Current Clinical Strategies

GynecologyandObstetr ics
2004E dition

New ACOG Treatment Guidelines

Paul D. Chan, M.D.

Susan M. Johnson, M.D.

Current Clinical Strategies Publishing

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Surgical Documentation
for Gynecology
GynecologicSur gicalH istory
IdentifyingD ata.A ge,gravi da(num berofpregnanci es),

para(num berofdel iveries).

ChiefCo mpliant.R easongi venby pati entforseek ing

surgicalcar e.

HistoryofP resentIllness(H PI).D escribethecourseof

thepati ent'si llness,i ncludingw heni tbegan,characterof

thesy mptoms;pai nonset(gradual orrapi d),characterof

pain(constant,i ntermittent,cram ping,radi ating);other

factorsassoci atedw ithpai n(uri nation,eati ng,strenuous

activities);aggravati ngorrel ievingfactors.Otherrel ated

diseases;pastdi agnostictesti ng.

ObstetricalH istory.P astpregnanci es,durati onsand

outcomes,preterm del iveries,operati vedel iveries.

GynecologicH istory:Lastm enstrualperi od,l engthof

regularcy cle.

PastM edicalH istory(P MH).P astm edicalprobl ems,

previoussurgeri es,hospi talizations,di abetes,hy perten­

sion,asthm a,heartdi sease.

Medications.C ardiacm edications,oral contracepti ves,

estrogen.

Allergies.P enicillin,codeine.

FamilyHisto ry.M edicalprobl emsi nrel atives.

SocialH istory. Alcohol,sm oking,drugusage,occupati on.

ReviewofS ystems(R OS):

General:Fever,fati gue,ni ghtsw eats.

HEENT:H eadaches,m asses,di zziness.

Respiratory:C ough,sputum ,dy spnea.

Cardiovascular:C hestpai n,ex tremityedem a.

Gastrointestinal:V omiting,abdom inalpai n,m elena

(blacktarry stool s),hem atochezia(bri ghtredbl oodper

rectum).

Genitourinary:D ysuria,hem aturia,di scharge.

Skin:E asybrui sing,bl eedingtendenci es.

GynecologicPh ysicalExamin ation

General:

VitalSi gns:T emperature,respi rations,heartrate,bl ood

pressure.

Eyes:P upilsequal lyroundandreacttol ightandaccom ­

modation(P ERRLA);ex traocularm ovementsi ntact

(EOMI).
Neck:Jugul arvenousdi stention(JV D),thy romegaly,
masses,l ymphadenopathy.
Chest:E qualex pansion,ral es,breathsounds.
Heart:Regularrateandrhy thm(RRR),firstandsecond
heartsounds,m urmurs.
Breast:S kinretractions,m asses(m obile,fix ed),ery ­
thema,ax illaryorsupr aclavicularnodeenlargem ent.
Abdomen:S cars,bow elsounds,m asses,
hepatosplenomegaly,guardi ng,rebound,costovertebral
angletenderness,herni as.
Genitourinary:U rethraldi scharge,uterus,adnex a,ova­
ries,c ervix.
Extremities:C yanosis,cl ubbing,edem a.
Neurological:M entalstatus,strength,tendonrefl exes,
sensorytesti ng.
LaboratoryE valuation:E lectrolytes,gl ucose,l iverfunc­
tiontests,I NR/PTT,CB Cw ithdifferential;X -rays,E CG(if
>35y rsorcardi ovasculardi sease),uri nalysis.
AssessmentandP lan:A ssignanum bertoeachprob­
lem.D iscusseachprobl em,anddescri besurgi calpl ansfor
eachnum beredprobl em,i ncludingpreoperati vetesti ng,
laboratorystudi es,m edications,andanti biotics.

DischargeSu mmary
Patient'sN ame:

ChartNu mber:

DateofA dmission:

DateofD ischarge:

AdmittingD iagnosis:

DischargeD iagnosis:

NameofA ttendingor W ardS ervice:

SurgicalP rocedures:

HistoryandP hysicalE xaminationandLabor atory

Data:D escribethecourseofthedi seaseuptotheti me

thepati entcam etothehospi tal,anddescri bethephy sical

examandl aboratorydataonadm ission.

HospitalC ourse:D escribethecourseofthepati ent's

illnessw hilei nthehospi tal,i ncludingeval uation,treat­

ment,outcom eoftreatm ent,andm edicationsgi ven.

DischargedC ondition:D escribei mprovementordeteri o­

rationi ncondi tion.

Disposition:D escribethesi tuationtow hichthepati ent

willbedischarged(hom e,nursinghom e).

DischargedM edications:Li stm edicationsandi nstruc­

tions.

DischargedInstr uctionsandFollow-upC are:Dateof

returnforfollow -upcareatclinic;diet,ex erciseinstr uc­

tions.

ProblemLi st:Li stal lacti veandpastprobl ems.

Copies:S endcopi estoattendi ngphy sician,cl inic,con­

sultantsandreferri ngphy sician.

SurgicalPr ogressN ote

Surgicalprogressnotesarew ritteni n“S OAP”form at.

SurgicalP rogressN ote

Date/Time:
Post-operativeD ayN umber:
ProblemLi st:A ntibioticday num berand
hyperalimentationday num beri fappl icable.Li steach
surgicalprobl emseparatel y(eg,status-postappendec­
tomy,hy pokalemia).
Subjective:D escribehow thepati entfeel si nthepa­
tient'sow nw ords,andgi veobservati onsaboutthe
patient.I ndicateany new pati entcom plaints,notethe
adequacyofpai nrel ief,andpassi ngoffl atusorbow el
movements.T ypeoffoodthepati enti stol erating(eg,
nothing,cl earl iquids,regul ardi et).
Objective:
VitalSi gns:M aximumtem perature(T max)overthe
past24hours.C urrenttem perature,vi talsi gns.
IntakeandOutput: V olumeoforal andi ntrave­
nousfl uids,vol umeofuri ne,stool s,drai ns,and
nasogastricoutput.
PhysicalE xam:
Generalappear ance:A lert,am bulating.
Heart:R egularrateandrhy thm,nom urmurs.
Chest: Cleartoauscul tation.
Abdomen:B owelsoundspresent,soft,
nontender.
WoundC ondition:C ommentonthew ound
condition(eg,cl eananddry ,goodgranul ation,
serosanguinousdrai nage).C onditionofdress­
ings,purul entdrai nage,granul ationti ssue,ery ­
thema;condi tionofsutures,dehi scence.A mount
andcol orofdrai nage
Labr esults:W hitecount,hem atocrit,andel ec­
trolytes,chestx -ray
AssessmentandP lan: Evaluateeachnum bered
problemseparatel y.N otethepati ent'sgeneral condi ­
tion(eg,i mproving),perti nentdevel opments,andpl ans
(eg,advancedi ettoregul ar,chestx -ray).Foreach
numberedprobl em,di scussany addi tionalordersand
plansfordi schargeortransfer.
ProcedureNote
Aprocedurenoteshoul dbew ritteni nthechartw hena
procedurei sperform ed.P rocedurenotesarebri efopera­
tivenotes.

ProcedureN ote

Dateandtim e:
Procedure:
Indications:
PatientC onsent:D ocumentthatthei ndications,ri sks
andal ternativestotheprocedurew ereex plainedtothe
patient.N otethatthepati entw asgi ventheopportuni ty
toask questi onsandthatt hepati entconsentedtothe
procedurei nw riting.
Labtests: E lectrolytes,I NR,C BC
Anesthesia:Local w ith2% l idocaine
DescriptionofP rocedure:B rieflydescri betheproce­
dure,i ncludingsteri leprep,anesthesi am ethod,pati ent
position,devi cesused,anatom icl ocationofprocedure,
andoutcom e.
ComplicationsandE stimatedB loodLoss(E BL):
Disposition:D escribehow thepati enttol eratedthe
procedure.
Specimens:D escribeany speci mensobtai nedand
laboratorytestsw hichw ereordered.

DischargeN ote
Thedi schargenoteshoul dbew ritteni nthepati ent’schart
priortodi scharge.

DischargeN ote

Date/time:
Diagnoses:
Treatment:B rieflydescri betreatm entprovi dedduri ng
hospitalization,i ncludingsurgi calproceduresandanti ­
biotictherapy .
StudiesPe rformed:E lectrocardiograms,C Tscans.
DischargeM edications:
Follow-upA rrangements:

PostoperativeC heck
Apostoperati vecheck shoul dbecom pletedontheeve­
ningaftersurgery .T hischeck i ssi milartoadai lyprogress
note.

ExampleP ostoperativeC heck

Date/time:
PostoperativeC heck
Subjective:N oteany pati entcom plaints,andnotethe
adequacyofpai nrel ief.
Objective:
Generalappear ance:
Vitals:M aximumtem peraturei nthel ast24hours
(Tmax),currenttem perature,pul se,respi ratoryrate,
bloodpressure.
UrineOu tput: Ifuri neoutputi sl essthan30ccper
hour,m orefl uidsshoul dbei nfusedi fthepati enti s
hypovolemic.
PhysicalE xam:
Chestandlungs:
Abdomen:
WoundE xamination:T hew oundshoul dbeex ­
aminedforex cessivedrai nageorbl eeding,sk in
necrosis,condi tionofdrai ns.
DrainageV olume:N otethevol umeandcharac­
teristicsofdrai nagefrom Jack son-Prattdrai nor
otherdrai ns.
Labs:P ost-operativehem atocritval ueandother
labs.
AssessmentandP lan:A ssessthepati ent’soveral l
conditionandstatusofw ound.C ommentonabnorm al
labs,anddi scusstreatm entanddi schargepl ans.

TotalA bdominalHy sterectomyand

BilateralSalpingo-oophorectomy
OperativeR eport
PreoperativeD iagnosis:45y earol dfem ale,gravi da3

para3,w ithm enometrorrhagiaunresponsi vetom edical

therapy.

PostoperativeD iagnosis: Sameasabove

Operation:T otalabdom inalhy sterectomyandbi lateral

salpingo-oophorectomy

Surgeon:

Assistant:

Anesthesia:General endotracheal

FindingsA tS urgery:E nlarged10x 12cm uterusw ith

multiplefi broids.N ormaltubesandovari esbi laterally.

Frozensecti onreveal edbeni gn tissue.A llspeci menssent

topathol ogy.

DescriptionofOper ativeP rocedure:A fterobtai ning

informedconsent,thepati entw astak entotheoperati ng

roomandpl acedi nthesupi neposi tion,gi vengeneral

anesthesia,andpreppedanddrapedi nsteri lefashi on.

AP fannenstieli ncisionw asm ade2cm abovethe

symphysispubi sandex tendedsharpl ytotherectusfasci a.
Thefascialincisionw asbila terallyincisedw ithcurved
Mayosci ssors,andtherectussheathw asseparatedsupe­
riorlyandi nferiorlyby sharpandbl untdi ssection.T he
peritoneumw asgraspedbetw eentw oK ellycl amps,el e­
vated,andi ncisedw ithascal pel.T hepel visw asex amined
withthefi ndingsnotedabove.A B alfourretractorw as
placedi ntothei ncision,andthebow elw aspack edaw ay
withm oistl aparotomysponges.T woK ochercl ampsw ere
placedonthecornuaoftheut erusandusedforretracti on.
Theroundl igamentsonbothsi desw erecl amped,
suturedw ith#0V icryl,andtransected.T heanteri orl eafof
thebroadl igamentw asi ncisedal ongthebl adderrefl ection
tothem idlinefrom bothsi des,andthebl adderw asgentl y
dissectedoffthel oweruteri nesegm entandcervi xw itha
spongesti ck.
Theretroperi tonealspacew asopenedandtheureters
werei dentifiedbi laterally.T hei nfundibulopelvicl igaments
onbothsi desw erethendoubl ycl amped,transected,and
doublyl igatedw ith#OV icryl.E xcellenthem ostasisw as
observed.T heuteri nearteri esw eresk eletonizedbi later­
ally,cl ampedw ithH eaneycl amps,transected,andsutured
with#OV icryl.T heuterosacral l igamentsw erecl amped
bilaterally,transected,andsuturel igatedi nasi milarfash­
ion.
Thecervi xanduterusw asam putated,andthevagi nal
cuffangl esw erecl osedw ithfi gure-of-eightsti tchesof#O
Vicryl,andthenw eretransfi xedtothei psilateralcardi nal
anduterosacral l igament.T hevagi nalcuffw ascl osedw ith
aseri esofi nterrupted#OV icryl,fi gure-of-eightsutures.
Excellenthem ostasisw asobtai ned.
Thepel visw ascopi ouslyi rrigatedw ithw armnorm al
saline,andal lspongesandi nstrumentsw ererem oved.
Thepari etalperi toneumw ascl osedw ithrunni ng#2-O
Vicryl.T hefasci aw ascl osedw ithrunni ng#OV icryl.T he
skinw ascl osedw ithstabl es.S ponge,l ap,needl e,and
instrumentcountsw erecorrectti mestw o.T hepati entw as
takentotherecovery room ,aw akeandi nstabl econdi tion.
EstimatedB loodLoss(E BL):150cc
Specimens:U terus,tubes,andovari es
Drains:F oleytogravity
Fluids:U rineoutput-100ccofcl earuri ne
Complications:N one
Disposition:T hepati entw astak entotherecovery room
instabl econdi tion.

VaginalH ysterectomy
Hysterectomyi sthem ostcom monm ajoroperati onper­
formedonnonpregnantw omen.M orethanone-thi rdof
Americanw omenw illundergothis procedure.T hesurgery
maybeapproachedabdom inally,vagi nally,orasal aparo­
scopicallyassi stedvagi nalprocedure.T herati oofabdom i­
naltovagi nalhy sterectomyi sapprox imately3:1.

I. Indicationsfor hy sterectomy
A. Pelvicr elaxation
B. Leiomyomata
C. Pelvicpai n(eg,endom etriosis)

D. Abnormaluteri nebl eeding

E. Adnexalm ass

F. Cervicali ntraepithelialneopl asia

G.E ndometrialhy perplasia

H. Malignancy

I. Pelvicrel axationi sthem ostcom moni ndicationand

accountsfor45percentofvagi nalhy sterectomies,
whilel eiomyomataarethem ostcom moni ndication
(40percent)fortheabdom inalprocedure.
II. Routeofhy sterectomy
A. Vaginalhy sterectomyi susual lyrecom mendedfor
womenw ithbeni gndi seaseconfi nedtotheuterus
whentheuteri new eighti sesti matedatl essthan280
g.I ti sthepreferredapproachw henpel vicfl oorrepai r
istobecorrectedconcurrentl y.
B. Contraindicationstohy sterectomy:
1. Lacko fu terinem obility
2. Presenceofanadnex alm assrequi ringrem oval
3. Contractedbony pel vis
4. Needtoex ploretheupperabdom en
5. Lackofsurgi calex pertise
C. Vaginalhy sterectomyi sassoci atedw ithfew ercom ­
plications,shorterl engthofhospi talization,andl ower
hospitalchargesthanabdom inalhy sterectomy.
III. Vaginalh ysterectomyo perativep rocedure
A. Aprophy lacticanti bioticagent(eg,cefaz olin[A ncef]
1gI V)shoul dbegi venasasi ngledose30m inutes
priortothefi rsti ncisionforvagi nalorabdom inal
hysterectomy.
B. Vaginalhy sterectomy
1. Thepati entshoul dbepl acedi nthedorsal
lithotomyposi tion.W henadequateanesthesi ai s
obtained,abi manualpel vicex aminationi sper­
formedtoassessuterinem obilityanddescentand
toconfi rmthatnounsus pectedadnex aldi seasei s
found.A fi naldeci sioncanthenbem adew hether
toproceedw ithavagi nalorabdom inalapproach.
 2. Thepati enti spreparedanddraped,andbl adder
catheterm aybei nserted.A w eightedspecul umi s
placedi ntotheposteri orvagi na,aD eaverorri ght
angleretractori sposi tionedanteri ortothecervi x,
andthentheanteri orandposteri orl ipsofthecer­
vixaregraspedw ithasi ngle-ordoubl e-toothed
tenaculum.
3. Tractioni spl acedonthecervi xtoex posethepos­
teriorvaginalm ucosa.UsingM ayoscissor s,the
posteriorcul -de-saci senteredsharpl y,andthe
peritoneumi dentified.A fi gure-of-eightsuturei s
thenusedtoattachtheperi toneumtotheposteri or
vaginalm ucosa.
4. AS teiner-Anvardw eightedspecul umi si nserted
intotheposteri orcul -de-sacafterthi sspacei s
opened.T heuterosacral l igamentsarecl amped,
withtheti pofthecl ampi ncorporatingthel ower
portionofthecardi nall igaments.T hecl ampi s
placedperpendi culartotheuteri neax is,andthe
pediclecutsothattherei s0.5cm ofti ssuedi stal
tothecl amp.A transfi xionsuturei sthenpl acedat
theti pofthecl amp.Oncel igated,theuterosacral
ligamentsaretransfi xedtotheposteri orl ateral
vaginalm ucosa.T hissuturei shel dw itha
hemostat.
5. Downwardtracti oni spl acedonthecervi xtopro­
videcountertracti onforthevagi nalm ucosaand
theanteri orvagi nalm ucosai si ncisedatthel evel
ofthecervi covaginalj unction.T hebl adderi sad­
vancedupw ardusi nganopen,m oistenedgauz e
sponge.A tthi spoi nt,thevesi covaginalperi toneal
reflectioni susual lyi dentifiedandcanbeentered
sharplyusi ngsci ssors.A D eaverorH eaneyretrac­
tori spl acedi nthem idlinetok eepthebl adderout
oftheoperati vefi eld.B luntorsharpadvancem ent
ofthebl addershoul dprecedeeachcl amppl ace­
mentunti lthevesi covaginalspacei sentered.
6. Thecardi nall igamentsarei dentified,cl amped,
cut,andsuturel igated.T hebl adderi sadvanced
outoftheoperati vefi eldusi ngbl untdi ssection
technique.T heuteri nevessel sarecl ampedto
incorporatetheanteri orandposteri orl eavesofthe
visceralperi toneum.
7. Theanteri orperi tonealfol di snow vi sualized,and
theanteri orcul -de-saccanbeentered.T he
peritonealrefl ectioni sgraspedw ithsm oothfor­
ceps,tented,andopenedw ithsci ssorsw iththe
tipspoi ntedtow ardtheuterus.A H eaneyor
Deaverretractori spl acedi ntothi sspacetopro­
tectthebl adder.
8. Theuteri nefundusi sdel iveredposteri orlyby pl ac­
ingatenacul umontheuteri nefundusi nsucces­
sivebi tes.A ni ndexfi ngeri susedtoi dentifythe
utero-ovarianl igamentandai di ncl amppl ace­
ment.T herem ainderoftheutero-ovari anl iga­
mentsarecl ampedandcut.T hepedi clesare
double-ligatedfi rstw ithasutureti eandfol lowed
byasuturel igaturem edialtothefi rstti e.
IV. Dischargeinstr uctions
A. Thew omani sencouragedtoresum ehernorm al
dailyacti vitiesasqui cklyasi scom fortable.W alking
andstai rcl imbingareencouraged;tubbathsor
showersareperm issible.
B. Thepati entshoul davoi dl iftingover20l bofw eight
forfourtosix w eeksaftersurgery tom inimizestress
ontheheal ingfasci a.V aginali ntercoursei sdi scour­
agedduri ngthi speri od.D rivingshoul dbeavoi ded
untilfullm obilityreturns andnarcoticanalgesiaisno
longerrequi red.

EndometrialSamplingandDilation
andCurettage

Theendom etrialcavi tyi sfrequentl yeval uatedbecauseof

abnormaluterinebleedi ng,pelvicpain,infertility ,orpreg­
nancycom plications.T hem ostcom mondi agnostici ndica­
tionsforobtai ningendom etrialti ssuei ncludeabnorm al
uterinebl eeding,postm enopausalbl eeding,endom etrial
dating,endom etrialcel lsonP apanicolaousm ear,and
follow-upofw omenundergoi ngm edicaltherapy for
endometrialhy perplasia.

I. Endometrialbi opsy
A. Theoffi ceendom etrialbi opsyoffersanum berof
advantagestoD &Cbecausei tcanbedonew ith
minimaltonocervi caldi lation,anesthesi ai snotre­
quired,andthecosti sapprox imatelyone-tenthofa
hospitalD&C.
B. Numerousstudi eshaves hownthattheendom etrium
isadequatel ysam pledw iththesetechni ques.
C. Pipelleen dometrialsam plingd eviceisthem ost
popularm ethodforsam plingtheendom etriall ining.
Thedevi cei sconstructedoffl exiblepol ypropylene
withanoutersheathm easuring3.1m mi ndi ameter.
D. Thedevi cei spl acedi ntheuterusthroughan
undilatedcervi x.T hepi stoni sful lyw ithdrawntocre­
atesucti onand,w hilethedevi cei srotated360de­
grees,thedi stalporti sbroughtfrom thefundustothe
internalostow ithdrawasam ple.T hedevi cei sre­
movedandthedi stalaspectofthei nstrumenti ssev­
ered,al lowingfortheex pulsionofthesam plei nto
formalin.
 E. Thedetecti onratesforendom etrialcancerby P ipelle
inpostm enopausalandprem enopausalw omenare
99.6and91percent,respecti vely.
F. D&Cshoul dbeconsi deredw hentheendom etrial
biopsyi snondi agnostic,butahi ghsuspi cionofcan­
cerrem ains(eg,hy perplasiaw ithaty pia,presenceof
necrosis,orpy ometra).
II. Dilationan dcu rettage
A. Dilationandcurettageisperfo rmedaseitheradiag­
nosticortherapeuti cprocedure.I ndicationsfordi ag­
nosticD &Ci nclude:
1. Anondi agnosticoffi cebi opsyi nw omenw hoareat
highri skofendom etrialcarci noma.
2. Insufficientti ssueforanal ysisonoffi cebi opsy.
3. Cervicalstenosi spreventsthecom pletionofan
officebi opsy.
B. DiagnosticD &Csareusual lyperform edw ith
hysteroscopytoobtai navi suali mageofthe
endometrialcavi ty,ex cludefocal di sease,andpre­
ventm issingunsuspectedpol yps.
C. Examinationunder anesthesia .A fteranesthesi a
hasbeenadm inistered,thesi ze,shape,andposi tion
oftheuterusarenoted,w ithparti cularattenti ontothe
axisofthecervi xandfl exionofthefundus.T hesi ze,
shape,andconsi stencyof theadnex aaredeter­
mined.T heperi neum,vagi na,andcervi xarethen
preparedw ithanasepti csol utionandvagi nalretrac­
torsarei nsertedi ntothevagi na.
D. Operativetechnique .A D& Cisperform edw iththe
womani nthedorsal l ithotomyposi tion.
1. Endocervicalcur ettage(E CC)i sperform edbe­
foredi lationofthecervi x.A K evorkian-Younge
curettei si ntroducedi ntothecervi calcanal upto
thei nternalos.C urettingofal lfourquadrantsof
thecanal shoul dbec onductedandthespeci men
placedonaT elfapad.
2. Soundinganddi lation.T ractioni sappl iedtoal ign
theax isofthecervi xandtheuteri necanal .T he
uterusshoul dbesoundedtodocum entthesi ze
andconfi rmtheposi tion.T hesoundshoul dbe
heldbetw eenthethum bandthei ndexfi ngerto
avoidex cessivepressure.
3. Cervicaldilation i sthenperform ed.T hedi latori s
graspedi nthem iddleofthei nstrumentw iththe
thumbandi ndexfi nger.T hecervi xi sgradual ly
dilatedbegi nningw iththe#13FrenchP rattdi lator.
Thedi latorshoul dbei nsertedthroughthei nternal
os,w ithoutex cessivelyenteri ngtheuteri necavi ty.
4. Sharpcur ettagei sperform edsy stematicallybe­
ginningatthefundusandappl yingevenpressure
ontheendom etrialsurfaceal ongtheenti rel ength
oftheuterustothei nternalcervi calos.T he
endometrialti ssuei spl acedonaT elfapadpl aced
inthevagi na.M ovingaroundtheuterusi nasy s­
tematicfashi on,theenti resurfaceofthe
endometriumi ssam pled.T hecurettageprocedure
iscom pletedw henthe" uterinecry "(gri ttinessto
palpation)i sappreci atedonal lsurfacesofthe
uterus.C urettagei sfol lowedby bl index traction
withR andallpol ypforcepstoi mprovetherateof
detectionofpol yps.
General Gynecology
ManagementoftheA bnormal
PapanicolaouSmear
TheP apanicolaousm eari sascreeni ngtestforabnorm ali­
tiesthati ncreasestheri sk ofcervi calcancer.T reatment
decisionsarebasedupontheresul tsofcol poscopically
directedbi opsiesofthecervi x.P apanicolaousm earreports
arecl assifiedusi ngtheB ethesdaS ystem,w hichw asre­
visedi n2001.

I. PapSme arRe port

Bethesda2001P apS mearR eport

InterpretationR esult
Negativefori ntraepitheliall esionorm alignancy(w hen
therei snocel lularevi denceofneopl asia,statethi si n
theGeneral C ategorizationaboveand/ori ntheI nter­
pretation/Resultsecti onofthereport,w hetherthereare
organismsorothernon-neopl asticfi ndings)
Infection(T richomonasvagi nalis,C andidaspp.,shi ft
infl orasuggesti veofbacteri alvagi nosis,
Actinomycesspp.,cel lularchangesconsi stentw ith
Herpessim plexvir us)
OtherN on-neoplasticFi ndings(O ptionaltor eport;
listn otin clusive):
Reactivecel lularchangesassoci atedw ithi nflamma­
tion(i ncludesty picalrepai r)radi ation,i ntrauterine
contraceptivedevi ce(I UD)
Glandularcel lsstatuspost-hy sterectomy
Atrophy
Other
Endometrialcel ls(i naw oman> 40y earsofage)
(specifyi f" negativeforsquam ousi ntraepithelial
lesion")
EpithelialCellA bnormalities
SquamousCell
Atypicalsquam ouscel ls
-ofundeterm inedsi gnificance(A SC-US)
-cannotex cludeH SIL(A SC-H)
Low-gradesquam ousi ntraepitheliall esion(LS IL)
encompassing:H PV/milddy splasia/CIN1
High-gradesquam ousi ntraepitheliall esion(H SIL)
encompassing:m oderateandsevere
dysplasia,C IS/CIN2andC IN3w ithfeatures
suspiciousfor invasi on( ifinvasionissus­
pected)
Squamouscel lcarci noma
GlandularC ell
Atypical
-Endocervicalcel ls(nototherw isespeci fiedor
specifyi ncom ments)
-GlandularC ell (nototherw isespeci fiedor
specifyi ncom ments)
-Endometrialcel ls(nototherw isespeci fiedor
specifyi ncom ments)
-Glandularcel ls(nototherw isespeci fiedor
specifyi ncom ments)
Atypical
-Endocervicalcel ls,favorneopl astic
-Glandularcel ls,favorneopl astic
Endocervicaladenocarci nomai nsi tu
Adenocarcinoma(endocervi cal,endom etrial,
extrauterine,nototherw isespeci fied(notother­
wisespeci fied)
OtherM alignantN eoplasms(speci fy)

II. Screeningfor cer vicalcancer

A. RegularP apsm earsarerecom mendedforal l
womenw hoareorhavebeensex uallyacti veand
whohaveacervi x.
B. Testingshoul dbegi nw henthew omanfi rstengages
insex uali ntercourse.A dolescentsw hosesex ual
historyi sthoughttobeunrel iableshoul dbepre­
sumedtobesex uallyacti veatage18.
C. Papsm earsshoul dbeperform edatl eastevery 1to
3y ears.T estingi susual lydi scontinuedafterage65
inw omenw hohavehadregul arnorm alscreeni ng
tests.W omenw hohavehadahy sterectomy,i nclud­
ingrem ovalofthecervi xforreasonsotherthancervi ­
calcancerori tsprecursors,donotrequi reP aptest­
ing.
III. Techniquesu sedin ev aluationo fth eab normal
papsm ear
A. Colposcopyal lowsex aminationofthel owergeni tal
tracttoi dentifyepi thelialchanges.A bnormalareas
shouldbetargetedforbi opsytodeterm ineapatho­
logicdi agnosis.
B. Humanp apillomavirustestin g
1. HPVi nfectioni sthel eadingeti ologicagenti nthe
developmentofprem alignantandm alignantl ower
genitaltractdi sease.P remenopausalw omenw ho
testposi tiveforcertai nty pesofH PVareathi gher
riskofcervi caldy splasia(H PVposi tive),w hile
thosew hoareH PVnegati veorhavety pesof
HPVD NAofl owoncogeni cpotenti alareatl ow
risk.
2. Them ostcom monlyusedH PVtesti stheH ybrid
CapturellHPVDNAAssa y( HCll) ,w hichte stsfo r
 high-riskH PVty pes16,18,31,33,35,39,45,51,
52,56,58,59,and68.H igh-riskH PVty pes16
and18arethevi rusesm ostfrequentl yi solatedi n
cervicalcancerti ssue.
IV. Atypicalsquam ouscells
A. Atypicalsq uamouscellso fu ndeterminedsig nifi­
cance(A SCUS)i sfurtherdi videdi ntoA SC-US,
whicharequal ifiedas" ofundeterm inedsi gnificance,"
andA SC-H,i nw hichahi gh-gradesquam ous
intraepitheliall esion(H SIL)cannotbeex cluded.
B. ASCrequi resfurthereval uation.T hiscy tologicdi ag­
nosisi scom monandfrequentl yassoci atedw ith
spontaneouslyresol ving,sel f-limiteddi sease.H ow­
ever,5to17percentofpati entsw ithA SCand24to
94p ercento fth osew ithASC- Hw illh aveCI NI Io rI II
atbi opsy.
C. Womenwit hA SC-US
1. Managementofm inimallyabnor malcer vical
cytologysm ears(A SC-US):
a. Ifl iquid-basedcy tologyi sused,refl extesti ngfor
HPVshoul dbeperform ed,al ternatively
cocollectionforH PVD NAtesti ngcanbedone
attheti meofaconventi onalcervi calcy tology
smear.
b. Colposcopyshoul dperform edi fhum an
papillomaviruste stingisp ositive.T hirtyto 6 0
percento fw omenw ithASCw illte stp ositivefo r
high-riskH PVty pesandrequi rei mmediate
colposcopy.
2. Patientsw ithaposi tivehi gh-riskty peH PVD NA
testshoul dbeeval uatedby col poscopy;thosew ith
anegati vetestm aybetri agedtorepeatcy tologic
evaluationi n12m onths.M anagementofw omen
whotestposi tiveforhi gh-riskH PVty pes,buthave
noC INconsi stsofei ther1)cy tologicaltesti ngre­
peatedi nsi xand12m onthsw ithcol poscopiceval ­
uationofA SC-USorgreateror2)H PVtesti ng
repeatedi n12m onthsw ithcol poscopyi fH PV
resultsareposi tive.
V. Specialcir cumstances
A. Whenan in fectiouso rganismisid entified,the
patientshoul dbecontact edtodeterm inei fshei s
symptomatic.A ntibiotictherapy i si ndicatedforsy mp­
tomaticinfection.
B. Reactivechangesduetoinflam mationareusual ly
notassoci atedw ithanorgani smontheP apsm ear.
TheP apsm eardoesnotneedtoberepeatedunl ess
thepati enti sH IVposi tive,i nw hichcasei tshoul dbe
repeatedi nfourtosi xm onths.
C. Atrophicepi theliumi sanorm alfi ndingi n
postmenopausalw omen.
1. Administrationofestrogencausesaty picalatro­
phic,butnotdy splastic,epi theliumtom aturei nto
normalsquam ousepi thelium.
2. Hormonaltherapy gi venforvagi nalatrophy shoul d
befol lowedby repeatcervi calcy tologyonew eek
aftercom pletingtreatm ent.I fnegati ve,cy tology
shouldberepeatedagai ni nfourtosi xm onths.I f
bothtestsarenegati ve,thew omancanreturnto
routinescreeni ngi ntervals,buti fei thertesti sposi ­
tiveforA SC-USorgreater,sheshoul dbeeval u­
atedw ithcol poscopy.
D. Immunosuppressedwom en,i ncludingal lw omen
whoareH IVposi tive,w ithA SC-USshoul dbere­
ferredfori mmediatecol poscopy,i nsteadofH PV
testing.
E. ASC-USwithabsenceofC INonbiopsy .I f
colposcopicex aminationdoesnotshow C IN,then
follow-upcy tologicaltesti ngshoul dbeperform edi n
12m onths.
F. ASC-USwit hb iopsyp rovenCIN.S incespontane­
ousregressi oni sobservedi napprox imately60per­
centofC INl ,ex pectantm anagementw ithseri alcy to­
logicsm earsatthreetofourm onthi ntervalsi srea­
sonablefortherel iablepati ent.
G. Womenwith A SC-H.A llw omenw ithA SC-Hon
cytologicalex aminationshoul drecei vecol poscopy.I f
repeatofcy tologyconfi rmsA SC-Hbutbi opsyi sneg­
ativeforC IN,fol low-upcy tologyi nsi xand12m onths
orH PVD NAtesti ngi n12m onthsi srecom mended.
Colposcopyshoul dberepeatedforA SCorgreateron
cytologyoraposi tivetestforhi ghri skH PVD NA.
BiopsyprovenC INi streated,asappropri ate.
VI. Low-an dh igh-gradein traepithelialn eoplasia
A. Low-gradesq uamousin traepitheliallesio ns (LSIL)
mayal sobereferredtoasC INI orm ilddy splasia.
Immediatereferral forcol poscopyi stherecom ­
mendedm anagementforLS IL.E ndocervicalsam ­
plingshoul dbedonei nnonpregnantw omeni nw hom
thetransform ationz onecannotbeful lyvi sualizedora
lesionex tendsi ntotheendocervi calcanal .
Endocervicalsam plingal soshoul dbedonei n
nonpregnantw omenw hennol esioni si dentifiedon
colposcopy.
1. IfnoC INi si dentifiedfol lowingsati sfactoryorun­
satisfactorycol poscopyandbi opsies,thenopti ons
forfol low-upi ncludeei ther:
a. Repeatcy tologytesti ngatsi xand12m onths,or
b. HPVD NAtesti ngat12m onths
2. Referralforrepeatcol poscopyi srequi redi fcy tol­
ogyy ieldsA SCorgreaterorH PVD NAi sposi tive
forahi gh-riskty pe.
3. Womenw ithhi stologicallyconfi rmedC INI LS IL
maybetreatedw ithabl ationorex cisionorfol lowed
 withseri alcy tologicsm earsevery threetosi x
monthsi ftheenti rel esionandl imitsofthetransfor­
mationz onearecom pletelyvi sualized.LS ILcon­
finedtotheendocervi calcanal m aybefol lowed
withrepeatsm earsobtai nedw ithacy tobrushand
withE CC.
4. Postmenopausalwom en.P ostmenopausal
womenm aybem anagedby seri alcy tologyatsi x
and12m onthsorH PVD NAtesti ngat12m onths
withreferraltocolposcopy forpositiveresults.
Womenw ithatrophy aretreatedw ithi ntravaginal
estrogenfol lowedby repeatcy tologysevenday s
aftercom pletionoftherapy ,w ithreferralto
colposcopyi fanabnorm alitypersi sts.I frepeat
cytologyi snorm al,thenanothercy tologytest
shouldbeobtai nedi nfourtosi xm onths.T he
womancanreturntorouti nesurvei llancei fboth
testsarenorm al,butshoul dbereferredfor
colposcopyi fei thertesti sposi tive.
5. Adolescents.I nitialcol poscopym aybedeferredi n
adolescents.I nstead,they m aybem anagedw ith
serialcy tologyatsi xand12m onthsorH PVD NA
testingat12m onthsw ithreferral tocol poscopyfor
positiver esults.
6. Pregnantw omen.C olposcopyshoul dbeper­
formed,w ithbi opsyandendocervi calcurettage
performedforany l esionsuspi ciousforH SILor
moreseveredi sease.
B. High-gradesquam ousintr aepitheliallesions
1. Ahi gh-gradesquam ousi ntraepitheliall esion
(HSIL)m aya lsob er eferredt oa sC INIIo rIII, se ­
veredy splasia,orcarci nomai nsi tu(C IS).Oneto
twopercentofw omenw ithH SILonacy tologic
smearhavei nvasivecancerattheti meoffurther
evaluationand20percentofw omenw ithbi opsy­
provenCI Sw illd evelopa nin vasiveca ncerifle ft
untreated.A llw omenw ithH SILshoul dbereferred
forcol poscopyandendocervi calsam pling.
C. Follow-upev aluation. Papsm earsarerecom ­
mendedevery threetofourm onthsforthefi rsty ear
aftertreatm entfordy splasia.W omenw ithcervi cal
dysplasiapr esentatthe LEEPor c onem arginor in
theconcom itantE CCal soneedafol low-up
colposcopyw ithendocervi calcurettageevery si x
monthsforoney ear.Rout inesurveillancecanbe
resumedi ftherei snorecurrenceafterthefi rsty ear.
Surveillanceconsi stsofP apsm earsonay earlybasi s
form ostw omen,andonatw ice-yearlybasi sforhi gh­
riskw omen(i e,H IVposi tive).
VII. Abnormalg landularcells
A. Areportofaty picalgl andularcel ls(A GC)i ndicates
thepresenceofgl andularcel lsthatcoul dbecom ing
fromtheendocervi calorendom etrialregi on.T he
Bethesda2001sy stemcl assifiesA GCi ntotw osub­
categories:
1. AGCendocervi cal,endom etrial,ornototherw ise
specified(N OS)
2. AGCfavorneopl asia,endocervi calorN OS
B. Additionalcategori esforgl andularcel labnorm alities
are:
1. Endocervicaladenocarci nomai nsi tu(A IS)
2. Adenocarcinoma
C. EvaluationofA GCor A ISoncer vicalcy tology:
Thesew omenshoul dbereferredforcol poscopyand
samplingoftheendocervi calcanal .W omenoverage
35andy oungerw omenw ithA GCandunex plained
vaginalbl eedingal soneedanendom etrialbi opsy.
Womenw ithonl yaty picalendom etrialcel lsoncy tol­
ogycanbei nitiallyeval uatedw ithendom etrialbi opsy.

D. Endometrialcellsin wo men> 40y earsofage:

Endometrialbi opsyshoul dbeperform ed.
References:S eepage166.

CervicalIntraepithelialNeoplasia
Cervicali ntraepithelialneopl asiareferstoaprei nvasive
precursorofcervi calcancer w hichcanbeeasi lydetected
andtreated.Over50,000new casesofcarci nomai nsi tu
aredi agnosedannual ly.T hepreval enceofC INvari esfrom
asl owas1.05percenti nfam ilypl anningorgeneral gy ne­
cologycl inicstoashi ghas13.7percenti nsex uallytrans­
mitteddi seasecl inics.

I. Nomenclature
A. Cervicali ntraepithelialneopl asia(C IN)di videsthe
epithelialth icknessin toth irds.
1. CINI referscel lulardy splasiaconfi nedtothe
basalthi rdoftheepi thelium.
2. CINI Ireferstol esionsconfi nedtothebasal tw o­
thirdsoftheepi thelium.
3. CINIIIr eferst oce llulard ysplasiae ncompassing
greaterthantw o-thirdsoftheepi thelialthi ckness,
includingful l-thicknessl esionsprevi ouslyterm ed
CIS.
B. Histologicallyeval uatedl esionsaregradedusi ngthe
CINnom enclature,w hilecy tologicsm earsarecl assi­
fiedaccordi ngtotheB ethesdasy stem.
II. Epidemiologyan dp athogenesis
A. CINi sty picallydetectedatanage10to15y ears
youngerthanthatreportedfori nvasivecervi calcarci ­
noma.T hedi agnosisofC INi susual lym adei n
womeni nthei r20s,carci nomai nsi tui sdi agnosedi n
 women25to35y earsofage,andi nvasivecancer
aftertheageof40.
B. Humanp apillomavirus(H PV)i nfectioni sthel ead­
ingcauseofprem alignantandm alignantl owergeni ­
taltractdi sease.H PVi sfoundi n70-78percentof
patientsw ithC INI andi n83-89percentofC INI I/III.
RiskfactorsforC INi ncludesex ualacti vityatanearl y
age,hi storyofsex uallytransm itteddi seases,m ultiple
sexualpartners,orsex ualacti vityw ithprom iscuous
men.Otherri skfactorsi ncludeci garettesm oking,
multiparity,andi mmunodeficiency.
III. Diagnosis
A. Womenarety picallyscreenedforC INby cervi cal
cytology(eg,di rectP apanicolaousm ear,T hinPrep).
B. Abnormalcy tologyresul tsshoul dbefurthereval u­
ated.E valuationofthecervi xfol lowingabnorm al
cytologyresul tsi ncludesvi suali nspection,repeat
cytology,col poscopy,di rectedbi opsy,and
endocervicalcurettage.
IV. Colposcopy
A. Colposcopyi sthepri marytechni queforeval uationof
abnormalcy tology.A bnormalareasoftheepi thelium
turnw hitefol lowingtheappl icationofdi luteaceti c
acid.Capillariesm aybei dentifiedw ithintheabnor­
malepi thelium.H igh-gradel esionstendtohavea
coarservesselpatternandla rgerintercapillary dis­
tance.A bnormalareascanbetargetedforbi opsy.
B. Indicationsfor colposcopy :
1. Abnormalcervi calcy tologysm ear
2. Abnormalfi ndingsonadj unctivescreeni ngtech­
niques,suchasH PVtesti ngorcervi cography
3. Clinicallyabnorm alorsusp iciouslook ingcervix
4. Unexplainedi ntermenstrualorpostcoi talbl eeding
5. Vulvarorvagi nalneopl asia
C. Technique
1. Ar epeatcer vicalcy tologysm eari sperform ed
priortocol poscopyi fm orethanthreem onths
haveel apsedsi ncethei ndexsm ear.
2. Thecer vixiscleansedandm oistenedw ithnor­
malsal ineandvi sualizedthroughthecol poscope.
Whitel esionsarerecordedasl eukoplakiaona
diagramofthecervi x.
3. Agr een-filterexam inationi sperform edtoen­
hancethevascul ararchi tectureanddetectaty pi­
calvessels.
4. Aceticacid3-5% i sappl iedw ithcottonsw absfor
30secondstostai nthecervi x.A reasof
acetowhiteepi theliumandabnorm alvascul ar
patternsarenoted.
5. Iftheenti retransform ationz oneand
squamocolumnarj unctioncanbevi sualized,the
colposcopyi ssati sfactory;otherw ise,i ti sunsati s­
factory.
6. Biopsies areobtai nedfrom theareasw iththe
mostsevereabnorm alities,i ncludingl eukoplakia,
atypicalvessel s,acetow hiteepi thelium,puncta­
tions,andm osaicism.B leedingcanbecontrol led
withM onsel'ssol utionorsi lverni trateappl ication.
7. Endocervicalcur ettageshoul dbeperform ed.
V. Managemento fcer vicalin traepithelialn eoplasia
A. Womenwith aty picalsq uamouscells(A SC)o r
low-gradesq uamousin traepitheliallesio ns
(LGSILo rL SIL)
1. Minimallyabnor malcer vicalcy tology.At ypical
squamouscel ls(A SC)orl ow-gradesquam ous
intraepitheliall esions(LGS ILorLS IL)i scom mon
andfrequentl yassoci atedw ithspontaneousl y
resolving,sel f-limiteddi sease.H owever,9to19
percento fp atientsw ithASCo rL GSILw illh ave
CINIIo rIIIa tco lposcopy.
2. Atypicalsquam ouscel lsrequi resfurthereval ua­
tionandtreatm entm aybei nitiatedi ftherei sbi ­
opsyprovendy splasia.
B. LSIL/CINI
1. Sincespontaneousregressi oni sobservedi n
morethan60percentofbi opsy-confirmedC INI
(milddy splasia),ex pectantm anagementw ith
serialcy tologicsm earsatthreetofourm onthi n­
tervalsm aybethepreferabl em anagementforthe
reliablepati ent.R epeatcol poscopyi srequi redfor
anyabnorm alcervi calcy tologysm ear.A l esion
thatpersi stsafter1to2y earsorany progressi on
duringthefol low-upperi odsuggeststheneedfor
treatment.
2. Somew omenm ayel ecttohaveabl ationorex ci­
sionofthel esiontorel ieveanx iety.
C. HSIL
1. Womenw ithhi ghgradesquam ousi ntraepithelial
lesions(H GSILorH SIL)oncervi calcy tology
smearareeval uatedby col poscopy,endocervi cal
curettage(E CC),anddi rectedbi opsies.T reatment
mayi ncludeproceduresthatabl atetheabnorm al
tissueanddonotproduceaspeci menforaddi ­
tionalhi stologiceval uationorproceduresthat
excisetheareaofabnorm ality,al lowingforfurther
histologicstudy .A nassessm enthastobem ade
astow hetherapati entqual ifiesforabl ativether­
apyori fsherequi resconi zationforex cisionand
furtherdi agnosticeval uation.
2. Requirementsfor ablativ etr eatment:
a. Accuratehi stologicdi agnosis/nodi screpancy
betweenP ap/colposcopy/histology
b. Noevi denceofm icroinvasion/invasion
 c. Noevi denceofgl andularl esion
(adenocarcinomai nsi tuori nvasive
adenocarcinoma)
d. Satisfactorycol poscopy(thetransform ation
zonei sful lyvi sualized)
e. Thel esioni sl imitedtotheectocervi xandseen
initse ntirety
f. Therei snoevi denceofendocervi cali nvolve­
mentasdeterm inedby col poscopy/ECC
3. Them ostcom monlyusedabl ativetreatm enttech­
niquesarecry otherapyandl aserabl ation.
4. Indicationsfor conizationar e:
a. Suspectedm icroinvasion
b. Unsatisfactorycol poscopy(thetransform ation
zonei snotful lyvi sualized)
c. Lesionex tendingi ntoendocervi calcanal
d. ECCreveal ingdy splasia
e. Lackofcorrel ationbetw eentheP apsm earand
colposcopy/biopsies
f. Suspectedadenocarci nomai nsi tu
g. Colposcopistunabl etorul eouti nvasivedi s­
ease
5. Excisionaltreatm entcanbeperform edby col d
knifeconi zationusi ngascal pel,l aserconi zation,
orthel oopel ectrosurgicalex cisionprocedure
(LEEP),alsocalledlar geloopex cisionofthe
transformationz one(LLE TZ).
D. Specificther apeutictechniques
1. Commontechniquesfor tr eatmentofC IN:
a. Cryotherapy(ni trousox ideorcarbondi oxide)
b. Loopelectr osurgicalex cisionpr ocedure (LEEP,
LLETZ).
c. Carbondi oxide(C O2)l aserabl ation
d. Excisional(col dk nife)coni zation
e. Carbondi oxidel aserconeex cision
2. Thetechni quesareofequal effi cacy,averagi ng
approximately90percenteffi cacy.
3. Cryotherapy
a. Cryotherapyconsi stsoftheappl icationofa
super-cooledprobedi rectlytothecervi call e­
sionusi ngtw ocool ingandthaw ingcy cles.T he
probem ustbeabl etocovertheenti rel esion
andthel esioncannotex tendi ntothe
endocervicalcanal .
b. Them ultiplecy clefreez e-thaw-freezetech­
niqueshoul dbeused,andthebl anching
shouldex tendatl east7to8m mbey ondthe
edgeofthecry o-probetoreachtheful ldepthof
thecervi calcry pts.M ildcram pingaccom panies
theprocedure.
c. Theadvantagesofthi sapproachi ncludel ow
costandal owcom plicationrate.D isadvan­
tagesareacopi ousvagi naldi schargel asting
forw eeksandal ackofti ssueforhi stology.
4. Loopelectr osurgicalexcisionpr ocedure
a. Thel oopel ectrosurgicalex cisionprocedure
(LEEPor LLET Z)hasbecom etheappr oachof
choicefortreati ngC INI Iand IIIb ecauseo fi ts
easeofuse,l owcost,andhi ghrateofsuccess.
Itcanbeperform edi ntheoffi ceusi ngl ocal
anesthesia.
b. Theprocedureusesaw irel oopthroughw hich
anel ectricalcurrenti spassed.T hetransform a­
tionz oneandl esionareex cisedtoavari able
depth,w hichshoul dbeatl east8m m,and
extending4to5m mbey ondthel esion.A n
additionalendocervi calspeci meni sfrequentl y
removedtoal lowhi stologiceval uation.
E. Adenocarcinomainsitu
1. TheB ethesda2001sy stemcl assifiesgl andular
cellabnorm alitiesi ntofoursubcategori es:
a. Atypicalgl andularcel lsendocervi cal,
endometrial,ornototherw isespeci fied(N OS)
b. Atypicalgl andularcel lsfavorneopl astic,
endocervicalorendom etrial
c. Endocervicaladenocarci nomai nsi tu(A IS)
d. Adenocarcinoma
2. Thecategori esA GCfavorneopl asiaandA IS
haveasom ewhathi gherl ikelihoodofbei ngasso­
ciatedw ithsi gnificantdi seasethanA GCN OS.
3. AISi saprecursorofadenocarci nomaofthecer­
vix.T hedi agnosisi sbaseduponhi stology.T he
lesionm aybel ocatedhi ghi ntheendocervi cal
canal.
4. Thei ncidenceofresi dualA ISori nvasive
adenocarcinomafol lowingconi zationforA ISi s
high.I fconi zationm arginsareposi tive,repeat
conizationshoul dbeperform edi npati entsw ho
wishto m aintainfe rtility.I ffe rtilityisn otd esired,
hysterectomyshoul dbeperform edasthedefi ni­
tivetherapeuti ci ntervention.
F. Follow-up
1. Patientsw ithp ositivem arginsa fterL EEPo rco ld
knifeconi zationareati ncreasedri skforresi dual
disease.
2. Carefulclin icalfo llow-upw ithcy tologya nd
colposcopy/biopsy(w heni ndicated)i nw omenw ith
positivem argins,i nsteadofi mmediate
retreatment,i sappropri atei npati entsw hoare
compliantw ithfrequentm onitoring.C ytologicas­
sessmentshoul dbeconti nuedatthreem onth
intervalsunti lnorm alforoney earaftertherapy
andy earlythereafter.
References:S eepage166.
Contraception
Approximately31percentofbi rthsareuni ntended;about
22percentw ere" mistimed,"w hile9percentw ere" un­
wanted."

I. Sterilization
A. Sterilizationisthem ostcom monandeffectiveform
ofcontracepti on.W hiletubal l igationandvasectom y
maybereversi ble,these proceduresshoul dbecon­
sideredperm anent.
B. Essurem icroinsertster ilizationd evicei saperm a­
nent,hy steroscopic,tubal sterilizationdevicew hichis
99.9percenteffecti ve.T hecoi l-likedevi cei si nserted
intheoffi ceunderl ocalanesthesi ai ntothefal lopian
tubesw herei ti si ncorporatedby ti ssue.A fterpl ace­
ment,w omenuseal ternativecontracepti onforthree
months,afterw hichhy sterosalpingographyi sper­
formedtoassurecorrectpl acement.P ostoperative
discomforti sm inimal.
C. Tuball igationi susual lyperform edasal aparo­
scopicprocedurei noutpati entsori npostpartum
womeni nthehospi tal.T hetechni quesusedare
unipolarorbipol arcoagulation,siliconerubberband
orspri ngcl ipappl ication,andparti alsal pingectomy.
D. Vasectomy(l igationofthevasdeferens)canbe
performedi ntheoffi ceunderl ocalanesthesi a.A
semenanal ysisshoul dbedonethreetosi xm onths
aftertheproceduretoconfi rmaz oospermia.
II. Oralcontr aceptives
A. Combined(estrogen-progesti n)oral contracepti ves
arerel iable,andthey havenoncontracepti vebene­
fits,w hichi ncludereducti oni ndy smenorrhea,i ron
deficiency,ovari ancanc er,endom etrialcancer.

CombinationOr alC ontraceptives

Drug Progestin,m g Estrogen

Monophasiccom binations

Ortho-Novum1/35 Norethindrone(1) Ethinylestradi ol

21,28 (35)

Ovcon3521,28 Norethindrone(0.4) Ethinylestradi ol

(35)

Brevicon21,28 Norethindrone(0.5) Ethinylestradi ol

(35)

Modicon28 Norethindrone(0.5) Ethinylestradi ol

(35)

Necon0.5/35E 21, Norethindrone(0.5) Ethinylestradi ol

28 (35)

Nortrel0.5/3528 Norethindrone(0.5) Ethinylestradi ol

(35)

Necon1/3521,28 Norethindrone(1) Ethinylestradi ol

(35)

Norinyl1/3521,28 Norethindrone(1) Ethinylestradi ol

(35)

Nortrel1/3521,28 Norethindrone(1) Ethinylestradi ol

(35)

Loestrin1/2021,28 Norethindroneace­ Ethinylestradi ol

tate(1) (20)

Microgestin1/2028 Norethindroneace­ Ethinylestradi ol

tate(1) (20)

Loestrin1.5/3021, Norethindroneace­ Ethinylestradi ol

28 tate(1.5) (30)

Microgestin1.5/30 Norethindroneace­ Ethinylestradi ol

28 tate(1.5) (30)

Alesse21,28 Levonorgestrel(0.1) Ethinylestradi ol

(20)

Aviane21,28 Levonorgestrel(0.1) Ethinylestradi ol

(20)

Lessina28 Levonorgestrel(0.1) Ethinylestradi ol

(20)

Levlite28 Levonorgestrel(0.1) Ethinylestradi ol

(20)

Necon1/5021,28 Norethindrone(1) Mestranol(50)

Norinyl115021,28 Norethindrone(1) Mestranol(50)

Ortho-Novum1/50 Norethindrone(1) Mestranol(50)

28

Ovcon5028 Norethindrone(1) Ethinylestradi ol

(50)

Cyclessa28 Desogestrel(0.1) Ethinylestradi ol

(25)
Drug Progestin,m g Estrogen

Apri28 Desogestrel(0.15) Ethinylestradi ol

(30)

Desogen28 Desogestrel(0.15) Ethinylestradi ol

(30)

Ortho-Cept21,28 Desogestrel(0.15) Ethinylestradi ol

(30)

Yasmin28 Drospirenone(3) Ethinylestradi ol

(30)

Demulen1/3521, Ethynodioldi acetate Ethinylestradi ol

28 (1) (35)

Zovia1/3521,28 Ethynodioldi acetate Ethinylestradi ol

(1) (35)

Demulen1/5021, Ethynodioldi acetate Ethinylestradi ol

28 (1) (50)

Zovia1/5021,28 Ethynodioldi acetate Ethinylestradi ol

(1) (50)

Levlen21,28 Levonorgestrel Ethinylestradi ol

(0.15) (30)

Levora21,28 Levonorgestrel Ethinylestradi ol

(0.15) (30)

Nordette21,28 Levonorgestrel Ethinylestradi ol

(0.15) (30)

Ortho-Cyclen21,28 Norgestimate(0.25) Ethinylestradi ol

(35)

Lo/Ovral21,28 Norgestrel(0.3) Ethinylestradi ol

(30)

Low-Ogestrel21,28 Norgestrel(0.3) Ethinylestradi ol

(30)

Ogestrel28 Norgestrel(0.5) Ethinylestradi ol

(50)

Ovral21,28 Norgestrel(0.5) Ethinylestradi ol

(50)

MultiphasicCo mbinations

Kariva28 Desogestrel(0.15) Ethinylestradi ol

(20,0,10)

Mircette28 Desogestrel(0.15) Ethinylestradi ol

(20,0,10)

Tri-Levlen21,28 Levonorgestrel Ethinylestradi ol

(0.05,0.075,0.125) (30,40,30)

Triphasil21,28 Levonorgestrel Ethinylestradi ol

(0.05,0.075,0.125) (30,40,30)

Trivora28 Levonorgestrel Ethinylestradi ol

(0.05,0.075,0.125) (30,40,30)

Necon10/1121,28 Norethindrone(0.5, Ethinylestradi ol

1) (35)

Ortho-Novum10/11 Norethindrone(0.5, Ethinylestradi ol

28 1) (35)

Ortho-Novum7/7/7 Norethindrone(0.5, Ethinylestradi ol

21,28 0.75,1) (35)

Tri-Norinyl21,28 Norethindrone(0.5, Ethinylestradi ol

1,0.5) (35)

Estrostep28 Norethindroneace­ Ethinylestradi ol

tate(1) (20,30,35)

OrthoTri -Cyclen21, Norgestimate(0.18, Ethinylestradi ol

28 0.215,0.25) (35)

B. Pharmacology
1. Ethinylestradi oli stheestrogeni nvi rtuallyal l
OCs.
2. Commonlyusedprogesti nsi ncludenorethi ndrone,
norethindroneacetate,andl evonorgestrel.
Ethynodioldi acetatei saprogesti n,w hichal sohas
significantestrogeni cacti vity.N ewprogesti ns
havebeendevel opedw ithl essandrogeni cacti v­
ity;how ever,theseagentsm aybeassoci atedw ith
deepvei nthrom bosis.
C. Mechanismsofaction
1. Them osti mportantm echanismofacti oni s
estrogen-inducedi nhibitionofthem idcyclesurge
ofgonadotropi nsecreti on,sothatovul ationdoes
notoccur.
2. Anotherpotenti alm echanismofcontracepti ve
actioni ssuppressi onofgonadotropi nsecreti on
duringthefollicularphase ofthecy cle,thereby
preventingfo llicularm aturation.
3. Progestin-relatedm echanismsal som aycontri b-
 utetothecontracepti veeffect.T hesei nclude
renderingtheendom etriumi sl esssui tablefor
implantationandm akingthecervi calm ucusl ess
permeabletopenetrati onby sperm .
D. Contraindications
1. Absoluteco ntraindicationsto OCs:
a. Previousthrom boemboliceventorstrok e
b. Historyofanestrogen-dependenttum or
c. Activel iverdi sease
d. Pregnancy
e. Undiagnosedabnorm aluteri nebl eeding
f. Hypertriglyceridemia
g. Womenoverage35y earsw hosm okeheavi ly
(greaterthan15ci garettesperday )
2. Screeningr equirements. Hormonalcontracep­
tioncanbesafel yprovi dedafteracareful m edical
historyandbl oodpressurem easurement.P ap
smearsarenotrequi redbeforeaprescri ptionfor
OCs.
E. Efficacy.W hentak enproperl y,OC sareavery effec­
tiveform ofcontracepti on.T heactual fai lureratei s2
to3percentdueprim arilyto m issedpillsorfailureto
resumeth erapya fterth ese ven-dayp ill-freein terval.

NoncontraceptiveB enefitsofOr alC ontraceptive

Pills

Dysmenorrhea Functionalovari ancy sts

Mittelschmerz Benignbreastcy sts
Metrorrhagia Ectopicpregnancy
Premenstrualsy ndrome Acne
Hirsutism Endometriosis
Ovarianandendom etrial
cancer

F. Drugin teractions. Them etabolismofOC si saccel ­

eratedby phenobarbi tal,pheny toinandri fampin.T he
contraceptiveeffi cacyofanOC i sl ikelytobede­
creasedi nw omentak ingthesedrugs.Otheranti biot­
ics(w iththeex ceptionofri fampin)donotaffectthe
pharmacokineticsofethi nylestradi ol.
G. Preparations
1. Therea retw oty peso fo ralco ntraceptivep ills:
combinationpillsthat containbothestrogenand
progestin,andtheprogesti n-onlypill(" mini-pill").
Progestin-onlypills,w hichareassociatedw ith
morebreak throughbl eedingthancom bination
pills,arerarely prescri bedex ceptinlactating
women.Com binationpillsarepack agedin21-day
or2 8-daycy cles.T hela stse venp illso fa 2 8-day
packareplacebopills.
2. Monophasiccom binationp illscontainthesam e
doseofestrogenandprogesti ni neachofthe21
hormonallya ctivep ills.Cu rrentp illsco ntaino n
average30to35 :g.P illscontaininglessthan50
:go fe thinyle stradiola re"lo w-dose"p ills.
3. 20µ gpr eparations.S everalpreparati onscontai n­
ingonl y20 :gofethi nylestradi olarenow avai l­
able(Lo-E strin1/20,M ircette,A lesse,A viane).
Theseareoftenusedforperi menopausalw omen
whow antcontracepti onw iththel owestestrogen
dosepossi ble.T hesepreparati onsprovi deenough
estrogentorel ievevasom otorfl ashes.
Perimenopausalw omenoftenex periencehot
flashesandprem enstrualm ooddi sturbancesdur­
ingth ese ven-dayp ill-freein terval.M ircette,co n­
tains10 :gofethi nylestradi olonfi veoftheseven
"placebo"day s,w hichreducesfl ashesandm ood
symptoms.
4. Yasmin contains30m cgofethi nylestradi oland
drospirenone.D rospirenonehasanti ­
mineralocorticoidacti vity.I tcanhel ppreventbl oat­
ing,w eightgai n,andhy pertension,buti tcani n­
creaseserum potassi um.Y asmini scontrai ndi­
catedi npati entsatri skforhy perkalemiadueto
renal,hepati c,oradrenal di sease.Y asminshoul d
notbecom binedw ithotherdrugsthatcani n­
creasepotassi um,suchasA CEi nhibitors,angi o­
tensinreceptorbl ockers,potassi um-sparingdi uret­
ics,potassi umsuppl ements,N SAIDs,orsal tsub­
stitutes.
5. Third-generationpr ogestins
a. Moresel ectiveprogesti nsi ncludenorgesti mate,
desogestrel,andgestodene.T heyhavesom e
structuralm odificationsthatl owerthei randro­
genacti vity.N orgestimate(eg,Ortho-C yclenor
Tri-Cyclen)anddesogestrel (eg,D esogenor
Ortho-Cept)arethel eastandrogeni ccom ­
poundsi nthi scl ass.T henew progesti nsare
notm uchl essandrogeni cthannorethi ndrone.
b. Thenew erOC sarem oreeffecti vei nreduci ng
acneandhi rsutismi nhy perandrogenicw omen.
Theyarethereforeanopti onforw omenw ho
havedi fficultytol eratingol derOC s.T herei san
increasedri skofdeepvenousthrom bosisw ith
theuseoftheseagents,andthey shoul dnotbe
routinelyused.
H. Recommendations
1. MonophasicOC scontai ningthesecondgenera­
tionprogesti n,norethi ndrone(Ovcon35,Ortho-
Novum1/35)arerecom mendedw henstarti nga
patientonOC sforthefi rstti me.T hisprogesti n
hasvery l owandrogeni cityw hencom paredto
 othersecondgenerati onprogesti ns,andal socom ­
paresfavorabl ytothethi rdgenerati onprogesti ns
inandrogeni city.
2. Thepillshouldbestartedonthefirstday ofthe
periodtoprovi dethem aximumcontracepti veef­
fectinthefir stcy cle.How ever,m ostw omenstar t
theirpillonthefirstS undayaftertheperiodstarts.
Someform ofback -upcontracepti oni sneededfor
thefi rstm onthi fonechoosestheS undaystart,
becausetheful lcontracepti veeffectm ightnotbe
providedinthefirstpillpack .

Factorsto Co nsiderin S tartingo rS witchingOr al

ContraceptiveP ills

Productsthat
Objective Action achievetheob­
jective

Tomi nimize Selectaproduct Alesse,A viane,

highri skof withal owerdos­ Loestrin1/20,
thrombosis ageofestrogen. Levlite,M ircette

Tomi nimize Selectaproduct Alesse,A viane,

nausea, withal owerdos­ Levlite,Loestri n
breastten­ ageofestrogen. 1/20,M ircette
dernessor
vascular
headaches

Tomi nimize Selectaproduct Lo/Ovral,Nordette,

spottingor withahi gherdos­ Ortho-Cept,Ortho-
break­ ageofestrogenor Cyclen,OrthoT ri-
through aprogesti nw ith Cyclen
bleeding greaterpotency .

Tomi nimize Selectaproduct Brevicon,

androgenic containingal ow­ Demulen1/35,
effects dose Modicon,Ovcon
norethindroneor 35
ethynodiol
diacetate.

Toavoi d Selectaproduct Brevicon,

dyslipidemi containingal ow­ Demulen1/35,
a dose Modicon,Ovcon
norethindroneor 35
ethynodiol
diacetate.

InstructionsontheU seofOr alC ontraceptiveP ills

Initiationo fu se(ch ooseo ne):

Thepatientbeginstak ingthepillsonthefirstday of
menstrualbl eeding.
Thepatientbeginstak ingthepillsonthefirstS unday
afterm enstrualbl eedingbegi ns.
Thepatientbeginstak ingthe pillsim mediatelyifsheis
definitelynotpregnantandhasnothadunprotectedsex
sinceherl astm enstrualperi od.

Missedpill
Ifithasbeenlessthan24hourssincethelastpillw as
taken,thepatienttak esapillrightaw ayandthenre­
turnsto n ormalp ill-takingr outine.
Ifithasbeen24hourssincethelastpillw astak en,the
patienttak esboththem issedpillandthenex tsched­
uledp illa tth esa metim e.
Ifithasbeenm orethan24hourssincethelastpillw as
taken( ie,tw oo rm orem issedp ills),th ep atientta kes
thela stp illth atw asm issed,th rowso utth eo ther
missedpillsandtak esthenex tpillontim e.A dditional
contraceptioni susedfortherem ainderofthecy cle.

Additionalcontr aceptivem ethod

Useanaddi tionalcontracepti vem ethodforthefi rst7
daysa fterin itiallysta rtingo ralco ntraceptivep ills.
Useanaddi tionalcontracepti vem ethodfor7day si f
morethan12hoursl atei ntak inganoral contracepti ve
pill.
Useanaddi tionalcontracepti vem ethodw hiletak ingan
interactingdrugandfor7day sthereafter.

