Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Nick Graham
Nic Todd
Vania Lim
Zak Peters
Jill Coolen
Table of Contents
History:
Physical:
• appearance:
• vitals: HR, BP, RR, Sats, T
• FHR:
• CVS:
• resp:
• GI: BS, tendernes, Leopold, SFH, contractions, scars, # fetuses
• GU: Presentation, Position, Place (station), Pelvis (size), Puncture (ROM), cervical
placement/texture/dilation
• MSK: rashes
Gestational Hypertension
Background:
• Definition:
• diastolic HTN which develops after 20 weeks gestation
• Etiology:
• imbalance of vasoconstrictors and vasodilators (+ arteriolar constriction,
capillary damage, protein extravasation and hemorrhage)
• Risk Factors:
• maternal: primagravida, new partner, PMHx, FHx, DM, HTN, renal insuff,
thrombophilias, extremes of age (<18 or >35), vascular/connective tissue
disease, African
• fetal: IUGR, oligohydramnios, GTN, multiple gest, fetal hydrops
• Classification:
• A. Pre-existing Hypertension
• essential
• secondary
• B. Gestational Hypertension
• 1. Without proteinuria (24hr urine protein < 0.3g/d)
• Without adverse conditions
• With adverse conditions
• 2. With proteinuria (24hr urine protein > 0.3g/d)
• Without adverse conditions
• With adverse conditions (24hr urine protein > 3.0g/d)
• C. Pre-existing hypertension and superimposed gestational hypertension
with proteinuria
• D. Unclassifiable antenatally
• Adverse Conditions: SBP>160, DBP>110, proteinuria >5g/24hr, HELLP, oliguria
(<500ml/24hr), CNS Sx, pulmonary edema, epigastric pain/tenderness, fetal growth
restriction
• Complications:
• meternal: hemorrhagic stroke, seizure, DIC, HELLP, left ventricular
failure, liver dysfunction, renal dysfunction, abruption
• fetal: placental insufficiency (fetal loss, IUGR, prematurity, abruptio
placentae)
History:
• ID:
• HPI:
• onset of BP (>20wks), baseline BP
• S/S: HA, visual changes, epigastric/RUQ pain, SOB, CP, decreased
urine output, wt gain, edema, N/V
• 4 cardinal questions (placental insufficiency)
• pregnancy complications
• U/S findings
• PGyneHx: STIs, abN paps
• PObsHx: previous pregnancies (most common in first)
• PMHx: HTN, renal disease
• PSHx:
• All:
• Meds:
• FHx:
• SHx:
Physical:
• appearance:
• vitals: BP 140/90 -> do bloodwork, 160/105 -> worrisome
• FHR:
• H+N: fundoscopy (papilledema)
• CVS: decreased heart sounds, S4 (pericardial edema)
• resp: crackles (pulmonary edema)
• GI: epigastric/RUQ pain, SFH (IUGR)
• GU:
• MSK:
• Neuro: hyperreflexia
Investigations:
• bloodwork
• CBC (thrombocytopenia of HELLP)
• Cr, urea, urate (renal insufficiency)
• AST, ALT (elevated in HELLP)
• LD, peripheral smear (hemolysis of HELLP)
• PT, PTT, d-dimer, fibrinogen (DIC)
• type and screen
• urine
• U/A (proteinuria)
• 24hr collection (proteinuria = >0.3g/d)
• fetal monitoring
• BPP w cord dopplers & EFW
Management:
Orders:
Background:
History:
• ID: age, GTPAL
• HPI (current GyneHx):
• menorrhagia
• menses (freq, duration, flow)
• intermenstrual or postcoital bleeding
• dysmenorrhea
• pelvic pain
• PGyneHx:
• menses
• STIs
• AbN paps
• PObsHx: past pregnancies
• PMHx:
• PSHx:
• All:
• Meds:
• FHx:
• SHx:
Physical:
• appearance:
• vitals:
• FHR:
• H+N:
• CVS:
• resp:
• GI:
• GU:
• speculum exam for cytology, swabs
• bimanual
• MSK:
• Neuro:
Management:
• Stabilize: ABCs; give crystalloids; ins/outs; insert foley; type and crossmatch if
severe
• Investigations:
• bloodwork
• CBC ± ferritin
• +/- type and crossmatch
• BhCG
• TSH
• hormones (FSH, progesterone, PRL, androgens)
• coagulation profile
• liver panel
• assessment of endometrium
• indications: age>40 or RFs for endometrial ca (nulliparity, obesity,
PCOS, FHx, tamoxifen)
• office endometrial biopsy; hysteroscopic sampling; D&C
• assessment of Cervix
• cervical cultures; pap smear
• pelvic U/S
• Treatment:
• Medical
• NSAIDs
• antifibrinolytics
• danazol
• progestins
• combined OCP
• progestin intrauterine system (Mirena)
• GnRH agonists
• Surigcal
• D&C
• endometrial ablation
• hysterectomy
• uterine artery embolization
Background:
Type Description
bleeding +/- cramping Cx closed no tissue passed U/S; void physical activity/
Treatened
intercourse if no FHR: allow to spont. pass vs D&C
Inevitable bleeding + cramping Cx open no tissue passed D&C +/- oxytocin
Incomplete bleeding + cramping Cx open tissue passed D&C +/- oxytocin
no more bleeding Cx closed uterine cavity empty U/S D&C if retained
Complete
fragments
Missed baby retained but dead Cx closed U/S D&C monitor for DIC if >12wks
Septic resuscitate patient amp+gent or clinda D&C +/- oxytocin
three or more consecutive losses investigations: karyotype, assess
Recurrent
structural abnormalities, assess autoantibodies
complications: uterine perforation, hemorrhage,
Therapeutic cervical laceration, infection, risk of sterility,
Asherman's syndrome
History:
• ID:
• HPI:
• describe bleed: onset, amount, pain/cramping, color, passage of tissue
• 4 cardinal questions
• Hx of current pregnancy:
• EDC
• prior bleeds
• U/S results
• PGyneHx:
• currently sexually active?
