2 Flashcards
What is the pathophysiology of thromboembolism?
Mediating factor is endothelial injury from traumatic delivery or cesarean. Postpartum risk is increased fivefold. Coagulability is increased in pregnancy. Risk is more elevated in coagulation protein deficiencies.
What are the clinical signs of superficial thrombophlebitis?
Symptoms include localized pain and sensitivity. Signs include erythema, tenderness, and swelling. Diagnosis is one of exclusion after ruling out DVT. Treatment is conservative: bed rest, local heat, NSAIDs.
What is the usual location of deep venous thrombosis?
The site of thrombosis is typically in the lower half of the body. Half of cases occur in the pelvic veins and half occur in the lower extremities.
What are the clinical signs of deep venous thrombosis?
Pain, skin sensitivity, or asymptomatic; calf pain on dorsiflexion (Homan), although these findings are not highly sensitive or specific. Diagnosis is by duplex Doppler (above knee) or venography (below knee).
What is the management of deep venous thrombosis?
Anticoagulation with IV heparin to increase PTT to 1.5–2.5. SQ heparin is used once therapeutic levels are achieved. Warfarin contraindiated because of teratogenicity. Thrombophilia workup should be performed.
What is pulmonary embolus?
This is a potentially fatal result of DVT in which emboli travel through the venous system to the lungs. The source of the emboli is most commonly in the lower extremities or pelvis.
What are the clinical signs of pulmonary embolus?
Chest pain and dyspnea (80%), tachypnea (90%), chest x–ray often normal; low pO2, ECG may show tachycardia, right axis deviation (usually normal). Spiral CT is the best initial test. Pulmonary angiography is most definitive diagnostic method.
What is the management of pulmonary embolus?
Treatment is full anticoagulation (IV, SQ) heparin to increase PTT by 1.5 to 2.5 times the control value. No warfarin is used antepartum due to teratogenic concerns. Thrombophilia workup should be performed.
What is intrauterine growth restriction?
Fetus with estimated fetal weight (EFW)
What are the fetal causes of intrauterine growth restriction?
Trisomies; infection (TORCH), congenital heart disease, neural tube defects, ventral wall defects. These causes typically lead to symmetric IUGR.
What are the placental causes of intrauterine growth restriction?
Infarction, abruption, twin–twin transfusion syndrome, velamentous cord insertion. Placental causes lead to asymmetric IUGR.
What are the maternal causes of intrauterine growth restriction?
Hypertension (e.g., chronic, preeclampsia), SLE, long–standing type 1 diabetes), malnutrition, tobacco, alcohol, street drugs. These causes typically lead to asymmetric IUGR.
What is symmetrical IUGR?
All ultrasound parameters (HC, BPD, AC, FL) are smaller than expected. Etiology is decreased growth potential, i.e., aneuploidy, early intrauterine infection, gross anatomic anomaly. Workup: sonogram, karyotype, and screen for fetal infections.
What is asymmetrical IUGR?
Ultrasound parameters show head sparing, but abdomen is small. Causes include decreased placental perfusion due to chronic maternal diseases (HTN, diabetes, SLE, cardiovascular disease) or abnormal placentation (circumvallate, infarction). AFI decreased.
What is the antepartum fetal monitoring for intrauterine growth restriction?
Monitoring is with serial sonograms, non–stress test, amniotic fluid index, biophysical profile, and umbilical artery Dopplers.
What is macrosomia?
Fetus with estimated fetal weight (EFW) >90–95th percentile for gestational age.
Birth weight
Accuracy of ultrasound in estimating birth weight is poor. Errors in prediction of EFW at term are ±400 grams.
What are the risk factors for ?
Gestational diabetes mellitus, overt diabetes, prolonged gestation, obesity, excessive pregnancy weight gain, multiparity, male fetus.
What are the maternal hazards of macrosomia?
Operative vaginal delivery, perineal lacerations, postpartum hemorrhage (uterine atony), emergency cesarean section, pelvic floor injury.
What are the fetal hazards of macrosomia?
Shoulder dystocia, birth injury, asphyxia. Neonatal hazards are neonatal intensive care admission, hypoglycemia, Erb palsy.
What is the management of macrosomia?
Consider elective cesarean (if EFW >4,500 g in diabetic mother or >5,000 g in nondiabetic mother) or early induction.