III. Injectablecontr aceptives

A. Depotm edroxyprogesteroneacetate ( DMPA,
Depo-Provera)i sani njectablecontracepti ve.D eep
intramusculari njectionof150m gresul tsi neffecti ve
contraceptionforthreetofourm onths.E ffectiveness
is99.7percent.
B. Womenw horecei vethefi rsti njectionafterthesev­
enthday ofthem enstrualcy cleshoul duseasecond
methodofcontracepti onforsevenday s.T hefi rst
injectionshoul dbeadm inisteredw ithinfi veday s
aftertheonsetofm enses,i nw hichcaseal ternative
contraceptioni snotnecessary .
C. Ovulationi ssuppressedforatl east14w eeksafter
injectionofa150m gdoseofD MPA.T herefore,
injectionsshoul drepeatedevery threem onths.A
pregnancytestm ustbeadm inisteredtow omenw ho
arem orethantw ow eeksl ateforani njection.
 D. Returno ffe rtilityca nb ed elayedfo ru pto 1 8m onths
aftercessati onofD MPA.D MPAi snoti dealfor
womenw hom ayw ishtobecom epregnantsoon
aftercessati onofcontracepti on.
E. Amenorrhea,i rregularbl eeding,andw eightgai n
(typically1to3k g)arethem ostcom monadverse
effectsofD MPA.A dverseeffectsal soi ncludeacne,
headache,anddepressi on.Fi ftypercentofw omen
reportam enorrheaby oney ear.P ersistentbl eeding
maybetreatedw ith50 :gofethi nylestradi olfor14
days.
F. Medroxyprogesteroneacetate/estr adiol
cypionate(M PA/E2C,Lunelle) i sacom bined(25
mgM PAand5m gE 2C),i njectablecontracepti ve.
1. Althoughm onthlyI Mi njectionsarerequi red,
MPA/E2Chasseveral desi rablefeatures:
a. Ithasnearl y100percenteffecti venessi npre­
ventingpregnancy .
b. Fertilityr eturnsw ithinth reeto fo urm onths
afteri ti sdi scontinued.
c. Irregularbl eedingi sl esscom monthani n
womengi venM PAal one.
2. Weightgai n,hy pertension,headache,m astalgia,
orothernonm enstrualcom plaintsarecom mon.
3. Lunelleshoul dbeconsi deredforw omenw ho
forgetto ta keth eirb irthco ntrolp illso rth osew ho
wantadi screetm ethodofcontracepti on.T he
initiali njectionshoul dbegi venduri ngthefi rst5
daysofthem enstrualcy cleorw ithin7day sof
stoppingoral contracepti ves.Lunel lei njections
shouldbegi venevery 28to30day s;33day sat
them ost.
G. Transdermalcontr aceptivepatch
1. OrthoE vrai satransderm alcontracepti vepatch,
whichi saseffecti veasoral contracepti ves.Ortho
Evradel ivers20 :gofethi nylestradi oland150
:gofnorel gestromindai lyfor6to13m onths.
Compliancei sbetterw iththepatch.T hepatchi s
appliedatthebegi nningofthem enstrualcy cle.A
newpatchi sappl iedeachw eekfor3w eeks;
week4i spatch-free.I ti ssol di npack agesof3
patches.E ffectivenessi ssi milartooral contra­
ceptives.
2. Breakthroughbl eedingduri ngthefi rsttw ocy cles,
dysmenorrhea,andbreastdi scomfortarem ore
commoni nw omenusi ngthepatch.A reacti onat
thesi teofappl icationofthepatchoccursi n1.9
percentofthew omen.C ontraceptiveeffi cacym ay
besl ightlyl oweri nw omenw eighingm orethan90
kg.
H. Contraceptivev aginalr ing(N uvaRing) delivers15
:gethi nylestradi oland120 :gofetonogestrel dai ly)
andi sw orni ntravaginallyforthreew eeksofeach
fourw eekcy cle.A dvantagesofthi sm ethodi nclude
avoidanceofgastroi ntestinalm etabolism,rapi d
returntoovul ationafterdi scontinuation,l owerdoses
ofhorm ones,easeandconveni ence,andi mproved
cyclecontr ol.
IV. Barrierme thods
A. Barrierm ethodsofcontrac eption,suchasthecon­
dom,di aphragm,cervi calcap,andsperm icides,
havefew ersi deeffectsthanhorm onalcontracepti on.
B. Thedi aphragmandcervi calcaprequi refi ttingby a
clinicianandareonl yeffecti vew henusedw itha
spermicide.T heym ustbel efti nthevagi naforsi xto
eighthoursafteri ntercourse;thedi aphragmneeds
toberem ovedafterthisperiodoftim e,w hilethe
cervicalcapcanbel efti npl aceforupto24hours.
Theseconsi derationshav ecausedthem tobel ess
desirablem ethodsofcont raception.A m ajoradvan­
tageofbarri ercontracepti vesi sthei reffi cacyi npro­
tectingagai nstsex uallytransm itteddi seasesand
HIVin fection.
V. Intrauterinedev ices
A. Thecurrentl yavai lablei ntrauterinedevi ces(I UDs)
aresafeandeffecti vem ethodsofcontracepti on:
1. CopperT380IU Di nducesaforei gnbody reac­
tioni ntheendom etrium.I ti seffecti vefor8to10
years.
2. Progesterone-releasingIU Dsi nhibitsperm sur­
vivalandi mplantation.T heyal sodecreasem en­
strualbl oodl ossandrel ievedy smenorrhea.
Paragard isrepl acedevery 10y ears.
Progestasert IUDsm ustberepl acedafterone
year.
3. LevonorgestrelIU D(M irena)provi deseffecti ve
contraceptionforfi vey ears.
B. Infection
1. Womenw hoareatl owri skforsex uallytransm it­
teddi seasesdonothaveahi gheri ncidenceof
pelvici nflammatorydi seasew ithuseofanI UD.
AnI UDshoul dnotbei nsertedi nw omenathi gh
riskforsex uallytransm ittedi nfections,and
womenshoul dbescreenedforthepresenceof
sexuallytransm itteddi seasesbeforei nsertion.
2. ContraindicationstoI UDs:
a. Womenathi ghri skforbacteri alendocardi tis
(eg,rheum aticheartdi sease,prostheti c
valves,orahi storyofendocardi tis).
b. Womenathi ghri skfori nfections,i ncluding
thosew ithA IDSandahi storyofi ntravenous
druguse.
c. Womenw ithuteri nel eiomyomasw hichal ter
thesi zeorshapeoftheuteri necavi ty.
VI. Lactation
 A. Womenw hobreast-feedhaveadel ayi nresum ption
ofovul ationpostpartum .I ti sprobabl ysafesttore­
sumecontracepti veusei nthethi rdpostpartum
monthforthosew hobreast-feedful lti me,andi nthe
thirdpostpartum w eekforthosew hodonotbreast­
feed.
B. Anonhorm onalcontracepti veorprogesterone-con­
taininghorm onalcontracepti vecanbestartedatany
time;anestrogen-contai ningoral contracepti vepi ll
shouldnotbestartedbeforethethi rdw eek
postpartumb ecausew omena restilla tin creased
riskofthrom boembolismpri ortothi sti me.Oral con­
traceptivep illsca nd ecreaseb reastm ilk,w hile
progesterone-containingc ontraceptivesm ayi n­
creasebreastm ilk.
VII. Progestin-onlyagents
A. Progestin-onlyagentsaresl ightlyl esseffecti vethan
combinationoral contracepti ves.T heyhavefai lure
ratesof0.5percentcom paredw iththe0.1percent
ratew ithcom binationoral contracepti ves.
B. Progestin-onlyoral contracepti ves(M icronor,N or-
QD,Ovrette)provi deauseful al ternativei nw omen
whocannottak eestrogen. Progestin-onlycontracep­
tioni srecom mendedfornursi ngm others.M ilkpro­
ductioni sunaffectedby useofprogesti n-only
agents.
C. Iftheusual ti meofi ngestioni sdel ayedform orethan
threehours,anal ternativeform ofbi rthcontrol
shouldbeusedforthefol lowing48hours.B ecause
progestin-onlyagentsaretak enconti nuously,w ith­
outhorm one-freeperi ods,m ensesm aybei rregular,
infrequentorabsent.
VIII. Postcoitalcontr aception
A. Emergencypostcoi talcontra ceptionconsi stsofad­
ministrationofdrugsw ithin72hourstow omenw ho
havehadunprotectedi ntercourse(i ncludingsex ual
assault),ortothosew hohavehadafai lureofan­
otherm ethodofcontrac eption(eg,brok encondom ).
B. Preparations
1. Menstrualbl eedingty picallyoccursw ithinthree
daysafteradm inistrationofm ostform sofhor­
monalpostcoi talcontracepti on.A pregnancy test
shouldbeperform edi fbl eedinghasnotoccurred
withinfourw eeks.
2. PrevenE mergencyC ontraceptiveK iti ncludes
fourcom binationtabl ets,eachcontai ning50 :gof
ethinylestradi oland0.25m gofl evonorgestrel,
andapregnancy testtorul eoutpregnancy before
takingthetabl ets.I nstructionsaretotak etw oof
thetabl etsassoonaspossi blew ithin72hoursof
coitus,andtheothertw otabl etstw elvehours
later.
3. Anoral contracepti vesuchasOvral (tw otabl ets
twelvehoursapart)orLo/Ovral (4tabl etstw elve
hoursapart)canal sobeused.
4. Nauseaandvom itingarethem ajorsi deeffects.
Meclizine50m g,tak enonehourbeforethefi rst
dose,reducesnauseaandvom itingbutcan
causesom esedati on.
5. PlanB isa p illp ackth atco ntainstw o0 .75m g
tabletsofl evonorgestreltobetak entw elvehours
apart.T hecosti scom parabletotheP revenk it
($20). Thisregi men maybem oreeffecti veand
bettertol eratedthananestrogen-progesti nregi ­
men.
6. CopperT380IU D.A copperi ntrauterinedevi ce
(IUD)pl acedw ithin120hoursofunprotected
intercoursecanal sobeusedasaform ofem er­
gencycontracepti on.A nadvantageofthi s
methodi sthati tprovi desconti nuingcontracep­
tionafterthei nitialevent.

EmergencyC ontraception

1. Considerpretreatm entonehourbeforeeachoral
contraceptivepilldose,usingoneofthefollow ing
orallyadm inisteredanti emeticagents:
Prochlorperazine(C ompazine),5to10m g
Promethazine(P henergan),12.5to25m g
Trimethobenzamide(T igan),250m g
Meclizine(A ntivert)50m g
2. Administerthefi rstdoseoforal contracepti vepi ll
within72hoursofunprotectedcoi tus,andadm inis­
tertheseconddose12hoursafterthefi rstdose.
Brandnam eopti onsforem ergencycontracepti on
includethefol lowing:
PrevenK it– tw op illsp erd ose( 0.5m go f
levonorgestreland100µ gofethi nylestradi ol
perdose)
PlanB –onepillperdos e(0.75m gof
levonorgestrelperdose)
Ovral– tw op illsp erd ose( 0.5m go f
levonorgestreland100µ gofethi nylestradi ol
perdose)
Nordette– fo urp illsp erd ose( 0.6m go f
levonorgestreland120µ gofethi nylestradi ol
perdose)
Triphasil– fo urp illsp erd ose( 0.5m go f
levonorgestreland120µ gofethi nylestradi ol
perdose)

References:S eepage166.
PregnancyT ermination
Ninetypercentofaborti onsareperform edi nthefi rsttri ­
mesterofpregnancy .A bout1. 5m illionlegalabortionsare
performedeachy eari ntheU nitedS tates.B efore16
weeksofgestati on,l egalaborti onm aybeperform edi nan
officesetti ng.M ajoranom aliesandm id-trimesterprem a­
tureruptureofm embranesarerecogni zedfetal i ndications
forterm ination.

I. Menstrualextr action
A. Manyw omenseek aborti onservi cesw ithin1-2
weeksofthem issedperi od.A bortionoftheseearl y
pregnanciesw ithasm all-borevacuum cannul ai s
calledm enstrualex tractionorm inisuction.T heonl y
instrumentsrequi redareaspecul um,atenacul um,a
Karmancannul a,andam odified50m Lsy ringe.
B. Theex tractedti ssuei sri nsedandex aminedi na
cleardi shofw aterorsal ineoveral ightsourceto
detectchorionicvilliandt hegestationalsac.T his
examinationi sperform edtorul eoutectopi cpreg­
nancyandtodecreasetheri skofi ncompleteabor­
tion.
II. First-trimesterv acuumcur ettage
A. Beyond7m enstrualw eeksofgestati on,l argercan­
nulasandvacuum sourcesarerequi redtoevacuate
apregnancy .V acuumcurettagei sthem ostcom mon
methodofaborti on.P roceduresperform edbefore13
menstrualw eeksarecal ledsucti onorvacuum curet­
tage,w hereassi milarprocedurescarri edoutafter13
weeksareterm eddi lationandevacuati on.
B. Technique
1. Uterinesi zeandposi tionshoul dbeassessed
duringapel vicex aminationbeforetheprocedure.
Ultrasonographyi sadvi sedi ftherei sadi screp­
ancyofm orethan2w eeksbetw eentheuteri ne
sizeandm enstrualdati ng.
2. Testsforgonorrheaandchl amydiashoul dbe
obtained,andthecervi xandvagi nashoul dbe
preparedw ithagerm icide.P aracervicalbl ocki s
establishedw ith20m Lof1% l idocainei njected
deepi ntothecervi xatthe3,5,7,and9o'cl ock
positions.T hecervi xshoul dbegraspedw itha
single-toothedtenacul umpl acedverti callyw ith
onebranchi nsidethecanal .U terinedepthi s
measuredw ithasound. Dilationthenshouldbe
performedw ithatapereddi lator.
3. Avacuum cannulaw itha diameterinm illimeters
thati sonel essthantheesti matedgestati onal
ageshoul dbeusedtoevacuatethecavi ty.A fter
theti ssuei srem oved,thereshoul dbeaqui ck
checkw ithasharpcurette,fol lowedby abri ef
reintroductionofthevacuum cannul a.T heaspi ­
ratedti ssueshoul dbeex aminedasdescri bed
previously.
4. Antibioticsareusedprophy lactically.D oxycycline
isthebestagentbecause ofabroadspectrum of
antimicrobialeffect.D -negativepati entsshoul d
receiveD (R ho[D])i mmunegl obulin.
C. Complications
1. Them ostcom monpostabortal com plicationsare
pain,bl eeding,andl ow-gradefever.M ostcases
arecausedby retai nedgestati onalti ssueoracl ot
intheuteri necavi ty.T hesesy mptomsarebest
managedby arepeatuteri neevacuati on,per­
formedunderl ocalanesthesi a
2. Cervicalshock. Vasovagalsy ncopeproducedby
stimulationofthecervi calcanal canbeseenafter
paracervicalbl ock.B rieftoni c-clonicacti vityrarel y
maybeobservedandi softenconfusedw ithsei ­
zure.T herouti neuseofatropi new ithparacervi cal
anesthesiaortheuseof consci oussedati onpre­
ventscervi calshock .
3. Perforation
a. Theri skofperforati oni sl essthan1i nevery
1,000fi rst-trimesteraborti ons.I ti ncreasesw ith
gestationalageandi sgreaterforparous
womenthanfornulliparousw omen.P erfora­
tioni sbesteval uatedby l aparoscopytodeter­
minetheex tentofthei njury.
b. Perforationsatthej unctionofthecervi xand
loweruteri nesegm entcanl aceratetheas­
cendingbranchoftheuteri neartery w ithinthe
broadl igament,gi vingri setoseverepai n,a
broadl igamenthem atoma,andi ntraabdominal
bleeding.M anagementrequi resl aparotomy,
ligationoftheseveredvessel s,andrepai rof
theuteri nei njury.
4. Hemorrhage
a. Excessivebl eedingm ayi ndicateuteri neatony ,
al ow-lyingi mplantation,apregnancy ofm ore
advancedgestati onalagethanthefi rsttri mes­
ter,orperforati on.M anagementrequi resrapi d
reassessmentofgestati onalageby ex amina­
tionofthefetal partsal readyex tractedand
gentleex plorationoftheuteri necavi tyw itha
curetteandforceps.I ntravenousox ytocin
shouldbeadm inistered,andtheaborti on
shouldbecom pleted.T heuterusthenshoul d
bem assagedtoensurecontracti on.
b. Whenthesem easuresfai l,thepati entshoul d
behospi talizedandshoul drecei vei ntravenous
fluidsandhaveherbl oodcrossm atched.P er­
sistentpostabortal bl eedingstrongl ysuggests
retainedti ssueorcl ot(hem atometra)or
 trauma,andl aparoscopyandrepeatvacuum
curettagei si ndicated.
5. Hematometra. Lowerabdom inalpai nofi ncreas­
ingi ntensityi nthefi rst30m inutessuggests
hematometra.I ftherei snofeverorbl eedingi s
brisk,andonex aminationtheuterusi sl arge,
globular,andtense,hem atometrai sl ikely.T he
treatmenti si mmediatereevacuati on.
6. Ectopicpr egnancy, incompleteab ortion,an d
failedabor tion
a. Earlydetecti onofectopi cpregnancy ,i ncom­
pleteaborti on,orfai ledaborti oni spossi ble
withex aminationofthespeci meni mmediately
aftertheaborti on.T hepati entm ayhavean
ectopicpregnancy ifnochorionicvilliare
found.T odetectani ncompleteaborti onthat
mightresul ti nconti nuedpregnancy ,theactual
gestationalsacm ustbei dentified.
b. Determinationoftheb-hC Gl evelandfroz en
sectionoftheaspi ratedti ssueandvagi nal
ultrasonographym aybeuseful .I ftheb-hC G
leveli sgreaterthan1,500-2,000m IU,chori ­
onicvilliarenotidentifi edonfroz ensection,or
retainedti ssuei si dentifiedby ul trasonography,
immediatel aparoscopyshoul dbeconsi dered.
Otherpati entsm aybefol lowedcl oselyw ith
serialb-hC Gassay sunti ltheprobl emi sre­
solved.W ithl ater(> 13w eeks)gestati ons,al l
ofthefetal partsm ustbei dentifiedby thesur­
geontopreventi ncompleteaborti on.
c. Heavybl eedingorfeverafteraborti onsug­
gestsretai nedti ssue.I fthepostabortal uterus
isl argerthan12-w eeksi ze,preoperati ve
ultrasonographyshoul dbeperform edtode­
terminetheam ountofrem ainingti ssue.W hen
feveri spresent,hi gh-dosei ntravenousanti bi­
otictherapy w ithtw oorthreeagentsshoul dbe
initiated,andcurettageshoul dbeperform ed
shortlythereafter.
III. Mifepristone(R U-486)for m edicalabor tioninthe
firsttr imester
A. TheFD Ahasapprovedm ifepristoneforterm ination
ofearl ypregnancy asfol lows:E ligiblew omenare
thosew hosel astm enstrualperi odbeganw ithinthe
last49day s.T hepati enttak es600m gof
mifepristone(three200m gtabl ets)by m outhonday
1,then400 :gm isoprostoloral lytw oday sl ater.
B. Afol low-upvi siti sschedul edonday 14toconfi rm
thatthepregnancy hasbeenterm inatedw ithm ea­
surementofb-hC Gorul trasonography.
IV. Second-trimesterabor tion. Mostaborti onsare
performedbefore13m enstrualw eeks.Laterabor­
tionsaregeneral lyperform edbecauseoffetal de­
fects,m aternali llness,orm aternalage.
A. Dilationandev acuation
1. Transcervicaldi lationandevacuati onofthe
uterus(D &E)i sthem ethodm ostcom monlyused
form id-trimesteraborti onsbefore21m enstrual
weeks.I ntheone-stagetechni que,forci bledi la­
tioni sperform edsl owlyandcareful lytosuffi cient
diametertoal lowi nsertionofl arge,strongovum
forcepsforevacuati on.T hebetterapproachi sa
two-stageprocedurei nw hichm ultipleLam inaria
areusedtoachi evegradual di latationoversev­
eralhoursbeforeex traction.U terineevacuati oni s
accomplishedw ithl ong,heavy forceps,usi ngthe
vacuumcannul atorupturethefetal m embranes,
drainam nioticfl uid,andensurecom pleteevacua­
tion.
2. Preoperativeul trasonographyi snecessary foral l
cases14w eeksandbey ond.I ntraoperativereal ­
timeul trasonographyhel pstol ocatefetal parts
withintheuterus.
3. Dilationandevacuationbec omesprogressively
moredi fficultasgestati onalageadvances,and
instillationtechniquesareoftenusedafter21
weeks.Dilationandevacuationcanbeofferedin
thel atem id-trimester,buttw osetsofLam inaria
tentsforatotal of36-48hoursi srecom mended.
Afterm ultistageLam inariatreatm ent,ureai si n­
jectedi ntotheam nioticsac.E xtractioni sthen
accomplishedafterl aborbegi nsandafterfetal
macerationhasoccurred.
References:S eepage166.

EctopicPregnancy
Ectopicpregnancy causes15% ofal lm aternaldeaths.
Onceapati enthashadanectopi cpregnancy ,therei sa7­
to13-fol di ncreasei ntheri skofrecurrence.

I. Clinicalm anifestations
A. Symptomsofectopi cpregnancy i ncludeabdom inal
pain,am enorrhea,andvagi nalbl eeding.H owever,
over50percentofw omenareasy mptomaticbefore
tubalrupture.
B. Symptomsofpregnancy (eg,breasttenderness,
frequenturi nation,nausea)areoftenpresent.I n
casesofrupture,l ightheadednessorshock m ay
occur.E Pshoul dbesuspectedi nany w omenof
reproductiveagew ithabdom inalpai n,especi ally
thosew hohaveri skfactorsforanex trauterinepreg­
nancy.
 RiskFactor sfor E ctopicP regnancy

GreatestR isk
Previousectopi cpregnancy
Previoustubalsurgery orsteriliz ation
Diethylstilbestrolex posurei nutero
Documentedtubal pathol ogy(scarri ng)
Useofi ntrauterinecontracepti vedevi ce

GreaterR isk
Previousgeni tali nfections(eg,P ID)
Infertility( Invitr ofe rtilization)
Multiplesex ualpartners

LesserR isk
Previouspel vicorabdom inalsurgery
Cigarettesm oking
Vaginaldouchi ng
Ageof1sti ntercourse< 18y ears

PresentingS ignsandS ymptomsofE ctopicP reg­

nancy

Symptom Percentage

Abdominalpai n 80-100%
Amenorrhea 75-95%
Vaginalbl eeding 50-80%
Dizziness,fainting 20-35%
Urgetodefecate 5-15%
Pregnancysy mp­ 10-25%
toms 5-10%
Passageofti ssue

Adnexaltender­ 75-90%
ness

Abdominaltender­ 80-95%
ness

Adnexalm ass 50%

Uterineenl arge­ 20-30%

ment

Orthostatic 10-15%
changes

Fever 5-10%

C. Physicalexam ination. Vitalsi gnsm ayreveal

orthostaticchangesand,occasi onally,fever.Fi nd­
ingsi ncludeadnex aland/orabdom inaltenderness,
anadnex alm ass,anduteri neenl argement.
II. Diagnosticev aluation
A. Womenw ithm oderate-orhi gh-riskfactorsforE P
andthosew hoconceivedafterin-vitrofertiliz ation
(IVF)shoul dbeeval uatedfo rE Passoonasthei r
firstm issedm enses.
B. Transvaginalultr asoundi sm ostuseful fori dentify­
ingani ntrauterinegestati on.A nex trauterinepreg­
nancyw illbevisualiz edinonly 16to32percentof
cases,thusapel vicul trasoundshow ing" no
intrauterineorex trauterinegestati on"doesnotex ­
cludethedi agnosisofE P.
1. Thei dentificationofani ntrauterinepregnancy
effectivelyex cludesthepo ssibilityofanectopicin
almostal lcases.H owever,pregnanci escon­
ceivedw ithassi stedreproducti vetechnol ogyare
anex ception,si ncethei ncidenceofcom bined
intrauterineandex trauterinepregnancy m aybe
ashi ghas1/100pregnanci es.
2. Anearl yi ntrauterinepregnancy i si dentified
sonographicallyby thepresenceofatruegesta­
tionalsac.U singT VS,thegestati onalsaci susu­
allyvi sibleat4.5to5w eeksofgestati onw iththe
doubledeci dualsi gnat5.5to6w eeks,they olk
sacappearsat5to6w eeksandrem ainsunti l10
weeks,andafetal pol ew ithcardi acacti vityi sfi rst
detectedat5.5to6w eeks.
C. beta-hCGconcentr ation.T hegestati onalsaci s
usuallyi dentifiedatbet a-hCGconcentrati onsabove
1500to2000I U/L.T heabsenceofani ntrauterine
gestationalsacatbeta-hC Gconcentrati onsabove
2000I U/Lstrongl ysuggestsanE P.
D. Progesteroneconcentrati onsarehi gheri n
intrauterinethanectopi cpregnanci es.A concentra­
tionofgreaterthan25ng/m Li susual ly(98to99
percent)associ atedw ithavi ablei ntrauterinepreg­
nancy,w ithl owerconcentrati onsi nectopi cand
intrauterinepregnanci esthataredesti nedtoabort.A
concentrationl essthan5ng/m Lal mostal ways(99.8
percent)m eansthepregnancy i snonvi able.H ow­
ever,therei snodi fferencei ntheprogesteronecon­
centrationbetw eenectopi candarrestedpregnan­
cies.P rogesteronem easurementsareuseful onl yto
confirmdi agnostici mpressionsal readyobtai nedby
hCGm easurementsandtransvagi nalsonography .
III. Clinicald ecisionm aking
 A. Beta-hCGconcentr ationgr eaterthan1500IU /L.
Thei nterpretationofabeta-hC Gatthi sl evelde­
pendsuponthefi ndingsonT VS.
1. Positiveultr asound.P resenceofani ntrauterine
pregnancyal mostal waysex cludesthepresence
ofanE P.Fetal cardi acacti vityoragestati onal
sacw ithacl earfetal pol eory olksaci nan
extrauterinel ocationi sdi agnosticofanE P;treat­
mentofE Pshoul dbei nitiated.
2. Negativeul trasound
a. AnE Pi svery l ikelyi ntheabsenceofan
intrauterinepregnancy onT VSw henthese­
rumbeta-hC Gconcentrati oni sgreaterthan
1500I U/L.T henex tstepi stoconfi rmthedi ag­
nostici mpressionby repeati ngtheT VSex ami­
nationandbeta-hC Gconcentrati ontw oday s
later.T hedi agnosisofE Pi scertai natthi sti me
ifani ntrauterinepregnancy i snotobservedon
TVSandtheserum beta-hC Gconcentrati oni s
increasingorpl ateaued.T reatmentofE P
shouldbei nitiated.
b. Afal lingbeta-hC Gconcentrati oni sm ostcon­
sistentw ithafai ledpregnancy (eg,arrested
pregnancy,bl ightedovum ,tubal aborti on,
spontaneouslyresol vingE P).W eeklybeta­
hCGconcentrati onsshoul dbem onitoredunti l
theresul ti snegati veforpregnancy .
B. Beta-hCGconcentr ationgr eaterthan1500IU /L
andanadnexalm ass.A nex trauterinepregnancy i s
almostcertai nw hentheserum beta-hC Gconcentra­
tioni sgreaterthan1500I U/L,anonspeci ficadnex al
massi spresent,andnoi ntrauterinepregnancy i s
observedonT VS.T reatmentofE Pshoul dbei niti­
ated.
C. Beta-hCGlessthan1500IU /L
1. Aserum beta-hC Gconcentrati onl essthan1500
IU/Lw ithaT VSex aminationthati snegati ve
shouldbefol lowedby repeti tionofbothofthese
testsinthreeday stofollow therateofriseofthe
hCG.B eta-hCGconcentrati onsusual lydoubl e
every1.5totw oday sunti lsi xtosevenw eeksof
gestationi nvi ablei ntrauterinepregnanci es(and
insom eectopi cgestati ons).A beta-hC Gconcen­
trationthatdoesnotdoubl eover72hoursassoci ­
atedw itharepeatT VSex aminationthatdoesnot
showani ntrauterinegestati onm eansthatthe
pregnancyi snonvi able,suchasanectopi cgesta­
tionori ntrauterinepregnancy thati sdesti nedto
abort.A norm ali ntrauterinepregnancy i snot
presentandm edicaltreatm entofE Pcanbei niti­
ated.
2. Anorm allyri singbeta-hC Gconcentrati onshoul d
beeval uatedw ithT VSunti lani ntrauterinepreg­
nancyoranectopi cpregnancy canbedem on­
strated.
3. Afal lingbeta-hC Gconcentrati oni sm ostconsi s­
tentw ithafai ledpregnancy (eg,arrestedpreg­
nancy,bl ightedovum ,tubal aborti on,spontane­
ouslyresol vingE P).W eeklybeta-hC Gconcentra­
tionsshoul dbem onitoredunti ltheresul ti snega­
tiveforpregnancy .
IV. Methotrexatether apyfor ectopicpr egnancy
A. Medicaltreatm entofectopi cpregnancy (E P)w ith
methotrexate(M TX)hassuppl antedsurgi caltherapy
inm ostcases.T hesuccessr ateis86to94per cent.
B. Methotrexatei safol icaci dantagoni st,w hich inhibits
DNAsy nthesisandcel lreproducti on.

Criteriafor R eceivingM ethotrexate

Absolutein dications
Hemodynamicallystabl ew ithoutacti vebl eedingor
signsofhem operitoneum
Nonlaparoscopicdi agnosis
Patientd esiresfu turefe rtility
Generalanesthesi aposesasi gnificantri sk
Patientisabletoreturnforfollow -upcare
Patienthasnocontrai ndicationstom ethotrexate

Relativein dications
Unrupturedm ass< 3.5cm ati tsgreatestdi mension
Nofetalcardiacm otiondetected
Patientsw hosebet-hC Gl eveldoesnotex ceed6,000­
15,000m lU/mL
 ContraindicationstoM ethotrexateTher apy

Absolutecontr aindications
Breastfeedi ng
Overtorl aboratoryevi denceofi mmunodeficiency
Alcoholism,al coholicl iverdi sease,orotherchroni c
liverdi sease
Preexistingbl ooddy scrasias,suchasbonem arrow
hypoplasia,l eukopenia,throm bocytopenia,orsi gnifi­
cantanem ia
Knownsensi tivitytom ethotrexate
Activepul monarydi sease
Pepticul cerdi sease
Hepatic,renal ,orhem atologicdy sfunction
Relativeco ntraindications
Gestationalsac> 3.5cm
Embryoniccardi acm otion

C. Contraindicationstom edicaltr eatment

1. Womenw hoarehem odynamicallyunstabl e,not
likelytobecom pliantw ithpost-therapeuti cm oni­
toring,andw hodonothaveti melyaccesstoa
medicali nstitutionshoul dbetreatedsurgi cally.
2. Thepresenceoffetal cardi acacti vityi sarel ative
contraindicationtom edicaltreatm ent.
3. Womenw ithahi ghbasel inehC Gconcentrati on
(>5000m IU/mL)arem orel ikelytoex perience
treatmentfai lure;they m aybebetterservedby
conservativel aparoscopicsurgery .
D. Protocol
1. Singledosether apy. Asi nglei ntramuscular
doseofm ethotrexate(50m gpersquarem eterof
bodysurfacearea)i sgi ven.T hebody surface
area( BSA)m aybe calculatedbaseduponheight
andw eight.
2. RhoGAMshoul dbeadm inisteredi fthew omani s
Rh(D)-negativeandthebl oodgroupofherm ale
partneri sR h(D)-positiveorunk nown.
E. Adverser eactionstoM TXareusual lym ildandsel f­
limiting.T hem ostcom monarestom atitisandcon­
junctivitis.R aresi deeffectsi ncludegastri tis,enteri ­
tis,derm atitis,pl euritis,al opecia,el evatedl iveren­
zymes,andbonem arrowsuppressi on.
F. Post-therapym onitoringandev aluation.S erum
beta-hCGconcentrati onandul trasoundex amination
shouldbeeval uatedw eekly.A ni ncreasei nbeta­
hCGl evelsi nthethreeday sfol lowingtherapy (i e,up
today 4)andm ildabdom inalpai nofshortdurati on
(onetotw oday s)arecom mon.T hepai ncanbe
controlledw ithnonsteroi dalanti inflammatorydrugs.
G. Aseconddoseofm ethotrexateshoul dbeadm in­
isteredi ftheserum beta-hC Gconcentrati ononD ay
7hasnotdecl inedby atl east25percentfrom the
Day0l evel.A pproximately20percentofw omenw ill
requireaseconddoseofM TX.
H. Thebeta-hC Gconcentr ationusual lydecl inesto
lessthan15m IU/mLby 35day spost-i njection,but
maytak easl ongas109day s.W eeklyassay s
shouldbeobtai nedunti lthi sl eveli sreached.

SideE ffectsA ssociatedwithM ethotrexateTr eat­

ment

Increasei nabdom inal Gastricdistr ess

pain(occursi nuptotw o­ Dizziness
thirdsofpati ents) Vaginalbl eedingorspot­
Nausea ting
Vomiting Severeneutropeni a
Stomatitis (rare)
Diarrhea Reversibleal opecia
(rare)
Pneumonitis

SignsofTr eatmentFai lureandTubal R upture

Significantlyw orseningabdom inalpai n,regardl essof

changei nbeta-hC Gl evels
Hemodynamicin stability
Levelsofbeta-hC Gthatdonotdecl ineby atl east15%
betweenday 4andday 7posti njection
Increasingorpl ateauingbeta-hC Gl evelsafterthefi rst
weekoftreatm ent

V. Operativem anagementcanbeaccom plishedby ei ther

laparoscopyorl aparotomy.Li nearsal pingostomyor
segmentalresecti oni stheprocedureofchoi cei fthe
fallopiantubei stoberetai ned.S alpingectomyi sthe
procedureofchoi cei fthetuberequi resrem oval.
References:S eepage166.
AcutePelvicPain
I. Clinicalev aluation
A. Assessmentofacutepel vicpai nshoul ddeterm ine
thepati ent’sage,obstetri calhi story,m enstrualhi s­
tory,characteri sticsofpai nonset,durati on,andpal ­
liativeoraggravati ngfactors.
B. Associatedsy mptomsm ayi ncludeuri naryorgas­
trointestinalsy mptoms,fever,abnorm albl eeding,or
vaginaldi scharge.
C. Pastm edicalhistor y.C ontraceptivehi story,surgi cal
history,gy necologichi story,hi storyofpel vici nflam­
matorydi sease,ectopi cpregnancy ,sex uallytransm it­
teddi seasesshoul dbedeterm ined.C urrentsex ual
activityandpracti cesshoul dbeassessed.
D. Methodofcontr aception
1. Sexualabsti nencei nthem onthsprecedi ngthe
onsetofpai nl essonsthel ikelihoodofpregnancy ­
relatedeti ologies.
2. Theri skofacuteP IDi sreducedby 50% i npati ents
takingoral contracepti vesorusi ngabarri er
methodofcontracepti on.P atientstak ingoral con­
traceptivesareatdecr easedri skforanectopi c
pregnancyorovari ancy sts.
E. Riskfactor sfor acutepelv icinflam matorydis­
ease.A gebetw een15-25y ears,sex ualpartnerw ith
symptomsofurethri tis,pri orhi storyofP ID.
II. Physicalexam ination
A. Fever,abdom inalorpel victenderness,andperi toneal
signsshoul dbesought.
B. Vaginaldi scharge,cervi calery themaanddi scharge,
cervicalanduteri nem otiontenderness,oradnex al
massesortendernessshoul dbenoted.
III. Laboratorytests
A. Pregnancytesting willidentify pregnancy -related
causesofpel vicpai n.S erumbeta-H CGbecom es
positive7day safterconcepti on.A negati vetestvi rtu­
allyex cludesectopi cpregnancy .
B. Completebl oodcount. Leuk ocytosissuggestan
inflammatoryprocess;how ever,anorm alw hitebl ood
countoccursi n56% ofpati entsw ithP IDand37% of
patientsw ithappendi citis.
C. Urinalysis.T hefi ndingofpy uriasuggestsuri nary
tracti nfection.P yuriacanal sooccurw ithani nflamed
appendixorfrom contam inationoftheuri neby vagi ­
naldi scharge.
D. Testingfor N eisseriagonor rhoeaeandC hlamydia
trachomatisa ren ecessaryifPI Disa p ossibility.
E. Pelvicul trasonographyi sofval uei nex cludingthe
diagnosisofanectopi cpregnancy by dem onstrating
ani ntrauterinegestati on.S onographym ayreveal
acuteP ID,torsi onoftheadnex a,oracuteappendi ci­
tis.
F. Diagnosticl aparoscopyi si ndicatedw henacute
pelvicpai nhasanuncl eardi agnosisdespi tecom pre­
hensiveeval uation.
III. Differentiald iagnosiso facu tep elvicp ain
A. Pregnancy-relatedcauses. Ectopicpregnancy ,
spontaneous,threatenedori ncompleteaborti on,
intrauterinepregnancy w ithcorpusl uteumbl eeding.
B. Gynecologicdisor ders.P ID,endom etriosis,ovari an
cysthem orrhageorrupture,adnex altorsi on,
Mittelschmerz,uteri nel eiomyomatorsi on,pri mary
dysmenorrhea,tum or.
C. Nonreproductivetr actcauses
1. Gastrointestinal.A ppendicitis,i nflammatorybow el
disease,m esentericadeni tis,i rritablebow elsy n­
drome,di verticulitis.
2. Urinarytr act.U rinarytracti nfection,renal cal cu­
lus.
IV. Approachto acu tep elvicp ainwith ap ositive
pregnancytest
A. Inafem alepati entofreproducti veage,presenti ng
withacutepel vicpai n,thefi rstdi stinctioni sw hether
thepai ni spregnancy -relatedornon-pregnancy -re­
latedonthebasi sofaserum pregnancy test.
B. Inthepati entw ithacutepel vicpai nassoci atedw ith
pregnancy,thenex tstepi sl ocalizationoftheti ssue
responsibleforthehC Gproducti on. Transvaginal
ultrasoundshoul dbeperform edtoi dentifyan
intrauterinegestati on.E ctopicpregnancy i scharacter­
izedby anoncy sticadnex alm assandfl uidi nthecul ­
de-sac.
V. Approachto acu tep elvicp ainin n on-pregnant
patientswithanegativ eH CG
A. AcuteP IDi sthel eadingdi agnosticconsi derationi n
patientsw ithacutepel vicpai nunrel atedtopreg­
nancy.T hepai ni susual lybi lateral,butm aybeuni lat­
erali n10% .C ervicalm otiontenderness,fever,and
cervicaldi schargearecom monfi ndings.
B. Acuteap pendicitis shouldbeconsi deredi nal lpa­
tientspresenti ngw ithacutepel vicpai nandanega­
tivepregnancy test.A ppendicitisi scharacteri zedby
leukocytosisandahi storyofafew hoursof
periumbilicalp ainfo llowedb ym igrationo fth ep ainto
therightlow erquadrant.Neutrophiliaoccursin75% .
Asl ightfeverex ceeding37.3°C ,nausea,vom iting,
anorexia,andreboundtendernessm aybepresent.
C. Torsionoftheadnexa usual lycausesuni lateral
pain,butpai ncanbebi laterali n25% .I ntense,pro­
gressivepai ncom binedw ithatense,tenderadnex al
massi scharacteri stic.T herei softenahi storyof
repetitive,transi torypai n.P elvicsonography often
confirmsthedi agnosis.Laparoscopi cdi agnosisand
surgicali nterventionarei ndicated.
 D. Rupturedor hem orrhagiccor puslutealcy st usu­
allycausesbi lateralpai n, buti tcancauseuni lateral
tendernessi n35% .U ltrasoundai dsi ndi agnosis.
E. Endometriosisusual lycauseschroni correcurrent
pain,buti tcanoccasi onallycauseacutepel vicpai n.
Thereusual lyi sahi storyofdy smenorrheaanddeep
dyspareunia.P elvicex amreveal sfi xeduteri ne
retrodisplacementandtenderuterosacral andcul -de­
sacnodul arity.Laparoscopy confi rmsthedi agnosis.
References:S eepage166.

ChronicPelvicPain
Chronicpel vicpai n(C PP)affectsapprox imatelyonei n
sevenw omeni ntheU nitedS tates(14percent).C hronic
pelvicpai n(> 6m onthsi ndurati on)i sl essl ikelytobe
associatedw ithareadi lyi dentifiablecausethani sacute
pain.
I. Etiologyo fch ronicp elvicp ain
A. Physicalandsexualabuse. N umerousstudi es
havedem onstratedahi gherfrequency ofphy sical
and/orsex ualabusei nw omenw ithC PP.B etween
30and50percentofw omenw ithC PPhaveahi s­
toryofabuse(phy sicalorsex ual,chi ldhoodoradul t).
B. Gynecologicpr oblems
1. Endometriosisi spresenti napprox imatelyone­
thirdofw omenundergoi ngl aparoscopyforC PP
andi sthem ostfrequentfi ndingi nthesew omen.
Typically,endom etriosispai ni sasharpor
“crampy”pai n.I tstarts attheonsetofm enses,
becomingm oresevereandprol ongedoversev­
eralm enstrualcy cles.I ti sfrequentl yaccom pa­
niedby deepdy spareunia.U terosacrall igament
nodularityi shi ghlyspeci ficforendom etriosis.
Examiningthew omanduri ngherm enstruation
maym akethenodul arityeasi ertopal pate.A
morecom mon,butl essspeci fic,fi ndingi stender­
nessi nthecul -de-sacoruterosacral l igaments
thatreproducesthepai nofdeepdy spareunia.
2. Pelvicadhesions arefoundi napprox imately
one-fourthofw omenundergoi ngl aparoscopyfor
CPP.A dhesionsform afteri ntra-abdominali n­
flammation;they shoul dbesuspectedi fthe
womanhasahi storyofsurgery orpel vici nflam­
matorydi sease(P ID).T hepai nm aybeadul lor
sharppul lingsensati onthatoccursatany ti me
duringthem onth.P hysicalex aminationi susual ly
nondiagnostic.
3. Dysmenorrhea(pai nfulm enstruation)and
mittelschmerz(m idcyclepai n)w ithoutotheror­
ganicpathol ogyareseenfrequentl yandm ay
contributetoC PPi nm orethanhal fofal lcases.
4. Chronicpelv icinflam matorydisease may
causeC PP.T herefore,cul turingforsex ually
transmittedagentsshoul dbearouti nepartofthe
evaluation.

MedicalD iagnosesandC hronicP elvicP ain

Medicaldiagnosis/sy mptom Prevalence

source

Boweld ysmotilityd isorders 50to80%

Musculoskeletaldi sorders 30to70%
Cyclicgy necologicpai n 20to50%
Urologicdi agnoses 5to10%
Endometriosis,advancedand/or Lessthan5%
withdensebow eladhesi ons
Unusualm edicaldi agnoses Lessthan2%
Multiplem edicaldi agnoses 30to50%
Noi dentifiablem edicaldi agnosis Lessthan5%

C. Nongynecologicm edicalpr oblems

1. Boweld ysmotility(eg,i rritablebow elsy ndrome
andconsti pation)m aybethepri marysy mptom
sourcei n50percentofal lcasesofC PPandm ay
beacontri butingfactori nupto80percentof
cases.P ainfrom i rritablebow elsy ndromei sty pi­
callydescri bedasacram py,recurrentpai nac­
companiedby abdom inaldi stentionandbl oating,
alternatingdi arrheaandconsti pation,andpas­
sageofm ucus.T hepai ni softenw orseduri ngor
nearthem enstrualperi od.A hi ghlysuggesti ve
signi sex quisitetendernesstopal pationw hich
improvesw ithconti nuedpressure.
2. Musculoskeletaldy sfunction,i ncludingabdom i­
nalm yofascialpai nsy ndromes,cancauseor
contributetoC PP.
D. Psychologicpr oblems
1. Depressivedisor derscontri butetom orethan
halfofal lcasesofC PP.Frequentl y,thepai n
becomesp arto fa cy cleo fp ain,d isability,a nd
mooddi sturbance.T hedi agnosticcri teriafor
depressioni ncludedepressedm ood,di minished
interesti ndai lyacti vities,w eightl ossorgai n,
insomniaorhy persomnia,psy chomotoragi tation
orretardati on,fati gue,feel ingsofw orthlessness,
lossofconcentrati on,andrecurrentthoughtsof
death.
 2. Somatoformdisor ders,i ncludingsom atization
disorder,contri buteto10to20percentofcases
ofC PP.T heessenti alfeatureofsom atization
disorderi sapatternofrecurri ng,m ultiple,cl ini­
callysignificantsom aticcom plaints.
II. Clinicalev aluationo fch ronicp elvicp ain
A. History
1. Thecharacter,i ntensity,di stribution,andl ocation
ofpai narei mportant.R adiationofpai norshoul d
beassessed.T hetem poralpatternofthepai n
(onset,durati on,changes,cy clicity)andaggravat­
ingorrel ievingfactors(eg,posture,m eals,bow el
movements,voi ding,m enstruation,i ntercourse,
medications)shoul dbedocum ented.
2. Associatedsy mptoms.A norexia,consti pation,
orfati gueareoftenpresent.
3. Previoussur geries,p elvicin fections,in fertility,
orobstetri cex periencesm ayprovi deaddi tional
clues.
4. Forpati entsofreproducti veage,theti mingand
characteristicsofthei rl astm enstrualperi od,the
presenceofnon-m enstrualvagi nalbl eedingor
discharge,andthem ethodofcontracepti onused
shouldbedeterm ined.
5. Lifesi tuationsandeventsthataffectthepai n
shouldbesought.
6. Gastrointestinalandurol ogicsy mptoms,i ncluding
therel ationshipbetw eenthesesy stemstothe
painshoul dberevi ewed.
7. Thepati ent'saffectm aysuggestdepressi onor
otherm ooddi sorders.
B. Physicalexam ination
1. Ifthew omani ndicatesthel ocationofherpai n
withasi nglefi nger,thepai ni sm orel ikelycaused
byadi scretesourcethani fsheusesasw eeping
motionofherhand.
2. Apel vicex aminationshoul dbeperform ed.S pe­
cialattenti onshoul dbegi ventothebl adder,ure­
thra.
3. Thepi riformism usclesshoul dbepal pated;
piriformisspasm can causepai nw hencl imbing
stairs,dri vingacar,orw henfi rstari singi nthe
morning.T hism usclei sresponsi bleforex ternal
rotationofthehi pandcanbepal pated
posterolaterally,cephal ictothei schialspi ne.T his
examinationi sm osteasi lyperform edi fthe
womanex ternallyrotatesherhi pagai nstthere­
sistanceoftheex aminer'sotherhand.P iriformis
spasmi streatedw ithphy sicaltherapy .
4. Abdominaldeform ity,ery thema,edem a,scars,
hernias,ordi stensionshoul dbenoted.A bnormal
bowelsoundsm aysugges tagastroi ntestinal
process.
5. Palpationshoul di ncludetheepi gastrium,fl anks,
andl owback ,andi nguinalareas.
C. Specialtests
1. Initiall aboratorytestsshoul di ncludecervi cal
cytology,endocervi calcul turesfor Neisseria
gonorrhoeae andC hlamydia,stool H emoccult,
anduri nalysis.Othertestsm aybesuggestedby
thehi storyandex amination.
2. Laparoscopyi shel pfulw henthepel vicex amina­
tioni sabnorm alorw heni nitialtherapy fai ls.
III. Management
A. Myofascialpai nsy ndromem aybetreatedby avari ­
etyofphy sicaltherapy techni ques.T riggerpoi nts
canoftenbetreatedw ithi njectionsofal ocalanes­
thetic(eg,bupi vacaine[M arcaine]),w ithorw ithout
theaddi tionofacorti costeroid.
B. Ifthepai ni srel atedtothem enstrualcy cle,treat­
mentai medatsuppressi ngthecy clem ayhel p.
Commonm ethodstoaccom plishthi si ncludead­
ministrationofdepotm edroxyprogesterone(D epo-
Provera)andconti nuouslydosedoral contracep­
tives.
C. Cognitive-behavioraltherapy i sappropri ateforal l
womenw ithC PP.R elaxationanddi stractiontech­
niquesareoftenhel pful.
D. Whenendom etriosisorpel vicadhesi onsaredi scov­
eredondi agnosticl aparoscopy,they areusual ly
treatedduri ngtheprocedure.H ysterectomym aybe
warrantedi fthepai nhaspersi stedform orethansi x
months,doesnotrespondtoanal gesics(i ncluding
anti-inflammatoryagents),andi mpairsthew oman's
normalfuncti on.
E. Antidepressantsor sleepingaids areuseful ad­
junctivetherapi es.A mitriptyline(E lavil),i nl owdoses
of25-50m gqhs,m aybeofhel pi ni mprovingsl eep
andreduci ngtheseveri tyofchroni cpai ncom ­
plaints.
F. Muscler elaxantsm ayproveuseful i npati entsw ith
guarding,spl inting,orreacti vem usclespasm s.
References:S eepage166.

Endometriosis
Endometriosisi scharacte rizedby thepresenceof
endometrialti ssueontheovari es,fal lopiantubesorother
abnormalsites,causingpainorinfertility .W omenare
usually25to29y earsol dattheti meofdi agnosis.A pproxi­
mately24percentofw omenw hocom plainofpel vicpai n
aresubsequentl yfoundtohave endometriosis.T heoveral l
prevalenceofendom etriosisi sesti matedtobe5to10
percent.
I. Clinicalev aluation
A. Endometriosisshoul dbeconsi deredi nany w omanof
reproductiveagew hohaspel vicpai n.T hem ost
commonsy mptomsaredy smenorrhea,dy spareunia,
andl owback pai nthatw orsensduri ngm enses.R ec­
talpai nandpai nfuldefecati onm ayal sooccur.Other
causesofsecondary dy smenorrheaandchroni c
pelvicpai n(eg,uppergeni taltracti nfections,
adenomyosis,adhesi ons)m ayproducesi milarsy mp­
toms.

DifferentialD iagnosisofE ndometriosis

Generalizedp elvic Dyspareunia

pain Musculoskeletalcauses
Pelvicin flammatory (pelvicr elaxation,levator
disease spasm)
Endometritis Gastrointestinaltract
Pelvicadhesi ons (constipation,i rritable
Neoplasms,beni gn bowelsy ndrome)
orm alignant Urinarytract(urethral sy n­
Ovariantorsi on drome,i nterstitialcy stitis)
Sexualorphy sical Infection
abuse Pelvicvascul arconges­
Nongynecologic tion
causes Diminishedl ubricationor
Dysmenorrhea vaginalex pansionbe­
Primary causeofi nsufficient
Secondary arousal
(adenomyosis, Infertility
myomas,i nfection, Malefactor
cervicalstenosi s) Tubaldi sease(i nfection)
Anovulation
Cervicalfactors(m ucus,
spermanti bodies,steno­
sis)
Lutealphasedefi ciency

B. Infertilitym ayb eth ep resentingco mplaintfo r

endometriosis.I nfertilepati entsoftenhavenopai nful
symptoms.
C. Physicalexam ination.T hephy sicianshoul dpal ­
pateforafi xed,retroverteduterus,adnex aland
uterinetenderness,pel vicm assesornodul arity
alongtheuterosacral l igaments.A rectovagi nalex ­
aminationshoul di dentifyuterosacral ,cul -de-sacor
septalnodul es.M ostw omenw ithendom etriosis
havenorm alpel vicfi ndings.
II. Treatment
A. Confirmatoryl aparoscopyi susual lyrequi redbefore
treatmenti si nstituted.I nw omenw ithfew sy mptoms,
anem pirictri aloforal contracepti vesorprogesti ns
maybew arrantedtoassesspai nrel ief.
B. Medicaltr eatment
1. Initialtherapy al soshoul di ncludeanonsteroi dal
anti-inflammatorydrug.
a. Naproxen(N aprosyn)500m gfol lowedby 250
mgP Oti d-qidprn[250,375,500m g].
b. Naproxensodi um(A leve)200m gP Oti dprn.
c. Naproxensodi um(A naprox)550m g,fol lowed
by275m gP Oti d-qidprn.
d. Ibuprofen(M otrin)800m g,then400m gP O
q4-6hprn.
e. Mefenamicaci d(P onstel)500m gP Ofol lowed
by250m gq6hprn.
2. Progestationalagents. Progestinsaresi milarto
combinationOC Psi nthei reffectsonFS H,LH
andendom etrialti ssue.T heym aybeassoci ated
withm orebothersom eadverseeffectsthan
OCPs.P rogestinsareeffecti vei nreduci ngthe
symptomsofendom etriosis.Oral progesti nregi ­
mensm ayi ncludeonce-dai lyadm inistrationof
medroxyprogesteroneatthel owesteffecti vedos­
age(5to20m g).D epotm edroxyprogesterone
maybegi veni ntramuscularlyevery tw ow eeksfor
twom onthsat100m gperdoseandthenoncea
monthforfourm onthsat200m gperdose.
3. Oralcontr aceptivepills(OC Ps)suppressLH
andFS Handpreventovul ation.C ombination
OCPsal leviatesy mptomsi naboutthreequarters
ofpati ents.Oral contracepti vescanbetak en
continuously(w ithnopl acebos)orcy clically,w ith
aw eekofplacebopillsbetw eency cles.T he
OCPscanbedi scontinuedaftersi xm onthsor
continuedi ndefinitely.
4. Danazol(D anocrine)hasbeenhi ghlyeffecti vei n
relievingthesy mptomsofendom etriosis,but
adverseeffectsm ayprecl udei tsuse.A dverse
effectsi ncludeheadache,fl ushing,sw eatingand
atrophicvagi nitis.A ndrogenicsi deeffectsi nclude
acne,edem a,hi rsutism,deepeni ngofthevoi ce
andw eightgai n.T hei nitialdosageshoul dbe800
mgperday ,gi veni ntw odi videdoral doses.T he
overallresponseratei s84to92percent.
 MedicalTr eatmentofE ndometriosis

Adverseef­
Drug Dosage fects

Danazol 800m gperday i n2 Estrogendefi ­

(Danocrine) divideddoses ciency,
androgenic
sideeffects

Oralcontra­ 1p illp erd ay( continu­ Headache,

ceptives ousorcy clic) nausea,hy ­
pertension

Medroxypro 5to20m goral lyper Sameasw ith

gesterone day otheroral
(Provera) progestins

Medroxypro 100m gI Mevery 2 Weightgai n,

gesterone weeksfor2m onths; depression,
suspension then200m gI Mevery irregularm en­
(Depo- monthfor4m onthsor sesor
Provera) 150m gI Mevery 3 amenorrhea
months

Norethindro 5m gperday oral lyfor Sameasw ith

ne 2w eeks;theni ncrease otheroral
(Aygestin) by2.5m gperday ev­ progestins
ery2w eeksupto15
mgperday

Leuprolide 3.75m gI Mevery Decreasei n

(Lupron) monthfor6m onths bonedensi ty,
estrogendefi ­
ciency

Goserelin 3.6m gS C(i nupper Estrogendefi ­

(Zoladex) abdominalw all)every ciency
28day s

Nafarelin 400m gperday :1 Estrogendefi ­

(Synarel) sprayin 1 n ostrilin ciency,bone
a.m.;1spray i nother density
nostrili np.m .;start changes,na­
treatmentonday 2to4 salirritation
ofm enstrualcy cle

C. GnRHagonists.T heseagents(eg,l euprolide

[Lupron],goserel in[Zol adex])i nhibitthesecreti onof
gonadotropin.GnR Hagoni stsarecontrai ndicatedi n
pregnancyandhavehy poestrogenicsi deeffects.
Theyproduceam ilddegreeofbonel oss.B ecause
ofconcernsaboutost eopenia,“add-back ”therapy
withl ow-doseestrogenhasbeenrecom mended.T he
dosageofl euprolidei sasi nglem onthly3.75-m g
depoti njectiongi veni ntramuscularly.Goserel in,i na
dosageof3.6m g,i sadm inisteredsubcutaneousl y
every28day s.A nasal spray (nafarel in[S ynarel])
maybeusedtw icedai ly.T heresponseratei ssi milar
tothatw ithdanaz ol;about90percentofpati ents
experiencepai nrel ief.
D. Surgicaltr eatment
1. Surgicaltreatm enti sthepreferredapproachto
infertilepati entsw ithadvancedendom etriosis.
Laparoscopicabl ationofendom etriosisl esions
mayresul ti na13percenti ncreasei ntheproba­
bilityofpregnancy .
2. Definitivesurgery ,w hichi ncludeshy sterectomy
andoophorectom y,i sreservedforw omenw ith
intractablepai nw honol ongerdesi repregnancy .
References:S eepage166.

PrimaryA menorrhea
Amenorrhea(absenceofm enses)resul tsfrom dy sfunction
ofthehy pothalamus,pi tuitary, ovaries,uterus,orvagi na.I t
isoftencl assifiedasei therpri mary(absenceofm enarche
byage16)orsecondary (absenceofm ensesform ore
thanthreecy clei ntervalsorsi xm onthsi nw omenw ho
wereprevi ouslym enstruating).
I. Etiology
A. Primaryam enorrheai susual lytheresul t ofage­
neticoranatom icabnorm ality.C ommoneti ologiesof
primaryam enorrhea:
1. Chromosomalabnorm alitiescausi nggonadal
dysgenesis:45percent
2. Physiologicdel ayofpuberty :20percent
3. Müllerianagenesi s:15percent
4. Transversevagi nalseptum ori mperforatehy men:
5percent
5. Absentproducti onofgonadotropi n-releasing
hormone(GnR H)by thehy pothalamus:5percent
6. Anorexianervosa:2percent
7. Hypopituitarism:2percent

CausesofP rimaryandS econdaryA menorrhea

 Abnormality Causes

Pregnancy

Anatomicab normalities

Congenitalabnorm al­ Isolateddefect

ityi nM ulleriandevel ­ Testicularfem inization
opment syndrome
5-Alpha-reductasedefi ­
ciency
Vanishingtestessy n­
drome
Defectintestisdeterm in­
ingfactor

Congenitaldefectof Agenesisofl owervagi na

urogenitalsi nusdevel ­ Imperforatehy men
opment

Acquiredabl ationor Asherman’ssy ndrome

scarringofthe Tuberculosis
endometrium

Disordersof
hypothalamic-pituitary
ovarianaxis
Hypothalamicdy sfunc­
tion
Pituitarydy sfunction
Ovariandy sfunction

CausesofA menorrheaduetoA bnormalitiesinthe

Hypothalamic-Pituitary-OvarianA xis

Abnormality Causes

Hypothalamic Functionalhy pothalamic

dysfunction amenorrhea
Weightl oss,eati ngdi sorders
Exercise
Stress
Severeorprolongedillness
Congenitalgonadotropi n-releas­
inghorm onedefi ciency
Inflammatoryorinfiltrativedis­
eases
Braintum ors-eg,
craniopharyngioma
Pituitarystal kdi ssectionorcom ­
pression
Craniali rradiation
Braini njury-traum a,hem or­
rhage,hy drocephalus
Othersy ndromes- Prader-Willi,
Laurence-Moon-Biedl

Pituitarydy sfunc­ Hyperprolactinemia

tion Otherpi tuitarytum ors­
acromegaly,corti cotroph
adenomas(C ushing'sdi sease)
Othertum ors-m eningioma,
germinoma,gl ioma
Emptysel lasy ndrome
Pituitaryi nfarctorapopl exy

Ovariandy sfunc­ Ovarianfai lure(m enopause)

tion Spontaneous
Premature(beforeage40
years)
Surgical

Other Hyperthyroidism
Hypothyroidism
Diabetesm ellitus
Exogenousandrogenuse

II. Diagnosticev aluation ofpr imaryam enorrhea

A. StepI: E valuateclin icalh istory:
1. Signsofpuberty m ayi ncludeagrow thspurt,
absenceofax illaryandpubichair,orapocrine
sweatgl ands,orabsenceofbreastdevel opment.
Lackofpubertal devel opmentsuggestsovari an
orpi tuitaryfai lureorachrom osomalabnorm ality.
2. Familyhi storyofdel ayedorabsentpuberty sug­
gestsa fa miliald isorder.
3. Shortstaturem ayi ndicateT urnersy ndromeor
hypothalamic-pituitarydi sease.
4. Poorheal thm aybeam anifestationof
hypothalamic-pituitarydi sease.S ymptomsof
otherhy pothalamic-pituitarydi seasei nclude
headaches,vi sualfi elddefects,fati gue,or
polyuriaandpol ydipsia.
5. Virilizationsuggestspol ycysticovary sy ndrome,
anandrogen-secreti ngovari anoradrenal tum or,
orthepresenceofY chrom osomem aterial.
6. Recentstress,changei nw eight,di et,orex ercise
habits;orillnessm aysuggesthy pothalamic
amenorrhea.
 7. Heroinandm ethadonecanal terhy pothalamic
gonadotropinsecreti on.
8. Galactorrheai ssuggesti veofex cessprol actin.
Somedrugscauseam enorrheaby i ncreasing
serumprol actinconcentrati ons,i ncluding
metoclopramideandanti psychoticdrugs.
B. StepII: P hysicalexam ination
1. Aneval uationofpubertal devel opmentshoul d
includecurrenthei ght,w eight,andarm span
(normalarm spanforadul tsi sw ithin5cm of
height)andaneval uationofthegrow thchart.
2. Breastdevel opmentshoul dbeassessedby T an­
nerstagi ng.
3. Thegeni talex aminationshoul deval uatecl itoral
size,pubertal hai rdevel opment,i ntactnessofthe
hymen,depthofthevagi na,andpresenceofa
cervix,uterus,andovari es.I fthevagi nacannot
bepenetratedw ithafi nger,rectal ex amination
mayal loweval uationofthei nternalorgans.P el­
vicul trasoundi sal souseful todeterm inethe
presenceorabsenceofm üllerianstructures.
4. Thesk inshoul dbeex aminedforhi rsutism,acne,
striae,increasedpigm entation,andvitiligo.
5. Classicphy sicalfeaturesofT urnersy ndrome
includel owhai rl ine,w ebneck ,shi eldchest,and
widelyspacedni pples.
C. StepIII: Basiclab oratorytestin g
1. Ifan ormalv aginao ru terusar en oto bviously
presentonphy sicalex amination,pel vic
ultrasonographyshoul dbeperform edtoconfi rm
thepresenceorabsenceof ovari es,uterus,and
cervix.U ltrasonographycanbeuseful toex clude
vaginalorcervi caloutl etobstructi oni npati ents
withcy clicpai n.
a. Uterusabsent
(1) Iftheuterusi sabsent,eval uationshoul d
includeak aryotypeandserum testoster­
one.T hesetestsshoul ddi stinguishabnor­
malm ülleriandevel opment(46,X X
karyotypew ithnorm alfem aleserum tes­
tosteroneconcentrati ons)from androgen
insensitivitysy ndrome(46,X Yk aryotype
andnorm alm aleserum testosteronecon­
centrations).
(2) Patientsw ith5-al phareductasedefi ciency
alsohavea46,X Yk aryotypeandnorm al
maleserum testosteroneconcentrati ons
but,i ncontrasttotheandrogeni nsensitiv­
itysy ndromew hichi sassoci atedw itha
femalephenoty pe,thesepati entsundergo
strikingviriliz ationatthetim eofpuberty
(secondarysex ualhai r,m usclem ass,and
deepeningofthevoi ce).
2. Uteruspr esent.Forpati entsw ithanorm alva­
ginaanduterusandnoevi denceofani mperfo­
ratehy men,vagi nalseptum ,orcongeni talab­
senceofthevagi na.M easurementofserum beta
humanchori onicgonadotropi ntoex cludepreg­
nancyandofserum FS H,prol actin,andT SH.
a. Ahi ghserum FS Hconcentrati oni si ndicative
ofpri maryovari anfai lure.A k aryotypei sthen
requiredandm aydem onstratecom pleteor
partialdel etionoftheX chrom osome(T urner
syndrome)orthepresenceofY chrom atin.
ThepresenceofaY chrom osomei sassoci ­
atedw ithahi gherri skofgonadal tum orsand
makesgonadectom ym andatory.
b. Al owornorm alserum FS Hconcentrati on
suggestsfuncti onalhy pothalamic
amenorrhea,congeni talGnR Hdefi ciency,or
otherdi sordersofthehy pothalamic-pituitary
axis.C ranialM Ri magingi si ndicatedi nm ost
casesofhy pogonadotropichy pogonadismto
evaluatehy pothalamicorpi tuitarydi sease.
CranialM RIi srecom mendedforal lw omen
withpri maryhy pogonadotropichy pogonadism,
visualfi elddefects,orheadaches.
c. Serumprol actinandthy rotropin(T SH)shoul d
bem easured,especi allyi fgal actorrheai s
present.
d. Iftherearesi gnsorsy mptomsofhi rsutism,
serumtestosteroneand
dehydroepiandrosteronesul fate(D HEA-S)
shouldbem easuredtoassessforan
androgen-secretingtum or.
e. Ifhy pertensioni spresent,bl oodtestsshoul d
bedraw nforeval uateforC YP17defi ciency.
Thecharacteri sticfi ndingsareel evationsi n
serumprogesterone(> 3ng/m L)and
deoxycorticosteroneandl owval uesforserum
17-alpha-hydroxyprogesterone(< 0.2ng/m L).
III. Treatment
A. Treatmentofpri maryam enorrheai sdi rectedat
correctingtheunderl yingpathol ogy;hel pingthe
womantoachievefertility ,ifdesired;andprevention
ofcom plicationsofthedi sease.
B. Congenitalanatom iclesionsor Y chr omosome
materialusual lyrequi ressurgery .S urgicalcorrec­
tionofavagi naloutl etobstructi oni snecessary be­
forem enarche,orassoonasthedi agnosisi sm ade
afterm enarche.C reationofaneovagi naforpati ents
withm üllerianfai lurei susual lydel ayedunti lthe
womeni sem otionallym ature.I fY chrom osome
materiali sfound,gonadectom yshoul dbeper­
formedtopreventgonadal neopl asia.H owever,
 gonadectomyshoul dbedel ayedunti lafterpuberty
inpati entsw ithandrogeni nsensitivitysy ndrome.
Thesepati entshaveanorm alpubertal grow thspurt
andfem inizeattheti meofex pectedpuberty .
C. Ovarianfailu rerequi rescounsel ingaboutthebene­
fitsandri sksofhorm onerepl acementtherapy .
D. Polycysticov arysy ndromei sm anagedw ithm ea­
surestoreducehi rsutism,resum em enses,and
fertilityandprevent ofendom etrial hyperplasia,obe­
sity,andm etabolicdefects.
E. Functionalhy pothalamicam enorrheacanusual ly
bereversedby w eightgai n,reducti oni nthei ntensity
ofex ercise,orresol utionofi llnessorem otional
stress.Forw omenw how anttoconti nuetoex ercise,
estrogen-progestinrepl acementtherapy shoul dbe
givento th osen otse ekingfe rtilityto p revento steo­
porosis.W omenw how anttobecom epregnantcan
betreatedw ithgonadotropi nsorpul satileGnR H.
F. Hypothalamicor pi tuitarydy sfunctionthati snot
reversible(eg,congeni talGnR Hdefi ciency)i s
treatedw ithei therex ogenousgonadotropi nsor
pulsatileGnR Hi fthew omanw antstobecom epreg­
nant.
References:S eepage166.

SecondaryA menorrhea
Amenorrhea(absenceofm enses)canbeatransi ent,
intermittent,orperm anentcondi tionresul tingfrom dy sfunc­
tionofthehy pothalamus,pi tuitary,ovari es,uterus,or
vagina.A menorrheai scl assifiedasei therpri mary(ab­
senceofm enarcheby age16y ears)orsecondary (ab­
senceofm ensesform orethanthreecy clesorsi xm onths
inw omenw hoprevi ouslyhadm enses).P regnancyi sthe
mostcom moncauseofsecondary am enorrhea.

I. Diagnosis
A. Step1: R uleoutpr egnancy.A pregnancy testi s
thefi rststepi neval uatingsecondary am enorrhea.
Measurementofserum betasubuni tofhC Gi sthe
mostsensitivetest.
B. Step2: A ssessthehistor y
1. Recentstress;changei nw eight,di etorex ercise
habits;orillnessesthatm ightresultinhy potha­
lamicam enorrheashoul dbesought.
2. Drugsassoci atedw itham enorrhea,sy stemic
illnessesthatcancausehy pothalamic
amenorrhea,recenti nitiationordi scontinuationof
anoral contracepti ve,androgeni cdrugs(danaz ol)
orhi gh-doseprogesti n,andanti psychoticdrugs
shouldbeeval uated.
3. Headaches,vi sualfi elddefects,fati gue,or
polyuriaandpol ydipsiam aysuggest
hypothalamic-pituitarydi sease.
4. Symptomsofestrogendefi ciencyi ncludehot
flashes,vagi naldry ness,poorsl eep,ordecreased
libido.
5. Galactorrheai ssuggesti veofhy perprolactinemia.
Hirsutism,acne,andahi storyofi rregularm enses
aresuggesti veofhy perandrogenism.
6. Ahi storyofobstetri calcatastrophe,severebl eed­
ing,di latationandcurettage,orendom etritisor
otheri nfectionthatm ighthavecausedscarri ngof
theendom etriall iningsuggestsA sherman'ssy n­
drome.

