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NR 602: MIDTERM STUDY GUIDE
Signs of pregnancy (presumptive, probable, positive)
- Presumptive Signs of Pregnancy: Symptoms that are suggestive of pregnancy are considered “presumptive signs” which means that they are the least objective or subjective signs which can also be caused by many other conditions other than pregnancy. - Amenorrhea: Highly suggestive of pregnancy in a healthy female with regular & predictable periods. Difficult to determine in a female who have irregular periods or in those who do not keep track of their menstrual cycles - Nausea & vomiting: Common symptom (~50% of pregnancies) typically occurring between 2-16 weeks gestation - Breast engorgement & darkening of the areolas: Occurs as early as 6-8 weeks gestation - Breast tenderness - Fatigue - Urinary Frequency - Slight increase in body temperature: Rise in temperature coincides with luteal phase and is the result of increased progesterone - “Quickening”: Mother feels the baby’s movements for the 1st time; starts at 16 weeks.
- Probable signs of pregnancy: mean that there is a high likelihood of pregnancy but there are still other conditions that may cause the findings. - Pregnancy tests are considered probable because β-hCG also presents in molar pregnancies and ovarian cancer.
- Positive Signs of Pregnancy: The most reliable and most objective signs of positive pregnancy are those where the provider can confirm the presence of a fetus - Palpation of the fetus by the health care provider - Ultrasound and visualization of the fetus - Fetal Heart Tones (FHT) auscultated by the health care provider Pregnancy and fundal height measurement
- Fundal height can provide valuable information on assessing the gestational age of the fetus as well as to monitor fetal growth. o 12 weeks: Uterine fundus first rises above the symphysis pubis o 16 weeks: Uterine fundus is between the symphysis pubis and umbilicus o 20 weeks: Uterine fundus is at the level of the umbilicus o 25-35 weeks: Measure the distance between the upper edge of pubic symphysis and the top of the uterine fundus with a tape measure. Fundal height in centimeters equals the number of gestational weeks (+/- 2cm). For example, a 28 week gestation fetus should have a fundal height that measures between 26 and 30cm.
- Between 25-35 weeks the fundal height should measure equally to the number of gestational weeks (+/- 2cm).
Naegele’s rule
- The EDD is calculated by adding seven days to the first day of the last menstrual period, subtracting three months and adding one year. *For example, if the patient's last menstrual period, LMP, was on August 10, 2019, the EDD would be calculated as follows. LMP equals August 10, 2019 plus seven days. August 17, 2019, minus three months. May 17, 2019 plus one year and that equals May 17, 2020. Hematological changes during pregnancy-See Table 29.2 p. 777
- blood volume increases by 30% to 50%, or 1,100 to 1,600 mL and peaks at 30 to 34 weeks’ gestation.
- The increase in blood volume improves blood flow to the vital organs and protects against excessive blood loss during birth.
- Fetal growth during pregnancy and newborn weight are correlated with the degree of blood volume expansion.
- Of the blood volume expansion occurring during pregnancy, 75% is considered to be plasma
- There is also a slight increase in red blood cell volume (RBC).
- The blood volume changes result in hemodilution, which leads to a state of physiologic anemia during pregnancy.
- As the RBC volume increases, iron demands also increase.
- Leukocytosis occurs in pregnancy, with white blood cell counts increasing to as much as 14,000 to 17,000 cells per mm^3 of blood ( Table 29-3 ).
- Clotting factors increase as well, creating a risk for clotting events during pregnancy.
- Systemic vascular resistance is reduced due to the effects of progesterone, prostaglandins, estrogen, and prolactin.
- This lowered systemic vascular resistance, in combination with inferior vena cava compression, is partly responsible for the dependent edema that occurs in pregnancy.