What are the most common indications for antepartum fetal testing?
Decreased fetal movements, diabetes, post dates, chronic hypertension, and IUGR.
What is the non–stress test?
Assesses frequency of accelerations, which are abrupt increases in FHR above baseline lasting 10 bpm, lasting >10 s; after 30 wks, increase should be >15 bpm, >15 s.
What is the cause of fetal heart rate accelerations?
Mediated by the sympathetic nervous system and always occur in response to fetal movements. Interpretation: Accelerations are always reassuring.
What is the criteria for a reactive non–stress test?
Presence of two accelerations in a 20–min window of time >15 beats/min and lasting >15 sec. This is reassuring and highly predictive for fetal well–being. Management is to repeat the NST weekly.
What is the criteria for a nonreactive nonstress test?
What is the management of nonreactive nonstress test?
Perform fetal vibroacoustic stimulation to provoke reactivity. If the NST is persistently nonreactive, then perform a biophysical profile.
What is the amniotic fluid index?
Assesses the deepest vertical amniotic fluid pocket in each of the four quadrants of the uterus. The sum of the pockets is the amniotic fluid index. 25 cm is polyhydramnios
What is the biophysical profile?
BPP measures five components of fetal well–being: NST, amniotic fluid volume, fetal gross body movements, fetal extremity tone, and fetal breathing movements. Scores given for each component are 0 or 2, with max score of 10 and min of 0.
What is a modified biophysical profile?
A modified BPP includes only the NST and amniotic fluid volume. Its predictive value is almost as high as a complete BPP.
What is a contraction stress test?
Assesses fetal tolerance to contractions. Based on presence of late decelerations, which are gradual decreases with onset–to–nadir time of >30 s. Deceleration onset and end is delayed in relation to contractions. Rarely performed.
What is a negative contraction stress test?
Absence of any late decelerations with contractions. This is reassuring and highly reassuring for fetal well–being. Management is to repeat the CST weekly.
What is a positive contraction stress test?
Late decelerations associated with 50% of contractions. 50% of positive CSTs are false positive and are associated with good FHR variability. 50% of true positives have absent variability. Management of positive CST is delivery.
What are the contraindications for contraction stress testing?
Conditions in which contractions would be hazardous to the mother or fetus, such as previous classical uterine incision, previous myomectomy, placenta previa, incompetent cervix, preterm membrane rupture, preterm labor.
What is the umbilical artery Doppler test?
Measures ratio of systolic and diastolic blood flow in umbilical artery. This test is predictive of poor perinatal outcome only in IUGR fetuses. Nonreassuring findings are absent diastolic flow and reversed diastolic flow.
What are the bones that comprise the pelvis?
The pelvis is constructed of four bones: ileum superior–laterally, ischium inferior–laterally, pubis anteriorly, and the sacrum and coccyx posteriorly.
What is labor?
Process whereby regular uterine contractions cause progressive effacement and dilation of the cervix, resulting in delivery of the fetus and expulsion of the placenta. Contractions normally occur at least every 5 min and last 30 s.
What is the normal physiologic mechanism that causes the frequency of contractions?
Increased contractions are caused by formation of gap junctions between uterine myometrial cells, which is caused by increasing levels of oxytocin and prostaglandins and multiplication of specific receptors.
What is cervical effacement?
Cervical softening and thinning occur as increasing levels of oxytocin and prostaglandins lead to breakage of disulfide linkages of collagen fibers, resulting in increasing water content. Uneffaced (0%) cervix is 2 cm long, 2 cm wide.
What is complete cervical dilation?
In early labor (latent phase), the rate of dilation is slow, but at 3–4 cm of dilation, the rate accelerates to a maximum rate in the active phase of labor. Complete dilation is 10 cm.
What are the cardinal movements of labor?
Engagement of presenting part below pelvic inlet. Descent presenting part down. Flexion of chin. Internal rotation of head from transverse to anterior–posterior. Extension of chin. External rotation of head. Expulsion of body.
What is stage one labor?
Begins with onset of regular uterine contractions and ends with complete cervical dilation at 10 cm. It is divided into a latent and an active phase.
What is the latent phase of stage one labor?
Begins with onset of regular contractions and ends with acceleration of cervical dilation at 3–4 cm of dilation. Average duration of the latent phase is 6.4 hours in a primipara and 4.8 hours in a multipara.