CausesofP rimaryandS econdaryA menorrhea

Abnormality Causes

Pregnancy

Anatomicab normalities

Congenitalabnorm al­ Isolateddefect

ityi nM ulleriandevel ­ Testicularfem inization
opment syndrome
5-Alpha-reductasedefi ­
ciency
Vanishingtestessy n­
drome
Defectintestisdeterm in­
ingfactor

Congenitaldefectof Agenesisofl owervagi na

urogenitalsi nusdevel ­ Imperforatehy men
opment

Acquiredabl ationor Asherman’ssy ndrome

scarringofthe Tuberculosis
endometrium

Disordersof
hypothalamic-pituitary
ovarianaxis
Hypothalamicdy sfunc­
tion
Pituitarydy sfunction
Ovariandy sfunction
CausesofA menorrheaduetoA bnormalitiesinthe
Hypothalamic-Pituitary-OvarianA xis

Abnormality Causes

Hypothalamicdy s­ Functionalhy pothalamic

function amenorrhea
Weightl oss,eati ngdi sor­
ders
Exercise
Stress
Severeorprolongedillness
Congenitalgonadotropi n-re­
leasinghorm onedefi ciency
Inflammatoryorinfiltrativedis­
eases
Braintum ors-eg,
craniopharyngioma
Pituitarystal kdi ssectionor
compression
Craniali rradiation
Braini njury-traum a,hem or­
rhage,hy drocephalus
Othersy ndromes- Prader-Willi,
Laurence-Moon-Biedl

Pituitarydy sfunc­ Hyperprolactinemia

tion Otherpi tuitarytum ors­
acromegaly,corti cotroph
adenomas(C ushing'sdi sease)
Othertum ors-m eningioma,
germinoma,gl ioma
Emptysel lasy ndrome
Pituitaryi nfarctorapopl exy

Ovariandy sfunc­ Ovarianfai lure(m enopause)

tion Spontaneous
Premature(beforeage40
years)
Surgical

Other Hyperthyroidism
Hypothyroidism
Diabetesm ellitus
Exogenousandrogenuse

DrugsA ssociatedwithA menorrhea

Drugsth atIn ­ Antipsychotics

creaseP rolactin Tricyclicanti depressants
Calciumchannel bl ockers

Drugswith E stro­ Digoxin,m arijuana,oral contra­

genicA ctivity ceptives

Drugswith Ov ar­ Chemotherapeuticagents

ianT oxicity

C. Step3: P hysicalexam ination.M easurementsof

heightandw eight,signsof otherillnesses,andevi­
denceofcachex iashoul dbeassessed.T hesk in,
breasts,andgeni talti ssuesshoul dbeeval uatedfor
estrogendefi ciency.T he breastsshoul dbepal pated,
includinganattem pttoex pressgal actorrhea.T he
skinshoul dbeex aminedforhi rsutism,acne,stri ae,
acanthosisni gricans,vi tiligo,thi cknessorthi nness,
andeasy bruisability .
D. Step4: B asiclabor atorytesting .I naddi tionto
measurementofserum hC Gtorul eoutpregnancy ,
minimall aboratorytesti ngshoul di ncludem easure­
mentsofserum prol actin,thy rotropin,andFS Hto
ruleouthy perprolactinemia,thy roiddi sease,and
ovarianfai lure(hi ghserum FS H).I ftherei s
hirsutism,acneori rregularm enses,serum
dehydroepiandrosteronesul fate(D HEA-S)andtes­
tosteroneshoul dbem easured.
E. Step5: F ollow-uplab oratory evaluation
1. Highser umpr olactinconcentr ation. Prolactin
secretioncanbetransi entlyi ncreasedby stressor
eating.T herefore,serum prol actinshoul dbem ea­
suredatl easttw icebeforecrani ali magingi sob­
tained,parti cularlyi nthosew omenw ithsm all
elevations(< 50ng/m L).T hesew omenshoul dbe
screenedforthy roiddi seasew ithaT SHandfree
T4becausehy pothyroidismcancause
hyperprolactinemia.
2. Womenw ithveri fiedhi ghserum prol actinval ues
shouldhaveacrani alM RIunl essavery cl ear
explanationi sfoundfortheel evation(eg,
antipsychotics).I magingshoul drul eoutahy po­
thalamicorpi tuitarytum or.
3. Highser umFS Hconcentr ation. Ahi ghserum
FSHconcentrati oni ndicatesthepresenceofovar­
ianfai lure.T histestshoul dberepeatedm onthly
onthreeoccasi onstoconfi rm.A k aryotypeshoul d
beconsi deredi nm ostw omenw ithsecondary
amenorrheaage30y earsory ounger.
4. Highser umandr ogenconcentr ations.A hi gh
serumandrogenval uem aysuggestthedi agnosis
ofpol ycysticovary sy ndromeorm aysuggestan
 androgen-secretingtum oroftheovary oradrenal
gland.Furthertesti ngforatum orm ighti ncludea
24-houruri necol lectionforcorti soland17­
ketosteroids,determ inationofserum 17-hy droxy­
progesteroneafteri ntravenousi njectionof
corticotropin(A CTH),andadex amethasonesup­
pressiontest.E levationof17-k etosteroids,D HEA-
S,or17-hy droxyprogesteronei sm oreconsi stent
withanadrenal ,ratherthanovari an,sourceof
excessandrogen.
5. Normalor lowser umgonadotr opinconcentr a­
tionsandallother testsnor mal
a. Thisresul ti soneofthem ostcom monout­
comesofl aboratorytesti ngi nw omenw ith
amenorrhea.W omenw ithhy pothalamic
amenorrhea(causedby m arkedex erciseor
weightl osstom orethan10percentbel owthe
expectedw eight)havenorm altol owserum
FSHval ues.C ranialM RIi si ndicatedi nal l
womenw ithoutanacl earex planationfor
hypogonadotropichy pogonadismandi nm ost
womenw hohavevi sualfi elddefectsorhead­
aches.N ofurthertesti ngi srequi redi ftheon­
setofam enorrheai srecentori seasi lyex ­
plained(eg,w eightl oss,ex cessiveex ercise)
andtherearenosy mptomssuggesti veofother
disease.
b. Highserum transferri nsaturati onm ayi ndicate
hemochromatosis,hi ghserum angi otensin­
convertingenz ymeval uessuggestsarcoi dosis,
andhi ghfasti ngbl oodgl ucoseorhem oglobin
A1cvaluesindicatediabetesm ellitus.
6. Normalser umpr olactinandFS Hconcentr a­
tionsw ithhi storyofuter inei nstrumentation
precedingam enorrhea
a. EvaluationforA sherman'ssy ndromeshoul dbe
completed.A progesti nchal lengeshoul dbe
performed(m edroxyprogesteroneacetate10
mgfor10day s).I fw ithdrawalbl eedingoccurs,
anoutfl owtractdi sorderhasbeenrul edout.I f
bleedingdoesnotoccur,estrogenand
progestinshoul dbeadm inistered.
b. Oralconj ugatedestrogens(0.625to2.5m g
dailyfor35day s)w ithm edroxyprogesterone
added(10m gdai lyforday s26to35);fai lureto
bleeduponcessati onofthi stherapy strongl y
suggestsendom etrialscarri ng.I nthi ssi tuation,
ahy sterosalpingogramorhy steroscopycan
confirmthedi agnosisofA shermansy ndrome.
II. Treatment
A. Athleticwo menshoul dbecounsel edontheneed
fori ncreasedcal orici ntakeorreducedex ercise.
Resumptionofm ensesusual lyoccurs.
B. Nonathleticw omenw hoar eunder weightshoul d
receivenutri tionalcounsel ingandtreatm entofeati ng
disorders.
C. Hyperprolactinemia istreatedw ithadopam ine
agonist.C abergoline(D ostinex)orbrom ocriptine
(Parlodel)areusedform ostadenom as.Ovul ation,
regularm enstrualcy cles,andpregnancy m ayusual ly
result.
D. Ovarianfailu reshoul dbetreatedw ithhorm one
replacementtherapy .
E. Hyperandrogenism istreatedw ithm easuresto
reducehirsutism ,resum em enses,andfertility and
preventingendom etrialhy perplasia,obesi ty,and
metabolicdefects.
F. Asherman'ssy ndromei streatedw ith
hysteroscopicl ysisofadhesi onsfol lowedby l ong­
termestrogenadm inistrationtosti mulateregrow thof
endometrialti ssue.
References: Seepage166.

Menopause
Menopausei sdefi nedasthecessati onofm enstrualperi ­
odsi nw omen.T heaverageageofm enopausei s51
years,w itharangeof41-55.T hedi agnosisofm enopause
ism adeby thepresenceofam enorrheaforsi xtotw elve
months,togetherw iththeoccurrenceofhotfl ashes.I fthe
diagnosisi si ndoubt,m enopausei si ndicatedby anel e­
vatedfollicle-stim ulatinghorm one(F SH)levelgreaterthan
40m lU/mL.

I. Perimenopausaltr ansition i sdefi nedasthetw oto

eighty earsprecedi ngm enopauseandtheoney ear
afterthel astm enstrualperi od.I ti scharacteri zedby
normalovul atorycy clesi nterspersedw ithanovul atory
(estrogen-only)cy cles.A saresul t,m ensesbecom e
irregular,andheavy break throughbl eeding,term ed
dysfunctionaluteri nebl eeding,canoccurduri ngl onger
periodsofanovul ation.
II. Effectsofestr ogendeficiency after m enopause
A. Hotflashes. Them ostcom monacutechangedur­
ingm enopausei sthehotfl ash,w hichoccursi n75
percentofw omen.A bout50to75percentofw omen
havecessati onofhotfl ashesw ithinfi vey ears.H ot
flashesty picallybegi nas asuddensensati onofheat
centeredonthefaceandupperchestthatrapi dly
becomesgeneral ized.T hesensati onl astsfrom tw o
tofourm inutesandi softenassoci atedw ithprofuse
perspiration.H otfl ashesoccurseveral ti mesper
day.
B. Sexualfunction .E strogendefi ciencyl eadstoa
 decreasei nbl oodfl owtothevagi naandvul va.T his
decreasei sam ajorc auseofdecreasedvagi nal
lubrication,dy spareunia, anddecreasedsex ualfunc­
tioni nm enopausalw omen.
C. Urinaryincontinence. M enopauseresul tsi natro­
phyoftheurethral epi theliumw ithsubsequentatro­
phicurethri tisandi rritation;thesechangespredi s­
posetobothstressandurgeuri naryi ncontinence.
D. Osteoporosis.A l ong-termconsequenceofestro­
gendefi ciencyi sthedev elopmentofosteoporosi s
andfractures.B onel ossex ceedsbonereform ation.
Between1and5percentofthesk eletalm asscan
bel ostpery eari nthefi rstseveral y earsafterthe
menopause.Osteoporosi sm ayoccuri nasl ittleas
teny ears.
E. Cardiovasculardisease. T hei ncidenceofm yocar­
diali nfarctioni nw omen,al thoughl owerthani nm en,
increasesdram aticallyafterthem enopause.
III. Estrogenr eplacementther apy
A. Datafrom theW HIandtheH ERStri alshasdeter­
minedthatconti nuous estrogen-progestintherapy
doesnotappeartoprotectagai nstcardi ovascular
diseaseandi ncreasesthe riskofbreastcancer,
coronaryheartdi sease,strok e,andvenous
thromboembolismoveranaveragefol low-upof5.2
years.A saresul t,thepri maryi ndicationforestrogen
therapyi sforcontrol ofm enopausalsy mptoms,such
ashotfl ashes.
IV. Preventionandtr eatmentofosteopor osis
A. Screeningfor osteopor osis.M easurementofB MD
isrecom mendedforal lw omen65y earsandol der
regardlessofri skfactors.B MDshoul dal sobem ea­
suredi nal lw omenundertheageof65y earsw ho
haveoneorm oreri skfactorsforosteoporosi s(i n
additiontom enopause).T hehi pi stherecom ­
mendedsi teofm easurement.
B. Bisphosphonates
1. Alendronate(Fosam ax)haseffectscom parable
tothoseofestrogenforboththetreatm entof
osteoporosis(10m g/dayor70m gonceaw eek)
andfori tspreventi on(5m g/day).A lendronate(i n
adoseof5m g/dayor35m g/week)canal so
preventosteoporosi si npostm enopausalw omen.
2. Risedronate(A ctonel),abi sphosphonate,has
beenapprovedforpreventi onandtreatm entof
osteoporosisatdosesof 5m g/dayor35m gonce
perw eek.I tseffi cacyandsi deeffectprofi leare
similartothoseofal endronate.
C. Raloxifene(E vista)i sasel ectiveestrogenreceptor
modulator.I ti savai lableforpreventi onandtreat­
mentofosteoporosi s.A tadoseof60m g/day,bone
densityi ncreasesby 2.4percenti nthel umbarspi ne
andhi poveratw oy earperi od.T hiseffecti ssl ightly
lessthanw ithbi sphosphonates.
D. Calcium.M aintainingaposi tivecal ciumbal ancei n
postmenopausalw omenrequi resadai lyi ntakeof
1500m gofel ementalcal cium;tom eetthi sm ost
womenrequi reasuppl ementof1000m gdai ly.
E. VitaminD. A llpostm enopausalw omenshoul dtak e
am ultivitamincontai ningatl east400I Uvi taminD
daily.
F. Exercise foratl east20m inutesdai lyreducesthe
rateofbonel oss.W eightbeari ngex ercisesare
preferable.
V. Treatmento fh otflash esan dv asomotorin stability
A. Them anifestationso fva somotorin stabilitya reh ot
flashes,sl eepdi sturbances,headache,andi rritabil­
ity.M ostw omenw ithse vereva somotorin stability
acceptshort-term estrogentherapy forthesesy mp­
toms.
B. Short-termestr ogenther apyfor r eliefofv asomo­
torin stabilityan dh otflash es
1. Short-termestrogentherapy rem ainsthebest
treatmentforrel iefofm enopausalsy mptoms,and
thereforei srecom mendedform ost
postmenopausalw omen,w iththeex ceptionof
thosew itha h istoryo fb reastca ncer,CHD,a
previousvenousthrom boemboliceventorstrok e,
orthoseathi ghri skforthesecom plications.
Short-termtherapy i sconti nuedforsi xm onthsto
fourorfi vey ears.A dministrationofestrogen
short-termi snotassoci atedw ithani ncreased
riskofbreastcancer.
2. Lowdoseestrogeni srecom mended(eg,0.3m g
conjugatedestrogens[P remarin]dai lyor0.5m g
estradiol[E strace]dai ly).T hesedosesareade­
quateforsy mptomm anagementandpreventi on
ofbonel oss.
3. Endometrialhy perplasiaandcancercanoccur
afterasl ittleassi xm onthsofunopposedestro­
gentherapy ;asaresul t,aprogesti nm ustbe
addedi nthosew omenw hohavenothadahy s­
terectomy.M edroxyprogesterone(P rovera),2.5
mg,i susual lygi venevery day ofthem onth.
4. Afterthepl annedtreatm enti nterval,theestrogen
shouldbedi scontinuedgradual lytom inimize
recurrenceofthem enopausalsy mptoms,for
example,by om ittingonepillperw eek(6pillsper
week,5 p illsp erw eek,4 p illsp erw eek).
C. Treatmento fv asomotorin stabilityin wo menn ot
takingestr ogen
1. Selectiveser otoninr euptakeinhibitor s
(SSRIs)alsor elievethesy mptomsofvasom otor
instability.
a. Venlafaxine(E ffexor),atdosesof75m g
 daily,reduceshotfl ashesby 61percent.M outh
dryness,anorex ia,nausea,andconsti pation
arecom mon.
b. Paroxetine(Zoloft),50m gperday ,rel ieves
vasomotorin stability.
c. Fluoxetine(P rozac)20m gperday al sohas
beneficialeffectsofal esserm agnitude.
2. Clonidine(C atapres)rel ieveshotfl ashesi n
80%.I naw omanw ithhy pertension,cl onidine
mightbeconsi deredasi nitialtherapy .I ti susual ly
givenasapatchcontai ning2.5m gperw eek.
Clonidineal som aybegi venoral lyi ndosesof0.1
to0.4m gdai ly.S ideeffectsoftenl imittheuse
andi ncludedry m outh,di zziness,consti pation,
andsedati on.
3. Megestrolacetate(M egace)i sasy nthetic
progestinw hichdecreas esthefrequency ofhot
flashesby 85percentatadoseof40to80m g
POdai ly.W eightgai ni sthem ajorsi deeffect.
VI. Treatmentofur ogenitalatr ophy
A. Lossofestrogencausesatr ophyofthevagi nalepi ­
theliumandresul tsi nvagi nali rritationanddry ness,
dyspareunia,andani ncreasei nvagi nali nfections.
Systemicestrogentherapy resul tsi nrel iefofsy mp­
toms.
B. Treatmento fu rogenitalatr ophyin wo menn ot
takingsy stemicestr ogen
1. Moisturizersan dlu bricants.R egularuseofa
vaginalm oisturizingagent(R eplens)andl ubri­
cantsduri ngi ntercoursearehel pful.W atersol u­
blel ubricantssuchasA stroglidearem oreeffec­
tivethanl ubricantsthatbecom em orevi scous
afterappl icationsuchasK -Yj elly.A m oreeffec­
tivetreatm enti svagi nalestrogentherapy .
2. Low-dosev aginalestr ogen
a. Vaginalr ingestr adiol(E string),a sila sticr ing
impregnatedw ithestradi ol,i sthepreferred
meansofdel iveringestrogentothevagi na.
Thesi lasticri ngdel ivers6to9µ gofestradi ol
tothevagi nadai lyforaperi odofthreem onths.
Theri ngsarechangedonceevery three
monthsby thepati ent.C oncomitantprogesti n
therapyi snotnecessary .
b. Conjugatedestr ogens(P remarin),0.5gm of
cream,orone-ei ghthofanappl icatorfuldai ly
intothevagi naforthreew eeks,fol lowedby
twicew eeklythereafter.C oncomitantprogesti n
therapyi snotnecessary .
c. Estracecr eam(estr adiol)canal soby gi ven
byvagi nalappl icatoratadoseofone-ei ghthof
anappl icatoror0.5g(w hichcontai ns50µ gof
estradiol)dai lyi ntothevagi naforthreew eeks,
followedby tw icew eeklythereafter.C oncomi­
tantprogesti ntherapy i snotnecessary .
d. Estradiol(V agifem).A tabl etcontai ning25
microgramsofestradi oli savai lableandi s
insertedi ntothevagi natw iceperw eek.C on­
comitantprogesti ntherapy i snotnecessary .
References:S eepage166.

PremenstrualSy ndromeand
PremenstrualDy sphoricDisorder
Premenstrualsy ndrome(P MS)i scharacteri zedby phy sical
andbehavi oralsy mptomsthatoccurrepeti tivelyi nthe
secondhal fofthem enstrualcy cleandi nterferew ithsom e
aspectsofthew oman'sl ife. Premenstrualdy sphoricdi sor­
der(P MDD)isthem ostsevereform ofP MS,w iththe
prominenceanger,irritability , andinternaltension.P MS
affectsupto75percentofw omenw ithregul arm enstrual
cycles,w hileP MDDaffectsonl y3to8percentofw omen.

I. Symptoms
A. Them ostcom monphy sicalm anifestationofP MSi s
abdominalbl oating,w hichoccursi n90percentof
womenw iththi sdi sorder;breasttendernessand
headachesareal socom mon,occurri ngi nm orethan
50percentofcases.
B. Them ostcom monbehavi oralsy mptomofP MSi san
extremesenseoffati guew hichi sseeni nm orethan
90percent.Otherfrequentbehavi oralcom plaints
includeirritability ,tensi on,depressedm ood,labile
mood(80percent),i ncreasedappeti te(70percent),
andforgetful nessanddi fficultyconcentrati ng(50
percent).
C. Othercom monfi ndingsi ncludeacne,oversensi tivity
toenvi ronmentalsti muli,anger,easy cry ing,and
gastrointestinalupset.H otfl ashes,heartpal pitations,
anddi zzinessoccuri n15to20percentofpati ents.
Symptomsshoul doccuri nthel utealphaseonl y.
SymptomC lustersC ommonlyN otedinP atients
withP MS

AffectiveS ymptoms Cognitiveor per for­

Depressionorsadness mance
Irritability Moodinstability orm ood
Tension swings
Anxiety Difficultyi nconcentrati ng
Tearfulnessorcry ingeas­ Decreasedeffi ciency
ily Confusion
Restlessnessor jitter iness Forgetfulness
Anger Accident-prone
Loneliness Socialavoi dance
Appetitechange Temperoutbursts
Foodcravi ngs Energetic
Changesi nsex uali nterest Fluidr etention
Pain Breasttendernessor
Headacheorm igraine swelling
Backpai n Weightgai n
Breastpai n Abdominalbl oatingor
Abdominalcram ps swelling
Generalorm uscularpai n Swellingofex tremities
Generalso matic
Fatigueorti redness
Dizzinessorverti go
Nausea
Insomnia

DSM-IVC riteriafor P remenstrualD ysphoricD isor­

der

• Fiveo rmo resy mptoms

• Atl eastoneofthefol lowingfoursy mptoms:
Markedlydepressedm ood,feel ingsofhopel ess­
ness,orsel f-deprecatingthoughts
Markedanx iety,tensi on,feel ingofbei ng" keyed
up"or" onedge"
Markeda ffectivela bility
Persistentandm arkedangerorirritability orin­
creasei ni nterpersonalconfl icts
• Additionalsy mptomsthatm aybeusedtofulfillthe
criteria:
Decreasedi nteresti nusual acti vities
Subjectivesenseofdi fficultyi nconcentrati ng
Lethargy,e asyfa tigability,o rm arkedla cko fe n­
ergy
Markedchangei nappeti te,overeati ng,orspeci fic
foodcravi ngs
Hypersomniao rin somnia
Subjectivesenseofbei ngoverw helmedoroutof
control
• Otherphy sicalsy mptomssuchasbreasttenderness
orsw elling,headaches,j ointorm usclepai n,asen­
sationofbl oating,orw eightgai n
• Symptomsoccurri ngduri ngl astw eekofl uteal
phase
• Symptomsareabsentpostm enstrually
• Disturbancesthati nterferew ith workorschool or
withusual soci alacti vitiesandrel ationships
• Disturbancesthatarenotanex acerbationofsy mp­
tomsofanotherdi sorder

D. DSM-IVcr iteriafor pr emenstrualdy sphoric disor­

der
1. Five or more ofthefol lowingsy mptomsm ust have
been present duri ng the w eek pri or to m enses,
resolvingw ithinafew day s after menses starts.A t
leastoneofthefi vesy mptomsm ust beoneofthe
firstfouronthislist:
a. Feelingsad,hopel ess,orsel f-deprecating
b. Feelingtense,anx ious,or" onedge"
c. Marked lability of m ood interspersed w ith fre­
quenttearful ness
d. Persistentirritability ,anger, andincreasedinter­
personalconfl icts
e. Decreasedi nteresti nusual activities, whichm ay
be associ ated w ith w ithdrawal from soci al rel a­
tionships
f. Difficultyconcentrati ng
g. Feelingfati gued,l ethargic,orl ackingi nenergy
h. Marked changes i n appeti te, w hich m ay be
associated w ith bi nge eati ng or cravi ng certai n
foods
i. Hypersomniao rin somnia
j. A subjective feelingofbei ngoverw helmedorout
ofcontrol
k. Otherphy sicals ymptoms,suchasbreasttender­
ness or sw elling, headaches, j oint or m uscle
pain,asensati onofbl oating,w eightgai n.

UCSDC riteriafor P remenstrualS yndrome

1. The presence by sel f report of at l east one of the

following som atic and affective sy mptoms duri ng the
fiveday spri ortom ensesi neach ofthethreem enstrual
cycles:
 Affective Somatic
Depression Breasttenderness
Angryoutbursts Abdominalbl oating
Irritability Headache
Confusion Swollenex tremities
Socialw ithdrawal
Fatigue

2. Reliefoftheabovesy mptomsw ithinfourday softhe

onsetofm enses,w ithout recurrenceunti latl east
cycleday 12.
3. Thesy mptomsarepresenti ntheabsenceofany
pharmacologictherapy ,horm onei ngestion,drugor
alcoholuse.
4. Identifiabledy sfunctioni nsoci aloreconom icperfor­
manceby oneofthefol lowingcri teria:
Maritalorrel ationshipdi scordconfi rmedby part­
ner
Difficultiesin p arenting
Poorw orkorschool perform ance,atten­
dance/tardiness
Increasedsoci ali solation
Legaldi fficulties
SuicidalI deation
Seekingm edicalattenti onforasom aticsy mp­
tom(s)

E. Differentiald iagnosis
1. PMDD shoul dbedi fferentiatedfrom prem enstrual
exacerbation of an underl ying m ajor psy chiatric
disorder, as well as m edical condi tions such as
hyper-orhy pothyroidism.
2. About13percentof women with PMS arefoundto
have a psychiatricdi sorderal onew ithno evidence
ofP MS,w hile38percent had premenstrualex acer­
bation of underl ying depressi ve and anx ietydi sor­
ders.
3. Womenw hopresentw ithP MShaveam uchhi gher
incidenceofm ajordepressi oni n the past andareat
greaterri skform ajordepressi oni nthefuture.
4. 39percentofw omenw ithP MDD m eet criteriafor
moodoranx ietydi sorders.
5. The assessm ent of pati ents w ith possi ble P MS or
PMDD shoul d begi n w ith the hi story, phy sical
examination, chem istry profi le, com plete bl ood
count,andserum T SH.T hehi storyshoul d focus in
particular on the regul arity of m enstrual c ycles.
Appropriate gy necologic endocrine eval uation
should be perform ed i f the cycles are i rregular
(lengthsl essthan25orgreaterthan36day s).
6. The p atient shoul d b e a sked t o r ecord sy mptoms
prospectivelyfortw om onths.I f thepati entfai ls to
demonstratea sy mptom free interval inth efo llicular
phase, she shoul d be eval uated for a m ood or
anxietydi sorder.
II. Treatmentofpr emenstrualdy sphoricdisor der
A. Serotoninr euptakeinhibitor s
1. Fluoxetine(S arafem)i saneffecti vetreatm entfor
PMDD w hen gi ven i n a dai ly dose of 20 m g/day.
The response rate i s 60 to 75 percent. T he m ost
common reasons for fai lure to conti nue the treat­
mentareheadache,anx iety,andnausea.
2. Otherdrugsthati nhibitserotoni nreuptak e, such as
clomipramine( Anafranil[gi venei therthroughoutthe
menstrual cy cle or restricted to the l uteal phase]),
sertraline(Zol oft)50to150m g/daythroughoutthe
menstrual cy cle, an d nefazodone (S erzone) 100­
300m gbi dal som aybeeffecti vei nP MS.
3. Venlafaxine (E ffexor) sel ectively i nhibits the
reuptakeofbothserotoni nandnorepi nephrineand
isal soeffecti ve(50to200m g/day).
4. Intermittent therap y given duri ng the l uteal phase
only(starti ngoncy cleday 14) has beenshow nto
beeffecti ve.
B. Alprazolam (Xanax),0.25m gT IDOR qi d,hasbee n
shown i n doubl e-blind, pl acebo-controlled crossover
studiestobebenefi ciali nP MS.
C. GnRH agonists (leupr olide [Lu pron] or buser elin)
have show n som e benefi t. H owever, w omen w ith
severeprem enstrual depressi onare unresponsiveto
GnRHagoni sts.T hephy sical symptoms maybem ore
responsivethanm oodsy mptomsi nw omen with PMS,
andsi deeffects(hy poestrogenism)m ayl imit theuse
ofthesedrugsforl ong-termtherapy .
1. GnRH agonists and " add-back" ther apy. A dd­
back therapy w ith estrogen (and a progesti n i f
indicated) mitigatesconcernsaboutbone loss from
prolonged adm inistration of GnRH agoni sts.
Leuprolideal onel edtoa75pe rcenti mprovement
in l uteal phase sy mptom scores. T his bene fit w as
maintained (60 percent i mprovement) dur ing a
crossover period i n w hich estrogen/progesti n
replacement w as added. A lendronate can be
considered in women whodonottol eratehorm onal
add-back therapy but need osteopo rosis prophy ­
laxis.
D. Danazoli nhibitspi tuitary gonadotropinsecreti on,and
is an effecti ve therapy for P MS. H owever, the
androgenic si de effects of danaz ol l imit its use to
patients w ho fai l to respond adequatel yto the above
therapies.
 TreatmentofP remenstrualS yndrome

Fluoxetine(S arafem)5-20m gqd

Sertraline(Zol oft)25-50m gqd
Paroxetine(P axil)5-20m gqd
Buspirone(B uSpar)25m gqdi ndi videddoses

Alprazolam(X anax)0.25-0.50m gti d

Mefenamicaci d(P onstel)250m gti dw ithm eals

Other
Spirolactone(A ldactone)25-200m gqd
Cabergoline(D ostinex)0.25m g-1m gtw iceaw eek
duringthel utealphaseforbreastpai n

E. Treatmentswithpossibleefficacy inP MS
1. Exercise an d relaxation techniques. T here i s
suggestiveevi dencethatex ercise,rel axation,and
reflexologym ayhel ptoal leviateP MSsy mptoms.
2. Diuretics. Spironolactone(A ldactone),25-200m g
qd, m ay si gnificantly decrease i n nega tive m ood
symptomscoresandsom aticsy mptom.
F. Recommendationsfor theclinicalm anagementof
PMS/PMDD
1. Because of the proven effi cacy and safety profi le,
serotonin reuptak e i nhibitors (S SRIs) are th e first
line thera py. Fl uoxetine (S arafem) has been the
beststudi ed.T heeffecti vedosei s20m g/day.
2. Approximately1 5p ercento fp atientsw ille xperience
significant side effects from an S SRI, i ncluding
nausea,j itteryness,andheadache.I nsuchpati ents,
a tri al of ei ther a l ower starti ng dose or a second
SSRI, such as sertral ine (Zol oft) 25-50 m g qd, i s
warranted.
3. Approximately 15 percent do not respond to a n
SSRIover severalm enstrualcy cles.T hesew omen
arecandi datesfor alprazolam (Xanax)0.25m gT ID
orQI Di nthel utealphaseofthecy cle.
4. Patients w ho do no t respond to S SRIs or
alprazolam ar e candi dates for ovul ation suppres­
sion agents.I npati entsw horespondw ell to GnRH
agonists, therapy may be ex tended bey ond si x
monthsw ithan attemptat" add-back"therapy w ith
estrogenandprogesterone.
References:S eepage166.

AbnormalVaginalBleeding
Menorrhagia(ex cessive bleeding) ism ostcom monlycaused
by anovulatory menstrual cycles.Occasi onallyi ti scaused by
thyroiddy sfunction,i nfectionsorcancer.
I. Pathophysiologyofnor malm enstruation
A. In response to gonadotropi n-releasing horm one fr om
the hy pothalamus, the pi tuitary gl and sy nthesizes
follicle-stimulating horm one (F SH) and luteiniz ing
hormone (LH ), w hich i nduce the ovari es to produce
estrogenandprogesterone.
B. Duringt hef ollicularphase, estrogenstim ulationcauses
ani ncreasei nendom etrial thi ckness.A fterovul ation,
progesteronecausesendom etrialma turation.M enstru­
ation i s caused by estrogen and progesterone w ith­
drawal.
C. Abnormalbl eedingi sdefi nedasbl eeding that occurs
at i ntervals of l ess than 21 day s, m ore than 36 days,
lastingl ongerthan7day s,or blood lossgreaterthan80
mL.
II. Clinicalev aluationo fab normalv aginalb leeding
A. A menstrual and reproducti ve hi story shoul d i nclude
last m enstrual peri od, regul arity, durati on, frequency ;
the numberofpadsusedperday ,andi ntermenstrual
bleeding.
B. Stress, ex ercise, w eight changes and sy stemic di s­
eases,parti cularlythy roid, renalorhepati cdi seasesor
coagulopathies,shoul dbesough t. Them ethodofbi rth
controlshoul dbedeterm ined.
C. Pregnancycom plications,suchasspontaneousabor­
tion, ectopi c pregnancy , pl acenta previ a and abrupti o
placentae, can cause heavy bl eeding. P regnancy
should al ways be consi dered as a possi ble cause of
abnormalvagi nalbl eeding.
III. Pubertyandadolescence--m enarchetoage16
A. Irregularity i s norm al duri ng the fi rst few m onths of
menstruation; however,soak ingm orethan25 pads or
30tam ponsduri ngam enstrualperi odi sabnorm al.
B. Absence o f p remenstrual sy mptoms ( breast t ender­
ness, bl oating, cram ping) i s ass ociated with
anovulatorycy cles.
C. Fever,parti cularlyi nassoci ationw ithpel vicorabdom i­
nal pai nm ay, i ndicatepel vici nflammatorydi sease.A
history ofeasy brui sings uggestsacoagul ationdefect.
Headaches and vi sual changes suggest a pi tuitary
tumor.
D. Physicalfindings
1. Pallor not associ ated w ith tachycardia or si gns of
hypovolemiasuggestschroni cex cessivebl oodl oss
secondary t o anovulatory bl eeding, adenom yosis,
uterinem yomas,orbl ooddy scrasia.
2. Fever,l eukocytosis,andpel victendernesssuggests
PID.
 3. Signs of i mpending shock i ndicate that the bl ood
loss i s r elated to pregnancy (i ncluding ectopi c),
trauma,sepsi s,orneopl asia.
4. Pelvicm assesm ay represent pregnancy,uteri neor
ovarian neopl asia, or a pelvic abscess or
hematoma.
5. Fine,thi nninghai r, andhy poactiverefl exessuggest
hypothyroidism.
6. Ecchymosesorm ultiplebrui sesm ayi ndicatetrau­
ma, coagulationdefects,m edicationuse, or dietary
extremes.
E. Laboratorytests
1. CBCandpl ateletcountandauri neorserum preg­
nancytestshoul dbeobtai ned.
2. Screeningforsex ually transmitted diseases,thy roid
function, and coagu lation disorders (parti al
thromboplastinti me, INR,bl eedingti me)shoul dbe
completed.
3. Endometrialsam plingi srarel ynec essaryforthos e
underage20.
F. Treatmentofi nfrequentbl eeding
1. Therapyshoul dbedi rectedatthe underlyingcause
whenpossi ble.I ftheC BCandotheri nitiall aboratory
testsarenorm alandthe history andphy sicalex ami­
nation are normal,reassurancei susual lyal lthati s
necessary.
2. Ferrous gl uconate, 325 m g bi d-tid, shoul d be pre­
scribed.
G. Treatmentoffr equentor heav ybl eeding
1. Treatmentw ithn onsteroidalanti -inflammatorydrugs
(NSAIDs) i mproves pl atelet aggregati on and i n­
creases uteri ne vasoconstri ction. N SAIDs are the
firstchoi cei nthetreatm ent of menorrhagia because
they are w ell tol erated and do not have the hor­
monaleffectsoforal contracepti ves.
a. Mefenamic acid(P onstel)500m gti d during the
menstrualperi od.
b. Naproxen(A naprox,N aprosyn)500m gl oading
dose, the n 250 m g ti d duri ng the m enstrual
period.
c. Ibuprofen(M otrin, Nuprin) 400 mgti dduri ngthe
menstrualperi od.
d. Gastrointestinaldistr essiscom mon.NS AIDsa re
contraindicated i n renal f ailure and pepti c ul cer
disease.
2. Ironshoul dal sobeadded as ferrous gluconate 325
mgtid.
H. Patients with hy povolemia or a hem oglobin l evel
below 7 g /dL should be hospi talized for horm onal
therapyandi ronrepl acement.
1. Hormonal therapy consi sts of estrog en (P remarin)
25m gI Vq6hunti lb leedingst ops.Th ereafter,o ral
contraceptivepillsshoul d beadm inisteredq6hx 7
days,thentaperslow lytoonepillqd.
2. If bl eeding conti nues, I V va sopressin ( DDAVP)
should be adm inistered. H ysteroscopy m ay be
necessary, and di lation and curettage i s a last
resort. T ransfusion m ay b e i ndicated i n severe
hemorrhage.
3. Ironshoul dal sobeadded as ferrous gluconate 325
mgtid.
IV. Primarychildbear ingy ears–ages16toear ly40s
A. Contraceptive com plications and pregnancy are the
most common causesofabnorm albl eedingi nthi sage
group.A novulationaccountsfor20% ofcases.
B. Adenomyosis,endom etriosis,andfi broidsi ncreasei n
frequency as a womanages,asdoendom etrialhy per­
plasia and endom etrial pol yps. P elvic i nflammatory
diseaseandendocri nedy sfunctionm ayal sooccur.
C. Laboratorytests
1. CBCandpl atelet count, Pap smear,andpregnancy
test.
2. Screeningforsex uallytransm ittedd iseases,thy roid­
stimulating horm one, and coagul ation di sorders
(partialthrom boplastinti me,I NR,bl eedingti me).
3. If a non-pregnant w oman has a pel vic m ass,
ultrasonography orhy sterosonography(w ithuteri ne
salinei nfusion)i srequi red.
D. Endometrialsam pling
1. Long-term unopposed estrogen sti mulation i n
anovulatory pati ents can result i n endom etrial
hyperplasia, which can p rogress to adeno­
carcinoma; therefore, i n peri menopausal pati ents
whohavebeenanovul atoryfor anex tendedi nterval,
theendom etriumshoul dbebi opsied.
2. Biopsyi sal sorecom mendedbeforei nitiationofhor­
monaltherapy forw omen over age30andforthose
overage20w hohavehadprol ongedbl eeding.
3. Hysteroscopyandendom etrialbi opsy with a Pipelle
aspirator shoul d be done on the fi rst day of m en­
struation (to avoi d an unex pected pregnancy ) or
anytimei fbl eedingi sconti nuous.
E. Treatment
1. Medicalp rotocolsforanovul atorybl eeding(dy sfunc­
tional uteri ne bl eeding) are si milar to those de­
scribedaboveforadol escents.
2. Hormonalther apy
a. Inw omenw hodonotdesi rei mmediatef ertility,
hormonal therapy m ay be used to treat
menorrhagia.
b. A21-day pack age of oral contraceptivesi sused.
Thepatientshouldtak eonepillthreetim esaday
for 7 days. Duringthe7day softherapy , bleeding
shouldsubsi de,and, followingtreatm ent,heavy
flow w ill occur. A fter 7 day s off the hormones,
 another 21-day pack age i s i nitiated, tak ing one
pill eachday for21day s,thennopills for 7 days.
c. Alternatively, m edroxyprogesterone (P rovera),
10-20m gper day for days16through25ofeach
month, w ill result in a reduction of m enstrual
bloodloss.P regnancyw illnotbeprevented.
d. Patients w ith severe bl eeding m ay have
hypotension and tachy cardia. T hese pati ents
require hospitalization,andestrogen(P remarin)
should be administeredI Vas25m gq4-6hunti l
bleedingsl ows (up to am aximumoffourdoses).
Oral contracepti ves s hould be i nitiated concur­
rentlyasdescri bedabove.
3. Ironshoul dal sobeadded as ferrous gluconate 325
mgtid.
4. Surgicaltreatm entcanbeconsi deredi fchi ldbearing
is com pleted and m edical m anagement fai ls to
providerel ief.
V. P r e m e n o p a u s a l , p e r i m e n o p a u s a l , a n d
postmenopausaly ears--age40andov er
A. Anovulatory bl eeding accounts for about 90% of
abnormalvagi nalbl eedingi nthi sagegroup.H owever,
bleedingshoul dbeconsi dered tobefrom cancer until
provenotherw ise.
B. History, ph ysical ex amination and l aboratory testi ng
are indicatedasdescri bedabove.M enopausal symp­
toms,personal or familyhi storyofm alignancyanduse
ofestrogenshoul dbesought.A pel vicm assrequi res
aneval uationw ithul trasonography.
C. Endometrialcar cinoma
1. In a peri menopausal or postm enopausal w oman,
amenorrheaprecedi ng abnormalbl eedingsuggests
endometrial cancer. E ndometrial eval uation i s
necessary b efore t reatment o f a bnormal va ginal
bleeding.
2. Before endom etrial sam pling, determ ination of
endometrial t hick ness b y t ransvaginal
ultrasonographyi s useful becausebi opsyi s often
notrequ iredw hentheendom etriumi sl essthan5
mmt hick.
D. Treatment
1. Cystic hy perplasia or endom etrial hy perplasia
without cy tologic aty pia i s treated w ith depo­
medroxyprogesterone,200m gI M,then100 to200
mg IM every 3 to 4 w eeks for 6 to 12 m onths.
Endometrial hy perplasia requires repeat
endometrialbi opsyevery 3to6m onths.
2. Atypicalhy perplasia requires fractionaldi lationand
curettage,fol lowedby progesti ntherapy or hyster­
ectomy.
3. Ifthepati ent'sendom etriumi snorm al(oratrophi c)
and contraception i s a concern, a l ow-dose oral
contraceptivem aybe used. Ifcontracepti oni snot
needed, estrogenandprogesteronetherapy shoul d
beprescri bed.
4. Surgicalm anagement
a. Vaginal or abdom inal hy sterectomy is th e
mostabsol utecurati vetreatm ent.
b. Dilatation and cur ettage can b e used as a
temporizingm easuretostopbl eeding.
c. Endometrialablationandr esectionby laser,
electrodiathermy“rol lerball,”orex cisional resec­
tionareal ternativestohy sterectomy.
References:S eepage166.
BreastC ancerSc reeningan dDia gno­
sis
Breast cancer isthem ostcom monform of cancer in women.
There are 200,000 new cases of breast cancer each y ear,
resulting in 47,000deathspery ear.T hel ifetimeri sk of breast
cancer i s one i n ei ght f or a woman w ho i s age 20. For
patientsunderage60,thechanceofbei ngdi agnosedw ith
breastcanceri s1i nabout400i nagi veny ear.

I. Pathophysiology
A. The eti ology of breast cancer rem ains unk nown, but
twobreastcancergeneshavebeencl oned–the BRCA­
1 and theB RCA-2genes.Onl y10% ofal lofthebreast
cancerscanbe explained by mutationsi nthesegenes.
B. Estrogen stimulation isani mportantprom oterofbreast
cancer, and,therefore,pati ents whohaveal onghi story
of menstruation are ati ncreasedri sk.E arlym enarche
andl atem enopauseareri skfactors forbreastcancer.
Lateageatbirthoffirstchild ornulliparity also increase
theri skofbreastcancer.
C. Familyhi storyofbreast cancer in afi rstdegreerel ative
andhi storyofbeni gnbreastdi sease also increase the
risk ofbreastcancer.T heuseofestrogen replacement
therapyororal contraceptivessl ightlyi ncreasestheri sk
of breast cancer. R adiation ex posure and al coholic
beverageconsum ptional soi ncreasetheri skofbreast
cancer.

RecommendedInter valsfor B reastC ancerS creen­

ingS tudies

Age 40-49 50-75y r

<40y r yr

Breast Monthl Monthl Monthly

Self-Ex­ yb y y
aminatio age30
n

Profes­ Every Annu­ Annually

sional 3y r, ally
Breast ages
Exam­ 20-39
ination

Mammo Annu­ Annually

graphy, ally
Low
Risk
Patient

Mammo Begin Annu­ Annually

graphy, at35 ally
High yr
Risk
Patient

II. Diagnosisandev aluation

A. Clinicalev aluationofabr eastm assshoul d assess
durationofthel esion,associ ated pain,rel ationshipto
them enstrual cy cleorex ogenoushorm oneuse,and
changei nsi zesi ncedi scovery. The presence of nipple
discharge and i ts character (bl oody or tea-col ored,
unilateral or b ilateral, spontaneous or ex pressed)
shouldbeassessed.
B. Menstrualhi story. The dateofl astm enstrual period,
age of m enarche, age of m enopause or surgi cal
removal of the ovari es, regu larity of the m enstrual
cycle, previ ous pre gnancies, age at fi rst pregnancy ,
andl actationhi storyshoul dbedeterm ined.
C. Historyofpr eviousbr east biopsies,breastcancer,
orcy stasp irationshoul dbei nvestigated.P reviousor
current oral contracepti ve and horm one repl acement
therapy and d ates and resul ts of previ ous m ammo­
gramsshoul dbeascertai ned.
D. Family hi story should docum ent breast cancer i n
relatives and the a ge at w hich fam ily m embers w ere
diagnosed.
III. Physicalexam ination
A. The breasts shoul d be inspected for asy mmetry,
deformity, sk in r etraction, ery thema, peau d'orange
(indicating breast edem a), and ni pple retracti on,
discoloration,ori nversion.
B. Palpation
1. Thebreasts should be palpatedw hilethepati enti s
sitting and then supine w ith the i psilateral arm
extended. T he enti re breast shoul d be pal pated
systematically.
2. Them assshoul dbeeval uated for size, shape,tex ­
ture, tenderness, fixationtosk inorchestw all. The
location ofthem assshoul dbedocum ented with a
diagram i n the patient’s chart. T he ni pples shoul d
 beex pressedtodeterm inew hetherdi schargecan
bei nduced. Nippledi schargeshoul dbeeval uated
for singleorm ultipleducts,col or,andany associ ­
atedm ass.
3. Theax illaeshoul dbepal patedforadenopathy , with
an assessment of si ze of the l ymph nodes, thei r
number, and fi xation. T he supraclavicular and
cervicalnodesshoul dal sobeassessed.
IV. Breastim aging
A. Mammography
1. Screening m ammography i s perform ed in the
asymptomatic p atients and consi sts of tw o vi ews.
Patients are not ex amined by a m ammographer.
Screening m ammography reduces m ortality fr om
breastcancerandshoul d usuallybei nitiated at age
40.
2. Diagnostic m ammography i s perform ed after a
breast m ass has been detected. P atients u sually
are ex amined by a m ammographer, and fi lms are
interpretedi mmediatelyandaddi tional views of the
lesion are com pleted. M ammographic fi ndings
predictiveofm alignancy includespi culatedm asses
witharchi tecturaldi stortion andm icrocalcifications.
A norm al m ammography i n the p resence of a
palpablem assdoesnotex cludem alignancy.
B. Ultrasonographyi susedasanadj uncttomam mogra­
phyto di fferentiate sol id from c ystic m asses. I t is the
primaryi magingm odality inpati entsy oungerthan30
yearsol d.
V. Methodsofbr eastbiopsy
A. Stereotacticcor eneedle biopsy.U singa computer­
drivenstereotacti cuni t, the lesioni sl ocalizedi nthree
dimensions,andanautom atedbi opsy needle obtains
samples. T he sensi tivity and speci ficity of thi s tech­
niqueare95-100% and94-98% ,respecti vely.
B. Palpable m asses. Fine-needle aspir ation biopsy
(FNAB) has a sensi tivity rangi ng from 90-98% .
Nondiagnosticaspi ratesrequi resurgi calbi opsy.
1. The sk in i s prepped w ith al cohol and the l esion i s
immobilized w ith the nonoperating hand. A 10 m L
syringe,w itha18to22gauge needle, isi ntroduced
intothecentral porti on of the mass ata90°angl e.
When the needl e enters the m ass, s uction i s ap­
plied by r etracting the pl unger, and the needl e i s
advanced. T he needl e i s di rected i nto di fferent
areasofthem assw hilem aintainingsucti ononthe
syringe.
2. Suction is sl owly rel eased before the needl e i s
withdrawn from the m ass. T he contents of the
needle a re pl aced onto gl ass sl ides for pathol ogic
examination.
C. Impalpablelesio ns
1. Needlelocalizedbiopsy
a. Under m ammographic gui dance, a needl e and
hookwirearepl aced intothebreastparenchy ma
adjacenttothe lesion. The patient istak entothe
operatingroom al ong with mammogramsforan
excisionalbreastbi opsy.
b. The sk in and underl ying ti ssues are infiltrated
with1% l idocainew ithepi nephrine.Forl esions
located w ithin 5 cm of the ni pple, a peri areolar
incision m ay be used or use a curved i ncision
locatedoverthem ass and parallel totheareol a.
Incise the sk in and subcutaneous fat, then
palpatethel esionandex cisethem ass.
c. Afterrem oval ofthespeci men,aspeci menx -ray
isperform edtoconfi rmthatthel esion hasbeen
removed.T he specimen canthenbe sent fresh
forpathol ogicanal ysis.
d. Close the su bcutaneous ti ssues w ith a 4-0
chromiccatgutsuture,andcl ose the skinw ith4­
0subcuti cularsuture.
References:S eepage166.

BreastD isorders
Breastpai n,ni pple di schargeandapal pablem assarethe
mostcom monbreastprobl emsforw hich womenconsul ta
physician.
I. NippleD ischarge
A. Clinicalev aluation
1. Nipple dischargem aybeasi gn of cancer; therefore,
itm ustbethoroughl yeval uated.A bout8% ofbi op­
sies performed for ni pple di scharge dem onstrate
cancer. T he durati on, bi laterality or uni laterality o f
thedi scharge,andthepr esenceofbl oodshoul d be
determined. A hi story of oral contr aceptives, hor­
monepreparati ons,phenothi azines,ni ppleorbreast
stimulation o r l actation shoul d be sought. D is­
charges t hat fl ow spontaneousl yare m ore l ikelyto
be pathologic thandi schargesthatm ustbem anually
expressed.
2. Unilateral, pi nk col ored, bl oody or non-m ilky di s­
charge, or di scharges associ ated w ith a m ass are
thedi scharges of mostconcern.M ilkydi schargecan
be caused by oral cont raceptive agents, estrogen
replacementthe rapy,phenothi azines,prol actinoma,
or hy pothyroidism. N ipple di scharge secondary to
malignancyi sm orel ikelytooccuri n older patients.
3. Risk factor s. T he assessm ent shoul d identifyri sk
factors,i ncludingageover50y ears,past personal
history of breast cancer, hi story of hy perplasia on
previousbreastbi opsies,and family historyofbreast
 cancer i n a fi rst-degree rel ative (m other, si ster,
daughter).
B. Physicalexam inationshoul di ncludei nspection ofthe
breastforul ceration or contourchangesand inspection
oftheni pple.P alpationshoul dbeperform ed with the
patienti nboththeupr ight andthesupi neposi tionsto
determinethepresenceofam ass.
C. Diagnosticev aluation
1. Bloodydi scharge.A m ammogramofthei nvolved
breast shoul d be obtai ned if the pati ent i s over 35
yearsol dandhasnothadam ammogram withinthe
preceding 6 m onths. B iopsy of any suspi cious
lesionsshoul dbecom pleted.
2. Watery,u nilaterald ischarge shouldbereferredto
asurgeonforeval uationandpossi blebi opsy.
3. Non-bloody d ischarge shoul d be tested for the
presence of bl ood with a H emoccult card. N ipple
discharge secondary tocarci nomausual lycontai ns
hemoglobin.
4. Milky,b ilaterald ischargeshoul dbeeval uated with
assaysofprol actinandthy roidsti mulating hormone
toex cludeanendocri nologiccause.
a. A mammogram shouldbeperform edi fthepati ent
isdueforrouti nem ammographicscreeni ng.
b. If resul ts of the m ammogram and t he
endocrinologicscreeni ng studies arenorm al,the
patient shoul d return for a follow-up vi sit i n 6
monthstoensurethat there hasbeenno specific
changei nthecharacterofthe discharge, suchas
developmentofbl eeding.
II. BreastP ain
A. Breast pai n i s the m ost com mon bre ast sy mptom
causing w omen to consult pri mary care phy sicians.
Mastalgiai sm orecom moni nprem enopausalw omen
than i n postm enopausal w omen, and i t i s rarel y a
presentingsy mptomofbreastcancer.
B. The e valuation o f b reast p ain should d etermine t he
type of pai n, i ts l ocation an d i ts rel ationship to the
menstrualcy cle.M ostcom monly,breastpai n isassoci ­
atedw iththem enstrualcy cle(cy clicm astalgia).
C. Cyclic paini susual lybi lateralandpoorl y localized. The
pain i s often rel ieved after the m enses. C yclic breast
painoccursm oreofteni ny oungerw omenand resolves
spontaneously.
D. Noncyclicm astalgiai sm ostcom moni nw omen40to
50 years ofage.I ti softenauni lateralpai n. Noncyclic
mastalgiai s occasionally secondary tothepresenceof
afi broadenomaorcy st,andthe painm ayberel ieved
bytreatm entoftheunderl yingbreastl esion.
E. Evaluation. Athoroughbreastex aminationshoul d be
performedtoex cludethepresenceofa breastm ass.
Women 35 y ears of age and ol der shoul d undergo
mammographyunl essam ammogram wasobtai nedi n
thepast12 months. Ifasuspi ciousl esioni sdetected,
biopsy i s requi red. W hen the phy sical ex amination i s
normal, i maging studi es are not i ndicated i n w omen
younger than 35 y ears of age. A follow-up cl inical
breast examination shouldbeperform edi n1-2 months.
F. Mastodynia
1. Mastodyniai sdefi nedasbreast paini ntheabsence
ofam assorotherpathol ogicabnorm ality.
2. Causesofm astodyniai nclude menstruallyrel ated
pain, costochondri tis, trauma, and scl erosing
adenosis.
III. FibrocysticCo mplex
A. Breast changes are usual ly m ultifocal, bi lateral, and
diffuse. One orm orei solatedfi brocysticl umpsorareas
of asy mmetrym aybe present. T he areas are usual ly
tender.
B. This di sorder predom inantly occurs i n w omen w ith
premenstrual abnorm alities, nulliparous w omen, and
nonusersoforal contracepti ves.
C. The di sorder usual lybegi ns in m id-20's or earl y30's.
Tenderness is associatedw ithm ensesandl asts about
a week. The upper outerquadrantofthebreasti sm ost
frequently i nvolved bilaterally. T here i s no i ncreased
riskofcancerforthem ajorityofpati ents.
D. Suspicious areas may be eval uated by fi ne needl e
aspiration( FNA)cy tology. I f ma mmography andFN A
are negative forcancer,andthecl inical examination is
benign,openbi opsyi sgeneral lynotneeded.
E. Medicalm anagementoffi brocysticcom plex
1. Oralcontr aceptivesareeffecti vefor severe breast
pain in m ost y oung w omen. S tart w ith a pill that
containsl owam ountsof estrogen and relativelyhi gh
amountsof progesterone(Loestri n,LoOvral ,Ortho-
Cept).
2. If oral contracepti ves do not provi de rel ief,
medroxyprogesterone,5-10m g/dayfrom day s15-25
ofeachcy cle,i sadded.
3. A professi onally fi tted support bra often provi des
significantrel ief.
4. Danazol (D anocrine), an anti gonadotropin, has a
response rate of 50 to 75 percent i n w omen w ith
cyclicpai n whorecei veddanaz oli nadosageof100
to 400 m g per day . D anazol thera py is recom ­
mendedonl yforpati entsw ithsever e,acti vity-limiting
pain. S ide effects i nclude m enstrual i rregularity,
acne,w eightgai nandhi rsutism.
5. Eveningpr imroseoil (g-linolenicaci d)i seffecti ve
inabout38to58percentofpati entsw ithm astalgia;
2-4gperday .
IV. BreastM asses
A. The norm al gl andular ti ssue of the breast i s nodul ar.
Nodularity i s a phy siologic process and i s not an
 indicationofbreastpathol ogy.D ominantm assesm ay
be discreteorpoorl ydefi ned,butthey di fferi ncharacter
from the surroundi ng breast ti ssue. T he di fferential
diagnosis of a dom inant breast m ass i ncludes
macrocyst (cl inically evi dent cy st), fi broadenoma,
prominentareasoffi brocysticchange,fatnecrosi sand
cancer.
B. CysticB reastM asses
1. Cysts are a com mon cause of dom inant breast
masses i n prem enopausal w omen m ore than 40
years of age, but they are an i nfrequent cause of
suchm assesi ny oungerw omen.C ystsareusual ly
welldem arcated,fi rmandm obile.
2. Ultrasonography or aspi ration m ust establ ish a
definitivedi agnosisforacy st.C ystsrequi re surgical
biopsyi f the aspirated fl uid i s bl oody, the pal pable
abnormality does not resol ve com pletely after the
aspiration of fl uid or t he sam e cy st recurs m ultiple
times i n a short peri od of ti me. R outine cy tologic
examinationofcy stfl uidi snoti ndicated.
3. Nonpalpablecy stsi dentifiedby m ammographya nd
confirmedtobesi mplecy stsby ul trasoundex amina­
tionrequi renotreatm ent.
C. SolidB reastM asses
1. Noncystic m asses i n prem enopausal w omen that
are cl early di fferent from the surroundi ng breast
tissue requi re hi stologic sam pling by fi ne-needle
aspiration,corecutti ng,needl e biopsy or excisional
biopsy.
2. SolidM assesinW omenLessThan4 0 Y earsof
Age
a. Ifthephy sicalex amination revealsnoevi denceof
a dom inant br east m ass, the pati ent shoul d be
reassured and i nstructed i n breast
self-examination. I f the cl inical si gnificance of a
physicalfi ndingi suncertai n,adi rectedul trasound
examination i s perform ed. I f thi s ex amination
does not dem onstrate a m ass, the phy sical
examination is repeated intw otofourm onths.I n
women 35 to 40y earsofagew hohave a normal
ultrasoundex amination,am ammogrammay al so
beobtai ned.
b. Asuspi ciousm assi ssol itary,di screte, hardand
adherent to adj acent ti ssue. M ammography
should be perform ed before obtai ning a patho­
logicdi agnosis.
c. If a cl inically beni gn m ass i s present, an ul tra­
sound examination andfi ne-needleaspi rationare
performed to confi rm that the m ass i s beni gn.
Thisapproachi sthe“tri pletest” (clinicalex amina­
tion, ul trasonography [or m ammography] and
fine-needleaspi ration).
3. SolidM assesinW omenM oreThan40 Yearsof
Age. A bnormalities detected on phy sical ex amina­
tioni nol derw omenshoul dbe regarded aspossi ble
cancers unti l they are proven to be beni gn. In
women m ore than 40 y ears of age, di agnostic
mammographyi s astandardpartoftheeval uation
ofasol idbreastm ass.
References:S eepage166.

SexualA ssault
Sexualassaul t is defined asany sex ualactperform edby one
person on another w ithout t he person's consent. S exual
assaulti ncludesgeni tal,anal ,ororal penetrati on byapartof
theaccused'sbody orby an object. Itm ayresul tfrom force,
the th reat o f fo rce, o r th e vic tim's inability to g ive co nsent.
Theannu al incidenceofsex ual assaul ti s 200per100,000
persons.

I. Psychologicaleffects
A. Aw omanw ho is sexually assaultedl osescontrol over
her l ife duri ng the peri od of the assaul t. H er integrity
and her l ife are threa tened. S he m ay ex perience
intense anx iety, anger, or fear. A fter the assaul t, a
"rape-trauma"sy ndromeoftenoccurs.T hei mmediate
responsem ayl astforhours or daysandi scharacter­
ized by general ized pai n, headache, chroni c pel vic
pain, eati ng and sl eep di sturbances, vagi nal sy mp­
toms,depressi on,anx iety,andm oodsw ings.
B. The del ayed phase i s characteri zed by fl ashbacks,
nightmares,andphobi as.
II. Medicalev aluation
A. Informedconsent mustbeobtai nedbeforetheex ami­
nation.A cuteinjuries should be stabilized.A bout1% of
injuries requi re hospi talization and m ajor operati ve
repair,and0.1% ofi njuriesarefatal .
B. A hi story and phy sical ex amination shoul d be per­
formed. A chaperon shoul d be present duri ng th e
historyandphy sicalex aminationtoreassurethevi ctim
and provi de s upport. Th e p atient s hould be ask ed to
state i n her ow n w ords w hat happened, i dentify her
attacker i f possi ble, and provi de detai ls of the act (s)
performedi fpossi ble.

ClinicalC areoftheS exualA ssaultV ictim

Medical
Obtaini nformedconsentfrom thepati ent
Obtainagy necologichi story
Assessandtreatphy sicali njuries
Obtainappropri atecul turesandtreatany ex isting
infections
Provideprophy lacticanti biotictherapy andoffer
immunizations
Providetherapy topreventunw antedconcepti on
Offerbasel ineserol ogictestsforhepati tisB vi rus,
humanim munodeficiencyviru s(HI V),andsy philis
Providecounsel ing
Arrangeforfol low-upm edicalcareandcounsel ing

Legal
Provideaccuraterecordi ngofevents
Documentin juries
Collectsam ples(pubi chai r,fi ngernailscrapi ngs,
vaginalsecreti ons,sal iva,bl ood-stainedcl othing)
Reporttoauthori tiesasrequi red
Assurechai nofevi dence

C. Previous obstetricandgy necologiccondi tions should

be sought, parti cularly i nfections, pregnancy , use of
contraception, and date of the l ast menstrual peri od.
Preexisting pregnancy , ri sk for preg nancy, and the
possibility of preex isting infections should be as­
sessed.
D. Physical exam ination of the enti re body and photo­
graphs or draw ings of the i njured areas sho uld be
completed.B ruises,abrasi ons,and lacerations should
be sought.S uperficial orex tensivel acerationsofthe
hymenandvagi na,i njurytotheurethra,andoccasi on­
ally rupture of the vagi nal vaul t i nto the abdom inal
cavitym aybenoted.B item arksarecom mon.
1. Pelvic exam ination shoul d assess the status of
thereproducti veorgans,col lectsam plesfrom the
cervix and vagi na, and test for N eisseria
gonorrhoeaeandC hlamydiatrachom atis.
2. AW oodlig htshoul dbeusedtofi ndsem enon the
patient's body : dri ed sem en will fl uoresce. S perm
and other Y -chromosome-bearing cel ls m ay be
identifiedfrom m aterialscol lectedfrom vi ctims.
E. A ser um sam ple shoul d be obtai ned for basel ine
serologyforsy philis, herpessim plexvirus,hepatitisB
virus,andH IV.
F. Trichomonas i s the m ost frequentl y ac quired S TD.
The ri sk of acquiring hum an i mmunodeficiency vi rus
(HIV) < 1% duri ng a si ngle act of het erosexual i nter­
course, but the ri sk depends on the popul ation i n­
volved and the sex ual acts perform ed. The ri sk of
acquiringgonorrhea is 6-12%, andtheri skofacqui ring
syphilisis3 %.
G. HepatitisB v irus is 20ti mesm orei nfectiousthan HIV
duringsex ual intercourse. HepatitisB i mmunegl obulin
(0.06 mLofhepati tisB i mmunegl obulinperk ilogram)
should be adm inistered i ntramuscularly as soon as
possiblew ithin14day sofex posure.I t i s fol lowed by
the standard three-dose immunization seri es w ith
hepatitis B vaccine (0,1,and6m onths),begi nning at
the time ofhepati tisB i mmunegl obulin administration.
H. Emergencycon traception. I f thepati enti s foundto
be a t r isk f or pregnanc y a s a r esult o f t he a ssault,
emergencycontracepti onshoul d beoffered.T heri sk
ofpregnancy aftersex ualassaul ti s 2-4% in victimsnot
alreadyusi ng contraception. Onedoseofcom bination
oralcontracepti vetabl etsi sgi venattheti methevi ctim
is seen and an addi tional dose i s gi ven i n 12 hours.
Emergencycontracepti on can be effective up to 120
hours after unprotected coi tus. M etoclopramide
(Reglan), 20 m g w ith each dose of horm one, i s pre­
scribed for nausea. A pregnancy te st shoul d be per­
formed at th e 2-week return vi sit i f concepti on i s
suspected.
 EmergencyC ontraception

1. Considerpretreatm entonehourbeforeeachoral
contraceptivepilldose,usingoneofthefollow ing
orallyadm inisteredanti emeticagents:
Prochlorperazine(C ompazine),5to10m g
Promethazine(P henergan),12.5to25m g
Trimethobenzamide(T igan),250m g
2. Administerthefi rstdoseoforal contracepti vepi ll
within72hoursofi ntercourse,andadm inisterthe
seconddose12hoursafterthefi rstdose.B rand
nameopti onsforem ergencycontracepti oni nclude
thefol lowing:
PrevenKit- -twop illsp erd ose( 0.5m go f
levonorgestreland100µ gofethi nylestradi olper
dose)
Ovral--twopillsperdose(0.5m goflevonorgestrel
and100µ gofethi nylestradi olperdose)
PlanB --onepillper dose(0.75m gof
levonorgestrelperdose)
Nordette--fourp illsp erd ose( 0.6m go f
levonorgestreland120µ gofethi nylestradi olper
dose)
Triphasil--fourpillsperdose(0.5m gof
levonorgestreland120µ gofethi nylestradi olper
dose)

ScreeningandTr eatmentofS exuallyTr ansmissi­

bleInfectionsFollowingS exualA ssault

InitialE xamination

Infection
• Testingforandgonorrheaandchl amydiafrom spec­
imensfrom any si tesof penetrationorattem pted
penetration
• Wetm ountandcul tureoravagi nalsw abspeci men
forT richomonas
• Serumsa mplefo rsy philis,h erpessim plexvir us,
hepatitisB vi rus,andH IV
PregnancyP revention
Prophylaxis
• HepatitisB vi rusvacci nationandhepati tisB i mmune
globulin.
• Empiricrecom mendedanti microbialtherapy for
chlamydial,gonococcal ,andtri chomonali nfections
andforbacteri alvagi nosis:
Ceftriaxone,125m gi ntramuscularlyi nasi ngle
dose,pl us
Metronidazole,2goral lyi nasi ngledose,pl us
Doxycycline100m goral lytw oti mesaday for7day s
Azithromycin(Zi thromax)i susedi fthepati enti s
unlikelytocom plyw iththe7day courseof
doxycycline;si ngledoseoffour250m gcaps.
Ifthepatientispenicillin -allergic,ciproflox acin500
mgP Oorofl oxacin400m gP Oi ssubsti tutedfor
ceftriaxone.I fthepati enti spregnant,ery thromycin
500m gP Oqi dfor7day si ssubsti tutedfor
doxycycline.
HIVprophy laxisconsi stsofz idovudine(A ZT)200
mgP Oti d,pl usl amivudine(3T C)150m gP Obi d
for4w eeks.

Follow-UpE xamination(2weeks)

• CulturesforN gonorrhoeaeandC trachom atis(not

neededi fprophy lactictreatm enthasbeenprovi ded)
• Wetm ountandcul tureforT vagi nalis
• Collectionofserum sam pleforsubsequentserol ogic
analysisi ftestresul tsareposi tive

Follow-UpE xamination(12weeks)

Serologictestsfori nfectiousagents:
Tpal lidum
HIV(repeattestat6m onths)
HepatitisB vi rus(notneededi fhepati tisB vi rus
vaccinew asgiven)

III. Emotionalcar e
A. The phy sician shoul d di scuss the i njuries and the
probability of infection or pregnancy w ith th e victim ,
andsheshoul dbeal lowedtoex pressheranx ieties.
B. Anxiolytic m edication m ay be useful ; l orazepam
(Ativan)1-5m gP Oti dprnanx iety.
C. Thepati entshoul dbereferred topersonnel trai nedto
handlerape-traum avi ctimsw ithin1w eek.
IV. Follow-upcar e
A. Thepati enti s seenfor medical fol low-upi n2w eeks
fordocum entationofheal ingofi njuries.
B. Repeat testing in cludes sy philis, hepatitis B , and
gonorrhea and chl amydia cul tures. H IV serol ogy
shouldberepeatedi n3m onthsand6m onths.
C. Apregnancy test should beperform edi fconcepti oni s
suspected.
References:S eepage166.
Osteoporosis
Over1.3m illionosteoporoticfrac turesoccureachy ear in the
United S tates. T he ri sk of al l fractures i ncreases w ith age;
among persons w ho survi ve unti l age 90 , 33 percent of
women w ill h ave a h ip fr acture. T he li fetime risk o f h ip
fractureforw hitew omenatage50i s 16 percent.Osteoporo­
sis i s characteri zed by l ow bone m ass, m icroarchitectural
disruption,andincreas edsk eletalfragility .