- Epulis of pregnancy, or hypertrophy of the gums accompanied by bleeding, may also occur and is due to decreased vascular resistance and increase in the growth of capillaries during pregnancy
𝗌 Together with the pituitary, it manages the production of hormones that serve as chemical messengers for the regulation of the gynecologic system. 𝗌 The hypothalamus initially releases gonadotropin-releasing hormone (GnRH) in a pulsatile manner. 𝗌 On average, the frequency of GnRH secretion is once per 60 to 100 minutes during the early follicular phase, increases to once per 60 to 70 minutes during the middle of the menstrual cycle, and then decreases during the luteal phase 𝗌 The release of GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). 𝗌 Two other hormones necessary for gynecologic health, estrogen and progesterone, are secreted by the ovaries at the command of FSH and LH. Pituitary 𝗌 The oval-shaped, pea-sized pituitary gland is located in a small depression in the sphenoid bone of the skull. It is controlled by the hypothalamus, which secretes releasing factors into a special blood vessel network (hypothalamic–hypophyseal portal system) that feeds the pituicytes. These releasing factors either stimulate or inhibit the release of pituitary hormones that travel via the circulatory system to target organs. 𝗌 The anterior pituitary synthesizes seven hormones:
- Growth hormone (GH)
- Thyroid-stimulating hormone (TSH)
- Adrenocorticotropin (ACTH)
- Melanocyte-stimulating hormone (MSH)
- Prolactin (PRL)
- Follicle-stimulating hormone (FSH)
- Luteinizing hormone (LH) 𝗌 FSH and LH (both gonadotropins) are responsible for regulating gynecologic organ activities. 𝗌 FSH targets the ovaries, where it stimulates the growth and development of the primary follicles and results in the production of estrogen and progesterone. 𝗌 The release of FSH from the pituitary is governed by a negative feedback mechanism involving these steroids. 𝗌 In contrast, LH targets the developing follicle within the ovary; it is responsible for ovulation, corpus luteum formation, and hormone production in the ovaries. 𝗌 Prolactin is responsible for preparing the mammary gland for lactation and brings about the synthesis of milk Ovaries and Uterus 𝗌 Complex changes occur in the ovaries and the endometrium as a result of the cyclic fluctuations of gonadotropic hormones. 𝗌 The endometrium emulates the activities of the ovaries; thus whatever happens in the uterus during the menstrual cycle is precisely correlated with whatever is occurring in the ovaries. 𝗌 The objective of the ovarian cycle is to produce an ovum, while the objective of the endometrial cycle is to prepare a site to nourish and maintain the ovum if it becomes fertilized. 𝗌 The ovarian cycle includes three distinct phases: See pg 89
- the follicular phase,
- ovulation,
- luteal phase. 𝗌 The endometrial cycle can be divided into: See pg 91
- the proliferative phase,
- the secretory phase,
- menstruation Vaccines during pregnancy
- A pregnant woman should get vaccinated against whooping cough and flu during each pregnancy to protect herself and her baby, with immunity for the first few months of life.
- Influenza-Can be given anytime during pregnancy; Do not give live vaccine
- Tdap- should be given during every pregnancy between 27-36 weeks Emergency contraception
- Sperm can live for up to 5 days in the female reproductive tract, and pregnancy can occur with intercourse 5 days prior to ovulation.
- The highest risk of pregnancy is in the 48 hours immediately preceding ovulation. However, due to the uncertainty of ovulation timing, emergency contraception is offered if unprotected intercourse (UPI) occurs at any time in the menstrual cycle.
- The Yuzpe, levonorgestrel, and ulipristal acetate emergency contraceptive pill (ECP) regimens as well as the copper IUD may all be used within 120 hours of UPI. *The Yuzpe and levonorgestrel methods have a dramatic decline in their effectiveness with time and should be used as soon as possible after an event of UPI. o The Yuzpe regimen consists of combined ECPs that must contain at least 100 mcg of ethinyl estradiol and 0.50 mg of levonorgestrel, repeated in 12 hours. A dedicated combined ECP product is not available in the United States, but numerous COCs can be used as combined ECPs (see Table 11-1, footnote i). COCs containing norgestrel are preferable to those with norethindrone, as failure rates are slightly higher with norethindrone (Zieman et al., 2015). Because the high dose of ethinyl estradiol causes unpleasant side effects, this regimen has largely fallen out of favor. o Until recently, the most widely used emergency contraception method was levonorgestrel ECPs, which contain either a 1.5-mg single dose (Plan B One-Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects. o Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. The effectiveness of this medication does not decline within the 120-hour window after UPI, as is the case for levonorgestrel and combined ECPs. Ulipristal acetate is available only by prescription.
- Ovarian function abnormalities are the most common cause of amenorrhea, and estrogen production is the most reliable measure of ovarian function.
- Athletic women, particularly long-distance runners, gymnasts, and professional ballet dancers, are at risk for amenorrhea, as are women who have anorexia and other eating disorders
- Women with a low BMI and low percentage of body fat combined with a high level of intensive physical activity have the highest risk for amenorrhea
- Laboratory tests to assess estrogen production include serum estradiol levels, progestogen challenge test, measurement of endometrial thickness, and serum FSH concentration.