• PObsHx:
• PMHx:
• PSHx:
• All:
• Meds:
• FHx:
• SHx:
Physical:
• appearance: pallor
• vitals: hypotensive, tachycardic
• FHR:
• H+N:
• CVS:
• resp:
• GI:
• GU:
• external genitalia
• speculum: cytology, cultures, assess Cx dilation
• bimanual: uterine tenderness, adnexal tenderness
• rectovaginal exam
• rectal exam
• MSK:
• Neuro:
Management:
Antepartum Bleeding
Background:
• Definition:
• vaginal bleeding @ >20wks GA
• NO PELVIC/RECTAL until previa ruled out
• ABC's first
• DDx:
• Vasa previa
• Placenta previa
• Abruptio placenta
• Uterine rupture
• Bloody show
• Cervical (cervicitis, polyp, cancer)
• Vaginal (post-coital)
• Non-gyne (hematuria, BRBPR)
• Abruptio Placenta
• classification: concealed vs apparent
• presentation: pain with bleeding, pain is sudden/constant, localized to back
and uterus
• RFs:
• HTN
• previous abruption
• large uterus (macrosomia, polyhydramnios, multiple gest)
• EtOH, smoking, cocaine
• uterine anomaly
• trauma
• multiparity
• management:
• maternal stabilization
• if mild and term: expectant delivery
• if mild and prem: observe mom and fetus; deliver
• if moderate/severe: vaginal delivery or C/S
• Placenta previa
• classification: partial vs complete vs marginal vs low-lying placenta
• presentation: painless bleeding
• RFs:
• multiple gest
• uterine anomalies
• multip
• accreta
• management:
• maternal stabilization
• admit and observe if: minimal bleeding, <36wks, fetus stable, no
contractions
• C/S if: previa unstable, fetal distress, >36wks
• Vasa previa
• presentation: painless bleeding, tachycardia, bradycardia, severe variables
• RFs:
• velamentous insertion of cord on low lying cervix
• diagnosis:
• Apt test
• palpable cord
• management:
• immediate C/S
• Uterine rupture
• presentation: painful bleeding, during labour: suprapubic pain, contractions
stop, vaginal bleeding, hemoperitoneum
• RFs:
• prior uterine surgery
• trauma
• uterine distension (macrosomia, polyhydramnios, multiple gest)
• uterine anomolies
• choriocarcinoma, difficult labor (forceps, vag breech, shoulder
dystocia)
• diagnosis: clinical
• management: TAH
History:
Physical:
• appearance: pallor
• vitals: hypotensive, tachycardic
• FHR:
• H+N:
• CVS:
• resp:
• GI:
• SFH, leopolds
• GU:
• do U/S first to R/O previa
• MSK:
• Neuro:
Management:
• bloodwork:
• CBC/d, type and crossmatch
• coags: PT, PTT, fibrinogen, FDP, D-dimer
• hemolysis: peripheral smear, haptoglobin, t.bili, LDH
• AST, ALT
• urine:
• urinalysis
• treatment:
• as per cause
Infertility
Background:
History:
• ID:
• F: age, GTPAL (clarify if previous pregnancies with current partner)
• M: age
• HPI:
• primary vs secondary infertility (i.e. any children previously)
• duration of unprotected intercourse
• coital frequency
• fertility W/U and Tx to date
• PGyneHx:
• menses:
• LNMP
• Menstrual Hx: menarche, regular/irregular, frequency, duration, flow
• Moliminal Sx: bloating, cramping, breast tenderness, mood changes
• Midcycle Sx: Mittlesmirtz, cervical mucus
• Dysmenorrhea: primary vs secondary
• Dyspareunia
• sexual: STIs/PID; contraceptive history
• paps: last, frequency, abN
• other: hyperandrogenism (hirsuitism, alopecia, acne), wt change
• PObsHx:
• PMHx: pituitary, thyroid, Cushings, endometriosis, PCOS, PID, uterine abnormalities
• PSHx: laparotomy, laparoscopic, D&C, bowel Sx
• All:
• Meds: folic acid
• FHx: infertility
• SHx:
• Male Partner:
• ID: age
• PMHx: pregnancies with other partners
• PSHx: torsion, inguinal repair, TURP, radiation
• All:
• Meds: chemotherapeutics
• FHx: infertility
• SHx: occupational exposure to heavy metals, hot showers
• GU Hx:
• heat/toxin exposure
• testicular trauma
• infections: STIs, mumps, TB
• underwear - tightie whities
• erections/ejaculations/libido
Physical (Female):
Physical (Male):
• appearance: body habitus, hair distribution
• vitals:
• H+N:
• CVS:
• resp:
• GI: DRE
• GU:
• hernias, varicoceles, penis, scrotum, testicular volume
• MSK:
• Neuro:
Investigations (Female):
• ovarian:
• bloodwork
• hormones: Day 3 FSH (check ovarian reserve), LH, estradiol, PRL,
TSH, day 21 prog (check ovulatory status)
• PCOS: DHEAS, testosterone, 17-hydroxyprogesterone, fasting
insulin, fasting glucose, lipid profile, sex hormone binding globulin
• endometrial Bx
• transvaginal U/S
• cervical:
• mucous analysis
• post-coital test
• uterine/tubes:
• HSG (day 5-10)
• laparoscopy
• peritoneal:
• laparoscopy
Investigations (Male):
• Semen analysis
Management:
• Azoospermia:
• therapeutic donor insemination (TDI)
• anonymous frozen sperm, IUI, 50% success rate at 6mos
• Oligospermia:
• attempt IUI, ICSI with IVF
• Ovulatory problems:
• treat cause
• Tubal problems:
• nothing if at least one tube is patent
• ?tubal surgery
• IVF if tubes grossly damaged
• Uterine factors:
• ?surgery
• Unknown:
• unknown
Prenatal Care
Background:
History:
Physical:
• appearance:
• vitals: baseline BP, vitals, weight
• H+N:
• CVS:
• resp:
• GI:
• GU:
• MSK:
• Neuro:
Investigations:
• bloodwork
• CBC
• blood type
• antibody screen
• Rubella titre
• varicella
• RPR
• HsbAg
• +/- HIV
• urinanalysis
• R&M, C&S
• PV
• pap (if none within 6 mos)
• swabs (GC, chlamydia, vaginal vault)
Management:
• subsequent visits
• qmonthly until 28wks
• q2wks from 28-36wks
• q1wk from 36wks to delivery
• 6wks postpartum
Background:
• Maternal mortality
• 0-4/10,000 deliveries
• eclampsia, amniotic fluid embolism, MVA
• Perinatal mortality
• neonatal death (within 1 wk): 3/1000
• stillborn: 4/1000
• Diabetes
• Hypertension
• preeclampsia, essential, chronic
• keep wt down 15-20lbs
• Antepartum hemorrhage
• aberuption, placenta previa
• Premature labour
• Premature ROM
• Rh disease
• Small for dates
Ectopic Pregnancy
• Etiology
• PID/salpingitis --> 50% secondary to damaged fallopian tube cilia from PID
• adhesions - tubal ligation reversal
• long tubes/anatomic abN --> fibroids, ovarian mass
• Kartagener's syndrome --> lack of motile cilia
• intrinsic abN of fertilized ovum
• conception late in cycle
• transmigration of fertilized ovum to contralateral tube
• Signs/Symptoms
• ectopic triad --> pain, bleeding, adnexal tenderness (+ cervical motion
tenderness)
• shoulder tip pain (referred from diaphragm)
• adnexal mass
• peritoneal signs --> tendernss (90%) +/- rebound (45%)
• temp > 38degC (20%)
• doughy abdo from clots
• Grey Turner's/Cullen's
• signs of pregnancy --> Chackwick's sign, Hegar's sign
• Dx
• U/S --> only definite if fetal cardiac activity detected in tube/uterus
• tubal ring --> specific finding on endovaginal U/S
• serial absolute hCG levels --> should double q48h w/ intra-uterine
pregnancy
• rise < 20% is 100% predictive of non-viable pregnancy
• prolonged doubling time, plateau, decreasing levels prior to 8 wks
--> non-viable gestation, provides NO info on implantation
LOCATION
• 1000 - 1200 w/o +ve U/S
• laparoscopy for definitive Dx
• may pass entire decidua at once and look like a SA
• Investigation
• bloodwork --> CBC, hCG, progesterone
• urine R&M, C&S --> r/o UTI/pyelo
• US --> transvaginal (hCG > 1500), transabdo (hCG > 4500)
• Management
• surgical
• indications --> hCG > 10,000 or hemoperitoneum
• linear salpingostomy if tube salvageable, otherwise salpingectomy,
inspect contralateral tube
• monitor hCG weekly until non-detectable --> 15% risk persistent
trophoblast
• give RhoGAM if pt Rhneg (applies to surgical and medical
management)
• medical
• MTX (std of care) --> suppresses growth, decreases risk rupture
• 50 mg/m2 IV or IM
• approx 84% success rate after single dose
• tubal patency after MTX up to 80%
• S/E --> increased liver enzymes, diarrhea, gastritis,
dermatitis
• follow hCG weekly until undetectable --> plateau/rising
levels implies persisting trophoblastic tissue --> REQUIRES
further medica/surgical Rx
• criteria for increased success of medical Rx
• pt clinically stable, NO Sx of rupture
• U/S --> empty uterine cavity, < 3.5 cm unruptured ectopic
pregnancy, NO fetal heart activity
• hCG 1000 - 10,000 mIU/mL
• NO contraindications fo MTX --> breastfeeding, hepatic/
renal/hematologic disease, PUD, active pulm disease
• compliance + good f/u!!