What is the active phase of stage one labor?
Begins at 3–4 cm of dilation, ending with complete cervical dilation. Cervical dilation is rapid. The cardinal movements of labor occur, with beginning descent of the fetus. Rate of dilation is 1.2 cm/h in a primipara and 1.5 cm/h in multipara.
What is stage two labor?
Begins with complete cervical dilation and ends with delivery of the fetus. Descent of the fetus through the birth canal occurs as maternal pushing efforts augment uterine contractions. Duration up to 2 h in a primipara and 1 h in multipara.
What is stage three labor?
Begins with delivery of fetus and ends with placental expulsion. Placental separation occurs as contractions shear off villi; augmented with oxytocin. Gush of blood, uterus changes to globular, lengthening cord. Duration up to 30 min.
What is stage four labor?
2–h period of close observation of the parturient immediately after delivery when vital signs and vaginal bleeding are monitored for onset of preeclampsia and postpartum hemorrhage.
What are the causes of prolonged latent phase?
Latent–phase abnormalities are most commonly caused by excessive analgesia. Other causes are hypotonic contractions or hypertonic contractions (high intensity but inadequate duration or frequency). Treatment: rest, sedation.
What is prolonged active phase of labor?
After cervical dilation is >2 cm, prolongation is diagnosed if cervical dilation is 2h.
What are the causes of prolonged active phase of labor?
Active–phase abnormalities may be caused by abnormalities of the passenger (excessive fetal size or abnormal fetal orientation in the uterus), abnormalities of the pelvis (bony pelvis size), or abnormalities of powers (inadequate contractions).
What is the management of prolonged or arrested active phase of labor?
Contractions should occur q2–3min, last 45–60 s with 50 mm Hg intensity. If contractions are hypotonic, administer oxytocin. If contractions hypertonic, give morphine. If labor is arrested despite adequate contractions, proceed to cesarean.
What is prolonged second stage of labor?
Cervical dilation at 10 cm, +1 station and failure to deliver the baby in 2 hours (primipara) or 1 hour (multipara). With epidural analgesia, add additional 1 hour.
What is the management of prolonged second stage of labor?
IV oxytocin. If the head is not engaged, proceed to cesarean section. If the head is engaged, consider a trial of either obstetric forceps or a vacuum extraction.
What is prolonged third stage of labor?
Failure to deliver the placenta within 30 minutes because of inadequate uterine contractions or abnormal placental implantation (accreta, increta, percreta). May require manual placental removal.
What are the types of prolapsed umbilical cord?
Prolapse can be occult (cord has not come through cervix but is being compressed), partial (cord is between head and the dilated cervical os but has not protruded into vagina), or complete (cord has protruded into vagina).
What are the risk factors for prolapsed umbilical cord?
Rupture of membranes with the presenting fetal part not applied firmly to the cervix and malpresentation. Amniotomy at –2 station. Severe variable decelerations.
What is the management of prolapsed umbilical cord?
Place patient in knee–chest position, elevate the presenting part, avoid palpating the cord, and perform immediate cesarean delivery.
What is shoulder dystocia?
Delivery of shoulders is delayed after delivery of head. Usually associated with fetal shoulders in anterior–posterior plane, with anterior shoulder impacted behind pubic symphysis. 1% of deliveries; neonatal neurologic damage in 2%.
What are the risk factors for shoulder dystocia?
Maternal diabetes, obesity, and postdates pregnancy, fetal macrosomia.
What is the management of shoulder dystocia?
Suprapubic pressure, maternal thigh flexion (McRobert’s), internal rotation of the fetal shoulders to the oblique plane (Wood’s corkscrew), manual delivery of the posterior arm, Zavanelli (cephalic replacement, then cesarean).
What is a first degree perineal laceration?
Involve only the vaginal mucosa. Suture repair is often not needed.
What is a second degree perineal laceration?
Involve the vagina and the muscles of the perineal body, but not involving the anal sphincter. Suturing is necessary.
What is a third degree perineal laceration?
Involve the vagina, the perineal body, and the anal sphincter but not the rectal mucosa. Suturing is necessary to avoid anal incontinence. 4th degree lacerations extend the vagina through rectal mucosa.
What are the indications for an episiotomy?