- A random serum estradiol level that is greater than 40 pg/mL indicates functioning ovaries. If the level is low, the woman may be amenorrheic because of ovarian failure or have hypothalamic amenorrhea. o A progesterone challenge test that produces withdrawal bleeding is indicative of functioning ovaries, because bleeding will occur only if a sufficient amount of circulating estrogen is present. A progesterone challenge can be accomplished by administering micronized progesterone (Prometrium) 400 mg daily for 7 to 10 days or medroxyprogesterone acetate (Provera) 10 mg daily for 7 to 10 days. Withdrawal bleeding should occur within 7 to 10 days after the progesterone is discontinued if the level of endogenous estrogen is appropriate to produce a withdrawal bleed and the outflow tract is patent. - If the response to the progesterone challenge is positive (withdrawal bleeding occurs), the woman does not have galactorrhea, and her prolactin level is normal, the possibility of a pituitary tumor is effectively ruled out. - In this case, the diagnosis is anovulation, and the treatment is a progestogen for the first 10 days of each month or a combined contraceptive (pill, patch, or vaginal ring). - The woman should also be evaluated for PCOS. - If the woman does not have a positive progestogen challenge, then a physician consult is warranted for further evaluation and management options. o Serum FSH indirectly measures ovarian function, with lower levels of FSH indicating normally functioning ovaries. In contrast, an elevated result may indicate ovarian function disorder or disease and warrants further investigation. - If the tests reveal that the ovaries are producing estrogen and the FSH level is normal, the diagnosis is chronic anovulation o Thyroid disease and hyperprolactinemia are also common causes of anovulation. A TSH level can detect either hypothyroidism (TSH is elevated) or hyperthyroidism (TSH is low), both of which can cause amenorrhea. Menstrual cycles almost always return to normal once the thyroid level is normalized. o Hyperprolactinemia is not always accompanied by galactorrhea (discharge from the nipples), but can be diagnosed by obtaining a serum prolactin level in women with amenorrhea. - Some medications, including antidepressants, opiates, calcium-channel blockers, and estrogens, can cause an elevated prolactin level; therefore, it is important to ask about medications when obtaining the health history.
- Hyperprolactinemia has many causes (see Chapter 16), but if it and the accompanying amenorrhea cannot be attributed to medication or another condition, then further evaluation to rule out pituitary tumors and hypothalamic mass lesions is necessary
- A dopamine agonist is the treatment of choice for hyperprolactinemia o Ovarian failure is diagnosed when low estrogen production is identified while the serum FSH is high. Premature ovarian failure can be due to many causes, including genetic conditions. o Functional hypothalamic amenorrhea is characterized by “the absence of menses due to the suppression of HPOA in which no anatomic organic disease is identified”
- The typical picture of a woman diagnosed with functional amenorrhea is the adolescent who is underweight, overexercises, and is experiencing a great deal of stress.
- In this setting, an energy deficit occurs, with a resultant negative impact on the HPOA
- Treatment generally focuses on weight gain and exercise reduction, although psychological counseling may also be helpful.
- A goal of treatment is to offset the bone loss that occurs during the estrogen- deficient periods of time
- All women with anovulation require management of this condition: If left untreated, endometrial cancer can occur, regardless of the woman’s age.
- Typically treatment consists of inducing menses using a progestogen such as medroxyprogesterone acetate 5 to 10 mg daily for the first 12 to 14 days of the cycle. Etiology, diagnosis, and treatment of dysmenorrhea (primary vs. secondary)
- Dysmenorrhea—defined as painful cramps that occur with menstruation—is the most commonly reported menstrual disorder, affecting as many as 81% of women
- Etiology-- The pain of dysmenorrhea originates from intense uterine contractions during the menstrual phase of the cycle, triggering endometrial prostaglandin production and release. o The excessive amount of prostaglandins causes the uterus to contract further, reducing uterine blood flow and causing ischemia and pain. o While the etiology of dysmenorrhea is not completely understood, studies support the hypothesis that uterine inflammation with menstrual cycles may also promote cross- organ pain sensitization, a mechanism by which dysfunction in one organ elicits neurogenic inflammation in another organ o The uterus lies in close proximity to the bladder, the bowel, and the peritoneum, and its contraction may elicit pain in those structures during the menstrual cycle. o This theory, along with the current knowledge about prostaglandins’ major role in dysmenorrhea, may help explain the chronicity of pain that may occur throughout the pelvic area during the menstrual cycle.
