is not a sexually transmitted infection (STI) in the traditional sense as it is not directly caused by a single pathogen.
Nonpregnant women with bacterial vaginosis have a higher risk of pelvic inflammatory disease (PID), postprocedural gynecologic infections, and STIs like HIV and herpes simplex virus type 2.
Many women with bacterial vaginosis are asymptomatic.
Symptomatic women often experience abnormal vaginal discharge and a fishy odor, particularly after intercourse or menstruation.
Trichomoniasis
Trichomoniasis, caused by the protozoan parasite Trichomonas vaginalis, is the most common nonviral STI in the United States.
African American women are disproportionately affected.
Risk factors include having multiple sex partners, low socioeconomic status, and douching.
Trichomoniasis is linked to PID, posthysterectomy cuff cellulitis, HIV, and other STIs.
Over half of infected individuals are asymptomatic or have minimal symptoms.
Symptomatic women may report abnormal vaginal discharge, itching, burning, or bleeding after intercourse.
While classified as an STI, recent diagnosis doesn't necessarily indicate recent acquisition due to the possibility of prolonged asymptomatic carriage in both men and women.
Vulvovaginal Candidiasis
Vulvovaginal candidiasis involves inflammation and infection of the vagina with Candida species.
It is the second most common cause of vaginitis.
Nearly half of females experience at least one episode in their lifetime.
Presentations range from asymptomatic colonization to severe symptoms such as burning, itching, swelling, painful urination, pain during intercourse, and abnormal discharge.
It is uncommon in prepubertal girls and postmenopausal women not using estrogen and is often overdiagnosed in these groups.
Initial Evaluation of Vaginitis
Recommended initial evaluation includes:
Complete medical history
Physical examination of the vulva and vagina
Clinical testing of vaginal discharge (pH, KOH whiff test, microscopy)
History should focus on:
Location, description, and duration of symptoms
Sexual history
Self-treatment with over-the-counter or prescription medications
Vulvovaginal hygiene practices (shaving, douching)
Underlying medical conditions (diabetes, HIV, inflammatory bowel disease)
Relationship of symptoms to the menstrual cycle
Physical examination:
Begins with a thorough assessment of the vulva and perianal skin.
Vulvar dermatoses may present with redness, hypopigmentation, papules, plaques, melanosis, swelling, or architectural changes indicative of chronic inflammation.
Candidiasis and trichomoniasis can cause vulvar redness and swelling in addition to vaginal findings, while bacterial vaginosis does not affect the vulva.
Speculum examination is performed to collect vaginal discharge samples for clinical testing.
While the discharge appearance may offer clues, it is not diagnostic on its own.
Clinical Testing:
pH testing: Swab should be obtained from the mid-vaginal wall to avoid false elevations from cervical mucus, blood, semen, lubricants, etc.
KOH whiff test (amine odor test)
Microscopic examination with saline and KOH
FDA-approved commercial tests can be used when pH paper, KOH, and microscopy are unavailable.
Diagnosis and Treatment of Bacterial Vaginosis
Diagnosis:
Clinical presentation: Watery, gray, homogenous discharge, often with a fishy odor.
Recommended diagnostic methods: Amsel criteria or Gram stain with Nugent scoring.
Routine bacterial culture is not recommended as the normal vaginal flora is heterogeneous.
Overdiagnosis is common, so clinical correlation is crucial to prevent unnecessary treatment.
Amsel Criteria (requires 3 out of 4 criteria for diagnosis):
Homogenous, thin, white-gray discharge coating the vaginal walls
More than 20% clue cells on saline microscopy (vaginal squamous cells with adherent coccobacilli)
Vaginal pH greater than 4.5
Positive KOH whiff test (fishy odor before or after mixing discharge with KOH)
Gram Stain with Nugent Scoring:
Considered the gold standard but primarily used in research settings.
Assigns a score based on bacterial morphotypes seen on Gram stain of vaginal secretions.