RiskFactor sfor Osteopor oticFr actures

Personalhi storyoffrac­ Whiter ace

tureasanadul t Advancedage
Historyoffractureina Lifelongl owcal ciumi n­
first-degreerel ative take
Currentci garettesm ok­ Alcoholism
ing Inadequatephy sicalac­
Lowbody w eight(l ess tivity
than58k g[127l b]) Recurrentfa lls
Femalese x Dementia
Estrogendefi ciency Impairedey esightdespi te
(menopausebeforeage adequatecorrecti on
45y earsorbi lateral Poorheal th/frailty
ovariectomy,prol onged
premenopausal
amenorrhea[greaterthan
oney ear])

I. Screeningfor osteopor osisandosteopeni a

A. Normal bone density i s defi ned as a bone m ineral
density(B MD) val ue w ithin one standard devi ation of
the m ean value i n y oung adul ts of the sam e sex and
race.
B. Osteopenia is defi ned as a B MD betw een 1 and 2.5
standarddevi ationsbel owthem ean.
C. Osteoporosis i s defined as a val ue m ore than 2.5
standard de viations bel ow the m ean; thi s l evel i s the
fracturethreshol d.T heseval uesarereferredtoasT ­
scores (numberofstandarddevi ationsaboveor below
them eanval ue).
D. Dual x-r ay absor ptiometry. In dual x -ray
absorptiometry (DXA),tw ophotonsareem ittedfrom an
x-raytube.D XAi sthem ostcom monlyused method for
measuringbonedensi tybecausei t gives verypreci se
measurements withm inimalradi ation.D XA measure­
mentsofthespi neandhi parerecom mended.
E. Biochemical m arkers of bone tur nover. Urinary
deoxypyridinoline (DP D) an d u rinary alp ha-1 to
alpha-2N -telopeptideofcol lagen(N TX)arethem ost
specific and cl inically useful m arkers of bone resorp­
tion.B iochemicalm arkersarenotuseful forthescreen­
ingordi agnosisof osteoporosisbecausetheval uesi n
normalandosteoporosi sov erlapsubstanti ally.
II. Recommendationsfor screeningfor oseteopor osis of
theN ationalO steoporosisFoundati on
A. Allw omenshoul dbecounsel edabout theri skfactors
for osteoporosi s, esp ecially sm oking cessati on and
limiting al cohol. A ll w omen shoul d be encouraged to
participatei nregul arw eight-bearingandex ercise.
B. MeasurementofB MDi srecom mendedforal l women
65 years and ol der regardl ess of ri sk factors. B MD
should alsobem easuredi nal lw omenunderthe age
of 65 y ears w ho have one or m ore ri sk factors for
osteoporosis (in additiontom enopause).T hehi pi sthe
recommendedsi teofm easurement.
C. Alladul tsshoul dbeadvi sed to consumeatl east1,200
mg of calciumperday and400to800I Uof vitamin D
perday .A dai lym ultivitamin(w hich provides 400 IU) is
recommended.I npati entsw ithdocum ented vitamin D
deficiency, osteoporosi s, or previ ous fracture, tw o
multivitamins may bereasonabl e,parti cularlyi f dietary
intakei si nadequateandaccesstosunl ighti spoor.
D. Treatment i s recom mended for w omen without ri sk
factorsw hohaveaB MDthati s2S D belowthem ean
fory oungw omen,andi nw omenw ith risk factorsw ho
haveaB MDthati s1.5S Dbel owthem ean.
III. Nonpharmacologic th erapy o f o steoporosis in
women
A. Diet. An opt imal di et for treatm ent (or preventi on) of
osteoporosis i ncludesanadequatei ntakeofcal ories
(toavoi dm alnutrition),cal cium,andvi taminD .
B. Calcium. Postmenopausalw omenshoul dbeadvi sed
totak e1000 to 1500 mg/day ofel ementalcal cium,i n
divideddoses,w ithm eals.
C. VitaminD total of800I Udai lyshoul dbetak en.
D. Exercise. W omen shoul d ex ercise for at l east 30
minutes three ti mes per w eek. A ny w eight-bearing
exerciseregi men,i ncludingw alking,i sacceptabl e.
E. Cessationof smokingi srecom mendedfor all women
becausesm okingci garettesaccel eratesbonel oss.
IV. Drugther apyofosteopor osisi nw omen
A. Selectedpostm enopausalw omenw ithosteoporosi so r
at hi gh ri sk for the di sease shoul d be considered for
drug therapy . P articular atte ntion shoul d be pai d to
treatingw omenw itha r ecentfr agilityfr acture,in cluding
hipfracture,because they are at highri skforasecond
fracture.
B. Candidatesfordrugtherapy arew omenw hoal ready
have postm enopausal osteoporosi s (l ess than -2.5)
andw omenw ithosteopeni a(T score -1 to-2.5)soon
afterm enopause.
C. Bisphosphonates
 1. Alendronate(Fosam ax)(10m g/dayor70 mg once
weekly)orr isedronate(A ctonel)(5m g/dayor35
mg once weekly)aregoodchoi cesfor the treatment
ofosteoporosi s.B isphosphonatetherapy i ncreases
bonem assand reducesthei ncidenceofvertebral
andnonvertebral fractures.
2. Alendronate(5 mg/dayor35m goncew eekly)and
risedronate (5 mg/dayof35m goncew eekly)have
beenapprovedforpreventi onofosteoporosi s.
3. Alendronate orri sedronateshoul dbetak enw itha
fullgl assofw ater30m inutesbeforethefi rstm eal
or beverageoftheday .P atientsshoul dnot lie down
foratl east30m inutes after taking thedosetoavoi d
theunusual com plicationo fp ill-inducedesophagi tis.
4. Alendronate i s w ell t olerated and effecti ve for at
leastseveny ears.
5. Thebi sphosphonates(al endronateor risedronate)
and ral oxifene are fi rst-line treatm ents for preven­
tion of osteoporosis.T hebi sphosphonatesarefi rst­
line therapy for treatment of osteoporosi s.
Bisphosphonatesarepref erredforpreventi onand
treatment of osteoporosi s because they i ncrease
bonem ineraldensi tym orethanral oxifene.
D. Selectiveestr ogenr eceptorm odulators
1. Raloxifene(E vista) (5m gdai lyoraonce-a-w eek
preparation)i sasel ectiveestrogen receptor modu­
lator (SERM)forpreventi onandtreatm ent of osteo­
porosis. I t i ncreases bone m ineral densi ty and
reduces serum total and l ow-density-lipoprotein
(LDL) cholesterol. I t al so appears to reduce the
incidence of vertebral fractures and i s one of the
first-linedrugsforprev entionofosteoporosi s.
2. Raloxifene i s somewhat l ess effecti ve than the
bisphosphonatesforthe preventionandtreatm ent
ofosteoporosi s.V enousthrom boembolismi sari sk.

TreatmentGuidelinesfor Osteopor osis

Calciumsuppl ementsw ithorw ithoutvi taminD suppl e­

mentsorcal cium-richdi et
Weight-bearingex ercise
Avoidanceofal coholtobaccoproducts
Alendronate(Fosam ax)
Risedronate(A ctonel)
Raloxifene(E vista)

Agentsfor Tr eatingOsteopor osis

Medication Dosage Route

Calcium 1,000to1,500 Oral

mgperday

VitaminD 400I Uperday Oral

(800I Uperday
inw interi n
northernl ati­
tudes)

Alendronate Prevention:5 Oral

(Fosamax) mgperday or
35m gonce-a­
week
Treatment: 10
mgperday or
70m gonce-a­
week

Risedronate 5m gdai lyor Oral

(Actonel) 35m gonce
weekly

Raloxifene 60m gperday Oral

(Evista)

Conjugated 0.3m gperday Oral

estrogens

E. Monitoringther esponsetother apy

1. Bonem ineraldensi tyandam arkerofboneturnover
should be m easured at basel ine, fol lowed by a
repeat measurement ofthem arkeri nthree months.
2. Ifthem arkerfal ls appropriately, the drugi shavi ng
thedesi red effect, andtherapy shoul dbeconti nued
for tw o y ears, at which ti me bone m ineral densi ty
can be m easured agai n. T he anti cipated three­
month decl ine i n markers i s 50 percent w ith
alendronate.
F. Estrogen/progestinther apy
1. Estrogen-progestintherapy i s nol ongerafi rst-line
approach for the treatm ent of osteoporosi s i n
postmenopausal w omen because of i ncreases i n
theri sk ofbreastcancer,strok e,venousthrom bo­
embolism,andcoronary di sease.
2. Indications for estrogen-progesti n in
postmenopausal w omen i nclude persi stent m eno­
pausalsy mptomsandpati entsw ithani ndicationfor
antiresorptivetherapy who cannottol eratetheother
drugs.
References:S eepage166.
Infertility
Infertilityisdefinedas failure ofacoupleofreproductiveage
to conceiveafter12m onthsorm oreofregul arcoi tus without
usingcontraception.I nfertilityisconsideredprim aryw henit
occursi naw omanw hohasneverestabl ishedapregnancy
andsecondary w heni t occursi naw omanw hohasahi story
of on e or m ore previous pregnancies. F ecundability is
defined as the probab ility o f a chieving a p regnancy w ithin
one m enstrual cy cle. I t i s esti mated that 10% to 20% of
couplesarei nfertile.

I. Diagnosticev aluation
A. History
1. The hi story shoul d i nclude the coupl e's ages , the
duration of in fertility, p revious in fertility in o ther
relationships,frequency of coitus,anduseofl ubri­
cants (whichcanbesperm icidal).M umpsorchi tis,
renaldi sease,radi ationtherapy ,sex ually transmit­
teddi seases,chroni cdi seasesuchastubercul osis,
majorstressandfati gue,orarecenthi story ofacute
viralorfebri lei llness should be sought.E xposureto
radiation,chem icals,ex cessiveheatfrom saunasor
hottubsshoul dbei nvestigated.
2. Pelvici nflammatoryd isease,previ ouspregnanci es,
douching practi ces, w ork ex posures, al cohol and
drug use,ex ercise,andhi storyof any eating disor­
dersshoul dbeeval uated.
3. Menstrual cy cle l ength and regul arity and i ndirect
indicators ofovul ation,suchasM ittelschmerz,m id­
cycle cervi cal m ucus change and prem enstrual
molimina,shoul dbeassessed.
B. Physicalexam inationfor thewom an
1. Vital si gns, hei ght, and w eight shoul d be noted.
Hypertension hai r di stribution, acne, hi rsutism,
thyromegaly, enl arged l ymph nodes, abdom inal
masses or scar s, galactorrhea, or acanthosi s
nigricans(suggesti veof diabetes)shoul db es ought.
2. Pelvicex amination shouldi ncludeaP apanicolaou
smear and bimanualex aminationtoassess uterine
sizeandany ovari anm asses.
3. Testing for C hlamydia trachom atis, M ycoplasma
hominis, and U reaplasma ureal yticum are recom ­
mended.
C. Physicalexam inationfor them an
1. Height,w eight,and hairdi stribution,gy necomastia,
palpable l ymph nodes or thy romegaly shoul d be
sought.
2. Theconsi stency,si ze,andposi tionofbothtesti cles
andthepresenceofvari coceleorabnorm all ocation
of the uret hral m eatus on the peni s shoul d be
noted. T esting for C hlamydia, U reaplasma, and
Mycoplasmashoul dbecom pleted.
D. The cornerstone of any infertility evaluation relies on
the assessm ent of si x basi c el ements: (1) semen
analysis, (2) sp erm-cervical m ucus i nteraction, (3)
ovulation, (4) tubal patency , and (5) uteri ne and (6)
peritonealabnorm alities.C ouplesof reproductiveage
who have i ntercourse regul arlyw ithout contracepti on
haveapprox imatelya25-30% chanceofconcei ving in
a gi ven m enstrual cy cle and an 85% chance of con­
ceivingw ithin1y ear.
E. Semena nalysis.T hespeci meni srouti nelyobtai ned
by m asturbation and col lected i n a cl ean gl ass or
plastic contai ner. I t i s custom ary to ha ve the m an
abstain from ej aculation for at l east 2 days before
producingthespeci men.C riteriaforanor mal sem en
analysis includeasperm c ountgreaterthan20 million
sperm/mLw ithatleast 50% m otilityand30% norm al
morphology.

SemenA nalysisInter pretation

SemenPa ram­ NormalV al­ PoorPro gno­

eter ues sis

Spermconcen­ >20x 106/m L <5m illion/m L

tration

Spermm otility >50%p rogres­ <10%m otility

sivem otility

Spermmo r­ >50%norm al <4%norm al

phology

Ejaculatevol ­ >2cc <2cc

ume

F. The postcoi tal test (P CT) i s used to assess sperm ­

cervical mucusi nteractionafteri ntercourse.T he PCT
providesi nformation regardingcervi calm ucusqual ity
andsurvivability ofsperm afterinterco urse. T heP CT
should be performed8hoursafteri ntercourseand1 to
2 day s before the predi cted time of ovul ation, w hen
there i s m aximum estrogen secreti on unopposed by
progesterone.
G. Ovulationassessm ent
1. Commonly usedm ethodsusedto assess ovulation
includem easuringa rise in basalbody tem perature
(BBT), i dentifying an el evation i n the m idluteal
phase seru m progesterone concentrati on, l uteal
 phase endometrial bi opsy, and detecti on of
luteinizing horm one (LH ) i n the uri ne. T he B BT
chart i s used to ac quire i nformation regardi ng
ovulation and the durati on of t he luteal phase.
Femalepati entsare instructedtotak ethei rtem per­
ature upon aw aking each m orning before an y
physical acti vity. A temperature ri se of 0.4°F
(0.22°C) for 2 consecuti ve day s i s i ndicative of
ovulation. T he i nitial ri se i n se rum progesterone
leveloccursbetw een48hoursbefore ovulationand
24 hours after ovul ation. For thi s reason, a ri se i n
temperaturei suseful i nestabl ishing that ovulation
has occurred, but i t shoul d not be used to predi ct
theonsetofovul ationi nagi vency cle.
2. Anothertest usedtoassessovul ationi sam idluteal
phaseserum progesterone concentration.A bl ood
sample isusual lyobtai nedforprogesterone7 days
after theesti matedday of ovulation.A concentration
greaterthan3.0ng/m L is consistentw ithovul ation,
whileaconcentrati on greater than 10ng/m Lsi gni­
fiesadequatel utealphasesupport.
3. Alternatively, uri ne LH k its can be used to assess
ovulation.U nliketheri sei nB BT andserum proges­
terone concentrati ons, w hich are useful for retro­
spectively docum enting ovul ation, uri nary LH k its
canbeusedto predict ovulation.Ovul ationusual ly
occurs24to36hours after detecting theLH surge.
H. Tubal patency can be e valuated by
hysterosalpingography (H S G ) and/or by
chromopertubationduri ngl aparoscopy.

Timingo fth eIn fertilityE valuation

Test Day

Hysterosalpingogram day7-10

PostcoitalT est day12-14

SerumP rogesterone day21-23

EndometrialB iopsy day25-28

II. Differentialdi agnosisandtr eatment

A. Thedifferential diagnosisof infertilityincludesovarian
(20%),pel vic (25%),cervi cal (10% ),andm ale(35% )
factors. In approximately10% ofcasesno explanation
isfound.Opti malfrequency ofcoi tus is every otherday
around the ti me of ovul ation; however, com parable
pregnancy rates are achi eved by 3-4 ti mes weekly
intercoursethroughoutthecy cle.
B. Ovarianfacto rin fertility
1. Anovari anfac tor is suggestedby i rregularcy cles,
abnormal B BT charts, m idluteal p hase serum
progesterone l evels l ess than 3 ng/m L, or l uteal
phase defect docum ented by endom etrial bi opsy.
Ovulatory dysfunction maybei ntrinsictotheovari es
or caused by thy roid, adrenal , prol actin, or central
nervous sy stem di sorders. Emotional stress,
changes inw eight,orex cessiveex erciseshoul dbe
sought because these di sorders can resul t i n
ovulatory dy sfunction. Luteal phase defi ciency i s
most oftentheresul tofi nadequateovari anproges­
teronesecreti on.
2. Clomiphenecitr ate(C lomid,C C)isthe most cost­
effective tr eatment to r th e tr eatment o f in fertility
relatedtoanovul ationorol igoovul ation.T heusual
starting doseofC Ci s50m g/dayfor 5 days, begin­
ning on the second to si xth day after i nduced or
spontaneous bleeding. Ovul ation i s ex pected be­
tween7and10day safterthel astdoseofC C.
3. Ovulation on a speci fied dosage of C C shoul d be
confirmedw itham idlutealphaseserum progester­
one assa y, BBT ri se, pel vic ul trasonography, or
urinaryovul ation-predictork its.I ntheeven t ovula­
tiondoesnotoccurw itha specified dose of CC, the
dose can be i ncreased by 50 m g/day i n a su bse­
quentcy cle.T hem aximumdoseofC Cshoul dnot
exceed 250 m g/day. T he addi tion of dex ametha­
sone i s advocated for w omen w ith el evated
dehydroepiandrosterone sulfatel evelsw horem ain
anovulatory despi te hi gh doses of C C. T he i nci­
denceofm ultiplegestati onsw ithC Ci s 5% to 10%.
Approximately3 3%o fp atientsw illb ecomep regnant
within fi ve cy cles of treatm ent. T reatment w ith C C
for m ore than si x ovul atory cy cles i s no t recom­
mendedbecauseofl owsuccessrates.
4. Human menopausal gonadotr opins (hM G,
Pergonal, M etrodin) ovul ation i nduction w ith i s
another opti on for the treat ment of ovul atory dy s­
function. B ecause of i ts ex pense and associ ated
risk of m ultiple gestati ons, gonadotropi n therapy
shouldbereservedforpati ents who remainrefrac­
tory toC Ctherapy .T hepregnancy ratew ith gonado­
tropintherapy i s 25% percy cle.T his i s m ostl ikely
theresultofrecruitm entofm orefolliclesw ithgonad­
otropintherapy .T hei ncidenceofm ultiplegestat ions
withgonadotropi ntherapy i s25% to30% .
5. Lutealphasedeficiency i streatedw ithprogester­
one,usual lyprescri bedas an intravaginalsupposi ­
tory at a dose of 25 m g tw ice a day unti l 8 to 10
weeksofgestati on.
6. Women withov ulatorydy sfunctionsecondary to
 ovarian fai lure or poor ovari an re serve shoul d
considerobtai ningoocy tesfrom adonorsource.
C. Pelvicfacto rin fertility
1. Pelvic f actor i nfertilityi s ca used b ycondi tions that
affect the fal lopian tubes, peri toneum, or u terus.
Tubal f actor i nfertility is a com mon sequela o f
salpingitis. Appendicitis, e ctopic p regnancy,
endometriosis, and pr evious pel vic or abdom inal
surgery can al so dam age the fal lopian tubes and
causeadhesi onform ation.
2. Endometriosis i s an other condi tion i nvolving the
peritoneal cavi tythati s com monlyassoci atedw ith
infertility.U terineabnorm alitiesareresponsi blefor
infertilityinabout2% of cases.E xamplesofuterine
abnormalitiesassociatedw ithinfertility are congeni­
tal deform ities of the uterus, leiomyomas, and
intrauterinescari ficationoradhesi ons (Asherman's
syndrome).
3. Them ainstayo ftr eatmento f pelvic factorin fertility
relies o n l aparoscopy and hy steroscopy. I n m any
instances, tubal reconstructi ve surgery , l ysis of
adhesions, and abl ation and re section of
endometriosis can be accomplished
laparoscopically.
D. Cervicalfacto rin fertility
1. Cervical factor infertility is suggested w hen w ell­
timedP CTsareconsi stentlyabnorm ali nt hepres­
ence of a norm al sem en ana lysis. C ervical factor
infertility results frominadequatem ucusproduction
by the cervi cal epi thelium, poor m ucus qual ity, or
thepresenceofanti spermanti bodies.
2. Patientsw ithanabnorm al PCTshoul dbescreened
forani nfectious etiology.T hepresenceofi mmotile
sperm or sperm s haking i n pl ace and not dem on­
stratingforw ardm otioni ssugge stiveofi mmunologi­
cally r elated in fertility. Sp erm-cervical m ucus a nd
antispermanti bodytesti ngarei ndicatedw henP CTs
arerepeatedl yabnorm al,despi tenorm al-appearing
cervicalm ucusandnorm alsem enanal ysis.
E. Male facto r in fertility includes condi tions that affect
sperm producti on, sperm m aturation, and sperm
delivery.I ntrauterinei nseminationi sfrequentl yusedto
treatm enw ithi mpairedsem enparam eters.
F. UnexplainedIn fertility
1. Theterm unex plained infertilityshouldbeusedonly
afterathoroughinfertility investigationhasfailedto
revealani dentifiablesourceand the duration ofi n­
fertility is 2 4 m onths o r m ore. Hi story, p hysical
examination, documentation of ovul ation,
endometrial bi opsy, sem en anal yses, P CT,
hysterosalpingogram,andl aparoscopyshoul d have
beencom pleted.
2. Becausecouplesw ithunex plainedinfertility lack an
identifiablecausativ e factor oftheirinfertility ,em piri­
cal treatmentw ithcl omiphenetherapy i ncreases the
spontaneous pregnancy rate to 6.8% per cy cle
comparedw ith2.8% i n placebo-control cycles.For
optimal resul ts, gonadotro pins shoul d be used for
ovulation i nduction. I ntrauterine i nsemination, i n
vitrofertiliz ationandgam eteint rafallopiantransfer
(GIFT)areaddi tionalopti ons.
References:S eepage166.

SexualD ysfunction
Almost tw o-thirds of the w omen m ay have had sex ual
difficulties at som e ti me. Fi fteen percent of w omen ex peri­
ence pai n w ith i ntercourse, 18-48% ex perience di fficulty
becomingaroused,46% notedi fficulty reaching orgasm, and
15-24%arenotorgasm ic.

I. Clinical ev aluation of sexual dy sfunction. S exual

difficulty can be caused by a l ack of communication,
insufficientsti mulation,al ackof understanding ofsex ual
response,l ack of nurturing, physicaldi scomfort,orfearof
infection.
II. Treatmentofsexualdy sfunction
A. Lackofar ousal
1. Difficulty becom ing sex ually aro used m ay occur i f
there i s i nsufficient forepl ay or i f ei ther partner i s
emotionally di stracted. A rousal phase dy sfunction
maybem anifestby i nsufficientvasocongesti on.
2. Treatmentconsi stsofS ensate Focusex ercises.I n
these exerci ses, the w oman and her partner tak e
turns caressi ng e ach other's body , ex cept for the
genitalarea.W hencaressi ngbecom espl easurable
for b oth p artners, t heymo ve o n t o manual genital
stimulation,andthentofurthersex ualacti vity.
B. Lackofor gasm
1. Lack oforgasm shoul dbe considereda problemi f
thepati entorherpartnerpercei ves it as one.N inety
percentofw omenareabl etoex perienceorgasm .
2. At-homem ethodsofov ercomingdy sfunction
a. The pati ent shoul d i ncrease self-awareness by
examining her body and geni tals at hom e. T he
patient shoul d i dentifysensi tive areas that pro­
duce pl easurable feel ings. T he i ntensity and
duration of psy chologic sti mulation m ay be
increasedby sex ualfantasy .
b. If,af tercom pletingtheabovesteps,anorgasm
has notbeenreached,thepati entm ayfi ndthat
theuseofavi bratoronoraroundt he clitoris i s
effective.
c. Oncem asturbationhas resultedi norgasm ,the
 patient shoul d m asturbate w ith he r partner
presentanddem onstratepl easurables timulation
techniques.
d. Oncehi ghl evelsof arousalhavebeenachi eved,
the coupl e m ay engage i n i ntercourse. M anual
stimulationofthecl itorisduri ng intercourse may
bebenefi cial.
C. Dyspareunia
1. Dyspareunia consi sts of pai n duri ng i ntercourse.
Organic disorders t hat m ay c ontribute to
dyspareuni a i ncl ude hy poestrogeni sm ,
endometriosis, ovari es l ocated i n the cul -de-sac,
fibroids,andpel vici nfection.
2. Evaluation for dy spareunia shoul d i nclude careful
assessment of the geni tal tract and an attempt to
reproduce symptomsduri ngbi manualex amination.
D. Vaginismus
1. Vaginismus consi sts of spasm of the l evator ani
muscle,m akingpenetrati oni nto the vaginapai nful.
Some w omen may be unabl e to undergo pel vic
examination.
2. Treatmentofv aginismus
a. Vaginal di lators. P lastic sy ringe covers or
vaginaldi latorsareavai lablei nsets of 4 gradu­
ated si zes. T he sm allest di lator (the si ze of the
fifthfi nger)i spl aced in thevagi naby thew oman.
As each di lator i s repl aced w ith the nex t l arger
sizew ithoutpai n,m usclerel axationoccurs.
b. Muscleawar enessexer cises
(1) The ex aminer pl aces one fi nger i nside the
vaginali ntroitus,and thew omani si nstructed
to contractthem usclethatsheusestostop
urinefl ow.T hew omantheni nsertsherow n
finger i nto the vagi na and contracts. T he
processi sconti nuedathom e.
(2) Onceaw oman cani dentifytheappropri ate
muscles, va ginal contracti ons can be done
withoutpl acingafi ngeri nthevagi na.
E. Medicationsthatinter ferewithsexualfunc tion.T he
most common of medicationsthati nterferew ithsex ual
function areanti hypertensiveagents,anti -psychotics,
andanti depressants.

MedicationsA ssociatedW ithS exualD ysfunction

inW omen

Medication Decreased Delayedor No

Libido Orgasm

Amphetamines X
andanorex ic
drugs

Cimetidine X

Diazepam X

Fluoxetine X

Imipramine X

Propranolol X

References:S eepage166.

UrinaryIncontinence
Womenb etween the agesof20to80y earhaveanoveral l
prevalenceforuri naryi ncontinenceof53.2percent.
I. TypesofU rinaryIncontinence
A. StressIncontinence
1. Stressi ncontinencei sthei nvoluntaryl ossofuri ne
producedby coughi ng,l aughingor exercising. The
underlying abnormality is t ypically u rethral
hypermobility caused by a failure of the anatom ic
supportsofthebl adderneck .Lossofbl adderneck
support is oftenattri butedtoi njuryoccurri ng during
vaginaldel ivery.
2. The l ack of norm al i ntrinsic pressure w ithin the
urethra--known as i ntrinsic urethral sphi ncter defi ­
ciency--is another factor l eading to stress i nconti­
nence.A dvancedage,i nadequateestrogenl evels,
previous vaginal surgery and certai n neurol ogic
lesions are associatedw ithpoorurethral sphi ncter
function.
B. Overactive B ladder. I nvoluntary l oss of uri ne pre­
ceded by a strong urge to voi d, w hether or not the
bladderi sful l,i sasy mptomofthecondi tion commonly
referred to as “urge i ncontinence.” Other com monly
used term s such as detrusor instability and detrusor
hyperreflexia refertoi nvoluntarydetrusorcontracti ons
observedduri ngurody namicstudi es.
II.Historyan dP hysicalE xamination
A. Aprel iminarydi agnosisof urinaryi ncontinencecanbe
madeonthebasi s ofahi story, phy sical ex amination
andafew si mpleoffi ceandl aboratorytests.
B. The m edical hi storyshoul d assess di abetes, strok e,
lumbar di sc di sease, chroni c l ung di sease, fe cal
impactionandcogni tivei mpairment.T heobstetri cand
 gynecologichi storyshoul di nclude gravity; parity;the
numberofvagi nal, instrument-assistedandcesarean
deliveries;theti mei ntervalbetw eendel iveries;previ ­
oushy sterectomyand/orvagi nal orbl adder surgery;
pelvicradi otherapy;traum a;andestrogenstatus.

KeyQu estionsin E valuatingP atientsfo rUr inary

Incontinence

Doy oul eakuri new heny oucough,l augh,l iftsom e­

thingorsneez e?H owoften?
Doy oueverl eakuri new heny ouhaveastrongurge
onthew aytothebathroom ?H owoften?
Howfrequentl ydoy ouem ptyy ourbl adderduri ngthe
day?
Howm anyti mesdoy ougetuptouri nateaftergoi ngto
sleep?I si ttheurgetouri natethatw akesy ou?
Doy oueverl eakuri neduri ngsex ?
Doy ouw earpadsthatprotecty oufrom l eakinguri ne?
Howoftendoy ouhavetochangethem ?
Doy oueverfi nduri neony ourpadsorcl othesand
wereunaw areofw henthel eakageoccurred?
Doesi thurtw heny ouuri nate?
Doy oueverfeel thaty ouareunabl etocom pletely
emptyy ourbl adder?

DrugsThatC anI nfluenceB ladderFuncti on

Drug Sideeffect

Antidepressants, Sedation,retenti on(over­

antipsychotics,seda­ flow)
tives/hypnotics

Diuretics Frequency,urgency
(OAB)

Caffeine Frequency, urgency

(OAB)

Anticholinergics Retention (overflow)

Alcohol S edation, frequency

(OAB)

Narcotics Retention,consti pation,

sedation(OA Bandover­
flow)

Alpha-adrenergic Decreasedurethral tone

blockers (stressi ncontinence)

Alpha-adrenergic Increasedurethral tone,

agonists retention(overfl ow)

Beta-adrenergicagoni sts Inhibiteddetrusorfunc­

tion,retenti on(overfl ow)

C. Because f ecal i mpaction h as been l inked t o u rinary

incontinence, a hi story that i ncludes freq uency o f
bowel mo vements, length o f t ime t o e vacuate a nd
whetherthepati entm ustspl inther vagina or perineum
duringdefecati onshoul dbeobtai ned.P atientsshoul d
bequesti onedaboutfecal i ncontinence.
D. Acom pletel ist of all prescriptionandnonprescri ption
drugsshoul dbe obtained. Whenappropri ate,di scon­
tinuation of thesem edicationsassoci atedw ithi nconti­
nenceorsu bstitutiono f appropriateal ternativem edica­
tions will o ften cu re o r sig nificantly im prove u rinary
incontinence.
E. PhysicalE xamination
1. Immediately before the phy sical ex amination, the
patientshoul dvoi dasnorm allyand completelyas
possible.T he voidedvol umeshoul dberecorded.A
post-voidresi dualvol umecanthenbedeterm ined
within10m inutesby catheteri zationorul trasound
examination.P ost-voidresi dualvol umes more than
100m Lareconsi deredabnorm al.
2. A cl ean uri ne s ample can be sent for cul ture and
urinalysis.
3. Determiningpost-voi dresi dualvol umeand urinaly­
sis al lows screeni ng for overfl ow i ncontinence,
chronicuri narytracti nfections,h ematuria,di abetes,
kidneydi seaseandm etabolicabnorm alities.
4. The abdom inal ex amination shoul d rul e out
diastasisrecti ,m asses,asci tesandorganom egaly.
Pulmonary and cardiovascularassessm entm aybe
indicatedtoassesscontrol of cough or theneedfor
medicationssuchasdi uretics.
5. The l umbosacral nerve roots shoul d be assessed
by checkingdeeptendonrefl exes, lower extremity
strength, s harp/dull s ensation and the
bulbocavernosusandcl itoralsacral refl exes.
6. Thepel vicex amination shouldi ncludeaneval ua­
tionfori nflammation,i nfectionandatrophy .S igns
of i nadequate estrogen l evels are thi nning and
paleness of the vaginal epi thelium, l oss of rugae,
disappearanceofthel abiam inoraandpresenceof
aurethral caruncl e.
7. Aurethral di verticulai susual lyi dentifiedasadi stal
 bulge under the urethra. Gentl e m assage of the
area w ill frequently pro duce a purulent discharge
fromtheurethral m eatus.
8. Testing for stress i ncontinence i s per formed by
asking the pati ent to cough vi gorously w hile the
examinerw atchesforl eakageofuri ne.
9. Whileperform ingthebi manualex amination,l evator
ani musclefuncti oncanbeeval uated by asking the
patienttoti ghtenher“vagi nalm uscles”and holdthe
contraction as l ong as possi ble. I t i s norm al f or a
womantobeabl etohol dsuchacontracti onforfi ve
to 10 seconds. T he bi manual ex amination should
also i nclude a rectal ex amination to assess anal
sphincter tone, fecal i mpaction, o ccult bl ood, or
rectall esions.
III. Treatmento fu rinaryin continence
A. Rehabilitation of the pelvic floor m uscles is the com ­
mon goal of t reatments t hrough the use of pel vic
muscleex ercises(K egel'se xercises),w eightedvagi nal
conesandpel vicfl oorel ectricalsti mulation.
B. A set of speci ally desi gned vagi nal w eights can be
used as m echanical bi ofeedback to augm ent pel vic
muscle ex ercises. T he w eights are hel d inside the
vagina by contracting the pel vic m uscles for 15 m in­
utesatati me.
C. Pelvicfl oorel ectricalsti mulationw ithavagi nalor anal
probeproducesacontracti onofthel evator ani muscle.
Cureori mprovementi n48percentoftreated patients,
comparedw ith13percentofcontrol subj ects.
D. Occlusivedevi ces,suchaspessari es,canm imicthe
effects of a retropubi c urethropex y. A properl y fi tted
pessarypreventsuri nel ossduri ngvi gorouscoughi ng
inthestandi ngposi tionw ithaful lbl adder.
E. Medicationssuchas estrogens andal pha-adrenergic
drugs m ay al so be effecti ve i n treati ng w omen w ith
stress i ncontinence. S tress i ncontinence m ay be
treated w ith l ocalized estrogen repl acement therapy
(ERT). Local ized ERT can be gi ven i n the form of
estrogen cream or an estradi ol-impregnated vagi nal
ring(E string).

MedicationsU sedtoTr eatU rinaryIncontinence

Drug Dosage

StressIncontinence

Pseudoephedrine 15to30m g,threeti mes

(Sudafed) daily

Vaginalestrogenri ng Inserti ntovagi naevery

(Estring) threem onths.

Vaginalestrogencream 0.5g,appl yi nvagi na

everyni ght

Overactivebladder

OxybutyninE R(D itropan 5to15m g,every m orn­

XL) ing

TolterodineLA (D etrol 2-4m gqd

LA)

Genericox ybutynin 2.5to10m g,tw otofour

timesd aily

Tolterodine(D etrol) 1to2m g,tw oti mesdai ly

Imipramine(T ofranil) 10to75m g,every ni ght

Dicyclomine(B entyl) 10to20m g,fourti mes

daily

Hyoscyamine 0.375m g,tw oti mesdai ly

(Cystospaz)

F. Alpha-adrenergic drugs such as pseudoephedri ne

improve stress i ncontinence by i ncrease resti ng
urethraltone.T hesedrugs causesubj ectivei mprove­
menti n20to60percentofpati ents.
G.S urgery to correct genui ne stress i ncontinence i s a
viable option for most pati ents. R etropubic
urethropexies (i e, B urch l aparoscopic and M ar­
shall-Marchetti-Krantz [M MK] procedures) and
suburethral sl ings have l ong-term success rates
consistentlyreportedi nthe80to96percentrange.
H. Anotherm inimallyi nvasiveprocedureforthet reatment
of stress i ncontinence caused by i ntrinsic sphi ncter
deficiencyisp eriurethralin jection.
I. Overactivebladder
1. Behavioraltherapy ,i ntheform ofbl adderretrai ning
and bi ofeedback, seek s to reestabl ish corti cal
controlofthebl adderby havi ngthepati enti gnore
urgency and voi d onl y i n response to corti cal si g­
nalsduri ngw akinghours.
2. Pharmacologicagents maybegi venem piricallyto
women w ith sy mptoms of overacti ve bl adder.
Tolterodine (Detrol) and ex tended-release
oxybutynin chl oride (D itropan X L) have l argely
 replaced genericox ybutyninasa first-line treatment
optionforoveracti vebl adderbecauseof favorable
sideeffectprofi les.
3. ERTi sal so an effectivetreatm entforw omenw ith
overactivebl adder.E veni npati entstak ingsy stemic
estrogen, localizedE RT(i e, estradiol-impregnated
vaginal ri ng) m ay i ncrease inadequate estrogen
levels and decreasethesy mptomsassoci ated with
overactivebl adder.
4. Pelvicfl oorel ectrical stimulationi sal soeffecti vei n
treatingw omenw ithoveracti vebl adder.P elvic floor
electrical stimulation resul ts i n a 50 percent cure
rateo fd etrusorin stability.
5. Neuromodulation of thesacral nerverootsthrough
electrodes i mplanted i n the sacral foram ina i s a
promising n ew su rgical t reatment t hat h as been
foundtobeeffecti vei nthetreatm entofurgei ncon­
tinence.
6. The FD A has recentl y approved ex tracorporeal
magnetic innervation,anoni nvasiveprocedurefor
thetreatm entofi ncontinencecausedby pelvicfl oor
weakness. E xtracorporeal m agnetic i nnervation
mayhavea place i nthetreatm entofw omenw ith
bothstressandurgei ncontinence.
References:S eepage166.

UrinaryT ractInfection
Urinarytracti nfections(U TIs)areal eading cause of morbid­
ity i n persons of al l ages. S exually active y oung w omen,
elderly persons and th ose undergoi ng geni tourinary i nstru­
mentationorcatheteri zationareatri sk.

I. Acuteu ncomplicatedcy stitisin y oungwo men

A. Sexuallyacti vey oung women are most atri skforU TIs.
B. Approximately 90 percent of uncom plicated cy stitis
episodes are caused by E scherichia c oli, 10 to 20
percent are caused by coagulase-negative S taphylo­
coccussaprophy ticusand5percentorl essarecaused
byother Enterobacteriaceaeorgani smsorenterococci .
Up to one-thi rd of uropathogens are resi stant to
ampicillin and, but the m ajority are suscepti ble to
trimethoprim-sulfamethoxazole (85 to95percent)and
fluoroquinolones(95percent).
C. Patients shoul d be eval uated fo r pyuria by uri nalysis
(wetm ountex aminationof spun urine) or adi psticktest
forl eukocyteesterase.

UrinaryT ractIn fectionsin A dults

Cate­ Diag­ First-lin Comments

gory nostic ether ­
criteria apy

Acute Urinaly­ TMP-SM Three-daycoursei s

uncom sisfor XD S best
plicate pyuria (Bactrim Quinolonesm aybe
dcy sti­ and ,S eptra) usedi nareasof
tis hema­ Trimetho TMP-SMXr esistance
turia prim ori npati entsw ho
(culture (Prolopri cannottol erate
notre­ m) TMP-SMX
quired) Ciproflox
acin
(Cipro)
Ofloxaci
n
(Floxin)

Recur­ Symp­ Ifthe Repeattherapy for

rent toms patient sevento10day s
cystitis anda has basedoncul turere­
in urine more sultsandthenuse
young culture than prophylactictherapy
women witha three
bacterial cystitis
countof episodes
more pery ear,
than100 treat
CFUp er prophy­
mLo f lactically
urine with
postcoita
l,pa­
tient­
directed
orcon­
tinuous
daily
therapy

Acute Urine Samea s Treatforsevento10

cystitis culture foracute days
in witha uncom­
young bacterial plicated
men countof cystitis
1,000to
10,000
CFUp er
mLo f
urine
Cate­ Diag­ First-lin Comments
gory nostic ether ­
criteria apy

Acute Urine If Switchfrom I Vtooral

uncom­ culture gram-ne administrationw hen
plicate witha gative thepati enti sabl eto
d bacterial organ­ takem edicationby
pyelo­ countof ism,oral mouth;com pletea
neph­ 100,000 fluoroqui 14-daycourse
ritis CFUp er nolone
mLo f If
urine gram-po
sitive
organ­
ism,
amoxi­
cillin
If
parenter
alad­
ministra­
tioni s
required,
ceftri­
axone
(Rocephi
n)ora
fluoroqui
nolone
If
Enteroco
ccus
species,
addoral
orI V
amoxicill
in

Com­ Urine If Treatfor10to14

plicate culture gram-ne days
duri ­ witha gative
nary bacterial organ­
tract countof ism,oral
infec­ more fluoroqui
tion than nolone
10,000 If
CFUp er Enteroco
mLo f ccus
urine species,
ampi­
cillino r
amoxi­
cillinw ith
orw ith­
outgent­
amicin
(Gara­
mycin)

Cathe­ Symp­ If Removecatheteri f

ter-ass toms gram-ne possible,andtreatfor
ociated anda gative sevento10day s
urinary urine organ­ Forpati entsw ith
tract culture ism,a long-termcatheters
infec­ witha fluoro­ andsy mptoms,treat
tion bacterial quinolon forfivetosevenday s
countof e
more If
than100 gram-po
CFUp er sitive
mLo f organ­
urine ism,
ampi­
cillino r
amoxi­
cillin
plus
genta­
micin
AntibioticTher apyfor U rinaryTr actInfections

Diagnostic Dura­ Empiricopti ons

group tionof
ther­
apy

Acuteun­ Three
complicated days Trimethoprim-sulfamethoxa
urinarytract zole( BactrimDS) ,o ne
infectionsin double-strengthtabl etP O
women twiced aily
Trimethoprim(P roloprim),
100m gP Otw icedai ly
Norfloxacin(N oroxin),400
mgtw iced aily
Ciprofloxacin( Cipro),2 50
mgtw iced aily
Lomefloxacin(M axaquin),
400m gperday
Ofloxacin(Fl oxin),200m g
twiced aily
Enoxacin(P enetrex),200m g
twiced aily
Sparfloxacin(Zagam ),400
mgasi nitialdose,then200
mgperday
Levofloxacin(Levaqui n),250
mgperday
Nitrofurantoin(M acrodantin),
100m gfourti mesdai ly
Cefpodoxime(V antin),100
mgtw iced aily
Cefixime(S uprax),400m g
perday
Amoxicillin-clavulanate(Au
gmentin),500m gtw ice
daily

Acuteun­ 14
complicated days Trimethoprim-sulfamethoxa
pyelonephrit zoleD S,onedou­
is ble-strengthtabl etP O
twiced aily
Ciprofloxacin( Cipro),5 00
mgtw iced aily
Levofloxacin(M axiquin),250
mgperday
Enoxacin(P enetrex),400m g
twiced aily
Sparfloxacin(Zagam )400
mgi nitialdose,then200
mgperday 104.50
Ofloxacin(Fl oxin),400m g
twiced aily
Cefpodoxime(V antin),200
mgtw iced aily
Cefixime(S uprax),400m g
perday

Upto3
days Trimethoprim-sulfamethoxa
zole(B actrim)160/800I V
twiced aily
Ceftriaxone(R ocephin),1g
IVperday
Ciprofloxacin( Cipro),4 00
mgtw iced aily
Ofloxacin(Fl oxin),400m g
twiced aily
Levofloxacin(P enetrex),250
mgperday
Aztreonam(A zactam),1g
threeti mesdai ly
Gentamicin(Garam ycin),3
mgperk gperday i n3di ­
videddosesevery 8hours

Compli­ 14 FluoroquinolonesP O
cateduri ­ days
narytract
infections Upto3 Ampicillin,1 g I Ve verysix
days hours,andgentam icin,3
mgperk gperday

Urinarytract Seven
infectionsin days Trimethoprim-sulfamethoxa
youngm en zole,onedoubl e-strength
tabletP Otw icedai ly
Fluoroquinolones

D. Treatmentofacuteuncom plicatedcy stitisiny oung

women
1. Three-day regimens appear to offer the opti mal
combination of conveni ence, l ow cost and an
efficacyc omparabletothatofseven-day orl onger
regimens.
2. Trimethoprim-sulfamethoxazole is the m ost
cost-effective treatm ent. T hree-day regimens of
ciprofloxacin (C ipro), 250 m g twice dai ly, and
ofloxacin (Floxin), 200 m g tw ice dai ly, produce
bettercureratesw ithlesstox icity.
 3. Quinolones that are useful i n treati ng com plicated
and uncom plicated cy stitis i nclude ci profloxacin,
norfloxacin, ofloxacin, enox acin (P enetrex),
lomefloxacin (Maxaquin),sparfl oxacin(Zagam )and
levofloxacin(Levaqui n).
4. Trimethoprim-sulfamethoxazolerem ainstheanti bi­
otic of choi ce i n the treatm ent of uncom plicated
UTIsi n young women.Fl uoroquinolonesarerecom ­
mended for pati ents w ho cannot tol erate sul fona­
mides ortri methoprimorw hohave a high frequency
of anti biotic resi stance. T hree day s i s the op timal
duration of treatm ent for uncom plicated cy stitis. A
seven-daycourseshoul dbeconsi deredi npregnant
women,di abeticw omenandw omen whohavehad
symptomsform orethanonew eek.
II. Recurrentcy stitisin y oungwo men
A. Up to 20 percent of y oung w omen w ith acute cy stitis
develop recurrent U TIs. T he causa tive organi sm
shouldbei dentifiedby uri necul ture.
B. Women w ho have m ore than three U TI recurr ences
within one y ear ca n be m anaged usi ng one of three
preventivestrategi es.
1. Acute sel f-treatment w ith a three-day course of
standardtherapy .
2. Postcoital prophy laxis with one-hal f of a
trimethoprim-sulfamethoxazole double-strength
tablet(40/200m g).
3. Continuous dai ly prophy laxis for si x m onths w ith
trimethoprim-sulfamethoxazole,one-hal ftabl etper
day(40/200 m g); ni trofurantoin, 50 to 100 m g per
day; norfl oxacin (Noroxin), 200 m g per day ;
cephalexin (K eflex), 250 m g per day ; or
trimethoprim(P roloprim),100m gperday .
III. ComplicatedUT I
A. A c omplicated U TI i s one that occurs because of
enlargement of the pros tate gl and, bl ockages, or the
presenceofresi stantbacteri a.
B. Accurateu rinecu ltureands usceptibilitya ren ecessary.
Treatment consi sts of an oral fl uoroquinolone. I n
patientsw horequi rehospi talization, parenteraladm in­
istration of ceftaz idime (Fortaz ) or cefoperaz one
(Cefobid),c efepime( Maxipime),az treonam(A zactam),
imipenem-cilastatin (P rimaxin) or the com bination of
an antipseudom onal penicillin (ticarcillin [T icar],
mezlocillin [M ezlin], p iperacillin [Pip racil]) w ith a n
aminoglycoside.
C. Enterococciarefrequentl yencountereduropathogens
in complicated UTIs. In a reas i n w hich
vancomycin-resistantE nterococcusfaeci umi s preva­
lent, quinupristin-dalfopristin(S ynercid)m aybeuseful .
D. Patients withcom plicatedU TIsrequi reatl easta 10- to
14-day course of therapy . Fol low-up uri ne cul tures
shouldbeperform edw ithin10to 14 daysaftertreat­
ment.
IV. Uncomplicatedpy elonephritis
A. Womenw ithacuteuncom plicatedpy elonephritism ay
present witham ildcy stitis-likei llnessandfl ank pai n;
fever, chills, nausea, vom iting, leuk ocytosis and
abdominal pai n; o r a serious gram -negative
bacteremia. Uncomplicated py elonephritis i s usual ly
causedby E .col i.
B. Thedi agnosis shoul dbec onfirmedby uri nalysis and
byuri necul ture.U rine cultures demonstratem orethan
100,000C FUperm Lof urine in 80 percentofw omen
withpy elonephritis.B loodcul turesareposi tivei n up to
20percentofw omenw hohavethi si nfection.
C. Empiric therapy usi ng an oral fl uoroquinolone i s
recommendedi nw omenw ithm ildtom oderatesy mp­
toms. Patients w ho a re to o ill to ta ke o ral a ntibiotics
should initially be treat ed w ith a parenterally
third-generation ceph alosporin, aztreonam, a
broad-spectrum penicillin, a quinolone or an
aminoglycoside.
D. The total durati on of therapy i s usu ally 14 day s. P a­
tients w ith persi stent sy mptoms after three day s of
antimicrobial therapy shoul d be eval uated by renal
ultrasonographyforevi dence of urinaryobstructi onor
abscess.
References:S eepage166.

PubicInfections
I. Molluscumcontagiosum
A. This di sease i s produced by a vi rus of the pox vi rus
family and i s spread by sex ual or cl ose personal
contact.Lesi onsareusual lyasy mptomatica ndm ulti­
ple,w itha ce ntralu mbilication.L esionsca nb e spread
by autoi noculation and l ast from 6 m onths to m any
years.
B. Diagnosis. Thechara cteristicappearancei sadequate
for di agnosis, but bi opsym aybe used to confi rm the
diagnosis.
C. Treatment. Lesi ons are rem oved by shar p dermal
curette, l iquid nitrogen c ryos urgery, or
electrodesiccation.
II. Pediculosispubis(cr abs)
A. Phthiruspubi si s a blood sucking lousethati sunabl e
tosurvi ve morethan24hoursoffthebody .I ti soften
transmitted sex ually and i s pri ncipally found on the
pubichai rs.D iagnosis is confirmed byl ocatingni tsor
adultl iceonthehai rshafts.
B. Treatment
1. Permethrin cr eam (E limite), 5% i s the m ost
effectivetreatm ent;i ti sappl iedfor10m inutesand
 washedoff.
2. Kwell sham poo, l athered for at l east 4 m inutes,
can alsobeused,buti ti scontrai ndicatedi npreg­
nancyorl actation.
3. All contam inated cl othing and l inen shoul d be
laundered.
III. Pubicscabies
A. This highly contagi ous i nfestation i s caused by the
Sarcoptesscabi ei(0.2-0.4m mi n length).T hei nfesta­
tioni stransm ittedby i ntimate contact orby contactw ith
infested cl othing. T he female m ite burrow s i nto the
skin, and after 1 m onth, severe pruri tus devel ops. A
multiform erupti on m ay devel op, characteri zed by
papules, vesi cles, pustul es, urti carial w heals, and
secondaryi nfectionson thehands,w rists,el bows,bel t
line,buttock s,geni talia,andouterfeet.
B. Diagnosisi sconfi rmed by visualization ofburrow sand
observation of p arasites, eggs, l arvae, or red fecal
compactionsunderm icroscopy.
C. Treatment. P ermethrin 5% cream (E limite) i s m as­
sagedi nfrom theneck dow n and removeby w ashing
after8hours.
References:S eepage166.

SexuallyT ransmissibleInfections
Approximately 12 m illion pat ients are diagnosed w ith a
sexuallytransm issiblei nfection(S TI)annual lyi n theU nited
States.S equellaofS TIsinclude infertility,chronicpelvicpain,
ectopicpregnancy ,andotheradversepregnancy outcom es.

DiagnosisandTr eatmentofB acterialS exuallyTr ans­

missibleInfections

Or­ Diag­ R e c o m - Alternative

ganis nostic m e n d e d
m Meth­ Treatment
ods

Chla Direct Doxycycline Ofloxacin(Fl oxin)300

mydia fluores­ 100m gP O2 mgP O2ti mesaday
trach­ cent timesaday for7day s
o­ anti­ for7day sor
matis body, Azithromycin
enzyme (Zithromax)1
immu­ gP O
no­
assay,
DNA
probe,
cellcu l­
ture,
DNA
amplifi­
cation

Neiss Culture Ceftriaxone Levofloxacin

eria DNA (Rocephin) (Levaquin)250m gP O
gono probe 125m gI Mor once
r­ Cefixime400 Spectinomycin2gI M
rhoea mgP Oo r once
e Ciprofloxacin
(Cipro)500
mgP Oo r
Ofloxacin
(Floxin)400
mgP O
plus
Doxycycline
100m g2
timesaday
for7day sor
azithromycin
1gP O

Trep Clinical Primaryand Penicillina llergyin p a­

one­ appear­ secondary tientsw ithpri mary,
ma ance syphilisa nd secondary,orearl y
palli­ Dark­ earlyl atent latentsy philis( <1y ear
dum field syphilis( <1 ofdurati on):
micros­ yeardura­ doxycycline100m g
copy tion): PO2ti mesaday for2
Nontrep benzathine weeks.
onemal penicillinG
test: 2.4m illion
rapid unitsI Mina
plasma singledose.
reagin,
VDRL
Trepon
emal
test:
MHA-
TP,
FTA-
ABS
 DiagnosisandTr eatmentofV iralS exuallyTr ansmis­
sibleInfections

Organ­ Diagnostic RecommendedTr eatment

ism Methods Regimens

Herpes Clinicala p­ Firstepi sode:A cyclovir(Zovi rax)

simplex pearance 400m gP O5ti mesaday for7­
virus Cellcu lture 10day s,orfam ciclovir(Fam vir)
confirmation 250m gP O3ti mesaday for7­
10day s,orval acyclovir(V altrex)
1gP O2ti mesaday for7-10
days.
Recurrentepi sodes:acy clovir
400m gP O3ti mesaday for5
days,or800m gP O2ti mesa
dayfor5day sorfam ciclovir125
mgP O2ti mesaday for5day s,
orval acyclovir500m gP O2
timesaday for5day s
Dailysuppressi vetherapy :
acyclovir400m gP O2ti mesa
day,orfam ciclovir250m gP O2
timesaday ,orval acyclovir250
mgP O2ti mesaday ,500m g
PO1ti meaday ,or1000m gP O
1ti meaday

Human Clinicala p­ Externalw arts:P atientm ayap­

papillo pearanceof plypodofi lox0.5% sol utionorgel
ma condyloma 2ti mesaday for3day s,fol ­
virus papules lowedby 4day sofnotherapy ,
Cytology foratotal ofupto4cy cles,or
imiquimod5% cream atbedti me
3ti mesaw eekforupto16
weeks.C ryotherapyw ithl iquid
nitrogenorcry oprobe,repeat
every1-2w eeks;orpodophy llin,
repeatw eekly;orT CA80-90% ,
repeatw eekly;orsurgi calre­
moval.
Vaginalw arts:cry otherapyw ith
liquidni trogen,orT CA80-90% ,
orpodophy llin10-25%

Human Enzyme Antiretroviralagents

immun immunoass
o­ ay
defi­ Western
ciency blot(for
virus confirma­
tion)
Polymerase
chainreac­
tion

TreatmentofP elvicInflam matoryD isease

Reg Inpatient Outpatient

ime
n

A Cefotetan(C efotan)2 Ofloxacin(Fl oxin)400

gI Vq12h;orcefox itin mgP Obi dfor14day s
(Mefoxin)2gI Vq6h plusm etronidazole
plusdox ycycline100 500m gP Obi dfor14
mgI VorP Oq12h. days.

B Clindamycin900m g Ceftriaxone
IVq8hpl usgentam icin (Rocephin)250m gI M
loadingdoseI VorI M once;orcefox itin2g
(2m g/kgofbody IMpl usprobeneci d1g
weight),fol lowedby a PO;orother
maintenancedose(1.5 parenteralthi rd-gener­
mg/kg)q8h. ationcephal osporin
(eg,ceftiz oxime,
cefotaxime)plus
doxycycline100m g
PObi dfor14day s.

I. ChlamydiaTr achomatis
A. Chlamydiatrachom atis is the mostpreval entS TIi nthe
UnitedS tates.C hlamydiali nfectionsarem ostcom mon
inw omenage15-19 years.
B. Routine screeni ng of as ymptomatic, sex ually acti ve
adolescentfem alesundergoi ngpel vicex aminationi s
recommended. A nnual screeni ng shoul d be done for
women age 20-24 y ears w ho are ei ther i nconsistent
usersofbarri ercontracepti vesorw ho acquiredanew
sexpartnerorhadm orethanonesex ualpartneri n the
past3m onths.
II. Gonorrhea. Gonorrhea has an i ncidence o f 800,000
cases annual ly. Routine screeni ng for gonorrhea i s
recommended am ong women at hi gh ri sk of i nfection,
including prosti tutes, w omen w ith a hi story of repeated
episodesofgonorrhea,w omenunderage2 5 yearsw ith
twoorm oresex partnersi nthepasty ear,and women with
mucopurulentcervi citis.
III. Syphilis
A. Syphilishasanincidenceof100,000casesan nually.
The rates are hi ghest i n the S outh, am ong A frican
 Americans,and amongthosei nthe20-to24-y ear-old
agegroup.
B. Prostitutes, persons w ith other S TIs, and sex ual
contacts of p ersons w ith active sy philis should be
screened.
IV. Herpessim plexv irusan dh umanp apillomavirus
A. An esti mated 200,000-500,00 0 new cases of herpes
simplex occur annual ly i n the U nited S tates. N ew
infectionsare most commoni nadol escentsandy oung
adults.
B. Human papillom avirus affects about 30% of y oung,
sexuallyacti vei ndividuals.
References:S eepage166.

PelvicInflammator yD isease
Pelvici nflammatorydi sease(P ID) is an acutei nfectionofthe
upper geni tal tract i n w omen, i nvolving any or al l of the
uterus,ovi ducts,andovari es. PIDi sacom munity-acquired
infection i nitiated by a sex ually transm itted agent. P elvic
inflammatorydisease accountsforapprox imately2.5m illion
outpatientvi sitsand200,000hospi talizationsannual ly.

I. Clinicalev aluation
A. Lower abdom inal pai n i s the cardinal presenti ng
symptomi nw omenw ithP ID, although the characterof
thepai nm aybequi te subtle. The onsetofpai nduri ng
orshortl y afterm ensesi sparti cularlysuggesti ve.T he
abdominal pai ni s usual lybi lateral andrarel yofm ore
thantw ow eeks'durati on.
B. Abnormaluteri nebl eeding occurs in one-thirdorm ore
ofpati entsw ith PID. Newvagi naldi scharge,urethri tis,
proctitis,fever,andchillscanbeassociatedsigns.
C. Riskfactor sfor P ID:
1. Agel essthan35y ears
2. Nonbarriercontracepti on
3. New,m ultiple,orsy mptomaticsex ualpartners
4. Previousepi sodeofP ID
5. Oralcontracepti on
6. African-Americanethni city
II. Physicalexam ination
A. Onlyone-hal fofpati entsw ithP IDhavefever. Abdomi­
nalex aminationreveal sdi ffuse tendernessgreatesti n
the lower quadrants,w hichm ayorm aynotbe symmet­
rical. R ebound tenderness and decreased bow el
sounds are com mon. T enderness in the ri ght upper
quadrantdoesn ote xcludeP ID,b ecause approximately
10 percent of these pati ents have peri hepatitis (Fi tz-
HughC urtissy ndrome).
B. Purulentendocervi caldi scharge and/or acutecervi cal
motionandadnex altendernessby bimanual examina­
tion isstrongl ysuggesti veofP ID.R ectovaginalex ami­
nationshoul dreveal theuteri neadnex altenderness.
III. Diagnosis
A. Diagnostic cr iteria and guidelines . T he i ndex of
suspicion for the cl inical di agnosis of P ID shoul d be
high,especi allyi nadol escentw omen.
B. TheCDChasrecom mendedm inimumcriteri ar equired
forem pirictreatm entofP ID.T hesem ajordeterm inants
includel owerabdom inal tenderness,adnex al tender­
ness,andcervi calm otion tenderness.M inordeterm i­
nants(i e,si gnsthatm ayi ncreasethesuspi cionofP ID)
include:
1. Fever(oral tem perature> 101°F;> 38.3°C)
2. Vaginaldi scharge
3. DocumentedS TD
4. Erythrocytesedi mentationrate(E SR)
5. C-reactiveprotei n
6. Systemicsi gns
7. Dyspareunia
C. Empirictr eatmentfor pelvicinflam matorydisease
isr ecommendedwhen:
1. Theex aminationsuggestsP ID
2. Demographics(ri skfactors) areconsi stentw ithP ID
3. Pregnancytesti snegati ve

Laboratory E valuation for P elvic I nflammatory

Disease

• Pregnancytest
• Microscopicex amofvagi naldi schargei nsal ine
• Completebl oodcounts
• Testsforchl amydiaandgonococcus
• Urinalysis
• Fecaloccul tbl oodtest
• C-reactiveprotei n(optional)

IV. Diagnostictesti ng
A. Laboratorytesti ng forpati ents suspectedofhavi ng
PID al ways be gins w ith a pregnancy test to rul e out
ectopic pregnancy and com plications of an
intrauterine pregnancy . A uri nalysis and a stool for
occultbl oodshoul dbeobtai nedbecauseabnorm ali­
ties in either reduce the probability of PID. Blood
countshavel imitedval ue. Fewer thanone-hal fofP ID
patientsex hibitl eukocytosis.
B. Gram stai n and m icroscopic ex amination of vagi nal
dischargem ayprovi deuseful i nformation. If acervi cal
Gramstai ni s positiveforGram -negativei ntracellular
diplococci, the probability ofP IDgreatly increases;if
negative,i ti sofl ittleuse.
C. Increased w hite bl ood cel ls (WBC) i n vagi nal fl uid
 may be the m ost sensi tive si ngle l aboratory test for
PID (78 p ercent for > 3 W BC per hi gh pow er fi eld.
However,thespeci ficityi sonl y39percent.
D. Recommendedlabor atorytests:
1. Pregnancytest
2. Microscopicex amofvagi naldi schargei nsal ine
3. Completebl oodcounts
4. Testsforchl amydiaandgonococcus
5. Urinalysis
6. Fecaloccul tbl oodtest
7. C-reactiveprotei n(optional)
E. Ultrasoundim agingisreserv edforacutely ill patients
withP IDi nw hom a pelvic abscess isaconsi deration.
V. Recommendations
A. Health careprovi dersshoul dm aintaina low threshold
for the di agnosis of P ID, and se xually acti ve y oung
women with l ower abdom inal, adnex al, and cervi cal
motion tenderness shouldrecei veem pirictreatm ent.
The speci ficity of these cl inical cri teria can be en­
hanced b y t he p resence o f f ever, abnormal cer vi­
cal/vaginaldi scharge,el evatedE SRand/orserum C ­
reactive protei n, and t he demonstration of cervi cal
gonorrheaorchl amydiai nfection.
B. If cl inical fi ndings (epi demiologic, sy mptomatic, and
physicalex amination)suggestP ID empiric treatment
shouldbei nitiated.

DifferentialDiag nosiso fP elvicIn flammatoryDis­

ease

Appendicitis Irritablebow elsy ndrome

Ectopicpregnancy Somatization
Hemorrhagicovari an Gastroenteritis
cyst Cholecystitis
Ovariantorsi on Nephrolithiasis
Endometriosis
UrinarytractI nfection

VI. Treatmentofpelv icinflam matorydisease

A. The tw o m ost i mportant i nitiators of P ID, N eisseria
gonorrhoeae and C hlamydia trachom atis, m ust be
treated, but coverage sho uld also be provi ded for
groupsA andB streptococci ,Gram negati ve enteric
bacilli(E scherichiacoli, Klebsiellaspp.,andP roteus
spp.),andanaerobes.
B. Outpatientther apy
1. For outpatient ther apy, the CDC recom mends
eitheroral ofl oxacin(Fl oxin,400m gtw icedai ly) or
levofloxacin(Levaqui n,500m gonce daily) withor
withoutm etronidazole (Flagyl, 500m gtw icedai ly)
for14day s.A nal ternativei sani nitial singledose
of ceftri axone (R ocephin, 250 m g I M), cefox itin
(Mefoxin, 2 g IM pl us probeneci d 1 g oral ly), or
anotherparenteral third-generationcephal osporin,
followedby dox ycycline(100m goral lytw icedai ly)
with or w ithout m etronidazole for 14 day s.
Quinolonesarenotrecom mendedtotreatg onor­
rheaacqui redi nC aliforniaorH awaii.I fthepati ent
mayhaveacqui redthe disease inA sia,H awaii,or
California,cefi xime or ceftriaxoneshoul dbeused.
2. Another alternative isaz ithromycin(Zi thromax,1g
PO for Chlam ydia co verage) and am oxicillin­
clavulanate ( Amoxicillin, 875 m g PO) once by
directlyo bservedth erapy,fo llowed bya moxicillin­
clavulanate(A moxicillin,875m gP OB ID)for7to
10day s.
C. Inpatientther apy
1. Forinpatienttreatm ent, theCDCsuggests either of
thefol lowingregi mens:
a. Cefotetan(C efotan), 2gI VQ12h,orcefox itin
(Mefoxin, 2gI VQ6h)pl usdox ycycline(100 mg
IVorP OQ12h)
b. Clindamycin (Cleo cin), 900 m g I V Q8h, pl us
gentamicin(1-1.5m g/kgI Vq8h)
2. Alternativer egimens:
a. Ofloxacin (Flox in), 400 m g I V Q12h or
levofloxacin(Levaqui n,500m gI V QD )w ith or
withoutm etronidazole(Fl agyl,500 mg IV Q8h).
Quinolones are not r ecommended to treat
gonorrhea acqui red i n C alifornia or H awaii. I f
the pati ent m ay have acq uired the di sease i n
Asia, Hawaii, o r Ca lifornia, ce fixime o r
ceftriaxoneshoul dbeused.
b. Ampicillin-sulbactam (Un asyn), 3 g I V Q6h
plusdox ycycline(100m gI VorP OQ12h)
3. Parenteral administration of anti biotics shoul d be
continued for 24 hour s after cl inical response,
followed by dox ycycline (100 m g P O B ID) or
clindamycin(C leocin,450m gP OQID ) foratotal
of14day s.
4. The following twor egimensm ayal sobe used:
a. Levofloxacin (Lev aquin), 500 m g I V Q24h ,
plus m etronidazole (Fl agyl, 500 m g I V Q8h).
Withthi s regimen, azithromycin(Zi thromax,1g
PO once) shoul d be gi ven as soon as the pa­
tienti stol eratingoral intake. Parenteraltherapy
is conti nued unti l the pel vic te nderness on
bimanualex aminationi sm ildorabsent.
D. Annual scr eening i s r ecommended for a ll se xually
active women underage25andforw omenover 25 if
theyhavenew orm ultiple sexual partners. A retestfor
chlamydia should be completedi n3to4m onths after
chlamydia treatment becauseofhi ghratesof reinfec­
tion.
 E. Additionalev aluation:
1. Serology for the hum an i mmunodeficiency vi rus
(HIV)
2. Papanicolaousm ear
3. Hepatitis B surface anti gen determ ination a nd
initiation ofthevacci neseri esforpati entsw ho are
antigennegati veandunvacci nated
4. HepatitisC vi russerol ogy
5. Serologicte stsfo rsy philis
References:S eepage166.