- Primary (absence of pelvic pathology) o more common than secondary dysmenorrhea, o often begins 6 to 12 months after menarche.
- Progestin implants
- Progestin IUD
- Depo Medroxyprogesterone Acetate
- Surgical intervention—extreme measure
Differentiate between PMS & PMDD
- Premenstrual syndrome (PMS) describes the cyclical recurrence of symptoms that impair
a woman’s health, relationships, and occupational functioning. o PMS can be defined as a cluster of mild to moderate physical and psychological symptoms that occur during the late luteal phase of menses and resolve with menstruation
- Premenstrual dysphoric disorder (PMDD) is a diagnostic label that applies to a much smaller
number of menstruating women experiencing severe PMS with predominantly negative affective symptoms. o PMDD encompasses cognitive, behavioral, emotional, and negative symptomatic changes that severely impair daily functioning, relationships, parenting, and ability to work in the late luteal menstrual phase The diagnostic criteria for PMDD are as follows: o In the majority of cycles, five or more symptoms, including affective and physical symptoms, are present during the week before menses and are absent in the follicular phase. o One (or more) of the following symptoms is present: irritability, depressed mood, marked anxiety, tension, or affective lability. o One or more of the following symptoms must additionally be present (the combination of symptoms in I and II must total five): decreased interest in usual activities, difficulty concentrating, fatigue, appetite change (decreased or increased), changes in sleep patterns (hypersomnia or insomnia), sense of feeling overwhelmed, physical symptoms such as breast tenderness, joint or muscle pain, bloating, or weight gain. o The symptoms markedly interfere with occupational or social functioning. o The symptoms are not due to an exacerbation of another disorder. o The preceding criteria have been confirmed by prospective daily ratings over at least two menstrual cycles
TABLE 23-1 Symptoms of Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Symptoms PMS PMDD Physical Abdominal bloating and pain Physical: same as PMS but may be more severe symptoms Mild weight gain from water Symptoms can begin immediately after ovulation retention Abdominal bloating and pain Constipation followed by diarrhea Headache at the onset of the menses Pelvic pain and cramping Headache Fatigue Pelvic pain and cramping Extremity edema
Abnormal uterine bleeding terminology *In women of reproductive age, the most common cause of a bleeding pattern that suddenly differs from a woman’s established menstrual pattern is a complication of pregnancy, including threatened or incomplete abortion, ectopic pregnancy, retained products of conception, or gestational trophoblastic disease **As a consequence, clinicians treating women of childbearing age who present with AUB— especially adolescents who may not be forthcoming about their sexual activity—should always first exclude pregnancy or a complication of pregnancy as a cause of the bleeding. Menorrhagia: heavy or prolonged menstrual bleeding Metrorrhagia: “irregular” intermenstrual bleeding or bleeding between menstrual periods Menometrorrhagia: “irregular” and heavy intermenstrual bleeding Post-Coital: bleeding that occurs after intercourse Post-Menopausal: bleeding that occurs after a menopausal woman has not had a period for at least 12 months Structural vs. Nonstructural etiologies of abnormal uterine bleeding Symptoms PMS PMDD Fatigue Extremity edema Nausea/food cravings Nausea/food cravings Psychologi c symptoms Depression Anxiety Anger/irritabilit y Insomnia Changes in libido Confusion, decrease in mental sharpness Social withdrawal Feelings of low self- esteem/poor self-image Marked affective lability Marked irritability or anger or increased interpersonal conflicts Markedly depressed mood, feelings of hopelessness, or self- deprecating thoughts Marked anxiety, tension, feelings of being “keyed up” or “on edge” Decreased interest in usual activities Subjective sense of difficulty concentrating Lethargy Insomnia or hypersomnia A subjective sense of being overwhelmed or out of control Diagnosti c criteria Symptoms begin up to 7 days prior to menses Remission of symptoms occurs from cycle days 4– 13 Symptoms are significant enough to impair activities of daily living Symptoms are charted in at least 2 cycles Symptoms are not due to another disorder Symptoms are associated with clinically significant distress or interference with work, school, social activities, or relationships with others The disturbance is not an exacerbation of the symptoms of another disorder (e.g., major depressive disorder) Criteria should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (the diagnosis may be made provisionally prior to this confirmation) Symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, medications other than treatment) or a general medical condition