Scores of 0–3: Normal flora
Scores of 4–6: Intermediate flora
Scores of 7–10: Bacterial vaginosis flora
Commercial Tests:
May be considered when microscopy is unavailable.
Examples include direct DNA probe assays for G. vaginalis and chromogenic point-of-care assays detecting sialidase activity.
The diagnostic value of tests identifying only a single organism is still being investigated.
Multiplex PCR panel tests combining PCR and DNA probe technology show promise as alternatives to microscopy. They can determine the ratio of lactobacilli to bacterial vaginosis-associated bacteria.
Treatment:
Symptomatic women should be treated to reduce overgrowth of anaerobic bacteria and allow lactobacilli to predominate.
Treatment may also reduce the risk of transmitting or acquiring other STIs.
Patients with bacterial vaginosis should be tested for HIV and other STIs.
Recommended treatments:
Oral or intravaginal metronidazole
Intravaginal clindamycin
Alternative treatments:
Oral secnidazole
Oral tinidazole
Oral clindamycin
Choice of therapy should be individualized based on patient preference, cost, convenience, adherence, ease of use, and previous treatment history.
Patients using intravaginal medications may want to avoid tampons to ensure proper drug distribution.
Management of Recurrent Bacterial Vaginosis:
Recurrent bacterial vaginosis is defined as at least three documented, separate episodes within a year.
Follow-up with rescreening is not necessary if symptoms resolve after treatment.
Recurrence is possible in up to 30% of patients within 3 months and 58% within 12 months.
Possible contributing factors include douching, frequent sexual activity, prior bacterial vaginosis, persistent pathogenic bacteria, or failure to reestablish a lactobacillus-dominant vaginal flora.
Management options for recurrent cases:
Twice-weekly suppressive metronidazole gel for 16 weeks after acute episode treatment
Changing the antibiotic or extending the treatment course
Diagnosis and Treatment of Trichomoniasis
Diagnosis:
Clinical presentation: Elevated vaginal pH, inflammatory discharge (potentially green-yellow and bubbly).
Preferred diagnostic test: Nucleic acid amplification testing (NAAT), due to its high sensitivity and specificity.
Microscopy has limited sensitivity (50–60%) and is not recommended.
Alternative options: FDA-approved commercial tests or vaginal culture.
NAAT:
Highly sensitive compared to microscopy.
Can be performed on vaginal, cervical, or urine specimens with high sensitivity and specificity.
Commercial Tests:
DNA probe technology can detect T. vaginalis in vaginal secretions.
Multiplex PCR panel tests that combine DNA probe and amplification technology are comparable to reference standards and can also screen for G. vaginalis and C. albicans.
Antigen-Detection Testing:
Rapid point-of-care option with results in approximately 10 minutes.
Culture:
Previously the gold standard, but now superseded by molecular methods.
Inconvenient, takes at least 5 days, and often requires special media.
Treatment:
Recommended treatment: Oral nitroimidazoles (metronidazole or tinidazole).
While a single dose of metronidazole has been the preferred regimen, recent studies suggest a 7-day course is more effective.
Metronidazole is generally cheaper than tinidazole but has more gastrointestinal side effects.
Alcohol should be avoided during treatment and for 24 hours after metronidazole or 72 hours after tinidazole due to the risk of a disulfiram-like reaction.
Metronidazole gel is ineffective for T. vaginalis infections.
Patients with metronidazole allergy should be referred for desensitization.
Low-level metronidazole resistance may occur, but high-level resistance is rare.
In cases of suspected resistance, tinidazole may be effective.
If retreatment fails and adherence is confirmed, culture and susceptibility testing should be considered.
Retesting within 3 months is recommended due to high recurrence rates.
Diagnosis and Treatment of Vulvovaginal Candidiasis
Diagnosis:
Clinical symptoms alone are unreliable for diagnosis.
Confirmation requires one of the following in a symptomatic patient:
Visualization of spores, pseudohyphae, or hyphae on wet mount microscopy
Positive vaginal fungal culture or commercial test for Candida species
Microscopy:
Convenient and cost-effective, but sensitivity is only 50–70%.