Vaginitis
Vaginitisi sthem ostcom mon gynecologic problemencoun­
teredby pri marycarephy sicians.I t may resultfrom bacteri al
infections, fungal i nfection, protoz oan i nfection, contact
dermatitis,atrophi cvagi nitis,oral lergicreacti on.
I. Clinicalev aluationo fv aginalsy mptoms
A. The ty pe and ex tent of sy mptoms, such as itching,
discharge,odor,orpel vicpai nshoul dbedeterm ined.
Achangei nsex ualpartnersor sexual activity,changes
incontracepti onm ethod,m edications(anti biotics),and
historyofpri orgeni tali nfectionsshoul dbesought.
B. Physicalexam ination
1. Evaluation of the vagi na shoul d i nclude cl ose in­
spection of the ex ternal geni talia for ex coriations,
ulcerations,b listers,p apillary structures, erythema,
edema,m ucosalthi nning,orm ucosalpal lor.
2. The col or, tex ture, and odor of vagi nal or cervi cal
dischargeshoul dbenoted.
C. Vaginalfl uidpH canbedeterm inedby i mmersing pH
paperi nthevagi naldi scharge.A pH levelgreaterthan
4.5 i ndicates the presence of bacter ial vagi nosis or
Trichomonasvagi nalis.
D. Salinewetm ount
1. Onesw abshoul dbe usedtoobtai nasam plefrom
the posteri or vagi nal for nix, obtai ning a " clump" of
discharge. P lace t he sample on a sl ide, add one
dropofnorm alsal ine,andappl yacoversl ip.
2. Coccoid bacteri a and cl ue cel ls ( bacteria-coated,
stippled,epi thelialcel ls)arecharacteri stic of bacte­
rialvagi nosis.
3. Trichomoniasis i s confi rmed by i dentification of
trichomonads –m obile,oval fl agellates. White blood
cellsarepreval ent.
E. Potassiumhy droxide(K OH)pr eparation
1. Placeasecond sampleonasl ide,appl yonedropof
10%potassi umhy droxide (KOH) and acoversl ip.A
pungent, fishy odor upon additionofK OH–aposi ­
tivew hifftest–strongl yi ndicatesbacteri alvagi nosis.
2. The K OH prep m ay reveal C andida i n the form of
thread-likehy phaeandbuddi ngy east.
F. Screening f or ST Ds. T esting for gonorrhea and
chlamydial i nfection shoul d be com pleted for w omen
witha new sexualpartner,purul entcervi caldi scharge,
orcervi calm otiontenderness.
II. Differentiald iagnosis
A. The m ost com mon cause of vaginitis i s bacteri al
vaginosis, fol lowed by C andida al bicans. T he preva­
lenceoftri chomoniasishas declinedi nrecenty ears.
B. Commonnonvagi naleti ologiesi ncludecontactderm a­
titis from sperm icidal cream s, l atex i n condom s, or
douching.A nyS TDcanpr oducevagi naldi scharge.

ClinicalM anifestationso fV aginitis

CandidalV agi­ Nonmalodorous,thi ck,w hite," cot­

nitis tagecheese-l ike"di schargethat
adherestovagi nalw alls
Hyphalform sorbuddi ngy eastcel ls
onw et-mount
Pruritus
NormalpH (< 4.5)

Bacterial Thin,dark ordul lgrey ,hom oge­

Vaginosis neous,m alodorousdi schargethat
adherestothevagi nalw alls
ElevatedpH l evel(> 4.5)
PositiveK OH(w hifftest)
Cluecel lsonw et-mountm icroscopic
evaluation

Trichomonas Copious,y ellow-grayorgreen,

Vaginalis homogeneousorfrothy ,m alodor­
ousdi scharge
ElevatedpH l evel(> 4.5)
Mobile,fl agellatedorgani smsand
leukocytesonw et-mountm icro­
scopiceval uation
Vulvovaginali rritation,dy suria

AtrophicV agi­ Vaginaldry nessorburni ng

nitis

III. Yeastv aginitis

A. Half of al l w omen have had at l east one ep isode of
yeastvagi nitis.C andidaal bicans accounts for 80%of
yeast i nfections. T he rem aining 20% are caused b y
Candida gl abrata or C andida tropi calis. P regnancy,
 oral contracepti ves, antibiotics, di abetes and H IV
infectionarecontri butingfactors.
B. Diagnosis
1. Typical sy mptoms are pruri tus, thi ck vagi nal di s­
charge, andgeni tali rritation.D ischargei sodorl ess
andcottagecheese-l ike.W omen maycom plainof
dysuria.
2. Physicalex amination mayreveal vul varery thema
andfi ssuring.
3. Laboratoryeval uation ofvagi nalfl uidreveal sapH
of l ess than 4.5 and the presence of hy phae on
10% potassi um hy droxide (K OH) w et m ount.
Elevations i n pH al so occur i n the presence of
semenorbl ood.
4. Microscopy w ill reveal hy phae. T he sensitivity of
theK OHw etm ounti sonl y50% to 70%.T herefore,
treatmentshoul dbei nstitutedevenw henhy phae
areabsentbutthecl inical impressioni sotherw ise
consistent.
5. Cultureshoul dbe considered ifthedi agnosisi si n
doubt or i n recurrent c ases. D ermatophyte test
mediumi ssensi tivey east.
C. Treatment
1. Uncomplicated vagi nitis. T hese epi sodes can be
treated w ith any nonprescri ption short-course (up
to 7-day ) preparati on, si nce al l are equal ly effec­
tive.

Treatmentr egimensfor y eastv aginitis*

1-dayr egimens
Clotrimazolevagi naltabl ets(M ycelexG),500m ghs* *
Fluconazoletabl ets(D iflucan),150m gP O
Itraconazolecapsul es(S poranox),200m gP Obi d
Tioconazole6.5% vagi naloi ntment(V agistat-1),4.6g
hs**[5g]

3-dayr egimens
Butoconazoleni trate2% vagi nalcream (Fem stat3),5
ghs [28g]
Clotrimazolevagi nali nserts(Gy ne-Lotrimin3),200m g
hs**
Miconazolevagi nalsupposi tories(M onistat3),200m g
hs**
Terconazole0.8% vagi nalcream (T erazol3),5ghs
Terconazolevagi nalsupposi tories(T erazol3),80m g
hs
Itraconazolecapsul es(S poranox),200m gP Oqd(4)

5-dayr egimen
Ketoconazoletabl ets(N izoral),400m gP Obi d(4)

7-dayr egimens
Clotrimazole1% cream (Gy ne-Lotrimin,M ycelex-7,
Sweet'nFreshC lotrimazole-7),5ghs* *
Clotrimazolevagi naltabl ets(Gy ne-Lotrimin,M ycelex-7,
Sweet'nFreshC lotrimazole-7),100m ghs* *
Miconazole2% vagi nalcream (Fem izol-M,M onistat7),
5ghs* *
Miconazolevagi nalsupposi tories(M onistat7),100m g
hs**
Terconazole0.4% vagi nalcream (T erazol7),5ghs

14-dayr egimens
Nystatinvagi naltabl ets(M ycostatin),100,000U hs
Boricaci dN o.0gel atinvagi nalsupposi tories,600m g
bid(2)

*Suppositoriescanbeusedi fi nflammationi spredom i­

nantlyvagi nal;cream si fvul var;acom binationi fboth.
Cream-suppositorycom binationpack savai lable:
clotrimazole(Gy ne-Lotrimin,M ycelex);m iconazole
(Monistat,M -Zole).I fdi agnosisi si ndoubt,consi der
oraltherapy toavoi dam eliorationofsy mptomsw ith
useofcream s.U se1-day or3-day regi meni fcom pli­
ancei sani ssue.M iconazoleni tratem aybeused
duringpregnancy .
**Nonprescriptionform ulation.I fnonprescri ptionthera­
piesfai l,useterconaz ole0.4% cream or80-m gsup­
positoriesatbedti mefor7day s.

2. Complicatedi nfectionsarem ore severe and curei s

moredi fficult. With useofnonprescri ptionprepara­
tions,the treatment course shouldbel onger(10to
14 d ays). S ince C andida sp ecies o ther t han
albicans m ay be m ore likely i n com plicated i nfec­
tions, treatm ent w ith terconaz ole (Terazol) shoul d
beconsi dered.S ingle-dose oralfl uconazole should
beavoi ded.
 Managementopti onsfor com plicatedor r ecurrent
yeastv aginitis

Extendany 7-day regi mento10to14day s

Eliminateuseofny lonorti ght-fittingcl othing
Considerdi scontinuingoral contracepti ves
Considereating8oz yogurt(w ithLactobacillus
acidophiluscul ture)perday
Improvegl ycemiccontrol i ndi abeticpati ents
Forl ong-termsuppressi onofrecurrentvagi nitis,use
ketoconazole,100m g(½of200-m gtabl et)qdfor6
months

D. Recurrent i nfection i s defi ned as m ore than four

episodes pery ear.S uppressivetherapy for6 months
is recommendedaftercom pletionof10to 14 days of
astandard regimen. Oralk etoconazole,100m gdai ly
for 6 m onths, has been show n to reduce th e recur­
rence rate to 5%. I f the sex ual partner has bal anitis,
topicaltherapy shoul dbeprescri bed.
IV. Trichomoniasis
A. Trichomoniasis i s responsi ble for l ess than 25% o f
vaginal infections. T he i nfection i s caused by
Trichomonas vaginalis,w hichi sasex ually transmitted
disease.M ostm enareasy mptomatic.
B. Diagnosis
1. Acopi ous,w aterydi schargei s common, and some
patientsm aynoti cean odor.Oftenfew sy mptoms
arepresent.U sually,thevul vaand vaginalm ucosa
arefreeofsi gnsofi nflammation.T hedi schargei s
thinandcharacteri zedby anel evatedp H,usual ly
6to7.Occasi onally,sm all punctatecervi calhem or­
rhages w ith ul cerations (stra wberry cervi x) are
found.
2. Microscopicex aminationofvagi nalfl uid mixed with
saline sol ution (“w et prep”) show s an i ncreased
number of l eukocytes and m otile tri chomonads.
Microscopyhas a sensi tivityof onl y50% to 70%.
Trichomonads are som etimes reported on P ap
smears,butfal se-positiveresul tsarecom mon.
3. Culturefori dentificationofT vaginalis has a sensi­
tivity of 95% and shoul d be perform ed when t he
clinicalfi ndings are consistentw ithtri chomoniasis
but m otile organi sms are absent. A rapi d DNA
probe test, w hich has a sensi tivity of 90% and a
specificityof99.8% ,canal sobeused.
C. Treatment. Oral m etronidazole (Fl agyl, P rotostat) i s
recommended.T reatmentofm alesex ualpartnersi s
recommended. Metronidazolegel (M etroGel-Vaginal)
is lesseffi caciousthanoral anti infectivetherapy . The
single 2-g dose of oral m etronidazole can be used
safelyi nany tri mesterofpregnancy .

Treatmentoptionsfor tr ichomoniasis

Initialm easures
Metronidazole(Fl agyl,P rotostat),2gP Oi nasi ngle
dose,orm etronidazole,500m gP Obi dX 7day s,or
metronidazole,375m gP Obi dX 7day s
Treatm alesex ualpartners

Measuresfor tr eatmentfailur e
Treatmentsex ualcontacts
Re-treatw ithm etronidazole,500m gP Obi dX 7day s
Ifi nfectionpersi sts,confi rmw ithcul tureandre-treat
withm etronidazole,
2-4gP OqdX 3-10day s

V. BacterialV aginosis
A. Bacterial vaginosis isapol ymicrobiali nfectioncaused
by an over growth of anaerobi c organi sms. I t i s the
mostcom moncause of vaginitis, accountingfor50%
ofcases.Gardnerel la vaginalis hasbeeni dentifiedas
oneofthek eyorgani smsi nbacteri alvagi nosis.
B. Diagnosis
1. Mosthavevagi nal di scharge(90% )andf oul odor
(70%). T ypically there i s a hom ogeneous vagi nal
discharge,pH hi gherthan4.5,“cl ue cells” (epithe­
lial cells studded with coccobacilli on m icroscopic
examination,andaposi tive“w hiff”test.
2. A s pecimen of vagi nal di scharge i s obtai ned by
speculum, and the pH i s determ ined before the
specimen i s di luted. N ext, the “w hiff” test i s per­
formed by addingseveral dropsof10% K OHtothe
specimen.T hetesti sposi tivew hena fishy odor is
detected. Fi nally, the speci men is vi ewed by
wet-mountm icroscopy.
C. Treatment consi sts of ora l metronidazole, 500 m g
twice a day for 7 day s. C ommon si de effects of
metronidazolei ncludenausea,a norexia,abdom inal
cramps, and a m etallic taste. A lcohol m ay cause a
disulfiram-like reaction. U se of si ngle-dose
metronidazolem ayresul ti nahi gherrecurrencerate
and an i ncrease i n gastrointestinal si de effects.
Topicalcl indamycini sanopti on,but the cream may
weakenl atexcondom sanddi aphragms.
VI. Otherdiagnosescausingv aginalsy mptoms
A. One-thirdo f p atients withva ginal sy mptoms w ill n ot
have l aboratory evi dence of ba cterial vagi nosis,
Candida, or T richomonas. Other cause s of the
vaginal sy mptoms i nclude cervi citis, al lergic reac­
tions,andvul vodynia.
 B. Atrophic v aginitis shoul d be considered i n
postmenopausalpati entsi fthem ucosaappearspal e
andthi nandw et-mountfi ndingsarenegati ve.
1. Oral estr ogen (P remarin) 0.3 m g qd sho uld
providerel ief.
2. Vaginal r ing estr adiol (Estring), a sila stic r ing
impregnatedw ithestradi ol,i s thepreferredm eans
of del ivering estrogen to the vagi na. T he si lastic
ring del ivers 6 to 9 µ g of estradi ol to the vagi na
daily. T he ri ngs are changed once every three
months. C oncomitant progesti n therapy i s not
necessary.
3. Conjugated estr ogens (P remarin), 0.5 gm of
cream,orone-ei ghthofanappl icatorfuldai ly into
the vagi na for three weeks, fol lowed by tw ice
weeklythereafter.C oncomitantprogesti ntherapy
isnotnecessary .
4. Estrace cr eam (es tradiol) can al so by gi ven by
vaginal appl icator at a dose of one-ei ghth of an
applicator or 0.5 g (w hich contains 50 µ g of
estradiol) dai ly i nto the vagi na for three w eeks,
followedby tw icew eeklythereafter.C oncomitant
progestintherapy i snotnecessary .
C. Allergyandchem icalir ritation
1. Patients shoul d be questi oned abou t use of sub­
stances that cause al lergic or chem ical i rritation,
such as deodorant soaps, l aundry d etergent,
vaginalcontracepti ves,bathoi ls,perfu medordy ed
toiletpaper,hottuborsw immingpool che micals,
andsy ntheticcl othing.
2. Topicalsteroi dsandsy stemicanti histaminescan
helpal leviatethesy mptoms.
References:S eepage166.
Gynecologic Oncology
CervicalC ancer

Invasivecervi calcarci nomai sthethi rdm ostcom moncancer

intheU nitedS tates.T heI nternationalFederati onofGy necol­
ogy and Obstetri cs (FI GO) r ecently revi sed i ts stagi ng
criteria. S urvival rates for w omen w ith ce rvical cancer
improve whenradi otherapyi scom bined with cisplatin-based
chemotherapy.

I. Clinicalev aluation
A. Human p apillomavirus is th e m ost im portant fa ctor
contributing to the d evelopment of cervi cal
intraepithelial neopl asia and cervi cal cancer. Other
epidemiologic risk factors associ ated w ith cervi cal
intraepithelial neopl asia and cervi cal cancer i nclude
historyofsex ual i ntercourseatanearl yage,m ultiple
sexualpartners,sex ually transmitteddi seases(i nclud­
ing chl amydia), and sm oking. A dditional ri sk factors
include a m ale partner or partners w ho have had
multiplesex ualpartners;previ ous historyofsquam ous
dysplasias of the cervi x, vagi na, or vul va; and
immunosuppression.
B. Thesi gnsandsy mptoms ofearl ycervi cal ca rcinoma
include wateryvagi naldi scharge,i ntermittentspotti ng,
andpostcoi talbl eeding. Diagnosis often canbem ade
with cy tologic screeni ng, col poscopically di rected
biopsy,orbi opsyofagross or palpable lesion.I ncases
of suspec ted m icroinvasion and earl y-stage cervi cal
carcinoma, cone bi opsy of the cervi x i s i ndicated to
evaluate th e p ossibility o f in vasion o r to d efine th e
depth an d extent of m icroinvasion. C old k nife cone
biopsy provi des the m ost accurate eva luation of the
margins.
C. Histology. Thetw om ajorhi stologicty pes of invasive
cervical carci nomas are squam ous cel l carci nomas
and adenocarci nomas. S quamous ce ll ca rcinomas
comprise 80% of cases, and adenocarci noma or
adenosquamous carci noma com prise approx imately
15%.
II. Management
A. Earlycarci nomasofthe cervix usuallycanbem anaged
bysurgi caltechni quesorradi ationtherapy .T hem ore
advanced carci nomas requi re pri marytreatm ent w ith
radiationtherapy .
B. Stagingofcer vicalcar cinoma
1. Staging of i nvasive cer vical cancer w ith the FI GO
systemi sachi evedby cl inicaleval uation.
2. Carefulcl inicalex aminationshoul d be performed on
allpati ents.
3. Various opti onal examinations, such as
ultrasonography, computed tom ography (C T),
magnetic resonance i maging (M RI), l ymphangio­
graphy,l aparoscopy,andfi ne-needleaspi ration,a re
valuable for treatm ent pl anning. S urgical fi ndings
provide ex tremely accurate i nformation about t he
extentofdiseaseandw illguidetreatm entplans but
willnotchangetheresultsofclinicalstaging.
4. While not requi red as part of FI GO stagi ng proce­
dures, variousradi ologictestsarefrequentl y under­
taken tohel pdefi netheex tentoftum orgrow th and
guidetherapy decisions, especiallyi npati entsw ith
locally advanced di sease (i e, stage I Ib or m ore
advanced).C omputedtom ographyoftheabdom en
and pel vis i s the most w idelyused i maging study .
MRI i s as accurate as C T i n as sessing nodal
involvement and provi des better definition of the
extentofl ocaltum orsw ithinthepel vis.

PretreatmentA ssessmentofW omenwithH istologic

DiagnosisofC ervicalC ancer

History
Physicalex amination
Completebl oodcount,bl oodureani trogen,creati nine,
hepaticfuncti on
Chestradi ography
Intravenouspy elographyorcom putedtom ographyof
abdomenw ithi ntravenouscontrast
Considerthefol lowing:bari umenem a,cy stoscopy,
rectosigmoidoscopy

Stagingo fCar cinomao fth eCer vixUter i:F IGO

Nomenclature
Stage0 C arcinomai nsi tu,cervi cali ntraepithelialneo­
plasiaGradeI II
StageI T hecarci nomai sstri ctlyconfi nedtothecervi x
(extensiontothecorpusw ouldbedi sregarded).
la Invasivecarci nomathatcanbedi agnosed
onlyby m icroscopy.A llm acroscopicallyvisi­
blel esions-evenw ithsuperfi ciali nvasion-are
allottedtoS tageI bcarci nomas.I nvasioni s
limitedtoam easuredstrom ali nvasionw itha
maximaldepthof5.0m mandahori zontal
extensionofnotm orethan7.0m m.D epthof
invasionshoul dnotbem orethan5.0m m
takenfrom thebaseoftheepi theliumofthe
originalti ssue-superficialorgl andular.T he
involvementofvascul arspaces-venousor
lymphatic-shouldnotchangethestageal lot­
ment.
la1 Measuredstrom ali nvasionofnot
morethan3.0m mi ndepthandex ten­
sionofnotm orethan7.0m m
Ia2 Measuredstrom ali nvasionofm ore
than3.0m mandnotm orethan5.0
mmw ithanex tensionofnotm ore
than7.0m m
Ib Clinicallyvisib lele sionslim itedto th ece rvix
uteriorprecl inicalcancersgreaterthanS tage
la
Ib1 Clinicallyvisib lele sionsn otm oreth an
4.0cm

Ib2 Clinicallyvisiblelesionsm orethan4.0

cm

StageIIC ervicalcarci nomai nvadesbey ondthe

uterus,butnottothepel vicw allortothel ower
thirdofthevagi na
Ila Noobvi ousparam etriali nvolvement

IIb Obviousparam etriali nvolvement

StageIII T hecarci nomahasex tendedtothepel vic

wall.Onrectal ex amination,therei snocancer-free
spacebetw eenthetum orandthepel vicw all.T he
tumori nvolvesthel owerthi rdofthevagi na.A llcases
withhy dronephrosisornonfuncti oningk idneyarei n­
cluded,unl essthey arek nowntobeduetoother
causes.

IIIa Tumori nvolvesl owerthi rdofthevagi na,w ith

noex tensiontothepel vicw all

IIIb Extensiontothepel vicw allorhy dronephrosis

ornonfuncti oningk idney

StageIV Thecarci nomahasex tendedbey ond

thetruepel vis,orhasi nvolved(bi opsy
proved)them ucosaofthebl adderor
rectum.B ullousedem a,assuch,does
notperm itacasetobeal lottedtoS tage
IV.
IVa Spreadofthegrow thtoadj acentorgans(bl ad­
derorrectum orboth)
IVb Spreadtodi stantorgans

Guidelinesfo rClin icalS tagingo fIn vasiveCer vical

Carcinoma

Examinationsshoul di ncludei nspection,pal pation,

colposcopy,endocervi calcurettage,hy steroscopy,
cystoscopy,proctoscopy ,i ntravenouspy elography,and
X-rayex aminationofl ungsandsk eleton.

Conizationofthecervi xi sconsi deredacl inicalex ami­

nation.

Suspectedbl adderorrectal i nvolvementshoul dbe

confirmedhi stologically.

Iftherei saquesti onaboutthem ostappropri atestage,

theearl ierstageshoul dbeassi gned.

C. Surgical ev aluation of cer vical car cinoma. T he

resultsofsurgi caleval uation shouldnoti nfluencethe
stage determ ined by using the FI GO cl inical stagi ng
system.H owever, the presence ofl ymphnodem etas­
tasis i s the most i mportant adverse predi ctor of sur­
vival. Surgicaleval uationofcervi calcanceri s the best
method of assessi ng nodal involvement.
Retroperitonealsurgi cal lymph nodedi ssectionofthe
pelvicandparaaorti cl ymphnodesprovi desi mportant
information about treatm ent pl anning and prognosi s.
Resectionofposi tivel ymph nodes is thoughttoprovi de
therapeuticbenefi t.
D. Treatmentofm icroinvasivecer vicalcance r.A ccord­
ingtotheFI GOcri teria,pati entsw ithstageI a1carci -
 noma coul d be treated w ith si mple hy sterectomy
without nodal di ssection or coni zation i n sel ected
cases. Thosepati entsw ithi nvasiongreaterthan 3 mm
andnogreaterthan5m m(stageI a2)shoul d undergo
radical hy sterectomy and pel vic l ymphadenectomy.
Althoughl ymphatic-vasculari nvasionshoul dnotal ter
the FI GO stage, i t i s an i mportant factor i n treatm ent
decisions. T he ri sk of recurrence w ith l ymphatic­
vasculari nvolvementi s3.1% i ftheex tentofi nvasion
is 3 m m or l ess and 15.7% i f i t i s greater than 3 m m
and nogreaterthan5m m.T herefore,thepresence of
lymphatic-vasculari nvasionw ouldsuggestt he needfor
moreradi caltreatm ent.
E. Treatmentofear ly-stage(Ib-lla)car cinoma
1. Both t reatment strategi es for stage I b and earl y­
stage I Ia i nvasive carci noma i nclude 1) a primary
surgical approach w ith rad ical hy sterectomy and
pelvic l ymphadenectomy or 2) pri mary radi ation
therapy w ith ex ternal beam radi ation and ei ther
high-dose-rate orl ow-dose-ratebrachy therapy. The
5-year survi val rate i s 87-92% usi ng ei ther ap­
proach.
2. Radicalsurgery l eavesthevagi nai n more functional
condition,w hileradi ationtherapy resul tsi na reduc­
tioni nl ength,cal iber, andl ubricationofthevagi na.
In premenopausalw omen,ovari anfuncti oncan be
preservedw ith surgery. Thesurgi calapproachal so
provides the opportuni ty for pel vic and abdom inal
exploration and provi des better cl inical and patho­
logic i nformation w ith w hich to i ndividualize treat­
ment.
F. Adjuvant th erapy fo llowing p rimary su rgery in
early-stagecar cinoma
1. Patients w ith h istologically documented
extracervical di sease (pel vic nodal i nvolvement,
positive m argins, or param etrial ex tension) are
treated withconcurrentpel vicradi ation therapy and
cisplatin-basedchem otherapy.T heuseofc ombined
adjuvant chem otherapy and radi ation therapy i n
these hi gh-risk pati ents following pri mary surgery
significantly i mproves rel apse-free survi val and
overallsurvi valratesw hencom paredw ithradi ation
therapyal one.
2. Following radi cal hy sterectomy, a subset of node­
negative pati ents w ho have a constel lation of pri ­
mary ri sk factor s (l arge tum ors, depth of strom al
infiltration,andl ymphovascularspacei nvolvement)
may be defi ned as havi ng i ntermediate ri sk for
relapse.Forthesepati ents,adj uvantpel vicr adiation
therapy provi des cl ear therapeuti c benefi t, w ith
significantly improved rel apse-free survi val rates
when com pared w ith those who had no further
therapy.
G. Treatment o f late-stag e car cinoma (lIb o r later ).
Cisplatin i s usual ly adm inistered weekly as a si ngle
agent because of i ts ease of del ivery and favorabl e
toxicityprofi le.W omenw ithl ocallyadvancedcervi cal
canceri nN orthA mericashoul drecei veci splatin-based
chemotherapyconcurrentw ithradi ationtherapy .
H. Longter mmo nitoring.A pproximately35% ofpati ents
will h ave p ersistent or r ecurrent d isease. A co mmon
approachi ncludesex aminations andP apt estse very
3-4 m onths for the fi rst 3 y ears, decreasi ng to tw ice
yearly i n the fourth and fi fth y ears, w ith and chest X ­
raysannual lyforupto5y ears.
References:S eepage166.

EndometrialCancer
Uterine canceri sthem ostcom monm alignantneopl asm of
thefem alegeni taltract and the fourthm ostcom moncancer
in w omen. A bout 6,000 w omen i n the U nited S tates di e of
this di sease each y ear. I t i s m ore f requent i n affl uent and
white, especi ally obese, pos tmenopausal w omen of l ow
parity. Hy pertension and diabetes mellitus are also predis­
posingfactors.

I. Riskfactor s
A. Any characteri stic that increases ex posure to unop­
posed estrogen i ncreases the ri sk fo r endom etrial
cancer.C onversely,decr easingex posuretoestrogen
limits the ri sk. U nopposed estrogen therapy , obesi ty,
anovulatorycy clesandestrogen-secreti ngneopl asms
all i ncrease the am ount of unopposed estrogen and
thereby i ncrease t he r isk f or e ndometrial ca ncer.
Smoking seem s to decrease estrogen ex posure,
therebydecreasi ngthecancer ri sk,and oral contracep­
tive use i ncreases progesti n levels, thus provi ding
protection.
B. Hormoner eplacementther apy. Unopposede strogen
treatment ofm enopausei sassoci atedw ithan eightfold
increasedi ncidence of endom etrialcancer.T headdi ­
tionofprogesti ndecreasesthi sri skdram atically.

RiskFactor sfor E ndometrialC ancer

Unopposedestrogenex posure
Medianageatdi agnosis:59y ears
Menstrualcy clei rregularities,speci ficallym enorrhagia
andm enometrorrhagia
Postmenopausalbl eeding
Chronicanovul ation
 Nulliparity

Earlym enarche(before12y earsofage)

Latem enopause(after52y earsofage)

Infertility

Tamoxifen(N olvadex)use

Granulosaandthecal cel ltum ors

Ovariandy sfunction

Obesity

Diabetesm ellitus

Arterialhy pertensionw ithorw ithoutatheroscl erotic

heartdi sease

Historyofbreastorcol oncancer

II. Clinicalev aluation

A. Ninety percent of pati ents with endom etrial cancer
have abnormal vaginalbl eeding,usual lypresenti ngas
menometrorrhagia in a peri menopausal w oman or
menstrual-likebl eedingi naw omanpastm enopause.
Perimenopausal w omen rel ate a history of
intermenstrual bl eeding, ex cessive bl eeding l asting
longerthansevenday sorani nterval ofl ess than 2 1
daysbetw eenm enses.H eavy,prol ongedbl eeding in
patients k nown to be at r isk for anovul atory cy cles
should prom pt hi stologic evaluation of the
endometrium.T hesiz e, contour,m obilityandposition
oftheuterusshoul dbenoted.
B. Patients w ho report abnorm al vagi nal b leeding and
have ri sk factors for endom etrial cancer shoul d have
histologic evaluation of t he endom etrium.
Premenopausal pati ents w ith am enorrhea for m ore
than si x to 12 m onths shoul d be offered endom etrial
sampling, especi ally i f they ha ve risk factors associ ­
ated with ex cessive estrogen exp osure.
Postmenopausal w omen w ith vagi nal bl eeding w ho
either are not o n hormonal repl acement therapy or
havebeenontherapy l ongerthansi xm onths should
beeval uatedby endom etrialsam pling.
C. Endometrialsam pling
1. In-officesam plingoftheendom etriall iningm aybe
accomplished withaN ovakorK evorkiancuret,the
Pipelle endom etrial-suction curet, o r the V abra
aspirator. B efore havi ng an i n-office bi opsy, the
patient shoul d tak e a preoperati ve dose of a
nonsteroidalanti -inflammatorydrug(N SAID).W ith
thepati ent inthel ithotomyposi tion,aspecul umi s
insertedi nthevagi nalcanal .T hecervi x should be
cleansed w ith a sm all am ount o f an anti septic
solution.A fter1m Lofal ocal anesthetici si nfused
into the anteri or l ip of t he cervix, a tenacul um i s
placed. T he paracervi cal bl ock i s then perform ed
using 1 or 2 percent l idocaine (X ylocaine) w ithout
epinephrine.
2. Thecannul ai sthenpl aced intheuterusand place­
ment i s confi rmed with the hel p of the centi meter
markings al ong the cannul a. T he i nner sl eeve i s
thenpul ledback while the cannulai shel dw ithinthe
cavity.T hisgeneratesa vacuum in thecannul athat
can beusedtocol lectendom etrialti ssuefordi agno­
sis.M ovingthecannul ai nandoutofthecav ityno
morethan2to3cm w itheachstrok e whileturni ng
thec annulacl ockwiseorcountercl ockwisei shel pful
inobtai ningspeci mensfrom theenti recavi ty.
III. Treatmento fen dometrialcan cer
A. The treatmentofendom etrial canceri s usual lysurgi ­
cal, such as total abdom inal hy sterectomy, bi lateral
salpingo-oophorectomy andeval uationform etastatic
disease, w hich m ay i nclude pel vic or para-aorti c
lymphadenectomy, peri toneal cy tologic ex amination
and peri toneal bi opsies. T he ex tent of th e surgical
procedurei sbased on the stage ofdi sease,w hichcan
bedeterm inedonl yattheti meoftheoperati on.

Stagingfor C arcinomaoftheC orpusU teri

Stage* Description

IA(G1,G2,
G3) Tumorl imitedtoendom etrium

IB(G1,G2, Invasionofl essthanonehal fof

G3) them yometrium

IC(G1,G2, Invasionofm orethanonehal fof

G3) them yometrium

IIA(G1,G2,
Endocervicalgl andi nvolvement
G3)

IIB(G1,G2, Cervicalstr omalin volvement

G3)

IIIA( G1,G 2, Invasionofserosaand/oradnex a

G3) and/orposi tiveperi tonealcy to­
logicr esults

IIIB( G1,G 2,
Metastasestovagi na
G3)
 Stage* Description

IIIC( G1,G 2, Metastasestopel vicand/orpara­

G3) aorticl ymphnodes

IVA( G1,G 2, Invasionofbl adderand/orbow el

G3) mucosa

IVB Distantm etastasesi ncluding

intra-abdominaland/ori nguinal
lymphnodes

*--Carcinomaofthecorpusi sgraded(G)accordi ngto

thedegreeofhi stologicdi fferentiation:G1= 5percent
orl essofasol idgrow thpattern;G2= 6to50percent
ofasol idgrow thpattern;G3= m orethan50percent
ofasol idgrow thpattern.

B. For m ost pati ents w hose cancers have progressed

beyond stage I B grade 2, postoperative radi ation
therapy isrecom mended.B ecausetum orresponseto
cytotoxic chemotherapy hasbeenpoor,chem otherapy
isu sedo nlyfo rp alliation.
C. Endometrialhy perplasiaw ithaty piashoul dbetreated
with hy sterectomy ex cept in ex traordinary cases.
Progestin treatmentisapossibility inw omeny ounger
than40y ears of age who refusehy sterectomyorw ho
wish to retai n thei r chi ldbearing potential, but an
endometrial biopsy shoul d be perform ed every three
months. T reatment of aty pical hy perplasia a nd w ell­
differentiated endom etrial cancer w ith progesti ns i n
womeny oungerthan40y earsofag e resul tsi ncom ­
plete r egression of di sease i n 94 percent and 75
percent,respecti vely.
D. Patients found to have hy perplasia w ithout aty pia
should be treated w ith pr ogestins and have an
endometrialbi opsyevery threetosi xm onths.
IV. Serousandclear celladenocar cinomas
A. Thesecancers areconsi deredi naseparatecategory
from endom etrioid adenocarc inomas. T hey have a
worse prognosis overall.P atientsw ithseri ouscarci no­
mashavea poorer survival.T he3y earsurvi vali s40%
forstageI di sease.
B. Serous and cl ear cell carci nomas are staged l ike
ovarian cancer. A total abdom inal hy sterectomy and
bilateral sal pingo-oophorectomy, l ymph node bi opsy,
and om ental bi opsy/omentectomy are com pleted.
Washingsfrom the pelvis, guttersanddi aphragmare
obtained,andthedi aphragmi ssam pledandperi toneal
biopsiescom pleted.
References:S eepage166.

OvarianC ancer
Aw omanhas a 1-in-70 risk ofdevel opingovari ancanceri n
herl ifetime.T he incidence is1.4per100,000w omenunder
age 40, i ncreasing to appro ximately 45 per 100,000 for
womenoverage60.T hem edianageatdi agnosis is 61.A
higher i ncidence of ovari an cancer i s seen i n women w ho
have never beenpregnantorw hoareof low parity. Women
whohavehadei therbreastorco loncancerorhaveafam ily
historyofthese cancers also areathi gherri sk of developing
ovarian cancer. P rotective factors i nclude m ultiparity, oral
contraceptive use, a history of breastfeedi ng, and
anovulatorydi sorders.

I. Screening. T here i s no proven m ethod of screeni ng for

ovarian cancer. R outine screeni ng by abdom inal or
vaginal ul trasound or m easurement of C A 125 levels i n
serum cannot berecom mendedforw omenw ithno known
risk fa ctors. For w omen w ith fa milial o varian ca ncer
syndromew how ishtom aintainthei rreproducti vecapac­
ity,transvagi nalul trasonography,anal ysis ofl evelsofC A
125i nserum ,or both, incom binationw ithfrequentpel vic
examinationsm aybeconsi dered.
II. Diagnosis
A. History. Therearenoearl ysy mptomsofcancer ofthe
ovary. A bdominal di scomfort, upper abdominal ful l­
ness, and ea rly satietyare associ ated w ith cancer of
the ovary . Other frequentl y encountered si gns and
symptoms are fati gue, i ncreasing abdom inal gi rth,
urinaryfrequency ,andshortnessofbreathcausedby
pleuraleffusi onorm assiveasci tes.
B. Physicalfin dings. Them ostfrequentl ynoted physical
findingofovari ancanceri sapel vicm ass. An adnexal
massthati sbi lateral,i rregular, solid, orfi xedsuggests
malignancy. Othe r fi ndings suggesti ve of m alignancy
areasci tes or a nodularcul -de-sac.T heri skofovari an
cancer i s si gnificantly hi gher in prem enarcheal and
postmenopausalw omenw ith an adnexalm assthani n
womenofreproducti veage.
C. Diagnosticwo rkup
1. Initial eval uation w ith a thorough hi story, phy sical
examination,andvagi nal probe ultrasonographyw ill
distinguish m ost beni gn m asses from m alignant
masses. C hest X -ray i s perform ed to rul e out
parenchymal or pl eural i nvolvement w ith effusi on.
Screening m ammography, i f i t has not been do ne
within6-12m onths,shoul dbeperform ed preopera­
tivelytorul eoutanotherpri marysource.
 2. Other studiesthatm aybehel pful i nthedi agnostic
workupi nclude bariumenem a,uppergastroi ntesti­
nal seri es, col onoscopy, upper gastroi ntestinal
endoscopy,i ntravenouspy elography,andcom puted
tomography (C T) scan or m agnetic resonance
imaging.
3. Thetum orm arker CA125m ayassi sti neval uation.
Sustained elevationofC A125l evelsoccursi nm ore
than 80% of pati ents w ith nonm ucinous epi thelial
ovarian carci nomas but i n onl y 1% of the general
population.Level sofC A125i n serum also may be
elevated i n pati ents w ith condi tions such as
endometriosis, l eiomyomata, pel vic i nflammatory
disease,hepat itis,congesti veheartfai lure,ci rrhosis,
andm alignanciesotherthanovari ancarci nomas.I n
postmenopausal pati ents with pel vic m asses, C A
125 l evels i n serum greater than 65 U /mL are
predictiveofam alignancyi n75% ofcases.
III. Primarytr eatmento fep ithelialo variancan cer
A. Primarytherapy for ovariancanceri scom pletestagi ng
and opti mal reduction of tum or vol ume. S ubsequent
therapydependsontheoperati vefi ndings.
B. Staging
1. Ovariancancer stagingi sbasedonsurgi caleval ua­
tion. A ccurate stagi ng i s of utm ost i mportance for
planningf urthert herapyandi ndi scussingprognosi s.
Stagingi sdeterm inedby cl inical,surgi cal,hi stologic,
andpathol ogicfi ndings,i ncludingresul tsofcy tologic
testingofeffusi onsorperi toneal w ashings.P leural
effusionsshoul dbesam pled.
2. Operativetechniques
a. The i ncision used shoul d prov ide m aximum
exposure of the pelvisandal lowthorougheval ua­
tion of the upper abdom en. I f present , ascites
shouldbe aspiratedandsentforcy topathologic
evaluation.A sm allam ount of heparin shouldbe
added to prevent cl otting o f bloody or m ucoid
specimens. I f asci tes i s not present, abdo minal
washingsw ithsal ineshoul dbe obtainedfrom the
pericolic gutters, thesuprahepati cspace,andthe
pelvis. A P ap test of the di aphragm should be
taken.
b. Theabdom inalcavi tyshoul dbeex ploredsy stem­
atically. Thel owersurfaceofthe diaphragm, the
upper abdom inal recesses, the l iver, and
retroperitoneal nodes shoul d be care fully noted
for tumori nvolvement.I naddi tion,thei ntestines,
mesentery, and om entum shoul d be ex amined.
The presence or absence of m etastases i n the
pelvis and abdom en should b e n oted, and the
exactl ocationandsi zeoftum ornodul essho uld
bedescri bed.
c. Incasesi nw hichdi seasei s grossl yconfi nedto
thepel vis,effortsshoul dbem ade to detect occult
metastasis withperi tonealcy tologies,bi opsiesof
peritoneum fromthepel visandperi colicgutters,
and resecti on of the greater om entum. In addi ­
tion, se lective pelvic and paraaorti c
lymphadenectomyal soshoul dbecarri edout.

DefinitionsoftheS tagesinP rimaryC arcinomaof

theOv ary

Sta Definition
ge

I Growthi sl imitedtotheovari es

IA Growthi sl imitedtooneovary ;noasci tes

presentcontai ningm alignantcel ls;notum or
ontheex ternalsurface;capsul ei si ntact
IB
Growthi sl imitedtobothovari es;noasci tes
presentcontai ningm alignantcel ls;notum or
IC ontheex ternalsurfaces;capsul esarei ntact
Tumori scl assifiedasei therstageI AorI Bbut
withtum oronthesurfaceofoneorbothova­
ries;orw ithrupturedcapsul e(s);orw ith
ascitescontai ningm alignantcel lspresentor
withposi tiveperi tonealw ashings

II Growthi nvolvesoneorbothovari esw ithpel ­

vicex tension
IIA
Extensionand/orm etastasestotheuterus
lIB and/ortubes
IIC Extensiontootherpel victi ssues

Tumori sei therstageI IAorl ibbutw ithtum or

onthesurfaceofoneorbothovari es;orw ith
capsule(s)ruptured;orw ithasci tescontai ning
malignantcel lspresentorw ithposi tive
peritonealw ashings
 III Tumori nvolvesoneorbothovari esw ith
peritoneali mplantsoutsi dethepel visand/or
positiveretroperi tonealori nguinalnodes;su­
perficiall iverm etastasisequal sstage III;t u­
mori sl imitedtothetruepel visbutw ith
IlIA histologicallyprovenm alignantex tensionto
smallbow elorom entum
Tumori sgrossl yl imitedtothetruepel visw ith
IIIB negativenodesbutw ithhi stologicallycon­
firmedm icroscopicseedi ngofabdom inal
peritonealsurfaces
IIIC Tumori nvolvesoneorbothovari esw ith
histologicallyconfi rmedi mplantsofabdom inal
peritonealsurfaces,noneex ceeding2cm i n
diameter;nodesarenegati ve
Abdominali mplantsgreaterthan2cm i ndi ­
ameterand/orposi tiveretroperi tonealori ngui­
nalnodes

IV Growthi nvolvesoneorbothovari esw ithdi s­

tantm etastases;i fpl euraleffusi oni spresent,
therem ustbeposi tivecy tologyfi ndingsto
assignacasetostageI V;parenchy mall iver
metastasisequal sstageI V

C. Cytoreductives urgery improvesresponseto chemo­

therapyandsurvi valofw omenw ithadvancedovari an
cancer.Operati vem anagement is designedtorem ove
asm uchtum or aspossi ble.W henam alignanttum or
is present, a thorough abdom inal ex ploration, total
abdominal hy sterectomy, bilateral salpingo­
oophorectomy,l ymphadenectomy,om entectomy,and
removalofal lgrosscancerarestandardtherapy .
D. Adjuvantther apy
1. Patientsw ithstageI AorI B disease (whohavebeen
completelysurgi callystaged)and who haveborder­
line,w ell- orm oderatelydi fferentiatedtum orsdonot
benefit fromaddi tionalchem otherapybecause their
prognosisi sex cellentw ithsurgery al one.
2. Chemotherapy i mprovessurvi valand is aneffecti ve
means of palliation of ovarian cancer. I n pati ents
whoareati ncreasedri skof recurrence(stageI G3
and al l I C-IV), chem otherapy i s recom mended.
Sequential cl inical trials of chem otherapy agents
demonstrate that ci splatin (or carbopl atin) given i n
combinationw ithpacl itaxeli sthem ostacti vecom bi­
nationi dentified.
References:S eepage166.

BreastC ancer
One o f 8 w omen w ill d evelop breast ca ncer. T he r isk o f
breastcanceri ncreasesw ithage;approx imatelyhal f ofnew
casesoccuri nw omenaged65y earsorol der.T wopercent
of 40- to 49-y ear-old w omen i n the U nited S tates devel op
breastcancerduri ngthefi fthdecadeofthei rl ives,and 0.3%
diefrom breast cancer.B reastcanceri sthem ostcom mon
malignancyi n American women, andthesecondm ostl ethal
malignancyi nw omen,fol lowingl ungcancer.

I. RiskFactor s
A. Major riskfactor sfor br eastcancer include:1)earl y
menarche, 2) nulliparity , 3) delay ed childbirth,
4)increasingage,5)race,and6)fam ilyhi story.

RiskFactor sfor B reastC ancer

MajorR iskFactor s
Earlym enarche
Nulliparity
Delayedch ildbirth
Increasingage
Race
Familyhi story

OtherR iskFactor s
Latem enopause
Obesity
Weightgai n
Increasedi ntra-abdomi­
nalfat(androi dbody
habitus)
Lackofregul arex ercise
Elevatedserum estradi ol
Elevatedfreetestoster­
onel evels
Aprevi ousprem alignant
breastbi opsy
Radialscarsi nbeni gn
breastbi opsies
Ahi storyofbreastcancer
Exposuretoi onizingradi ­
ation
Higherbonem ineralden­
sity
Smoking
Alcoholconsum ption
Elevatedin sulin-like
growthfactor-I (I GF-I )
levels
Increased
mammographicdensi ty
Oralcontracepti ves
 RiskFactor sfor B reastC ancer

FamilialR iskFactor sfor B reastC ancer

Morethan50% ofw omeni nfam ilyhavebreastcancer
Breastcancerpresenti nm orethanI generati on
Multipleoccurrencesofbreastcancer(> 3)i ncl ose
relatives
Onsetatl essthanage45y ears
Historyofbi lateralbreastcancer
Highrateofco-ex istingovari ancancer
BRCA1genem utation

B. Nulliparity and i ncreased age at first pregnancy are

associated w ith an i ncreased ri sk for breast cancer .
Nulliparity a lone a ccounts for 16% of new cases of
breastc ancer eachy ear.T herel ativeri sk forbreast
canceri ncreasesw ithadvanci ngage.
C. Race i s an i ndependent ri sk factor. W hile w hite
women are at an i ncreased ri sk for breast cancer,
African A merican w omen w ith breast cancer have
higherfatal ityratesandal aterstageatdi agnosis.
D. A fam ily hi story of breast cancer, especi ally i n fi rst­
degreerel atives,i ncreasestheri sk.
E. A historyof breast cancer i ncreases a w oman's ri sk
forsubsequentbreastcancers.I fthew omanh as no
familyhi storyofbreastcancer , thenthei nitialoccur­
rencew assporadi c,and thei ncidencefordevel oping
a second breast cancer is 1% per y ear. I f the i nitial
occurrence washeredi tary,thei ncidence for develop­
ingasecond breast canceri s3% pery ear.A pproxi­
mately 10% ofw omenw ithb reastca ncerw illd evelop
asecondpri marybreastcancer.
F. Familial o r G enetic Risk F actors. A m utation in a
tumor-suppresser geneoccursi n1of400 women and
isl ocatedonchrom osome17q.C arriersofaB RCA1
mutation have an 85% l ifetime ri sk of devel oping
breast cancer. I n addi tion, the ri sk of col on and
ovarian cancers i s al so i ncreased (40% to 50% ) i n
thesegroups.T he70% of breastcancerpati entsw ho
do not have i nherited m utations on B RCA1 have
mutationsonB RCA2.T hecum ulative lifetimeri skof
breast cancer inaw omanw iththeB RCA2m utation is
87%.
G. Conclusions. Seventy-five percent of w omen w ith
newly di agnosed breast cancer demonstrate no
specific,i dentifiableri skfactor.M ostprem enopausal
breast cancer cases a re genetically determ ined. I n
contrast,m anypost-m enopausal casesareenvi ron­
mentallyrel ated.
II. ScreeningGu idelines
A. BreastS elf-Examination. Allw omenol der than age
20y earsshoul dperform regular monthlybreastsel f­
examinations. M enstruating w omen shoul d ex amine
their breasts in thefi rst7to10day softhem enstrual
cycle.

BreastS creeningC riteria

Age ClinicalB reast Mammogra­

Examination phy

30-39 Every1-3y ears None

40-49 Annual Optional1-2

years

>50 Annual Annual

Womenaged50to69y earsshoul dbeofferedm am­

mographyandrecei veacl inicalbreastex amination
every1to2y ears.

B. ClinicalB reastE xamination(C BE)i srecom mended

every1to3y earsforw omenaged30to39y earsand
annuallyforthoseaged40y earsandol der.
C. Mammography. Mammographyal onei s 75%sensi ­
tive, and, w hen com bined w ith C BE, the screening
sensitivity for d etecting breast cancer i ncreases to
88%. S creening gui delines from the U S P reventive
Services Task Forcesuggestm ammographyal one or
withC BEevery 1to2 yearsforw omenaged50to69
years. R ecent evi dence suggests a benefi t from
annualm ammographyw ith or withoutC BEforw omen
aged40to49y ears.
III. Historyan dP hysicalE xamination
A. In th e woman w ith a suspi cious breast m ass, ri sk
factorsandafam ilyhi storyofbreastc ancersshoul d
be assessed . A personal hi story of radi ation to the
chest or breast, breast m asses, biopsies, hi story of
collagen vascul ar di sease, and m enstrual and
gynecologichi storyare also important.S ymptomsof
nippledi scharge,pai n,sk inchanges,o r rashesm ay
occur.
B. Onphy sical examination, thebreastm assshoul dbe
palpatedfor size,posi tion,adherenceofthetum orto
thesk inorchestw all,densi ty,fl uctuance,andtender­
ness.I naddi tion,bothbreastsanda xillaeshoul dbe
examined for other tum ors and any l ymph nodes. A
searchforsupracl avicularl ymphnodesshoul dal sobe
conducted.
C. Any evi dence of sk in changes, ul ceration, peau
 d'orange (thi ckening of sk in to resem ble an orange
skin), or l ymphedema is suspi cious for l ocally ad­
vancedcancer.
D. Immediate m ammography shoul d b e obtained. A
white bl ood count, hem atocrit, and ery throcyte sedi ­
mentationratem aybeneededi fcanceri sfound.
IV. Diagnosis
A. The defi nitive di agnosis i s m ade by p athological
evaluationofti ssue.
B. A com bination of cl inical breast ex amination, m am­
mography,andfi ne-needleaspi ration andbi opsym ay
be s ufficient to m ake a di agnosis. I f al l studi es are
"benign," there i s a greater than 99% chance that a
benignbreastl esioni spresent.
C. Openbi opsyi ntheoperati ngroom or wire-localization
of a suspi cious l esion noted on m ammographym ay
be necessary i f fi ne-needle asp iration and bi opsy i s
nondiagnostic. B iopsy by stereo-tacti c tec hnique i n
radiologyal som aybeusedtoobtai nti ssuefor diag­
nosisofthesuspi ciousarea.
V. Definition and classification of br east cancer for
staging
A. The definition for stagi ng and the cl assification o f
stages for bre ast cancer fol low the sy stem of the
International U nion A gainst C ancer. T his sy stem i s
based on the tum or, nodes, an d metastases (T NM)
nomenclature.

Definitionsfor B reastC ancerS taging

Tumor

TIS Carcinomai nsi tu(i ntraductalcarci noma,

Iobular)

T0 Noevi denceofpri marytum or

T1 Tumor< 2cm i ngreatestdi mension

T2 Tumor> 2cm but< 5cm i ngreatestdi men­

sion

T3 Tumor> 5cm i ngreatestdi mension

T4 Tumorofany si zew ithdi rectex tension

intoch estw allo rsk in

Nodes

N0 Noregi onall ymphnodem etastases

N1 Metastasesto m ovableip silaterala xillary

node(s)

N2 Metastasesto ip silaterala xillaryly mph

node(s),fi xedtooneanotherorother
structures

Metastases

M0 Nodi stantm etastases

MI Metastasesto m ovableip silaterala xillary

node(s);
metastasesto ip silaterala xillaryly mph
node(s);fi xed
tooneanotherorotherstructures;or
metastasesto
ipsilateralin ternalm ammaryly mph
node(s);di stant
metastases

ClassificationofB reastC ancerS taging

Stage Description*

0 TIS,N0,M 0

I TI,N0,M 0

IIA T0,NI ,M 0

IIB T2,NI ,M 0,orT 3,N0,M 0

IIIA T0,N 2,M0 ,o rT I,N 2,M0 ,o rT 2,N 2,M0 ,

orT 3,NI ,orN2,M 0

IIIB T4,a nyN ,M0 o ra nyT ,N 3

IV AnyT ,any N ,M I

*Tumor/nodes/metastases

B. The H ER-2 gene (c-erbB -2, H ER-2/neu) h as been

identified, andtheH ER-2receptori s correlated with
aggressive bi ological behavi or of the cancer and a
poorcl inicaloutcom e.
 C. The stagi ng of breast cancer di ctates not onl y the
prognosis butal sodi rectstreatm entm odalityrecom ­
mendations. T he prognosi s for w omen i s based on
theirage,tum orty pe,i nitial tum orsi ze,pre senceof
nodes and stagi ng, and horm one-re-ceptor status.
Theoveral l10-y earsurvi valratesforthem orecom ­
monbreastcancerstage s aregreaterthan90% for
stage 0, greater than 75% for stage I , greater than
50%forstageI IA,andapprox imately50% f orstage
IIB.
VI. Treatmentofbr eastcancer
A. Treatment choi ces for ductal carcinoma i n si tu, a
stage 0 cancer, i nclude 1) m astectomy, 2)
lumpectomy fol lowed by radi ation therapy , or 3)
lumpectomy fol lowed by radi ation therapy and t hen
tamoxifen i f the tumor i s estrogen-receptor test
positive.
B. SurgicalTr eatment
1. Severall ong-termstudi esshow thatconservati ve
therapyandradi ationresul t i natl eastasgooda
prognosis as radi cal m astectomy. S kin-sparing
mastectomy i nvolves rem oving al l the breast
tissue, the ni pple, and the areol ar com plex. T he
remainder of the surface sk in ti ssue rem ains
intact. R econstruction i s then com pleted w ith a
natural-appearing breast. T his procedure i s con­
sideredforthosew omenw ithductal carcinoma in
situ orT 1orT 2i nvasivecarci nomas.B ecausea
mastectomy l eaves 3.5% of the breast ti ssue
behind, the recurrence rate for thi s procedure i s
comparablew itham odifiedradi calm astectomy.
2. Local ex cision of the tum or m ass ( lumpectomy)
followed by l ymph node stagi ng and subse quent
adjuvant horm one therapy , chem otherapy, or
radiationtherapy i sanacceptedtreatm ent. Long­
termstudi eshave foundthatrecurrenceratesare
similar w hen l umpectomy w as com pared w ith
radiation therapy and m astectomy. One study
showed no recurrence i f 1-cm m argins w ere
obtained followed by theuseofradi ationtherapy .
C. RadiationTher apy. Externalbeam radi ation therapy
has proven effecti ve i n preventi ng r ecurrence of
breast ca ncer and for p alliation o f p ain. T he r isk o f
relapse after radiation therapy ranges from 4% to
10%.Lum pectomycannow be performed followed by
implantationofhi gh-dosebrachy therapycatheters.
D. Anti-Hormonal Ther apy. H ormonal therapy i s
indicated for those tum ors that test posi tive for
hormone re ceptors. T amoxifen has both estrogeni c
andanti -estrogeniceffects.I n women whoareol der
than50y earsw ithbreastcancersthat test positivefor
hormonereceptors,tam oxifenuseproducesa20%
increasei n5-y earsurvi valrates.T heresponserate
inadvancedcasesi ncreasesto35% .
E. Chemotherapy
1. Chemotherapyi susedi nw omen at riskform eta­
static di sease. C ytotoxic agents used i nclude
methotrexate, fl uorouracil, cy clophosphamide
(Cytoxan, N eosar), dox orubicin, m itoxantrone
(Novantrone),andpacl itaxel(T axol). Inthem an­
agementof stage 0di sease,chem otherapyi snot
usedin itially.
2. Stage I and stage I I di sease are treated w ith
chemotherapy based on the relative ri sk of sy s­
temicrecurrence.T his ri sk i s of tenbasedonthe
woman's age, ax illary ly mph node involvem ent,
tumor s ize, horm one receptor status, hi stologic
tumor grade, and cel lular aggressi veness. S ys­
temicchem otherapyi s recommendedforw omen
with stage I di sease w ho have node- negative
cancers and a tum or si ze greater than 1 cm i n
diameter.
3. Women w ith stage I IA breast cance r are treated
with adj uvant chem otherapy w ith or w ithout
tamoxifen. S ome w omen w ith posi tive l ymph
nodes are pl aced on chem otherapy, i ncluding
doxorubicin,fl uorouracil,andm ethotrexate.
4. In women w ith stage III b reast ca ncer, si milar
agents are sel ected. D oxorubicin i s parti cularly
useful i n treati ng i nflammatory breast cancer. I n
women w ith stage IIIB ca ncer, ch emotherapy i s
usually adm inistered before pri mary surgery or
radiation therapy . H igh-dose chem otherapy pl us
stem-cell transpl antation does not i mprove sur­
vival rates. I n w omen w ith stage I V di sease,
chemotherapy i s useful i n treati ng m etastatic
breastcancer.
References: Seepage166.
Obstetrics
PrenatalC are
I. Prenatalhistor yandphy sicalexam ination
A. Diagnosisofpr egnancy
1. Amenorrheai s usually thefi rstsi gnofconcepti on.
Othersy mptomsi nclude breast fullnessandtender­
ness, sk in changes, nause a, vomiting, uri naryfre­
quency,andfati gue.
2. Pregnancy tests. U rine pregnancy tests m ay be
positive w ithin day s of the fi rst m issed m enstrual
period.S erumb etah umanch orionicg onadotropin
(HCG)i saccura teuptoafew day safteri mplanta­
tion.
3. Fetalhear ttones can bedetectedasearl yas11-12
weeks from the l ast m enstrual period (LM P) by
Doppler. T he norm al fetal heart rate i s 120-1 60
beatsperm inute.
4. Fetalm ovements(" quickening")arefi rstfel tby the
patientat17-19w eeks.
5. Ultrasound will visualiz e a gestational sac at 5-6
weeksandafetal pol e withm ovementandcardi ac
activityby 7-8 weeks. Ultrasoundcanesti matefetal
ageaccuratel yi fcom pletedbefore24w eeks.
6. Estimateddateof confinement.T hem eandura­
tionofpregnancy i s 40w eeksfrom theLM P. Esti­
mateddate ofconfi nement(E DC)canbecal culated
byN ägele'srul e:A dd7day stothefi rst dayofthe
LMP,thensubtract3m onths.
B. Contraceptive histor y. R ecent oral contraceptive
usage often causes postpill am enorrhea, and m ay
causeerroneouspregnancy dati ng.
C. Gynecologicandobstetr ichistor y
1. Gravidityi s the total numberofpregnanci es.P arity
is ex pressed as the num ber of term pregnanci es,
pretermpregnanci es,aborti ons,andl ivebi rths.
2. Thecharacterandl engthofprevi ousl abors,ty pe of
delivery, com plications, i nfant status, and bi rth
weightarerecorded.
3. Assess prior cesareansecti onsanddeterm ine type
of C -section (l ow transvers e or cl assical), and
determinereasoni tw asperform ed.
D. Medical and sur gical histor y and pri or hospi taliza­
tionsaredocum ented.
E. Medicationsandal lergiesarerecorded.
F. Familyhi story ofm edicali llnesses,heredi taryi llness,
orm ultiplegestati oni ssought.
G. Social histor y. Cigarettes, alcohol, or illicit drug
use.
H. Review of sy stems. A bdominal pai n, consti pation,
headaches, vagi nal bl eeding, dy suria or uri nary fre­
quency,orhem orrhoids.
I. Physicalexam ination
1. Weight, funduscopi c ex amination, thy roid, breast,
lungs,andheartareex amined.
2. An ex tremity and neurol ogic ex am are com pleted,
and the presence of a cesarean secti on scar i s
sought.
3. Pelvicexam ination
a. Papsm earand c ulturef or gonorrheaarecom ­
pletedrouti nely.C hlamydiacul turei scom pleted
inhi gh-riskpati ents.
b. Estimationofgestational age byuter inesize
(1) The nongravi d uterus i s 3 x 4 x 7 cm . T he
uterus beginstochangei nsi zeat5-6 weeks.
(2) Gestationalagei sesti matedby uterinesi ze:
8 weeks= 2x norm al si ze;10w eeks= 3 x
normal;12w eeks= 4x norm al.
(3) At12 weeks the fundusbecom espal pableat
thesy mphysispubi s.
(4) At16w eeks,theuterusi sm idwaybetw een
thesy mphysispubisandtheum bilicus.
(5) At 2 0w eeks, th eu terus is a t th eu mbilicus.
After 20 w eeks, there i s a correl ation b e­
tweenthenum berofw eeksof gestationand
the num ber of centi meters from the pubi c
symphysistothetopofthefundus.
(6) Uterine si ze that ex ceeds the gestational
datingby 3orm orew eekssuggests multiple
gestation, m olar pregnancy , or (m ost com ­
monly) an i naccurate date for LM P.
Ultrasonography w ill confirm inaccurate
datingori ntrauterinegrow thfai lure.
c. Adnexaarepal patedform asses.
II. Initialv isitlab oratorytestin g
A. CBC,A Bbl ood typing and Rhfactor,anti bodyscreen,
rubella,V DRL/RPR,hepati tisB surfaceA g.
B. Papsm ear,uri nepregnancy test, urinalysis and urine
culture.C ervicalcul turefor gonorrheaandchl amydia.
C. Tuberculosissk intesti ng,H IVcounsel ing/testing.
D. Hemoglobin el ectrophoresis i s i ndicated i n ri sks
groups,suchassi cklehem oglobini n Africanpati ents,
B-thalassemia i n M editerranean pati ents, and al pha­
thalassemia i n A sian pati ents. T ay-Sachs carri er
testingi si ndicatedi nJew ishpati ents.
III. Clinicala ssessmentatfir sttr imesterpr enatalv isits
A. Assessment at each pr enatal vi sit i ncludes m aternal
weight,bl oodpressure, uterine size,andeval uationfor
edema,protei nuria,andgl ucosuria.
B. FirstD opplerhearttones should becomedetectabl eat
10-12w eeks,andthey shoul dbesoughtthereafter.
C. Routineprenatal vi taminsareprobabl y notnecessary .
 Folic aci d suppl ementation preconceptual ly and
throughoutthe early part ofpregnancy hasbeenshow n
todecreasethei ncidenceof fetal neural tube defects.

FrequencyofP renatalC areV isitsinLow-R isk

Pregnancies

<28w eeks Everym onth

28-36w eeks Every2w eeks

36-delivery Every1w eekunti ldel iv­

ery

D. FirstTr imesterE ducation.D iscusssm oking,al cohol,

exercise,di et,andsex uality.
E. Headacheandbackache. A cetaminophen (Tylenol)
325-650 m g every 3-4 hours i s effecti ve. A spirin is
contraindicated.
F. Nausea and v omiting. F irst-trimester m orning sick ­
nessm ayberel ievedby eating frequent,sm allm eals,
getting out of bed sl owlyafter eati ng a few crac kers,
andby avoi dingspi cyorgreasy foods. Promethazine
(Phenergan) 12.5-50 m g PO q4-6h prn or
diphenhydramine(B enadryl)25-50m gti d-qidi suseful .
G. Constipation. A high-fiber d iet wi th p syllium
(Metamucil),i ncreasedfl uidi ntake,andregul arex er­
ciseshoul dbeadvi sed.D ocusate (Colace) 100 mg bid
mayprovi derel ief.
IV. Clinicalassessm entatsecondtr imesterv isits
A. Questionsfor each follow-upv isit
1. Firstdetectionoffetalm ovement(quickening)
shouldoccurataround17w eeks in am ultigravida
and at 19 weeks i n a pri migravida. Fetal m ove­
mentshoul d be documented ateachvi sitafter17
weeks.
2. Vaginalbleedingor sy mptomsof preterm labor
shouldbesought.
B. Fetalhear tr atei sdocum entedateachvi sit
C. Maternalser umtesting at15-16weeks
1. Triple scr een ( "-fetoprotein, hum an chori onic
gonadotropin[hC G],andestri ol).I nw omenunder
age 35y ears,screeni ngforfetal D own syndrome is
accomplished with atri plescreen.M aternal serum
alpha-fetoproteini s elevated in 20-25%ofal lcases
ofD ownsy ndrome,andi t is elevated infetal neural
tube defi cits. Level s of hCG are hi gher i n D own
syndrome and l evels of unconj ugated estriol are
loweri nD ownsy ndrome.
2. If levels areabnorm al, anul trasoundex amination
isperform edand geneticam niocentesisi soffered.
Thetri plescreeni dentifies60% ofD ownsy ndrome
cases. Low levels of all th ree se rum analytes
identifies60-75% ofal lcasesoffetal tri somy18.
D. At 15-18 weeks, genetic am niocentesis shoul d be
offered to pati ents > 35 y ears ol d, and i t shoul d be
offered i f a bi rth defect has occurred i n the m other,
father,ori nprevi ousoffspri ng.
E. Screeningul trasoundshoul d usuallybeobtai nedat
16-18w eeks.
F. At 2 4-28 weeks, a one-hour Gl ucola (bl ood gl ucose
measurement 1 ho ur after 50-gm oral gl ucose) i s
obtainedtoscreenfor gestational diabetes. Thosew ith
apar ticularri sk (eg,previ ousgestati onal di abetesor
fetal macrosomia),requi reearl iertesti ng.I fthe 1 hour
testresul ti sgreaterthan 140 mg/dL, a 3-hourgl ucose
tolerancetesti snecessary .
G. Second tr imester education . Discom forts include
backache, round ligament pain, consti pation, and
indigestion.
V. Clinicalassessm entatthir dtr imesterv isits
A. Fetalm ovementi sdocum ented.V aginal bleeding or
symptoms of preterm l abor shoul d be sought.
Preeclampsia sy mptoms (bl urred vi sion, headache,
rapidw eightgai n,edem a)aresought.
B. Fetalhear tr atei sdocum entedateachvi sit.
C. At 26-30 weeks, repeat hem oglobin and hem atocrit
are obtained to determ ine the need for i ron
supplementation.
D. At28-30weeks, an antibody screeni sobtai nedi nR h­
negativew omen,andD immunegl obulin(R hoGAM)i s
administeredi fnegati ve.
E. At 36 weeks, repeat serologic testing for sy philis is
recommendedforhi ghri skgroups.
F. Gonorrheaandchlam ydiascr eeningis repeatedin
thethi rd-trimesteri nhi gh-riskpati ents.
G. Screening for groupB str eptococcuscolonization
at35-37weeks
1. Lower vagi nal and rec tal cul tures are recom­
mended; cu ltures shoul d not be col lected by
speculum ex amination. The opti mal m ethod for
GBS screeni ng i s col lection of a si ngle standard
culturesw abofthedi stalvagi naandrectum .
H. Thirdtr imestereducation
1. Signs of labor . The pati ent shoul d cal l phy sician
whenruptureofm embranes or contracti onshave
occurredevery 5m inutesforonehour.
2. Danger signs. P reterm l abor, rupture of m em­
branes,bl eeding,edem a,si gnsofpreecl ampsia.
3. Commondiscom forts. Cramps,edem a,frequent
urination.
I. At 3 6 weeks, a cervi cal ex am m ay be com pleted.
Fetal posi tion shoul d be asse ssed by pal pation
 (Leopold’sM aneuvers).
References:S eepage166.

NormalLabor
Laborconsi stsof the process byw hichuteri ne contractions
expelthefetus.A term pregnancy is 37 to 42w eeksfrom the
lastm enstrualperi od(LM P).