Evaluation and management of abnormal uterine bleeding: See Week 2 lesson Material
- Management: Management goals for treating AUB are to (1) normalize the bleeding, (2) correct any anemia, (3) prevent cancer, and (4) restore quality of life. o The clinician should always consider the woman’s choice of treatment when developing a plan of care. o Concomitant therapy may be necessary to achieve these goals, particularly if the bleeding is severe and threatens hemodynamic stability. o Estrogen therapy will provide rapid growth of a denuded endometrium. o Once the acute bleeding is under control, additional treatment options such as oral contraceptives, use of the levonorgestrel intrauterine system, and progestin therapy (among others) are available for long-term treatment
o If testing reveals that the woman is anemic because of the bleeding, she will need iron therapy. o Table 24.5 pg 591: Pharmacological management: A variety of pharmacologic choices are available for women with HMB, including combined oral contraceptives (COCs), progestogen-only therapy, and levonorgestrel-releasing intrauterine devices o Nonsteroidal anti-inflammatory drugs are useful for ovulatory–idiopathic HMB. The heavier the bleeding, the better the effectiveness of NSAIDs, o surgical management options for HMB include D & C, endometrial ablation, uterine artery embolization, and hysterectomy. In the presence of a thin endometrium, medical therapy for excessive uterine bleeding is reasonable. Breast mass types and diagnostic studies Fibroadenomas o Benign neoplasms which occurs most frequently in young women, usually within the first 20 years after puberty. o The frequency is a slightly higher and tends to occur at an earlier age in the African American population than in Caucasian women. o They are usually discovered accidentally and typically present as solid, well-defined masses which are non-tender and mobile. Multiple fibroadenomas are possible. o The incidence of fibroadenomas decrease with age but may still occur in menopause. o Etiology is unknown but a hormonal relationship is likely since they can increase in size during pregnancy or with estrogen therapy. Cysts o Benign fluid-filled sacs that are encapsulated within the breast. o Single or multiple cysts may be present occurring in one or both breasts. o Cysts are most common in women between the ages of 35 and 50, prior to menopause but can be found in women of any age pre- and post-menopause. Lipomas o Fatty tumors that can appear anywhere in the body, including the breast. They are usually not tender and occur in the later reproductive years. Hamartoma o Overgrowth of mature breast cells which may contain fatty, fibrous and/or glandular tissue. o Hamartomas are smooth and painless masses. Fat Necrosis o Usually the result of breast trauma or surgery. o Tenderness may or may not be present. o Sometimes indistinguishable from carcinoma. o If left untreated, fat necrosis masses usually gradually disappear without intervention. Phyllodes tumors o Rare benign breast tumor arising from the fibroepithelial cells. o The tumors tend to grow very quickly and become very large. o The lesion can be, but rarely is, malignant. o Requires biopsy Diagnostic Studies
- Mastalgia, or mastodynia, are other words used for breast pain, which is a relatively common phenomenon in females once they reach the reproductive years.
- Breast pain can be classified into 3 different categories:
- cyclical breast pain
- non-cyclical breast pain and
- extramammary (chest wall) pain.
- Although most breast symptoms have benign causes, mastalgia can cause significant anxiety and concern for a female due to fear of cancer.
- The majority of cases of breast pain however are benign, and breast pain is rarely a primary symptom of a developing cancer.
- The likelihood of mastalgia as a symptom of cancer increases though when a woman reaches menopause where there is lack of hormonal influence. Cyclical Mastalgia
- The majority of breast pain is cyclic and coincides with the menstrual cycle which induces breast engorgement and tenderness.
- Symptoms occur most often in the 2 weeks before the onset of menses (luteal phase) and are at their worst right before menses begins.
- The pain is usually bilateral and poorly localized and is often described as dull or achy.
- Breast size does not seem to influence the occurrence or perception of pain and cyclical pain is more likely to affect pre-menopausal women. Fibrocystic Breast Changes
- Fibrocystic breast changes are the most common cause of cyclic breast pain in women of reproductive age and is characterized by painful, multiple mobile masses in the breast.
- Fibrocystic changes are usually seen bilaterally and the pain and size of the masses typically increase during the luteal phase of the menstrual cycle.
- Fibrocystic changes commonly occur in the 3rd decade of life and are benign.