• baseline labs --> CBC, BUN/Cr, liver enzymes, T&S
• f/u --> quantitative hCG q3d until 15% fall, then q weekly until < 15
• 2nd dose in 1 wk if 30% fall NOT observed
• rpt TV U/S in 3 wks
• HSG in 3 mo
• NO EtOH, folic acid, or sex until full resolution
Malpresentation:
Presentation Types:
• Cephalic (97/100)
• vertex->vaginal : most common=occiput anterior; followed by left/right
occiput transverse and occuput posterior
• face (1/500) : mentoanterior (60%) --> vaginal delivery
• brow(1/1400) : unstable b/t vertex and face. Vaginal delivery if converts,
but most likely C/S
• Breech (3/100)
• frank (65% or 2/100) : external version with vaginal or C/S
• complete (10%) : external version or C/S
• incomplete (1-2 footling)(25%) : external version or C/S
• Compound (1/700) : limb prolapses with presenting part. Deliver vaginally unless
converts to shoulder
• Shoulder (3/1000) : associated with transverse or oblique lie. C/S these babies!
Risk Factors:
Maternal: big uterus (linked with multiparity), uterine or pelvic abnormalities (contracted
pelvis)
Maternal-fetal: poly/oligohydraminos, previa
Fetal: small baby (premature/IUGR), multiple gestation, congenital abnormalities (6%
associated with malpresentation -- 2x normal rate or congenital abnormalities)
Diagnosis:
• Leopolds
• Vaginal exam
• Always confirm with ultrasound
Management:
Procedure Criterion Risks Contraindication
Maternal: previous
classical C/S or
>37 weeks GA,
myomectomy
unengaged,
External Maternal-Fetal:
singleton, reactive Abruption
version-->tocolysis, Oligohydraminos,
NST. Cord compression
analgesia, U/S guided previa, PROM, prev
(lots of fluid) Uterine rupture
+/- Rhogam T3 bleed
(multiparity)
Fetal: IUGR,
(small baby)
congenital
abnormality
Maternal: Adequate
pelvis
Cord compression,
Fetal: >36 GA, Congenital
Vaginal Delivery birth trauma,
2200-3800 grams, abnormality
asphyxia
continuous FHM,
flexed head
Shoulder Dystocia
1. gentle downward traction on head => "turtle sign" = fetal chin pulled back after
delivery of head
2. call for help
3. cut an episiotomy
4. McRobert's Maneuver: flex maternal thighs against abdomen
5. Suprapubic pressure
6. Shoulders rotated to an oblique diameter
7. Woods' Corkscrew Maneuver: place hand behind posterior shoulder and rotate
forwards 180 degrees
8. delivery of posterior arm
9. Rubin's Maneuver: abduction of the shoulders
10. deliberate fracture of the clavicle
11. Zavanelli's Maneuver: cephalic replacement -> emerg C/S
Fetal Monitoring
Antepartum:
SFH – 20cm at 20wks GA, should grow 1cm/wk
FHM – done at pre-natal checks, NO impact on survival
Wt gain – avg gain = 20 – 25 lbs (wt should change to 20 – 25lbs above IDEAL body wt)
- commonly lose wt w/in 3 mo post-partum
FM – first noticed by 18 – 20 wks (primigravidas), 14 – 16 wks (multigravidas)
- Normal = min 6 FM over 2 hrs w/ mom at rest
- normally felt less in last mo b/c of decreased space
- MOST helpful in HIGH RISK pregnancy
NST – suggests uteroplacental insufficiency OR suspected fetal distress
- reactive = 2 accels > 15bpm from baseline lasting >15 sec over 20 min
- non-reactive = < 2 accels > 15 bpm from baseline lasting 15s over 40 min
o perform BPP if NST non-reactive
- only 50% normal babies reactive if ≤ 26wk GA
BPP – NST + 30 min U/S assessment of fetus
Diagnosis of Labour
- def’n of labour
o regular, painful contractions
o assoc w/ progressive DILATATION and EFFACEMENT of cervix and DESCENT of
presenting part (STATION) à cervical changes
- preterm à > 20, < 37 wks GA
- term à 37 – 42 wks GA
- post-term à > 42 wks GA
- Braxton-Hicks contractions à “false labour”
o Irreg, occur throughout pregnancy
o NOT assoc w/ any dilation, effacement or descent
Pelvic Examination:
Background:
• prevalence:
• physical assault: 1/3 to 1/10 women living with a man
• sexual assault: 1/8 in USA
• RFs for physical assault:
• age 18-24
• pregnancy
• disability
• FHx of abuse
• attempted divorce/breakup
History:
• ID:
• quiet/secluded area, do not leave pt alone (have nurse/crisis counsellor
present), contact assault crisis team
• CC: (often non-specific)
• story doesn't fit injuries
• delayed presentation
• recognizable injury patterns/locations
• constant visits with non-specific S/S's (HA, abdo pain, pelvic pain, etc.)
• depression
• EtOH/drug abuse
• avoidance of male relationships
• changes in sexual behavior
• increased anxiety
• decreased self-esteem
• phobic reactions to being alone
• new onset nightmares
• HPI:
• careful/accurate documentation!