Self-treatment before evaluation can hinder visualization.
Culture:
Preferred for confirming yeast presence when microscopy is negative.
Helpful for identifying non-albicans Candida species.
Useful for evaluating recurrent or resistant cases.
Important to correlate with symptoms as cultures may be positive in asymptomatic individuals.
Commercial Tests:
PCR tests offer rapid results but are expensive and not FDA-approved for yeast detection.
DNA probe technology kits are available, but some lack speciation capabilities.
Newer DNA probe tests with PCR can differentiate Candida species into three groups and may be useful for complicated yeast infections.
Classification and Treatment:
Vulvovaginal candidiasis is classified as uncomplicated or complicated based on clinical presentation, microbiology, host factors, and treatment response.
Complicated cases require more aggressive treatment.
Uncomplicated Vulvovaginal Candidiasis:
Recommended treatment: Intravaginal azole therapy or oral fluconazole.
Treatment choice should be individualized.
Over-the-counter imidazole creams and suppositories are readily available, but many prefer a single oral fluconazole tablet.
Topical treatments may cause burning and irritation.
Oral fluconazole is generally well-tolerated but may cause mild, self-limiting side effects like gastrointestinal upset, headache, and elevated liver enzymes.
Complicated Vulvovaginal Candidiasis:
Defined as:
Recurrent vulvovaginal candidiasis (4 or more infections in 12 months)
Severe symptoms
Infection with non-albicans Candida species
Infection in an immunocompromised woman (e.g., HIV, immunosuppressive medications, diabetes)
Culture is essential for identifying the yeast species.
Oral fluconazole is effective for complicated infections with C. albicans, but resistance has been documented.
Culture and susceptibility testing are recommended for persistent symptoms after treatment or when non-albicans isolates are identified.
Recurrent vulvovaginal candidiasis:
Diagnosis requires documentation of infections with objective data, including yeast speciation by culture.
Extended antifungal treatment is recommended.
Suppressive therapy with weekly intravaginal or oral azoles improves cure rates and reduces recurrence.
Prolonged fluconazole treatment (150 mg weekly for 6 months) effectively controlled over 90% of recurrent episodes and offered prolonged protection in about 50% of patients with C. albicans infections.
Intermittent topical agents like clotrimazole are alternatives for patients who cannot or will not take fluconazole.
Severe vulvovaginal candidiasis:
Characterized by vulvar symptoms like redness, erosion, fissures, and swelling.
Requires prolonged treatment with topical intravaginal azole for 10–14 days or two to three doses of oral fluconazole taken 3 days apart.
Non-albicans Candida species:
Less responsive to topical imidazoles or oral fluconazole.
Suspect in women with persistent symptoms after uncomplicated vulvovaginal candidiasis treatment.
Vaginal fungal culture is recommended to identify the species.
Intravaginal boric acid (600 mg daily for at least 14 days) is effective for C. glabrata and other atypical species.
Topical flucytosine is an alternative but often expensive.
Treatment Without Examination
Self-diagnosis of vaginitis is not recommended due to limited accuracy and nonspecific symptoms.
Women with vaginitis symptoms, particularly those who have self-treated for presumed candidiasis without success, should seek clinical evaluation.
In-office examination is necessary before treatment.
Adverse Effects of Nonprescription Antifungal Use
Topical nonprescription antifungals generally have cure rates and adverse effects similar to prescription therapies.
Failure to respond to initial treatment warrants clinical evaluation.
Contact dermatitis (burning and irritation) may occur in about 5% of users.
Using antifungals for the wrong condition or experiencing treatment failure can delay diagnosis and appropriate treatment.
Excessive use of nonprescription antifungals can lead to unnecessary costs.
Vaginitis Findings on Cervical Cytology
Pap tests are unreliable for diagnosing vaginitis.
Diagnostic confirmation is recommended for incidental findings of candidiasis, bacterial vaginosis, or trichomoniasis on Pap tests.