- Fluctuations in size and rapid appearance or disappearance of a breast mass help to differentiate these lesions from carcinoma but imaging and referral is necessary is a dominant mass is present. Non-cyclical Mastalgia
- Non-cyclic breast pain is less common and is unrelated to the menstrual cycle, so it is not hormone influenced.
- Pain generally presents in 1 specific location and is constant or intermittently painful.
- Pain is usually described as a tightness, burning or general soreness and is more commonly experiences by post-menopausal women.
- Etiologies may include periductal mastitis, stretching of cooper’s ligament, trauma, cyst, inflammatory cancer (ductal cancer) or idiopathic. Extra-mammary Mastalgia
- Chest wall pain is unrelated to the breast and referred from another source such as torn or strained muscles in the chest or shoulders, inflammation of the costal cartilage and rib injuries. Nipple Discharge
- Nipple discharge is also a common breast complaint among women and it is likely that you will encounter a patient presenting to your office for evaluation.
- Nipple discharge is categorized into 3 types:
- normal lactation
- benign physiologic nipple discharge (galactorrhea)
- pathologic nipple discharge Physiologic Nipple Discharge
- Galactorrhea is a considered a physiologic nipple discharge because it is frequently the result of an excess of prolactin from the pituitary gland which stimulates milk production.
- Galactorrhea is usually bilateral (but may be unilateral), multi-ductal and milky in appearance in the non-lactating adult. It can occur in males as well as females.
- In females, absent or irregular menstrual periods are likely. Pathologic Nipple Discharge
- Pathologic nipple discharge on the other hand is non-milky, spontaneous, and most often unilateral and uniductal.
- Nipple discharge with a bloody appearance is more suggestive of intraductal malignancy or a benign intraductal papilloma and should raise a red flag to the provider.
- Mammary duct ectasia, on the other hand, is another source of non-milky discharge.
- Ectasia is the result of mammary duct dilation with surrounding inflammation and fibrosis.
- It can present with variable colors (green, brown or black) and may be seen in both breast and/or multiple ducts. Treatment
- Once a benign diagnosis or normal findings have been established by biopsy or imaging, simple reassurance is often all that is needed. Symptomatic treatment for mastalgia may also include the following recommendations:
- Wear a sports or supportive, wire-free bra
- Minimizing caffeine may provide anecdotal relief
- NSAIDs
- Evening primrose oil and vitamin E supplementation-their utility is controversial since benefits have not been shown consistently in research
- Danazol, bromocriptine and tamoxifen have been found effective and used for severe cases but the significant side effects have limited the acceptability of their use
- Changing to contraceptive pill or hormone replacement therapy with less estrogen or progesterone may offer some relief associated with cyclic mastalgia Clinical signs and symptoms of ectopic pregnancy
- Ectopic pregnancy is the implantation of a fertilized ovum in locations other than the uterine cavity.
- It is the second leading cause of maternal mortality in the United States.
- Approximately 95% of all ectopic pregnancies occur in the fallopian tube
- Growth of the fetus in the fallopian tube puts the woman who is pregnant at high risk for pregnancy loss, tubal rupture, excessive blood loss, and future infertility due to tubal scarring. Box 31-1 summarizes risk factors associated with ectopic pregnancy. Signs/Symptoms
- Pelvic and abdominal pain and unexplained vaginal bleeding are the primary symptoms experienced by most women with ectopic pregnancy.
Breast cancer screening guidelines (USPSTF) https://www.uspreventiveservicestaskforce.org/home/getfilebytoken/ hPPj9vB9ZvPmUMG7Wnvcjp Diagnosis and treatment of non-STI vaginitis (vulvovaginal candidiasis, bacterial vaginosis)
Vulvovaginal candidiasis, caused by Candida species and commonly called a "yeast" infection, affects
most females at some time in their lives, with the highest incidence during the reproductive years. Clinical findings
- Vulvovaginal candidiasis classically presents with symptoms such as pruritus (the most common symptom), vaginal soreness, dyspareunia, vulvar burning, external dysuria, and abnormal vaginal discharge.
- Vulvar and labial erythema, fissures, and satellite papular lesions may be present.
- Symptoms associated with vulvovaginal candidiasis tend to flare prior to the onset of menses.