I. ObstetricalH istoryandP hysicalE xamination

A. Historyofthepr esentlabor
1. Contractions.T hefrequency ,durati on,onset,and
intensity of uteri ne cont ractions shoul d be deter­
mined. C ontractions m ay be accom panied by a
'’bloodyshow "( passageofbl ood-tingedm ucusfrom
thedi latingcervi calos).B raxtonH ickscontracti ons
are often fel t by pati ents duri ng the l ast w eeks of
pregnancy.T hey areusual lyi rregular,m ild,anddo
notcausecervi calchange.
2. Rupture of m embranes. Leak age of fl uid m ay
occural oneori nconj unctionw ithuteri necontrac ­
tions. The patient may reportal argegushoffl uidor
increased m oisture. T he col or of the l iquid shoul d
be determ ine, i ncluding the p resence of bl ood or
meconium.
3. Vaginalbleeding should beassessed.S pottingor
blood-tinged mucus i s com mon i n norm al l abor.
Heavyvagi nal bleeding may beasi gnofpl acental
abruption.
4. Fetal mo vement. A progressi ve decre ase in fetal
movementfrom basel ine,shoul dprom ptanassess­
ment of fetal w ell-being w ith a nonstress test or
biophysicalprofi le.
B. Historyofpr esentpr egnancy
1. Estimated date of confinem ent ( EDC) is ca lcu­
latedas40w eeksfrom thefi rstday oftheLM P.
2. Fetal hear t tones are fi rst he ard with a D oppler
instrument10-12w eeksfrom theLM P.
3. Quickening (m aternal percepti on of fetal m ove­
ment)occursatabout17w eeks.
4. Uterinesize before16w eeksi s anaccuratem ea­
sureofdates.
5. Ultrasound m easurement of fetal si ze before 24
weeksofgestati on is anaccuratem easureofdates.
6. Prenatal histor y. M edical probl ems duri ng thi s
pregnancy sho uld be revi ewed, i ncluding uri nary
tracti nfections,di abetes,orhy pertension.
7. Antepartum testing. Nonstr ess tests, contr action
stresstests,bi ophysicalprofi les.
8. Reviewofsy stems.S everehe adaches,scotom as,
hand and faci al edem a, or epi gastric pai n
(preeclampsia) shoul d be sought. D ysuria, uri nary
frequency or fl ank pai n m ay i ndicate cy stitis or
pyelonephritis.
C. Obstetricalhistor y.P astpregnanci es,durati ons and
outcomes, preter m del iveries, operati ve del iveries,
prolonged l abors, pregnancy -induced hy pertension
shouldbeassessed.
D. Past m edical history of asthm a, hy pertension, or
renaldi seaseshoul dbesought.
II. Physicalexam ination
A. Vitalsi gnsareassessed.
B. Head. Fundusc opy shoul d seek hem orrhages or
exudates, w hich m ay suggest di abetes or hy perten­
sion. Faci al, hand and ank le edema suggest
preeclampsia.
C. Chest. A uscultation of the l ungs for w heezes and
cracklesm ayi ndicateasthm aorheartfai lure.
D. UterineSize .U ntilthem iddleof the thirdtri mester,the
distance i n centimeters from the pubi c sy mphysis to
theuteri nefundusshoul dcorrel ate withthegestati onal
age i n w eeks. T oward term , t he m easurement be­
comesprogressi velyl essrel iablebecause ofengage­
mentofthepresenti ngpart.
E. Estimationoffetal weighti scom pleted by palpation
ofthegravi duterus.
F. Leopold's m aneuvers are used to determine the
positionofthefetus.
1. The fi rst m aneuver determ ines w hich fetal pol e
occupiestheuteri nefundus.T hebreechm ovesw ith
the fetal body . T he vertex i s rounder and harder,
feels m ore gl obular than the bree ch, and can be
movedseparatel yfrom thefetal body .
2. Second m aneuver. T he l ateral aspects of the
uterusarepal patedtodeterm ineonw hich sidethe
fetal back orfetal ex tremities(the small parts)are
located.
3. Third m aneuver. The presenti ng part i s m oved
fromsi detosi de.I fm ovement is difficult,engage­
mentofthepresenti ngparthasoccurred.
4. Fourth m aneuver. W ith the fetus p resenting by
vertex, the cephalicprom inencem aybepal pableon
thesi deofthefetal sm allparts.
G. Pelvic exam ination. T he adequacy of the bony
pelvis, t he integrity of the fetal m embranes, the
degree of cervi cal dilatation and effacem ent, and
the stati on of the pr esenting part shoul d be deter­
mined.
H. Extremities. S evere l ower ex tremity or hand edem a
suggestspreecl ampsia.D eep-tendonhy perreflexiaa nd
clonusm aysi gnali mpendingsei zures.
I. Laboratorytests
1. Prenatal labs shoul d be docum ented, i ncluding
CBC,bl oodty pe,R h,anti bodyscreen,serol ogictest
 forsy philis,rubella antibody titer,urinaly sis, culture,
Pap smear, cervi cal cul tures for gonorrhea and
Chlamydia, and hepati tis B surfa ce antigen
(HbsAg).
2. During l abor, the C BC, uri nalysis and R PR a re
repeated. T he H BSAG is r epeated for high- risk
patients.A cl otofbl oodi spl acedonhol d.

LaborHistory and
Physical
Chiefco mpliant:C ontractions,

ruptureofm embranes.

HPI:___y earol dGravi da(num ber

ofpregnanci es)P ara(num berof

deliveries).

Gestationalage,l astm enstrual

period,esti mateddateofconfi ne­

ment.

Contractions(onset,frequency ,

intensity),ruptureofm embranes

(time,col or).V aginalbl eeding

(consistency,quanti ty,bl oody

show);fetalm ovement.

FetalH eartR ateS trip:Ba seline

rate,accelerations,reactivity ,

decelerations,contracti onfre­

quency.

Dates:Fi rstday ofl astm enstrual

period,esti mateddateofconfi ne­

ment.U ltrasounddati ng.

PrenatalC are:Dateoffirstex am,

numberofvi sits;hassi zebeen

equaltodates?i nfections,

hypertension,di abetes.

ObstetricalH istory:Datesofprior

pregnancies,gestati onalage,route

(C-sectionw ithi ndicationsandty pe

ofuteri nei ncision),w eight,com pli­

cations,l engthofl abor,hy perten­

sion.

GynecologicH istory:M enstrual

history(m enarche,i nterval,dura­

tion),herpes,gonorrhea,

chlamydia,aborti ons;oral contra­

ceptives.

J. Fetal hear t r ate. T he baseline heart rate, variability ,

accelerations,anddecel erationsarerecorded.

III. Normallab or
A. Labor i s ch aracterized b y u terine co ntractions o f
sufficientfrequency ,i ntensity, and duration toresul ti n
effacementanddi latationofthecervi x.
B. Thefir ststage ofl aborstartsw iththe onset of regular
contractionsandendsw ith completedi latation(10cm ).
This stagei sfurthersubdi videdi ntothel atentand an
activephases.
1. The l atent phas e starts w ith the onset of regul ar
uterine contracti ons and i s characteri zed by sl ow
cervical di latation to 4 cm . T he l atent phase i s
variablei nl ength.
2. The acti ve phase fol lows and i s characteri zed by
more rapi d di latation to 10 cm . D uring the acti ve
phaseofl abor,theaveragerateofcervi cal di lata­
tioni s1.5cm /houri nthe multipara and1.2cm /hour
inthenul lipara.
C. The second stage of labor begi ns w ith com plete
dilatation of the cervi x and ends w ith del ivery of the
infant.I ti schara cterizedby vol untaryandi nvoluntary
pushing.T heaveragesecond stageofl abori sone-hal f
houri nam ultiparaand1houri nthepri mipara.
D. Thethir dstageoflabor begins withthedel iveryofthe
infantandendsw iththedel iveryofthepl acenta.
E. Intravenous fluids . I V fl uid duri ng labor i s usual ly
Ringer's l actate or 0.45% norm al sal ine w ith 5%
dextrose.I ntravenousfl uidi nfusedrapi dly or givenas
a bol us shoul d be dex trose-free bec ause m aternal
hyperglycemiacanoccur.
F. Activity. P atients i n the l atent phase o f l abor are
usuallyal lowedtow alk.
G. Narcoticandanalgesicdr ugs
1. Nalbuphine(N ubain)5to10m gS CorI Vq2-3h.
2. Butorphanol(S tadol)2m gI Mq3-4hor0.5-1.0m g
IVq1.5-2.0h OR
3. Meperidine(D emerol) 50 to100m gI Mq3-4hor10
to25m gI Vq1.5-3.0h OR
4. Narcoticsshoul dbeavoi dedi fthei rpeak acti onw ill
nothavedi minishedby the time ofdel ivery.R espi­
ratory depression i s reversed w ith nal oxone
(Narcan): A dults, 0. 4 mg I V or I M and neonates,
0.01m g/kg.
H. Epiduralanesthesia
1. Contraindications i nclude i nfection in the l umbar
area, cl otting defect, acti ve neurologic di sease,
sensitivity to the anestheti c, hy povolemia, and
septicemia.
2. Risksi ncludehy potension,respi ratoryarrest,tox ic
drug reacti on, and rare neurol ogic com plications.
 An epidural hasnosi gnificanteffectonthe progress
ofl abor.
3. Before the epi dural i s i nitiated, t he patient i s hy ­
drated w ith 500-1000 m L of dex trose-free i ntrave­
nousfl uid.

LaborandDelivery
AdmittingO rders
Admit:LaborandD elivery
Diagnoses:I ntrauterinepreg­
nancyat____w eeks.
Condition:S atisfactory
Vitals:q1hrperrouti ne
Activity:M ayam bulateastol er­
ated.
Nursing:I andO.C atheterize
prn;ex ternalori nternalm onitors.
Diet:N POex cepti cechi ps.
IVFl uids:LactatedR ingersw ith
5%dex troseat125cc/h.
Medications:
Epiduralat4-5cm .

Nalbuphine(N ubain)5-10m g

IV/SCq2-3hprn OR

Butorphanol(S tadol)0.5-1m gI V

q1.5-2hprnOR
Meperidine(D emerol)25-75m g
slowI Vq1.5-3hprn
pain AND
Promethazine(P henergan)25-50

mg,I Vq3-4hprnnausea OR

Hydroxyzine(V istaril)25-50m g

IVq3-4hprn

Fleetenem aP Rprnconsti pation.

Labs:C BC,di pstickuri nepro­

tein,bl oodty peandR h,anti body

screen,V DRL,H BsAg,rubel la,

typeandscreen(C -section).

 I. Intrapartum antibiotic pr ophylaxis for gr oup B

streptococcusisr ecommendedfor thefollowing:
1. Pregnant w omen w ith a posi tive scr eening cu lture
unless a plannedC esareansecti oni sperform edi n
theabsenceofl abororruptureofm embranes
2. Pregnantw omenw hogavebi rthtoaprevi ousi nfant
withinvasiveGB Sdisease
3. Pregnantw omenw ithdocum entedGB Sbacteri uria
duringthecurrentpregnancy
4. Pregnantw omen whosecul turestatusi s unk nown
(culture not perform ed or resul t not avai lable) and
who al so have del iveryat < 37 w eeks of gestat ion,
amniotic m embrane rupture for > 18 hours, or
intrapartumtem perature> 100.4ºF( >38ºC)
5. The recom mended I AP re gimen is penicillin G (5
millionunitsI V initial dose,then2.5m illionunits IV
Q4h). Inw omenw ith non-immediate-typepenicillin­
allergy, cefaz olin (A ncef, 2 g i nitial dose, then 1 g
Q8h) is recom mended. Clindam ycin (900 mg I V
Q8h) or erythromycin(500m gI V Q6h)arerecom ­
mended for pati ents at hi gh ri sk for anaphy laxis to
penicillins as long as thei r GB S isol ate is docu­
mented to be sus ceptible to both cl indamycin and
erythromycin.
IV. Normalsp ontaneousv aginald elivery
A. Preparation. A s t he mu ltiparous p atient appr oaches
completedi latationoras the nulliparouspati entbegi ns
to crow n the fetal scal p, prepara tions are m ade for
delivery.
B. Maternalposi tion. Them otheri susual lypl acedi nthe
dorsallith otomyp ositionw ithle ftla teraltilt.
C. Deliveryofafetusinanocciputanter iorposition
1. Deliveryofthehead
a. The fetal head i s del ivered by ex tension as the
flexed head passesthroughthevagi nali ntroitus.
b. Oncethefetal headhas beendel ivered,ex ternal
rotationtothe occiputtransverseposi tionoccurs.
c. The orophary nx and nose of the fetus are
suctioned w ith the bul b sy ringe. A fi nger i s
passed i nto the vagi na al ong the fetal neck to
check for a nuchal cord. I f one i s pre sent, i t i s
lifted over the vertex . I f thi s cannot be accom­
plished,thecordi sdoubl y clamped anddi vided.
d. Ifshoul derdy stociai s anticipated, the shoulders
shouldbedel iveredi mmediately.
2. Episiotomy consi sts of i ncision o f the peri neum,
enlarging the vaginal orifice attheti meofdel ivery.I f
indicated,an episiotomyshoul dbeperform edw hen
3-4cm offetal scal pi svi sible.
a. Withadequatel ocal or spinal anesthetici npl ace,
am edial episiotomy iscom pletedby i ncisingthe
perineumtow ardtheanusandi ntothevagi na.
b. Avoid cutti ng i nto the anal sphi ncter or the rec­
tum. A short perineumm ayrequi ream ediolateral
episiotomy.
c. Application of pressure attheperi nealapex w ith
atow el-coveredhand helps topreventex tension
oftheepi siotomy.
3. Deliveryoftheanter ior shoulder isa ccomplished
by gentledow nwardtracti ononthefetal head. The
posteriorshoul deri sdel iveredby upw ardtracti on.
4. Deliveryofthebody .T hei nfanti s grasped around
the back w ith the l eft hand, and the ri ght hand i s
placed, nearthevagi na,underthe baby's buttocks,
supporting the i nfant’s body . T he i nfant’s body i s
rotated tow ard the operator and supported by the
operator’sforearm ,freei ngtheri ghthandto suction
the m outh and nose. T he baby 's head shou ld be
kept low er than the body to facilitate drainage of
secretions.
5. Suctioning ofthenoseandorophary nx is repeated.
6. The um bilical cord is doubl y cl amped and cut,
leaving2-3cm ofcord.
D. Deliveryoftheplacenta
1. Thepl acentausual ly separatesspontaneousl yfrom
theuteri ne wallw ithin5m inutesofdel ivery.Gentl e
fundal m assage and gentle tracti on on the cord
facilitatesd eliveryo fth ep lacenta.
2. The pl acenta shoul d be ex amined for m issing
cotyledonsorbl indvessel s.T he cut endofthecord
should be ex amined for 2 arte ries and a vei n. T he
absenceofone umbilical arterysuggestsa congeni­
talanom aly.
3. Prophylaxisagai nstex cessivep ostpartumb loodl oss
consists of external fundal m assage and ox ytocin
(Pitocin), 2 0 u nits i n 1 000 mL of I V f luid a t 1 00
drops/minute afterdel iveryofthepl acenta.Ox ytocin
cancausem arkedhy potension ifadm inisteredasa
IVbol us.
4. After delivery of the pl acenta, the bi rth canal i s
inspectedforl acerations.
 DeliveryNote
1. Notetheage,gravi da,para,andgestati onalage.
2. Timeofbi rth,ty peofbi rth(spontaneousvagi nal
delivery),posi tion(l eftocci putanteri or).
3. Bulbsucti oned,sex ,w eight,A PGARscores,
nuchalcord,andnum berofcordvessel s.
4. Placentaex pressedspontaneousl yi ntact.D e­
scribeepi siotomydegreeandrepai rtechni que.
5. Notel acerationsofcervi x,vagi na,rectum ,peri ­
neum.
6. Estimatedbl oodl oss:
7. Disposition:M othertorecovery room i nstabl e
condition.I nfanttonursery i nstabl econdi tion.

RoutinePostpartumO rders
Transfer:T orecovery room ,thenpostpartum w ard

whenstabl e.

Vitals:C heckvi tals,bl eeding,fundusq15m inx 1hr

orunti lstabl e,thenq4h.

Activity:A mbulatei n2hoursi fstabl e

NursingO rders:I funabl etovoi d,strai ght

catheterize;si tzbathsprnw ith1:1000B etadineprn,

icepack toperi neumprn,recorduri neoutput.

Diet:R egular

IVFl uids:D 5LRat125cc/h.D iscontinuew hen

stableandtak ingP Odi et.

Medications:
Oxytocin(P itocin)20uni tsi n1LD 5LRat100
drops/minuteor10U I M.
FeS04325m gP Obi d-tid.
SymptomaticM edications:
Acetaminophen/codeine(T ylenol#3)1-2tabP O

q3-4hprn OR

Oxycodone/acetaminophen(P ercocet)1tabq6h

prnpai n.

Milkofm agnesia30m LP Oq6hprnconsti pation.

DocusateS odium(C olace)100m gP Obi d.

Dulcolaxsupposi toryP Rprnconsti pation.

AandD cream orLanol inprni fbreastfeedi ng.

Breastbi nderorti ghtbraz ierandi cepack sprni f

nottobreastfeed.

Labs:H emoglobin/hematocriti nA M.Gi verubel la

vaccineiftiter<1:10.

ActiveM anagementofLabor
The activem anagementofl abor referstoacti vecontrol over
the course of l abor. T here are three essenti al el ements to
active m anagement are careful di agnosis of l abor by stri ct
criteria,constantm onitoringof labor, and prompti ntervention
(eg,am niotomy,hi gh dose oxytocin) ifprogressi sunsati sfac­
tory.

I. Criteriafo ractiv em anagemento flab or:

A. Nulliparous
B. Termpregnancy
C. Singletoni nfanti ncephal icpresentati on

D. Nopregnancy com plications

E. Experiencingspontaneousonsetofl abor.

II. Diagnosiso flab or

A. Thedi agnosisofl abori sm adeonl y whencontracti ons
areaccom paniedby any oneofthefol lowing:
1. Bloodyshow
2. Ruptureofthem embranes
3. Fullcervi caleffacem ent
B. Women w ho m eet these cri teria are adm itted to the
laboruni t.
III. Managemento flab or
A. Ruptureofm embranes.I ntactfetal m embranesare
artificiallyrupturedonehourafter the diagnosisofl abor
is m ade to perm it assessment of the quanti tyof fl uid
andthepresenceofm econium.R uptureofthe mem­
branesm ayaccel eratel abor.
B. Progressdur ingthefir ststageoflabor
1. Satisfactory progress i n the fi rst stage of l abor i s
confirmed bycervi caldi latationofatl east1cm per
hourafterthem embraneshavebeenruptured.
2. In the absence of m edical contrai ndications, l abor
thatfai lstoprogressattheforegoi ngratei streated
withox ytocin.
3. Progress dur ing the second stag e of labor is
measuredby fetal descentandrotati on.
a. The second stage of l abor i s di vided i nto two
phases: the fi rst phase i s the ti me fr om full
dilatationunti lthefetal headreachest hepel vic
floor; the second phas e e xtends from the ti me
the head reaches the pel vic fl oor to del ivery of
thei nfant.
b. Thefi rstphaseofthese cond stagei scharacter­
izedby descentofthefetal head.I f the fetal head
is high inthepel visatful ldi latation, the woman
often has no urge to push and shoul d not be
encouragedtodoso.Ox ytocintreatm entm aybe
useful i f the fetal hea d fails to descend after a
periodofobservati on.
C. Administrationof oxytocin. Oxytocinis administered
fortreatm entof failureofl abortoprogress,unl essi ts
usei scontrai ndicated. Oxytocin mayonl ybeadm inis­
teredi fthefol lowingcondi tionsarem et:
 1. Fetalm embranesareruptured
2. Absenceofm econiumi nam nioticfl uid
3. Singletonfetusi navertex posi tion
4. Noevi denceoffetal di stress

HighDo seOxy tocin(P itocin)Reg imen

Beginox ytocin6m Uperm inuteI V

Increasedoseby 6m Uperm inuteevery 15m inutes
Maximumdose:40m Uperm inute

D. Failuretopr ogress(dy stocia)i s diagnosedw henthe

cervixfai ls todi lateatl east1cm per hourduri ngthe
first stage of l abor or w hen the fetal head fai ls to
descend duri ng the se cond stage of l abor. T hree
possible causes for fai lure to progress are possi ble
(excludingm alpresentationsandhy drocephalus):
1. Inefficientuteri neacti on
2. Occiput-posteriorposi tion
3. Cephalopelvicdi sproportion.
E. Inefficientuteri neacti oni sthem ostcom moncause of
dystociai nthenul liparous gravida,especi allyearl yi n
labor. Secondary arrestofl aborafterprevi ouslysati s­
factory progress m ay be due to an occi put-posterior
position or cephal opelvic di sproportion. It i s often
difficult for the cl inician to di fferentiate am ong these
entities, thus oxy tocin i s adm inistered i n al l cases of
failuretoprogress(unl essacontrai ndicationex ists).
F. In the fi rst stage, progress ive cervi cal di latation of at
least 1 cm per hour shoul d occur w ithin one hour of
establishingeffi cientuteri necontracti ons(fi vetoseven
contractions w ithin 15 m inutes) w ith ox ytocin. T he
second stage i s consi dered prol onged i f i t ex tends
longer than tw o hours i n w omen w ithout epi dural
anesthesiaandl ongerthanthreehours in women with
epiduralanesthesi adespi teadequatecontracti onsand
oxytocinaugm entation.
References:S eepage166.

Perineal Lacer ations and

Episiotomies
I. First-degreelacer ation
A. Afi rstdegreeperi neal laceration extendsonl ythrough
thevagi nalandperi nealsk in.
B. Repair:P laceasi nglel ayer of interrupted3-Ochrom ic
orV icrylsuturesabout1cm apart.
II. Second-degree lacer ation and r epair of m idline
episiotomy
A. A second degree l aceration ex tends deep ly into the
soft tissues oftheperi neum,dow nto,butnoti ncluding,
the ex ternal anal sphi ncter capsul e. T he di sruption
involvesthebul bocavernosusandtransverseperi neal
muscles.
B. Repair
1. Proximate the deepti ssuesoftheperi nealbody by
placing3-4i nterrupted2-Oor 3-O chromic or Vicryl
absorbablesutures. Reapproximatethesuperfi cial
layers of the peri neal body w ith a runni ng suture
extendingtothebottom oftheepi siotomy.
2. Identify the apex of the vagi nal l aceration. S uture
the vaginalm ucosaw ithrunni ng,i nterlocking,3-O
chromicorV icrylabsorbabl esuture.
3. Closetheperi nealsk inw itharunni ng,subcuti cular
suture.T ieoffthesutureandrem ovetheneedl e.
III. Third-degreelacer ation
A. This l aceration e xtends through the peri neum and
throughtheanal sphi ncter.
B. Repair
1. Identify each sever ed end of the ex ternal anal
sphinctercapsul e,andgraspeach endw ithanA llis
clamp.
2. Proximate the capsul e of the sphi ncter w ith 4
interrupted sutures of 2-O or 3 -O Vicryl suture,
making sure the suturesdonotpenetratetherectal
mucosa.
3. Continuetherepai rasfor aseconddegreel acera­
tion as above. S tool softeners and si tz baths are
prescribedpost-partum .
IV. Fourth-degreelacer ation
A. The l aceration ex tends through the peri neum, anal
sphincter, and e xtends through the rectal m ucosa to
exposethel umenoftherectum .
B. Repair
1. Irrigate the l aceration w ith ste rile sal ine sol ution.
Identifytheanatom y,i ncludingtheapex of the rectal
mucosallacer ation.
2. Approximatetherectal subm ucosaw itha running
sutureusi nga3-O chromic on aGI needl eex tend­
ingtothem arginoftheanal sk in.
3. Place asecondl ayerofrunni ngsutureto invert the
first suture line, andtak esom etensi onfrom thefi rst
layercl osure.
4. Identify and grasp the torn edges of the external
anal sphi ncter capsul e w ith A llis cl amps, and
perform a repai r as for a thi rd-degree laceration.
Closetherem ainingl ayers as forasecond-degree
laceration.
5. A l ow-residue di et, stool soft eners, and si tz baths
areprescri bedpost-partum .
References:S eepage166.
FetalH eartR ateA ssessment
Fetal heart rate (FH R) asses sment eval uates the fetal
condition byi dentifyingFH Rpatternsthatm ay be associated
withadversefetal orneonatal outcome or are reassuringof
fetalw ell-being.
I. Fetalm onitoringtechni ques
A. Electronic fetal m onitoring. The el ectronic fetal
monitor determines theFH Randconti nuouslyrecords
iti ngraphi calform .
B. External fetal m onitoring. T he FH R i s m easured by
focusing an ul trasound beam on the fetal heart. T he
fetalm onitori nterpretsD opplersi gnals.
C. Internalfetalm onitoringofFH Ri sani nvasive proce­
dure.A spi ralel ectrodei si nserted transcervicallyi nto
thefetal scal p.T hei nternal electrode detects the fetal
(ECG) and cal culates the fetal heart rate based upon
the i nterval betw een R w aves. T his si gnal provi des
accurate m easurement of beat-to-beat and basel ine
variability.
D. Biophysical pr ofile. T he biophy sical p rofile ( BPP)
consists of el ectronic fetal heart rate eva luation com ­
bined w ith sonographi cally assessed fetal breathi ng
movements, m otor m ovement, gross feta l tone, and
amnioticfl uidvol ume.
II. Fetalhear tr atepatter ns
A. The fetal heart rate pattern recorded by an el ectronic
fetal m onitor i s categori zed as reassuri ng or
nonreassuring.
B. Reassuringfetalhear tr atepatter ns
1. Abasel inefetal heartrateof120to160bpm
2. AbsenceofFH Rdecel erations
3. Ageappropri ateFH Raccel erations
4. NormalF HRva riability( 5to 2 5b pm).
C. Earlydeceler ations(i e,shal lowsy mmetricaldecel era­
tions i n w hich the nadir o f t he d eceleration o ccurs
simultaneously w ith the peak of the contracti on) and
mild bradycardiaof100to119bpm arecausedby fetal
head com pression, and t hey a re n ot a ssociated w ith
fetalaci dosisorpoorneonatal outcom e.
D. Them ajorityoffetal arrhy thmiasare benignandspon­
taneouslyconverttonorm alsi nusrhy thmby 24hours
afterbi rth.P ersistenttachy arrhythmiasm aycausefetal
hydrops if present for m anyhours to day s. P ersistent
bradyarrhythmiasareoftenassoci atedw ithfetal heart
disease (eg, cardi omyopathy rel ated to l upus), but
seldomr esultin h ypoxiao ra cidosisin fe tallife .
E. FHRaccel erations andm ildvari abledecel erationsare
indicativeofanorm allyfuncti oningautonom icnervous
system.
F. Nonreassuringfetalhear tr atepatter ns
1. Nonreassuring FH R patterns are nonspeci fic and
require further eval uation. T he fetus m ay not be
acidotici nitially;how ever,conti nuation orw orsening
ofthecl inicalsi tuationm ayresul ti nfetal aci dosis.
2. Latedeceler ations are characterizedby asm ooth
U-shapedfal l i nthefetal heartratebegi nningafter
the contracti on has s tarted and endi ng after the
contractionhas ended.T he nadirofthedecel eration
occurs after the peak of the contracti on. M ild l ate
decelerations are a refl ex central nervous sy stem
responsetohy poxia,w hileseverel atedecel erations
suggestdi rectm yocardialdepressi on.
3. Sinusoidal hear t r ate i s defi ned as a pattern of
regular variability r esembling a sine w ave w ith a
fixed peri odicity of three to fi ve cy cles per m inute
and an am plitude of 5 to 40 bpm . T he si nusoidal
pattern i s caused by m oderate fetal hy poxemia,
oftensecondary tofetal anem ia.
4. Variable deceler ations are characteri zed by the
variable onset of abrupt sl owing of the FH R i n
associationw ithuteri necontracti ons.M ild or moder­
atevari abledecel erations do not haveal atecom po­
nent, are of short durati on and depth, and end by
rapid return to a norm al basel ine FH R. They are
usually i ntermittent. T his pattern i s not ass ociated
withaci dosisorl owA pgarscores.S everevari able
decelerationshaveal atecom ponentduri ngw hich
the fetal pH fal ls. T hey al so m ay di splay l oss of
variability or rebound tachycardia and last longer
than 60 seconds or fall to l ess than 70 bpm . T hey
tend to becomepersi stentandprogressi velydeeper
andl ongerl astingoverti me.
5. Fetaldistr esspatter ns
a. Fetaldi stressi s likelytocausefetal orneonatal
deathordam age if leftuncorrected.Fetal di stress
patterns a re associ ated w ith fetal aci demia and
hypoxemia.
b. Undulating baseline.A lternatingtachy cardia and
bradycardia, often w ith reduced variability be­
tweenthew idesw ingsi nheartrate.
c. Severe brady cardia. Fetal heart rate bel ow 100
bpm foraprol ongedperi odofti me(i e,atl east 10
minutes).
d. Tachycardia w ith dim inished variability that is
unrelated to dr ugs or addi tional non-reassuri ng
periodicpatterns(eg,l atedecel erationsorsevere
variabledecel erations)
III. Intrapartumfetalsu rveillance
A. Transient epi sodes of hy poxemia and hy poxia are
generally w ell-tolerated by the fetus. P rogressive or
severe episodes may leadtofetal aci dosisandsubse­
quent asphy xia. One goal of i ntrapartum fetal s urveil­
lancei stodi stinguishthe fetus withFH Rabnorm alities
 who i s w ell com pensated from one w ho i s a t risk for
neurological im pairment o r death. A ncillary tests are
usefulforthi spurpose.
B. Ancillarytests
1. Fetalscalpstim ulation.Fetal sca lp sti mulationi s
similar to the vi broacoustic sti mulation tes t used
antepartum.A bsenceo faci dosis(i e,fetal pH greater
than 7.20) i s confirmed by el icitation of a FH R
accelerationw hen an examinersti mulatesthefetal
vertex w ith the ex amining finger. Fetal scal p sam ­
pling i s recom mended to further eval uate posi tive
testr esults.
2. Fetal scalp blood sam pling. Capillary b lood col­
lectedfrom thefetal scal pty picallyhasapH l ower
than arterial blood.A pH of7.20w as initially thought
torepresentthecri tical valuefori dentifyingseri ous
fetalstressandani ncreasei nthei ncidenceofl ow
Apgarscores.T hedegreeoftechnical skill required
prohibitsw idespreaduseofthi sm odality.
IV. Managementofnonr eassuringF HRpatter nsdur ing
labor
1. Determine the cause of the abnorm ality (eg, cord
prolapse, maternalm edication,abrupti on placenta)
2. Attempttocorrecttheprobl emori nitiatem easures
toi mprovefeta l oxygenation(eg,changem aternal
position,adm inisterox ygenandi ntravenousfl uids,
consideram nioinfusionortocol ysis)
3. Ifthenonreassuri ngpattern doesnotresol vew ithin
afe wm inutes,p erforma ncillaryte ststo d etermine
thefetal condi tion
4. Determinew hetheroperati vei ntervention is needed
B. Thepresenceofaccel erationsal mostal ways assures
theabsenceoffetal aci dosis.T herefore, if suchaccel ­
erations are not observed, they shoul d be el icited by
manual or vi broacoustic sti mulation. T here i s a 50
percent riskoffetal aci dosisi nfetuses in whom accel­
erations cannot beel icited,sofurthereval uationby fetal
scalp sam pling for pH i s indicated to hel p cl arify the
fetalaci d-basestatus.S erial evaluation every20to30
minutes is necessary i f the FH R pattern rem ains
nonreassuring. E xpeditious del ivery is i ndicated for
persistentnonreassuri ngFH Rpatterns.

ManagementofV ariantFetalH eartR ateP atterns

FHRP attern Diagnosis Action

Normalrate Fetusisw ell None

normal oxygenated
variability,a c­
celerations,
nodecel era­
tions

Normalva riabil­ Fetusisstill Conservative

ity,a ccelera­ wellox ygen­ management.
tions,m ildnon­ atedcentral ly
reassuringpat­
tern(brady ­
cardia,la te
decelerations,
variable
decelerations)

Normalva riabil­ Fetusisstill Continuecon­

ity,± a ccelera­ wellox ygen­ servativem an­
tions, atedcentral ly, agement.C on­
moderate-se­ buttheFH R sidersti mula­
vere suggests tiontesti ng.
nonreassuring hypoxia Preparefor
pattern rapiddel iveryi f
(bradycardia, patternw ors­
latedecel era­ ens
tions,vari able
decelerations)

Decreasing Fetusm aybe Deliveri fspon­

variability, onthevergeof taneousdel iv­
±accel erations, decompen­ eryisrem ote,
moderate-se­ sation ori fsti mulation
verenonreas­ supportsdi ag­
suringpatterns nosisof
(bradycardia, decompen­
latedecel era­ sation.N ormal
tions,vari able responseto
decelerations) stimulationm ay
allowtim eto
awaitavagi nal
delivery

Absentvari abil­ Evidenceof Deliver.Stim u­

ity,noaccel era­ actualori m­ lation
tions,m oder­ pendingas­ ori n-utero
ate/severe phyxia management
nonreassuring maybeat­
patterns temptedi fde­
(bradycardia, liveryisn ot
latedecel era­ delayed
tions,vari able
decelerations)

References:S eepage166.
AntepartumFetalSurveillance
I. Antepartumfetalsu rveillancetech niques
A. Antepartum fetal survei llance shoul d be i nitiated i n
pregnancies inw hichtheri skoffetal dem ise is known
tobei ncreased.T heseprobl emscani ncludem aternal
conditionssuchasanti phospholipid syndrome, chronic
hypertension, renal di sease, systemic lupus
erythematosus,orty pe1 diabetesm ellitus. Monitoring
shouldal so be initiatedi npregnancy -relatedcondi tions
such as p reeclampsia, i ntrauterine grow th restri ction
(IUGR),m ultiplegestati on,poorobstetri cal history,or
posttermpregnancy .
B. Antepartumfetalsurveillancecanincludethe nonstress
test ( NST), BPP, ox ytocin challenge te st (OCT), or
modifiedBPP.
C. Nonstresstest
1. AN STi sperform edusi nganel ectronic fetalm oni­
tor.T esting isgeneral lybegunat 32 to34w eeks.
Testingi sperform edatdai ly to weeklyi ntervalsas
longasthei ndicationfortesti ngpersi sts.
2. The test i s reacti ve i f there are tw o or m ore fetal
heart rate accel erations of 15 bpm above the
baselineratel astingfor15secondsi na 20m inute
period. A nonreacti ve NST does not show such
accelerationsovera40m inuteperi od. Nonreactivity
may be rel ated to fetal i mmaturity, a sl eep cy cle,
drugs,fetal anom alies,orfetal hy poxemia.
3. If the N ST i s nonre active, i t i s consi dered
nonreassuring andfurthereval uationor delivery of
thefetusi s i ndicated.A t term,del iveryratherthan
further eval uation i s usual ly w arranted. A
nonreassuring N ST preterm usual ly shoul d be
assessedw ith ancillaryte sts, sin ceth efa lsep osi­
tive rat e of an isolated N ST m aybe 50 to 60 per­
cent.
D. Fetalm ovementassessm ent(“kickcounts”)
1. A di minution i n the m aternal percepti on of fetal
movement often but not i nvariably precedes fetal
death,i nsom ecasesby several day s.
2. Thew omanl ieson her side and countsdi stinctfetal
movements.P erceptionof 10 distinctm ovementsi n
aperi odof up to 2 hoursi sconsi deredreassuri ng.
Once 10 m ovements h ave been percei ved, the
count m ay be discontinued. I n the absence of a
reassuring count, non stress testi ng i s recom ­
mended.

Indicationsfo rA ntepartumF etalS urveillance

Maternal Pregnancycom plica­

antiphospholipidsy n­ tions
drome preeclampsia
poorlycontrol led decreasedfetal m ovement
hyperthyroidism oligohydramnios
hemoglobinopathies polyhydramnios
cyanoticheartdi sease Intrauterinegrow threstri c­
systemicl upus tion
erythematosus posttermpregnancy
chronicrenal di sease isoimmunization
typeI diabetesm ellitus previousunex plainedfetal
hypertensivedi sorders demise
multipleg estation

E. Ancillarytests
1. Vibroacousticstim ulationi sperform edby placing
an arti ficial l arynx on the maternal abdom en and
delivering a shor t burst of sound to the fetus. T he
procedurecanshorten the durationofti meneeded
to produce reacti vity and th e frequency of
nonreactive N STs, w ithout com promising the
predictiveval ueofareacti veN ST.
2. Oxytocinch allengetest
a. The oxytocin chal lenge test (OC T) i s done by
intravenously infusingdi luteox ytocinunti lthree
contractionsoccurw ithintenm inutes.T hetesti s
interpretedasfollow s:
b. Aposi tivetest isdefi nedby thepresenceofl ate
decelerationsfol lowing50percentorm ore ofthe
contractions
c. A negative test hasnol ateorsi gnificant variable
decelerations
d. An equi vocal-suspicious pattern consi sts of
intermittent lateorsi gnificantvari abledecel era­
tions, w hile an equi vocal-hyperstimulatory pat­
tern referstofetal heartrate decelerations occur­
ringw ithcontracti ons morefrequentthanevery
twom inutesorl astingl ongerthan90seconds
e. Anunsati sfactorytesti s one in whichthetraci ng
is uninterpretable orcontracti onsarefew er than
threei n10m inutes
f. Aposi tivetesti ndicatesdecreasedfetal reserve
andcorrel atesw itha20 to 40 percenti ncidence
of abnorm al FH R patterns duri ng l abor. A n
equivocal-suspicious testw ithrepeti tive variable
decelerations i s al so associ ated w ith abnorm al
FHRpatternsi nl abor,w hichareoftenrel atedto
cordcom pressionduetool igohydramnios.
3. Fetalbi ophysicalpr ofile
a. The fetal bi ophysical profile score refers to the
sonographic assessm ent of four bi ophysical
variables: fetal m ovement, fetal t one, fetal
 breathing, am niotic f luid vol ume and nonstress
testing.E achofthesefi ve parameters is givena
scoreof0or2poi nts, dependinguponw hether
specific cr iteria a re m et. F etal BPS is a
noninvasive,hi ghly accuratem eansforpredi ct­
ingthepresenceoffetal asphy xia.
b. Criteria
(1) Anorm alvari ablei s assignedascoreoftw o
and an abnorm al vari able a score of z ero.
Them aximalscorei s 10/10 and them inimal
scorei s0/10.
(2) Amniotic fluid v olume i s based upon an
ultrasound-basedobj ectivem easurementof
the l argest vi sible p ocket. T he sel ected
largestpock etm usthave atransversedi am­
eterofatl eastonecenti meter.

ComponentsoftheB iophysicalP rofile

Parameter Normal( score= 2 ) Abnormal

(score= 0)

Nonstress >2accel erations> 15 <2acceler a­

test beatsperm inute tions
abovebasel inedur­
ingtestl asting> 15
secondsi n20m in­
utes

Amniotic Amnioticfl uidi ndex AFI< 5orno

fluidv ol­ >5oratl east1 pocket> 2cm
ume pocketm easuring2 x2 cm
cmx 2cm i nperpen­
dicularpl anes

Fetal SustainedFB M(> 30 Absenceof

breathing seconds) FBMorshort
movement gaspsonl y
<30seconds
total

Fetalbody >3epi sodesofei ther <3epi sodes

move­ limbortrunk m ove­ duringtest
ments ment

Fetaltone Extremitiesin fle xion Extensionat

atrestand> 1epi ­ restorno
sodeofex tensionof returnto
extremity,handor flexionafter
spinew ithreturnto movement
flexion

Atotal scoreof8to10i sreassuri ng;ascoreof6i s

suspicious,andascoreof4orl essi som inous.
Amnioticfl uidi ndex= thesum ofthel argestverti cal
pocketi neachoffourquadrantsonthem aternalabdo­
menin tersectinga tth eu mbilicus.

c. Clinicalu tility
(1) The f etal BPS i s noninvasive and hi ghly
accurateforpredi ctingthepresenceoffetal
asphyxia.T heprobability of fetal acidemia is
virtuallyz erow henthescorei s normal (8 to
10). T he fal se negati ve rate (i e, fetal de ath
withinonew eek ofal asttestw ithanorm al
score) i s ex ceedinglyl ow. The l ikelihood of
fetal com promise and death ri ses as the
scorefalls.
(2) Theri skoffetal demise within one weekofa
normal test res ult i s 0.8 per 1000 w omen
tested. T he posi tive predi ctive val ue of the
BPSfor evidenceoftr uefetalcom promiseis
only 50 perce nt, w ith a negati ve predi ctive
valuegreaterthan99.9percent.
d. Indicationsandfr equencyoftesti ng
(1) ACOGr ecommendsantepar tumtestingin
thefo llowingsitu ations:
(a) Women w ith hi gh-risk factors for fetal
asphyxia shoul d un dergo antepartum
fetal s urveillance w ith t ests ( eg, BPS,
nonstresstest)
(b) Testing may be i nitiated as earl y as 26
weeks of gestati on w hen cl inical condi ­
tions suggest earl y feta l compromise i s
likely.I nitiatingtesti ngat32 to 34w eeks
of gestationi sappropri atefor most preg­
nanciesatincreasedrisk ofstillbirth.
(c) A r eassuring t est ( eg, BPS o f 8 to 1 0)
should be repeated peri odically (w eekly
or tw ice w eekly) unti l del ivery w hen the
high-riskcondi tionpersi sts.
(d) Anysi gnificantdeteri orationi nthe clinical
status (eg, w orsening preecl ampsia,
decreased fetal ac tivity) requi res fetal
reevaluation.
(e) Severe ol igohydramnios (no verti cal
pocket> 2cm oram nioticfl uidi ndex< 5)
requires eitherdel iveryorcl ose maternal
andfetalsurveillance.
(f) Inductionofl abor maybeattem ptedw ith
abnormalantepartu m testingasl ongas
the fetal heart rate and contracti ons are
 monitored continuouslyandarereassur­
ing. C esarean del ivery i s i ndicated i f
therearerepeti tivel atedecel erations.
(2) The m inimum gestati onal age for testi ng
shouldrefl ectthel owerl imitthati ntervention
withdel iveryw ouldbeconsi dered. Thisage
isnow 24to25w eeks.
(3) Modifiedbi ophysical pr ofile.A ssessment
of amnioticfl uidvol umeand nonstress test­
ing appear to be as rel iable a predi ctor of
long-term fetal well-being as t he full BPS.
The r ate o f stillb irth w ithin one week o f a
normalm odifiedBPS is thesa mea sw itht he
fullBPS, 0.8per 1000w omentested.

Guidelinesfo rA ntepartumT esting

Indication Initiation Frequency

Post-termpreg­ 41w eeks Twiceaw eek

nancy

Pretermrupture Atonset Daily

ofm embranes

Bleeding 26w eeksor Twiceaw eek

atonset

Oligohydramnios 26w eeksor Twiceaw eek

atonset

Polyhydramnios 32w eeks Weekly

Diabetes 32w eeks Twiceaw eek

Chronicor 28w eeks Weekly.I n­

pregnancy-in­ creaseto
ducedhy perten­ twice-weeklyat
sion 32w eeks.

Steroid-depend­ 28w eeks Weekly

entorpoorl ycon­
trolledasthm a

Sicklecelldis­ 32w eeks Weekly(m ore

ease (earlierif oftenifsever e)
symptoms)

Impairedrenal 28w eeks Weekly

function

Substanceabuse 32w eeks Weekly

Priorstillb irth At2 w eeks Weekly

beforepri or
fetaldeath

Multiplegestati on 32w eeks Weekly

Congenitalanom ­ 32w eeks Weekly

aly

Fetalgrow thre­ 26w eeks Twiceaw eek

striction oratonset

Decreasedfetal Attim eof Once

movement complaint

F. Perinatalou tcome.A nabnorm alN STresul tshoul dbe

interpreted w ith cauti on. Fur ther assessm ent of fetal
conditionusingt heNST ,OCT , orBPPs houldusually
beperform edtohel pdeterm inew hether the fetus isi n
immediatej eopardy.
G. Managementofabnor maltestr esults
1. Maternal reports of decreased fetal m ovement
should be evaluated by an NST , CST , BPP, or
modifiedBPP. These results,if n ormal,u suallya re
sufficient to e xclude i mminent fetal j eopardy. A
nonreactive N ST or an abnorm al m odified B PP
generally shoul d be fol lowed by addi tional test ing
(either a CST o r a f ull BPP) . In many ci rcum­
stances, a po sitive C ST resul t general ly i ndicates
thatdel iveryi sw arranted.
2. A BPP scor e of 6 is consider ed equivoca l; in the
term fetus, thi s score general ly shoul d prom pt
delivery, w hereas i n t he p reterm f etus, i t should
result i n a repeat BPP i n 2 4 hours. I n the i nterim,
maternal corti costeroid adm inistration shoul d be
consideredforpregnanci esofl essthan34w eeksof
gestation. R epeat equi vocal scores shou ld resul t
eitheri ndel iveryorconti nuedi ntensivesurvei llance.
A BPP s coreo f 4 u suallyin dicates t hat d eliveryis
warranted.
3. Preterm del ivery i s i ndicated for nonreassuri ng
antepartum fetal testi ng resul ts that have been
confirmedby addi tionaltesti ng.A tterm ,addi tional
testingcanbeom itted since the risk fromdel iveryi s
small. Depending on the fetal heart rate pattern,
inductionofl aborw ithconti nuous FHRandcontrac-
 tion monitoring maybeattem ptedi ntheabsence of
obstetrical contraindications.R epetitivel atedecel ­
erations or severe vari able decel erations usual ly
requirecesareandel ivery.
References:S eepage166.

BriefPostoper ativeC esareanSection

Note
Pre-opdi agnosis:
1. 23 y ear ol d G 1P0, esti mated gestati onal age = 40
weeks
2.D ystocia
3.N on-reassuringfetal traci ng
Post-opdiagnosis: Sameasabove
Procedure: P rimary l ow segm ent transverse cesarean
section
AttendingS urgeon,A ssistant:
Anesthesia:E pidural
OperativeFindings: Weight and sexofi nfant,A PGARsat
1m inand5m in;norm aluterus,tubes,ovari es.
Cordp H:
Specimens:P lacenta,cordbl ood(ty peandR h).
EstimatedB loodLoss: 800cc;nobl oodrepl aced.
Fluids,bl oodandur ineoutput:
Drains:F oleytogravity .
Complications:N one
Disposition:P atientsenttorecovery room in stable condi­
tion.

CesareanSectionO perativeR eport

PreoperativeD iagnosis:
1. 23 y ear ol d G 1P0, esti mated g estational age = 40
weeks
2.D ystocia
3.N on-reassuringfetal traci ng
PostoperativeD iagnosis: Sameasabove
TitleofOper ation:P rimaryl ow segmenttransversecesar­
eansecti on
Surgeon:
Assistant:
Anesthesia:E pidural
Findings A t S urgery: M ale i nfant i n occiput posteri or
presentation. T hin m econium w ith none bel ow the cords,
pediatricspresentatdel ivery,A PGAR's6/8,w eight3980g.
Normaluterus,tubes,andovari es.
DescriptionofOper ativeP rocedure:
After assuringi nformedconsent,thepati entw as taken to
the operating room andspi nalanesthesi aw asi nitiated.T he
patient w as pl aced i n the dorsal , supi ne posi tion w ith l eft
lateral tilt.T heabdom enw aspreppedanddrapedi n sterile
fashion.
A Pfannenstiel skini ncisionw asm adew ithascal peland
carriedthroughtothel evelofthefasci a.T hefasci ali ncision
was ex tended bi laterally w ith M ayo scissors. T he fasci al
incisionw asthengraspedw iththeK ochercl amps,el evated,
and sharpl y and bl untly di ssected superi orly and inferiorly
fromtherectusm uscles.
Therectusm uscles werethenseparatedi nthem idline,
andtheperi toneumw astentedup,andenteredsharpl yw ith
Metzenbaum scissors. Theperi toneali ncisionw as extended
superiorlyandi nferiorlyw ithgoodvi sualizationofthebl adder.
Abl adderbl adew astheni nserted,andthevesi couterine
peritoneum w as i dentified, grasped w ith the pi ck-ups, and
enteredsharpl yw ith the Metzenbaumsci ssors.T hisi ncision
wasthenex tendedl aterally,andabl adderfl ap was created.
The bl adder w as retracted usi ng the bl adder bl ade. The
lower uter ine segm ent w as i ncised i n a transverse fashi on
with the scalpel, then ex tended bi laterally w ith bandage
scissors. T he bl adder bl ade w as rem oved, and the i nfants
head w as del ivered atraumatically. T he nose and m outh
were su ctioned and the cord cl amped and cut. T he i nfant
was handed of f to the pedi atrician. C ord gases and cord
bloodw eresent.
Thepl acentaw asthenrem ovedm anually,andtheuterus
was ex teriorized, and cleared of al l cl ots and debri s. T he
uterinei ncisionw asrepai red with1-Ochrom ici narunni ng
lockingfashi on.A secondl ayerof1-Ochrom ic was used to
obtainex cellenthem ostasis.T hebl adderfl apw asrepai red
with a 3-O V icryl i n a runni ng fashi on. T he cul -de-sac w as
clearedof clots and theuterusw asreturnedtotheabdom en.
Theperi toneumw ascl osed with3-0V icryl.T hefasci aw as
reapproximatedw ithOV icryl in a running fashion.T hesk in
wascl osedw ithstapl es.
The pati ent tol erated the procedure w ell. N eedle and
spongecountsw erecorrectti mestw o.T wo grams of Ancef
wasgi venatcordcl amp,anda sterile dressing waspl aced
overthei ncision.
Estimated B lood Loss (E BL): 800 cc; no bl ood repl aced
(normalbl oodl ossi s500-1000cc).
Specimens:P lacenta,cordpH ,cordbl oodspeci mens.
Drains:F oleytogravity .
Fluids:I nput-2000ccLR ;Output-300cccl earuri ne.
Complications: None.
Disposition: T he pati ent was tak en to the recovery room
thenpostpartum w ardi nstabl econdi tion.
Postoperative M anagement after
CesareanSection
I. PostC esareanS ectionOr ders
A. Transfer:topostpartum w ardw henstabl e.
B. Vitalsigns: q4hx 24hours,I andO.
C. Activity:B edrestx 6-8hours, then ambulate; if given
spinal, k eep pati ent fl at on back x 8h. I ncentive
spirometerq1hw hileaw ake.
D. Diet: N POx 8h,thensi psofw ater. Advancetocl ear
liquids,thentoregul ardi etastol erated.
E. IVFl uids:I VD 5 LR or D5 ½ NSat125cc/h.Fol eyto
gravity;di scontinueafter12hours.I and O catheterize
prn.
F. Medications
1. Cefazolin( Ancef)1gm IVPBx onedoseattim eof
cesareansecti on.
2. Nalbuphine(N ubain)5to10 mgS CorI Vq2-3h OR
3. Meperidine(D emerol) 50-75m gI Mq3-4hprnpai n.
4. Hydroxyzine (Vistaril) 25-50 m g I Mq3-4h prn nau­
sea.
5. Prochlorperazine(C ompazine)10m gI Vq4-6hprn
nausea OR
6. Promethazine(P henergan)25-50m gI V q3-4hprn
nausea
G. Labs: CBCin AM .
II. PostoperativeD ay#1
A. Assess p ain, l ungs, ca rdiac st atus, f undal hei ght,
lochia,passi ngoffl atus, bowelm ovement,di stension,
tenderness,bow elsounds,i ncision.
B. DiscontinueI Vw hentak ingadequateP Ofl uids.

C. DiscontinueFol ey,andI andOcatheteri zeprn.

D. Ambulateti dw ithassi stance;i ncentivespi rometerq1h

whileaw ake.
E. Checkhem atocrit,hem oglobin,R h,and rubellastatus.
F. Medications
1. Acetaminophen/codeine (Tylenol#3)1-2P Oq4-6h
prnpai n OR
2. Oxycodone/acetaminophen(P ercocet)1 t ab q6hprn
pain.
3. FeSO4325m gP Obi d-tid.
4. MultivitaminP Oqd, Colace 100 mgP Obi d.M ylicon
80m gP Oqi dprnbl oating.
III. PostoperativeDay #2
A. If passi ng gas and/or bow el m ovement, advance to
regulardi et.
B. Laxatives:D ulcolaxsuppprn or Milk of magnesia30cc
POti dprn.M ylicon80m gP Oqi dprnbl oating.
IV. PostoperativeD ay#3
A. Iftransversei ncision,rem ovestapl esandpl acesteri ­
stripsonday 3.I faverti cali ncision,rem ovestapl eson
postopday 5.
B. Dischargehom eonappropri atem edications; follow up
in2and6w eeks.

LaparoscopicB ilateralT ubalLigation

OperativeR eport
Preoperative D iagnosis: Mul tiparous fem ale desi ring

permanentsteriliz ation.

PostoperativeD iagnosis:S ameasabove

TitleofOper ation:Laparoscopi cbi lateraltubal l igationw ith

Faloperi ngs

Surgeon:

Assistant:

Anesthesia:General endotracheal

FindingsA tS urgery:N ormaluterus,tubes,andovari es.

DescriptionofOper ativeP rocedure

After i nformed consent, the pati ent was tak en to the

operating room wheregeneral anesthesi aw asadm inistered.
The pati ent w as ex amined under anesthesia and found to
havea n ormalu terusw ithn ormal adnexa.S hew asp laced
in the dorsal l ithotomyposi tion and prepped and dr aped i n
sterile fashion.A bi valvespecul umw aspl aced in the vagina,
andtheanteri or lip of thecervi xw asgraspedw ithasi ngle
toothedtenacul um. Auteri nem anipulatorw aspl acedi ntothe
endocervicalcanal andarti culatedw iththetenacul um.T he
speculumw asrem ovedfrom thevagi na.
Aninfraum bilical incision w asm adew ithascalpel,then
while tenti ng up on the abdom en, a V erres needl e was
admitted i nto the i ntraabdominal cavi ty. A sal ine drop test
was perform ed and noted to be w ithin norm al l imits.
Pneumoperitoneum w as attai ned w ith 4 l iters of carbon
dioxide. T he V erres needl e w as rem oved, and a 1 0 m m
trocar and sl eeve were advanced i nto the i ntraabdominal
cavity w hile tenti ng up on the abdom en. T he l aparoscope
wasi nsertedandproperl ocationw asconfi rmed.A second
incisionw asm ade2cm abo ve thesy mphysispubi s,anda
5 m m trocar and sl eeve w ere i nserted i nto the abdom en
underl aparoscopicvi sualizationw ithoutcom plication.
Asurvey reveal ed normalpel vicandabdom inalanatom y.
AFal operi ngappl icatorw asadvancedthroughthesecond
trocar sl eeve, and the l eft Fal lopian tube w as i dentified,
followed out to the fi mbriated end, and grasped 4 cm from
thecornual regi on.T heFal operi ngw as applied to ak nuckle
oftubeandgoodbl anchingw asnotedatthesi teofappl ica­
tion.N obl eedingw asobserve dfrom them esosalpinx.T he
Faloperi ngappl icatorw asrel oaded,andaFal operi ngw as
applied i n a similar fashi on to the opposi te tube. C arbon
dioxidew asal lowedtoescapefrom theabdom en.
The i nstruments w ere rem oved, and the sk in i ncisions
werecl osedw ith#3-OV icryl i nasubcuti cularfashi on.T he
instruments w ere rem oved from t he vagi na, and ex cellent

hemostasisw asnoted.T hepati enttol eratedtheprocedure

well,andsponge,l ap and needle counts werecorrectti mes

two. T he pati ent w as tak en to the recovery room i n stabl e

condition.

EstimatedB loodLoss(E BL):< 10cc

Specimens:N one

Drains:F oleytogravity

Fluids:1500ccLR

Complications: None

Disposition:T hepati ent wastak entotherecovery room i n

stablecondi tion.

PostpartumT ubal LigationO perative

Report
Preoperative D iagnosis: M ultiparous female after vagi nal

delivery,desiringperm anentsteriliz ation.

PostoperativeD iagnosis: Sameasabove

TitleofOper ation:M odifiedP omeroybi lateral tubal ligation

Surgeon:

Assistant:

Anesthesia:E pidural

FindingsA tS urgery:N ormalfal lopiantubesbi laterally

DescriptionofOper ativeP rocedure:

After assuringi nformedconsent, thepati entw astak en

totheoperati ngroom and spinal anesthesiaadm inistered.A
small,transverse, infraumbilicalsk inincisionw asm adew ith
a s calpel, and the i ncision w as carri ed dow n through the
underlying fasci a unti l the peri toneum w as i dentified a nd
entered. T he l eft fal lopian tube w as i dentified, brought i nto
the i ncision and gra sped w ith a B abcock cl amp. T he tube
wasthenfol lowedouttothefi mbria.A n avascular midsection
of the fallopian tubew asgraspedw ithaB abcockcl ampand
broughti ntoak nuckle.T hetubew asdoubl yl igated with an
O-plain suture and transected. T he speci men w as sent to
pathology. E xcellent hem ostasis w as noted, and the tube
was returned to the abdo men. The sam e procedure w as
performedontheopposi tefal lopiantube.
The fasci a was then cl osed w ith O-V icryl i n a si ngle
layer.T hesk inw ascl osed with3-OV icryli nasubcuti cular
fashion.T hepati enttol eratedthe procedure well.N eedleand
spongecountsw erecorrectti mes2.
EstimatedB loodLoss(E BL):< 20cc
Specimens:S egmentsofri ghtandl efttubes
Drains:F oleytogravity
Fluids:I nput-500ccLR ;output-300cccl earuri ne
Complications: None
Disposition: Thepati entw astak entotherecovery room i n
stablecondi tion.

PreventionofD Isoimmuniz ation

The morbidityandm ortalityofR hhem olyticdi seasecanbe
significantly reduced by i dentification of w omen at ri sk for
isoimmunizationandby adm inistration of Di mmunoglobulin.
Administration of D i mmunoglobulin [R hoGAM, R ho(D)
immunoglobulin, R hIg] i s very effecti ve i n the preventi ng
isoimmunizationtotheD anti gen.

I. Prenataltesting
A. Routine prenatal l aboratoryeval uation i ncludes A BO
andD bl oodty pedeterm inationandanti bodyscreen.
B. At28-29w eeksofgestati onw omanw hoareD nega­
tivebutnotD i soimmunizedshoul dbe retestedforD
antibody. I f the test reveal s that no D anti body i s
present, prophy lactic D i mmunoglobulin [R hoGAM,
Rho(D)i mmunoglobulin,R hIg]i si ndicated.
C. IfDantibody ispresent,Dim munoglobulinw illnotbe
beneficial, and speci alized m anagement of the D
isoimmunized pregnancy i s undertak en to m anage
hemolyticdi seaseofthefetusandhy dropsfetal is.
II. Routinead ministrationo fDim munoglobulin
A. Abortion. Dsensi tization may becausedby aborti on.
D sensi tization occurs m ore frequentl y after i nduced
abortionthan afterspontaneousaborti on,andi toccurs
more frequently after l ate aborti on than after earl y
abortion. D sen sitization occurs fol lowing i nduced
abortion i n 4-5% of suscepti ble w omen. All
unsensitized,D -negativew omenw hohave an induced
or spontaneous aborti on should be treated w ith D
immunoglobulin unl ess the father i s k nown to be D
negative.
B. Dosage of D i mmunoglobulin i s determ ined by the
stage of gestati on. I f the aborti on occurs before 13
weeks of gestati on, 50 m cg of D i mmunoglobulin
prevents sensi tization. For aborti ons occurri ng at 13
weeksofgestati onandl ater,300-m cgi sgi ven.
C. Ectopic pr egnancy can cause D sensi tization. A ll
unsensitized,D -negativew omen whohaveanectopi c
pregnancy shoul d be gi ven D i mmunoglobulin. T he
dosage i s d etermined by the gestati onal age, as
describedaboveforaborti on.
D. Amniocentesis
1. Di soimmunizationcanoccurafter amniocentesis.D
immunoglobulin,300m cg,shoul dbeadm inistered
to unsensi tized, D -negative, suscepti ble patients
followingfi rst-andsecond-tri mester amniocentesis.
2. Followingthi rd-trimesteram niocentesis,300m cgof
Di mmunoglobulinshoul dbeadm inistered.I fam nio­
centesisi sperform edanddel iveryi s plannedw ithin
48 hours, D i mmunoglobulin can be w ithheld unti l
 afterdel ivery, whenthenew borncanbetestedfor
D posi tivity. If the am niocentesis i s ex pected to
precededel iveryby m orethan48hours,thepati ent
shouldrecei ve 300m cgofD i mmunoglobulinatthe
timeofam niocentesis.
E. Antepartumpr ophylaxis
1. Isoimmunizedoccursi n 1-2% ofD -negativew omen
during the antepartum period. D i mmunoglobulin,
administered both duri ng pregnancy a nd
postpartum, can reduce the i ncidence o f D isoim­
munizationto0.3% .
2. Antepartum prophylaxisi sgi venat28-29w eeks of
gestation. Antibody-negative,R h-negativegravi das
should have a repeat assessm ent at 28 w eeks. D
immunoglobulin(R hoGAM,R hIg),300m cg,i sgi ven
to D-negativew omen.H owever,i fthefather of the
fetus i s k nown w ith certai nty to be D negati ve,
antepartumprophy laxisi snotnecessary .
F. PostpartumD i mmunoglobulin
1. Di mmunoglobulini sgi vento the D negativem other
assoonafterdel ivery ascordbl oodfi ndingsi ndicate
thatthebaby i sR hposi tive.
2. A w oman at ri sk w ho i s i nadvertently not gi ven D
immunoglobulinw ithin7 2h oursafterdel iveryshoul d
still receive prophy laxis at any ti me up unti l tw o
weeksafterdel ivery.I f prophylaxis isdel ayed,i tm ay
notbeeffecti ve.
3. A quanti tative K leihauer-Betke anal ysis shoul d be
performed in situationsi nw hichsi gnificant maternal
bleeding m ay h ave occurred (eg, after m aternal
abdominal traum a, abrupti o pl acentae, ex ternal
cephalic version).I fthequanti tativedeterm ination is
thoughttobem orethan30m L, D immune globulin
should be gi ven to the m other i n m ultiples of one
vial (300 m cg) for each 30 m L of esti mated fetal
whole bl ood i n her ci rculation, unl ess the father of
thebaby i sk nowntobeD negati ve.
G. Abruptio placentae, pl acenta pr evia, cesar ean
delivery, intrauterine m anipulation, or m anual
removalofthe placenta maycausem orethan30m L
of fetal -to-maternal bl eeding. I n these condi tions,
testingfore xcessivebl eeding(K leihauer-Betketest)or
inadequate D i mmunoglobulin dosage (i ndirect
Coombstest)i snecessary .
References:S eepage166.
Complications of Preg­
nancy
Nausea and Vomiting of P regnancy
andH yperemesisG ravidarum
Nauseaandvom itingtoaff ects about70% to85% ofpreg­
nant w omen. S ymptoms of nausea and vom iting of preg­
nancy (N VP) are m ost com mon duri ng the fi rst tri mester;
however, som e w omen have persi stent nausea for thei r
entire pregnancy . H yperemesis often occurs i n associ ation
with hi gh l evels of hum an ch orionic gonadotropi n (hC G),
suchasw ithm ultiplepregnanci es,trophob lasticdi sease,and
fetalanom aliessuchastri ploidy.

ConditionsthatP redisposetoE xcessiveN ausea

andV omiting

Viralgastroenteri tis
Gestationaltrophobl asticdi sease
Hepatitis
Urinarytr actin fection
Multifetalgestati on
Gallbladderdi sease
Migraine

I. Treatmentofnauseaandv omitingofpr egnancy

A. Patientsshoul davoi dodorsorfoodsthatseem tobe
aggravating the nausea. U seful di etary m odifications
include avoidingfatty orspi cyfoods,andstoppi ngi ron
supplements. Frequentsm allm ealsal so may improve
symptoms. R ecommendations i nclude bl and and dry
foods,hi gh-proteinsnack s, andcrack ersatthebedsi de
tobetak enfi rstthi ngi nthem orning.
B. Cholecystitis, pepti c ul cer di sease, or hepati tis can
cause nausea and vom iting and s hould be ex cluded.
Gastroenteritis, appendicitis, py elonephritis, and
pancreatitis alsoshoul dbeex cluded.Obstetri c expla­
nationsfornauseaandvom itingm ayi ncludem ultiple
pregnanciesorahy datidiformm ole.
C. Non-pharmacologic rem edies are adequate for up to
90% o f p atients w ith N VP. H owever, abou t 1 0% w ill
require medication andabout1% havesevereenough
vomitingthatthey requi rehospi talization.
D. Vitamin ther apy. Pyridoxine i s effecti ve as first-line
therapyandi srecom mendedup to 25 mgthreeti mes
daily.P yridoxineserum l evelsdonotappeartocorre­
late w ith the preval ence or degree of nausea a nd
vomiting.M ultivitaminsal soareeffecti veforpreventi on
of N VP. P remesis R x i s a prescri ption tabl et w ith
controlled-releasevi taminB 6,75m g,so itcanbegi ven
once aday .I tal socontai nsvi taminB 12(12m cg), folic
acid(1m g),andcal ciumcarbonate(200m g).
E. Over-the-CounterTher apy. If pyridoxineal onei s not
efficacious, an al ternative i s to com bine over-the­
counterdox ylamine25m g(U nisom)andpy ridoxine25
mg. One could combinethe25m gofpy ridoxine three
times dai ly w ith dox ylamine 25 m g, 1 tablet every
bedtime,and½tabl et morning andafternoon.T herei s
noevi dencethatdox ylaminei sateratogen.

DrugTher apyfor N auseaandV omitingofP reg­

nancy

Genericnam e(tr ade Dosage

name)

Antihistamines

Doxylamine(U nisom) 25m g½tabB ID,1tab

qhs

Dimenhydrinate(D rama­ 25to100m gpo/i m/iv

mine) every4to6hr

Diphenhydramine(B ena­ 25to50m gpo/i m/ivev­

dryl) ery4to6hr

Trimethobenzamide 250m gpoevery 6to8hr

(Tigan) or
200m gi m/prevery 6to8
hr

Meclizine(A ntivert) 12.5to25m gB ID/TID

Phenothiazines

Promethazine 12.5to25m gpo/i v/pr

(Phenergan) every4to6hr

Prochlorperazine 5to10m gpo/i vevery 6

(Compazine) to8hror
25m gprevery 6to8hr
 Prokineticagents

Metoclopramide(R eglan) 10to20m gpo/i vevery 6

hr

Serotonin(5-H T3)antagonists

Ondansetron(Zofran) 8m gpo/i vevery 8hr

Corticosteroids

Methylprednisolone 16m gpoT IDfor3day s

(Medrol) then½doseevery 3
daysfor2w ks

F. PharmacologicTher apy
1. Prescribed m edication i s the ne xt step i f di etary
modifications and vi tamin B6 therapy w ith
doxylaminearei neffective.T hephenot hiazinesare
safeandeffecti ve,andprom ethazine(P henergan)
ofteni stri edfi rst.Oneof thedi sadvantages of the
phenothiazines i s thei r potenti al for dy stonic ef­
fects.
2. Metoclopramide(R eglan)i stheanti emeticdrug
ofchoi ce in pregnancy inseveral E uropeancoun­
tries. There was noi ncreasedri skofbi rth defects.
3. Ondansetron ( Zofran) has been com pared w ith
promethazine(P henergan),andthetw odrugsare
equally eff ective, but ondansetron i s m uch m ore
expensive. N o data hav e been publ ished on fi rst
trimesterteratogeni cri skw ithondansetron.
II. Hyperemesisgr avidarum
A. Hyperemesisgravi darumoccursi ntheex treme0.5%
to 1% of pati ents w ho have i ntractable vom iting.
Patientsw ithh yperemesishaveabnorm alel ectrolytes,
dehydration w ith hi gh uri ne-specific gravi ty, k etosis
andacetonuri a,anduntreated havew eightl oss> 5%
ofbody w eight.I ntravenoushy drationi s the firstl ineof
therapy forpati entsw ithseverenausea and vomiting.
Administration of vi tamin B 1 suppl ements m ay be
necessarytopreventW ernicke'sencephal opathy.
B. Antiemetics are gi ven parenteral ly to p atients w ith
hyperemesis. C orticosteroids m ay have a benefi t i n
hyper-emesis i f other anti emetic therapy has fai led.
Oneproposedregi meni sm ethylprednisolone15to20
mg given intravenously every 8 hours. A
methylprednisoloneoral taperregi meni sm oreeffec­
tivethanoral prom ethazine.
References:S eepage166.