• (approach HPI chronologically)
• date and time of assault and present exam
• physical surroundings and circumstances of assault
• nature of assault and associated pain
• weapons or foreign objects used and where used
• number of assailants
• other known victims
• acts committed (coitus, fellatio, cunnilingus, sodomy)
• if ejaculation occurred and where
• condom use
• if vomiting/LOC occurred
• if patient washed, wiped, bathed, couched, defecated, brushed teeth,
changed clothes
• use of drugs, EtOH, meds in proximity to assault
• date of last tetanus
• date and time of last consensual intercourse
• PGyneHx:
• PObsHx:
• PMHx: PTSD
• PSHx:
• All:
• Meds:
• FHx:
• SHx:
Physical:
• vitals:
• screening entire P/E:
• collect evidence:
• collect clothes
• inspect clothes, skin, nails
• fingernail cleanings
• comb pubic hair; collect head and pubic hair
• saliva sample
• GU:
• external inspection
• speculum
• vaginal/anal/throat swabs for GC, CT, and sperm
• GI:
• DRE
• MSK: signs of trauma
Investigations:
Management:
• repair trauma
• +/-tetanus toxoid
• GC/CT prophylaxis
• offer emergency contraceptive/counselling re: pregnancy
• offer HIV prophylaxis (not routinely given)
• counseling/eduction
• ?psych
• ?police
• ?social work
• follow-up:
• 2 wks: GC, B-hCG
• 6 wks: syphilis
• 12 wks: HIV
Urinary Incontinence
Background:
• Stress incontinence: loss of urine occuring with increased abdominal pressure
(coughing, laughing,lifting) often due to bladder prolapse or weak sphincter
• Urge incontinece: loss of urine due to involuntary bladder spasm, urgency,
frequency, nocturnal, multiple triggers
• Mixed
• Overflow: urine leaks from overdistended bladder with chronic urinary retention
• due to outlet obstruction, bladder underactivity, previous surgery, aging,
bad bladder habits, neurologic disorders, anticholindergics
• Functional & transient incontinence: geriatrics, due to restricted mobility, UTI,
severe constipation, diuretics, antipsychotics, psychological
Etiology
• Delirium
• Infection
• Atrophic vaginitis
• Pharmacologic, psychological
• Endocrine
• Restricted mobility
• Stool impaction
History:
• ID:
• HPI: OPQRST - increased abdominal pressure, fluid intake/voiding, fever, polydipsia,
flank pain
• PGyneHx:
• Pee: volume, aware, dysuria, urgency, hematuria, nocturia,
hesitancy, double voiding, pads/liners, skin irritation, impact
• Prolapse: bulge, mass in vagina, reduce prolapse to void/defecate
• Poop: freq/consistency of BM, constipation, blood, bulging into rectum,
flatal/fecal incontinence
• PObsHx:
• PMHx: CVA, dementia, cancer, DM, hypercalcemia, nephrolithiasis, depression,
chronic cough
• PSHx:
• All:
• Meds:
• FHx:
• SHx: smoking, caffeine, EtOH, mobility
• ROS: sensory/motor changes, constipation, menopause, atrophic vaginitis
Physical:
• appearance:
• vitals:
• H+N:
• CVS:
• resp:
• GI: masses
• GU: prolapse
• MSK: edema
• Neuro: mobility, look at back and limbs
Investigations:
• U/A for C&S, R&M
• Stress test - examine urethral meatus while pt coughs
• Cotton tip applicator test - insert Q-tip to urethrovesical junction, pt strains, normal
angle of change 30 degrees
• Urethrocystoscopy
• Cystometrogram - observe pressure changes in bladder during filling
• Uroflometry - record rates of urine flow
• Voiding cystourethrogram - observe bladder filling, mobility of bladder base,
anatomic changes while voiding
• U/S
• Methylene blue - observe vesicovaginal fistula
• PVR
Management:
• Stress incontinence: lifestyle changes, phsyio (kegels, vaginal cones), pessaries,
surgery
• Urge incontinence: lifestyle changes (stop caffeine/EtOH, fluid management,
prompted voiding), kegels, bladder training, medications (anticholinergics, TCAs,
local estrogen)
• Overflow incontinence: double voiding, pessaries, self-catheterization, avoid irritants
Menopause
Definintion:
• permanent cessation of menses >12mos without any pathologic or physiologic
cause
• Mean: 51 years
• Premature: >2sd (approx 40yrs)
History:
• ID:
• HPI: fatigue, hot flushes, night sweats, poor concentration, ?sleep deprivation,
insomnia, irritability, anxiety, depression
• PGyneHx: LMP, Menses (Regularity, cycle), Duration, Intermenstrual bleeding, pain
with intercourse, Fibroids, Last Pap
• PObsHx:
• PMHx: OA, GB disease, migraine, bleeding disorders, HTN, DM, dyslipidemia, CAD/
CVA/A/TIA
• PSHx: hysterectomy, D&C, endometrial biopsy
• All:
• Meds:
• FHx:
• SHx:
• ROS:
• H&N: Headaches, lightheadedness
• CVS: palpitations
• GU: UTI, urgency, frequency (trigone estrogen dependent), vaginal dryness,
dyspareunia, pruritis, D/C, increased infections, decreased libido
• Skin: dryness, hirsuitism, formication
Physical:
• appearance:
• vitals:
• H+N:
• CVS:
• resp:
• GI:
• GU:
• MSK:
• Neuro:
Investigations:
• FSH high, LH mod increased, estradiol low
Management:
• Perimenopause:
• Normal FSH - low dose OCP
• High FSH - HRT
• HRT: indicated for significant Sx
• Systemic versus local
• if patient has a uterus use progestin
• Methods - sequential (daily estrogen, progestin 10-14d, menses),
continuous (no menses)
• Risks - VTE, endometrial hyperplasia, breast ca, GB disease, CVD
• Benefits - decreased osteoporosis, decreased colon ca
• Alternative - black cohosh, don quai, soy
IUGR
def'n - infant wt < 10th percentile for particular GA (not assoc w/ any constitutional or
familial cause)
Etiology/Risk Factors:
• maternal
• lifestyle --> malnutrition, smoking, drug abuse, alcoholism
• systemic
• cyanotic heart disease, pulmonary insufficiency
• DM type I, SLE
• chronic HTN, chronic renal disease
• prev IUGR
• maternal-fetal
• any disease causing placental insufficiency
• PIH, chronic HTN, chronic renal insufficiency, gross placental morphological
abN (infarction, hemangiomas)
• fetal
• TORCH infections
• multiple gestation
• congenital anomalies
Clinical Features:
symmetric (type I) - 20% asymmetric (type II) - 80%
occurs early in pregnancy occurs late in pregnancy
inadequate growth of head and brain sparing - head : abdo ratio
body INCREASED
head : abdo ratio may be usually assoc w/ placental
NORMAL insufficiency
usually assoc w/ congenital more favorable prognosis than
anomalies or TORCH infections type I
Complications:
• prone to meconium aspiration, asphyxia, polycythemia,
• hypoglycemia, temp instability, mental retardation
• greater risk perinatal morbidity + mortality
Investigations:
• SFH at every antepartum visit
• if mother at high risk or SFH lags > 2cm behind GA:
• BPP --> US should incl assessment of BPD, head + abdo circumference,
femur length, fetal weight, amniotic fluid vol (decreased assoc w/ IUGR)
• Doppler analysis of umbilical cord blood flow prn
Management:
• prevention --> risk modificiation prior to pregnancy (ideal)
• modify controllable risk factors --> smoking, EtOH, nutrition, maternal illness
• confrim dates + assess parents' size
• bed rest in LLDP
• serial BPP (weekly or biweekly) to monitor fetal growth and det cause of IUGR (if
possible)
• delivery when extra-uterine existence less dangerous than continued intra-uterine
existence
• delivery if GA > 34 wks w/ significant oligo
• liberal use of C/S since IUGR fetus tolerates labour poorly (b/c of poor placenta)
Oligohydramnios
def'n - amniotic fluid index of 5cm (2in) or less (< 5th percentile)
AFI determined by sum of vertical diameter of fluid pockets in 4 quadrants on US
sign of CHRONIC placental insufficiency
Etiology:
• early onset oligo (T1/2)