Not done routinely because of more pain; longer return to sexual activity; more extensions into anus. Possible indications include shoulder dystocia, non–reassuring tracing, forceps/vacuum delivery, breech delivery, narrow canal.
What is an epidural block?
Injection of local anesthetic into the epidural space to block the lumbosacral nerve roots during both stages 1 and 2 of labor. Used for either vaginal delivery or cesarean.
What are the complications of epidural block?
Hypotension from peripheral vascular dilation because of sympathetic blockade, spinal headache from inadvertent dural puncture, and CNS bleeding or infection. Hypotension treated fluids, ephedrine. Spinal headache.
What is the treatment of spinal headache after epidural block?
Hydration and blood patch.
What is the normal fetal heart rate at term?
Normal values are between 110 and 160 beats/min.
What are the causes of fetal bradycardia?
FHR is
What is the fetal tachycardia?
FHR is >160 beats/min. Hypoxia. Beta–adrenergic agonists (terbutaline, ritodrine), fever, thyrotoxicosis. Fetal arrhythmia, prematurity. Unexplained tachycardia is nonreassuring.
What are fetal heart rate accelerations?
Abrupt increases in FHR lasting 10 beats/min lasting >10 s; >32 weeks the increase should be >15 beats/min lasting >15 s. Accelerations are reassuring.
What are early decelerations of fetal heart rate?
Gradual decreases in FHR beginning and ending simultaneously with contractions. Early decelerations are mediated by vagal stimulation and occur in response to fetal head compression. Early decelerations have no impact on outcome.
What are variable decelerations of fetal heart rate?
Abrupt decreases of at least 15 bpm with onset–to–nadir time of 60 bpm or >60 s.
What is the significance of mild to moderate variable decelerations?
Mild to moderate variables have no impact on clinical outcome. Severe variables are nonreassuring and may be associated with fetal acidosis.
What are late decelerations of fetal heart rate?
Gradual decreases in FHR below baseline with onset–to–nadir time of >30 s. Deceleration onset and end is delayed in relation to contractions. Myocardial depression in response to uteroplacental insufficiency. Lates are nonreassuring; acidosis.
What is the triad of early decelerations?
Gradual drop of FHR. Gradual return of FHR. Mirror image of contraction.
What is the criteria for a reassuring fetal heart rate tracing?
Baseline rate is between 110 and 160 beats/min. Accelerations are present. Decelerations are absent. Variability is present.
What is the criteria for nonreassuring fetal heart rate tracing?
Baseline rate shows tachycardia or bradycardia without explanation. Accelerations are absent. Repetitive variable decelerations are severe. Repetitive late decelerations. Variability is absent.
What are the steps in intrauterine resuscitation?
Stop oxytocin, give terbutaline 0.25 mg SQ. 500 mL NS to enhance uteroplacental perfusion. O2 mask. Amnioinfusion. Left–lateral. Turn to other side to relieve cord compression. Exam for prolapsed cord. Digital scalp stimulation to cause accelerations.
What is the indication for intrapartum fetal scalp blood pH?
Used in labor if the EFM strip is equivocal. Prerequisites include cervical dilation, ruptured membranes, and adequate descent of the fetal head. Contraindicated in fetal blood dyscrasia. Normal fetal pH is 7.20.
What is the normal postpartum umbilical artery blood pH?
Used to confirm fetal status at delivery and involves obtaining samples of umbilical cord venous and arterial blood. Arterial pH, Pco2, and HCO3 values are higher than venous, but Po2 is lower. Normal fetal pH is 7.20.
What are the indications for forceps delivery?
Prolonged second stage because of dysfunctional labor or suboptimal fetal head orientation. Nonreassuring strip. To avoid maternal pushing when pushing may be hazardous. Breech presentation.
What are the prerequisites for forceps delivery?
Clinically adequate pelvic dimensions. Full cervical dilation. Engaged fetal head. Orientation of fetal head is certain.
What is vacuum extraction?
Cuplike instrument that is held against the fetal head with suction. Traction is applied to the fetal scalp, which along with maternal pushing efforts, results in descent of the head, leading to vaginal delivery.
What are the advantages of vacuum extraction over forceps?
Precise knowledge of fetal head position and attitude is not essential. The vacuum extractor does not occupy space adjacent to the fetal head. Third– and fourth–degree lacerations are fewer. Fetal head rotation occurs spontaneously.