Candidiasis:
Vaginal Candida species are present in 20–30% of asymptomatic women.
Treatment is not indicated for asymptomatic cases.
Symptomatic patients with positive Pap results should undergo confirmatory testing.
Bacterial Vaginosis:
Pap tests have low sensitivity for bacterial vaginosis.
Confirmatory testing is needed in symptomatic patients with suggestive findings.
Asymptomatic individuals do not require evaluation or treatment.
Trichomoniasis:
Pap tests have low sensitivity for detecting trichomonads.
Confirmatory testing is necessary if trichomonads are suspected.
Treatment is recommended for confirmed cases.
Probiotics and Nonmedical Approaches
Probiotics (vaginal or oral) and nonmedical therapies are not recommended for treating or preventing vaginitis.
Candidiasis:
Lactobacillus products (oral or vaginal) are ineffective for treatment or prevention.
Other nonmedical therapies (yogurt, garlic, tea tree oil, low-carbohydrate diet, douching) lack sufficient data on efficacy and are not FDA-regulated.
Bacterial vaginosis:
Probiotics are not recommended for treatment, augmentation of antimicrobial therapy, or maintaining vaginal balance.
Studies have not shown benefit from vaginal lactobacillus supplements, alone or with antibiotics.
Trichomoniasis:
Nitroimidazoles are the only recommended and effective treatment.
Referral for desensitization is recommended for intolerant or allergic patients.
Treatment of Sexual Partners
Trichomoniasis:
Current sexual partners should be treated presumptively and abstain from sexual activity until they complete therapy and are asymptomatic.
Partner management reduces transmission and recurrence.
Bacterial vaginosis:
Data do not support partner treatment for affecting relapse or remission rates.
Uncomplicated vulvovaginal candidiasis:
Partner treatment is not necessary.
Summary of Recommendations
Level A (Good and Consistent Scientific Evidence):
Amsel criteria or Gram stain with Nugent scoring is recommended for diagnosing bacterial vaginosis.
Oral or intravaginal metronidazole or intravaginal clindamycin is recommended for treating bacterial vaginosis. Alternatives include oral secnidazole, tinidazole, or clindamycin.
NAAT is recommended for diagnosing trichomoniasis.
Oral nitroimidazoles are recommended for treating trichomoniasis.
Diagnosis of symptomatic vulvovaginal candidiasis requires either visualization of fungal elements on microscopy or a positive culture/commercial test for Candida species.
Extended antifungal treatment is recommended for recurrent vulvovaginal candidiasis.
Level B (Limited or Inconsistent Scientific Evidence):
Retesting within 3 months after trichomoniasis treatment is recommended due to high recurrence rates.
Pap tests are unreliable for vaginitis diagnosis, and confirmatory testing is needed for incidental findings.
Level C (Consensus and Expert Opinion):
Complete history, physical examination, and vaginal discharge testing (pH, KOH whiff test, microscopy) are recommended for initial vaginitis evaluation.
Intravaginal azole therapy or oral fluconazole is recommended for treating uncomplicated vulvovaginal candidiasis.
Self-diagnosis is not recommended.
Probiotics and nonmedical therapies are not recommended.
Partners of women with confirmed trichomoniasis should be treated presumptively.
203
Vasa Previa
Vasa Previa
Obstetrics
Admission -
Signs and symptoms of labor
30 -34 wks
34-37
Vilimentous cord insertion
Bilobed placenta
2cm of cerivcal canal
risk is fetal demise
204
VAVD
VAVD
Obstetrics
205
Von Willebrand’s disease
Von Willebrand’s disease
Gynecology
206
VTE Prevention after GYN Surgery
VTE Prevention after GYN Surgery
Gynecology
Importance: Preventable complication in GYN surgery.
Risk factors: Virchow’s triad (stasis, injury, hypercoagulability).
Sources: ACOG Practice Bulletin No. 232, ACCP Guidelines.
Surgical risk factors: Age, surgery duration, obesity, immobility, medications, and medical conditions.