• decreased prod'n --> renal agenesis/dysplasia, urinary obstruction, PUV
(males), poor placental perfusion
• increased loss --> prolonged amniotic fluid leak (most often labour ensues)
• PHx of early oligo
• late onset oligo (T3)
• amniotic fluid normally decreases after 35 wks
• common in post-term pregnancies
• PHx late oligo
• PROM
Clinical Features:
• cord compression, mec aspiration
• early onset
• fetal anomalies --> 15 - 25%
• amniotic fluid bands (T1) --> Potter's facies, limb deformities, abdo wall
defects
• late onset
• pulm hypoplasia
• marker for infants who may not tolerate labour well
Dx:
• US
Investigations:
• ALWAYS warrants admission and investigation
• r/o ROM --> Hx, amniostick, pH, nitrazine paper, ferning on microscopy
• fetal monitoring --> NST, CTG, BPP
Management:
• consider delivery if at term
Macrosomia
def'n - infant weight > 90th percentile for particular GA, or > 4,000 gm
Etiology/Risk Factors:
• maternal obesity, DM/gestational DM
• PHx of macrosomic infant
• prolonged gestation, multiparity
Clinical Features:
• increased risk perinatal mortality
• CPD (cephalopelvic disproportion) + birth injuries more common --> shoulder
dystocia, fetal bone fracture
• complications of DM in labour --> neonatal hypoglycemia, preterm labour, increased
incidence of stillbirth
Investigations:
• serial SFH
• further investigations if mother at high risk, or SFH > 2cm ahead of GA
• US predictors:
• polyhydramnios
• 3rd trimester abdo circumference > 1.5cm/wk
• head circumference --> HC/AC ratio < 10th percentile
• femur length --> FL/AC ratio < 20th percentile
Management:
• Rx underlying causes --> minimize wt gain in obese, tight glycemic control, induce
at 41 - 42 wks GA, consider C/S if risk of CPD
• C/S often safer than vaginal delivery
Polyhydramnios
def'n - amniotic fluid vol (AFV) > 2,000mL at any stage in pregnancy (> 95th percentile,
</= 20 cm)
US criteria: > 8 x 8cm (3.1 x 3.1 in) pocket of amniotic fluid
Etiology:
• idiopathic (40% - most common)
• maternal causes
• DM type I --> causes abnormalities of transchorionic flow
• maternal-fetal
• chorioangiomas
• multiple gestation
• fetal hydrops --> increased erythroblastosis
• fetal causes:
• chromosomal anomaly --> up to 2/3 of fetuses w/ severe polyhydramnios
• resp --> cystic adenomatoid malformed lung
• CNS --> anencephaly, hydrocephalus, meningocele
• GI --> TEF, duodenal atresia, facial clefts/neck masses (malformations that
interfere w/ swallowing)
Clinical Features:
• pressure symptoms from overdistended uterus --> dyspnea, edema,
hydronephrosis, GERD
• uterus large for dates, difficulty palpating fetal parts + hearing fetal heart tones
• acute onset assoc w/ multiple gestation
Complications:
• cord prolapse, placental abruption,
• malpresentation, preterm labour, uterine dysfxn,
• PPH
• increased perinatal mortality
Management:
• find underlying cause --> screen for maternal disease/infection (DM, Rh), fetal US
eval
• mild - mod cases --> no Rx
• severe cases --> hospitalize, consider therapeutic amniocentesis
Prematurity
Background:
History:
Physical:
• appearance:
• vitals:
• FHR:
• H+N:
• CVS:
• resp:
• GI: uterine tenderness (chorioamnionitis, placental abruption)
• GU:
• external: pooling of fluids (ROM), PVB (abruption, previa, bloody show)
• cervix: assess dilation, effacement, presenting part, station
• MSK:
• Neuro:
Investigations:
Management:
• bed rest
• IVF: 500ml D5W IV
• tocolytic medications
• beta-adrenergic agonists (Ritodrine or Terbutaline)
• contraindications to the use of tocolytic meds: advanced labor,
maternal cardiac disease, severe preeclampsia/eclampsia, severe
vaginal bleeding, maternal hyperthyroidism, uncontrolled diabetes
mellitus, non-reassuring fetal status, severe intrauterine growht
restriction, chorioamnionitis, fetal demise, lethal fetal anomaly
• side effects: N/V, HA, restlessness, agitation, fever
• complications: pulmonary edema, hypotension, cardiac failure,
cardiac arrhythmia, myocardial ischemia, hyperglycemia,
hypokalemia, hypocalcemia
• MgSO4
• side effects: hot flashes, headache, nausea, dizziness, nystagmus,
dryness of the mouth, lethargy, urticarial eruptions
• complications: pulmonary edema, hypocalcemia, hypotension, resp
depression/arrest, fetal and neonatal depression, cardiac
depression/arrest
• prostaglandin sytnthesis inhibitors (indomethacin, ketorolac, sulindac)
• side effects: N/V, heartburn
• complications: PPH, prolonged bleeding time, oligo, premature
closure of the ductus
• calcium antagonists (nifedipine)
• side effects: dizziness, flushing, nausea, HA
• complicaitons: hypotension, liver toxicity
• corticosteroids (betamethasone, dexamethasone)
• antibiotics (if GBS positive or unknown)
• maternal transport to appropriate facility
Birth Control
Background:
• absolute contraindications
• smoking over 35
• migrane with aura
• DVT/PE
• MI
• cancer: ovarian, breast, hepatic
• liver disease
• familial hyperlipidemia
• undiagnosied vaginal bleeding
• pregnancy
• relative contraindications:
• hypertension
• fibroids
• DM
• migrane
• Roman Catholic religion
History:
• ID:
• HPI: reason for starting BC, current method of BC
• PgyneHx:
• menses: LMP, PMP
• sexual:
• M/W/both, # of partners
• types
• coitarche
• contraception
• STIs/PID
• paps:
• procedures:
• PObsHx: currently pregnant, past pregnancies
• PMHx:
• migranes with aura strokes MI, angina DVT / PE
• breast/ovarian/hepatic cancer liver disease familal hyperlipidemia
• (hypertension)
• PSHx:
• All:
• Meds:
• antibiotics:
• rifampicin
• anti-convuslants:
• FHx:
• as per PMHx
• Shx
• smoking over 35yo
Physical:
• appearance:
• vitals: BP
• H+N:
• CVS:
• resp:
• GI:
• GU:
• MSK:
• Neuro:
Investigations:
• vitals
• BhCG
• liver enzymes: AST, ALT
• lipid panel
• pap, cervical cultures
Management:
Background:
• Risk Factors
• HPV 16,18 (high)
• HPV 6,11 (low)
• early coitarche
• multiple partners
• unprotected sex
• previous STDs
• high risk partners
• Signs/Symptoms
• early: discharge (clear->brown->red), post coital bleeding
• late: irregular spont bleeding, belvic & back pain, bowel & bladder Sx
• signs: red, raised, friable lesion, exophytic, fungating tumor
• Screening
• 1st pap @ 18yo or when 1st sexually active for baseline
• if has 3 N paps and no FR -> q3y
• if has 3 N paps and >/= 70 can stop
• if hyst for benign reasons can stop
• false +vc 5-10%, false -ve 10-40%
• not as sensitive for adenocarcinoma (5%) as for SCC (95%)
• work up and Rx for adeno different from below
Interpretation of Results:
• Pap Results
• atypia
• generic/infxn: repeat in 4mo
• HPV changes: colpo
• ASCUS or LGSIL
• repeat in 4mo
• negative: repeat in 4mo and swab
• positive: colpo
• ASCH or HGSIL or Invasion
• no visible lesion: colpo
• visible lesion: Bx
• Cancer
• colpo
• endometrial cells present
• endometrial Bx
• Colposcopy
• if lesion is well visualized and not in endocervical canal: Bx
• if lesion is poorly visuallized or extends into canal: Bx and ECC (endocerv
curretage)
• Biopsy Results
• if agrees with colpo/ECC: Rx
• if differs with colpo/ECC: cone Bx
• if reports microinvasion or higher: cone Bx
• ECC Results
• if abN: cone Bx
Managment:
def'n - loss of >500 mL of blood at time of vaginal delivery OR >1000 mL of blood w/ C/S
• early --> w/in fist 24 hrs
• late --> b/w 24 hrs + 6 wks after delivery
etiology (4T's)
1.) tone
• uterine atony
• most common cause of PPH, occurs w/in first 24 hrs
• avoid by giving oxytocin w/ delivery of anterior shoulder
• due to....