- Vaginal discharge is usually described as thick, white, and clumpy ("cottage-cheese-like"), but it may be watery, minimal, or not present, and there is typically little, if any, associated odor. DIAGNOSTIC METHODS
- The clinical symptoms of vulvovaginal candidiasis overlap with other causes of vaginitis, so diagnostic evaluation is recommended. Most patients with symptomatic vulvovaginal candidiasis can be readily diagnosed on the basis of a microscopic examination of vaginal secretions. o Vaginal pH: The vaginal pH should be normal (3.8 to 4.5) in the setting of candidiasis. If the pH is abnormally high (greater than 4.5), it suggests an alternative diagnosis of bacterial vaginosis or trichomoniasis, or a mixed infection. o Potassium Hydroxide (KOH) and Saline Wet Mount Preparation and Microscopy: Visualization under microscopy of pseudohyphae (mycelia) and/or budding yeast (conidia) on 10% KOH wet prep examination or saline wet mount can confirm the diagnosis of vulvovaginal candidiasis Treatment of Uncomplicated Vulvovaginal Candidiasis Infections
- The 2015 STD Treatment Guidelines recommend a variety of short-course intravaginal antifungal agents to treat uncomplicated vulvovaginal candidiasis
- Many of the treatment options are available in over-the-counter formulations, and prescription intravaginal medications are also available.
- The recommendations include one option for patients who prefer oral therapy: fluconazole 150 mg orally in a single dose.
- The short-course topical formulations are effective in treating uncomplicated vulvovaginal candidiasis and azole drugs are more effective than topical nystatin.
- An estimated 80 to 90% of patients with vulvovaginal candidiasis who complete treatment with an azole have a relief in symptoms and negative cultures. Treatment of Recurrent Vulvovaginal Candidiasis
- For patients who develop recurrent vulvovaginal candidiasis (four or more episodes within 1 year), the 2015 STD Treatment Guidelines recommend a strategy of using a longer 7 to 14 day
initial course of therapy to achieve clinical remission, followed by a 6 month maintenance regimen.
- The longer course initial therapy options include topical therapy for 7 to 14 days or oral fluconazole given as a 100 mg, 150 mg, or 200 mg oral dose every third day (day 1, 4, and 7) for a total of 3 doses; the goal of the intensive initial therapy is to achieve mycologic remission before using maintenance therapy.
- The preferred maintenance therapy consists of oral fluconazole (100, 150, or 200 mg) given weekly for 6 months); maintenance therapy has been demonstrated to reduce episodes of vulvovaginal candidiasis, but symptoms recur in about 30 to 50% of women once maintanence therapy is stopped.
- For patients who cannot take oral fluconazole maintenance therapy, topical azole therapy given intermittently can be used as an alternative. Treatment of Severe Vulvovaginal Candidiasis
- Severe disease, which can involve significant skin breakdown, fissuring, and edema, requires treatment with 7 to 10 days of topical azole therapy or two doses of oral fluconazole 150 mg given 72 hours apart. Low-dose topical steroid preparations may also provide immediate symptomatic relief.
Bacterial Vaginosis
Bacterial vaginosis is a gynecologic condition that is related to alterations in the normal vaginal flora and is the most common cause of vaginitis among reproductive-age women. CLINICAL MANIFESTATIONS
- Up to half of all women with bacterial vaginosis have no symptoms.
- If symptomatic, most women with bacterial vaginosis will have a malodorous (“fishy odor”), homogenous, clear, white or gray vaginal discharge that is reported more commonly after sexual intercourse and after completion of menses; labial and/or vulvar swelling and other signs or symptoms of inflammation are typically absent.
- Symptoms may remit spontaneously.
- Qualitative studies have shown that bacterial vaginosis can negatively impact self-esteem, sexual relationships, and quality of life. Diagnostic criteria
- Amsel’s criteria--The presence of three of the following four criteria provides sufficient evidence for a clinical diagnosis of bacterial vaginosis:
- Vaginal pH greater than 4.5, which is the most sensitive but least specific sign.
- The presence of “clue cells” (bacterial clumping upon the borders of epithelial cells) on wet mount examination. To meet the criteria for positive clue cells, the clue cells should constitute at least 20% of vaginal epithelial cells viewed on saline microscopy (an occasional clue cell does not fulfill this criterion).
- Positive amine, "whiff" or "fishy odor" test (liberation of biologic amines with or without the addition of 10% KOH).
- Homogeneous, nonviscous, milky-white discharge adherent to the vaginal walls.