Preventive Strategies (9:54 - 11:44)
• Preoperative VTE assessment using the Caprini score.
• Balancing VTE risk vs. bleeding risk.
• Strategies: mechanical, pharmacological, or both.
DVT & PE Evaluation (11:44 - 16:47)
• Clinical symptoms: DVT signs (unilateral swelling, warmth), PE signs (SOB, chest pain).
• Diagnostic tools: Well’s score, Doppler ultrasound, CT angiogram.
• Challenges in post-op patients due to elevated D-dimer from surgery.
PE Treatment Overview (16:47 - 20:02)
• Generalists’ role: Co-management with specialists.
• Medications: DOACs, unfractionated heparin, low molecular weight heparin.
• Specific indications for using IV heparin.
Management and Monitoring (20:02 - 24:48)
• Monitoring protocols: PTT for heparin, INR for warfarin, anti-factor 10a for LMWH.
• Reversal agents and treatment during pregnancy: warfarin vs. heparin.
Complications: Heparin-induced Thrombocytopenia (HIT) (24:48 - 28:31)
• Two types of thrombocytopenia: benign vs. immune-mediated HIT.
• HIT mechanism: immune reaction to heparin-platelet factor 4 complex.
Comparative Medications and Mechanisms (28:31 - 30:45)
• Medication comparisons: Heparins, warfarin, DOACs, LMWH.
• Overview of anticoagulants’ mechanism of action in the clotting cascade.
• Special considerations for pregnancy and reversibility of agents.
207
Vulvar cancer
[ ]
208
Vulvar Skin Disorders
Vulvar Skin Disorders
Gynecology
Outline of Vulvar Skin Disorders
The sources provide information about the diagnosis and management of common vulvar skin disorders.
Vulvar skin disorders include a variety of inflammatory conditions of the vulva.
Common symptoms include:
Pruritus (itching)
Pain
Burning
Common vulvar skin disorders include:
Contact dermatitis
Lichen simplex chronicus
Lichen sclerosus
Lichen planus
Other vulvovaginal disorders that should be considered in the differential diagnosis include:
Vaginitis
Candidiasis
Bacterial vaginosis
Trichomoniasis
Vulvar low-grade squamous intraepithelial lesions
Vulvar high-grade squamous intraepithelial lesions
Genitourinary syndrome of menopause (vulvovaginal atrophy)
Vulvar pain (vulvodynia)
Genital HPV infection
Paget disease of the vulva
Systemic diseases:
Crohn disease
Hidradenitis suppurativa
Trauma
Iatrogenic causes
Initial evaluation of patients with vulvovaginal symptoms should include:
A comprehensive medical history
Onset, duration, location, and nature of vulvar symptoms
Relationship of symptoms to the menstrual cycle
Possible precipitating or known risk factors
A physical examination
Examination of the entire vulva from clitoris to below the anus
Assessment for changes in color and texture
Assessment for fissures, excoriations, erosions, ulcers, and other lesions
Speculum examination to look for erythema, erosion, ulceration, synechiae, and discharge
Evaluation of abnormal vaginal discharge if an infectious etiology is suspected:
pH testing
Potassium hydroxide "whiff test"
Microscopy
FDA-approved diagnostic tests
Vaginal fungal culture
Testing for sexually transmitted infections
Vulvar biopsy is recommended for visible lesions in the following circumstances:
Lesions are atypical (e.g., new pigmentation, indurated, affixed to underlying tissue, bleeding, or ulcerated)
Concern for malignancy
Lesions in immunocompromised patients
Uncertain diagnosis
Lesions that do not respond to standard therapy
Lesions that worsen during therapy
Common irritants and allergens that can cause vulvar skin disorders:
Hygiene products:
Adult or baby wipes
Soaps, bubble bath, bath salts, shampoos, and conditioners
Vaginal hygiene products
Antiseptics
Clothing:
Synthetic nylon underwear
Tight clothing or undergarments
Colored or chemically treated clothing
Topical agents:
Emollients
Lubricants
Contraceptive creams, jellies, and foams
Condoms
Sanitary products
Topical medications (anesthetics, antibacterials, antimycotics, corticosteroids)
Other:
Laundry detergents, fabric softeners, and dryer sheets
Shaving cream and shaving
Rubber products
Tea tree oil
Body fluids (semen, saliva)
Patient counseling for prevention and control of vulvar disorders should include advice to:
Avoid vulvar irritants and allergens
Use mild soaps and avoid using soap on the vulva
Cleanse the vulva with water only
Gently pat the vulva dry after bathing
Apply preservative-free, unscented emollients
Use a peri-bottle to rinse after urination
Use 100% cotton, unscented menstrual pads
Use adequate lubrication for intercourse
The sources provide detailed information about the diagnosis, treatment, and management of specific vulvar skin disorders including contact dermatitis, lichen simplex chronicus, lichen sclerosus, and lichen planus.