• labour --> prolonged, precipitous, induced, augmented
• uterus --> infection, over-distention
• placenta --> abruption, previa
• maternal factors --> grand multiparity, PIH
• halothane anesthesia
2.) tissue
• retained placenta
• retained blood clots in atonic uterus
• gestational trophoblastic neoplasia
3.) trauma
• laceration (vagina, cervix, uterus), episiotimy
• hematoma --> vaginal, vulvar, retroperitoneal
• uterine rupture, uterine inversion
4.) thrombin (coagulopathy
• usually identified before delivery (low plts increases risk)
• includes hemophilia, DIC, aspirin use, TIP, TTP, vWD (mos common)
Investigations
• assess degree of blood loss + shock clinically
• explore uterus + lower genital tract for evidence of tone, tissue or trauma
Management
• ABCs, cross+type 4 units pRBCs
• Rx depends on cause
• CBC, coag profile
• 2 large bore IVs + crystalloids
Surgical therapy
Medical therapy
(intractable PPH)
oxytocin 20 U/L NS
or RL continuous
D&C --> may cause
infusion,
Asherman's
plus may give 10U
syndrome w/
intramyometrial
vigorous scraping
(IMM)after placenta
delivery
Hemabate
laparotomy w/
(carboprost) 0.25mg
bilateral ligation of
IM/IMM q15min up to
uterine artery (may
max 2mg
be effective),
synthetic PGF-2
internal iliac artery
alpha analog,
(not proven), ovarian
contraindicated in
artery, or hypogastric
CV, pulm, renal,
artery
hepatic dysfxn
ergotamine
(methylergonavine hyst (last option) w/
maleate) 0.25mg IM/ angiographic
IMM q5min up to embolization if
1.25mg - can give as post-hyst bleeding
IV bolus of 0.125mg
(may exacerbate
HTN)
Retained Placenta
def'n - placenta undelivered after 30 min post-partum
etiology
• placenta separated but not delivered
• abN placenta implantation --> accreta (adherent to myometrium), increta (invasion
into myometrium), percreta (invasion through myometrium)
Risk Factors
• placenta previa
• prior C/S
• post-pregnancy curettage
• prior manual placental removal
• uterine infection
Investigations
• explore uterus, assess degree of blood loss
Management
• 2 large bore IVs, type + screen
• Brant maneuver --> firm traction on umbilical cord w/ one hand applying suprapubic
pressure to hold uterus in place
• oxytocin 10 IU in 20 mL NS into umbilical vein
• manual removal (if above fails), D&C if required
Uterine Inversion
def'n - uterine prolapse through cervix +/- vaginal introitus
Etiology
• iatrogenic --> xs cord traction w/ fundal placenta
• xs use of uterine tocolytics
• more common in grand multiparous --> lax uterine ligaments
Clinical features
• may cause profound vasovagal response --> vasodilation + hypovolemic shock
Management
• URGENT management, call anesthesia
• ABCs --> IV crystalloids
• use tocolytic drug (terbutaline) or nitro IV --> relax uterus + aid replacement
• replace uterus WITHOUT removing placenta
• remove placenta manually + withdraw slowly
• IV oxytocin infusion after uterus replaced
• re-explore uterus
• may require GA +/- laparotomy
Post-partum Pyrexia
def'n - fever > 38degC on any 2 of first 10 days post-partum
Etiology (B-5W)
1.) breast engorgement or mastitis (S. aureus)
2.) wind --> atelectasis, pneumonia
3.) water --> UTI
4.) wound --> C/S incision, episiotomy
5.) walking/veins --> pelvic thrombophlebitis (Dx of exclusion), DVT, IV site cellulitis
6.) womb --> endometritis --> spiking fever in 24 hrs (blood + genital cultures)
Investigations
• CBC/diff, lytes
• blood cultures
• urine for R&M, C&S
• CXR (if indicated)
• +/- venous dopplers, V/Q scan, spiral CT
Treatment
• empiric Rx for wound infections --> clinda + gent (amp + gent by OSCE pack notes)
• prophylaxis against post-C/S endometritis --> begin Abx immed after cord clamping
+ give only 1-3 doses
Amenorrhea
primary amenorrhea - no menses by age 14 in absence of secondary sex char OR no
menses by age 16 with secondary sex char
secondary amenorrhea - absense of menses > 6mo after documented menarche
Etiology:
1.) anatomical
• failure of end organs (enzyme defects, Turner syndrome)
• absence of end organs (uterine agenesis)
• outflow tract defects (septum, imperforate hymen, cervical stenosis, Asherman's
syndrome - intra-uterine adhesions)
2.) ovarian failure
• lack of germ cells (eg. menopause)
• inappropriate response to FSH
• exposure to radiation/chemo
3.) endo imbalances
• pregnancy
• hyper/hypothyroidism
• failure of hypo-pit-gonadal axis (Kallman's syndrome)
• hyperandrogenism (PCOS, ovarian/adrenal tumor, testosterone injections)
• Cushing's
4.) other
• androgen insensitivity synreome (AIS)
• drugs (metoclopramide, neuroleptics, danazol)
Hx:
• ID - age, GTPAL
• CC - amenorrhea
• HPI
• pubertal milestones
• menstrual Hx - ?age of menarche, cycles, duration, etc....
• if primary --> prolonged intense exercising, xs dieting, social issues,
psych issues
• ?sexually active --> r/o pregnancy
• Sx of estrogen def --> hot flushes, night sweats
• signs of ovulation --> moliminal Sx
• other Sx
• galactorrhea, recent wt gain, H/A, visual changes
• Sx of virilization
• use of contraception
• PObsHx/PGyneHx
• paps, STDs
• prev pregnancies --> ?Sheehan's syndrome
• PMHx
• prev radiation therapy
• prev chemotherapy
• FHx
• delayed/absent puberty
• SHx
• meds/allergies
Phys exam:
• General: Tanner staging, assess stature, hair distribution (androgen xs/insensitivity)
• HEENT:
• palpate thyroid --> enlarged, nodules
• CVS/pulm
• abdo:
• palpable masses, inguinal hernias
• GU:
• external genitalia, vagina --> atrophy, clitoromegaly, imperforate hymen,
vaginal septum, evidence of estrogenization of hymen, absence of vagina
• bimanual exam
• neuro:
• visual changes
Investigations:
• beta-hCG, hormones (FSH, LH, androgens + estradiol)
• TSH, prolactin, cortisol/ACTH (Cushing's)
• progesterone challenge --> assess estrogen status
• Provera 10 mg OD for 10 days
• any uterine bleed w/in 2-7 days after completion --> positive test,
withdrawal bleed (adequate estrogen)
• no bleeding --> hypoestrogenism, or xs androgens
• karyotype if indicated --> if premature ovarian failure
• US --> confirm anatomy, PCOS
Rx:
1.) hypothalamic dysfxn (low/N FSH, LH)
• if FSH/LH low --> consider CT/MRI of head
• stop meds, reduce stress, adequate nutrition, decrease xs exercise
• clomiphene citrate if pregnancy desired
• otherwise OCP to induce menstruation (withdrawal bleed)
2.) hyperprolactinemia
• bromocriptine if fertility desired, OCP if not
• surgery for macroadenoma (rarely)
• consider CT head --> document presence of pit micro/macroadenoma
3.) premature ovarian failure (high FSH, LH)