SpontaneousA bortion
Abortion isdefi nedasterm inationofpregnancy resul tingi n
expulsion of an i mmature, nonvi able fetus. A fetus of < 20
weeksgestati onorafetusw eighing< 500 gm isconsi dered
an abortus. S pontaneous abor tion occurs i n 15% of al l
pregnancies.

I. Threatened abor tion i s defi ned as vagi nal bl eeding

occurring i n the fi rst 20 w eeks of pregnan cy, w ithout the
passageofti ssueorruptureofm embranes.
A. Symptoms of pregnancy (nausea, vom iting, fati gue,
breast tenderness, uri nary frequ ency) are usual ly
present.
B. Speculumex amreveal sbl ood coming fromthecervi cal
os without am niotic fl uid or ti ssue i n the endocervi cal
canal.
C. Thei nternalcervi calosi scl osed,and theuterusi ssoft
andenl argedappropri ateforgestati onalage.
D. Differentiald iagnosis
1. Benign and m alignant lesions. T he cervi x often
bleeds from an ectropi on of fri able tissue.
Hemostasis can be accom plished by appl ying
pressureforseveral m inutesw ithal argesw aborby
cautery w ith a si lver ni trate sti ck. A typical cervi cal
lesionsareeval uatedw ithcol poscopyandbi opsy.
2. Disordersofpr egnancy
a. Hydatidiform m ole may present w ith earl y
pregnancybl eeding,passageof grape-likevesi ­
cles, and a uterus that i s enl arged i n ex cess of
that ex pected from dates. A n a bsence of heart
tonesby Doppler after12w eeksi scharacteri stic.
Hyperemesis,preecl ampsia,orhy perthyroidism
may be present. U ltrasonography confi rms the
diagnosis.
b. Ectopic pr egnancy shoul d be ex cluded w hen
first tr imester bl eeding i s associ ated w ith pel vic
pain. Orthostatic l ight-headedness, sy ncope or
shoulderpai n (from diaphragmatici rritation)m ay
occur.
(1) Abdominal tenderness i s noted, and pel vic
examination reveal s cervi cal m otion tender­
ness.
(2) Serumbeta-H CGi sposi tive.
E. Laboratorytests
1. Complete bl ood count. T he CBC w ill n ot r eflect
acutebl oodl oss.
2. Quantitativeser um beta-H CG lev el m aybeposi ­
tive i n nonvi able gestati ons since beta-H CG m ay
persist in the ser um for sever al weeks after fetal
death.
 3. Ultrasonography should detect fetal heart m otion
by 7 weeks gestationorol der.Fai luretodetectfetal
heart motionafter9w eeksgestati onshoul d prompt
considerationofcurettage.
F. Treatmentofthr eatenedabor tion
1. Bed rest w ith sedati on and absti nence from i nter­
course.
2. Thepati entshoul dreport increased bleeding (>nor­
malm enses),cram ping,passageof tissue, orfever.
Passedti ssueshoul dbesavedforex amination.
II. Inevitable ab ortion i s defi ned as a threatened aborti on
withadi latedcervi cal os.M enstrual-likecram psus ually
occur.
A. Differentiald iagnosis
1. Incompleteabor tioni s diagnosed whenti ssuehas
passed. T issue m ay be vi sible i n t he vagi na or
endocervicalcanal .
2. Threatened abor tion i s di agnosed w hen the
internalosisclosedand willnotadm itafingertip.
3. Incompetentcer vixi scharacteri zedby di latationof
thecervi xw ithoutcram ps.
B. Treatmento fin evitableab ortion
1. Surgicalevacuati onoftheuterusi snecessary .
2. Di mmunoglobulin(R hoGAM)i sadm inisteredtoR h­
negative, u nsensitized p atients t o p revent
isoimmunization. B efore 13 w eeks ge station, the
dosage i s 5 0 mc g I M; a t 1 3 w eeks g estation, t he
dosagei s300m cgI M.
III. Incomplete ab ortion i s characteri zed by cram ping,
bleeding, passageofti ssue,andadi latedi nternalos
withti ssuepresenti nthevagi na or endocervicalcanal .
Profusebl eeding,orthostati cdi zziness, syncope,and
postural pulse andbl oodpressurechangesm ayoccur.
A. Laboratoryev aluation
1. Completebl oodcount. CBC willn otr eflecta cute
bloodl oss.
2. Rhty ping
3. Bloodty pingandcr ess-matching.
4. Karyotypingofproductsofconcepti oni scom pleted
iflo ssisr ecurrent.
B. Treatment
1. Stabilization. I f the pati ent has si gns and sy mp­
toms of heavy bl eeding, at l east 2 l arge-bore I V
catheters(< 16gauge)are placed. LactateR inger’s
ornorm alsal inew ith40U ox ytocin/Li s givenI Vat
200m L/hourorgreater.
2. Products of concepti on are rem oved from the
endocervical canal anduterusw ithari ng forceps.
Immediaterem ovaldecreasesbl eeding.C urettage
isp erformeda ftervita lsig nsh avesta bilized.
3. Suctiondilationandcur ettage
a. Analgesiaconsi stsofm eperidine (Demerol),35­
50 mg IV over 3-5 m inutes unti l the pati ent i s
drowsy.
b. The pati ent i s pl aced in the dorsal l ithotomy
position i n sti rrups, prepared, draped, and se­
dated.
c. Aw eightedspecul umi spl acedi ntravaginally,the
vagina and cer vix are cl eansed, and a
paracervicalbl ocki spl aced.
d. Bimanualex aminationconfi rms uterineposi tion
and si ze, and uteri ne soundi ng confi rms the
directionoftheendocervi calcanal .
e. Mechanical di latation is com pletedw ithdi lators
if ne cessary. C urettage i s perform ed w ith an 8
mm sucti on curette, w ith a single-tooth
tenaculumontheanteri orl ipofthecervi x.
4. Post-curettage. A fter curettage, a bl ood count i s
ordered. I f the vi tal si gns are stabl e for several
hours,thepati enti s dischargedw ithi nstructionsto
avoidcoi tus,douchi ng,or theuseoftam pons for 2
weeks.Ferrous s ulfateandi buprofenareprescri bed
forpai n.
5. Rh-negative, unsensi tized pati ents are gi ven I M
RhoGAM.
6. Methylergonovine(M ethergine),0.2m gP O q4h
for 6doses,i sgi veni fthere is continued moderate
bleeding.
IV. Completeabor tion
A. A com plete aborti on i s di agnosed w hen com plete
passageofproducts of conception hasoccurred.T he
uterusi s w ell cont racted,andthecervi cal osm aybe
closed.
B. Differentiald iagnosis
1. Incompleteabor tion
2. Ectopicpr egnancy.P roductsof conception should
beex aminedgrossl yandsubm ittedforpathol ogic
examination. If no fetal tissu eo rvilli a reo bserved
grossly, ectopi c pregnancy m ust be e xcluded by
ultrasound.
C. Managementofcom pleteabor tion
1. Between 8 and 14 w eeks, curett age i s necessary
becauseofthehighprobabilit ythattheabortion was
incomplete.
2. Di mmunoglobulin(R hoGAM)i sadm inisteredt oR h­
negative,unsensi tizedpati ents.
3. Beta-HCG l evels are obtai ned w eekly unti l z ero.
Incompleteaborti oni ssuspectedi fbeta-H CGl evels
plateauorfai ltoreachz erow ithin4w eeks.
V. Missedabor tioni sdi agnosedw henproductsofconcep­
tion are retained after the fetus has ex pired. I f products
are retai ned, a severe coagulopathyw ith bl eeding often
occurs.
 A. Missedaborti onshoul dbe suspected whenthepreg­
nant uterus fai ls to grow as ex pected or w hen fetal
hearttonesdi sappear.
B. Amenorrhea m ay persi st, or i ntermittent vaginal
bleeding,spotti ng,orbrow ndi schargem aybenoted.
C. Ultrasonographyconfi rmsthedi agnosis.
D. Managementofm issedabor tion
1. CBC w ith pl atelet count, fi brinogen l evel, part ial
thromboplastin t ime, and A BO bl ood ty ping and
antibodyscreenareobtai ned.
2. Evacuation of the u terus i s com pleted after fetal
deathhas been confirmed.Dilationandevacuation
by suction curettagei sappropri atew hentheuterus
isl essthan12-14w eeksgestati onalsi ze.
3. Di mmunoglobulin( RhoGAM)isa dministeredto
Rh-negative,unsensi tizedpati ents.
References:S eepage166.

UrinaryT ractInfectionsinPr egnancy

Urinary tract i nfection (UTI) i s a com mon probl em i n preg­
nancy. Althoughasy mptomaticbacteri uriaoccursw ith equal
frequency i n pregnant and nonpreg nant w omen, i t p ro­
gresses to sy mptomatic infection m ore frequentl y duri ng
pregnancy.T hepreval enceofasy mptomaticbacteri uriai s5
to 9 percent. I f asy mptomatic bacteri uria i s not treated,
pyelonephritis w ill dev elop in 20 to 40 percent of pregnant
patients.

I. Riskfactor sfor U TIinpr egnancy:

A. Previoushi story ofU TI,especi allybefore20w eeksof
gestation
B. Multiparity
C. Presenceofhem oglobinS

D. Lowersoci oeconomicstatus

E. Sexualacti vity

F. Anatomicalabnorm alities

G. Diabetesm ellitus

H. Advancedm aternalage

II. Microbiology. Escherichia coli isresponsi blefor60to 90

percentofcasesofasy mptomaticbacteri uria, cystitis, and
pyelonephritis.
III. Asymptomaticb acteriuria
A. Asymptomatic bacteri uria refers to th e isolation of
>100,000 C FU of a si ngle organ ism/mL from a
midstream-voidedspeci meni naw omanw ithoutU TI
symptoms.I toccursi n5to 9percentofpregnanci es,
usually devel oping in the fi rst m onth of gestati on,
particularlyi nm ultiparousw omen.
B. Diagnosis.T hedefi nitionofaposi tiveuri necul ture is
>105CF U/mL.
C. Treatment
1. Sulfisoxazole(Gantr isin)500 mgP OT IDforthree
days.
2. Amoxicillin 500m gP OT IDforthreeday s.
3. Amoxicillin-clavulanate( Augmentin),500m gP O
BIDforthreeday s.
4. Nitrofurantoin (M acrodantin) 50 m g P O QI D for
sevenday s])
5. Cefixime(S uprax)250 mgP OQD forthreeday s.
6. Fosfomycin(M onurol) 3gP Oasasi ngledose.
7. Thesedrugsshoul dbeusedonl yi f the isolate has
been establ ished to be suscepti ble to the agent.
Sulfonamides can displace bilirubin from plasm a
binding si tes i n the new born and m ay cause
kernicterus. S ulfonamide therapy i s not recom ­
mendedi nthethi rdtri mester.
8. Relapsesty picallyoccuri nthefi rsttw ow eeksafter
treatment an d are m ost com mon w hen the
bacteriuria originates i n the k idney (50 percent).
Relapsesshoul d be treated withtw ow eeksoforal
antibiotics.
9. Suppressivether apyi srecom mendedforw omen
with persi stent bacteri uria (i e, > 2 posi tive uri ne
cultures).N itrofurantoin(M acrodantin[50to 100m g
orallyatbedti me])for thedurati onofthepregnancy
or cephal exin (K eflex [250 to 50 0 mg oral ly at
bedtime]) may be used. A cul ture for test of cure
can beobtai nedaw eekafter completion of therapy
andthenrepeatedm onthlyun til com pletionofthe
pregnancy.
IV. Cystitis
A. Cystitis occurs i n 0.3 to 1.3 percent of pregnant
women.B acteria are confinedtothel oweruri narytract
inthesepati ents.
B. Clinicalf eaturesanddiagnosis .A cutecy stitisshoul d
be consi dered i n any gra vida with sy mptoms of fre­
quency, urgency , dy suria, hem aturia, or suprapubi c
pain i n the absence of fever and fl ank p ain. Urine
culturei sthe" goldstandard" fordi agnosis.H owever,
a C FU count > 102/mL shoul d be consi dered posi tive
on am idstreamuri nespeci meni nw omenw ithacute
symptomsandpy uria.
C. Treatmentofcy stitis
1. Urine cul ture shoul d be obtai ned i n pati ents w ith
signs and sy mptoms suggesti ve of cy stitis, and
empiric a ntibiotic t herapy shoul d b e i nitiated. Th e
treatmentshoul dbeadj usted dependinguponthe
final cul ture resul ts and the pati ent's re sponse to
therapy.T hesam em icroorganismsassoci atedw ith
asymptomaticbacteri uriaareresponsi bleforcy sti­
tis.
2. Amoxicillin 250m gT ID.
3. Nitrofurantoin(M acrodantin)100m gB ID.
 4. Cephalexin(K eflex)500m gB IDtoQI D.
5. Amoxicillin-clavulanate(A ugmentin)500m gB ID
or250m gT ID
6. Trimethoprim-sulfamethoxazole(B actrim)1D S
BIDbutnoti nthethi rdtri mesterofpregnancy .
7. Cefpodoxime(C efzil)100m gB ID.
8. Cefixime(S uprax)400m gQD .
9. All of these drugs can be used for three to seven
days. Monthlyur ine culturesshoul dbeperform ed
beginning one t o two w eeks after com pletion of
treatment.
V. Pyelonephritis
A. Pyelonephritiscom plicates1to2percentofal lpreg­
nancies.S eventy-threepercentofcasesw erei denti­
fied i n the antepartum pe riod and 46 percent are
diagnosedi nthesecondtri mester.
B. Clinical featur es and diagnosis. A com bination of
fever, chills, and c ostovertebral angle tenderness is
the usual presentati on. Other sy mptoms i nclude
dysuria,nausea,vom iting,andrespi ratorydi stress.
C. Pyuriai spresenti nvi rtuallyal l women withthi sdi sor­
der. U rinalysis reveal s one or tw o bacteri a per hi gh
powerfi eld(H PF)i nanunspuncatheteri zedspeci men
or20bacteri a per HPF in aspunspeci men;w hitecel l
casts confirmthedi agnosis.U rinecul tureandsuscep­
tibilityte stinga reco mpleted.
D. Complications.A pproximately20percentofw omen
with py elonephritis devel op com plications such as
septic shock , anem ia, acute respi ratory di stress
syndrome (A RDS), renal i nsufficiency, peri nephric
abscess,andprem aturel aborandbi rth
E. Inpatienttr eatment
1. Pyelonephritisi npregnantw omeni susual lytreated
withhospi talization andi ntravenousanti bioticsunti l
thew omani safebri lefor24to48hours.
2. Parenteral beta l actams or gentam icin are the
preferredanti biotics.
a. Cefazolin( Ancef)1- 2gm I VPBq8hOR
b. Ampicillin1 g mI VPBq 4-6h AND
c. Gentamicin2m g/kgI VPBt hen1.5m g/kg IV q8h
OR
d. Ampicillin-sulbactam ( Unasyn) 1 .5-3 g m I VPB
q6h.
3. Symptoms t hat persi st for m ore than 48 hours,
despite adequate i ntravenous anti biotic therapy ,
requirearenal ul trasoundtoassess forperi nephric
abscessorrenal cal culi.
4. Intravenous treatm ent shoul d conti nue unti l the
patient isafebri lefor48hours.I npatient therapy is
followed by an outpatient course of anti biotics to
complete10to14day softreatm ent.
5. Antimicrobial pr ophylaxis with ni trofurantoin
(Macrodantin [50 to100m gP Oqhs]) or cephalexin
(Keflex [250 to 500 m g P O qhs]), and peri odic
urinalysis and uri ne cul ture are recom mended for
therem ainderofthepregnancy .
F. Outpatient tr eatment m ay be consi dered i n th e
setting of uncom plicated disease (eg, absence of
underlyingm edicalc onditions,anatom ica bnormalities,
pregnancycom plications,orsi gnsofsepsi s).
References:S eepage166.

TraumaDuringPregnancy
Traumai sthel eadingcauseofnonobstetri c death in women
of reproducti ve age. S ix percent of al l pregnanci es are
complicatedby som ety peoftraum a.

I. Mechanismo fin jury

A. Bluntabdom inaltr auma
1. Bluntabdom inaltraum asecondary tom otorvehi cle
accidents is the l eading cause of nonobstetri c­
related fetal death duri ng pregnancy , fol lowed by
falls and assaul ts. U terine rupture or l aceration,
retroperitoneal hem orrhage,renal injuryandupper
abdominal injuries m ay al so occur after bl unt
trauma.
2. Abruptio placentae occurs i n 40-50% of pati ents
with m ajor traum atic i njuries and i n up to 5% of
patientsw ithm inori njuries.
3. Clinical fin dings in b lunt ab dominal tr auma.
Vaginal bl eeding, uteri ne tenderness, ut erine con­
tractions, fetal tachycardia,l atedecel erations,fetal
acidosis,andfetal death.
4. Detectionofabr uptioplacenta e.B eyond20w eeks
of gestati on, external el ectronic m onitoring can
detect u terine contracti le acti vity. T he presence of
vaginalbl eedingandtetani corhy pertoniccontra c­
tions ispresum ptiveevi denceofabrupti opl acentae.
5. Uteriner upture
a. Uterine rupturei sani nfrequentbut life-threaten­
ing com plication. I t usual lyoccurs after a d irect
abdominali mpact.
b. Findings of uteri ne rupture range from subtl e
(uterine tenderness, nonreassuri ng fetal heart
ratepattern)tosevere,w ith rapid onset ofm ater­
nalhy povolemicshock anddeath.
6. Directfetalinj uryi s ani nfrequentcom plicationof
blunttraum a.
a. Thefetusi sm orefrequentl yi njured asaresul tof
hypoxiafrom bl oodl ossorabrupti on.
b. Inthefirsttrim esterthe uterusi sw ell protected by
the m aternal pel vis; therefore, m inor traum a
 usually does notusual lycausem iscarriagei nthe
firsttrim ester.
B. Penetratingtr auma
1. Penetrating abdom inal traum a f rom gunshot and
stabw oundsduri ngpregnancy has apoorprogno­
sis.
2. Perinatal mortalityi s 41-71% .M aternal m ortalityi s
lessthan5% .
II. Majortr aumain p regnancy
A. Initial eva luation o f m ajor ab dominal tr auma in
pregnant pati ents does not di ffer from eval uation of
abdominaltraum ai nanonpregnantpati ent.
B. Maintainair way, breathing, andcir culatoryv olume.
Two l arge-bore (14-16-gauge) i ntravenous l ines are
placed.
C. Oxygen shoul d be adm inistered by m ask or
endotracheal i ntubation. M aternal ox ygen saturati on
should be k ept a t >90% (an ox ygen parti al pressure
[pO2]of60m mH g).
D. Volumer esuscitation
1. Crystalloidi ntheform of lactated Ringer'sornorm al
salineshoul dbegi venasa3:1repl acementforthe
estimated blood lossoverthefi rst30-60m inutesof
acuteresusci tation.
2. O-negativepack edredcel ls arep referredi f em er­
gentbl oodi sneeded before the patient'sow nbl ood
typei sk nown.
3. A uri nary catheter shoul d be pl aced to m easure
urineoutputandobserveforhem aturia.
E. Deflection oftheuter usoffthei nferiorvena cava and
abdominalaortacanbe achieved bypl acingthepati ent
in the l ateral decubi tus posi tion. I f the pati ent m ust
remain supi ne, m anual d eflection of the uterus to the
left and placement ofaw edgeunderthepati ent'shi p or
backboardw illtiltthepatient.
F. Secondary sur vey. F ollowing sta bilization, a m ore
detailedsecondary survey ofthepati ent,i ncluding fetal
evaluation,i sperform ed.
III. Minortr aumain p regnancy
A. Clinicalev aluation
1. Pregnant pati ents w ho sustain seem ingly m inimal
traumarequi reaneval uationtoex cludesi gnificant
injuries. C ommon " minor" trauma i nclude fal ls,
especiallyi nthethi rdtri mester,bl owstotheabdo­
men,and" fender benders" motorvehi cleacci dents.
2. The pati ent shoul d be questi oned about seat bel t
use, lossofconsci ousness,pai n, vaginal bleeding,
ruptureofm embranes,andfetal m ovement.
3. Physicalexam ination
a. Physical ex amination shoul d focus on upper
abdominaltenderness(l iverorspl een damage),
flankpai n (renal trauma),uteri nepai n(pl acental
abruption, uteri ne rupture), and pai n over the
symphysispubi s(pel vicfracture,bl adderl acera­
tion,fetalsk ullfracture).
b. A searchfororthopedi ci njuriesshoul dbecom ­
pleted.
B. Managementofm inortr auma
1. The m inor traum a pati ent w ith a fetus that i s l ess
than 20 w eeks gestati on (not y et vi able), w ith no
significant i njury can be safel y di scharged af ter
documentation o f f etal heart r ate. P atients w ith
potentiallyvi able fetuses (over 20 w eeks of gesta­
tion) requi re fetal m onitoring, l aboratory tests and
ultrasonographiceval uation.
2. A com plete bl ood count, uri nalysis (hem aturia),
blood ty pe and screen (to check R h status), and
coagulation pane l, including m easurement of the
INR,P TT,fi brinogenandfi brinspl itproducts,shoul d
beobtai ned.T hecoagul ationpanel i sus eful ifany
suspicionofabrupti onex ists.
3. TheK leihauer-Betke(K B)test
a. This test detects fetal red bl ood cells i n the
maternal ci rculation. A K B stai n shoul d be ob­
tainedrouti nelyforany pregnanttr aumapati ent
whosefetusi sover12w eeks.
b. Regardless of the pati ent's bl ood type and R h
status, the K B test can hel p determine i f
fetomaternalhem orrhagehasoccurred.
c. The K B test can al so be used to determine the
amount of R ho(D) i mmunoglobulin (R hoGAM)
requiredi npati entsw hoareR h-negative.
d. Aposi tive KBstai ni ndicatesuteri netraum a,and
any pati ent w ith a posi tive K B s tain shoul d re­
ceive at least24hoursofconti nuousuteri ne and
fetalm onitoringandacoagul ationpanel .
4. Ultrasonography i s l ess sensi tive for di agnosing
abruption thani sthefi ndingofuteri ne contractions
on external tocody namometry. Absence o f
sonographic evi dence of abruption does not com ­
pletelyex cludeanabrupti on.
5. Patients w ith abdom inal pai n, s ignificant brui sing,
vaginal bleeding, ruptureofm embranes,oruteri ne
contractions shoul d be adm itted to the hospi tal for
overnightobservati on and continuousfetal m onitor.
6. Uterine con tractions and vagi nal bl eeding are
suggestiveofabrupti on.E veni fvagi nalbl eedingi s
absent, th e p resence o f co ntractions is still a co n­
cern, since the uterus cancontai nupto2Lof blood
fromaconceal edabrupti on.
7. Traumapati entsw ithnouteri necontracti on activity,
usually do no t have abrupti on, w hile pati ents w ith
greaterthanonecont ractionper10m inutes(6per
hour)havea20% i ncidenceofabrupti on.
References:S eepage166.
GestationalDiabetesM ellitus
Poorlycontrol ledgestati onaldi abetes is associatedw ithan
increase inthei ncidenceofpreecl ampsia, polyhydramnios,
fetal m acrosomia, bi rth trauma, operati ve del ivery, and
neonatalh ypoglycemia.T herei sani ncreasedi ncidenceof
hyperbilirubinemia, hy pocalcemia, and ery thremia. T he
perinatal m ortality i s i ncreased, as i s the l ikelihood of
development of obesi ty and di abetes i n offspri ng duri ng
childhood. Later developm ent of diabetes m ellitus in the
mother isal som orefrequent.T hepreval enceof gestational
diabetesi s higher inbl ack,H ispanic,N ativeA merican,and
Asian w omen than w hite w omen. T he preval ence
ofgestati onaldi abetesi s1.4to14percent.

RiskFactor sfor GestationalD iabetes

• Afam ilyhi storyofdi abetes,especi allyi nfi rstdegree

relatives
• Prepregnancyw eightof110percentofi dealbody
weight(pregravi dw eightm orethan90k g)orm oreor
weightgai ni nearl yadul thood.
• Agegreaterthan25y ears
• Aprevi ousl argebaby (greaterthan9pounds[4.1
kg])
• Historyofabnorm algl ucosetol erance
• Hispanic,A frican,N ativeA merican,S outhorE ast
Asian,andP acificI slandancestry
• Aprevi ousunex plainedperi natall ossorbi rthofa
malformedchi ld
• Them otherw asl argeatbi rth(greaterthan9pounds
[4.1k g])
• Polycysticovary sy ndrome

I. Screeninganddiagnosticcr iteria
A. Screeningfo rg estationaldi abetesshoul dbeperform ed
at24to28w eeksofgestati on. However, itcanbedone
as earl y as the fi rst prenatal vi sit i f there i s a hi gh
degree of suspi cion that the pregnant w oman has
undiagnosed ty pe 2 di abetes (eg, obesi ty, previ ous
gestational di abetes o r fetal m acrosomia, age > 25
years,fam ilyhi storyofdi abetes).
B. 50-g or al glucose challenge i s gi ven and venous
serumorpl asmagl ucosei sm easured one hourl ater;
aval ue> 140m g/dL(7.8m mol/L) is consideredabnor­
mal.W omenw ithanabnorm alval ue arethengi vena
100-g,three-houroral gl ucosetol erancetest(GT T).

Criteriafor GestationalD iabeteswithThr eeH our

OralGlucoseToler anceTest

Fasting >95m g/dL

1hour >180m g/dL

2hour >155m g/dL

3hour >140m g/dL

Anytwoor m oreabnor malr esultsar ediagnosticof

gestationaldiabetes.

II. Treatmento fg estationald iabetesm ellitus

A. Diet
1. Dietarytherapy should be startedi nw omenw hodo
not meetcri teriaforgestati onaldi abetes (abnormal
glucose tol erance test) i f t hey have fasti ng bl ood
glucoseconcentrati ons >90m g/dLor an abnormal
glucosechal lengetest.
2. Caloricintake
a. Pregnantwom enwho are 80 to120per centof
idealbody w eight: 30k calperpresentw eighti n
kgperday .
b. Overweight pr egnant w omen (12 0 to 150
percent of ideal body weight): 24 k cal per
presentw eighti nk gperday .
c. Morbidlyo bese pr egnant wom en (> 150 per ­
cent o f i deal body weight): 12 to 15 k cal per
presentw eighti nk gperday .
d. Pregnant w omen w ho a re less than 8 0 p er­
cento fid ealb odyweig ht:40 kcalperpresent
weighti nk gperday .
3. Caloriedistr ibution: 40percentcarbohy drate,20
percentprotei n,and40percentfat.
a. Withthi scal oriedi stribution,75to80percentof
women w ith gestati onal di abetes can achi eve
normoglycemia.
b. Three m eals and three snack s per day are
recommended. Breakfastm ustbevery small (10
percent of total cal ories) to prevent the bl ood
glucose concentrati on one hour after break fast
from ri sing ab ove 120 m g/dL. T he rem aining
calories shoul d be di stributed as 30 percent at
bothl unchand dinner,w iththel eftovercal ories
distributedassnack s.
TreatmentGo alsfo rGestatio nalDiab etesM ellitus

Time BloodS ugar

Fasting <90m g/dL

1hrpostprandi al <120m g/dL

B. Initiationo fin sulinth erapy

1. Approximately15percentofw omenw ithg estational
diabetesrequi rei nsulinbecauseofel evatedbl ood
glucosedespi tedi etarytherapy .
2. Insulin s hould be i nitiated w hen the fasti ng bl ood
glucoseconcentrati oni s greaterthan90m g/dLand
theone-hour postprandial bloodgl ucoseconcentra­
tion i s greater than 120 m g/dL on tw o or more
occasionsw ithinatw o-weeki ntervaldespi tedi etary
therapy.
3. Insulinr egimen
a. If i nsulin i s requi red because the fast ing blood
glucose concentrati on i s hi gh, an i ntermediate­
acting in sulin, su ch a s NPH in sulin, is g iven
beforebedt ime.T hei nitialdoseshoul dbe0.15
U/kgbody w eight.
b. Ifpostprandi albl ood glucoseconcentrati ons are
high, thenregul ari nsulinori nsulinl ispro should
be gi ven before m eals a t 1.5 U per 10 gram s
carbohydratei nthe breakfast mealand1.0U per
10g rams ca rbohydratei nt hel unch anddi nner
meals.
c. If both preprandi al and postprandi al bl ood gl u­
coseconcentrati onsarehi gh, thenafour-i njec­
tion per day regi men should be i nitiated. T he
total dose i s 0.7 U /kg for w eeks si x t o 18, 0.8
U/kgforw eeks19to26,0.9U /kgforw eeks2 7
to36,and1.0U /kgforw eeks37toterm .
d. The insulinshoul dbedi videdas45percenta s
NPHi nsulin,30percentbefore breakfastand15
percentbeforebedti me,andabout55percent as
preprandial r egular i nsulin, 2 2 p ercent b efore
breakfast, 16.5 percent b efore l unch, and 16.5
percent before di nner. I nsulin resi stance i n­
creases as gestati on proceeds, requi ring an
increasei ni nsulindose.
C. Fetalsu rveillance
1. Fetal survei llance shoul d be i nitiated i n the thi rd
trimester in womeni nw homgestati onaldi abetes is
not w ell-controlled, w ho requi re i nsulin, or have
other com plications of pregnancy (eg, hy perten­
sion).C ountingfetal m ovementsi sasi mple wayto
assess fetalw ell-being.Few erthantenfetal m ove­
mentsi na12-hourperi od is associated with apoor
outcome.
2. Earlydeliv ery. Women withgoodgl ycemiccontrol
andno othercom plicationsofpregnancy i deallyw ill
deliverat39to40w eekso f gestation.I ndications
for del ivery before the 39th w eek i nclude poor
glycemic control and fetal abnorm alities. I f ea rly
delivery i s i ndicated, l ung m aturity shoul d be as­
sessedby am niocentesis if deliverycoul dbesafel y
postponedi ntheabsenceoffetal pul monary matu­
rity.
3. Normald elivery.T hegreatm ajorityofw omen with
gestational di abetes p roceed to term and have a
spontaneousvagi nal del ivery. T hem aternal bl ood
glucose concentrati on s hould be m aintained be­
tween 70 and 90 m g/dL. I nsulin can usual ly be
withheld duringdel ivery,andani nfusionof normal
saline i s u sually s ufficient to maintain
normoglycemia.

Low-dosageCo nstantIn sulinIn fusionfo rth e

IntrapartumP eriod

BloodG lu­ Insulin Fluids(125m L/h)

cose Dosage
(mg/100 (U/h)
mL)

<100 0 5%dextrose/Lactated
Ringer'ssol ution

100-140 1.0 5%dex trose/Lactated

Ringer'ssol ution

141-180 1.5 Normalsal ine

181-220 2.0 Normalsal ine

>220 2.5 Normalsal ine

Dilutionis25Uofregularin sulinin250m Lofnorm al

saline,w ith25m Lfl ushedthroughl ine,adm inis­
teredi ntravenously.

D. Postpartumconcer nsandfol low-up

1. Nearly al l w omen w ith gestati onal di abetes are
normoglycemic afterdel ivery.H owever,they are at
risk for gestati onal di abetes, i mpaired gl ucose
tolerance,andovertdi abetes.
 2. Immediatelyafter delivery,bl oodgl ucoseshoul dbe
measuredtoensurethatthem other nol ongerhas
hyperglycemia. Fasti ng bl ood glucose concentra­
tions shoul d be bel ow 115 m g/dL and one-hour
postprandial concentrati ons shoul d be bel ow 140
mg/dL.
References:S eepage166.

DiabetesM ellitus
Approximately 4 percent ofpregnantw omenhavedi abetes:
88 percent have gestational diabetes m ellitus, w hile the
remaining12percenthavepregestati onaldi abetes.Ofthose
withpregestati onaldi abetes,35 percent have type1and65
percentty pe2di abetes.
I. Glycemiccontr olandfetalandm aternalcom plications

A. Pregnancy in diabetesi sassoci atedw ithani ncrease

in ri sk of congeni tal anom alies and spontaneous
abortionsi nw omenw hoa re inpoorgl ycemic control
during the peri od of fetal organogenesi s, w hich is
nearlycom pleteatsevenw eekspostconcepti on.
B. Macrosomia. Anotherconsequenceofpoorgl ycemic
control i n pregnant w omen w ith di abetes i s fetal
macrosomia, w hich l eads to dy stocia, an i ncreased
need for cesarean del ivery, and an i ncrease i n fet al
morbidity.
C. Glucose m onitoring. Freque nt m easurements of
blood gl ucose are m andatory i n w omen w ith ty pe 1
diabetes duri ng pregnancy . I f the fi rst m orning bl ood
glucose value ishi gh,testi ngshoul dal sobe performed
atbedti meandi nm iddleoftheni ght.

Testingdur ingP regnancyi nTy peI D iabetes

Test Frequency

HemoglobinA 1c Every4 -6 weeks

Bloodgl ucose 4-8t imesd ailya th ome;d uring

weekly/biweeklyvi sits'i np hysi­
cian'soffice

Urinek etones During periodo f illness;w hen

anybl oodgl ucoseval uei s> 200
mg/dL

Urinalysis Weekly/biweeklyoffi cevi sits

Serumc reatinine Eachtri mester

Thyroidf unctiont ests Baselinem easurementsof serum

freeT 4andT SH

Eyeex amination Atbasel ineandasnecessary

perreti nalspeci alist

D. Urinary ketones shoul d be m easured periodically,

especially w hen the w oman is ill or w hen any blood
glucose val ue i s over 200 m g/dL. A t these ti mes
ketoacidosism ayoccur,acom plicationthat is associ­
atedw ithahi ghm ortalityratei nthefetus.
E. Targetbl oodgl ucosev alues
1. Hemoglobin A 1c (H bA1c) shoul d be m easured
everyfour to si x w eeks and m ore frequentl y if the
woman'sgl ycemiccontrol i spoor.
2. Bloodglucosegoalsinapr egnantdiabetic:
a. Fasting capillaryb loodg lucoseconcentrati on
of 55 to 65 m g/dL, about 85 p ercent for the
venouspl asmaconcentrati on.
b. One-hourpostpra ndialb loodgl ucoseconcen­
trationl essthan120m g/dL.
F. Recommendationsfor calor icintake:
1. Woman atidealbody weight:30k cal/kgperday .
2. 20 to 50 per cent above ideal body weight: 24
kcal/kgperday .
3. More than50per centabov eidealbody weight:
12to18k cal/kgperday .
4. Morethan10per centbelowidealbody weight:
36to40k cal/day.
G. Recommended distr ibution of calories: 40 to 50
percentcarbohy drate,20percentprotei n, and 30 to40
percentfat.P atientsshoul deatthreem eals andthree
snacksperday .T hecal oriedi stributionshoul dbe10
percent of calories at break fast, 30 percent at both
lunch and di nner, and 30 percent as snack s. A dai ly
supplement of ferroussul fate(30m g)and folate (400
:g)i sal sorecom mended.
H. Insulinr egimen
1. Most w omen w ith ty pe 1 di abetes requi re at l east
three injections ofi nsulinperday .A fteranearl yri se
in i nsulin requi rements betw een w eeks 3 and 7,
thereofteni sasi gnificantdecl inebetw eenw eeks7
and15,fol lowedby ari se duri ngtherem ainderof
pregnancy.
2. The average i nsulin requi rement i n pregnant
women w ith type 1 di abetes i s 0.7 uni ts/kg i n the
firsttri mester,ofteni ncreasingto0.8 U/kg forw eeks
18to26,0.9U /kgforw eeks27to 36, and 1.0U /kg
forw eeks37toterm .
InsulinA djustmentB asedonB loodGlucose(B G)

Time Insulin Adjustment

dose
beingad­
justed

7:30 Bedtime IfB Gi s> 90m g/dL,check at

AM NPH bedtimeand3:00A M.I fbed­
timeval uei shi gh,i ncrease
dinnerregul ari nsulin.I fbed­
timeval uenorm albut3:00A M
valuei sabove100m g/dL,
thenrai sebedti meN PHby 2
units.I f3:00A Mval uei sbe­
low60m g/dL,thendecrease
bedtimeN PHby 2uni ts.I f
7:30A Mval uei sbel ow60
mg/dL,reducebedti meN PH
by2uni ts.

10:00 Morning If1hourpostprandi alval uei s

AM regular above140m g/dL,i ncrease
nextm orningregul ari nsulinby
2uni ts.I ftheval uei s< 110
mg/dL,decreasenex tm orning
AMregul arby 2uni ts.

1:00 Lunchregu­ If1hourpostprandi alval uei s

PM lar above140m g/dL,i ncrease
lunchregul ari nsulinforthe
nextday by 2uni ts.I ftheval ue
Isbel ow110m g/dL,decrease
nextday 'sl unchregul ari nsulin
by2uni ts.

4:30 Morning IfB Gi sabove90m g/dL,then

PM NPH increasem orningN PHby 2
units.I f90i sbel ow60m g/dL,
thendecreasem orningN PH
by2uni ts.

6:00 Dinnerregu­ If1hourpostprandi alval uei s

PM lar above140m g/dL,i ncrease
dinnerregul ari nsulinby 2
units.I f1hourval uei sbel ow
110m g/dL,decreasedi nner
regulari nsulinby 2uni ts.

3. Women with type2di abetesal soshoul dbe treated

with in sulin. Du ring th e fir st tr imester, in sulin r e­
quirements are si milar i n w omen w ith ty pe 1 and
type 2 di abetes. H owever, as the pregnancy pro­
ceeds intothethi rdtri mester,i nsulinrequi rements
increaseproporti onatelym ore in women withty pe2
thanty pe1di abetes.
4. A com binationofregul ari nsulinandi ntermediate­
acting i nsulin (such as N PH i nsulin) shoul d be
administered. T he i nsulin is i nitially di stributed as
follows:
a. 45 p ercent of the total dai ly dose i s gi ven as
NPH i nsulin and 22 percent as reg ular i nsulin
beforebreak fast.
b. 17percentofthetotal dai lydosei sgi venasboth
NPHandregul ari nsulinbeforedi nner.
c. Theprem ealdoseofregul ari nsulin isgi venon
a sl iding scale accordi ng to the bl ood gl ucose
value.
5. Macrosomiai sdefi nedasfetal w eight greaterthan
4.0to4.5k gorbi rthw eightabove the90thpercen­
tileforgest ationalage.M acrosomicfetusesareat
increased ri sk for a prol onged second stag e of
labor, shoul der dy stocia, operati ve del ivery, and
perinataldeath.
6. Congenitalanom alies. Ultrasonographyi sessen­
tial for the eval uation of congeni tal anom alies.
Congenital anom alies that occur w ith hi gher fre­
quencyi ncludeanencephal y, microcephaly,caudal
regressionsy ndrome,andgeni tourinaryandgastro­
intestinalanom alies.C ongenitalheartdi seasem ay
include hy pertrophic cardi omyopathy, atri al and
ventricularsepti cdefects ,transposi tionofthe great
vesselsandcoarctati onoftheaorta.
7. Polyhydramniosca noccurbecauseofi ncreased
amnioticfl uidosm olalityandpol yuriasecondary to
fetalhy perglycemia.
8. Antepartum su rveillance. I n w omen with di et­
controlledgestati onaldiabetes,fetal surveillance is
usuallynoti nitiatedunti l40w eeksgestati on, since
thesew omen are atvery l owri skforcom plications.
More ri gorous m onitoring i s recom mended for
women w ho h ave addi tional i ndications for cl oser
fetal su rveillance, su ch a s h ypertension. S urveil­
lance begi ns earl ier i n w omen w ith e ither gesta­
tionalorpregestati onaldi abetest reatedw ithi nsulin.
Testing i s begun at the 35th w eek of gestat ion if
therei s ex cellentgl ycemic control . T estingshoul d
start at26to28w eeksi n women with poor control,
nephropathy,orhy pertension.
 I. Laboranddel ivery
1. Insulin i s requi red before acti ve l abor and can be
given subcutaneousl y or by i ntravenous i nfusion
witha goalofm aintainingbl oodgl ucoseconcentra­
tionsbetw een70 and90m g/dL.T hei nsulini nfusion
consists of adm inistration of 15 uni ts of regul ar
insulini n150 mLofnorm alsal ineI Vatarateofone
tothreeuni tsperhour.
2. Normal sal ine m ay b e suffi cient to m aintain
euglycemiaw henl abori santi cipated.
3. Whenacti vel aborbegi ns,i nsulin resistance rapidly
decreases and i nsulin requi rements fal l rapi dly.
Thus,conti nuingi nsulintherapy i s l ikelytol eadto
hypoglycemia. T o prevent thi s, gl ucose should be
infused at a rate of 2.5 m g/kg per m in. Capillary
blood gl ucose shoul d be m easured hourl y. T he
glucose i nfusion shoul d be doubl ed for the nex t
hour i f t he b lood gl ucose val ue i s l ess than 60
mg/dL.H oweveri f the valuei s120m g/dLorm ore,
regular i nsulin i s gi ven subcutaneousl yor i ntrave­
nously until thebl oodgl ucoseval uefal lsto70 to 90
mg/dL. T he i nsulin dose i s ti trated to m aintain
normoglycemiaw hilegl ucosei si nfused at arateof
2.5m g/kgperm in.
4. Ifacesareansecti oni spl anned,the bedtimeN PH
insulin dose may be gi ven on the m orning of sur­
gery and every ei ght hours thereafter i f surgery i s
delayed.
5. Insulinrequi rementsdropsharpl yafter delivery, and
thenew m otherm aynotrequi rei nsulinfor 24 to 72
hours.I nsulinrequi rementsshoul d berecal culated
at thi s ti me at 0.6 uni ts/kg per day based upon
postpartum weight. P ostpartum cal orie requi re­
mentsareapprox imately25k cal/kgperday ,and27
kcal/kgperday i nl actatingw omen.
6. Womeni nw homl abori si nducedshoul drecei veno
morning i nsulin. B lood gl ucose m onitoring and
glucose and i nsulin i nfusion are m anaged as for
activel abor.
References:S eepage166.

Group B Streptococcal Infection i n

Pregnancy
GroupB streptococcus(GB S;S treptococcusagal actiae), a
Gram posi tivecoccus,i s ani mportantcauseofi nfectioni n
neonates,causi ngsepsi s, pneumonia,andm eningitis.GB S
infectioni sacqui redi nuteroor duringpassagethroughthe
vagina. Vaginal colonization withGB Sduri ngpregnancy m ay
lead to prem ature b irth, and GB S i s a frequent cause of
maternaluri narytracti nfection,chori oamnionitis,postpartum
endometritis,andbacterem ia.

I. Clinicalev aluation
A. The primary ri sk factor for GB S i nfection i s m aternal
GBSgeni tourinaryorgastroi ntestinalcol onization.
B. The r ate of transm ission from col onized m others to
infants is approximately 50percent.H owever,onl y1to
2percentofal l col onized i nfantsdevel opearl y-onset
GBSdi sease.
C. Maternalobstetr icalfactor sass ociatedwithneona­
talGB Sdisease:
1. Deliveryatl essthan37w eeksofgestati on
2. Prematureruptureofm embranes
3. Ruptureof membranesfor18orm orehoursbefore
delivery
4. Chorioamnionitis
5. Temperaturegreaterthan38°C duri ngl abor
6. Sustainedi ntrapartumfetal tachy cardia
7. Priordel iveryofani nfantw ithGB Sdi sease
D. Manifestations of ear ly-onset GB S disease. Ea rly­
onset di sease resul ts i n bacterem ia, general ized
sepsis, pneum onia, or m eningitis. T he cl inical signs
usuallyareapparenti nthefi rsthoursofl ife.
II. 2002 CDC g uidelines fo r in trapartum an tibiotic p ro­
phylaxis:
A. All pregnant w omen shoul d be screened for GB S
colonizationw ithsw abs of boththel owervagi naand
rectum at 35 to 37 w eeks of gestati on. P atients are
excluded f rom screening i f they had GB S bacteri uria
earlier i n the pr egnancy or i f they gave bi rth to a
previousi nfantw ithi nvasiveGB Sdi sease.T hesel atter
patientss houldrecei vei ntrapartumanti bioticprophy ­
laxisregardl essofthecol onizationstatus.
B. Intrapartuma ntibioticpr ophylaxisi sr ecommended
forthefollowing:
1. Pregnantw omenw ithaposi tive screeningcul ture
unlessapl annedC esareansecti oni sperform edi n
theabsenceofl abororruptureofm embranes
2. Pregnantw omenw hogavebi rth to a previous infant
withinvasiveGB Sdisease
3. Pregnant womenw ithdocum entedGB S bacteriuria
duringthecurrentpregnancy
4. Pregnant womenw hosecul turestatus is unknown
(culture not perform ed or resul t not available) and
whoal sohavedel iveryat< 37w eeksofgestati on,
amniotic m embrane rupture for > 18 hours, or
intrapartumtem perature> 100.4ºF( >38ºC)
C. Intrapartum antibiotic pr ophylaxis is not r ecom­
mendedfor thefollowingpatients:
1. PositiveGB Sscreeni ngcul turei n a previouspreg­
nancy(unl ess thei nfanthadi nvasiveGB Sdi sease
 or the screeni ng cul ture i s al so posi tive i n the
currentpregnancy )
2. Patientw houndergoesapl anned Cesarean section
withoutl abororruptureofm embranes
3. Pregnant w omen w ith negati ve GB S screeni ng
culturesat35to 37 weeksofgestati oneveni fthey
have one or m ore o f the above i ntrapartum ri sk
factors
D. RecommendedI APre gimen
1. PenicillinG (5 million unitsI Vinitialdose,then 2.5
million units I V Q4h) is recom mended for m ost
patients.
2. In wo men with n on-immediate-type p enicillin­
allergy,cefaz olin(A ncef,2gi nitial dose,then1g
Q8h)i srecom mended.
3. Patientsathig hr iskfor anaphy laxistopenicil­
lins are treatedw ithcl indamycin(900m gI VQ8h)
or ery thromycin (500 m g I V Q6h) as l ong as thei r
GBS i solate i s docum ented to be suscepti ble to
bothcl indamycinandery thromycin.
4. For patients at high r isk for anaphy laxis and a
GBS resistant isolate (orw ithunk nown suscepti­
bility)toclindam ycinorery thromycin,vancom ycin(1
gQ12h)shoul dbegi ven.
5. Antibiotictherapy isconti nuedfrom hospi taladm is­
sionthroughdel ivery.
E. Approach to thr eatened pr eterm de livery at < 37
weeks of gestation: A pati ent with negative GB S
cultures (after 35 w eeks of ge station) shoul d not be
treatedduri ngthrea tenedl abor.I fGB Scul tureshave
not been perform ed, these speci mens s hould b e
obtained and peni cillin G a dministered a s above; i f
cultures are negative at 48 hours, penic illin can be
discontinued.I fsuchapati ent has not deliveredw ithin
fourw eeks,cul turesshoul dberepeated.
F. If scr eening cultur es taken at the tim e of thr eat­
ened deliv ery or pr eviously per formed (after 35
weeksofgestation)ar epositiv e,penicillinshould be
continuedforatl east48hoursunl essdel iverysuper­
venes.P atients who havebeentreatedfor >48hours
and have not delivered shoul d recei ve I AP as above
whendel iveryoccurs.
References:S eepage166.

PrematureRuptur eofM embranes

Premature rupture of m embranes (P ROM) i s the m ost
common di agnosis associ ated w ith preterm del ivery. T he
incidence ofthi sdi sordertobe7-12% .I npregnanci es of less
than37w eeksofgestati on,preterm bi rth(andi tssequel ae)
andi nfectionarethem ajorconcernsafterP ROM.

I. Pathophysiology
A. Premature r upture of m embranes i s defi ned as
ruptureofm embranespri ortotheonsetofl abor.
B. Pretermpr ematurer uptureo fm embranesi sdefi ned
asruptureofm embranespri ortoterm .
C. Prolongedr uptureofm embranesconsi sts ofrupture
ofm embranesform orethan24hours.
D. Thel atent per iodi s theti mei nterval from ruptureof
membranes to the onset of regul ar contracti ons or
labor.
E. Manycases ofpreterm P ROMarecausedby i diopathic
weakening of the membranes, m any of w hich are
causedby subcl inicali nfection.Othercausesof PROM
include hy dramnios, i ncompetent cervi x, abruptio
placentae,andam niocentesis.
F. Atterm ,about8% ofpatientsw illpresentw ithruptured
membranespri ortotheonsetofl abor.
II. Maternalandneonatalcom plications
A. Labor usual ly fol lows shortl y after the occurrence of
PROM. Ninety percent of term pati ents and 50% of
preterm pati ents go i nto l abor w ithin 24 hours after
rupture.
B. Patients w ho do not go i nto l abor immediatelyare at
increasing ri sk of i nfection as the durati on of ruptu re
increases.C horioamnionitis,endom etritis,sepsi s, and
neonatali nfectionsm ayoccur.
C. Perinatal risks w ith preterm P ROM are pri marily
complications from i mmaturity, i ncluding respi ratory
distresssy ndrome,i ntraventricularhem orrhage,patent
ductusarteri osus,andnecroti zingenterocol itis.
D. Prematuregestati onalagei sam oresi gnificantcause
of neonatalm orbiditythani sthedurati on of membrane
rupture.
III. Diagnosiso fp rematurer uptureo fm embranes
A. Diagnosis i s b ased o n h istory, p hysical e xamination,
and l aboratory testi ng. T he pati ent's hi story al one i s
correcti n90% ofpati ents.U rinaryl eakageorex cess
vaginaldi schargei ssom etimesm istakenforP ROM.
B. Sterilespeculum exam isthefi rststepi nconfi rming
thesuspi cionofP ROM.D igital examination shouldbe
avoidedbecausei ti ncreasestheri skofi nfection.
1. The general appearance of the cervi x shoul d be
assessed vi sually, and p rolapse o f t he u mbilical
cord or a fet al ex tremity shoul d be ex cluded. C ul­
tures for group B streptococcus, gonorrhea, and
chlamydiaareobtai ned.
2. A pool of fl uid i n the posteri or vagi nal forni x sup­
portsthedi agnosisofP ROM.
3. The presence of am niotic fl uid i s confi rmed by
nitrazine testi ng for an al kaline pH . A mniotic fl uid
causes ni trazine paper to turn dark bl ue because
the pH i s abo ve 6.0-6.5. N itrazine m ay be fal se-
 positive withcontam inationfrom bl ood,sem en,or
vaginitis.
4. Ifpool ingand nitrazine are bothnon-confi rmatory,a
swabf rom t hep osteriorf ornix shouldb esm eared
on a sl ide, al lowed to dry , and ex amined under a
microscopefor" ferning,"i ndicatingam nioticfl uid.
5. Ultrasound ex amination f or ol igohydramnios i s
usefultoconfi rmthedi agnosis,butol igohydramnios
maybecausedby otherdi sordersbesi desP ROM.
IV. Assessmentofpr ematurer uptureofm embranes
A. The gestati onal age m ust be careful ly assessed.
Menstrual hi story, prenatal ex ams, and pr evious
sonogramsarerevi ewed.A nul trasoundexa mination
shouldbeperform ed.
B. The patient shoul d be eval uated for the presence of
chorioamnionitis [fever (over 38°C ), l eukocytosis,
maternal and fetal tachy cardia, uteri ne tenderness,
foul-smellingvagi naldi scharge].
C. Thepati entshoul dbeeval uatedforl abor, and asteri le
speculumex aminationshoul dassesscervi calchange.
D. Thefetusshoul dbe evaluated with heartratem onitor­
ingb ecausePROM in creasesth er isko fu mbilicalco rd
prolapseandfetal di stresscausedby oligohydramnios.
V. Managementofpr ematurer uptureofm embranes
A. Termpatients
1. At 36 w eeks and bey ond, m anagement of P ROM
consistsofdel ivery.P atientsi nacti vel aborshoul d
beal lowedtoprogress.
2. Patientsw ithchori oamnionitis,w hoarenot inl abor,
should bei mmediatelyi nducedw ithox ytocin (Pito­
cin).
3. Patients w ho a re n ot y et i n a ctive l abor ( in t he
absence of fetal di stress, m econium, or cl inical
infection) maybedi schargedfor48hours,and labor
usually fol lows. I f l abor has not begun w ithin a
reasonableti meafterruptureofm embranes,i nduc­
tion w ith ox ytocin (P itocin) i s appropri ate. U se of
prostaglandinE 2i ssafeforcervi calri pening.
B. Pretermpatients
1. Pretermpati entsw ithP ROMpri orto36w eeksare
managed ex pectantly. D elivery i s del ayed for the
patients w ho are not i n l abor, not i nfected, and
withoutevi denceoffetal di stress.
2. Patientsshoul dbem onitoredfori nfection.C ultures
forgonococci , Chlamydia, andgroupB streptococci
are obtained.S ymptoms,vi talsi gns,uteri ne tender­
ness,odorofthel ochia,andl eukocytecountsare
monitored.
3. Suspectedoccul tchori oamnionitisi s diagnosedby
amniocentesisforGram stai nandcul ture,w hich will
revealgram posi tivecocci i nchai ns.
4. Ultrasound ex amination shoul d be perform ed to
detectol igohydramnios.
5. Intrapartum antibiotic pr ophylaxis group B
streptococcalisr ecommendedf ort hef ollowing:
a. Pregnant w omen w ith a posi tive screeni ng
culture unl ess a pl anned C esarean secti on i s
performedi ntheabsenceofl abororru ptureof
membranes
b. Pregnant w omen w ho gave bi rth to a previ ous
infantw ithi nvasiveGB Sdi sease
c. Pregnant w omen w ith docum ented GB S
bacteriuriaduri ngthecurrentpregnancy
d. Pregnant w omen w hose cul ture status i s un­
known(cul turenotperform edorresul tnotavai l­
able)andw ho alsohavedel iveryat< 37w eeks
ofgestati on,am nioticm embranerupturefor> 18
hours, or i ntrapartum tem perature >100.4ºF
(>38ºC)
e. Therecom mendedI AP regimenispenicillinG(5
million unitsI Vinitialdose,then2.5 million units
IV Q4h). I n w omen with non-i mmediate-type
penicillin-allergy, cefaz olin (A ncef, 2 g in itial
dose,then1gQ8h)i srecom mended.
6. Prolongedconti nuousfetal heartrate monitoringi n
the i nitial assessm ent shoul d be fol lowed by fre­
quentfetal eval uation.
7. Premature l abor i s the m ost com mon outcom e of
preterm PROM.T ocolyticdrugsareoften used and
corticosteroidsare r ecommendedtoaccel eratefetal
pulmonarym aturity.
8. Expectant m anagement consists of i n-hospital
observation. D elivery i s i ndicated for
chorioamnionitis, i rreversible fetal di stress, or
premature labor. Oncegestati onreaches36 weeks,
the pati ent m ay be m anaged as any othe r term
patient w ith P ROM. A nother opti on i s to eval uate
the fetus at l ess than 36 w eeks for pul monary
maturity and ex pedite d elivery once m aturity i s
documentedby testi ng of amniotic fluidcol lectedby
amniocentesis or fro m the vagi na. A posi tive
phosphatidylglyceroltesti ndicatesfetal lungm atu­
rity.
C. Previable or pr eterm pr emature r upture of m em­
branes
1. Inpati entsi nw homm embranesrupturevery earl y
in pregnancy(eg,< 25w eeks).T herei sa relatively
lowlik elihood(<25% )thatasurvivinginfantw illbe
delivered, and infants that do survive w ill delive r
veryprem atureandsuffersi gnificantm orbidity.
2. Fetaldefor mationsy ndrome.T hefetussuffering
fromprol ongedearl y oligohydramniosm aydevel op
pulmonary hy poplasia, faci al deform ation, l imb
contractures,anddeform ity.
 3. Termination ofpregnancy i sadvi sablei f the gesta­
tional agei s earl y.If the patientel ectstoconti nue
thepregnancy ,ex pectantm anagementw ithpel vic
restathom ei sreasonabl e.
D. Chorioamnionitis
1. Chorioamnionitis requi res del ivery (usual ly vagi ­
nally),regardl essofthegestati onalage.
2. Antibioticther apy
a. Ampicillin2 g mI Vq 4-6h AND
b. Gentamicin100m g(2m g/kg) IV load, then 100
mg(1.5m g/kg)I Vq8h.
References:S eepage166.

PretermLabor
Preterml abori s thel eadingcauseofperi natalm orbidityand
mortality i n the U nited S tates. I t usual ly resul ts i n preterm
birth,acom plicationthataffects8to10percentofbi rths.

RiskFactor sfor P retermLabor

Previouspreterm del ivery Infectiouscauses

--Chorioamnionitis
Lowsoci oeconomicsta­ --Bacterialvagi nosis
tus --Asymptomatic
Non-whiterace bacteriuria
Maternalage< 18y ears --Acutepy elonephritis
or> 40y ears --Cervical/vaginalcol ­
Pretermprem aturerup­ onization
tureofthem embranes Fetalcauses
Multipleg estation --Intrauterinefetal
Maternalhi storyofoneor death
morespontaneous --Intrauterinegrow th
second-trimesterabor­ retardation
tions --Congenitalanom a­
Maternalcom plications lies
--Maternalbehavi ors Abnormalpl acentation
--Smoking Presenceofaretai ned
--Illicitd rugu se intrauterinedevi ce
--Alcoholuse
--Lackofprenatal
care
Uterinecauses
--Myomata(particu­
larlysubm ucosalor
subplacental)
--Uterineseptum
--Bicornuateuterus
--Cervicalincom pe­
tence
--Exposuretodi ethyl­
stilbestrol(D ES)

I. Riskfactor sfor pr etermlabor . Preterml abori s charac­

terized by cervi cal effacem ent and/or di latation, and
increasedu terineir ritabilityth ato ccursb efore 37 weeks of
gestation. W omen w ith a hi story of pr evious preterm
delivery carrythehi ghestri sk of recurrence, estimated to
bebetw een17and37percent.
II. Managementofpr eterml abor
A. Tocolysis
1. Tocolytictherapy m ayoffersom e short-termbenefi t
in the m anagement of preterm labor. A d elay i n
deliverycanbeusedtoa dministercorti costeroids
to enhance pul monary m aturity and reduce the
severityoffetal respi ratorydi stress syndrome, and
to reduce the ri sk of i ntraventricular hem orrhage.
No study has convi ncingly dem onstrated an im­
provementi nsurvi valorneonatal outcom ew ith the
useoftocol ytictherapy al one.
2. Contraindications t o t ocolysis include
nonreassuringfetal heartratetraci ng, eclampsia or
severe pree clampsia, fetal dem ise (si ngleton),
chorioamnionitis, fetal m aturity and m aternal
hemodynamicin stability.
3. Tocolytic therapy i s i ndicated for regular uteri ne
contractions and cervi cal change (effacem ent or
dilatation). Oral terbutal ine (B ricanyl) fol lowing
successful parenteral tocol ysis i s not associ ated
withprol ongedpregnancy orreducedi ncidenceof
recurrentpreterm l abor.
PretermLabor ,Thr eatenedor A ctual

1. Initialassessm enttodeterm inew hetherpati enti s

experiencingpreterm l abor
a. Assessfor thefollow ing:
i. Uterineacti vity
ii. Ruptureofm embranes
iii. Vaginalbl eeding
iv. Presentation
v. Cervicaldi lationandeffacem ent
vi. Station
b. R eassessesti mateofgestati onalage
2. Searchforapreci pitatingfactor/cause
3. Considerspeci ficm anagementstrategi es,w hich
mayi ncludethefol lowing:
a. Intravenoustocol ytictherapy (deci sionshoul dbe
influencedby gestati onalage,causeofpreterm
laborandcontrai ndications)
b. Corticosteroidtherapy (eg,betam ethasone,i na
dosageof12m gI Mevery 24hoursforatotal of
twodoses)
c. Antibiotictherapy i fspeci fici nfectiousagenti s
identifiedori fpreterm prem atureruptureofthe
membranes

TocolyticTher apyfor theM anagementofP reterm

Labor

Medi­ Mechanismof
cation action Dosage

Mag­ Intracellular 4to6gl oadingdose;

nesium calciumantag­ then2to4gI Vevery
sulfate onism hour

Terbut Beta2- 0.25to0.5m gS C

aline adrenergic everythreetofour
(Brican receptorago­ hours
yl) nist
sympathomim
etic;de­
creasesfree
intracellular
calciumio ns

Ritodri Samea s 0.05to0.35m gper

ne terbutaline minuteI V
(Yutop
ar)

Nifedip Calciumchan­ 5to10m gS Levery

ine nelbl ocker 15to20m inutes(up
(Procar tofourtim es),then
dia) 10to20m goral ly
everyfourtosi x
hours

Indome Prostaglandin 50-to100-m grectal

thacin inhibitor suppository,then25
(Indoci to50m goral lyevery
n) sixhours

ComplicationsA ssociatedW iththeU seof

TocolyticA gents

Magnesiumsulfate Indomethacin(I ndocin)

•R enalfai lure
•P ulmonaryedem a •H epatitis
•P rofound •Gastrointestinal
hypotension bleeding
•P rofoundm uscular Nifedipine(P rocardia)
paralysis •T ransient
•M aternaltetany hypotension
•C ardiacarres t
•R espiratorydepres­
sion
Beta-adrenergic
agents
•H ypokalemia
•H yperglycemia
•H ypotension
•P ulmonaryedem a
•A rrhythmias
•Ca rdiacin suffi­
ciency
•M yocardiali schemia
•M aternaldeath

B. Corticosteroidth erapy
1. Dexamethasone and betam ethasone are the
preferred corti costeroids for a ntenatal therapy .
Corticosteroidtherapy forfetal maturation reduces
mortality, respi ratory di stress sy ndrome and
intraventricularhem orrhagei ni nfantsbetw een 24
and34w eeksofgestati on.
2. In womenw ithpreterm prem atureraptureofm em­
branes(P PROM), antenatalcorti costeroidtherapy
 reducestheri sk of respiratorydi stresssy ndrome.I n
womenw ithP PROMat less than30to32w eeksof
gestation, i n the absence of clinical
chorioamnionitis, antenatal corti costeroid use i s
recommended because of the hi gh ri sk of
intraventricularhem orrhageatthi sear lygestati onal
age.

RecommendedA ntepartumC orticosteroidR egi­

mensfor FetalM aturationinP retermInfants

Medication Dosage

Betamethason 12m gI Mevery 24hoursfortw o

e(C elestone) doses

Dexametha­ 6m gI Mevery 12hoursforfour

sone doses

C. Intrapartuma ntibioticpr ophylaxisgr oupB str epto­

coccalisr ecommendedfor thefollowing:
1. Pregnantw omenw ithaposi tive screening culture
unlessapl anned Cesarean sectioni sperform edi n
theabsenceofl abororruptureofm embranes
2. Pregnant w omen w ho gave bi rth to a pre vious
infantw ithi nvasiveGB Sdi sease
3. Pregnantw omenw ithdocum entedGB Sbacteri uria
duringthecurrentpregnancy
4. Pregnant womenw hosecul turestatus is unknown
(culturenotperform edorresul tnotavai lable)and
who alsohavedel iveryat< 37 weeks of gestation,
amniotic m embrane rupture for > 18 hours, or
intrapartumtem perature> 100.4ºF (>38ºC)
5. The rec ommended I AP r egimen is penicillin G (5
millionunitsI Vinitialdose,then2.5m illionunitsI V
Q4h).I nw omenw ithnon- immediate-typepenicillin­
allergy, cefaz olin(A ncef,2gi nitial dos e, then1g
Q8h)i srecom mended.
D. Bed r est. Although bed rest i s often prescri bed for
women at hi gh ri sk for preterm l abor and del ivery,
there are no concl usive studies docum enting i ts
benefit.A recentm eta-analysisfoundnobenefi ttobed
resti nthepreventi onofpreterm l aborordel ivery.
References:S eepage166.

BleedingintheSecondHalfofPreg­
nancy
Bleedingi nthesecondhal fof pregnancy occurs in 4%ofal l
pregnancies.I n50% ofcases,vagi nalbl eedingi ssecondary
topl acentalabrupti onorpl acentaprevi a.