Topical corticosteroids are a common treatment for many vulvar skin disorders.
The potency of the topical corticosteroid should be chosen based on the severity and chronicity of the condition.
Common topical corticosteroid ointments:
High potency: betamethasone dipropionate 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinonide 0.05%, triamcinolone acetonide 0.5%
Medium potency: desoximetasone 0.05%, hydrocortisone butyrate 0.1%, hydrocortisone valerate 0.2%, mometasone furoate 0.1%, triamcinolone acetonide 0.025%, 0.1%
Low potency: desonide 0.05%, hydrocortisone 1%, 2.5%
An ointment formulation is preferable to creams, gels, or lotions, which can contain alcohol or preservatives that may irritate the vulva.
209
Well woman exam
Well woman exam
Gynecology
210
Wound Complications
Wound Complications
Gynecology
211
Zika
Zika
Zika Virus: Risks, Transmission, and Prevention
This article provides information about the Zika virus, particularly the risks it poses during pregnancy and the steps that can be taken to prevent infection.
Risks of Zika Virus During Pregnancy
Zika virus infection during pregnancy can cause serious birth defects, including microcephaly and other brain abnormalities. Microcephaly can lead to lifelong problems such as:
Seizures
Feeding problems
Hearing loss
Vision problems
Learning difficulties
There is currently no vaccine for Zika virus, making prevention crucial.
Zika Virus Transmission
Zika virus can be transmitted in the following ways:
Through the bite of an infected mosquito Mosquitoes carrying the Zika virus are active both during the day and at night.
From a pregnant woman to her fetus during pregnancy or around the time of birth
Through sexual contact
Symptoms of Zika Virus Infection
Symptoms of Zika virus infection are usually mild and include:
Fever
Rash
Joint pain
Red, itchy eyes
Many people infected with the Zika virus do not experience any symptoms.
Zika Virus Prevention: Before and During Pregnancy
If you are considering becoming pregnant:
Talk to your healthcare professional about your pregnancy plans, the risks of Zika virus infection during pregnancy, and your male partner's risk of Zika virus exposure.
Take strict measures to avoid mosquito bites.
If you are pregnant:
Take strict measures to avoid mosquito bites.
Use a condom every time you have sex if your partner lives in or travels to an area where Zika virus is spreading.
Avoid traveling to areas where Zika virus is spreading.
Consult your healthcare professional to discuss testing if you or your sexual partner have traveled to or live in an area where Zika virus is present, or if you or your partner have symptoms of Zika virus infection.
Mosquito Bite Prevention Strategies
If travel to an area with Zika virus transmission is unavoidable, strictly follow these steps to prevent mosquito bites:
Use EPA-registered bug spray containing DEET, picaridin, IR3535, oil of lemon eucalyptus, paramenthane-diol, or 2-undecanone. These sprays are safe for pregnant and breastfeeding women when used as directed.
Wear long-sleeved shirts and long pants.
Treat clothing and gear with permethrin or buy permethrin-treated items.
Stay in air-conditioned or screened-in areas during the day and night.
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