• Rx assoc autoimmune disorders --> thyroid, adrenal
• HRT or OCP to prevent manifestations of hypoestrogenic state
• karyotype
• removal of gonadal tissue if Y chromosome present (at 18yrs or earlier if dysgenic
gonads)
4.) PCOS
• cycle control
• lifestyle modification to decrease peripheral estrone formation --> decrease
BMI, exercise
• OCP or cyclic Provera --> prevent endometrial hyperplasia (unopposed
estrogen)
• oral hypoglycemia (metformin, rosiglitazone, pioglitazone)
• infertility
• ovulation induction --> clomid
• bromocriptine if high prolactin
• hirsutism
• OCP
Pelvic Mass
Differential:
• Gyne
• Ovary
• functional ovarian cyst, neoplasm (epithelial, germ cell, stromal,
metastatic, tubo-ovarian abscess, endometrioma, ovarian
pregnancy)
• Fallopian tube
• tubal pregnancy, tubal cyst, abcess, tubal carcinoma
• Uterus
• pregnancy, fibroids, uterine ca, polyps, gestational pregnancy,
endometrioma, adenomyoma, sarcoma, anomaly
• Cervix
• polyp, fibroid, cancer, hematoma, ectopic
• Non-Gyne
• GI
• appendix: appendicitis, abscess, neoplasm
• colon: inflammatory bowel disease, diverticulum/abscess,
carcinoma, mesenteric cyst, meckel's, other ca, constipation
• Urologic
• bladder/urethra: diverticulum, neoplasm, endometriosis, bladder
distension
• kidney: pelvic kidney, neoplasm, anomaly, abscess
• Other
• MSK, neuro, endocrine, lymphoma, metastatic ca
History:
• ID:
• HPI:
• OPQRST (esp timing with menses)
• bowel: diarrhea, constipation, dyschezia, BRBPR, melenia, N/V, anorexia
• bladder: incontinence, blood per urethra
• vagina: bleeding, discharge, intermenstrual bleeds, dysparunia, infertility
• constitutional S/S: fever, wt loss
• current Gyne Hx:
• menses:
• sexual: STDs, PID, contraception
• paps/procedures:
• PGyneHx:
• PObsHx:
• PMHx:
• PSHx:
• All:
• Meds:
• FHx: ca (breast, ovarian, colon, endometrial), fibroids
• SHx:
Physical:
• appearance:
• vitals:
• FHR:
• H+N:
• CVS:
• resp:
• GI:
• GU:
• MSK:
• Neuro:
Investigations:
• bloodwork:
• CBC/d, +/- type and screen
• B-hCG, AFP, CA-125
• urine:
• urinalysis
• cervical:
• pap
• swabs
• imaging:
• vaginal or pelvic U/S
• CT, MRI
• barium enema
• IVP
Pelvic Pain
Differential:
• Acute
• Gyne
• PID
• torsion (ovarian, fibroid)
• rupture (ectopic, ovarian cyst)
• vaginismus
• Non-Gyne
• piriformis spasm/levator spasm
• appendicitis
• kidney stones
• diverticulitis
• UTI
• perforation
• Chronic
• Gyne
• Menses-related
• Dysmennorhea
• Mittleschmurtz
• PMS
• Endometriosis
• Adenomyosis
• Non-menses related
• Fibroids
• Neoplastic
• Benign cysts
• Non-Gyne
• adhesions
• IBD
• IBS
• Psychogenic
• Neoplastic
History:
• ID:
• HPI:
• OPQRST (esp timing with menses)
• bowel: diarrhea, constipation, dyschezia, BRBPR, melenia, N/V, anorexia
• bladder: incontinence, blood per urethra
• vagina: bleeding, discharge, intermenstrual bleeds, dysparunia, infertility
• constitutional S/S: fever, wt loss
• current Gyne Hx:
• menses:
• sexual: STDs, PID, contraception
• paps/procedures:
• PGyneHx:
• PObsHx:
• PMHx:
• PSHx:
• All:
• Meds:
• FHx: ca (breast, ovarian, colon, endometrial), fibroids
• SHx:
Physical:
• appearance:
• vitals:
• FHR:
• H+N:
• CVS:
• resp:
• GI:
• GU:
• MSK:
• Neuro:
Investigations:
• bloodwork:
• CBC/d, +/- type and screen
• B-hCG, AFP, CA-125
• urine:
• urinalysis
• cervical:
• pap
• swabs
• imaging:
• vaginal or pelvic U/S
• CT, MRI
• barium enema
• IVP
Chlamydia
• most common bacterial STI in Canada; often assoc w/ N. gonorrheae
• screen high risk groups and during pregnancy
Risk Factors:
1.) sexually active youth < 25 yrs old
2.) Hx prev STI
3.) new partner in last 3 mo
4.) multiple partners
5.) not using barrier contraception
6.) contact w/ infected person
Clinical Features:
• asymptomatic (70%)
• muco-purulent endocervical d/c
• urethral syndrome --> dysuria, freq, pyuria, NO BACTERIA
• pelvic pain
• post-coital bleeding or intramenstrual bleeding (esp if on OCP)
Complications:
• actue salpingitis, PID, chronic pelvic pain
• infertility --> tubal obstruction from low grade salpingitis
• perinatal infection --> conjunctivitis, pneumonia
• ectopics
• Fitz-Hugh-Curtis syndrome (liver capsule infection)
• Reiter's syndrome --> arthritis, conjunctivitis, urethritis
• test of cure for chlamydia req in pregnancy --> cure rates lower in pregnant pop'n
(retest in 3-4 wks post-initiation of Rx)
Gonorrhea
• symptoms + RF same as w/ Chlamydia
• Neisseria gonorrheae
Clinical Features:
• latent infection
• NO visible lesions --> detected by DNA hybridization tests
• asymptomatic
• subclinical infection
• visible lesion ONLY after 5% acetic acid applied + magnified OR found on
pap test
• clinical infection
• visible wart-like lesion w/o magnification
• hyperkeratotic, verrucous or flat, macular lesions
• vulvar edema
• lesions tend to get larger during pregnancy --> C/S if birth canal obstruction
Clinical Features:
• may be asymptomatic
• initial Sx present 2 - 21 days after contact
• prodromal Sx --> tingling, burning, pruritus
• multiple, painful, shallow ulcerations w/ small vesicles --> INFECTIOUS lesions
• appear 7 - 10 days after initial infection
• inguinal lymphadenipathy, malaise, fever --> often w/ first infection
• dysuria, urinary retention if urethral mucosa affected
Syphilis
• Treponema pallidum
• screen high risk groups, and in pregnancy
• 1/3 experience late complications if untreated
Classifications:
• Primary syphilis --> 3 - 4 wks after exposure
• PAINLESS chancre on vulva, vagina, cervix
• painless inguinal lymphadenopathy
• serological tests usually NEG
• Secondary syphilis (can resolve spont) --> 2 - 6 months after initial infection
• nonspecific Sx --> malaise, anorexia, H/A, diffuse lymphadenopathy
• generalized maculopapular rash --> palms, soles, trunk, limbs
• conylomata lata --> anogenital, broad-based fleshy grey lesions
• serological tests usually POS
• Tertiary syphilis
• may involve ANY organ system
• neuro --> tabes dorsalis, general paresis
• CV --> aortic aneurysm, dilated aortic root
• gumma of vulva --> rare, nodule that enlarges, ulcerates, becomes necrotic
• congenital syphilis
• may cause fetal anomalies, stillbirths, neonatal deaths
• latent syphilis
• NO clinical manifestations, detected by serology only
History:
ID: age, GTPAL
HPI:
• discharge (amt, color, odor, consistency, duration ,freq, relationship to menses,
sexual activity, contraception)
• pain - OPQRST
• urethral Sx --> dysuria, hematuria, freq
• bleeding - IMB, PCB, quantify and characterize
• contraception - type used, use EVERY time?