I. Clinical ev aluation of bleeding second half o f pr eg­

nancy
A. Historyof traumaorpai nandtheam ountandcharac­
terofthebl eedingshoul dbeassessed.
B. Physicalexam ination
1. Vital si gns and pul se pressure are m easured.
Hypotension and tachy cardia are si gns of seri ous
hypovolemia.
2. Fetal heart rate pattern and uteri ne acti vity are
assessed.
3. Ultrasoundex aminationoftheuterus, placentaand
fetusshoul dbecom pleted.
4. Speculum anddi gitalpel vicex aminationshoul dnot
bedoneunti lpl acentaprevi ahasbeenex cluded.
C. LaboratoryE valuation
1. Hemoglobinandhem atocrit.
2. INR,par tial thromboplastintim e,plateletcount,
fibrinogen lev el, an d fib rin sp lit p roducts are
checkedw henpl acental abruptioni ssuspectedor
iftherehasbeensi gnificanthem orrhage.
3. Ar ed-toptube ofbl oodi s usedtoperform abed­
sideclottest.
4. Bloodty peandcross-m atch.
5. Urinalysisforhem aturiaandprotei nuria.
6. The Apttest i susedtodi stinguishm aternalorfetal
source of bleeding. (Vaginalbl oodi sm ixedw ithan
equal part 0.25% sodi um hy droxide. Fetal bl ood
remainsred;m aternalbl oodturnsbrow n.)
7. Kleihauer-Betketest ofm aternalbl oodi sused to
quantifyfetal tom aternalhem orrhage.
II. Placentalabr uption(abr uptioplacentae) isdefi nedas
complete or partial placentalseparati onfrom thedeci dua
basalisafter20w eeksgestati on.
A. Placentalabrupti onoccursi n1i n100del iveries.
B. Factorsassociatedwithplacentalabr uption
1. Preeclampsiaandhy pertensivedi sorders
2. Historyofpl acentalabrupti on
3. Highm ultiparity
4. Increasingm aternalage
5. Trauma
6. Cigarettesm oking
7. Illicitd rugu se( especiallyco caine)
8. Excessiveal coholconsum ption
9. Pretermprem atureruptureofthem embranes
10. Rapiduteri nedecom pression after deliveryofthe
first fetus in a twin gestati on or rupture of m em­
branesw ithpol yhydramnios
11. Uterinel eiomyomas
 C. Diagnosisofplacentalabr uption
1. Abruption i s characteri zed by vagi nal bl eeding,
abdominal pai n, u terine tenderness, and uteri ne
contractions.
a. Vaginal bl eeding i s vi sible i n 80% ; bl eeding i s
concealedi n20% .
b. Pain i s usual ly of sudd en onset, constant, and
localizedtotheuterusandl owerback .
c. Localizedorgeneral izeduteri netendernessand
increased uteri ne tone are found w ith severe
placentalabrupti on.
d. An i ncrease i n uteri ne si ze m ay occur w ith
placental abrupti on w hen the bl eeding i s con ­
cealed.C oncealedbl eeding may bedetectedby
serial measurements of abdom inal gi rth and
fundalhei ght.
e. Amnioticfl uidm aybebl oody.
f. Fetalm onitoringm aydetectdi stress.
g. Placentalabrupti onm aycausepreterm l abor.
2. Uterine contr actions by tocody namometry i s the
mostsensi tivei ndicatorofabrupti on.
3. Laboratory fi ndings i nclude protei nuria and a
consumptive coagul opathy, characterized by de­
creased fibrinogen,prothrom bin,factorsV andV III,
andpl atelets.Fi brinspl itproductsareel evated.
4. Ultrasonography has a sensitivity i n detecti ng
placentalabrupti onofonl y15% .
D. Managementofplacentalabr uption
1. Mildplacentalabr uption
a. Ifm aternalstability and reassuringfetalsurveil­
lance are assured and the fetus i s i mmature,
closeex pectantobservati onw ithfetal m onitoring
isju stified.
b. Maternalhem atologicparam etersare monitored
andabnorm alitiescorrected.
c. Tocolysis w ith m agnesium sul fate i s i nitiated i f
thefetusisim mature.
2. Moderatetosev ereplacentalabr uption
a. Shocki saggressi velym anaged.
b. Coagulopathy
(1) Bloodi stransfusedtorepl acebl oodl oss.
(2) Clotting factors m ay be rep laced usi ng
cryoprecipitateor fresh-frozenpl asma.One
unit of fresh-froz en pl asma i ncreases
fibrinogen by 10 mg/dL. C ryoprecipitate
contains250m gfi brinogen/unit; 4 gm(15-20
U)i saneffecti vedose.
(3) Platelettransfusi oni s indicated ifthepl atelet
count i s l ess than 50,000/m cL. One uni t of
platelets rai ses the pl atelet count 5000­
10,000/mcL; 4 to 6 U i s the sm allest useful
dose.
c. Oxygenshoul dbeadm inisteredanduri neoutput
monitoredw ithaFol eycatheter.
d. Vaginaldel iveryi sex peditedi nal lbutthem ild­
estcasesoncethe motherhasbeenstabiliz ed.
Amniotomyandox ytocin(P itocin)augm entation
maybeused.C esareansecti oni si ndicatedfor
fetaldi stress,severeabrupti on,orfai ledtri al of
labor.
III. Placenta pr evia occ urs when any part of the pl acenta
implants i n the l ower uteri ne segment. I t i s associ ated
with a ri sk of serious m aternal hem orrhage. P lacenta
previaoccursi n1i n200pregnanci es. Ninetypercentof
placenta previ as di agnosed i n the second tri mester
resolvespontaneousl y.
A. Total p lacenta pr evia occurs w hen the i nternal
cervicalosi scom pletelycoveredby pl acenta.
B. Partialplacentapr eviaoccursw henpartof the cervi­
calosi scoveredby pl acenta.
C. Marginalplacentapr eviaoccursw henthepl acental
edgei sl ocatedw ithin2cm ofthecervi calos.
D. Clinicalev aluation
1. Placenta p revia presents w ith a sudden onset of
painless vagi nal bl eeding i n the second o r thi rd
trimester.T hepeak i ncidenceoccursat34w eeks.
Thei nitialbl eedingusual ly resolvesspontaneousl y
andthenrecursl ateri npregnancy .
2. One fourth of pati ents pres ent w ith bl eeding and
uterinecontracti ons.
E. Ultrasonographyi saccuratei ndi agnosing placenta
previa.
F. Managementofplacentapr evia
1. Inapregnancy > 36w eeksw ithdocum entedfetal
lungm aturity,theneonateshoul dbei mmediately
deliveredby cesareansecti on.
2. Low verti cal uteri ne i ncision is probably safer i n
patientsw ithananteri orpl acenta.I ncisionsthrough
thepl acentashoul dbeavoi ded.
3. If severe hem orrhage j eopardizes the m other or
fetus, cesareansecti oni s i ndicatedregardl essof
gestationalage.
4. Expectant m anagement i s appropri ate for i mma­
ture fetuses if bleedingi snotex cessive,m aternal
physicalacti vitycanberestri cted,i ntercourse and
douching can be prohi bited, and the hem oglobin
canbem aintainedat> 10m g/dL.
5. Rhi mmunoglobulini sa dministeredtoR h-negative­
unsensitizedpati ents.
6. Delivery i s i ndicated once fetal lung m aturity has
beendocum ented.
7. Tocolysisw ithm agnesiumsul fatem ay be used for
immaturefetuses.
IV. Cervicalbleeding
A. Cytologicsam plingi snecessary .
 B. Bleeding can be control led w ith cauteri zation or
packing.
C. Bacterialandvi ralcul turesare sometimesdi agnostic.
V. Cervicalp olyps
A. Bleedingi susual lysel f-limited.
B. Traumashoul dbeavoi ded.
C. Polypectomy ma y co ntrol b leeding and y ield a
histologicdi agnosis.
VI. Bloody show i s a fr equent beni gn cause of l ate thi rd
trimester bl eeding. I t i s characteri zed by bl ood-tinged
mucusassoci atedw ithcervi calchange.
References:S eepage166.

Preeclampsia-eclampsiaandC hronic
Hypertension
Thearefour major hypertensivedi sordersi npregnancy are
preeclampsia-eclampsia,c hronichy pertension,preec lampsia
superimposed upon chroni c hy pertension, and gestati onal
hypertension.P reeclampsiai s characterizedby hy pertension
and protei nuria devel oping after 20 w eeks of gestation.
Chronic hy pertension i s defi ned as sy stolic pre ssure > 140
mm H g, di astolic pressure >90 m m H g, or both tha t ante­
dates pregnancy or i s present before the 20th w eek of
pregnancy.
I. Incidenceandr iskfactor sfor pr eeclampsia
A. Hypertensive disorders occur inabout12to22percent
ofpregnanci es.P reeclampsia occurs in 3to8percent
of pregnanci es. A w oman under the age of 20 y ears
whoi sundergoi ngherfi rstpregnancy i sati ncreased
risk for preecl ampsia. T he pri migravid state i s a
predisposing factor. Thei ncidenceofpreecl ampsia in
asecondpregnancy i sl ess than1percenti nw omen
who have had a norm otensive fi rst preg nancy, a s
compared to 5-7 percent i n w omen w ho had
preeclampsiaduri ngthefi rstpregnancy .
B. Riskfactor sfor pr eeclampsia:
1. Primigravidstate
2. Historyofpreecl ampsia
3. A hi gher bl ood pressure at the i nitiation of preg­
nancyandal argebody si ze
4. Afam ilyhi storyofpreecl ampsiai sassoci atedw ith
atw otofivefoldincreaseinrisk
5. Multiplepregnancy
6. Preexistingm aternalhy pertension
7. Pregestationaldi abetes
8. Antiphospholipidanti bodysy ndrome
9. Vascularorconnecti veti ssuedi sease
10. Advancedm aternalage(> 35to40y ears)
II. Clinicalm anifestationsofpr eeclampsia
A. Preeclampsiai scharacteri zedby the gradualdevel op­
ment of hy pertension, protei nuria, and edem a i n
pregnancy, parti cularly i n a pri migravida. T hese
findings typicallybecom eapparenti nthel atterpartof
thethi rdtri mesterand progress untildel ivery.I nsom e
women,how ever,sy mptomsbegi n in thel atterhal fof
the second tri mester. S igns and sy mptoms of
preeclampsia occurringbefore20w eeksofgestati on
are unusual unl ess there i s an underl ying mo lar
pregnancy, drug use or w ithdrawal, or chrom osomal
aneuploidyi nthefetus.
B. Hypertension. P regnancy rel ated hy pertension i s
definedasasy stolic blood pressuregreaterthan140
mmH g or diastolic bloodpressuregreaterthan90m m
Hg i n a w oman w ho w as norm otensive p rior to 20
weeksofgestati on. Hypertensioni susual lytheearl iest
clinical fi nding of preecl ampsia. T he bl ood pressure
(BP) may risei nthesecondtri mester,but usually does
not reach the hy pertensive range (>140/90) unti l the
thirdtri mester,oftenafterthe37thw eekofgestati on.
C. Proteinuria. Inaddi tiontohy pertension,m ostpati ents
alsohaveprotei nuria(i e,1+ ondi pstickor 0.3gprotei n
orgreateri na24-houruri nespeci men).
D. Eclampsia refers to the devel opment of grand m al
seizuresi naw omanw ithpreecl ampsia.P reeclampsia­
eclampsia i s caused by general ized vasospasm,
activationofthecoagul ation system,andchangesi n
autoregulatory sy stems rel ated to bl ood pressure
control.
E. Edemaandintr avascular volume. Mostwo menwi th
preeclampsiahaveedem a.A lthoughperi pheraledem a
is common i n norm al pregnancy , sudden and rapi d
weight gai n and facial edem a often occur i n w omen
whodevel oppreecl ampsia.
F. Hematologicchanges. Increasedpl ateletturnoveri s
aconsi stent featureofpreecl ampsia.T hem ostcom ­
mon coagul ation abnorm ality i n preecl ampsia i s
thrombocytopenia.
G. Liverin volvementm aypresent as rightupperquad­
rant or epi gastric pai n, el evated l iver enzymes and
subcapsularhem orrhageorhepati crupture.
H. Central ner vous sy stem. Headache, bl urred vision,
scotomata,and,rarel y,corti cal blindness arem anifes­
tations of preecl ampsia; sei zures i n a preecl amptic
womanaredefi nedasecl ampsia.
I. Fetusandplacenta. T hefetal consequencesarefetal
growthrestri ctionandol igohydramnios.S evereo re arly
onset preeclampsiaresul ti nthegreatest decrements
inbi rthw eight.
III. Diagnosis
A. Thedi agnosis of preeclampsiai sl argelybasedupon
clinicalfeaturesdevel opingafter 20w eeksofgestati on
inaw omanw how asprevi ouslynorm otensive.

DiagnosisofP reeclampsia

Systolicbl oodpressuregreaterthan140m mH g
or
Diastolicbl oodpressuregreaterthan90m mH g
AND
Arandom uri neprotei ndeterm inationof1+ ondi pstick
or30m g/dLorprotei nuriaof0.3gorgreateri na
24-houruri nespeci men

B. Plasma ur ic acid concentr ation. Preeclampsia i s

typically associ ated w ith a ri se i n the pl asma urate
leveltoabove5.5to6m g/dL.
C. Laboratoryev aluation:
1. Hematocrit: hem oconcentration supports the
diagnosisofpreecl ampsia
2. Plateletcount
3. Quantificationofprotei nex cretion
4. Serumcreati nineconcentrati on
5. Serumuri caci dconcentrati on
6. Serum al anine and aspartate am inotransferase
concentrations(A LT,A ST)
7. Lactic aci d dehy drogenase c oncentration (LD H)
andredbl oodcel lsm earm ay indicatethepres­
enceofm icroangiopathichem olysis.

Criteriafor S evereP reeclampsia

Newonsetprotei nuriahy pertensionandatl eastoneof

thefol lowing:
Symptomsofcentral nervoussy stemdy sfunction:
Blurredvi sion,scotom ata,al teredm entalstatus,
severeheadache
Symptomsofl ivercapsul edi stention:
Rightupperquadrantorepi gastricpai n
Hepatocellulari njury
Serumtransam inaseconcentrati onatl easttw ice
normal
Severebl oodpressureel evation:
Systolicbl oodpressure> 160m mH gordi astolic
>110m mH gontw ooccasi onsatl eastsi xhours
apart
Thrombocytopenia
Lessthan100,000pl ateletsperm m3
Proteinuria:
Over5gram si n24hoursor3+ orm oreontw o
randomsam plesfourhoursapart
Oliguria< 500m Li n24hours
Intrauterinefetal grow threstri ction
Pulmonaryedem aorcy anosis
Cerebrovascularacci dent
Coagulopathy

IV. Treatmentofpr eeclampsia

A. The defi nitive treatm ent of preecl ampsia is delivery.
Delivery i s recom mended for w omen w ith m ild
preeclampsiaatornearterm andform ostw omenw ith
severe pr eeclampsia regardl ess of gestati onal age,
except l ess than 33 w eeks of gesta tion w hose onl y
criterionforseveredi seasei s:
1. Severeprotei nuria(greaterthan5gi n24hours).
2. Mildi ntrauterine fetalgrow threstri ction(fi fthtotenth
percentile).
3. Severe preecl ampsia by bl ood pressure cri teria
alonebefore32 weeks ofgestati on,i ftherei sbl ood
pressurereducti onandresol ution ofany l aboratory
abnormalitiesafterhospi talization.
B. Treatment of hy pertension. A ntihypertensive tre at­
menti s indicated if thesy stolicbl oodpressurei s> 170
mm H g. T he preferred agents are m ethyldopa for
prolongedantenatal therapy ,andhy dralazine,l abetalol
or ni fedipine for peri partum treatm ent of acute hy per­
tensiveepi sodes. Sodiumrestri ctionanddi ureticshave
norol ei ntherapy .R estricted physical activity canl ower
bloodpressure.

AcuteTr eatmentofS evereH ypertensioni n

Preeclampsia

Thegoal i sagradual reducti onofbl oodpressuret o a

level below160/105m m Hg.S uddenandsevere
hypotensionshoul dbeavoi ded.

Hydralazine:5m gI V,repeat5to10m gI Vevery 20

minutestom aximumcum ulativetotalof20m go r until
bloodpressurei s controlled.

Labetalol(T randate):20m gI V,fol lowedby 40m g,

then80m g,then80m gat10m inutei ntervalsunti lthe
desiredresponsei sachi eved oram aximumtotal dose
of220m gi s administered.

Methyldopa(A ldomet)250m gB IDoral ly,m aximum

dose4g/day
 FetalA ssessmentinP reeclampsia

Mild Dailyfetal m ovementcounti ng

preeclampsia Ultrasoundex aminationforesti ma­
tionoffetal w eightandam niotic
fluiddeterm inationatdi agnosis.
Repeati nthreew eeksi fthei nitial
examinationi snorm al,tw ice
weeklyi ftherei sevi denceoffetal
growthrestri ctionor
oligohydramnios.
Nonstresstestand/orbi ophysical
profileonceortw icew eekly.T est­
ingshoul dberepeatedi mmediately
iftherei sanabruptchangei nm a­
ternalcondi tion.

Severe Dailynonstresstesti ngand/orbi o­

preeclampsia physicalprofi le

C. Antenatal co rticosteroids to prom ote fetal l ung

maturationshoul d be administeredtow omenl essthan
34w eeksofgestati onw hoareathi ghri sk for delivery
withinth en extsevenday s.B etamethasone(tw odoses
of 12 m g gi ven i ntramuscularly 24 hours apart) or
dexamethasone(fourdosesof6 mggi veni ntramuscu­
larly12hoursapart)m aybeused.
D. Maternal mo nitoring. Laboratory evaluation (eg,
hematocrit, pl atelet count, creati nine, uri ne protei n,
LDH, AST,A LT,uri caci d)shoul dbe repeated once or
twicew eeklyi nw omenw ithm ildstabl e preeclampsia.
E. Womenwithsev erepr eeclampsia shouldbedel iv­
ered or hospi talized for the durati on of pregnancy .
Prolonged ant epartum m anagement m ay be consi d­
eredi nsel ected women under32w eeksofgestati on,
suchasthosew hosecondi tioni mprovesafterhospi tal­
ization and w ho have no evi dence of end-organ
dysfunctionorfetal deteri oration.
F. Timingandi ndicationsfor del ivery.D eliveryator by
40 w eeks of gesta tion shoul d be consi dered for al l
womenw ithpreecl ampsia.W omen with mild disease
andafavorab le cervixm aybenefi t from i nductionas
early as 38 w eeks, w hile those w ith stable severe
disease shoul d b e d elivered a fter 3 2 t o 3 4 w eeks i f
possible (w ith dem onstration of fetal pul monary
maturity).

Indicationsfor D eliveryinP reeclampsia

Maternali ndications Gestationalagegreaterthan

orequal to38w eeksofgesta­
tion
Plateletcountl essthan
100,000cel lsperm m3
Deterioratingl iverfuncti on
Progressivedeteri orationi n
renalfuncti on
Abruptiopl acentae
Persistentsevereheadaches
orvi sualchanges
Persistentsevereepi gastric
pain,nausea,orvom iting

Fetali ndications Severefetal grow threstri ction

Nonreassuringresul tsfrom
fetaltesting
Oligohydramnios

G. Route of de livery. D eliveryi s usual lyby the vagi nal

route, with cesarean del iveryreserved for obstetri cal
indications. C ervical ri pening a gents ma y b e u sed i f
thecervi xi snotfavorabl e.
H. Anticonvulsantther apy
1. Anticonvulsanttherapy i s initiated duringl aborunti l
24 to 48 hours postpartum . M agnesium sul fate i s
thedrugofchoi ceforsei zurepreventi on.
2. Magnesium r egimen. A l oading dose of 6 g
intravenously i s gi ven, fol lowed by 2 g/h as a
continuousi nfusion.
I. Postpartum c ourse. Hypertension due to
preeclampsia resolves postpartum,oftenw ithinafew
days,butsom etimestak esafew w eeks.
V. Management ofeclam psia
A. Maintenance of ai rway patency and preventi on of
aspiration are the i nitial m anagement priorities. T he
patientshoul dbe rolledontoherl eftsi deandapad­
dedtonguebl adepl acedi nherm outh,i fpossi ble.
B. Controlofconv ulsions. Magnesium sulfate, 2to4g
IVpushrepeatedevery 15 minutes toam aximumof6
g.M aintenancedose ofm agnesiumsulfate: 2to3
g/hour by continuousi ntravenousi nfusion.D iazepam
may al so be gi ven as 5 m g I V push repeated as
needed to a m aximum cum ulative dose of 20 m g to
stoptheconvul sions;how ever,benz odiazepines have
profounddepressanteffectsonthefetus.
VI. Preexistenthy pertension
A. Methyldopa (Aldomet) has beenm ostw idelyusedand
long-termsafety tothefetushasbeencl earlydem on­
strated. A CE i nhibitors shoul d not be conti nued i n
pregnancy. ß-bl ockers are general ly safe, al though
they m ay i mpair fe tal grow th w hen used earl y i n
 pregnancy,parti cularlyatenol ol.T hiazide diuretics can
beconti nuedasl ongasvol umedepl etion is avoided.

TreatmentofH ypertensioni nP regnancy

Drug Dose

Methyldopa 250m gB IDoral ly,m aximumdose4

(Aldomet) g/day

Labetalol 100m gB IDoral ly,m aximumdose

(Trandate) 2400m g/day

B. Risksofchr onich ypertension. Chronichy pertension

is associ ated w ith a th reefold i ncrease i n peri natal
mortality,atw ofoldi ncreasei nabrupti o placentae, and
an i ncreased rate of i mpaired fetal growth. T here i s
alsoahi gher rate of pretermdel iverybefore35w eeks
ofgestati on.
C. Indications for tr eatment. I ndications for
antihypertensive therapy are a di astolic press ure
persistentlyabove100m m Hg, systolicpressure> 150
to 180 m m Hg or signs of hy pertensive end-o rgan
damage. S evere hy pertension (bl ood pressure of
180/110 m mHg or higher) requi res i ntravenous ther­
apy. Hydralazine andl abetalolarethedrugsofchoi ce
fori ntravenousadm inistration.
D. Fetal surveillance is w arranted w hen there i s
preeclampsiaori ntrauterine growth restriction.S erial
sonographic assessm entoffetal grow thi s i ndicated,
withnonstresstesti ngorbi ophysicalprofi le examina­
tionw eeklystarti ngat28w eeks,i ncreasingtotw ice­
weeklyat32w eeks.
E. Delivery. W oman w ith m ild, uncom plicated chroni c
hypertension can be al lowed to go i nto spon taneous
labor and del iver at term . E arlier del ivery can be
considered f or w omen with superimposed
preeclampsia or p regnancy com plications (eg, fetal
growthr estriction,p reviousstillb irth).
References:S eepage166.

Herpes Simplex Vir us Infections in

Pregnancy
Herpes simplexvi rus(H SV)ty pe2i spri marilyresponsi ble for
genitalH SVdi sease.M aternal-fetaltransm issionofH SVi s
them ajorconsequenceofm aternal HSV infection,resul ting
in encephalitis,di sseminateddi sease,andsk in disease. The
most co mmon mode of transm ission i s vi a contact of the
fetusw ithi nfectedvagi nalsecreti onsduri ngdel ivery.

I. Diagnosis
A. Riskfactor s.B lackorH ispanic race, age,andy earsof
sexual ex perience are hi ghly correl ated w ith H SV-2
infection. Other factors i nclude l ower fam ily i ncome,
lowerl evelofeducati on,m ultiplesex ual partners, and
havingothersex uallytransm itteddi seases.
B. Thegol dstandardfordi agnosis of acuteH SVi nfection
isvi ralcul ture,w hichm aybecom eposi tivew ithintw o
tothreeday safteri noculation.
C. Polymerase chai n reacti on (P CR) i s used to rapi dly
detectH SVD NAfrom l esions or genitalsecreti onsand
is superior to othertests.P CRhasbeenused to detect
HSV from pregnant w omen w ith recurrent H SV at
delivery and their i nfants i n i nstances i n w hich H SV
culturesw erenegati ve.
II. Clinicalpr esentation
A. Primary genitalepi sodegeni talH SVi scharacteri zed
by m ultiple pai nful ve sicles i n cl usters. T hey m ay be
associated w ith pruri tus, d ysuria, vagi nal di scharge,
andtender regional adenopathy .Fever,m alaise,and
myalgia often occur one to tw o day s pri or to the ap­
pearanceofl esions.T hel esions mayl astfourtofi ve
days prior to crusting. T he skin w ill reepithelializ e in
about 10 day s. V iral sheddi ng m ay l ast for 10 to 12
daysafterreepi thelialization.
B. Nonprimary fi rst-episode geni tal H SV refers to
patients w ith preex isting anti bodies to one of the tw o
typesofvi rusw hoacqui retheothervi rusanddevel op
genitall esions.N onprimarydi seasei sl essseverew ith
fewersy stemicsy mptoms,andl essl ocalpai n.
C. Recurrent H SV episodes are characteri zed by l ocal
painorparesthesi a followed by vesicularl esions.T hey
are generally feweri nnum berandoften unilateral but
maybepai nful.
III. Pregnancy
A. Estimatedr isksofm aternal-fetaltr ansmission:
1. Primary or nonpri mary fi rst epi sode w ith an acti ve
lesionatdel ivery:50percent
2. Asymptomaticfi rstepi sode:33percent
3. RecurrentH SVw ithacti vel esion:3to4percent
4. Asymptomaticr ecurrence:0.04percent
IV. Neonataleffects
A. HSVneonatal i nfectioni sm ostoftenacqui redthrough
thebi rthcanal .T hei ncidenceofneonatal H SV infec­
tion i s 1 i n 3000. A pproximately 60 to 70 percent of
infectedneonatesarei nfectedw ithH SV-2.
B. Categories of neonatal disease i nclude l ocalized
disease of the sk in, ey es and m outh (S EM), central
nervous sy stem (C NS) di sease w ith or w ithout SEM
involvement,anddi sseminateddi sease
 C. The m ortality rate i s 1 5 percent am ong chi ldren w ith
CNS di sease and 57 percent w ith d isseminated di s­
ease.
V. Treatment
A. Primaryin fection
1. Acyclovir (Zovi rax) the rapy(200 m g P O fi ve ti mes
per day or 400 m g P O T ID for 7 to 14 day s) and
analgesia i s recom mended. Acyclovir i s safe i n
pregnancy. A cyclovir reduc es the durati on of vi ral
shedding.
2. Suppressive therapy (400 m g P O B ID) for the
remainderofpregnancy shoul d usuallybeadm inis­
teredbecauseacy clovirm ayp reventsy mptomatic
HSVrecurrencesatterm .
B. Recurrenti nfection.A cyclovirreducessheddi ngby 80
percentandm ay reducecl inicalrecurrences.W omen
with freque nt HSV recurrences m ay benefi t from
suppression(acy clovir400m gP OB ID)nearterm .
C. Roleofcesar eansection
1. Cesareansecti on shouldbeofferedtow omenw ho
have acti ve l esions or sy mptoms of v ulvar pai n or
burning at the ti me of del ivery and a hi story of
genitalherpes.
2. Prophylacticcesareansecti oni snot recommended
forw omenw ithrecur rentH SV andnoevi denceof
activel esionsattheti me ofdel ivery.Lesi onsw hich
have crusted ful ly are consi dered heal ed and not
active.
3. Cesareansecti oni s notrecom mendedfor women
withrecurrentgeni talherpes and activenongeni tal
HSVl esions.T hel esionsshoul dbecoveredw ithan
occlusivedressi ng.
D. Verypr eterm infants(< 30to32weeks)inpr eterm
labor:I fthem otherhasacti veH SV,del ayofdel ivery
for bet amethasone therapy i s appropri ate. C esarean
sectionafterei therdocum entedpul monary maturityor
betamethasonew ouldbeappropri atei facti vel esions
arepresent.T heuse ofacy clovirduri ngthi sti mem ay
behel pfultoshortentheti meofacti vel esionsfo r the
mother.
E. Herpes culturesorthem oresensi tiveP CR test is often
performed on the neonate at del ivery to i dentify ex­
posedi nfants.
References:S eepage166.

DystociaandA ugmentation of Labor

I. Normallab or
A. Firststageoflabor
1. The fi rst stage of l abor consi sts of the period from
theonset of laborunti lcom pletecervi caldi lation(10
cm).T hisstagei sdi videdi ntothel atentp haseand
theacti vephase.
2. Latentphase
a. Duringthel atentphase,ut erinecontracti onsare
infrequent andi rregularandresul ti nonl ym odest
discomfort.T heyresul ti ngradual effacem entand
dilationofthecervi x.
b. Aprol onged latent phase isonethatex ceeds20
hours in the nullipara or one that ex ceeds 1 4
hoursi nthem ultipara.
3. Activephase
a. The activephaseofl aboroccursw hen the cervix
reaches3-4cm ofdi latation.
b. Theacti vephaseofl abor isch aracterizedb ya n
increased rateofcervi caldi lationandby descent
ofthepresenti ngfetal part.
B. Secondstageoflabor
1. The second sta ge of labor consi sts of the peri od
fromcom pletecervi caldi lation (10cm )unti ldel ivery
ofthei nfant.T hisstagei susual lybri ef, averaging20
minutes for parous w omen and 50 m inutes for
nulliparousw omen.
2. The durati on of the second stage of l abor i s unre­
lated to peri natal out come in the absence of a
nonreassuring fetal heart rate pattern as l ong as
progressoccurs.
II. Abnormallab or
A. Dystocia i s defi ned as di fficult l abor or chi ldbirth
resulting from abnorm alities of the cervi x and uterus,
thefetus,them aternalpel vis,or a combinationofthese
factors.
B. Cephalopelvic dispr oportion i s a d isparity betw een
the size ofthem aternal pel visandthefetal headthat
precludesvagi naldel ivery. This condition canrarel ybe
diagnosedi nadvance.
C. Slower-than-normal (protraction disor ders) or
completecessationofpr ogress(ar restd isorder)are
disordersthatcanbedi agnosedonl y after theparturi ent
hasenteredtheacti vephaseofl abor.
III. Assessmentoflabor abnor malities
A. Labor abnor malitiescausedby inadequateuter ine
contractility(p owers).T hem inimaluteri necontracti le
patternofw omen inspontaneous l aborconsi stsof3to
5contracti onsi na10-m inuteperi od.
B. Labor abnormalities causedby fetalchar acteristics
(passenger)
1. Assessmentofthefetusconsistsofestim ating fetal
weight and posi tion. E stimations of fetal si ze, even
those obtai ned by ul trasonography, are frequentl y
inaccurate.
2. In the fi rst s tage of l abor, the di agnosis of dy stocia
can not be m ade unl ess the active phase of l abor
 and adequate uteri ne contra ctile forces have been
present.
3. Fetal an omalies such as hy drocephaly,
encephalocele,andsoft tissue tumorsm ayobstruct
labor. Fetal i maging shoul d be consi dered w hen
malpresentation oranom aliesaresuspectedbased
on vagi nal or abdom inal ex amination or when the
presentingfetal parti spersi stentlyhi gh.
C. Labor abnor malities due to the pelv ic passage
(passage)
1. Inefficient uterineacti onshoul dbecorrectedbefore
attributingdy stociatoapel vicprobl em.
2. The bony pel vis i s very rarel y the factor that l imits
vaginal del iveryof a fetus i n cephal ic pr esentation.
Radiographicpel vimetry isofl imitedval uei nm anag­
ingm ostcephal icpresentati ons.
3. Clinicalpelvim etrycanonly beusefultoqualitatively
identify the general archi tectural features of the
pelvis.
IV. Augmentationofl abor
A. Uterine hy pocontractility should be augm ented only
after both t he m aternal pel vis and fetal presentati on
havebeenassessed.
B. Contraindicationstoaugm entationi nclude placentaor
vasa p revia, u mbilical co rd prolapse, p rior cla ssical
uterine i ncision, pel vic structural deform ities, and
invasivecer vicalcancer .
C. Oxytocin(P itocin)
1. The goal of ox ytocin adm inistration i s to sti mulate
uterine acti vity that i s suffi cient to prod uce cervi cal
change and fetal descent w hile avoi ding uteri ne
hyperstimulationandfetal com promise.
2. Minimally effectiv e uter ine activ ity i s 3 contr ac­
tions per10m inutesaveragi nggreaterthan25m m
Hgabove baseline.A m aximumof5contracti onsi n
a10-m inuteperi odw ithresul tantcervi cal di latation
isconsi deredadequate.
3. Hyperstimulationi scharacteri zedby m orethan five
contractions i n 10 m inutes, contracti ons l asting 2
minutesorm ore,or contractionsofnorm aldurati on
occurringw ithin1m inuteofeachother.
4. Oxytocini sadm inisteredw hen a patient isprogress­
ingsl owlythroughthe latent phase ofl abororhasa
protractionoranarrestdi sorder ofl abor,orw hena
hypotonicuteri necontracti onpatterni si dentified.
5. A pel vic ex amination shoul d be performed before
initiationofox ytocini nfusion.
6. Oxytocini susual lydi luted10uni tsi n 1 liter ofnorm al
salineI VPB.

LaborS timulationwith Oxy tocin(P itocin)

Starting Incremen­ Dosage Maximum

Dose talIn ­ Interval Dose
(mU/min) crease (min) (mU/min)
(mU/min)

6 6 15 40

7. M a n a g e m e n t o f o x y t o c i n - i n d u c e d
hyperstimulation
a. The m ost com mon adverse effect of
hyperstimulationi sfetal heartratedecel eration
associatedw ithuteri nehy perstimulation. Stop­
ping or decreasi ng the dose of ox ytocin m ay
correcttheabnorm alpattern.
b. Additionalm easuresm ayi nclude changingthe
patient to the l ateral decubi tus p osition and
administeringox ygen orm orei ntravenousfl uid.
c. If oxytocin-induced uteri ne hy perstimulation
does not respond to cons ervative m easures,
intravenous terbutal ine (0.125-0.25 m g) or
magnesium sul fate ( 2-6 g i n 10-20% di lution)
maybeusedtostoputeri necontracti ons.
References:S eepage166.

FetalM acrosomia
Excessivebi rthw eighti sassoci atedw ithani ncreasedri skof
maternal and n eonatal i njury. M acrosomia i s defi ned as a
fetus w ith an esti mated w eight of m ore than 4,500 gram s,
regardlessofgestati onalage.

I. Diagnosisofm acrosomia
A. Clinical estimates o f f etal w eight based on Leopold's
maneuvers or fundal hei ght m easurements a re often
inaccurate.
B. Diagnosis ofm acrosomiarequi resul trasound evalua­
tion; how ever, esti mation of fetal w eight based on
ultrasoundi sassoci atedw ithal argem arginoferror.
C. Maternal w eight, hei ght, pre vious obstetri c hi story,
fundalhei ght,andthe presence of gestationaldi abetes
shouldbeeval uated.
II. Factorsin fluencingfetalweig ht
A. Gestationalage. Post-termpregnancy i sari sk factor
for m acrosomia. At 42 w eeks and bey ond, 2.5% of
fetusesw eighm orethan4,500g.T ento twentypercent
ofm acrosomici nfantsarepost-term fetuses.
B. Maternalweig ht. Heavy womenhaveagreaterri skof
givingbi rthtoex cessively large infants.Fi fteento35%
of womenw hodel iverm acrosomicfetuses weigh 90 kg
orm ore.
 C. Multiparity. M acrosomic i nfants are 2-3 t imes m ore
likelytobeborntoparousw omen.
D. Macrosomiain ap riorin fant. Theri skof delivering an
infantw eighingm orethan4,500gi si ncreasedi fapri or
infantw eighedm orethan4,000g.
E. Maternaldiabetes
1. Maternal di abetes i ncreases the ri sk of fetal
macrosomiaandshoul derdy stocia.
2. Cesarean del iveryi s i ndicated w hen the esti mated
fetalw eightex ceeds4,500g.
III. Morbidityan dm ortality
A. Abnormalities o f lab or. M acrosomic fetuses have a
higheri ncidenceofl aborabnorm alities andi nstrumen­
tald eliveries.
B. Maternalmo rbidity. Macrosomicfetuseshave a two­
tothreefol di ncreasedrateofcesareandel ivery.
C. Birthin jury
1. The i ncidence of bi rth i njuries occurri ng during
deliveryofam acrosomici nfanti sm uchgreaterw ith
vaginalthanw ithcesareanbi rth. Them ostcom mon
injury i s brachi al pl exus pal sy, often caused by
shoulderdy stocia.
2. The incidence ofshoul derdy stociai ni nfantsw eigh­
ing more than 4,500gi s8-20% .M acrosomic infants
also m ay sustain fractures of the cl avicle or hu­
merus.
IV. Managementofdeliv ery
A. Iftheesti matedfetal w eighti sgreater than4500gm i n
thenondi abeticor greater than 4000gm i nthedi abetic
patient,del iveryby cesareansecti oni si ndicated.
B. Managementofshoul derdy stocia
1. If a shoul der dy stocia occurs, an assi stant shoul d
provide suprapubi c pressure to di slodge the i m­
pacted anteri or fetal shoul der from the sy mphysis.
McRoberts m aneuver (ext reme hi p fl exion) shoul d
bedonesi multaneously.
2. If the shoul der rem ains i mpacted anteri orly, an
ample epi siotomy should be cut and the posteri or
armdel ivered.
3. Inal mostal li nstances,oneorbothofthesepro ce­
duresw illresultin successful delivery.T heZ avanelli
maneuverconsi stsofrepl acementofthefetal l ead
into t he va ginal canal and del ivery by em ergency
cesareansecti on.
4. Fundal pressure i s not recommended because i t
often re sults i n further i mpaction of the shoul der
againstthesy mphysis.
References:S eepage166.

ShoulderDy stocia
Shoulder dy stocia, defi ned as fai lure of the sho ulders to
deliver fol lowing the head, i s an obstetri c em ergency. T he
incidencevari esfrom 0.6% to1.4% ofal lvagi naldel iveries.
Up to 30%ofshoul derdy stociascanresul ti nbrachi al plexus
injury;m anyfew ersus tain seri ousasphy xiaordeath.M ost
commonly, sizedi screpancysecondary tofetal macrosomia
isassoci atedw ithdi fficultshoul der delivery.C ausalfactors
ofm acrosomiai ncludem aternal diabetes, postdatesgesta­
tion,andobesi ty.T hefetusofthe diabetic gravida mayal so
have disproportionately l arge shoul ders and body si ze
comparedw iththehead.

I. Prediction
A. The di agnosis of shoul der dystocia i s m ade after
deliveryofthehead.T he“turtl e”si gn is theretracti on
of the chi n agai nst the perineum or retracti on of the
headi ntothebi rthcanal . This sign demonstratesthat
the shoulder girdlei sresi stingentry i ntothe pelvic inlet,
andpossi blyi mpactionoftheanteri orshoul der.
B. Macrosomia has the strongest associ ation. A COG
defines m acrosomia as an esti mated fetal w eight
(EFW)greaterthan4500g.
C. Risk factors for m acrosomia i nclude m aternal bi rth
weight, pri or m acrosomia, preexisting di abetes, obe­
sity, m ultiparity, advanced m aternal age, and a pri or
shoulder dy stocia. T he recurrence rate has been
reportedtobe13.8% ,nearl yseventi mesthe pri mary
rate. S houlder dy stocia occurs i n 5.1% of obese
women.I ntheantepartum peri od,ri sk factorsi nclude
gestational di abetes, ex cessive w eight gai n, short
stature, m acrosomia, and postterm pr egnancy.
Intrapartum factorsi ncludeprol ongedsecond stage of
labor, abnorm al fi rst stage, arrest di sorders, and
instrumental (especially m idforceps) del ivery. M any
shoulderdy stociasw illoccurintheabsenceofany risk
factors.
II. Management
A. Shoulder dy stocia is a m edical and possi bly surgi cal
emergency.T woassi stants shouldbecal ledfori fnot
already p resent, a s w ell a s a n anesthesiologist and
pediatrician.A generousepi siotomyshoul dbecut.T he
followingsequencei ssuggested:
1. McRobertsm aneuver:T hel egsarerem oved from
the l ithotomy posi tion and fl exed at the hi ps, w ith
flexion of the k nees agai nst the abdom en. T wo
assistants are requi red. This m aneuver m ay be
performed prophy lactically i n anti cipation of a
difficultdel ivery.
2. Suprapubicpr essure: Anassi stanti srequested to
apply pressure dow nward, ab ove the sy mphysis
pubis. This can bedonei nal ateraldi rectiontohel p
dislodgetheanteri orshoul der from behind thepubi c
symphysis.I tcan also be performedi nanti cipation
 ofadi fficultdel ivery.Fundal pressure mayi ncrease
the l ikelihood of uteri ne rupture and i s contr aindi­
cated.
3. Rotational m aneuvers: T he W oods' corkscrew
maneuver consi sts of pl acing tw o fi ngers against
theanteri oraspect of the posteriorshoul der.Gentl e
upward rotat ional pressure i s appl ied so that the
posteriorshoul der girdlerotatesanteri orly,al lowing
it to be del ivered fi rst. T he R ubin m aneuver i s the
reverse of W oods's m aneuver. T wo fingers are
placedagai nsttheposteri oraspectof the posterior
(or anterior)shoul derandforw ardpressureappl ied.
This resul ts i n adducti on of the shoul ders a nd
displacementoftheanteri or shoul derfrom behi nd
thesy mphysispubi s.
4. Posteriorar mr elease:T heoperatorpl acesa hand
into the posteri or vagi na al ong the i nfant's back.
The posteri or arm i s i dentified and fol lowed to the
elbow. T he el bow i s then sw ept acros s the chest,
keepingtheel bowfl exed.T hefetal forearm orhand
is then grasped and the posteri or arm del ivered,
followed by the anteri or shoul der. I f the fetus sti ll
remains undel ivered, vagi nal del ivery shoul d be
abandonedandtheZ avanellim aneuverperform ed
followedby cesareandel ivery.
5. Zavanelli m aneuver: The fetal head i s repl aced
into the w omb. T ocolysis i s recom mended to pro­
duce uterinerel axation.T hem aneuverconsi stsof
rotationofthehead toocci putanteri or.T heheadi s
then fl exed and pushed back i nto the vagi na,
followed abdom inal del ivery. I mmediate prep ara­
tionsshoul dbem adeforcesareandel ivery.
6. If cephal ic repl acement fai ls, an e mergency
symphysiotomy shoul d be perform ed. The urethra
shouldbe laterally displacedtom inimizetheri skof
loweruri narytracti njury.
B. The M cRoberts m aneuver alone w ill successfully
alleviatetheshoul derdy stociai n42% to79% ofcases.
For those requi ring addi tional m aneuvers, vagi nal
delivery can be ex pected i n m ore than 90% . Fi nally,
favorableresul tshave been reportedfortheZavanel li
maneuveri nupto90% .
References:S eepage166.

PostdatesPregnancy
A term ges tation i s defi ned as one com pleted i n 38 to 42
weeks. P regnancy i s consi dered prol onged or po stdates
wheni tex ceeds294da ys or42w eeksfrom thefi rstday of
thel astm enstrual peri od(LM P).A bout10% of thosepreg­
nancies are postdates. T he i ncidence of pati ents reachi ng
the42ndw eeki s3-12% .

I. Morbidityan dm ortality
A. Therateof maternal, fetal,andneonatal com plications
increasesw ith gestational age.T hecesareandel ivery
ratem orethandoubl esw henpassi ngthe42ndw eek
compared w ith 40 w eeks because of cephal opelvic
disproportionresul tingfrom l argeri nfantsandby fetal
intoleranceofl abor.
B. Neonatal com plications from postdates pregnanci es
include pl acental insufficiency, bi rth traum a from
macrosomia, m econium aspi ration sy ndrome, an d
oligohydramnios.
II. Diagnosis
A. Theaccuratedi agnosis ofpostdatespregnancy can be
made onl y by proper dati ng. T he esti mated date of
confinement(E DC)i sm ostaccur atelyd eterminedearl y
inpregnancy .A nE DCcanbecal culatedby subtracti ng
3 m onths from the fi rst day of the l ast m enses and
adding7day s(N aegele'srul e). Othercl inicalparam e­
ters that shoul d be consi stent w ith the E DC i nclude
maternal percepti onoffetal m ovements(qui ckening)
at about16to20w eeks;fi rstauscul tationof fetal heart
tones w ith D oppler u ltrasound by 12 w eeks; uteri ne
size a t early ex amination (fi rst tri mester) consi stent
with d ates; and, at 2 0 w eeks, a f undal hei ght 20 cm
abovethesy mphysispubisorattheum bilicus.

ClinicalE stimatesofGestationalA ge

Parameter Gestationalage (weeks)

Positiveuri nehC G 5

Fetalhearttonesby 11to12
Doppler

Quickening
Primigravida 20
Multigravida 16

Fundalheightatum bili­ 20
cus

B. Inpati entsw ithout reliablecl inicaldata,ul trasoundi s

beneficial.U ltrasonographyi sm ostaccuratei nearl y
gestation. T he crow n-rump l ength becom es l ess
accurate after 12 w eeks i n determ ining gestati onal
agebecausethefetusbegi nstocurve.
III. Managemento fth ep ostdatesp regnancy
 A. A postdates pati ent w ith a favorabl e cerv ix should
receivei nduction of labor.Onl y8.2% ofpregnanci es
at 42 w eeks have a ri pe c ervix (B ishop score > 6).
Induction at 41 w eeks w ith P GE2 cervical ri pening
lowersthecesareandel iveryrate.
B. Cervicalr ipeningw ithpr ostaglandin
1. ProstaglandinE 2 gel is aval uabletool fori mproving
cervicalri penessandfori ncreasingthel ikelihood
ofsuccessful i nduction.
2. Pre- and postappl ication fetal m onitoring are
usually uti lized. I f the fetus has a nonreassuri ng
heart rate traci ng or there i s excessive uteri ne
activity,theuseofP GE2 gel i s not advisable. The
incidenceofuteri nehy perstimulationw ithP GE2 gel,
at approx imately 5% , i s c omparable to that seen
withox ytocin.C urrentP GE2m odalities includethe
following:
a. 2 to 3 m g of P GE2 suspended in a g el p laced
intravaginally
b. 0.5 m g of P GE2 suspended i n a gel pl aced
intracervically(P repidil)
c. 10m gofP GE2 gel i nasustai ned-release tape
(Cervidil)
d. 25 :g of P GE1 (one-fourth of tablet) pl aced
intravaginallyevery 3to4hours(m isoprostol)
C. Strippingofm embranes,s tartingat38w eeksand
repeated w eekly m ay be an effecti ve m ethod of
inducing l abor i n post-term w omen with a favorabl e
cervix. S tripping of m embranes i s perform ed by
placing a fingeri nthecervi calosandci rcling 3 times
inthepl anebetw eenthefetal headandcervi x.
D. Expectant m anagement with antenatal sur veil­
lance
1. Begin testi ng near the en d of the 41st w eek of
pregnancy. A ntepartum testi ng consi sts of the
nonstress test (N ST) combined w ith the am niotic
fluid i ndex (A FI) tw ice w eekly. T he fal se-negative
rateis6.1/1000(stillbirthw ithin1w eek of areas­
suringtest)w ithtw icew eeklyN STs.
2. The A FI i nvolves m easuring the deepest verti cal
fluidpock eti neach uterine quadrantandsum ming
the four together. Less than 5 cm i s con sidered
oligohydramnios, 5 to8cm borderl ine,andgreater
than8cm norm al.
E. Fetal m ovement counting (kick c ounts). F etal
movement has been correl ated with fetal heal th. I t
consistofhavi ngthem other lie onhersi deandcount
fetal m ovements. P erception of 10 di stinct m ove­
ments in a peri od of up to 2 hours i s consi dered
reassuring.A fter1 0mo vementshavebeenpercei ved,
thecountm aybedi scontinued.
F. Deliveryi si ndicatedi ftheam nioticfl uidi ndexi sl ess
than5cm ,a nonreactive non-stress testi si dentified,
or if decelerationsarei dentifiedonthenonstresstest.
G. Intrapartumm anagement
1. Meconiumstaining ism orecom moni npostdates
pregnancies. I f ol igohydramnios i s present,
amnioinfusiond ilutesmeconi umanddecreasesthe
numberofi nfantsw ithm econiumbel owthevocal
cords. I nstillation of norm al saline through an
intrauterine pressure catheterm ayreducevari able
decelerations.
2. Macrosomiashoul dbe suspected inal lpostdates
gestations.Fetal w eightshoul dbe estimatedpri or
to labor i n a ll p ostdates pregnancies.
Ultrasonographic w eight predi ctions general ly fal l
within20% oftheactual bi rthw eight.
3. Management of suspected m acrosomia. Th e
pediatricianandanesthesi ologistshoul dbenoti fied
so that they can pr epare for del ivery. C esarean
delivery shoul d b e consi dered i n pati ents w ith an
estimated fetal w eight greater than 4500 g and a
marginal pelvis,orsom eonew ithaprevi ousdi ffi­
cult vaginal deliveryw ithasi milarlysi zed or larger
infant.
4. Intrapartumasphy xiai sal som orecom moni nthe
postdatespregnancy .T herefore,cl oseobservati on
of the fetal heart rat e tracing i s necessary duri ng
labor. V ariable decel erations representi ng cord
compression are frequentl y seen i n postdates
pregnancies
5. Cord com pression can be treated w ith
amnioinfusion,w hichcanreducevari abled ecelera­
tions.Latedecel erations arem oredi rectevi dence
of fetal hy poxia. If i ntermittent, l ate decel erations
are m anaged conservati vely w ith posi tioning and
oxygen.I fpersi stentl atedecel erations are associ­
ated w ith d ecreased va riability o r a n e levated
baseline fetal heart rate, i mmediate evaluation or
deliveryi si ndicated.T his additional evaluation can
include observation f or f etal heart accel eration
following fetal scal p or acousti c sti mulation, or a
fetalscalppH.
References:S eepage166.

InductionofLabor
Induction ofl aborreferstosti mulationofuteri ne contractions
priortotheonsetofspontaneousl abor. B etween1990and
1998, the rate of l abor i nduction doubl ed from 10 to 20
percent.
I. Indicationsfo rlab orin duction:
A. Preeclampsia/eclampsia, and other hy pertensive
diseases
B. Maternaldiabetesm ellitus
C. Prelaborruptureofm embranes

D. Chorioamnionitis

E. Intrauterinefetal grow threstri ction(I UGR)

F. Isoimmunization

G.I n-uterofetaldem ise

H. Posttermpregnancy

II. Absoluteco ntraindicationsto lab orin duction:

A. Priorclassicaluter ineincision
B. Activegeni talherpesi nfection
C. Placentaorvasaprevi a

D. Umbilicalco rdp rolapse

E. Fetalm alpresentation,suchastransversel ie

II. Requirementsfo rin duction

A. Prior to undertak ing labor i nduction, assessm ents of
gestational age, fetal si ze and presentati on, cl inical
pelvimetry, and ce rvical ex amination shoul d be per­
formed.Fetal m aturityshoul dbe evaluated, andam nio­
centesisfor fetal lung maturity maybeneededpri orto
induction.
B. Clinicalcr iteriathatconfir mter mgestation:
1. Fetal heart ton es docum ented for 30 w eeks by
Doppler.
2. Thirty-six w eeks have el apsed si nce a serum or
urine hum an chori onic gonado tropin (hC G) preg­
nancytestw asposi tive.
3. Ultrasoundm easurementofthecrow n-rumpl ength
at 6 to 11 w eeks of gestati on or bi parietal diame­
ter/femur l ength at 12 to 20 w eeks of gest ation
supportacl inicallydeterm inedgestati onalageequal
toorgreaterthan39w eeks.
C. Assessmentofcer vicalr ipeness
1. Acervi calex aminationshoul d beperform edbefore
initiatingattem ptsatl abori nduction.
2. The m odified B ishop scori ng sy stem i s most com ­
monlyus ed to assess the cer vix. A scor eis calcu­
latedbaseduponthestati onoft he presentingpart
andcervi caldi latation,efface ment,consi stency,and
position.

ModifiedB ishopS coringS ystem

0 1 2 3

Dilation, Closed 1-2 3-4 5-6

cm

Efface­ 0-30 40-50 60-70 >80

ment,
percent

Station* -3 -2 -1,0 +1, +2

Cervical Firm Medium Soft

consisten­
cy

Position of Posterior Midposi­ Anterior

thecervi x tion

*B asedona-3to+ 3scal e.

3. The l ikelihood of a vagi nal del ivery after l abor

inductioni ssi milartothat after spontaneousonset
ofl abori ftheB ishopscorei s> 8.
III. Inductiono flab orwith o xytocin
A. The uterine responsetoex ogenousox ytocinadm inis­
trationi speri odicuteri necontracti ons.
B. Oxytocinr egimen(P itocin)
1. Oxytocini sgi ven intravenously. Oxytocini sdi luted
by pl acing 10 uni ts i n 1000 m L of n ormal sal ine,
yielding an ox ytocin concentrati on of 10 mU/mL.
Begin at 6 mU/min andi ncreaseby 6m U/minevery
15m inutes.
2. Active management ofl aborregi mensusea high­
doseox ytocini nfusionw ithshorti ncrementalti me
intervals.

HighD ose Oxytocin Regimen

Beginox ytocin6m Uperm inutei ntravenously

Increasedoseby 6m Uperm inuteevery 1 5m inutes
Maximumdose:40m Uperm inute
Maximumtotal doseadm inistered-during-labor:1 0 U
Maximumdurati onofadm inistration:si xhours

3. Thedoseofm aximumox ytocin is usually40m U/min.

The dose isty picallyi ncreasedunti lcontracti onsoccur
attw otothreem inutei ntervals.
IV. Cervicalr ipeningagents
A. Ari peningp rocessshoul dbeconsi deredpri ortouseof
oxytocinusew henthecervi xi sunfavorabl e.
B. Mechanicalm ethods
1. Membrane s tripping is a w idely utiliz ed technique,
whichcausesrel easeof eitherprostagl andinF2-al pha
fromthe deciduaandadj acentm embranesorprosta­
glandinE 2from thecervi x.W eekly membranestri p­
ping begi nning at 38 w eeks of gestati on re sults i n
 deliveryw ithinashorterperi odof time (8.6 versus15
days).
2. Amniotomyi san effectivem ethodofl abori nduction
when perform ed in w omen w ith parti allydi lated and
effaced cervi ces. Caution shoul d be ex ercised to
ensurethatthefetal vertex i sw ell-applied tothecervi x
andtheum bilicalcordorotherfetalpartisnotpresent­
ing.
3. Foleycathe ter.A nuni nflatedFol eycathetercanbe
passed throughanundi latedcervi xandthen inflated.
Thistechni que is aseffecti veasprostagl andinE 2gel .
The useofex tra-amnioticsal inei nfusion with a balloon
catheter or a doubl e bal loon cat heter (A tad ri pener)
alsoappearstobeeffecti veforcervi calri pening.
C. Prostaglandins
1. Localadm inistrationofpros taglandins tothevagi naor
theendocervi xi stheroute of choicebecauseoffew er
side effectsandacceptabl ecl inicalresponse. Uncom­
mon side e ffects include fever, chills, vom iting, and
diarrhea.
2. Prepidil contains0.5m gofdi noprostonei n2.5m Lof
gel fori ntracervical adm inistration.T hedosecanbe
repeatedi n6to 12 hoursi ftherei si nadequatecervi cal
changeandm inimal uterineacti vityfol lowingthefi rst
dose.T hem aximum cumulative dosei s1.5m g(i e,3
doses) w ithin a 24-hour peri od. T he ti me i nterval
betweenthefi naldose and initiationofox ytocinshoul d
be 6 to 12hoursbecauseofthepotenti alforuteri ne
hyperstimulationw ithconcurrentox ytocinandprosta­
glandinadm inistration.
3. Cervidil is a vagi nal i nsert containing 10 m g of
dinoprostone i n a ti med-release form ulation. T he
vaginal insert administers them edicationat0.3m g/h
andshoul dbel eft in placefor12hours.Ox ytocinm ay
bei nitiated 30to60m inutesafterrem ovalofthei nsert.
4. Anadvantageofthevagi nal insert over thegel form u­
lation i s that the i nsert can be rem oved i n cases of
uterine h yperstimulation o r abnormalities o f t he f etal
heartratetraci ng.
V. Complicationsofl abori nduction
A. Hyperstimulationandtachy systolem ayoccur w ith use
ofprostagl andincom poundsorox ytocin.H yperstimulation
is defined as uteri ne contracti ons l asting at l east tw o
minutesorfi veor more uterinecontracti onsi n10m inutes.
Tachysystole is defined as sixorm orecontracti onsi n20
minutes.
B. ProstaglandinE 2(P GE2) preparationshaveuptoa5
percentrateofuteri nehy perstimulation.Fetal heart rate
abnormalitiescanoc cur,butusual lyresol veuponrem oval
ofthedrug.R arelyhy perstimulationortachy systole can
causeuteri ne rupture. RemovingtheP GE2vagi nali nsert
willu suallyh elpr everseth e effects of the hyperstimulation
andtachy systole.C ervical and vaginal lavageafterl ocal
applicationofprostagl andincom poundsi snothel pful.
C. Ifox ytocini sbei ngi nfused,i tshoul dbedi scontinuedto
achieveareassuri ngfetal heart rate pattern.P lacingthe
womani nthel eftl ateralpo sition,adm inisteringox ygen,
and increasing intravenous fluidsm ayal sobeofbenefi t.
Terbutaline0.25 mg subcutaneously(atocol ytic)m aybe
given.
References:S eepage166.

PostpartumHe morrhage
Obstetric hem orrhage rem ains a l eading causes of m aternal
mortality.P ostpartumhem orrhagei sdefi ned as the lossofm ore
than500m Lofbl oodfol lowingde livery.H owever,theaverage
blood loss in anuncom plicatedvagi naldel iveryi sabout500m L,
with5% l osingm orethan1,000m L.
I. Clinicalev aluationofpostpar tumhem orrhage
A. Uterineatony i s them ostcom moncauseofpostpartum
hemorrhage. C onditions associ ated w ith uteri ne a tony
include an overdi stended uterus (eg, pol yhydramnios,
multiplegestati on),rapi dorprol ongedl abor,m acrosomia,
highpari ty,andchori oamnionitis.
B. Conditions associated with bleeding from tr auma
includeforcepsdel ivery,m acrosomia,preci pitousl aborand
delivery,andepi siotomy.
C. Conditionsas sociatedw ithb leedingf romc oagulopathy
and thr ombocytopenia i nclude abrupti o pl acentae,
amnioticfl uidem bolism,preecl ampsia, coagulationdi sor­
ders,autoi mmunethrom bocytopenia,andanti coagulants.
D. Uteriner upturei sassoci atedw ith previous uterinesurgery ,
internalpodal icversi on,breechex traction,m ultiplegesta­
tion,andabnorm alfetal presentati on.H ighpari tyi sari sk
factorforbothuteri neatony andrupture.
E. Uterinein version is detectedby abdom inalvagi nalex ami­
nation, w hich w ill reveal a uterus w ith an unusual shape
afterdel ivery.
II. Managementofpostpar tumhem orrhage
A. Followingd eliveryofthepl acenta,theuter us shouldbe
palpatedtodeterm inew hetheratony is present. If atonyi s
present,vi gorousfundal m assage should be administered.
Ifbl eedingconti nuesdespi te uterinem assage,i tcanoften
becontrol ledw ithbi manualuteri necom pression.
B. Genitaltr actlacer ations shouldbesuspectedi npati ents
who have a fi rm uter us, but w ho conti nue to bl eed. T he
cervixandvagi nashoul dbei nspectedtorul eoutl acera­
tions.I fnolacerationisf oundbutbleedingisstillprofuse,
theuterusshoul dbem anuallyex amined to excluderupture.
C. The placenta and uter us should be ex amined for re­
tained p lacental f ragments. P lacenta a ccreta i s u sually
manifestby fai lureofs pontaneouspl acentalseparati on.
 D. Bleedingfr om non-genitalar eas(venouspuncturesi tes)
suggests coagul opathy. Laborator y tests that confi rm
coagulopathy i nclude I NR, parti al throm boplastin ti me,
platelet c ount, f ibrinogen, f ibrin s plit p roducts, and a cl ot
retractiontest.
E. Medicalm anagementofpostpar tumhem orrhage
1. Oxytocin(P itocin)i susual lyg ivenrouti nelyi mmediately
after deliverytosti mulateuteri nefi rmnessand diminish
bloodl oss.20uni tsofox ytocin in1,000m Lofnorm al
saline or R inger's lactate i s adm inistered at 100
drops/minute.Ox ytocinshoul dn ot be givenasarapi d
bolus i njection because of the potenti al for ci rculatory
collapse.
2. Methylergonovine(M ethergine)0.2m gcan be given
IM if uterinem assageandox ytocinarenoteffecti vei n
correcting uterine atonyand providedtherei snohy per­
tension.
3. 15-methyl pr ostaglandin F2-al pha (H emabate), one
ampule(0.25m g),canbegi ven IM, with repeat injections
every20m in,upto 4 doses canbegi veni fhy pertension
ispresent;i ti scontrai ndicatedi nasthm a.

TreatmentofP ostpartumH emorrhageS econdaryto

UterineA tony

Drug Protocol

Oxytocin 20U i n1,000m Lofl actated

Ringer'sasI Vi nfusion

Methylergonovine 0.2m gI M
(Methergine)

Prostaglandin(15 0.25m gasI Mevery 15-60

methylP GF2-alpha minutesasnecessary
[Hemabate,
Prostin/15M])

F. Volumer eplacement
1. Patientsw ith postpartumhem orrhagethati srefractory
to m edical ther apy requi re a second l arge-bore I V
catheter. I f the pati ent has had a m ajor bl ood group
determinationandhas a negativei ndirectC oombstest,
type-specificbl oodm aybegi venw ithoutw aitingfora
complete cross-m atch. Lactated R inger's sol ution or
normalsal inei sgenerousl yi nfusedunti lbl oodcanbe
replaced.R eplacementconsi stsof3m Lofcry stalloid
solutionper1m Lofbl oodl ost.
2. A Foleycatheteri s pl aced,anduri neoutputi s m ain­
tainedatgreaterthan30m L/h.
G. Surgical m anagement of postpar tum hem orrhage. I f
medicaltherapy fai ls,l igationof the uterine oruteroovari an
artery,i nfundibulopelvicvessel s,orhy pogastricarteri es,or
hysterectomym aybei ndicated.
H. Managementofuter inei nversion
1. Thei nverteduterusshoul dbei mmediatelyreposi tioned
vaginally.B loodand/orfl uidsshoul d be administered. If
theplacentais still attached, itshouldnotberem oved
untiltheuterushasbeenreposi tioned.
2. Uterinerel axationcan be achievedw ithahal ogenated
anestheticagent.T erbutalinei sal souseful for relaxing
theuterus.
3. Followingsuccessful uteri nereposi tioningandpl acental
separation, ox ytocin (P itocin) i s gi ven to contract the
uterus.
References:S eepage166.

AcuteEndometritis
Acute endom etritis i s ch aracterized by the presence of
microabscessesorneutrophi lsw ithintheendom etrialgl ands.
I. Classificationofendom etritis
A. Acuteendom etritisi nthenonobstetri cpopul ationi susual ly
relatedtopel vici nflammatorydi sease(P ID)secondary to
sexuallytransm ittedi nfectionsorgy necologicprocedures.
Acutee ndometritisi ntheobstetri cpopul ationoccursasa
postpartum infection, usual ly after a l abor concl uded by
cesareandel ivery.
B. Chronicendom etritisi n thenonobstetri cpopul ationi sdue
toi nfections(eg, chlamydia, tuberculosis,andotherorgan­
isms rel ated to cervicitis and P ID), i ntrauterine forei gn
bodies(eg,i ntrauterine device,subm ucousl eiomyoma),or
radiation t herapy. I n t he o bstetric popu lation, c hronic
endometritisi sassoci atedw ithretai nedproductsofconcep­
tionafterarecentpregnancy .
C. Symptomsi nbothacute and chronic endometritisconsi stof
abnormal vaginal bl eeding and pel vic pai n. H owever,
patients withacuteendom etritisfrequentl yhavefeversi n
contrasttochroni cendom etritis.
II. Postpartumendom etritis
A. Endometritisi nthe postpartum period referstoi nfectionof
thedeci dua(i e,pregnancy endom etrium), frequentlyw ith
extension i nto the m yometrium (endom yometritis) an d
parametrialti ssues(param etritis).
B. The si ngle m ost i mportant ri sk factor for postpartum
endometritis i s rout e of del ivery. T he i ncidence of
endometritisafteravagi nalbi rthi sl essthanthreepercent,
buti s5to10ti meshi gheraftercesareandel ivery.
C. Other proposed ri sk factors i nclude prol onged l abor,
prolongedruptureofm embranes,mu ltiplevagi nalex amina-
 tions,i nternal fetalm onitoring,m aternaldi abetes,presence
ofm econium,andl owsoci oeconomicstatus.
D. Microbiology. Postpartum endom etritis i s usual ly a
polymicrobiali nfection,producedby am ixtureof aerobes
andanaerobesfrom thegeni taltract.

TypeandFr equencyofB acterialI solatesi nP ostpartum

Endometritis*

Isolate Frequency(per cent)

Gramp ositive
GroupB streptococci 8
Enterococci 7
S.epi dermidis 9
Lactobacilli 4
Diphtheroids 2
S.Au reus 1

Gramnegati ve
G.vagi nalis 15
E.Co li 6
Enterobacteriumspp. 2
P.m irabilis 2
Others 3

Anaerobic
S.bi vius 11
OtherB acteroidesspp. 9
Peptococci-peptostreptoc 22
ci

Mycoplasma
U.ureal yticum 39
M.h ominis 11

C.tr achomatis 2

E. Vaginalcol onizationw ithgroupB streptococcus(GB S)i sa

risk factor for postpartum endom etritis; GB S co lonized
womenat delivery have an 80percentgreaterl ikelihoodof
developingpostpartum endom etritis.
F. Clinical m anifestations and di agnosis. E ndometritis i s
characterize,by fever,uteri netendern ess,foul l ochia,and
leukocytosis that devel op w ithin fi ve da ys of del ivery. A
temperaturegreaterthanorequal to100.4ºF(38ºC )i nthe
absence of other causes of fever, such as pneumonia,
wound cel lulitis, and uri nary tract i nfection is the m ost
commonsi gn.
G. Laboratorystudi esarenotdi agnosticsi ncel eukocytosis
occurs frequentl y i n all postpartum pati ents. H owever, a
risingneutrophi l countassoci atedw ithel evatednum bersof
bands i s suggesti ve of i nfectious di sease. B acteremia
occurs i n 10 to 20 percent of pati ents; usual ly a si ngle
organismi si dentifieddespi tepol ymicrobiali nfection.B lood
cultures shoul d be obtai ned i n febri le pati ents fol lowing
delivery.
H. Treatment
1. Postpartumendom etritisi s treated withbroadspectrum
parenteral anti biotics i ncluding coverage for beta­
lactamasep roducinganaerobes.T hestandardt reatment
ofcl indamycin(900m gq8h) plus gentamicin (1.5m g/kg
q8h)i ssafeandeffecti ve,w ithreportedcure rates of90
to97percent.

AntibioticR egimensfor E ndometritis

Clindamycin(900m gI VQ8hours)pl usgentam icin(1.5

mg/kg IVQ8hours)
Ampicillin-sulbactam(Unasy n)3gram sI VQ6hours
Ticarcillin-clavulanate(T imentin)3.1gram sI VQ4hours
Cefoxitin(M efoxin)2gram sI VQ6hours
Ceftriaxone(R ocephin)2gram sI VQ24hourspl us
metronidazole500m gP OorI VQ8hours*
Levofloxacin(Levaqui n)500m gI VQ24hourspl us
metronidazole500m gP OorI VQ8hours*

*S houldnotbegi ventobreastfeedi ngm others

Ifchl amydiai nfectioni ssuspected,az ithromycin1gram
POforonedoseshoul dbeaddedtotheregi men

2. Treatmentshoul dconti nueunti l thepati enti scl inically

improvedandafebri lefor24 to48hours.Oral anti biotic
therapy i s not necessary after successful parenteral
treatment,unl essbacterem iai spresent.
3. Modificationsi ntherapy m aybenecessary i fthere isno
responsetothei nitialanti bioticre gimenafter48to72
hours.A pproximately20percentoftre atmentfai luresare
duetoresi stantorgani sms, suchasenterococci w hich
arenotcoveredby cephal osporinsorcl indamycinpl us
gentamicin.T headditionof ampicillin (2 g q4h)tothe
regimencani mprovetheresponserate. Metronidazole
(500 m g P O or I V q8h) m ay be m ore effect ive than
clindamycin agai nst Gram negati ve anaerobes but i s
generallynotusedin mothers whow illbebreastfeeding.
References:S eepage166.
PostpartumFever W orkup
History: Postpartum fever is > 100.4 F (38 degrees C ) on 2

occasions> 6hapartafterthefi rstpostpartum day (duri ngthefi rst

10 days postpartum ), or > 101 on the fi rst postpartum day .

Dysuria,abdom inalpai n,di stention,breastpai n,cal fpai n.

Predisposing Factor s: Cesarean secti on, prol onged l abor,

premature rupture of m embranes, i nternal m onitors, m ultiple

vaginalex ams, meconium, manualpl acentaex traction,anem ia,

poornutri tion.

PhysicalE xamination: Temperature,throat,chest,l ungex ams;

breasts, abdom en. C ostovertebral angl e tenderness, uteri ne

tenderness,phl ebitis,cal ftenderness;w oundex am.S peculum

exam.

Differential D iagnosis: U TI, upper respi ratory i nfection,

atelectasis, pneum onia, w ound i nfection, m astitis, epi siotomy

abscess;uteri nei nfection,deepvei nthrom bosis,py elonephritis,

pelvicabscess.

Labs:C BC, SMA7, bloodC &Sx 2,catheterU A,C &S.Gonococ­

cuscul ture,chl amydia;w oundC &S,C XR.

References
Referencesm aybeobtai nedat www.ccspublishing.com/ccs