What are the indications for primary cesarean section?
Cephalopelvic disproportion is the most common indication for cesarean delivery. Failure of the adequate progress in labor. Fetal malpresentation. Nonreassuring EFM strip.
What is the criteria for vaginal birth after cesarean?
Successful vaginal delivery after cesarean occurs at a rate of 80%. Criteria for trial of labor include previous low segment transverse uterine incision and clinically adequate pelvis.
What is external cephalic version?
Manipulating the gravid abdomen to turn the fetus from transverse lie or breech presentation at 37 weeks’ gestation. and success rate is 60–70%. Potential hazards are umbilical cord compression or placental abruption requiring emergency cesarean.
What is postpartum lochia?
Superficial layers of endometrial decidua are shed through vagina during first 3 postpartum weeks. First few days red (lochia rubra), changing to pinkish (lochia serosa), ending with a whitish (lochia alba) by end of 2nd week.
What type of concentration is contraindicated in breast–feeding women?
Estrogen–progestin should not be used because estrogen will decrease milk. In nonlactating women, combination pills should be started after 3 weeks, after reversal of hypercoagulable state to decrease the risk of DVT.
What type of hormonal contraception can be used in breast–feeding women?
Progestin contraceptives (e.g., mini–pill, Depo–Provera, Implanon) do not diminish milk production so can safely be used during lactation. They can be started immediately after delivery.
What are the postpartum indications for RhoGAM?
If the mother is Rh(D) negative and her baby is Rh(D) positive, she should receive 300 µg of RhoGAM IM within 72 hours of delivery.
What is the postpartum treatment of rubella negative mothers?
If the mother is rubella IgG antibody negative, she should be administered active immunization with live–attenuated rubella virus. She should avoid pregnancy for 1 month to avoid potential fetal infection.
What is the most common cause of excessive postpartum bleeding?
Uterine Atony (50%). Retained placenta causes 10%.
What are the risk factors for uterine atony?
Rapid or protracted labor (most common), chorioamnionitis, MgSO4, beta–adrenergic agonists, and overdistended uterus.
What are the clinical findings of uterine atony?
A soft, doughy uterus (feels like dough) palpable above the umbilicus.
What is the management of uterine atony?
Uterine massage and uterotonic agents (e.g., oxytocin, methylergonovine, or carboprost). Lacerations of the cervix, vagina or perineum cause 20% of postpartum hemorrhage.
What are the risk factors for postpartum disseminated intravascular coagulation?
Abruptio placenta (most common), severe preeclampsia, amniotic fluid embolism, and prolonged retention of a dead fetus. Presents as generalized oozing or bleeding from IV sites or lacerations in presence of a contracted uterus.
What is the management of postpartum disseminated intravascular coagulation?
Removal of pregnancy tissues from the uterus, intensive care unit support, and selective blood–product replacement.
What is the management of uterine inversion?
Uterine replacement by elevating the vaginal fornices and lifting the uterus back into its normal anatomic position, followed by IV oxytocin.
What is the most common cause of postpartum fever on days 1–2?
Urinary tract infection. Risk factors include multiple intrapartum catheterizations and vaginal examinations due to prolonged labor.
What is the most common cause of postpartum fever on post partum day 2–3?
Endometritis is the most common cause of postpartum fever. Risk factors include emergency cesarean section prolonged labor. Prolonged membrane rupture and with uterine tenderness.
What is the most common cause of postpartum fever on post partum day 4–5?
Wound infection. Risk factors include emergency cesarean section after prolonged membrane rupture and prolonged labor. There is persistent spiking fever despite antibiotics, along with wound erythema, fluctuance, or drainage.
What is the most common cause of postpartum fever on day 5–6?
Thrombophlebitis. Risk factors include emergency cesarean section after prolonged membrane rupture and prolonged labor.
What are the clinical findings in septic thrombophlebitis?
Persistent wide fever swings despite broad–spectrum antibiotics with normal pelvic and physical examination. Management is intravenous heparin for 7–10 days to increase the PTT values at 1.5 to 2.0 times baseline.
What is the most common cause of postpartum fever on day 7–21?
Infectious mastitis. Risk factors include lactational nipple trauma leading to nipple cracking and allowing Staphylococcus aureus bacteria to enter breast ducts and lobes. Management is oral dicloxacillin. Breast feeding should be continued.