• sexual activity - last episode, type of activity, STI protection
• partner - how long, his/her past sexual Hx + RF
• ?genital lesions
• other S/S --> rashes, burning/pruritus, conjunctivitis, arthritis, non-specific Sx
• LNMP - ?risk/suspicion of ectopic
PGyneHx:
• prev STIs
• partner - men or women or both
• age of first sexual activity, new/multiple partners
• menses - duration, freq, dysmenorrhea, menorrhagia
• dyspareunia
• paps - freq, any abN
PObsHx:
PMHx/PSurgHx:
FHx:
SHx: smoking, EtOH, recreational drugs, occupation
Allergies:
Meds: prev STD Rx, OCP
Phys Exam:
General appearance:
HEENT: throat lesions, conjunctivitis, LN
CVS/pulm: ?signs of tertiary syphilis
abdo: tenderness, inguinal LN
GU:
• external exam - visible lesions, erythema, edema, obvious d/c or bleeding
• speculum exam - d/c, bleeding
• bimanual exam
derm: rashes
MSK: joint inflamm (Reiter's)
Investigations:
• cervical culture - chlamydia, gonorrhea
• rectal + throat culture - gonorrhea
• gram stain - GN intracellular diplococci (gonorrhea)
• PCR - chlamydia, ?HPV (in U.S.), HSV
• cytology (pap smear)
• HPV - koilocytosis (nuclear enlargement + atypia w/ perinuclear halo
• HSV - multinucleated giant cells, acidophilic intranuclear inclusion bodies
• Bx of visible + acetowhite lesions at colposcopy - HPV
• viral culture for HSV if ulcer present
• syphilis investigations
• aspirate of ulcer serum or node
• darkfield microscopy --> most sens + specific for syphilis (spirochetes)
• VDRL, RPR - non-treponemal screening tests, non-reactive after Rx
• FTA-ABS - specific anti-treponemal antibody tests
Management:
• chlamydia
• doxy 100mg po BID x 7days, or azithro 1g po x 1 dose (may use in
pregnancy)
• treat partners!!
• REPORTABLE disease
• gonorrhea
• ceftriaxone 125mg IM x 1 dose, cefixime 400 mg po x 1 dose, or cipro 500
mg po
• use cephalosporin in pregnant (avoid quinolones), or 2g
spectinomycin IM
• PLUS doxy or azithro --> Rx concomitant chlamydial infection
• treat partners!!
• REPORTABLE disease
• condylomata acuminata (HPV)
• patient applied
• podofilox 0.5% sol'n or gel BID x 3days, then 4 days off, then
repeat x 4 wks
• imiquimod (Aldara) 5% cream 3x/wk qhs x 16 wks
• given by provider
• cryotherapy w/ liq nitrogen q1-2 wks
• podophyllin resin in tincture of benzoin - weekly (contraindicated in
pregnancy)
• TCA or bichloroacetic acid weekly - safe in pregnancy
• surgical removal/laser
• intralesional IFN
• imiquimod, podophyllin, podfilox --> do NOT use in pregnancy
• HSV
• 1st episode --> acyclovir 400mg po TID x 7-10 days, or famciclovir 250mg
TID, valacyclovir 1g BID
• recurrent episode --> acyclovir 400 mg po TID x 5 days, or famciclovir
120mg BID, valacyclovir 500mg BID x 3-5days
• daily suppressive Rx --> consider if 6-8 attacks/yr
• acyclovir 400mg po BID, famciclovir 250mg BID, valacyclovir 500mg
• severe disease --> acyclovir 5-10mg/kg IV q8h x 5-7days
• eduate re: transmission
• avoid contact from prodrome until lesions cleared
• BARRIER contraception
• syphilis
• Rx primary, secondary, latent syphilis of <1 yr duration
• PenG 2.4 mill units IM
• treat partners!!
• REPORTABLE disease
• Rx latent syphilis > 1 yr duration
• PenG 2.4 mill units IM q week x 3 wks
• Rx neurosyphilis
• IV aqueous penicillin
Vaginal Discharge
Hx:
1.) ID - name, age
2.) CC - vaginal d/c
3.) HPI - characterize d/c
• color, consistency, odor, quantity, duration, freq
• relationship to menses, sexual activity, contraception
4.) Assoc Sx
• pain, dysmenorrhea, dyspareunia
• bleeding --> duration, freq, quantity, #pads/clots, relation to menses/sex
• pruritus
• urinary Sx --> dysuria, hematuria, urgency, frequency
• fever, chills, rigors, fatigue
• sores, rash, swelling, warts
5.) PObsHx
• GTPAL, etc....
6.) PGyneHx
• LMP, cycle length, cycle regularity
• BCPs, STDs
• pap smear - date, result
• abortions, ectopics
• surgery
• douching, foreign body
• infertility
7.) Sexual Hx
• sexually active?
• age of 1st sexual activity?
• # of partners in lifetime, M/F/both?
• oral, vaginal, anal intercourse
• types of protection used, consistency of protection use
• PHx of STD + Rx
• partners w/ STD
• trauma/pain during sex
• travel Hx, sexual contacts while travelling
• pregnant?
8.) PMHx (incl HIV, immunosuppression), PSurgHx, SHx, FHx
9.) Meds/allergies --> BCP, HRT
Phys exam
1.) speculum exam --> look for discharge, cervical friability, yeast, cervical lesions, foreign
bodies
2.) vulvar inspection --> atrophy, irritation
3.) bimanual exam --> masses
Investigations
1.) swab for gonorrhea/chlamydia
2.) swab for vaginosis/trich
3.) wet mount for trich/vaginosis
DDx
1.) physiologic
• neonate period --> greyish sticky d/c w/ possible blood due to maternal estrogens
• 6 - 12 mo prior menarche --> thin whitis d/c
• mid-cycle discharge --> high estrogen states --> pregnancy + OCP use
2.) neoplastic --> VAIN, vaginal squamous cell, cervical CA, fallopian CA
3.) infectious
• cervicitis --> gonorrhea, chlamydia
• vulvovaginitis --> BV, Candida, Trichomonas, polymicrobial
• pyosalpinx, salpingitis
Bacterial Vaginosis
1.) Dx
• fishy odour
• grey-white thin, sticky, homogenous d/c
• POS whiff test
• clue cells on gram stain, lack of WBC + lactobacilli
• pH > 5
2.) Rx
• Flagyl 500 mg po BID X 7 days or 2g single dose
Candida
1.) Risk factors
• Abx
• diabetes
• HIV
• high estrogen states
• vaginal contraceptives
• stress
2.) Dx
• white, cottage cheese d/c
• pruritus (+ excoriations)
• vulvar burning w/ intercourse
• local edema + hyperemia
• NEG whiff test
• hyphae + buds on KOH slide
• pH < 5
3.) Rx
• miconazole (monostat) X 10 - 14 days OR clotrimazole (canestan) X 1 - 7 days OR
fluconazole 150 mg po single dose
• terconazole for resistant Candida
Trichomonas
1.) Dx
• frothy grey-white to yellow-green copious d/c, pooling of d/c
• pruritus (occasional), dysuria, dyspareunia
• local edema + erythema, strawberry cervix or vagina
• POS whiff test
• trichomonads on wet mount --> MOTILE
• pH > 5
2.) Rx
• flagyl 2gm single dose + Rx sexual partners
• wait until after 1st trimester if pregnant
Chlamydia
1.) Dx
• mucopurulent d/c
• hypertrophic cervical inflamm
• do culture
2.) Rx
• azithro, doxy
Gonorrhea
1.) Dx
• may be asymptomatic
• urinary grequency, dysuria
2.) Rx
• cipro