What is loop electrosurgical excision procedure?
LEEP is a technique used for diagnosing and treating cervical dysplasia. It uses an electric current passed through a thin wire loop to remove abnormal cervical tissues.
What are the American Cancer Society recommendations for mammography screening?
Initial study age 34 if there are risk factors (e.g., breast cancer in first–degree relative, family history of BRCA gene). Start annual routine screening at age 40 in women without risk factors.
What is the management of pelvic relaxation?
Kegels. Estrogen replacement in postmenopausal women. Pessaries inserted into vagina. Vaginal hysterectomy with an anterior and posterior vaginal repair. The anterior and posterior colporrhaphy uses endopelvic fascia plication.
What is sensory irritative incontinence?
Involuntary increases in bladder pressure because of detrusor contractions stimulated by irritation from infection, stone, tumor, or a foreign body. Loss of urine occurs with urgency, frequency, and dysuria day or night.
What is stress incontinence?
Most common form of urinary incontinence. Increases in bladder pressure because of intraabdominal pressure increases (coughing and sneezing). Loss of urine in small spurts with coughing or sneezing. Proximal urethra is not supported.
What are the signs of stress incontinence?
Pelvic examination may reveal a cystocele. Neurologic examination is normal. The Q–tip test is positive (cotton–tip applicator is placed in urethra and the patient increases intraabdominal pressure, Q–tip will rotate). Cystometric studies normal.
What is the management of stress incontinence?
Kegels. Estrogen in postmenopausal. Surgical therapy elevates the urethral sphincter by attachment of the sphincter to the symphysis pubis (Burch, MarshallMarchetti–Kranz). Tension–free vaginal tape procedure.
What is motor urge incontinence?
Involuntary increases in bladder pressure caused by idiopathic detrusor contractions that cannot be voluntarily suppressed. Loss of urine occurs in large amounts without warning day and night. The most common symptom is urgency.
What are the signs of urge incontinence?
Pelvic and neurologic examination are normal. Urinalysis and culture are normal. Cystometric studies show normal residual volume, but involuntary detrusor contractions are present even with small volumes of urine in the bladder.
What is the management of urge incontinence?
Anticholinergic medications (e.g., oxybutynin [Ditropan]); NSAIDs to inhibit detrusor contractions; tricyclic antidepressants; calcium–channel blockers.
What is overflow incontinence?
Increased bladder pressure, overdistended, hypotonic bladder, causing involuntary urine loss because of diabetic neuropathy, multiple sclerosis, ganglionic blockers, anticholinergics. Loss of urine occurs intermittently in small amounts, day and night.
What is the triad of stress incontinence?
Involuntary loss of urine with coughing and sneezing. No urine lost at night.
What is the triad of hypertonic bladder?
Involuntary loss of urine. Inability to suppress urge to void. Urine loss day and night.
What is the triad of hypotonic bladder?
Involuntary loss of urine. Detrusor muscle not contracted. Urine loss day and night.
What are the signs of overflow incontinence?
Neurologic examination will show decreased pudendal nerve sensation. Cystometric studies show markedly increased residual volume, but without involuntary detrusor contractions.
What is the management of overflow incontinence?
Intermittent self–catheterization. Discontinue anticholinergics. Cholinergic medications to stimulate bladder contractions and alpha–adrenergic blocker to relax the bladder neck.
What medications are used as bladder relaxants?
Antispasmodics: oxybutynin (Ditropan), flavoxate (Urispas). Anticholinergics: Probanthine. Tricyclics: imipramine (Tofranil).
What medications are used to increase vesical neck contraction?
Ephedrine, imipramine, estrogen.
What is the normal vaginal pH?
The vagina is normally acidic
What is the bacterial vaginosis?
Most common (50%) cause of vaginal complaints. Normal lactobacilli are replaced by anaerobes and facultative aerobes. Frequently postmenopausal; not sexually transmitted, but associated with sexual activity.
What are the symptoms of bacterial vaginosis?
The most common patient complaint is a fishy odor. Itching and burning are not present.
What are the speculum examination abnormalities in bacterial vaginosis?
Vaginal discharge is thin, grayish–white. No vaginal inflammation. The vaginal pH is >5.0. A positive whiff” test is elicited when KOH is placed on the discharge.”
What is the triad of bacterial vaginosis?
Vaginal discharge pH >4.5. Fishy odor. Clue” cells.”
What is the management of bacterial vaginosis?
Metronidazole or clindamycin orally or vaginally. Metronidazole is safe in pregnancy, including the first trimester.
What is the triad of Trichomonas vaginitis?
Vaginal discharge pH
What is the Trichomonas vaginitis?
Most common cause of vaginal complaints worldwide and the second most common sexually transmitted disease in the United States. Caused by a flagellated pear–shaped protozoan that can be asymptomatic in male semen.
What are the symptoms of Trichomonas vaginitis?
Itching, burning, and pain with intercourse.
What are the speculum examination abnormalities of Trichomonas vaginitis?
Vaginal discharge is frothy and green. Vaginal epithelium is edematous and inflamed. Erythematous cervix with strawberry” appearance. The vaginal pH is elevated >5.0.”
What are wet mount findings in Trichomonas vaginitis?
Motile trichomonads” on a saline preparation. WBCs are seen.”
What is the management of Trichomonas vaginitis?
Oral metronidazole for the patient and sexual partner. Vaginal metronidazole gel has a 50% failure rate. Metronidazole is safe in pregnancy, including the first trimester.
What is the Candida vaginitis?
Second most common vaginal complaint in the United States. The most common organism is Candida albicans. It is not transmitted sexually.
What are the risk factors for Candida vaginitis?
Diabetes mellitus, systemic antibiotics, pregnancy, obesity, and decreased immunity.
What are the symptoms of candida vaginitis?
Itching, burning, and pain with intercourse.
What are the speculum examination abnormalities in Candida vaginitis?
Vaginal discharge is curdy and white. Vaginal epithelium is edematous and inflamed. Vaginal pH is normal
What are the wet mount abnormalities in Candida vaginitis?
Pseudohyphae on a KOH prep. WBCs.
What is the management of Candida vaginitis?
Single oral dose of fluconazole or vaginal azole” creams. Asymptomatic sexual partners do not need treatment.”
What is normal psychologic vaginal discharge?
Thin, watery cervical mucus discharge seen with estrogen dominance.
What is the management of excessive physiologic vaginal discharge?
Steroid contraception with progestins.
What is the triad of yeast vaginitis?
Vaginal discharge with pH
65–year–old woman with vulvar itching. 1–cm white lesion of labia minora. Enlarged inguinal node. What is the diagnosis?
Vulvar cancer.
What are vulvar dystrophies?
Benign lesions without malignant predisposition vulvar itching, including squamous hyperplasia and lichen sclerosis.
What is vulvar squamous hyperplasia?
Whitish focal or diffuse areas that are firm and cartilaginous on palpation. Thickened keratin and epithelial proliferation. Management is fluorinated corticosteroid cream.
What is vulvar lichen sclerosis?
Bluish–white papula that can coalesce into white plaques. Thin and parchment–like. Epithelial thinning. Management is Clobetasol cream.
What is vulvar squamous dysplasia?
White, red, or pigmented, often multifocal. Cellular atypia is restricted to the epithelium without breaking through the basement membrane. Dysplasia. Management is surgical excision.
What is vulvar carcinoma in situ?
The appearance is indistinguishable from vulvar dysplasia. Cellular atypia is full thickness but does not penetrate the basement membrane. Management is laser vaporization.
What is vulvar squamous cell cancer?
The most common type of invasive vulvar cancer is squamous cell carcinoma, which has been associated with HPV.
What is vulvar melanoma?
The second most common histologic type of vulvar cancer is melanoma of the vulva. The most important prognostic factor is the depth of invasion. Dark or black lesion.
What is vulvar Paget disease?
Malignant red lesion, which is most common in postmenopausal white women. In 18–20% of cases there is invasion of basement membrane. Patients with Paget disease of the vulva have a higher association of other cancers from GI tract, GU, breast.
What is the management of vulvar squamous cell cancer?
Modified radical vulvectomy without lymphadenectomy. Any patient with vulvar cancer with invasion >1 mm should be treated with a lymphadenectomy.
What is molluscum contagiosum?
Common, benign, viral skin infection in children, sexually active adults, and immunodeficient patients. The molluscipox virus causes umbilicated tumors of the skin. Transmitted by skin contact. Management includes curettage and cryotherapy.
What is vulvar Condylomata acuminata?
Benign cauliflower– like vulvar lesions caused by HPV types 6 & 11. No malignant predisposition. Treat clinical lesions only.
What is a Bartholin cyst?
Obstruction of the Bartholin gland duct may occur due to infection (GC). The duct often remains obstructed, resulting in cystic dilation of the gland. Management is conservative unless there are pressure symptoms.
What are cervical polyps?
Fingerlike growths on cervix or endocervix. Relatively common in older multiparous women. Vaginal bleeding after intercourse. Bleeding occurs between normal menstrual periods. Biopsy reveals mildly atypical cells, infection.
What is the management of cervical polyps?
Polyps can be removed by gentle twisting followed by electrocautery or laser. An antibiotic may be given after the removal. Most cervical polyps are benign.
What are nabothian cysts?
Mucus–filled cyst on surface of cervix. Cyst appears as a small, white, pimple–like elevation. Singly or in groups. More common in women of reproductive age. Optional treatment is electrocautery or cryotherapy.
What are the signs of cervicitis?
Mucopurulent cervical discharge. No pelvic tenderness is noted. Cervical cultures are positive for chlamydia or gonorrhea. WBC and ESR are normal.
What is the management of cervicitis?
Oral azithromycin in a single dose or oral doxycycline BID for 7 days.
What is the etiology of cervical cancer?
Human papilloma virus 16, 18, 31, 33, and 35 are associated with cancer of the cervix. HPV 6 and 11 are associated with benign condyloma acuminata.
What are the risk factors for cervical cancer?
Early age of intercourse, multiple sexual partners, cigarette smoking, and immunosuppression.
When should Pap smears be started?
3 yrs after sexual activity or age 21 years, whichever occurs first. If under 30 years old, screen annually if using conventional methods or every 2 years if using liquid–based methods. If >30 years, screen every 2–3 years.
When should Pap smear screening be discontinued?
At age 70 if patient has had >3 consecutive normal Pap smears, and after total hysterectomy, if the procedure was performed for benign disease.
What is the management of abnormal HPV DNA testing?
HPV 16, 18, 31,33, 35 are associated with premalignant and invasive cervical cancer. If cells are reported with ASCUS with HPV 6 or 11, then repeat Pap smear in 1 year; however, if it is HPV DNA 16 or 18, evaluate by colposcopy, biopsy.
What are the causes of atypical squamous cells of undetermined significance?
ASCUS Pap smears can result from inflammatory and atrophic lesions, or may be caused by the initial stages of HPV infection. 10–15% of ASCUS Pap smears can have a premalignant lesion, small percentage have invasive carcinoma.
What are the diagnostic options for atypical squamous cells of undetermined significance?
A patient with an ASCUS Pap smear can be managed with any of 3 options: repeat cytology in 3–6 months, HPV DNA typing, or colposcopic evaluation and biopsy.
What is the management of atypical squamous cells of undetermined significance?
Accelerated repeat Paps. Repeat Pap at 4– to 6–month intervals until 2 consecutive, negative Paps. If a repeat Pap is ASC–US or worse, do colposcopy. HPV DNA testing is also an option for ASC–US. Colposcopy only if high–risk HPV DNA.
What is the indication for Colposcopy?
Patients with abnormal Pap should be evaluated by colposcopy. Nonpregnant patients undergoing colposcopy also undergo endocervical curettage. Lesions on ectocervix (mosaicism, punctation, white lesions, abnormal vessels) are biopsied.
What are the indications for cone biopsy?
If Pap smear is worse than histology, then cone biopsy. Other indications for conization of the cervix include abnormal ECC histology, a lesion seen entering endocervical canal, and a biopsy showing microinvasive carcinoma of cervix.
What is the management of cervical intraepithelial neoplasia1?
Observation and follow–up without treatment is appropriate for CIN 1 and includes any of the following: repeat Pap in 6 and 12 months; colposcopy and repeat Pap in 12 months; or HPV DNA testing in 12 months.
What are the indications for cervical ablative modalities?
Ablation used for CIN 1, 2, and 3. Cryotherapy, laser, electrofulguration. Excisional procedures include loop electrosurgical excision procedure or cold–knife conization. Hysterectomy only acceptable with recurrent CIN 2 or 3.
What is invasive cervical cancer?
Cervical neoplasia that has penetrated through the basement membrane.
